|Year : 2014 | Volume
| Issue : 4 | Page : 201-208
Risk factors profile for noncommunicable diseases among adult urban population of puducherry in India
RC Chauhan, AJ Purty, M Natesan, A Velavan, Z Singh
Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Submission||01-Apr-2014|
|Date of Decision||11-Jul-2014|
|Date of Acceptance||04-Nov-2014|
|Date of Web Publication||11-Dec-2014|
R C Chauhan
Department of Community Medicine, Pondicherry Institute of Medical Sciences, Puducherry 605 014
Source of Support: None, Conflict of Interest: None
Introduction and Objectives: Almost two-thirds of all deaths worldwide are due to noncommunicable diseases (NCDs), which are primarily associated with tobacco-use, alcohol consumption, physical inactivity, unhealthy diet, obesity and raised blood pressure and are largely preventable. Despite the increasing burden of NCDs and their risk factors in India, information on the prevalence of preventable risk factors is restricted to some areas. This study was done to assess the prevalence and distribution of various risk factors for NCD in population of an urban area of Puducherry, in South India. Methodology: This population-based survey was conducted using the "World Health Organization step-wise approach to surveillance of NCDs" (steps) methodology. All the eligible subjects in systematic randomly selected households were interviewed. Standardized protocols were used to assess major behavioral risk factors (tobacco-use, alcohol consumption, unhealthy diet and physical inactivity) and physiological risk factors (overweight, abdominal obesity and raised blood pressure) for NCDs. Means and proportions were calculated for measured variables, and Chi square test was applied to find the associations. Results: Among 569 study subjects interviewed, almost half (48%) were aged <40 years and 52% (n = 295) were men. The prevalence of various risk factors was; tobacco-use (13.4%), alcohol consumption (14.2%), physical inactivity (51.5%), unhealthy diet (86.5%), overweight (36.0%), obesity (21.3%), abdominal obesity (63.3), hypertension (25.3%) and prehypertension (47.8%). Tobacco-use and alcohol consumption was significantly more prevalent among males (p < 0.05). Almost half of the study subjects had two or more risk factors. Conclusion: Present community-based study reveals the high burden of NCDs risk factors in urban population of Puducherry and the burden was particularly higher among males. This also reiterates the need to address these issues comprehensively as a part of NCDs prevention and control strategy. Further, multi-sectoral efforts like ban on sale or raising the tax on alcohol and tobacco products, health education and communication activities, enabling environment for people to engage in physical activities and other measures to lower the burden of NCDs risk factors in community have to be encouraged.
Keywords: Cross-sectional study, noncommunicable diseases, risk factors, World Health Organization steps
|How to cite this article:|
Chauhan R C, Purty A J, Natesan M, Velavan A, Singh Z. Risk factors profile for noncommunicable diseases among adult urban population of puducherry in India
. J Obes Metab Res 2014;1:201-8
|How to cite this URL:|
Chauhan R C, Purty A J, Natesan M, Velavan A, Singh Z. Risk factors profile for noncommunicable diseases among adult urban population of puducherry in India
. J Obes Metab Res [serial online] 2014 [cited 2021 Jun 20];1:201-8. Available from: https://www.jomrjournal.org/text.asp?2014/1/4/201/146796
| Introduction|| |
Noncommunicable diseases (NCDs) are the leading cause of deaths worldwide, accounting for 63% (almost two-thirds) of the 57 million deaths that occurred in 2008.  Eighty percent of these deaths occurred in low and middle-income countries, including India, where NCDs were estimated to account for 53% of all deaths.  NCDs are associated to common behavioral and physiological risk factors like tobacco-use, harmful use of alcohol, physical inactivity, unhealthy diet, obesity and raised blood pressure that are easily measurable and largely modifiable. These risk factors for NCDs are also leading risk factors for mortality. In terms of attributable deaths, the leading risk factors globally are raised blood pressure (to which 13% of global deaths are attributed), followed by tobacco-use (9%), raised blood glucose (6%), physical inactivity (6%) and being overweight or obese (5%). 
The prevalence of these risk factors varied between various income group countries with some risk factors like tobacco-use among men, overweight and obesity are more common in middle-income countries whereas prevalence of insufficient physical activity is nearly twice in high-income countries compared to low-income countries.  In India, the prevalence of various risk factors for NCDs like tobacco smoking (13.9%), physical inactivity (14.0%), raised blood pressure (35.5%), overweight (11%) and obesity (1.9%) is high.  Apart from these, persons with prehypertension also have a greater risk of developing hypertension than do those with lower blood pressure levels.  Also, prehypertension is associated with increased risk of major cardiovascular events, independent of other cardiovascular risk factors. 
Due to population growth and ageing together with economic transition and resulted changes in risk factors profile, NCDs and the attributed number of related deaths are expected to increase substantially in the future; particularly in low- and middle-income countries and this increase is most marked in the urban population.  As a large percentage of NCDs are preventable through the reduction of behavioral risk factors; tobacco-use, harmful use of alcohol, physical inactivity and unhealthy diet and these risk factors are largely modifiable so reducing the burden of these common risk factors are likely to make a substantial impact on mitigating the mortality and morbidity due to NCDs.
There are limited studies to assess the burden of NCDs risk factors, particularly in population of South India. This community-based study among the general population would provide an estimate of the magnitude of the various risk factors for NCDs and will assist in developing strategies for control of modifiable risk factors for NCDs. Further, the findings of this study will be helpful in assessing the progress of various measures taken to reduce the burden of NCDs risk factors in the population of Puducherry.
| Methodology|| |
The union territory of Puducherry consists of four unconnected districts and has a population of approximately 1.2 million. It is located about 160 km south of Chennai on the Coromandel Coast of the Bay of Bengal in India. In contrast to other parts of India, nearly 70% of the population reside in urban areas, and literacy rate is high (~85%). Puducherry was known as Pondicherry, which was a French Colony before India's independence. The city attained fame due to its association with Sri Aurobindo - a great seer. This community-based cross-sectional study was conducted in an urban area of Puducherry. The study area with an approximate population of twelve thousand is the field practice area of Department of Community Medicine, Pondicherry Institute of Medical Sciences.
Sample size and sampling
A sample size of 560 was calculated to give the true prevalence with a relative precision of 10% and 95% of confidence level. Being a field practice area, a house to house survey was done routinely, and list of all the households in the study area was available. Using systematic random sampling method 600 households were selected and from these household one adult was randomly selected by lottery method. Pregnant women, disabled and acutely ill subjects were excluded from the study. The study protocol was approved by the institute ethics committee. After providing participant information sheet (in local language) and explaining about the study purpose and procedures, informed written consent was obtained from all subjects. In case the subject could not sign, a thumb impression was taken.
Data collection and quality assurance
This study was done as part of re-orientation of medical education posting, where the data were collected by 6 th semester MBBS students with support, guidance and supervision of interns, postgraduate students and faculty from Department of Community Medicine. All the students were given training for data collection including taking informed consent, administering questionnaire, interview techniques, and proper physical measurements. Each selected household was visited and the available subject at that time was interviewed. If nobody was present in the household during the first visit, the student revisited it. Random checks for 10% of the performas were done by postgraduate students on the collected data under the supervision faculty of Department of Community Medicine. Data collection was done during the month of February 2013.
The World Health Organization (WHO) step-wise tool used and after translating in local language and pretesting, the questionnaire was suitably modified.  Two steps of the WHO step-wise approach were used for the study.
- Step 1: (Interview): Includes questionnaire-based survey for sociodemographic variables and behavioral risk factors, such as tobacco-use, alcohol-use, physical activity, diet.
- Step 2: (Physical measurements): Standard procedures were followed for measuring height, weight, waist circumference (WC) and blood pressure. Height was measured to the nearest 0.1 cm using anthropometric rod. Weight was recorded to the nearest 0.1 kg using SECA digital weighing scale. Body mass index (BMI) was calculated by dividing observed weight in kilograms by height in meter square (kg/m 2 ). WC was measured to the nearest 0.1 cm by using a flexible nonstretchable tape at the narrowest point between the lower end of the rib cage and iliac crest with the subjects standing. Blood pressure was measured from the right arm after the subject had been sitting for at least 5 min using OMRON digital automatic blood pressure monitor. The average of the three readings taken 5 min apart was used for analysis.
- Step 3: (Bio-chemical estimation): Bio-chemical estimation could not be done due to limited resources.
Tobacco-user was defined as those who have ever smoked cigarettes or used oral tobacco products in the past.  Alcohol consumer was defined as a person who reported consuming alcohol within the past 1-year.  Consumption of <5 servings of fruits and/or vegetables/day was considered as a risk factor.  One serving of fruit was defined as 1 medium size piece of apple, banana or orange, chopped, cooked, canned fruit or cup of fruit juice, not artificially flavored. One serving of vegetable was defined as 1 cup of raw green leafy vegetable, cup of other vegetables (cooked or chopped) or cup of vegetable juice. Physical inactivity was defined as <10 min of activity at a stretch, during leisure, work or transport.  It included questions on the number of days and time spent on vigorous and/or moderate activities at work; travel to and from places, and recreational activities. Subjects were termed as having low physical activity if she/he did not fulfill the criteria of having vigorous or moderate activity.
Overweight was defined as BMI 25 kg/ 2 .  Abdominal obesity was defined as WC ≥ 90 cm for men or 80 cm for women.  Hypertension was defined as systolic blood pressure (SBP) of 140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg and prehypertension was defined as SBP 120-139 mmHg or DBP 80-89 mmHg.  All subjects currently on anti-hypertensive medications, or having written prescriptions of anti-hypertensive drugs, were classified as hypertensive, irrespective of their current blood pressure reading. Family history of hypertension, diabetes and cardiovascular diseases was based on if anyone in their family (parents/brothers/sisters/children) is suffering/suffered or had died of hypertension, diabetes and cardiovascular diseases. The four major behavioral risk factors (current daily smoker, current drinker, <5 servings of fruits and/or vegetables intake/day and low physical activity) were considered while counting the number of risk factors present.
Data were entered in Microsoft excel spread sheet 2007 (Microsoft Corporation) and data cleaning was done. Statistical package SPSS for a windows version 16.0 (SPSS Inc.) was used for the analyses. Proportions for dichotomous variables and mean values for continuous variables such as BMI, WC, and blood pressure were calculated. Linear trend for risk factors was evaluated in various age groups trend Chi-square. Multivariable logistic regression model was applied to assess the association of overweight, abdominal obesity and hypertension to sociodemographic variables and behavioral risk factors. All statistical tests applied were two-tailed, and p < 0.05 was considered statistically significant.
| Results|| |
A total of 569 subjects of age 18 years and above participated in the study.
Almost half (48%) of the study participants were aged <40 years, and 52% (n = 295) were men. Majority of participants (88%) were literate. Majority of male participants (69%) were employed, and females were homemakers. Eight percent of the participants were unemployed. More than three quarter (87%) of the participants were having monthly income of <10000 INR and even 22% had income of INR <3000/month. The sociodemographic characteristics of the study population are described in [Table 1].
The mean and standard deviation for some continuous variables and various risk factors are given in [Table 2]. In the present study, mean age of the participants was 43.13 ± 15.7 years. The mean systolic and DBPs were 128.2 ± 17.7 mmHg and 77.9 ± 10.5 mmHg respectively. The overall mean BMI was 25.7 ± 4.9 kg/m 2 and WC was 88.4 ± 12.1 cm. The average pulse rate was 80.7 ± 10.5/min, and there was no significant difference for various mean values for male and female.
In the present study, we found that the four major risk factors for NCDs (tobacco consumption, harmful use of alcohol, physical inactivity and low fruit and vegetable consumption) were rampant in the urban study population. The overall prevalence of tobacco-use was 13.4% (n = 76) and this prevalence was significantly higher among males (23.4%) as compared to females. Alcohol consumption among study participants was high with 14.2% (n = 81) being current drinkers. None of the women reported having alcohol containing drinks as compared to 27.5% (n = 81) of men. The proportion of the study population who were sedentary or performing light activity was 51.5% (n = 293) while only 7.7% (n = 44) were doing some type of vigorous activities. For diet, 86.5% of participants reported consuming <5 servings of fruit and/or vegetables/day. The mean fruit and/or vegetable intake were 2.3 servings/day with one serving/day for fruits and two servings/day for vegetables.
The prevalence of overweight and obesity was 36.0% in women and 21.3% in men. Abdominal obesity was present in 42.4% (n = 125) of men and 85.8% (n = 235) of the female participants. The overall prevalence of hypertension and prehypertension in this study was 25.3% (n = 144) and 47.8% (n = 272) respectively. Of the 144 individuals with hypertension only 53.4% (n = 74) were known hypertensive, and the remaining were detected first time during the study. Gender-wise prevalence of various risk factors for NCDs is shown in [Table 3].
|Table 3: Prevalence of various risk factors for NCDs in study population by sex (n=569) |
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One-sixth of study participants (16.5%) were having family history of hypertension and almost equal to that reported a family history of heart diseases (17.0). Family history of diabetes and hypertension was significantly more prevalent among women. Among the subjects, 67.1% of men and 30.7% of women had ≥ ≥ 2 risk factors. The presence of ≥≥ 2 risk factors among men was significantly higher as compared to women.
Results of multiple logistic regression analysis are shown in [Table 4]. The prevalence of behavioral and anthropometric risk factors increases with age. Tobacco-use was associated with a lower prevalence of abdominal obesity. Alcohol intake was associated with higher odds of abdominal obesity and hypertension. Reduced physical activity was associated with higher odds of overweight, abdominal obesity and hypertension. Consumption of ≥5 servings of fruits and vegetables/day was also having lesser odds of abdominal obesity and hypertension.
|Table 4: Multiple logistic regression analysis relating step 2 variables with step 1 variables |
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| Discussion|| |
There are few studies done in South India on assessment of NCDs risk factors. The steps instrument provides a good quality comparable data for the prevalence of NCDs risk factors. Using WHO steps approach, our study found a high prevalence of risk factors for NCDs among of adult urban population of Puducherry.
Except a few subjects (11.1%), all others were having one or more risk factors for NCDs. The prevalence of tobacco-use in the present study (13.4%) is comparable to the findings of a study in Gujarat (12.8) but lower than that in Delhi (25%) and Kerala. ,,, The prevalence of tobacco-use is also lesser than studies in other South-East Asian countries (40-60%). , Tobacco-use among men in the present study (23.4%) was significantly higher than women (2.6%) but this was similar to other studies.
In the present study, the prevalence of alcohol intake among men was 27.5% that is higher than that found by Gupta et al. in Mumbai, but lesser than that observed by Anand et al. in Haryana. , Women, having a very low prevalence of tobacco-use and alcohol intake (0%), suggesting potentially beneficial influences of the cultural and social mores.
Low physical activity observed in men (57.2%), and women (45.2%) of women in the present study is consistent with other studies. , Although the prevalence of low physical activity among both sex is high, the higher prevalence among men as compared to women is contrary to some studies. , This is the sedentary lifestyle of urban men and women that has resulted in the high prevalence of overweight (33.5%) and obesity (19.2%). The prevalence of overweight in our study is much higher than a study done in urban Indonesia.  This higher prevalence was observed in all age-groups and in both the sexes. No gender difference was observed. A higher prevalence of abdominal obesity (women - 85.8%; men - 42.5%) was observed among females in the present study but many cross-sectional surveys recorded high and equal prevalence of abdominal obesity and overweight with both men and women in urban area. ,,, Distribution of fat is as important as the total amount of fat in the body. Marked adverse metabolic consequences are seen with abdominal obesity as this is also an independent predictor of noninsulin-dependent diabetes mellitus (NIDDM), coronary heart disease (CHD), NIDDM, CHD, hypertension, breast cancer, and premature death. The observed higher prevalence of abdominal obesity among women could be due to different measurement lower cut-points for this condition as compared to men.The consumption of an inappropriate diet is associated with many NCDs. However, fewer Indian studies have quantified the consumption of fruits and vegetables in the general population. In our study, 86.4% of subjects were consuming a diet low in fruit and vegetable content which is very high. A comparison of various risk factors prevalence in our study and other similar studies is shown in [Table 5].
|Table 5: Summary of findings from present study and comparison with similar studies |
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Using the JNC 7 criteria among the age group 18 years above, we found a prevalence of 25.3% for hypertension and 47.8% for prehypertension in the present study. The prevalence of hypertension has been increasing in India, with a prevalence of hypertension in urban areas of India ranged from 2.6% to 5.2% between 1960-1980 and 20-33% in the last decade. ,,,, The prevalence of hypertension has been reported to range between 20% and 40% in urban adults.  Our findings (men - 26.4%; women - 24.1%) are also similar to these studies, and high prevalence of hypertension in the present study (25.3%) confirms this rising trend. In addition, there was a high prevalence of prehypertension in our study (49.7%). In Indians, among urban residents of >18 years living in Chennai, the prevalence of prehypertension was reported as 47%.  This was also similar to that reported from developed countries.  In the current study, the prevalence of hypertension increased significantly from age group 30-39 to 60-69 years. The ratio of hypertensive to prehypertensive individuals also increased with age and this trend likely is a result of progression of subjects with prehypertension to hypertension. Greenlund et al. reported that subjects with prehypertension were 1.65 times as likely to have at least 1 other adverse cardiovascular risk factor than those who were normotensive and to have 1.8 times increased risk of cardiovascular events.  Along with other factors, a high prevalence of prehypertension and hypertension are also likely to be a contributor to a large number of deaths due to cardiovascular disease in India.
Although women had a higher prevalence of overweight and abdominal obesity, they had a lower prevalence of hypertension. This may be due to using of lower cut-point for abdominal obesity among women or due to biological protection of women against the effect of excess adiposity. We also found an increased risk of hypertension and prehypertension among subjects with a sedentary lifestyle.
In our study, tobacco-use was associated with a lower prevalence of abdominal obesity and alcohol intake was associated with higher odds of abdominal obesity and hypertension. Less physical activity was associated with higher odds of overweight, abdominal obesity and hypertension. Consumption of ≥ 5 servings of fruits and vegetables/day was also having lesser odds of abdominal obesity and hypertension. Other studies also have similar results. ,
At least 80% of heart disease, stroke, and type 2 diabetes and 40% of cancer could be avoided through healthy diet, regular physical activity, and avoidance of tobacco-use.  Further, policies and programmes directed to reducing the burden of these common risk factors are likely to make a substantial impact on mitigating the burden due to NCDs.  We need comprehensive strategic integrated actions to minimize exposure to risk factors at the population level and reduce the risk in individuals at high risk to provide early, medium-term and long-term effects. 
Our study explored NCD risk factors in an urban area for the first time in Puducherry. Through this study, we intended to measure the status of NCD risk factors in this population group so that appropriate recommendations could be made to improve any prevalent risk factors. We followed the WHO step-wise approach to surveillance that is a standardized method for collecting, analyzing, and disseminating data in WHO member countries. Data collection was done by trained medical students under continuous supervision of the medical faculty. During the course of data collection, any needy respondent was referred to the hospital for further management ensuring that the study incorporated socio-ethical values. Due to limited resources, bio-chemical measurements were not done. Because the sample size is moderate and due to convenience, only limited area was surveyed so that the results of the present study cannot be generalized to other urban areas.
| Conclusions|| |
Our study reveals high burden of NCDs risk factors in urban population of Puducherry and reiterates the need to address these issues comprehensively as a part of NCD prevention and control strategy. The multi-sectoral efforts like ban on sale or raising the tax on alcohol and tobacco products, health education and communication activities, enabling environment for people to engage in physical activities and other measures to lower the burden of NCDs risk factors in community need to be encouraged. Further, the NCDs risk factors were found to be distributed unequally among the population with respect to age groups and gender. Hence, for formulation of any strategies for NCD prevention and control, it is important to keep in mind the differential distribution of NCDs risk factors in the population. Step-wise approach of WHO offers an entry point for low and middle-income countries to initiate NCDs surveillance, as it allows for the development of a flexible, increasingly comprehensive and complex surveillance system depending on local needs and resources. Further surveys are recommended based on this approach to ensure data comparability over time and between different sites. It is also important to study trends of various NCD risk factors.
| Acknowledgement|| |
The authors are highly obliged to all the participants of the study. The authors acknowledge the medical undergraduates of 6 th semester MBBS, Pondicherry Institute of Medical Sciences, who were involved in data collection. Author also thanks the interns, teaching/nonteaching staff of Community Medicine Department for their continuous support in completing the study.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]