Krishna Kumar Sharma

Normotension, Prehypertension, and Hypertension in Urban Middle-Class Subjects in India: Prevalence, Awareness, Treatment, and Control

OBJECTIVE We conducted a multisite study to determine the prevalence and determinants of normotension, prehypertension, and hypertension, and awareness, treatment, and control of hypertension among urban middle-class subjects in India. METHODS We evaluated 6,106 middle-class urban subjects (men 3,371; women, 2,735; response rate, 62%) in 11 cities for sociodemographic and biological factors. The subjects were classified as having normotension (BP < 120/80), prehypertension (BP 120-139/80-89), and hypertension (documented or BP ≥ 140/90). The prevalence of other cardiovascular risk factors was determined and associations evaluated through logistic regression analysis. RESULTS The age-adjusted prevalences in men and women of normotension were 26.7% and 39.1%, of prehypertension 40.2% and 30.1%, and of hypertension 32.5% and 30.4%, respectively. The prevalence of normotension declined with age whereas that of hypertension increased (P-trend < 0.01). A significant association of normotension was found with younger age, low dietary fat intake, lower use of tobacco, and low obesity (P < 0.05). The prevalence of hypercholesterolemia, diabetes, and metabolic syndrome was higher in the groups with prehypertension and hypertension than in the group with normotension (age-adjusted odds ratios (ORs) 2.0-5.0, P < 0.001). The prevalences in men and women, respectively, of two or more risk factors were 11.1% and 6.4% in the group with normotension, 25.1% and 23.3% in the group with prehypertension, and 38.3% and 39.1% in the group with hypertension (P < 0.01). Awareness of hypertension in the study population was in 55.3%; 36.5% of the hypertensive group were receiving treatment for hypertension, and 28.2% of this group had a controlled BP (< 140/90 mm Hg). CONCLUSIONS The study found a low prevalence of normotension and high prevalence of hypertension in middle-class urban Asian Indians. Significant associations of hypertension were found with age, dietary fat, consumption of fruits and vegetables, smoking, and obesity. Normotensive individuals had a lower prevalence of cardiometabolic risk factors than did members of the prehypertensive or hypertensive groups. Half of the hypertensive group were aware of having hypertension, a third were receiving treatment for it, and quarter had a controlled BP.

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.

Prevalence of diabetes and cardiovascular risk factors in middle-class urban participants in India.

Objectives To determine the prevalence of diabetes and awareness, treatment and control of cardiovascular risk factors in population-based participants in India. Methods A study was conducted in 11 cities in different regions of India using cluster sampling. Participants were evaluated for demographic, biophysical, and biochemical risk factors. 6198 participants were recruited, and in 5359 participants (86.4%, men 55%), details of diabetes (known or fasting glucose >126 mg/dL), hypertension (known or blood pressure >140/>90 mm Hg), hypercholesterolemia (cholesterol >200 mg/dL), low high-density lipoprotein (HDL) cholesterol (men <40, women <50 mg/dL), hypertriglyceridemia (>150 mg/dL), and smoking/tobacco use were available. Details of awareness, treatment, and control of hypertension and hypercholesterolemia were also obtained. Results The age-adjusted prevalence (%) of diabetes was 15.7 (95% CI 14.8 to 16.6; men 16.7, women 14.4) and that of impaired fasting glucose was 17.8 (16.8 to 18.7; men 17.7, women 18.0). In participants with diabetes, 27.6% were undiagnosed, drug treatment was in 54.1% and control (fasting glucose ≤130 mg/dL) in 39.6%. Among participants with diabetes versus those without, prevalence of hypertension was 73.1 (67.2 to 75.0) vs 26.5 (25.2 to 27.8), hypercholesterolemia 41.4 (38.3 to 44.5) vs 14.7 (13.7 to 15.7), hypertriglyceridemia 71.0 (68.1 to 73.8) vs 30.2 (28.8 to 31.5), low HDL cholesterol 78.5 (75.9 to 80.1) vs 37.1 (35.7 to 38.5), and smoking/smokeless tobacco use in 26.6 (23.8 to 29.4) vs 14.4 (13.4 to 15.4; p<0.001). Awareness, treatment, and control, respectively, of hypertension were 79.9%, 48.7%, and 40.7% and those of hypercholesterolemia were 61.0%, 19.1%, and 45.9%, respectively. Conclusions In the urban Indian middle class, more than a quarter of patients with diabetes are undiagnosed and the status of control is low. Cardiovascular risk factors—hypertension, hypercholesterolemia, low HDL cholesterol, hypertriglyceridemia, and smoking/smokeless tobacco use—are highly prevalent. There is low awareness, treatment, and control of hypertension and hypercholesterolemia in patients with diabetes.

High prevalence of metabolic syndrome among urban subjects in India: A multisite study

OBJECTIVE Metabolic syndrome is an important cardiovascular risk factor. To determine its prevalence among urban subjects in India we performed a multisite study. METHODS The study was performed at eleven cities using cluster sampling. 6198 subjects (men 3426, women 2772, response 62%, age 48±10 years) were evaluated for socio-demographic, lifestyle, anthropometric and biochemical factors. Prevalence of metabolic syndrome was determined using harmonized Asian-specific criteria. Significant socioeconomic and lifestyle associations were determined. RESULTS Age adjusted prevalence (%, 95% confidence intervals) of metabolic syndrome in men and women was 33.3 (31.7-34.9) and 40.4 (38.6-42.2) (harmonized criteria), 23.9 (22.4-26.4) and 34.5 (32.0-36.1) (modified Adult Treatment Panel-3, ATP-3) and 17.2 (15.3-19.1) and 22.8 (20.1-24.2) (ATP-3). Individual components of metabolic syndrome in men and women, respectively, were: high waist circumference 35.7 (34.1-37.3) and 57.5 (55.6-59.3), high blood pressure 50.6 (48.9-52.3) and 46.3 (44.4-48.1), impaired fasting glucose/diabetes 29.0 (27.5-30.5) and 28.0 (26.3-29.7), low HDL cholesterol 34.1 (32.5-35.7) and 52.8 (50.9-54.7) and high triglycerides 41.2 (39.5-42.8) and 31.5 (29.7-33.2) percent. Prevalence of metabolic syndrome was significantly greater in subjects with highest vs. lowest categories of education (45 vs. 26%), occupation (46 vs. 40%), fat intake (52 vs. 45%), sedentary lifestyle (47 vs. 38%) and body mass index (66 vs. 29%) (p<0.05). CONCLUSION There is high prevalence of metabolic syndrome in urban Indian subjects. Socioeconomic (high educational and occupational status) and lifestyle (high fat diet, low physical activity, overweight and obesity) factors are important.

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.

Geographic epidemiology of cardiometabolic risk factors in middle class urban residents in India: cross-sectional study

Objective To determine epidemiology of cardiovascular risk factors according to geographic distribution and macrolevel social development index among urban middle class subjects in India. Methods We performed cross-sectional surveys in 11 cities in India during years 2005–2009. 6198 subjects aged 20–75 years (men 3426, women 2772, response 62%) were evaluated for cardiovascular risk factors. Cities were grouped according to geographic distribution into northern (3 cities, n = 1321), western (2 cities, n = 1814), southern (3 cities, n = 1237) and eastern (3 cities, n = 1826). They were also grouped according to human social development index into low (3 cities, n = 1794), middle (5 cities, n = 2634) and high (3 cities, n = 1825). Standard definitions were used to determine risk factors. Differences in risk factors were evaluated using χ2 test. Trends were examined by least squares regression. Findings Age–adjusted prevalence (95% confidence intervals) of various risk factors was: low physical activity 42.1% (40.9–43.3), high dietary fat 49.9% (47.8–52.0), low fruit/vegetables 26.9% (25.8–28.0), smoking 10.1% (9.1–11.1), smokeless tobacco use 9.8% (9.1–10.5), overweight 42.9% (41.7–44.1), obesity 11.6% (10.8–12.4), high waist circumference 45.5% (44.3–46.7), high waist–hip ratio 75.7% (74.7–76.8), hypertension 31.6% (30.4–32.8), hypercholesterolemia 25.0% (23.9–26.9), low HDL cholesterol 42.5% (41.3–43.7), hypertriglyceridemia 36.9% (35.7–38.1), diabetes 15.7% (14.8–16.6), and metabolic syndrome 35.7% (34.5–36.9). Compared with national average, prevalence of most risk factors was not significantly different in various geographic regions, however, cities in eastern region had significantly lower prevalence of overweight, hypertension, hypercholesterolemia, diabetes and metabolic syndrome compared with other regions (P < 0.05 for various comparisons). It was also observed that cities with low human social development index had lowest prevalence of these risk factors in both sexes (P < 0.05). Conclusions Urban middle–class men and women in eastern region of India have significantly lower cardiometabolic risk factors compared to northern, western and southern regions. Low human social development index cities have lower risk factor prevalence.

Evaluation of statin prescriptions in type 2 diabetes: India Heart Watch-2

Background Contemporary treatment guidelines advise statin use in all patients with diabetes for reducing coronary risk. Use of statins in patients with type 2 diabetes has not been reported from India. Methods We performed a multisite (n=9) registry-based study among internists (n=3), diabetologists (n=3), and endocrinologists (n=3) across India to determine prescriptions of statins in patients with type 2 diabetes. Demographic and clinical details were obtained and prescriptions were audited for various medications with a focus on statins. Details of type of statin and dosage form (low, moderate, and high) were obtained. Patients were divided into categories based on presence of cardiovascular risk into low (no risk factors, n=1506), medium (≥1 risk factor, n=5425), and high (with vascular disease, n=1769). Descriptive statistics are presented. Results Prescription details were available in 8699 (men 5292, women 3407). Statins were prescribed in 55.2% and fibrates in 9.2%. Statin prescription was significantly greater among diabetologists (64.4%) compared with internists (n=53.3%) and endocrinologists (46.8%; p<0.001). Atorvastatin was prescribed in 74.1%, rosuvastatin in 29.2%, and others in 3.0%. Statin prescriptions were lower in women (52.1%) versus men (57.2%; p<0.001) and in patients aged <40 years (34.3%), versus those aged 40–49 (49.7%), 50–59 (60.1%), and ≥60 years (62.2%; p<0.001). Low-dose statins were prescribed in 1.9%, moderate dose in 85.4%, and high dose in 12.7%. Statin prescriptions were greater in the high-risk group (58.0%) compared with those in the medium-risk (53.8%) and low-risk (56.8%) groups (p <0.001). High-dose statin prescriptions were similar in the high-risk (14.5%), medium-risk (11.8%), and low-risk (13.5%) groups (p=0.31). Conclusions Statins are prescribed in only half of the clinic-based patients in India with type 2 diabetes. Prescription of high-dose statins is very low.

Association of low educational status with microvascular complications in type 2 diabetes: Jaipur diabetes registry-1

Objective: To determine the association of educational status (ES), as a marker of socioeconomic status, with the prevalence of microvascular complications in diabetes. Methods: Successive patients (n = 1214) presenting to our centre were evaluated for sociodemographic, anthropometric, clinical, and therapeutic variables. Subjects were classified according to ES into Group 1 (illiterate, 216); Group 2 (<primary, 537), Group 3 (<higher secondary, 312), and Group 4 (any college, 149). Descriptive statistics are reported. Results: Mean age of patients was 52 ± 10 years, duration of diabetes 7 ± 7 years, and 55% were men. Prevalence of various risk factors was smoking/tobacco 25.5%, obesity body mass index ≥25 kg/m2 64.0%, abdominal obesity 63.4%, hypertension 67.5%, high fat diet 14.5%, low fruits/vegetables 31.8%, low fibre intake 60.0%, high salt diet 16.9%, physical inactivity 27.5%, coronary, or cerebrovascular disease 3.0%, and microvascular disease (peripheral, ocular or renal) in 20.7%. Microvascular disease was significantly greater in illiterate (25.9%) and low (23.6%) compared to middle (15.0%) and high (14.7%) ES groups (P < 0.05). Age- and sex-adjusted logistic regression analysis revealed that in illiterate and low ES groups respectively, prevalence of smoking/tobacco use (odds ratio 3.84, confidence intervals 2.09–7.05 and 2.15, 1.36–3.41); low fruit/vegetable (2.51, 1.53–4.14 and 1.99, 1.30–3.04) and low fibre intake (4.02, 2.50–6.45 and 1.78, 1.23–2.59) was greater compared to high ES. Poor diabetes control (HbA1c >8.0%) was significantly greater in illiterate (38.0%), low (46.0%) and middle (41.0%) compared to high (31.5%) ES subjects (P < 0.05). Conclusions: There is a greater prevalence of the microvascular disease in illiterate and low ES diabetes patients in India. This is associated with the higher prevalence of smoking/tobacco use, poor quality diet and sub-optimal diabetes control.

Educational status-related disparities in awareness, treatment and control of cardiovascular risk factors in India.

Objective To determine association of socioeconomic status, defined by educational status (ES), with awareness, treatment and control of cardiovascular risk factors. Methods We performed an epidemiological study at 11 cities in India using cluster sampling. 6198 subjects (3426 men, 2772 women, response 62%, age 48±10 years) were evaluated for sociodemographic, lifestyle, anthropometric and biochemical factors. ES was categorised according to years of schooling into low (≤10 years), medium (11–15 years) and high (>15 years). Risk factors were diagnosed according to current guidelines. Awareness, treatment and control status were determined for hypertension, diabetes and hypercholesterolaemia. For smoking/tobacco use, quit rate was determined. Descriptive statistics are reported. Results Age-adjusted and sex-adjusted prevalence (%) of various risk factors in low, medium and high ES subjects was hypertension 31.8, 29.5 and 34.1, diabetes 14.5, 15.3 and 14.3, hypercholesterolaemia 24.0, 23.9 and 27.3, and smoking/tobacco use 24.3, 14.4 and 19.0. Significantly increasing trends with low, medium and high ES were observed for hypertension awareness (30.7, 37.8, 47.0), treatment (24.3, 29.2, 35.5) and control (7.8, 11.6, 15.5); diabetes awareness (47.2, 51.5, 56.4), treatment (38.3, 41.3, 46.0) and control (18.3, 15.3, 22.8); hypercholesterolaemia awareness (8.9, 22.4, 18.4), treatment (4.1, 6.2, 7.9) and control (2.8, 3.2, 6.9), as well as for smoking/tobacco quit rates (1.6, 2.8, 5.5) (χ2 for trend, p<0.05). Conclusions Low ES subjects in India have lower awareness, treatment and control of hypertension, diabetes and hypercholesterolaemia and smoking quit rates.

Non-physician health workers for improving adherence to medications and healthy lifestyle following acute coronary syndrome: 24-month follow-up study

Objective To evaluate usefulness of non-physician health workers (NPHW) to improve adherence to medications and lifestyles following acute coronary syndrome (ACS). Methods We randomized 100 patients at hospital discharge following ACS to NPHW intervention (n = 50) or standard care (n = 50) in an open label study. NPHW was trained for interventions to improve adherence to medicines – antiplatelets, β-blockers, renin–angiotensin system (RAS) blockers and statins and healthy lifestyles. Intervention lasted 12 months with passive follow-up for another 12. Both groups were assessed for adherence using a standardized questionnaire. Results ST elevation myocardial infarction (STEMI) was in 49 and non-STEMI in 51, mean age was 59.0 ± 11 years. 57% STEMI were thrombolyzed. On admission majority were physically inactive (71%), consumed unhealthy diets (high fat 77%, high salt 58%, low fiber 57%) and 21% were smokers/tobacco users. Coronary revascularization was performed in 90% (percutaneous intervention 79%, bypass surgery 11%). Drugs at discharge were antiplatelets 100%, β-blockers 71%, RAS blockers 71% and statins 99%. Intervention and control groups had similar characteristics. At 12 and 24 months, respectively, in intervention vs control groups adherence (>80%) was: anti platelets 92.0% vs 77.1% and 83.3% vs 40.9%, β blockers 97.2% vs 90.3% and 84.8% vs 45.0%), RAS blockers 95.1% vs 82.3% and 89.5% vs 46.1%, and statins 94.0% vs 70.8% and 87.5% vs 29.5%; smoking rates were 0.0% vs 12.5% and 4.2% vs 20.5%, regular physical activity 96.0% vs 50.0%, and 37.5% vs 34.1%, and healthy diet score 5.0 vs 3.0, and 4.0 vs 2.0 (p < 0.01 for all). Intervention vs standard group at 12 months had significantly lower mean systolic BP, heart rate, body mass index, waist:hip ratio, total cholesterol, triglyceride, and LDL cholesterol (p < 0.01). Conclusions NPHW-led educational intervention for 12 months improved adherence to evidence based medicines and healthy lifestyles. Efficacy continued for 24 months with attrition.