India is a country with diversified population differing

Transcription

1 Original Article# High Prevalence of Metabolic Syndrome and Cardiovascular Risk Among Police Personnel Compared to General Population in India Shabana Tharkar*, S Kumpatla*, P Muthukumaran*, Vijay Viswanathan* Abstract Objective : There is a paucity of data on the prevalence of metabolic syndrome and diabetes in different occupational categories in India. The aim of this study was to determine the prevalence of metabolic syndrome and associated cardiovascular risk factors among police personnel and compare with the general population (GP). Methods : Two populations similar in demography were selected for this study. A total of 719 men aged 30 years from Chennai, were randomly selected (police n = 318, GP n = 401). Fasting blood samples were collected, glucose and lipid profile were estimated. Prevalence of metabolic syndrome was determined using IDF definition. Risk associations for metabolic syndrome and diabetes were analyzed using multiple logistic regression analyses. Results : The prevalence of metabolic syndrome (57.3 vs 28.2 %; χ 2 = 64.5, p< ) was significantly higher among police compared to GP. Regression analyses showed that age, body mass index, alcohol consumption and smoking were associated with metabolic syndrome while age, family history of diabetes, abdominal adiposity and increased body mass index were associated with diabetes among the policemen. The police had higher prevalence of individual cardio metabolic abnormalities and diabetes in comparison with GP (p<0.05). Conclusion: Prevalence of metabolic syndrome and other cardiometabolic abnormalities were significantly higher among the police. Further research is required to determine the causative factors and effective intervention strategies must be planned to keep the police force healthy and vigilant. Introduction India is a country with diversified population differing with respect to social and cultural habits, varied occupation and income groups. With industrialization, there is a transition in economy and lifestyle. Erstwhile, prevalence of non communicable diseases was low, but today, it is on the rise, with wide ranges among the general population in India. For example, diabetes has a range of 2-3% in certain rural areas of northern India to as high as 18% in urban India. 1-6 Metabolic syndrome, which is considered to have at risk status for the development of future cardiovascular disease is also on the rise. 7 For instance in developed countries like US, 64 million out of 201 million US individuals aged 20 years have metabolic syndrome. 8 Evidence from research suggests that certain occupational groups like factory workers in Japan are more prone to the development of type 2 diabetes. 9 *M. V. Hospital for Diabetes and Diabetes Research Centre (WHO Collaborating Centre for Research, Education and Training in diabetes) No-4, Main Road, Royapuram, Chennai-India. #Rapid Publication Received : ; Accepted : In US, a cohort study done on police force showed that this occupational group has high risk for development of non communicable diseases and cardiovascular disease (CVD) events at an earlier age and that they die much earlier compared to other groups. 10,11 Several studies have demonstrated that the lifestyle and working environment of the police is under constant stress with a high rate of smoking and alcohol addiction. 12,13 Given the fact that policemen lead a physically inactive life, have irregular diet and limited choice of food while on duty, take overtime and shift work, suffer from disrupted sleep patterns, stress and have high rates of tobacco and alcohol consumption than the general population, they have been found to have an increased prevalence of CVD risk factors and type 2 diabetes than any other occupational group and among the general population in many countries A study done in US showed that employment as a law enforcement officer is associated with an increased cardiovascular disease morbidity and this relationship persists after considering several conventional risk factors. 22 In India, epidemiological studies have been done extensively for prevalence of diabetes and other non communicable diseases like hypertension among the JAPI VOL. 56 NOVEMBER

2 general population 5 but data on specific occupational groups is limited. There is no epidemiological data on the prevalence of diabetes and metabolic syndrome among police personnel from India. Therefore, this study was conducted among the Chennai city police to evaluate and determine the prevalence and associated risk factors for diabetes and metabolic syndrome. Methods A cross sectional design and multistage random sampling technique was adopted to select two groups of population. A total of 719 men aged 30 years were studied (police: n= 318, general population; n = 401). Sampling was done in two zones- North and Central Chennai. The police stations from these two selected zones were included in the study and screening was done. The response rate among the policemen was 76.3%. The general population was derived from settlements in close proximity to the police stations. The two groups were similar in demographic characteristics and differed only in occupation. The response rate was 76.3%. A proforma was designed for the purpose of data collection and was pre-tested on 20 subjects. Necessary alterations were made and the instrument was finalized. It had all the details about socio-demographic characteristics, income details, recording anthropometry details and biochemical parameters, past medical history, brief dietary details, smoking and alcohol status, and levels of physical activity. Screening was done by a multi disciplinary team comprising of an epidemiologist, diabetologist, field workers, phlebotomist, nurses, dietitians, and educators. Written consent was obtained from the subjects before recruiting them in the study. The study protocol was approved by ethics committee of the institution. Anthropometry and blood pressure measurement: Height, weight and waist measurements were recorded. Waist circumference was measured in centimeters placing the tape on the navel after loosening the outer garments. The waist was defined as the smallest girth between the costal margin and iliac crests. Body mass index (BMI) (weight in kg/height in m 2 ) was later calculated. Blood pressure measurements were taken in resting state. Blood collection and biochemical estimations: Venous blood samples were collected after a minimum of 8 hours of overnight fasting. Blood was collected in an oxalate-fluoride tube and transported on ice for plasma glucose estimation in the laboratory. Plasma glucose was estimated using glucose oxidase method. Fasting serum sample was used for estimation of lipids including total cholesterol, triglycerides and high density lipoprotein cholesterol (HDL-C). All the biochemical estimations were done using enzymatic procedures with in 5 hrs and Hitachi 917 auto analyzer was used for all assays. Diagnosis of diabetes was made on the basis of WHO definition for diagnosis of diabetes in the fasting state. 23 Diagnosis of the metabolic syndrome was made using IDF definition and presence of metabolic syndrome was confirmed when three or more of the following risk factors are present; Waist circumference: >=90 cms (specific for Indians): Blood pressure: 130/85 mmhg; Fasting plasma glucose ( 100 mg/ dl); Triglycerides 150 mg/dl; HDL-Cholesterol< 40 mg/dl. The other risk factors taken were body mass index ( 25kg/ m 2 ) and total cholesterol ( 200 mg/dl). Statistical Procedures SPSS version 10.0 was used for statistical analysis. Mean and standard deviations were estimated for continuous variables. Prevalences are reported in percentages. Students t test/chi square test were used as appropriate to test statistical significance. Multivariate logistic regression analyses were done using diabetes and metabolic syndrome as the dependant variables. P value of <0.05 was considered as significant. Results The entire study population was age matched (mean age police: GP, 44.3:43.3 years). Table 1 shows the general characteristics of study populations and prevalence of CVD risk factors. Educational status and positive family history of diabetes were similar in both the study groups. Increased hours of television watching was more common among the general population (p<0.05). Alcohol consumption was significantly higher among the police. The level of physical activity was statistically different between the groups (p<0.05). In general, sedentary life style was observed among police group. Crude prevalences of metabolic syndrome, type 2 diabetes and hypertension for both the Table 1 : General characteristics of study populations and prevalence of CVD risk factors GP POLICE N=401 N=318 Education No formal education 18 (4.5) 3 (0.9) School/High School 249(62.1) 237(74.5) Graduate/Post Graduate 126 (31.4) 78 (24.5) Professional 8 (2.0) Income (Indian Rs.) < 10, (94.0) 233 (73.3) 10,000-20, (5) 83 (26.1) > 20, (1) 2 (0.6) FH - DM 111 (27.7) 100 (31.4) TV Watching (Hrs/Day) <1 39(9.7) 155 (48.7)* (74.8) 140 (44)* >2 62 (15.5) 23 (7.2)* Habits Smoking 83 (20.7) 72 (22.6) Alcohol 44 (11.0) 99 (31.1)* Tobacco 33 (8.2) 27 (8.5) Physical Activity (Hrs/ Day)** Standing 3.2± ±3.1* Sitting 3.5 ± ±3.0* Walking 2.1± ±2.4* Crude Prevalences (i) Metabolic syndrome * (ii) Type 2 Diabetes * (iii) Hypertension * * denotes p<0.05; Values are n (%) or mean ± SD** JAPI VOL. 56 NOVEMBER 2008

3 groups are shown which are significantly higher among the police. Table 2 shows the mean anthropometric, hemodynamic and biochemical details of the study subjects. Mean values of BMI, waist circumference, fasting plasma glucose, both systolic and diastolic blood pressure and cholesterol were significantly higher among the police. Fig. 1 shows the prevalence of individual abnormalities among police in comparison with general population. Abdominal obesity (GP;32.7 vs Police 65.1%, χ 2 =73.6,p<0.001) and increased BMI (GP; 35.4 vs Police 62.9%,, χ 2 =52.6, P<0.001) are the two most highly prevalent abnormalities among the police. Prevalence of increased triglycerides level (GP; 40.6% vs police 49.7%, χ 2 = 5.5, P = 0.02) and blood pressure (GP; 29.2% vs Police 58.5%, χ 2 = 61.3, P<0.0001) were significantly higher in police compared to GP. Table 3 (Panel a) shows the results of multiple logistic regression analysis. The variables significantly associated with type 2 diabetes among police were age, family history of diabetes, BMI and abdominal adiposity (increased waist circumference). Table 3 (Panel b) shows the variables associated with Table 2 : Anthropometric, haemodynamic and biochemical details of the study subjects Variables GP POLICE P Value N=401 N=318 Age (years) BMI (kg/m 2 ) 23.8± ±4.1 < WC (cm) 85.9± ± 11.6 < FPG (mg/dl) 108± ± 49.9 <0.001 Total cholesterol 177.2± ± (mg/dl) TG (mg/dl) 159.9± ± HDL - C (mg/dl) 41.4± ± LDL - C (mg/dl) 104.4± ± VLDL - C (mg/dl) 30.0± ± SBP (mm/hg) 124.1± ±18.8 < DBP (mm/hg) 78.7 ± ±12.5 < Values are mean ± SD; P<0.05 denotes statistical significance. Fig. 1 : Shows the prevalence of individual cardio metabolic abnormalities among the police (cops) in comparison with general population (GP). * denotes p<0.05 presence of metabolic syndrome in multiple logistic regression analysis. The significant variables were age, body mass index, alcohol consumption and tobacco use. The variables age and BMI showed strong association with both the dependant variables- type 2 diabetes and metabolic syndrome. The odds ratio of age was 10.4 (CI= ) for diabetes and 3.9 (CI = ) for metabolic syndrome and odds ratio of BMI was 2.2 (CI = ) and 3.1 (CI = ) for metabolic syndrome. Discussion This study was a part of an on going intervention project for the policemen for primary prevention of non communicable diseases in the high risk category. This study is probably the first of its kind done in India with properly designed methodology to estimate the metabolic syndrome and cardiovascular risk factors among the police personnel (ie) focusing on a specific occupational group. At baseline, the study showed very high prevalences metabolic syndrome, hypertension and diabetes among the police which were highly significant when compared with the general population. The police group had a higher mean of biochemical parameters and anthropometric measurements. In India very sparse data is available on the prevalence of non communicable diseases and prediabetic conditions among the police force as a specific occupational group. Erstwhile a study from Kolkata to assess the prevalence of only diabetes showed similar results that their police had around 5% higher prevalence of diabetes than the general population. 24 Research from other countries suggest that law enforcement officers and police had a higher risk for developing coronary artery disease and diabetes and that the age at mortality is earlier compared to other occupational groups. 11,21 Table 3 : Results of multiple logistic regression analyses: Panel a Dependent variable: Diabetes compared to normoglycemic subjects Significant Variables Odds 95% P value ratio Confidence interval Age (years) 10.4 ( ) < FH-DM 2.4 ( ) BMI (kg/m2) 2.2 ( ) 0.02 Abdominal obesity 2.0 ( ) (waist circumference cm) Non Significant - Physical activity, Income, Habits. Panel b Dependent variable: Presence of metabolic syndrome Significant Variables Odds 95% P value ratio Confidence interval Age (years) 3.9 ( ) Alcohol consumption 2.3 ( ) and tobacco use Non Significant: Physical activity, Income, family history of diabetes JAPI VOL. 56 NOVEMBER

4 Another observation is the lack of physical activity among the police. The results showed that they either sit or stand for long hours and walked less compared to the GP (p<0.05). It was noted that exercise and physical activity has decreased among the police even though it did not have a significant association in the regression analysis. Although everyone is aware of the stringent rules and health specifications followed at the time of their recruitment, nobody has yet established evidence regarding the derailment of health after completion of few years of service. Further detailed research is needed to evaluate the risk factors and their attributable risk responsible for the ill health of policemen, Lifestyle studies of policemen showed very high rate of addiction to alcohol and smoking habits. 16 They work under tremendous pressure and stress which may make them alcohol and smoking dependant. 17 This combination can have a synergistic and detrimental effect on the deterioration of their health status. Our study also showed that the alcohol and smoking habits were more among the policemen. Research has established evidence beyond doubt that smoking is a leading cause for coronary artery disease and recent reports stated that it may have link 25, 26 with glucose intolerance and diabetes too. Hence the findings of this study reveal that this occupational group has a very high risk for development of cardiovascular disease and diabetes. They had significantly higher BMI and waist circumference, hypertriglyceridemia and high blood pressure when compared with the GP. In our study the risk factors associated with metabolic syndrome were age, body mass index, alcohol and tobacco use. Since this study was performed with the aim of providing the baseline information on prevalence rates for the intervention programs, complete lifestyle patterns were not assessed and further indepth research is recommended to study the other associated lifestyle and environmental factors. In conclusion, the prevalence of metabolic syndrome, hypertension, type 2 diabetes and individual cardiovascular abnormalities were high among the police than the general population. Acknowledgement We are grateful to all the policemen who participated in the study. We thank our survey team members Mrs. Alamelu and Miss. U. Latha for blood collection. Mrs. Malini, Mrs. Anujiji and Miss Vimala for survey proforma filling, Mrs. V. Gowri and Miss. Reena for BP measurements. REFERENCES 1. Gupta R. Trends in hypertension epidemiology in India, review article. Journal of Human Hypertension 2004;18: Mohan V, Deepa M, Deepa R, Shanthirani CS, Farooq S, Ganesan A, Datta M. Secular trends in the prevalence of diabetes and glucose tolerance in urban south India- The Chennai Urban Rural Epidemiology study (CURES 17). Diabetologia 2006;49: Kutty VR, Joseph A, Soman CR. High prevalence of type II diabetes in an urban settlement in Kerala. India, Ethnicity and Health 1999;4: Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, Rao PV, YajnikCS, Prasanna KS, Nair JD. Diabetes Epidemiology Study Group in India (DESI). High prevalence of diabetes and impaired glucose tolerance in India : National Urban Diabetes Survey. Diabetologia 2001;44: Mohan V, Deepa M, Farooq S, Datta M, Deepa R. Prevalence awareness and control of hypertension in Chennai CURES-52. J Assoc Physicians India 2007;55: Ramachandran A, Mary S, Yamuna A, Murugesan N, Snehalatha C. High prevalence of diabetes and cardiovascular risk factors associated with urbanization in India. Diabetes Care 2008;31: Ford ES. Risks for all cause mortality, cardiovascular disease and diabetes associated with the metabolic syndrome: a summary of the evidence. Diabetes Care 2005;28: Ford ES, Giles WH, Mokdad AH. Increasing prevalence of metabolic syndrome among US adults. Diabetes Care 2004;27: Morikawa Y, Nakagawa H, Ishizaki M, Tabata M, Nishijo M, Miura K, Kawano S, Kido T, Nogawa K. Ten-year follow-up study on the relation between the development of non-insulin-dependent diabetes mellitus and occupation. American Journal of Industrial Medicine 1998;31: Violanti JM, Vena JE, Petralia S. Mortality of a Police Cohort: American Journal of Industrial Medicine 1998;33: Sparrow D, Thomas HE, Weiss ST. Coronary heart disease in police officers participating in the Normative Aging Study. Am J Epidemiol 1983;118: Smith DR, Devine S, Leggat PA, Ishitake T. Alcohol and tobacco consumption among police Officers. Kurume Medical Journal 2005;52: Richmond RL, Wodak A, Kehoe L, Heather N. How healthy are police? A survey of lifestyle factors. Addiction 1998;93: Forastiere F, Perucci CA, Di Pietro A, Miceli M, Rapiti E, Bargagli A, Borgia P. Mortality among urban policemen in Rome. Am J Ind Med 1994;26: Franke WD, Anderson DF. Relationship between physical activity and risk factors for cardiovascular disease among law enforcement officers. J Occup Med 1994;36: Ohno K. Alcohol drinking patterns among policemen in Shiga, Kyoto Yamaguchi and Okinawa prefectures. Arukoru Kenkyuto Yakubutsu 1995;30: Violanti JM, Marshall JR, Howe B. Police occupational demands, psychological stress, and the coping function of alcohol. J Occup Med 1984;25: Paton D, Violanti JM. Traumatic Stress in Critical Occupations: Recognition, Consequences and Treatment. Springfield, IL: Charles C Thomas Violanti JM, Vena JE, Marshall JR. Disease risk and mortality among police officers: New evidence and contributing factors. J Police Sci Admin 1986;14: Derek RS, Sue D, Peter AL, Tatsuya Ishitake. Alcohol and Tobacco Consumption among Police Officers. Kurume Medical Journal 2005;52: Teruo Nagaya, Hideyo Yoshida, Hidekatsu Takahashi, Makato Kawai. Policemen and firefighters have increased risk for type- 2 diabetes mellitus probably due to their large body mass index. A follow-up study in Japanese men. Am J Ind Med 2006;49: Franke WD, Collins SA, Hinz PN. Cardiovascular disease morbidity in an Iowa law enforcement cohort, compared with the general Iowa population. Department of Health and Human Performance, Iowa State University, Ames 50011, USA. 23. WHO: Definition, diagnosis and classification of Diabetes mellitus and its complications. Part I: Diagnosis and classification of diabetes Mellitus. Geneva, Dept of non communicable disease Surveillance, World Health Org., Diabetes highly prevalent among Kolkata cops: study Thursday, 13 December channel: JAPI VOL. 56 NOVEMBER 2008

5 India. 25. Houston TK, Person SD, Pletcher MJ, Liu K, Iribarren C, Kiefe CI. Active and passive smoking and development of glucose intolerance among young adults in a prospective cohort: CARDIA study. BMJ Online (7 April 2006) 26. Xing L Wang, Ah Siew Sim, Renee F Badenhop, R Michael Mccredie, David EL, Wilcken. A smokingdependent risk of coronary artery disease associated with a polymorphism of the endothelial nitric oxide synthase gene. Nature Medicine 1996;2:41-5. Announcement Office bearers for API Chapter Jabalpur Chief Patron : BN Srivastav Patrons : AK Barat : SK Goutam Chairman : SK Mishra Secretary : Anupam Sahni Vice Chairman : Ajit Dubey : Anil Jain Immediate Past Chairman : Anupam Shrivastav Immediate Past Secretary : Abhijeet Pal Chairman Elect : MK Parashar API State Chairman : MS Johari Treasurer : Mukesh Dodeja JAPI VOL. 56 NOVEMBER