Natesan Chidambaram

Prevalence, risk factors and awareness of hypertension in India: a systematic review

Indians have high rates of cardiovascular disease. Hypertension (HTN) is an important modifiable risk factor. There are no comprehensive reviews or a nationally representative study of the burden, treatments and outcomes of HTN in India. A systematic review was conducted to study the trends in prevalence, risk factors and awareness of HTN in India. We searched MEDLINE from January 1969 to July 2011 using prespecified medical subject heading (MeSH) terms. Of 3372 studies, 206 were included for data extraction and 174 were observational studies. Prevalence was reported in 48 studies with sample size varying from 206 to 167 331. A significant positive trend (P<0.0001) was observed over time in prevalence of HTN by region and gender. Awareness and control of HTN (11 studies) ranged from 20 to 54% and 7.5 to 25%, respectively. Increasing age, body mass index, smoking, diabetes and extra salt intake were common risk factors. In conclusion, from this systematic review, we record an increasing trend in prevalence of HTN in India by region and gender. The awareness of HTN in India is low with suboptimal control rates. There are few long-term studies to assess outcomes. Good quality long-term studies will help to understand HTN better and implement effective prevention and management programs.

Rationale and design of the Primary pREvention strategies at the community level to Promote Adherence of treatments to pREvent cardiovascular diseases trial number (CTRI/2012/09/002981)

INTRODUCTION Cardiovascular diseases (CVDs) are a leading cause of morbidity and mortality in low-income countries including India. There is a need for effective, low-cost methods to prevent CVDs in rural India. One strategy is to identify and implement interventions at high-risk individuals using community health workers (CHWs). There is a paucity of CHW-based CVD intervention trials from low-income countries. METHODS We designed a multicenter, household-level, cluster-randomized trial with 1:1 allocation to intervention and control arms. The CHWs undertook a door-to-door survey and screened 5,699 households in 28 villages from 3 rural regions in India to identify at-risk households. The households were defined as those with ≥1 individual aged ≥35 years and at moderate or high risk for CVD based on the non-laboratory-based National Health and Nutrition Examination Survey score. All at-risk individuals were invited to attend a physician-led village clinic that provided a CVD risk reduction prescription and education about target risk factor levels for CVD control. All households in which at least 1 member at moderate to high risk for CVD had received a risk reduction prescription were eligible for randomization. Households randomized to the CHW-based intervention will receive 1 household visit by a CHW every 2 months, for 12 months. During these visits, CHWs will measure blood pressure, ascertain and reinforce adherence to prescribed therapies, and modify therapy to meet targets. Households randomized to the control arm do not receive CHW visits. At 12 months after randomization, we will evaluate 2 primary outcomes of systolic blood pressure and adherence to antihypertensive drugs and secondary outcomes of INTERHEART risk score, body mass index, and waist-to-hip ratios. At 18 to 24 months after randomization and 6 to 12 months after the last intervention, we will record these outcomes to evaluate sustainability of intervention. RESULTS Community health workers screened a total of 5,033 households that included 9,248 individuals and identified 2,571 households with 3,784 at-risk individuals. We randomized 2,438 households (1,219 to intervention and 1,219 to control groups). CONCLUSION Our large trial of CHWs in rural India will provide important information regarding a promising approach to primary prevention of CVDs.

Rationale and design of a randomized controlled trial evaluating community health worker-based interventions for the secondary prevention of acute coronary syndromes in India (SPREAD).

BACKGROUND There is a need to evaluate and implement cost-effective strategies to improve adherence to treatments in coronary heart disease. There are no studies from low- to middle income countries (LMICs) evaluating trained community health worker (CHW)-based interventions for the secondary prevention of coronary heart disease. METHODS We designed a hospital-based, open randomized trial of CHW-based interventions versus standard care. Patients after an acute coronary syndrome (ACS) were randomized to an intervention group (a CHW-based intervention package, comprising education tools to enhance self-care and adherence, and regular follow-up by the CHW) or to standard care for 12 months during which study outcomes were recorded. The CHWs were trained over a period of 6 months. The primary outcome measure was medication adherence. The secondary outcomes were differences in adherence to lifestyle modification, physiological parameters (blood pressure [BP], body weight, body mass index [BMI], heart rate, lipids), and major adverse cardiovascular events. RESULTS We recruited 806 patients stabilized after an ACS from 14 hospitals in 13 Indian cities. The mean age was 56.4 (± 11.32) years, and 17.2% were females. A high prevalence of risk factors such as hypertension (43.4%), diabetes (31.9%), tobacco consumption (35.4%), and inadequate physical activity (70.5%) was documented. A little over half had ST-elevation myocardial infarction (53.7%), and 46.3% had non-ST-elevation myocardial infarction or unstable angina. CONCLUSION The CHW interventions and training for SPREAD have been developed and adapted for local use. The results and experience of this study will be important to counter the burden of cardiovascular diseases in low- to middle income countries.

Relationship of Sodium and Magnesium Intakes to Hypertension Proven by 24-Hour Urianalysis in a South Indian Population

The Healthy Eating Asians Remain Together (HEART) study was carried out to investigate the relationship between 24‐hour urine nutritional biomarkers and cardiometabolic risks in India. A total of 168 participants underwent health examination to assess body mass index, blood pressure, and 24‐hour urine samples. The participants were divided into normotensive and hypertensive. The average blood pressure, weight, and body mass index were significantly high in patients considered to be hypertensive, and 24‐hour urine biomarkers showed significant differences in sodium and magnesium/creatinine ratios in patients aged 40 and older. High sodium intake and reduction in magnesium consumption are associated with increased blood pressure in patients from India.

Effect of Dietary Soy Protein Supplement in Dyslipidemic South Indian Population: A Randomized, Double-Blind, Placebo Controlled, Parallel-Group Trial

Forty subjects identified as dyslipidemic were assigned randomly to either soy powder (Soy) or red bean powder (Placebo). The soy group received daily a sachet of 18.1 g soy power containing 85 K cal and the placebo group received daily placebo sachet (23.1 g) of red bean powder containing 85.5 K cal in addition to the usual diet for four weeks. Intake of soy/placebo powder was assessed by measurement of 24-hour urinary isoflavone excretions at baseline and at the end of the intervention period. Relative to placebo, soy powder has significant effect over some Cardiovascular Disease (CVD) markers and Metabolic Syndrome (MetS) indices including abdominal circumference, triglycerides, HbA1c and insulin. These data support that the dietary consumption of soy has the property to reduce risk factors for CVD and MetS.

160 NUTRITIONAL FACOTRS FOR HYPERTENSION IN INDIA: THE FIRST REPORT OF HEART STUDY BASED ON BIOLOGICAL MARKER ESTIMATION OF 24-HOUR URINE SAMPLES

Aim: WHO-coordinated CARDIAC (Cardiovascular Diseases and Alimentary Comparison) Study covering 61 populations in 25 countries demonstrated 24-hour urinary (24U) magnesium (Mg) excretion was inversely related with cardiometabolic disease risks such as obesity, hypertension, hypercholesteremia etc. As the second generation of CARDIAC Study, HEART (Healthy Eating Asians Remain Together) Study was carried out to investigate the relationship of 24U nutritional biomarkers with cardiometabolic risks in India. Methods: WHO-CARDIAC protocol was carried out for 180 males and females aged 30-59 (60 males and females from three age groups 30-39, 40–49 and 50–59) who were selected from the community list in Chidambaram, India. Participants were invited for health examination to check body mass index (BMI), blood pressure (BP) by an automated BP measurement system (Omron HEM 907), 24U samples, fasting blood samples and questionnaires about dietary customs and medical history. Results: The average systolic and diastolic BPs were 133.2/84.3 in males and 133.7/76.8 in females, and the average BMI were 25.4 in males and 26.2 in females, higher than the average metabolic syndrome risks of CARDIAC Study populations. Participants were divided into hypertensives with BP ≥140/90 and normotensives. 24U biomarkers showed no significant differences in NaCl excretion and Na/K ratio, but Mg/creatinine ratios were significantly higher 112 mg/g in normotensive males and females than 68 and 67 in hypertensive males and females. Conclusion: Marked Mg intake reduction may be related to hypertension in Indian vegetarians whose Mg intakes are decreased because of their changes in dietary customs to eat polished grains commonly.