Aachu Agrawal

Younger age of escalation of cardiovascular risk factors in Asian Indian subjects

BackgroundCardiovascular risk factors start early, track through the young age and manifest in middle age in most societies. We conducted epidemiological studies to determine prevalence and age-specific trends in cardiovascular risk factors among adolescent and young urban Asian Indians.MethodsPopulation based epidemiological studies to identify cardiovascular risk factors were performed in North India in 1999–2002. We evaluated major risk factors-smoking or tobacco use, obesity, truncal obesity, hypertension, dysglycemia and dyslipidemia using pre-specified definitions in 2051 subjects (male 1009, female 1042) aged 15–39 years of age. Age-stratified analyses were performed and significance of trends determined using regression analyses for numerical variables and Χ2 test for trend for categorical variables. Logistic regression was used to identify univariate and multivariate odds ratios (OR) for correlation of age and risk factors.ResultsIn males and females respectively, smoking or tobacco use was observed in 200 (11.8%) and 18 (1.4%), overweight or obesity (body mass index, BMI ≥ 25 kg/m2) in 12.4% and 14.3%, high waist-hip ratio, WHR (males > 0.9, females > 0.8) in 15% and 32.3%, hypertension in 5.6% and 3.1%, high LDL cholesterol (≥ 130 mg/dl) in 9.4% and 8.9%, low HDL cholesterol (<40 mg/dl males, <50 mg/dl females) in 16.2% and 49.7%, hypertriglyceridemia (≥ 150 mg/dl) in 9.7% and 6%, diabetes in 1.0% and 0.4% and the metabolic syndrome in 3.4% and 3.6%. Significantly increasing trends with age for indices of obesity (BMI, waist, WHR), glycemia (fasting glucose, metabolic syndrome) and lipids (cholesterol, LDL cholesterol, HDL cholesterol) were observed (p for trend < 0.01). At age 15–19 years the prevalence (%) of risk factors in males and females, respectively, was overweight/obesity in 7.6, 8.8; high WHR 4.9, 14.4; hypertension 2.3, 0.3; high LDL cholesterol 2.4, 3.2; high triglycerides 3.0, 3.2; low HDL cholesterol 8.0, 45.3; high total:HDL ratio 3.7, 4.7, diabetes 0.0 and metabolic syndrome in 0.0, 0.2 percent. At age groups 20–29 years in males and females, ORs were, for smoking 5.3, 1.0; obesity 1.6, 0.8; truncal obesity 4.5, 3.1; hypertension 2.6, 4.8; high LDL cholesterol 6.4, 1.8; high triglycerides 3.7, 0.9; low HDL cholesterol 2.4, 0.8; high total:HDL cholesterol 1.6, 1.0; diabetes 4.0, 1.0; and metabolic syndrome 37.7, 5.7 (p < 0.05 for some). At age 30–39, ORs were- smoking 16.0, 6.3; overweight 7.1, 11.3; truncal obesity 21.1, 17.2; hypertension 13.0, 64.0; high LDL cholesterol 27.4, 19.5; high triglycerides 24.2, 10.0; low HDL cholesterol 15.8, 14.1; high total:HDL cholesterol 37.9, 6.10; diabetes 50.7, 17.4; and metabolic syndrome 168.5, 146.2 (p < 0.01 for all parameters). Multivariate adjustment for BMI, waist size and WHR in men and women aged 30–39 years resulted in attenuation of ORs for hypertension and dyslipidemias.ConclusionLow prevalence of multiple cardiovascular risk factors (smoking, hypertension, dyslipidemias, diabetes and metabolic syndrome) in adolescents and rapid escalation of these risk factors by age of 30–39 years is noted in urban Asian Indians. Interventions should focus on these individuals.

Twenty-year trends in cardiovascular risk factors in India and influence of educational status

Background: Urban middle-socioeconomic status (SES) subjects have high burden of cardiovascular risk factors in low-income countries. To determine secular trends in risk factors among this population and to correlate risks with educational status we performed epidemiological studies in India. Methods: Five cross-sectional studies were performed in middle-SES urban locations in Jaipur, India from years 1992 to 2010. Cluster sampling was performed. Subjects (men, women) aged 20–59 years evaluated were 712 (459, 253) in 1992–94, 558 (286, 272) in 1999–2001, 374 (179, 195) in 2002–03, 887 (414, 473) in 2004–05, and 530 (324, 206) in 2009–10. Data were obtained by history, anthropometry, and fasting blood glucose and lipids estimation. Response rates varied from 55 to 75%. Mean values and risk factor prevalence were determined. Secular trends were identified using quadratic and log-linear regression and chi-squared for trend. Results: Across the studies, there was high prevalence of overweight, hypertension, and lipid abnormalities. Age- and sex-adjusted trends showed significant increases in mean body mass index (BMI), fasting glucose, total cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides (quadratic and log-linear regression, p < 0.001). Systolic blood pressure (BP) decreased while insignificant changes were observed for waist–hip ratio and low-density lipoprotein (LDL) cholesterol. Categorical trends showed increase in overweight and decrease in smoking (p < 0.05); insignificant changes were observed in truncal obesity, hypertension, hypercholesterolaemia, and diabetes. Adjustment for educational status attenuated linear trends in BMI and total and LDL cholesterol and accentuated trends in systolic BP, glucose, and HDL cholesterol. There was significant association of an increase in education with decline in smoking and an increase in overweight (two-line regression p < 0.05). Conclusion: In Indian urban middle-SES subjects there is high prevalence of cardiovascular risk factors. Over a 20-year period BMI and overweight increased, smoking and systolic BP decreased, and truncal obesity, hypercholesterolaemia, and diabetes remained stable. Increasing educational status attenuated trends for systolic BP, glucose and HDL cholesterol, and BMI.

Cardiovascular risk according to educational status in India.

OBJECTIVE Influence of socioeconomic status on cardiovascular risk has not been well studied in low income countries. To determine risks in various educational status (ES) subjects we performed a study in India. METHODS Epidemiological study was performed in years 1999-2003 in Jaipur (India) for coronary risk factors among 1280 adults 20-59 years (men 619, women 661). ES was categorized into low (education ≤5 years); middle (6-12 years) and high (>12 years). Prevalence of risk factors and Framingham risk scores were determined. RESULTS Low ES was in 306, middle in 436 and high in 538. In low, middle and high ES respectively age-adjusted prevalence (%) of smoking was 19.0, 19.3, and 11.7; obesity 9.5, 16.7, and 22.1, hypertension 15.3, 30.5, and 44.0; hypercholesterolemia ≥200mg/dl 46.0, 48.4, and 54.6; low HDL cholesterol <40mg/dl 46.4, 56.4, and 38.3; metabolic syndrome 20.9, 25.7, and 28.6; and diabetes 6.9, 5.5, and 26.4. Framingham risk score was 5.7±4.8, 6.3±5.7 and 4.7±5.1 and calculated cardiovascular risk probability 5.2±5.7, 6.8±7.8 and 5.2±6.0 (P(trend)<0.05). Framingham risk score was significantly greater in low and middle ES (6.1±5.3) compared to high (4.7±5.1) (p<0.001). Adjustment for smoking attenuated the risk. CONCLUSION Low and middle educational status urban subjects in India have greater cardiovascular risk.

Low use of statins and other coronary secondary prevention therapies in primary and secondary care in India.

Objective: To determine the frequency of use of pharmacotherapy with aspirin, beta blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor in patients with stable coronary heart disease (CHD) among physicians at different levels of health care in Rajasthan state, India. Methods: Physicians practicing at tertiary hospitals and clinics at tertiary, secondary and primary levels were contacted. Prescriptions of CHD patients were audited and descriptive statistics reported. Results: We evaluated 2,993 prescriptions (tertiary hospital discharge 711, tertiary 688, secondary 1,306, and primary 288). Use of aspirin was in 2,713 (91%) of prescriptions, beta blockers 2,057 (69%), ACE inhibitors or angiotensin receptor blockers (ARBs) 2,471 (82%), and statins 2,059 (69%). Any one of these drugs was prescribed in 2,991 (100%), any two in 2,880 (96%), any three in 1,740 (58%), and all four in 1,062 (35.5%) (P < 0.001). As compared to tertiary hospital, prescriptions at tertiary, secondary, and primary levels were lower: aspirin (96% vs 95%, 91%, 67%), beta blockers (80% vs 62%, 66%, 70%), statins (87% vs 82%, 62%, 21%): two drugs (98% vs 96%, 98%, 85%), three drugs (75% vs 58%, 55%, 28%), or four drugs (54% vs 44%, 28%, 7%) (P < 0.01). Use of ACE inhibitors/ARBs was similar while nitrates (43% vs 23%, 43%, 70%), dihydropyridine calcium channel blockers (12% vs 15%, 30%, 47%), and multivitamins (6% vs 26%, 37%, 47%) use was more in secondary and primary care. Conclusions: There is suboptimal use of various evidence-based drugs (aspirin, beta blockers, ACE inhibitors, and statins) for secondary prevention of CHD in India.

Secular trends in cholesterol lipoproteins and triglycerides and prevalence of dyslipidemias in an urban Indian population.

BackgroundCoronary heart disease is increasing in urban Indian subjects and lipid abnormalities are important risk factors. To determine secular trends in prevalence of various lipid abnormalities we performed studies in an urban Indian population.MethodsSuccessive epidemiological Jaipur Heart Watch (JHW) studies were performed in Western India in urban locations. The studies evaluated adults ≥ 20 years for multiple coronary risk factors using standardized methodology (JHW-1, 1993–94, n = 2212; JHW-2, 1999–2001, n = 1123; JHW-3, 2002–03, n = 458, and JHW-4 2004–2005, n = 1127). For the present analyses data of subjects 20–59 years (n = 4136, men 2341, women 1795) have been included. In successive studies, fasting measurements for cholesterol lipoproteins (total cholesterol, LDL cholesterol, HDL cholesterol) and triglycerides were performed in 193, 454, 179 and 252 men (n = 1078) and 83, 472, 195, 248 women (n = 998) respectively (total 2076). Age-group specific levels of various cholesterol lipoproteins, triglycerides and their ratios were determined. Prevalence of various dyslipidemias (total cholesterol ≥ 200 mg/dl, LDL cholesterol ≥ 130 mg/dl, non-HDL cholesterol ≥ 160 mg/dl, triglycerides ≥ 150 mg/dl, low HDL cholesterol <40 mg/dl, high cholesterol remnants ≥ 25 mg/dl, and high total:HDL cholesterol ratio ≥ 5.0, and ≥ 4.0 were also determined. Significance of secular trends in prevalence of dyslipidemias was determined using linear-curve estimation regression. Association of changing trends in prevalence of dyslipidemias with trends in educational status, obesity and truncal obesity (high waist:hip ratio) were determined using two-line regression analysis.ResultsMean levels of various lipoproteins increased sharply from JHW-1 to JHW-2 and then gradually in JHW-3 and JHW-4. Age-adjusted mean values (mg/dl) in JHW-1, JHW-2, JHW-3 and JHW-4 studies respectively showed a significant increase in total cholesterol (174.9 ± 45, 196.0 ± 42, 187.5 ± 38, 193.5 ± 39, 2-stage least-squares regression R = 0.11, p < 0.001), LDL cholesterol (106.2 ± 40, 127.6 ± 39, 122.6 ± 44, 119.2 ± 31, R = 0.11, p < 0.001), non-HDL cholesterol (131.3 ± 43, 156.4 ± 43, 150.1 ± 41, 150.9 ± 32, R = 0.12, p < 0.001), remnant cholesterol (25.1 ± 11, 28.9 ± 14, 26.0 ± 11, 31.7 ± 14, R = 0.06, p = 0.001), total:HDL cholesterol ratio (4.26 ± 1.3, 5.18 ± 1.7, 5.21 ± 1.7, 4.69 ± 1.2, R = 0.10, p < 0.001) and triglycerides (125.6 ± 53, 144.5 ± 71, 130.1 ± 57, 158.7 ± 72, R = 0.06, p = 0.001) and decrease in HDL cholesterol (43.6 ± 14, 39.7 ± 8, 37.3 ± 6, 42.5 ± 6, R = 0.04, p = 0.027). Trends in age-adjusted prevalence (%) of dyslipidemias in JHW-1, JHW-2, JHW-3 and JHW-4 studies respectively showed insignificant changes in high total cholesterol (26.3, 35.1, 25.6, 26.0, linear curve-estimation coefficient multiple R = 0.034), high LDL cholesterol ≥ 130 mg/dl (24.2, 36.2, 31.0, 22.2, R = 0.062), and high low HDL cholesterol < 40 mg/dl (46.2, 53.3, 55.4, 33.7, R = 0.136). Increase was observed in prevalence of high non-HDL cholesterol (23.0, 33.5, 27.4, 26.6, R = 0.026), high remnant cholesterol (40.1, 40.3, 30.1, 60.6, R = 0.143), high total:HDL cholesterol ratio ≥ 5.0 (22.2, 47.6, 53.2, 26.3, R = 0.031) and ≥ 4.0 (58.6, 72.5, 70.1, 62.0, R = 0.006), and high triglycerides (25.7, 28.2, 17.5, 34.2, R = 0.047). Greater correlation of increasing non-HDL cholesterol, remnant cholesterol, triglycerides and total:HDL cholesterol ratio was observed with increasing truncal obesity than generalized obesity (two-line regression analysis p < 0.05). Greater educational level, as marker of socioeconomic status, correlated significantly with increasing obesity (r2 men 0.98, women 0.99), and truncal obesity (r2 men 0.71, women 0.90).ConclusionIn an urban Indian population, trends reveal increase in mean total-, non-HDL-, remnant-, and total:HDL cholesterol, and triglycerides and decline in HDL cholesterol levels. Prevalence of subjects with high total cholesterol did not change significantly while those with high non-HDL cholesterol, cholesterol remnants, triglycerides and total-HDL cholesterol ratio increased. Increasing dyslipidemias correlate significantly with increasing truncal obesity and obesity.

High prevalence and low awareness, treatment and control of hypertension in Asian Indian women

Hypertension is an important public health problem in India. To determine its prevalence, awareness, treatment and control among women, we performed a nationwide study. Population-based studies among women aged 35–70 years were performed in four urban and five rural locations. Stratified sampling was performed and we enrolled 4608 (rural 2604 and urban 2004) of the targeted 8000 (57%). Demographic details, medical history, diet, physical activity, anthropometry and blood pressure (BP) were recorded. Descriptive statistics are reported. Logistic regression was performed to determine the association of hypertension and its awareness, treatment and control with socioeconomic factors. Age-adjusted prevalence of hypertension (known or BP⩾140/⩾90 mm Hg) was observed in 1672 women (39.2%) (rural 746, 31.5%; urban 926, 48.2%). Significant determinants of hypertension were urban location, greater literacy, high dietary fat, low fibre intake, obesity and truncal obesity (P<0.01). Hypertension awareness was noted in 727 women (42.8%), more in urban (529, 56.8%) than in rural (198, 24.6%). Of these, 38.6% of the women were on treatment (urban 35.7, rural 46.5) and of those treated, controlled blood pressure (<140 and <90 mm Hg) was observed in 21.5% (urban 28.3 vs 10.2). Among hypertensive subjects, treatment was noted in 18.3% (rural 13.1, urban 22.5) and control in 3.9% (rural 1.3, urban 5.9). A significant determinant of low awareness, treatment and control was rural location (multivariate-adjusted P<0.05). There is a high prevalence of hypertension in middle-aged Asian Indian women. Very low awareness, treatment and control status are observed.

Determinants of urban-rural differences in cardiovascular risk factors in middle-aged women in India: a cross-sectional study.

OBJECTIVES Cardiovascular diseases (CVD) are the most important cause of death amongst middle-aged Indian women. To determine prevalence of CVD risk factors and their determinants we performed a nationwide study. METHODS Population based studies amongst women 35-70 years were performed in four urban and five rural locations in India. Location based stratified sampling was performed and we enrolled 4624 (rural 2616, urban 2008) of eligible 8000 women (58%). Demographic details, medical history, diet, physical activity and anthropometry were recorded using standardised techniques. Blood haemoglobin, glucose and total cholesterol were determined. Risk factors were diagnosed using current guidelines. Descriptive statistics are reported. Stepwise multivariate logistic regression was performed to identify determinants of urban-rural differences. RESULTS In urban women mean body mass index (BMI), waist circumference, waist-hip ratio (WHR), systolic BP, haemoglobin, fasting glucose and cholesterol were significantly greater (p<0.01). Age-adjusted prevalence of risk factors (%) in urban vs rural was of obesity BMI ≥ 25 kg/m(2) (45.6 vs 22.5), truncal obesity WHR>0.9 (44.3 vs 13.0), hypertension (37.5 vs 29.3), hypercholesterolemia ≥ 200 mg/dl (27.7 vs 13.5), and diabetes (15.1 vs 4.3) greater whilst any tobacco use (19.6 vs 41.6) or smoking lower. Significant determinants of urban-rural differences were greater income and literacy, dietary fats, low physical activity, obesity and truncal obesity (p<0.01). CONCLUSIONS Greater prevalence of CVD risk factors in urban middle-aged women is explained by greater income and literacy, dietary fat, low physical activity and obesity.

High trans fatty acid content in common Indian fast foods

Purpose – Trans fatty acids (TFA) are deleterious to health and can lead to multiple diseases. The purpose of this paper is to study their content in Indian sweets and snacks (fast foods).Design/methodology/approach – The paper used the food composition and analysis tables of the Indian National Institute of Nutrition to determine fatty acid composition of common nutrients. Separate tables provide nutrient composition of various Indian sweets and snacks including methods of preparation and amount of ingredients used. The paper calculated detailed nutritive value of these fast foods with focus on fatty acid composition using these tables. The nutritive values of more than 200 Indian sweets and snacks were determined and are presented.Findings – The study shows that Indian sweets and snacks are very energy‐dense with calorie content varying from 136 to 494 kcal/100 g in sweets and 148‐603 kcal/100 g in snacks. TFA content of sweets varies from 0.3 to 17.7 g/100 g and snacks from 0.1 to 19.8 g/100 g. This tr...

Migrating husbands and changing cardiovascular risk factors in the wife: a cross sectional study in Asian Indian women

Objective The authors studied the influence of migration of husband on cardiovascular risk factors in Asian Indian women. Methods Population-based studies in women aged 35–70 years were performed in four urban and five rural locations. 4608 (rural 2604 and urban 2004) of the targeted 8000 (57%) were enrolled. Demographic details, lifestyle factors, anthropometry, fasting glucose and cholesterol were measured. Multivariate logistic and quadratic regression was performed to compare influence of migration and its duration on prevalence of risk factors. Results Details of migration were available in 4573 women (rural 2267, rural–urban migrants 455, urban 1552 and urban–rural migrants 299). Majority were married, and illiteracy was high. Median (interquartile) duration of residence in urban locations among rural–urban migrants was 9 (4–18) years and in rural areas for urban–rural migrants 23 (18–30) years. In rural, rural–urban migrants, urban and urban–rural migrants, age-adjusted prevalence (%) of risk factors was tobacco use 41.9, 22.7, 18.8 and 38.1; sedentary lifestyle 69.7, 82.0, 79.9 and 74.6; high-fat diet 33.3, 54.2, 66.1 and 61.1; overweight 21.3, 42.7, 46.3 and 29.7; large waist 8.5, 38.5, 29.2 and 29.2; hypertension 30.4, 49.4, 47.7 and 38.4; hypercholesterolaemia 14.4, 31.3, 26.6 and 9.1 and diabetes 3.9, 15.8, 14.9 and 8.4, respectively (p<0.001). In rural–urban migrants, there was a significant correlation of duration of migration with waist size, waist-to-hip ratio and systolic blood pressure (quadratic regression, p<0.001). Association of risk factors with migration remained significant, though attenuated, after adjustment for socioeconomic, lifestyle and obesity variables (logistic regression, p<0.01). Conclusions Compared with rural women, rural–urban migrants and urban have significantly greater cardiometabolic risk factors. Prevalence is lower in urban–rural migrants. There is significant correlation of duration of migration with obesity and blood pressure. Differences are attenuated after adjusting for social and lifestyle variables.

Disparities in Prevalence of Cardiometablic Risk Factors in Rural, Urban-Poor, and Urban-Middle Class Women in India.

Objective Urbanization is an important determinant of cardiovascular disease (CVD) risk. To determine location-based differences in CVD risk factors in India we performed studies among women in rural, urban-poor and urban middle-class locations. Methods Population-based cross-sectional studies in rural, urban-poor, and urban-middle class women (35–70y) were performed at multiple sites. We evaluated 6853 women (rural 2616, 5 sites; urban-poor 2008, 4 sites; urban middle-class 2229, 11 sites) for socioeconomic, lifestyle, anthropometric and biochemical risk factors. Descriptive statistics are reported. Results Mean levels of body mass index (BMI), waist circumference, waist-hip ratio (WHR), systolic BP, fasting glucose and cholesterol in rural, urban-poor and urban-middle class women showed significantly increasing trends (ANOVAtrend, p <0.001). Age-adjusted prevalence of diabetes and risk factors among rural, urban-poor and urban-middle class women, respectively was, diabetes (2.2, 9.3, 17.7%), overweight BMI ≥25 kg/m2 (22.5, 45.6, 57.4%), waist >80 cm (28.3, 63.4, 61.9%), waist >90 cm (8.4, 31.4, 38.2%), waist hip ratio (WHR) >0.8 (60.4, 90.7, 88.5), WHR>0.9 (13.0, 44.3, 56.1%), hypertension (31.6, 48.2, 59.0%) and hypercholesterolemia (13.5, 27.7, 37.4%) (Mantel Haenszel X2 ptrend <0.01). Inverse trend was observed for tobacco use (41.6, 19.6, 9.4%). There was significant association of hypertension, hypercholesterolemia and diabetes with overweight and obesity (adjusted R2 0.89–0.99). Conclusions There are significant location based differences in cardiometabolic risk factors in India. The urban-middle class women have the highest risk compared to urban-poor and rural.