© JAPI • march 2012 • VOL. 60 11
Original Article
Persistent High Prevalence of Cardiovascular Risk
Factors in the Urban Middle Class in India: Jaipur Heart
Watch-5
Rajeev Gupta1, KK Sharma1, Arvind Gupta2, Aachu Agrawal3, Indu Mohan1, VP Gupta1,
RS Khedar1, Soneil Guptha4
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 2009-10. 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 2002-3 and 2004-5 in
subjects 20-59 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 2002-03 and
2005-06 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.
I
Introduction
ndia 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 2001-2003 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
25-69 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 302017; 2Jaipur Diabetes Research Centre, Jaipur
302015; 3Department of Home Science, University of Rajasthan, Jaipur
302004; and 4Jaipur Heart Watch Foundation, Jaipur 302001.
countries.8-10 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.11-13
Limited number of studies have been performed to study trends
in cardiovascular risk factors in India14,15 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 studies16,17 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),
12
© JAPI • march 2012 • VOL. 60
Table 1 : Demographic and lifestyle variables in the study
subjects
Men
(n=451)
Women
(n=288)
Age (mean years)
Age groups
20-29
67 (14.9) 21 (7.3)
30-39
58 (12.9) 49 (17.0)
40-49
100 (22.2) 74 (25.7)
50-59
101 (22.4) 63 (21.9)
60-69
76 (16.9) 58 (20.1)
70+
49 (10.9) 23 (8.0)
Educational status
0-10 yr
60 (13.4) 89 (31.4)
11-15 years
182 (40.7) 123 (43.5)
>15 years
205 (45.9) 71 (25.1)
Social status
Upper middle
65 (14.7) 105 (37.4)
Middle
53 (12.0) 29 (10.3)
Lower middle
323 (73.2) 147 (52.3)
Regular physical activity
High
8 (1.8)
4 (1.4)
Moderate
130 (28.6) 38 (13.0)
Low
316 (69.6) 250 (85.7)
Fat intake
>20 g/day
101 (26.6) 78 (31.3)
Desirable <20 g day
278 (73.4) 171 (68.7)
Regular fruits and vegetables intake
Low <3 helpings/day
105 (29.7) 51 (23.6)
Desirable >3 helpings/day
249 (70.3) 165 (76.4)
Smoking
95 (21.1) 12 (4.2)
Other tobacco use
36 (8.0)
3 (1.04)
Numbers in parentheses are percent.
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)
educational and medical facilities and municipal taxes. The
study was performed in three middle SES municipal wards in
Jaipur with a population of 20-30 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 2010.
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
Men (n=451) Women (n=288) Total (n=739)
Overweight/Obesity
BMI >25.0
BMI >30.0
Truncal obesity
Waist >100 cm
men, >90 cm
women
WHR >0.95 men,
>0.85 women
Hypertension
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
Diabetes (known or
fasting glucose >126
mg/dl)
Metabolic syndrome
(ATP-3)
205 (46.2)
37 (8.3)
142 (50.7)
39 (13.9)
348 (48.1)
75 (10.4)
58 (12.9)
143 (31.9)
76 (26.6)
154 (53.9)
134 (18.1)
289 (39.3)
177 (39.5)
71 (24.6)
252 (34.4)
148 (33.0)
31 (6.9)
93 (32.7)
13 (4.4)
241 (32.8)
46 (6.2)
95 (21.1)
256 (57.1)
113 (25.1)
62 (21.9)
157 (55.3)
124 (43.7)
158 (21.5)
415 (56.6)
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, 10-15 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. Hypertension was
diagnosed when systolic BP was >140 mm Hg and/or diastolic
BP >90 mm Hg or a person was a known hypertensive.21 Obesity
was defined as BMI >25 kg/m2.22 Truncal obesity 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
Diabetes 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
© JAPI • march 2012 • VOL. 60 13
Table 3: Age specific mean values of various risk factors and trends in men and women
Men (n=451)
Height
Body mass index
Waist
Waist:hip ratio
Systolic BP
Cholesterol
LDL cholesterol
Non-HDL cholesterol
HDL cholesterol
Triglycerides
Glucose fasting
Women (n=288)
Height
Body mass index
Waist
Waist:hip ratio
Systolic BP
Cholesterol
LDL cholesterol
Non-HDL cholesterol
HDL cholesterol
Triglycerides
Glucose fasting
20-29
67
171.5±7.4
23.2±3.7
84.7±9.8
0.88±0.06
128.3±11.3
172.6±41.6
101.5±34.9
127.5±41.4
45.1±8.8
129.8±66.2
83.3±11.8
21
155.9±4.9
24.3±5.9
78.1±11.0
0.84±0.08
117.4±10.9
165.4±37.8
94.4±32.3
114.1±35.9
51.4±10.4
98.5±56.5
80.7±10.3
30-39
58
167.3±7.7
24.9±3.7
89.1±13.9
0.93±0.06
124.5±12.3
190.6 ±34.6
112.8±29.7
146.9±34.7
43.7±8.0
170.6±122.4
92.4±23.0
49
155.7±5.7
25.8±5.7
82.6±12.3
0.87±0.08
116.3±14.3
176.2±32.1
101.4±28.0
125.2 ±30.4
51.0±10.9
119.0 ±73.5
85.8±14.2
Age groups
40-49
50-59
100
101
168.5±7.2
167.5±7.5
25.3±3.5
26.2±3.8
88.8±11.8
93.9±13.1
0.92±0.06
0.95±0.09
126.8±14.5
131.0±17.1
194.8±52.0
186.6±41.1
115.6±48.4
110.7±36.4
148.9±50.2
136.1±39.3
45.9±9.3
47.5±8.3
166±87.6
142.0±73.6
110.8±51.0
106.6±40.8
74
63
156.8±5.9
154±6.6
26.5±4.8
26.6±3.8
84.9±13.9
85.4±12.6
0.87±0.07
0.88±0.09
125.1±13.9
132.9±14.7
185.0±36.5
196.1±41.9
106.7±28.4
112.0±34.8
132.9±33.4
140.6±38.8
51.8±8.5
55.5±12.7
131.5 ±55.1
143.2±60.8
101.3±51.6
109.9±60.1
60-69
76
164.5±7.1
25.2±4.2
93.6±13.1
0.96±0.08
136.3±16.0
182.5±39.5
106.7±32.5
133.4±36.7
47.1±9.5
133.5 ±56.7
114.7±45.4
58
154.3±7.0
26.6±4.3
85.1±12.4
0.87±0.08
139.9±19.7
198.8±39.8
115.2±33.7
141.7±35.9
57.1±13.6
132.8±47.48
107.3±46.5
70+
49
164.3±8.4
24.5±3.4
86.3±13.2
0.93±0.08
140.0±17.6
190.2±43.7
111.6±38.1
141.6±40.8
48.6±10.7
149.7±93.0
110.3±37.7
23
153.1±9.4
25.6±4.7
82.8±12.2
0.89±0.08
140.5±18.6
204.0±36.2
117.3±31.0
141.5±33.9
62.5±16.1
120.8±42.7
102.5±19.7
P value
(ANOVA trend)
<0.001
0.004
0.005
<0.001
<0.001
0.347
0.539
0.739
0.043
0.565
<0.001
0.020
0.215
0.154
0.236
<0.001
<0.001
0.001
<0.001
<0.001
0.055
0.005
LDL low density lipoprotein; HDL high density lipoprotein.
was determined using ANOVA for continuous variables and
Mantel-Haenszel X2 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
30-59 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 guidelines23
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, ptrend <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 X2 test, ptrend <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 2002-03 and
2005-06 (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 X2 ptrend
>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
14
© JAPI • march 2012 • VOL. 60
Table 4: Age-specific prevalence of risk factors and trends
Men (n=451)
Smoking
Other tobacco use
Obesity BMI ≥ 25 kg/m2
Obesity BMI > 30 kg/m2
High Waist > 100 cm
High WHR > 0.95
Hypertension
Cholesterol ≥ 200 mg/dl
LD cholesterol ≥ 130 mg/dl
Non-HDL cholesterol ≥ 160 mg/dl
HDL cholesterol < 40 mg/dl
Triglycerides ≥ 1 50 mg/dl
Total:HDL cholesterol ≥ 4.5
Diabetes
Metabolic syndrome
Women (288)
Smoking
Other tobacco use
Obesity BMI > 25 kg/m2
Obesity BMI > 30 kg/m2
High Waist > 90 cm
High WHR > 0.85
Hypertension
Cholesterol ≥ 200 mg/dl
LDL cholesterol ≥ 130 mg/dl
Non-HDL cholesterol ≥ 160 mg/dl
HDL cholesterol < 50 mg/dl
Triglycerides ≥ 150 mg/dl
Total:HDL cholesterol ≥ 4.5
Diabetes
Metabolic syndrome
20-29
67
15 (22.7)
9 (14.3)
20 (29.9)
3 (4.5)
3 (4.5)
7(10.4)
19(28.8)
18 (26.9)
10 (14.9)
13 (19.4)
17 (25.4)
24 (35.8)
16 (23.9)
0.0(0.0)
14 (20.9)
21
1 (4.8)
0(0.0)
6 (30.0)
2 (10.0)
3 (15.0)
9 (45.0)
1 (4.8)
3 (14.3)
3 (14.3)
3 (14.3)
10 (47.6)
3 (14.3)
1 (4.8)
0
3 (14.3)
30-39
58
11 (19.7)
4 (7.4)
28 (49.1)
4 (7.0)
9 (15.5)
24 (41.4)
16 (28.1)
18(31.0)
14 (24.1)
18 (31.0)
18 (31.0)
23 (39.7)
23 (39.7)
4(7.5)
14 (24.6)
49
3 (6.1)
1 (2.0)
28 (57.1)
6 (12.2)
12 (25.0)
28 (58.3)
5 (10.4)
16 (37.7)
9 (18.4)
8 (16.3)
26 (53.1)
10 (20.4)
7 (14.3)
1(2.3)
9 (19.1)
Age groups
40-49
50-59
100
101
21 (21.0)
26 (26.2)
7 (7.1)
10 (10.3)
54 (55.1)
64 (64.6)
9(9.2)
17(17.2)
12 (12.1)
26 (25.7)
33 (33.3)
54 (53.5)
42 (42.0)
54 (54.0)
41 (41.4)
37(37.0)
25(25.3)
24 (24.0)
30 (30.0)
30(29.7)
29 (29.3)
14 (14.0)
46(47.5)
32 (32.0)
36 (36.4)
28 (28.0)
23 (27.1)
24 (27.6)
29 (30.5)
24 (24.7)
74
63
0 (0.0)
1 (1.6)
1 (1.4)
0(0.0)
46 (62.2)
43 (71.7)
16 (21.6)
11 (18.3)
28 (37.8)
24 (38.1)
43 (58.1)
38 (60.3)
22 (29.7)
36 (57.1)
26 (35.6)
31 (49.2)
15 (20.8)
20 (31.7)
15 (20.3)
19 (30.2)
31 (43.1)
20 (31.7)
24 (33.3)
23 (36.5)
4 (5.6)
9 (14.3)
9 (14.8)
12 (24.0)
19 (27.1)
17 (28.3 )
60-69
76
12 (15.8)
4 (5.4)
44 (60.3)
9(12.3)
21 (28.0)
48 (64.0)
50 (66.7)
27 (35.5)
19(25.0)
20 (26.3)
17(22.4)
25 (32.9)
17 (22.4)
25 (36.8)
22 (30.1)
58
4 (7.2)
1 (1.8)
35 (62.5)
7 (12.5)
20 (34.5)
31 (53.4)
36 (62.1)
28 (48.3)
23 (39.7)
20 (34.5)
18 (31.0)
17 (29.3)
7(12.1)
15 (34.1)
21 (36.8)
70+
49
10 (20.4)
2 (4.3)
23 (46.9)
3 (6.1)
5 (10.2)
22 (44.9)
30 (61.2)
17 (34.7)
13 (26.5)
16 (32.7)
10 (20.4)
16 (32.7)
11 (22.4)
16 (41.0)
13 (28.3)
23
3 (13.0)
0 (0.0)
9 (40.9)
3 (13.6)
7 (30.4)
14 (60.9)
17 (73.9)
11 (52.4)
9 (42.9)
7 (33.3)
4 (19.0)
5 (23.8)
1 (4.8)
7 (43.8)
6 (30.0)
P value (X2
trend)
0.245
0.285
0.004
0.175
0.007
<0.001
<0.001
0.304
0.181
(0.296)
0.107
0.192
0.172
<0.001
0.317
0.160
0.795
0.313
0.990
0.188
0.676
<0.001
0.001
0.001
0.142
0.001
0.272
0.822
<0.001
0.028
Numbers in parentheses are percent. BMI body mass index; WHR waist-hp ratio; LDL low density lipoprotein; HDL high density lipoprotein.
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.31-33 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.36-40 Our
results are also comparable to previous studies among middle
class subjects in Jaipur.16,17 Similar trend analyses have not been
reported from India. Ahlawat et al14 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 al41 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
transition42 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
MetS
MetS
Diabetes
Diabetes
High cholesterol
High cholesterol
Hypertension
Hypertension
Truncal obesity
Truncal obesity
Obesity
Obesity
0
0.5
1
1.5
2
2.5
0
3
0.5
1
1.5
2
2.5
3
Low physical activity
Low educational status
MetS
MetS
Diabetes
Diabetes
High cholesterol
High cholesterol
Hypertension
Hypertension
Truncal obesity
Truncal obesity
0.5
1
1.5
High fat diet
2
2.5
3
60
58
53
50
44
51
47
45
40
36
0
0.5
1
1.5
2
2.5
3
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. MetS metabolic syndrome.
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 studies16,17 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 countries44 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 Asia27 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
39
34 34
32
31
30
26 26
18 19
20
18
13
10
0
8
Smoking
Obesity
Truncal
obesity
JHW-3
Obesity
Obesity
0
15
% prevalence in subjects 20-59 years
© JAPI • march 2012 • VOL. 60 Hypertension
JHW-4
High
cholesterol
High
triglycerides
11 10
Diabetes
JHW-5
Fig. 2: Age- and sex-adjusted prevalence of cardiovascular risk
factors among middle socioeconomic status subjects aged 20-59
years in the present Jaipur Heart Watch (JHW-5) study conducted
in years 2009-10 as compared to previous studies in 2002-3 (JHW316) and 2004-5 (JHW-417) 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.
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.
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