ISSN- 01-1216 Indian J. Prev. Soc. Med. Vol. 44.1-2, 2013 PREVALENCE OF RISK FACTORS FOR NON-COMMUNICABLE DISEASE IN A RURAL AREA OF PATNA, BIHAR A WHO STEP WISE APPROACH Pragya Kumar 1, CM Singh 2, Neeraj Agarwal 3, Sanjay Pandey 4, Alok Ranjan 5, GK Singh 6. ABSTRACT Background: Cardiovascular diseases are reaching epidemic proportions in India. Behavioural risk factors (viz tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol) account for considerable proportion of coronary heart disease and cerebro-vascular disease. Objective: To find out the prevalence of risk factors for non-communicable diseases in a rural setup. Setting: A rural area under Phulwarisharif block of Patna District. Study design: Community based cross-sectional study. Study subjects: 400 subjects aged more than 15 years selected by appropriate sampling technique. Methodology: Modified WHO STEP wise tool in local language was used to elicit data on socio-demographic status, tobacco and alcohol use, measures of dietary habits and physical inactivity. Standard procedure was followed as per STEPs protocol for blood pressure and anthropometric measurements. Data were entered and analyzed using Epi-Info Version 7. Results: Current smokers were 37.22% in men and 2.72% in women. Prevalence of current alcohol consumption in men was 47.22% women and men were consuming fewer amounts of fruits and vegetable than the recommended. The overall prevalence of hypertension was 23.33% in males and 13.18% in females. The proportion of women having waist hip ratio >0.85 was significantly (P<0.05) higher as compared to men with waist hip ratio >1 and women with prevalence of overweight was 12.22% in men and 13.18% among women. The prevalence of obesity among men and women was almost similar. Conclusion: This study revealed high prevalence of NCD risk factors for non-communicable diseases in rural area and emphasize the need to address these issues as part of NCD prevention and control strategy. Key words: Risk factors, non-communicable diseases, WHO STEP wise approach. INTRODUCTION Of the estimated 57 million global deaths in 2008, 36 million (63%) were due to non-communicable diseases (NCDs) 1,2. Population growth and increased longevity are leading to a rapid increase in the total number of middle-aged and older adults, with a corresponding increase in the number of deaths caused by NCDs. It is projected that the annual number of deaths due to cardiovascular diseases will increase from 17 million in 2008 to 25 million in 20, with annual cancer deaths increasing from 7.6 million to 13 million. As a result of such trends, the total number of annual NCD deaths is projected to reach 55 million by 20 whereas annual infectious disease deaths are projected to decline over the next 20 years 3. The largest proportion of NCD deaths is caused by cardiovascular disease (48%), followed by cancers (21%) and chronic respiratory diseases (12%). Diabetes mellitus is directly responsible for 3.5% of NCD deaths. 1. Assistant Professor, 2. Additional Professor, 3. Professor & Head, 4. Assistant Professor, 5. Associate Professor, Department of Community & Family Medicine 6. Director, All India Institute of Medical Sciences (AIIMS), Patna Corresponding author: Dr CM Singh, Department of Community & Family Medicine, All India Institute of Medical Sciences, Phulwari Sharif, Patna-801505; Email drcmsingh@yahoo.co.in Indexed in : Index Medicus (IMSEAR), INSDOC, NCI Current Content, Database of Alcohol & Drug Abuse, National Database in TB & Allied Diseases, IndMED, Entered in WHO CD ROM for South East Asia.
Behavioural risk factors, including tobacco use, physical inactivity, unhealthy diet and the harmful use of alcohol, are estimated to be responsible for about 80% of coronary heart disease and cerebro-vascular disease 4 Cardiovascular diseases have assumed epidemic proportions in India as well. In terms of the number of lives lost due to illhealth, disability, and early death (DALYs), NCDs (inclusive of injuries) accounts for 62% of the total disease burden while 38% is from communicable diseases, maternal and child health, and nutrition all combined 5. A total of nearly 64 million cases of CVD are likely in the year 2015, of which nearly 61 million would be CHD cases (the remaining would include stroke, rheumatic heart disease and congenital heart diseases). Deaths from this group of diseases are likely to amount to be a staggering 3.4 million 6. Targeting the risk factors for non-communicable diseases is recognized as an essential preventive strategy. Coronary heart disease is more prevalent in Indian urban populations and there is a clear declining gradient in its prevalence from semi-urban to rural populations. Epidemiological studies show a sizeable burden of CHD in adult rural (3-5%) and urban (7-10%) populations. Thus, of the 30 million patients with CHD in India, there would be 14 million of who are in urban and 16 million in rural areas. In India about 50 per cent of CHD-related deaths occur in people younger than 70 years compared with only 22 per cent in the West. Extrapolation of these numbers estimates the burden of CHD in India to be more than 32 million patients. Progressive ageing of population, improving socioeconomic conditions and changed life styles have increased the vulnerability for non-communicable diseases and these are spreading to rural and peri urban areas as well 8. Most of the noncommunicable diseases share common preventable risk factors such as tobacco use, high alcohol consumption, raised blood pressure, sedentary life style and obesity. To anticipate the epidemic in non-communicable disease, WHO has initiated the world wide surveillance of risk factors using the WHO STEP wise approach to surveillance of risk factors for noncommunicable diseases 9. Thus utilizing data in formulation of population based strategies by making cost effective interventions both for people with established disease and for those at high risk of developing the disease, which would help in prevention of significant proportion morbidity & mortality due to NCDs. However, to the best of the authors' knowledge, virtually no study has been undertaken on people of Bihar to investigate the prevalence of CVD risk factors. Keeping this in mind, the present community-based cross-sectional study was aimed to investigate various risk factors of NCDs in Phulwarisharif area using the WHO STEP approach. MATERIAL AND METHODS A cross-sectional study was conducted in the rural area Phulwarisharif block, Patna district of Bihar from September 2012 to vember 2012. To calculate the sample size, the prevalence of obesity was taken as one of the NCD risk factor; one of the previous studies demonstrated the prevalence of obesity to be 21% in rural area of Kerala 10. For 21 % of prevalence of obesity with 20% margin of error and 5% level of significance, the calculated sample size was 376. Allowing for a non-response of 20 % the required sample size was 450. The total number of surveyed individuals was 416 out of which 16 were excluded applying the exclusion criteria.the number of participants analysed were 400 thus the non response rate (4%) was less than the anticipated (20%). The study was undertaken in the Phuliya tola which is a rural area and comes under Phulwarisharif block from September 2012 to December 2012. It is almost 2 km from the AIIMS, Patna. The total household in this area is approx. 450. Adults aged more than 15 years residing in this area have formed the universe of the study. All the households in this area constituted the sampling frame. It was assumed that there would be at least 1 adult more than 15 years in every household, house to house visit was made to get the required sample size. If more than Indian J. Prev. Soc. Med Vol. 44. 1-2 47
adult of the specified age was there in any household, only one was taken by random selection. The number of study subjects who were interviewed and analysed were 400. Seriously ill study subjects who were unable to stand erect and study subjects who were unavailable in spite of three informed home visits one week apart were excluded from the study. The objective of the study and the method was explained to the Sarpanch of respective village and his cooperation was sought. House to house survey was carried out in morning as well as evening hours to get maximum number of study subjects at home. The WHO STEP-wise tool was used and the behavioural risk factor Questionnaire was suitably modified and translated in local language. It included questions on sociodemographic status, data on tobacco and alcohol use, measures of dietary habits and physical inactivity. Standard procedure was followed as per STEPs protocol for blood pressure and anthropometric measurements. Blood pressure was measured as per STEPs protocol by the same observer using a standard mercury sphygmomanometer. Three measurements were taken and the mean of the second and third readings was used for the analysis purpose. The participant took rest for three minutes between each of the readings A person s waist hip ratio, which is a continuous variable, was calculated by waist circumference (cm) divided by hip circumference (cm).verbal consent was obtained from each of the study subjects prior to entering the study. Definitions 9 Current daily smokers were defined as those who were currently smoking cigarettes, bidis or hookah daily. Current daily smokeless tobacco users were defined as those who were currently using chewable tobacco products, gutka, naswar, khaini or zarda paan daily. Current alcohol drinkers were defined as those who reported to consuming alcohol within the past one month. One serving of vegetable was considered to be 1 bowel of raw green leafy vegetables or½ cup of other vegetables (cooked or chopped raw). One serving of fruit was considered to be 1 medium size piece of apple, banana or orange. Physical inactivity was defined as less than 10 minutes of activity at a stretch, during leisure, work or transport. Body mass index (BMI) was calculated by dividing the weight (in kilograms) by square of height (in meters). Overweight was defined as BMI 23kg/m 2 and < 25 kg/m 2 (Asian standards) Obesity was defined as BMI 25 kg/m 2 (Asian standards 11 ). Hypertension was defined as BP 140 and/or 90 mm of Hg or currently on antihypertensive drugs. The results of the measurement were provided to the respondents and all case needing referral were referred to the block Primary health centre for further management. Data were entered and analysed using Epi info version 7. RESULTS Socio-demographic profile: In course of a house-to-house survey conducted in the study area, 416 subjects were surveyed, of which 400 (96%) participated in the study. Sixteen subjects were excluded from the study because of their ill health. The numbers of males and females subjects were 180 and 220, respectively. The average ages (±SD) of males and females were 40.6 16.95 years and 36.3 12.6 years respectively. Indian J. Prev. Soc. Med Vol. 44. 1-2 48
The literacy level of males (86.6%) was higher as compared to females (43.3%). Considerable proportions of males (46.7%) were self-employed while amongst women, 81.4% were housewives. As per the Prasad Classification of household income level, 41.2% of the households belonged to lower middle class category after adjusting for the all India consumer price index for the study period. Behavioural Risk Factors Age Category Table- 1: Prevalence of tobacco use and Alcohol Use by age and sex (N=400) Male Total Current smoker Current smokeless tobacco Current alcohol consumers Female Current smokeless tobacco Total. %. %. %. % 18-24 39 13 33.33 18 46.15 09 23.08 31 00 00.00 25-34 38 18 47.36 32 84.21 25 65.79 74.70 35-44 41 17 41.46 33 80.48 30 73.17 68 05 07.35 45-54 21 08 38.09 17 80.95 12 57.14 20 10.00 55-64 18 05 27.77 13 72.22 05 27.78 18 16.66 >65 23 06 26.08 17 73.91 17.40 09 33.33 TOTAL 180 67 37.22 130 72.22 85 47.22 220 15 06.81 Table-1 presents the age-sex wise distribution of the prevalence of current smokers, smokeless tobacco users and alcohol users. The prevalence of smokeless tobacco users 72.22% (95% CI 69.29-75.15) in males was significantly higher (p<0.05) as compared to the current smokers 37.22% (95% CI; 33.80-40.63), and alcohol drinkers 47.22 (95% CI; 43.58 50.86). Also, the prevalence of alcohol drinkers in males was significantly higher (p<0.05) as compared to the current smokers. Further, the prevalence of smokeless tobacco users among males was significantly higher (P<0.05) as compared to the females 6.81% (95% CI 5.97-7.65). The maximum prevalence of all these risk factors was in the age group 25-34 years after that showing a decreasing trend of prevalence with the increasing age. The prevalence of smokeless tobacco was almost doubled in the age group of 25-34 year (84.21%) as compared to 18-24 years (46.15%). Smoking tobacco in the form of bidis was most common and surti and gutka were the most common form of smokeless tobacco. Among women the prevalence of current smokeless tobacco was 6.81% (95% CI 5.97-7.65).The prevalence was highest in the females who were more than 65 years (33.33%). Out of the total females (220), only 6 were current smoker (2.72%). In contrast to males, an increasing trend of prevalence was observed with increasing age among females in relation to smokeless tobacco users. Out of the total females (220) none was current alcoholic. Fruits And Vegetable Use: A significant proportion of the study subjects were taking fruits once a day which was slightly higher in males 58.88% (95% CI 55.35-62.42) than females 53.63% (95% CI 50.35-56.92), but not statistically significant (p>0.05).the intake of vegetables was twice a day in majority of the study subjects. The proportions of vegetable intakes among males and females were 78.88% (95% CI 76.45-81.32) and 80% (95% CI 77.88-82.11) respectively, with no statistically significant difference (p>0.05). Physical Activity: The proportion of study subjects, who were doing at least 20 minutes of vigorous activity for three days, was 27.5% (95% CI; 25.54-29.45). The proportion of study subjects doing 5 or more days of moderate-intensity activity or walking at least 30 minutes per day was 61.25% (95% CI; 58.92-63.57). The proportion of study subjects performing Indian J. Prev. Soc. Med Vol. 44. 1-2 49
moderate-intensity activity among males 67.22% (95% CI; 64.01-70.44) was significantly higher (p<0.05) as compared to females 56.36% (95% CI; 53.11-59.61). Such level of physical activity was highest in the 25-44 years age showing 94.2% and 90.3% for males and females respectively and lowest in the 55-74 years age showing 73.5% and 67.5% for males and females respectively. Table- 2 : Age sex wise distribution of prevalence of hypertension (N=400) Age Category Male Hypertensive Prevalence (95% CI) Female Total Hypertensive Prevalence (95% CI) Total. %. % 18-24 39 10.25 31 00 00.00 25-34 38 07 18.42 74 05 06.75 35-44 41 08 19.51 68 11 16.18 45-54 21 05 23.80 20 05 25.00 55-64 18 08 44.44 18 06 33.33 >65 23 10 43.48 9 22.22 Total 180 42 23.33 220 29 13.18 The prevalence of known hypertensive s (self reported or who are on antihypertensive) was significantly higher (p<0.05) in males 6.6% (95% CI; 5.75-7.57) as compared to females 4.5% (95% CI: 3.97-5.11). The overall prevalence of hypertension was 23.33% (95% CI; 20.71-25.94) in males and 13.18% (95% CI: 11.66-14.69) in females, indicating significantly higher proportion of hypertensive s among males as compared to females, and further across all age categories of except 45-54 years, showing almost similar level of prevalence by sex. An increasing trend of prevalence of hypertensive was observed with increasing age in both males and females, having highest prevalence in 55-64 years of age. Anthropometric Risk Factors Age group in years Table-3: Distribution of Waist Hip Ratio among Study Subjects (N=400) Men WHR Women WHR Men 1.00 >1.00 Women 0.85 >0.85 18-24 39 38 97.43 01.56 31 21 67.74 10 32.25 25-34 38 34 89.47 10.52 74 51 68.91 23 31.08 35-44 41 31 75.60 10 24.39 68 43 63.23 25 36.76 45-54 21 16 76.19 05 23.80 20 11 55.00 09 45.00 55-64 18 12 66.66 06 33.33 18 08 44.44 10 55.55 >65 23 16 69.56 07 30.43 09 33.33 06 66.66 Total 180 147 81.66 33 18.33 220 137 62.27 83 37.72 Table-3 presents the age-sex wise distribution of waist-hip ratio. The proportion of women having waist-hip ratio >0.85 was significantly higher (p<0.05) as compared to men having waist-hip ratio >1, indicating higher risk of developing cardiovascular disease among females. This difference in prevalence of high waist-hip ratio among women was statistically significant across all age categories. We observed a strong association between sex and high waist-hip ratio (chi-square with 1 df = 9.42, p=0.00), also the odds ratio of having high waist hip ratio among females as compared to males was 2.08 (95% CI ; 1.26 3.44: p=0.0014). The mean WHR (±SD) in men was 0.93(0.09) and in women was 0.83 (0.07). Indian J. Prev. Soc. Med Vol. 44. 1-2 50
Table- 4: Distribution of Body Mass Index (BMI) among study subjects (N-400) Age group in years Men BMI (Kg/m 2 ) in Men <18.5 18.5-22.99 23-24.99 25 Female BMI (Kg/m 2 ) in Women <18.5 18.5-22.99 23-24.99 25 18-24 39 11 (28.20) 26 (66.66) 01 (.56) 01 (.56) 31 11 (35.48) 18 (58.06) (06.45) 00 (00.00) 25-34 38 08 (20.05) 21 (55.26) (07.90) 06 (15.78) 74 27 (36.48) 28 (37.83) 08 (10.81) 11 (14.86) 35-44 41 (09.75) 20 (48.78) 07 (17.07) 10 (24.40) 68 14 (20.58) 30 (44.11) 10 (14.70) 14 (20.58) 45-54 21 (09.52) 07 (33.33) (19.05) 08 (38.09) 20 (20.00) 05 (25.00) (20.00) 07 (35.00) 55-64 18 06 (33.33) (16.66) (16.66) 06 (33.33) 18 (11.11) 09 (50.00) (16.61) (22.22) >65 23 05 (21.74) 12 (52.17) (17.40) (08.70) 9 (33.33) (22.22) (22.22) (22.22) Total 180 36 (20.00) 89 (49.44) 22 (12.22) 33 (18.33) 220 61 (27.72) 92 (41.81) 29 (13.18) 38 (17.27) Among men 12.22% (95% CI 10.65-13.78 ) had BMI more than 23 Kg/m 2 as compared to 13.18 %(95% CI 11.66-14.69) among women. The prevalence of obesity (BMI >25 Kg/m 2 ) among men and women was almost similar when BMI was used as a criteria [18.33% (95% CI 16.14-20.52) and 17.27% (95% CI 15.38-19.16)] respectively. The prevalence of obesity in men and women was maximum in the age group of 45-54 years [ 38.09%(95% CI 28.00-48.18) and 35.00%(95% CI 25.- 44.97) ].The prevalence of obesity was significantly more in women than men in > 65 years age group.(22.22% and 8.75% respectively).the mean BMI(±SD) was 21.42(4.12). DISCUSSION This study supports findings from other studies showing that rural populations are not spared from the emerging burden of risk factors for chronic non communicable diseases. Once regarded as diseases of the affluent, noncommunicable disease burden is increasing in developing countries that have not yet finished tackling poverty-related diseases. Traditionally the risk factors for CVD have been categorised as behavioural, anthropometric and biochemical. Due to lack of resources at present time, we were able to collect data only on the behavioural and anthropometric risk factor. Behavioural Risk Factors: Tobacco use in India is high and there are various forms of tobacco consumption among population. Our study indicated that current smokers were 37.22% in men and 2.72% in women which is in line with the result reported by Anand et al 12 in Faridabad and Kutty et al 13 in Thiruvananthapuram. Other studies 14-23 reported prevalence of current smokers ranging from 10%-36%. However study conducted in rural area of Faridabad by Anand et al (2008) 24 showed high prevalence of current smokers, 41.0% in men and 13.0 % among women The prevalence of smokeless tobacco use was 72.22% in males and 6.81% in females which was higher than the finding reported by Anand et al (2008) 24 in which the prevalence of smokeless tobacco was 7.1 % and 1.2% among men and Indian J. Prev. Soc. Med Vol. 44. 1-2 51
women respectively. This can be due to higher social acceptability of smokeless tobacco than smoking in this area. Among men, bidi and gutka was the most common form of smoking and smokeless tobacco use respectively, while among women it was snuff and gul (tobacco tooth powder) as most common form of smokeless tobacco consumption. Similar results have been obtained by NCD- ICMR (2005) 26 conducted at six different centres, where they found bidi and gutkha among men and snuff among women as most common form of tobacco consumption. In our study prevalence of current alcohol consumption in men was 47.22% and none among women reports to consume alcohol. This was similar to as reported by other studies 16,18,27. There was sharp rise in prevalence among men in the age group 25-44 years, which can be due more independence gained during this part of life. Our study revealed that women and men were consuming fewer amounts of fruits and vegetable than the recommended. Our study finds that the level of physical activity was highest in the 25-44 years age, and lowest in the 55-74 years of age. This finding is similar to the findings of SD Bhardwaj et al 27. This study showed high burden of hypertension among study subjects. The overall prevalence of hypertension was significantly higher in males than in females. The burden increased in the elderly. This is similar to the findings reported by Anand et al 21. Recently ICMR has published their Phase-I NCD Risk Factor Survey reports from seven states of India 26. Our study showed similar findings with the report and most of the risk factors were in the 95% C.I. However in the present study, prevalence of risk factors like low fruits and vegetable consumption was found to be higher while of obesity to be lower, as reported in ICMR report. Similar findings have been reported by other studies 16, 17. Anthropometric Risk Factors : The proportion of women having waist-hip ratio >0.85 was significantly higher (p<0.05) as compared to men having waist-hip ratio >1.This finding is in consistency with Gupta et al 14. In the study population women were at twice the higher risk of developing cardiovascular disease than men taking waist hip ratio criteria into account. The prevalence of obesity (BMI 25 Kg/m 2 ) was almost similar in both men and women. The Overweight increased with age in all the age groups both in men and women except in 45-54 year age group, finding that can be attributed to their decrease physical inactivity as age advances. These findings are in consistency with the study done by ICMR 26. CONCLUSION Our study reveals high burden of NCD risk factors in rural area and emphasize the need to address these issues as a part of NCD prevention and control strategy. The Integrated Disease Surveillance Programme, launched by the Government of India in 20, incorporates key elements of chronic disease risk factor surveillance, but it s functionality in the district is questionable. There is a need to strengthen the existing surveillance system so as to monitor, evaluate and guide policies and programmes. REFERENCES 1. Cause-specific mortality: regional estimates for 2008. Geneva, World Health Organization, 2011. 2. Causes of death 2008: data sources and methods. Geneva, World Health Organization, 2011 3. World Health statistics, 2012: WHO. 4. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva, World Health Organization, 2009. 5. World Health Organization, Global Burden of Diseases. Indian J. Prev. Soc. Med Vol. 44. 1-2 52
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