Putting NCD Risk Factors Among South Asian Immigrants in United Arab Emirates on Surveillance Screen Syed M Shah, MBBS, MPH, PhD Associate Professor Institute of Public Health, FMHS, UAE University 1

Co-Investigators Tom Loney PhD Iain Blair, MBBS, MRCP Mohamud Sheek-Hussein MD, PHD Mohamed El Sadig PhD Salma Al Dhaheri MD Iffat El Barazi PhD Layla Al Marzouqi MBBS, MRCP Tar-Ching Aw MBBS, MRCP, PhD Raghib Ali DPH, MSc, MRCP 2

Non-communicable Disease (NCD) Risk Factors in South Asian Cardiovascular disease, cancer, chronic respiratory disease and diabetes account for approximately 60% of all deaths globally, making them the world’s biggest killers. Moreover, 80% of deaths associated with these diseases occur in low- and middle-income countries Ref. 3

Where West and East Meet N Engl J Med 2010;363:

NCD Risk Factors in South Asian Immigrants? South Asian populations (India, Pakistan, Bangladesh, Sri Lanka, and Nepal) contribute the highest proportion of the burden of cardiovascular diseases compared with any other region globally. Risk factors for myocardial infarction, hypertension and type 2 diabetes are developed at a lower age in South Asians than in other ethnic groups South Asian migrants living in other countries have higher death rates from coronary heart disease at relatively younger ages compared to the local population Yusuf S et al. Circulation 2001;104: Y Yusuf et el Circulation 2011;104: Reddy et al. N Engl J Med 2004;350: Joshi et al JAMA 2007; 297:

Prevalence of Depression and Suicidal Behaviors Among Male Migrant Workers in United Arab Emirates 6 Immigrant Minority Health 2011 DOI /s

NCD Risk Factors in Male South Asian Immigrants (India, Pakistan, Bangladesh) 7

Ethics Approval, Abu Dhabi Health Services (SEHA) Cross-sectional study Representative sample (n=1375; 76.4% participation rate) of South Asian adult immigrant males in Al Ain, UAE Visa Screening Center, Al Ain, Abu Dhabi 8

NCD Risk Factors in Male South Asian Immigrants (India, Pakistan, Bangladesh) WHO “STEPS Methodology”, for the measurement of NCD risk factors at the country level Questionnaires were conducted in Urdu or Bangla and interview-led by a native Urdu or Bengali speaking research assistant International Physical Activity Questionnaire (IPAQ-short version) 9

NCD Risk Factors in Male South Asian Immigrants (India, Pakistan, Bangladesh) Blood Pressure (BP) measured with calibrated automated device (Omron HEM-705c) Hypertension was defined as an average BP ≥140/90 mmHg and/or if the participant was undertaking treatment of previously diagnosed hypertension Blood samples were taken and WHO cut-off of HbA1c ≥ 6.5% was used to indicate the presence of diabetes mellitus in the sub-sample. 10

NCD Risk Factors in Male South Asian Immigrants (India, Pakistan, Bangladesh) Weight, height, waist and hip circumference were measured using standard instuments (SECA Hamburg, Germany) We used a waist-to-hip ratio (WHR; waist in cm/hip circumference in cm) ≥0.90 to define central obesity in our male population World Health Organization cut-offs were used to classify overweight ( kg/m 2 ) and obese (30.0 kg/m 2 ) adults We used the WHO world reference population to obtain age-standardized rates 11

NCD Risk Factors in Male South Asian Immigrants (India, Pakistan, Bangladesh) Out of 1800 eligible males, 1375 (76.4%) participated, from India (n=433), Pakistan (n=383) and Bangladesh (n=559). The mean age of study population was 34.0 years (95% confidence interval (CI): 33.4, 34.5). 12

Characteristics of Study Population CharacteristicsIndiaPakistanBangladesh Mean age (95%CI) 36.3 (35.3, 37.2) 34.8 (33.7, 35.9) 31.7 (31.0, 32.5) Education % (95%CI) None 3.1 (1.6, 5.0) 23.9 (19.6, 28.4) 12.9 (10.2, 15.9) Primary or middle 23.3 (19.2, 27.6) 31.4 (26.7, 36.2) 46.0 (41.7, 50.2) Secondary or high school 36.9 (32.2, 41.7) 28.3 (23.7, 33.1) 27.6 (23.8, 31.5) College or university 36.7 (31.7, 41.5) 16.4 (12.7, 20.4) 13.5 (6.6, 22.3) Monthly Pay (Dirham) 2,213 2,1071,349 13

Characteristics of Study Population CharacteristicsIndiaPakistanBangladesh Rural Vs Urban % (95%CI) 64.3 (59.3, 69.1) 56.7 (51.3, 61.9) 83.2 (79.7, 86.3) Married % (95%CI) 78.5 (74.1, 82.5) 75.3 (70.5, 79.7) 60.1 (55.7, 64.3) Accommodation With non-relatives 51.4 (46.4, 56.3) 41.1 (36.1, 46.2) 58.6 (54.5, 62.8) With family 10.5 (7.6, 13.7) 15.0 (11.8, 19.3) 7.8 (5.6, 10.2) Single 13.3 (10.1, 16.8) 11.1 (8.1, 14.5) 8.9 (6.6, 11.5) With sponsor 13.3 (10.1, 16.8) 16.7 (13.0, 20.7) 12.2 (9.5, 15.1) Labor camp 11.5 (8.5, 14.8) 16.1 (12.5, 20.1) 12.4 (9.7, 15.3) 14

Characteristics of Study Population CharacteristicsIndiaPakistanBangladesh Years in UAE % (95% CI) Up to 1 year 11.2 (8.1, 14.6) 10.5 (7.4, 14.1) 10.3 (7.6, 13.3) 2 to 5 years 31.3 (26.6, 36.2) 30.5 (25.5, 35.7) 38.6 (34.1, 43.2) 6 to 10 years 21.2 (17.1, 25.6) 17.1 (13.1, 21.4) 23.1 (19.3, 27.1) >10 years 36.3 (31.4, 41.3) 41.9 (36.5, 47.4) 28.0 (23.9, 32.2) 15

Characteristics of Study Population CharacteristicsIndiaPakistanBangladesh Occupation % (95% CI) Driver 21.5 (17.5, 25.7) 33.9 (29.1, 38.8) 19.2 (16.0, 22.7) Laborer 14.1 (10.8, 17.2) 12.8 (9.5,16.4) 20.3 (17.0, 23.8) Construction 12.6 (9.5, 16.1) 8.3 (5.7, 11.4) 13.1 (10.4, 16.1) Agriculture 8.2 (5.6,11.1) 25.0 (20.7, 29.6) 20.5 (17.2, 24.1) Salesman 12.6 (9.5, 16.1) 3.1 (1.6, 5.1) 3.3 (2.2, 5.4) Professional, 10.8 (7.9, 14.1) 6.7 (4.4, 9.5) 3.6 (2.2, 5.4) Business shopkeeper 5.4 (3.4, 7.8) 4.2 (2.4, 6.5) 4.0 (2.5, 5.8) Hospitality worker 8.2 (5.7, 11.1) 0.8 (0.5, 11.0) 6.5 (4.6, 8.8) Tailor 3.6 (1.9, 5.7) 1.9 (0.7, 3.5) 6.8 (4.8, 9.1) Other 16

Alarming Trends in NCD Risk Factors 17 U-weight BMI 30

Alarming Trends in NCD Risk Factors 18

Prevalence of Central Obesity by Nationality (waist-to-hip ratio≥0.90) 19

Proportion of Participants Smoking Cigarettes 20

Proportion of Participants Using Smokeless Tobacco 21

Proportion Exposed to 2ndhand tobacco at home/ work 22

Proportion Reported Alcohol Use 23

Proportion Walk Daily for at least 30 minutes 24

Reported Physical Activity During Last 7 Days 25

Prevalence of Diabetes (HbA1c≥6.5%) 26

Never had their Blood Pressure Measured 27

Age-standardized prevalence of hypertension (BP≥140/90 mm Hg or using antihypertensive drugs) 28

Prevalence of Awareness among those with hypertension 29

Prevalence of Overweight & obesity 30

Prevalence of Hypertension by Job 31

Prevalence of Diabetes by Job 32

Prevalence of Cigarette Smoking by Job 33

Prevention of NCD Risk Factors through Population-based Strategies the Way Forward Risk Level