1. Risk factor profile for chronic non-communicable diseases: Results of a community-based study in Kerala, India K.R. Thankappan, Bela Shah*, Prashant Mathur*, P.S. Sarma, G. Srinivas**, G.K. Mini, Meena Daivadanam Biju Soman & Ramachandran S. Vasan Indian J Med Res 131, January 2010, pp 53-63

2. Introduction: Heart disease, stroke, cancer and other chronic non communicable diseases (NCDs) contributed to 35 of the 58 million deaths (60.3%) in the world in 2005. In India, NCDs were responsible for 53 per cent of deaths and 44 per cent of disability Adjusted life years. NCDs have common risk factors such as tobacco use, unhealthy diet, physical inactivity and excess adiposity. Policies and programmes focusing on reducing the burden of these common risk factors are likely to make a substantial impact on mitigating the mortality and morbidity due to NCDs

3. Objective of the Article: To assess the burden of NCD risk factors (STEPS1-3) in a community based setting in Kerala which is likely to provide a window into the prevalence of NCD risk factors in the future in other parts of India To estimate the relations of behavioral risk factors to socio- demographic correlates (both STEP1), the associations of anthropometric risk factors (STEP 2) with behavioural risk factors (STEP1); To evaluate if socio-demographic, behavioral (STEP1) and anthropometric risk factors (STEP 2) can predict biochemical (STEP3) risk factors; and To estimate awareness, treatment and adequacy of control of hypertension and diabetes.

4. Learning Objective: To learn epidemiology of non communicable diseases To understand regression analysis.

5. Material & Methods Sample size: The sample size calculated using the means of the risk factors aimed to include approximately 250 individuals in each age and sex group between ages 15 and 64 yr (stratified into 10 yr intervals). Rural sample: Eight out of the 15 wards of the Panchayat were randomly selected in order to get a total sample size of 2510 individuals (52.7% women) in the age group of 15-64 yr. Urban sample: Out of 81 wards in the city. one of the wards was selected randomly and two adjacent wards were added to complete the required sample size. From these three wards, 2475 individuals (50.3% women) were selected stratified by age and sex groups similar to the rural sample selection process. Slum sample: The largest four slums out of 37 were targeted according to population size, and 2464 individuals (50.2% women) stratified by age and sex groups were selected similar to the sampling scheme used for the rural and urban areas.

6. Material and Methods Sample for biochemical examination: Because biochemical analysis is expensive and logistically challenging in resource-poor settings, it was restricted to a subsample of 1500 individuals (500 each in rural, urban and slum areas stratified by age and sex groups) selected through systematic random sampling. Data collection (STEP ): The protocol developed by the WHO STEPS program5 was adopted. STEP 1: collection of information on socio-demographic variables, and behavioural risk factors, i.e., tobacco use, alcohol use, physical inactivity, diet and related factors using a questionnaire. Clinical measurements (STEP 2): Height, weight, waist circumference, and blood pressure were measured using standardized instruments and protocols.

7. Material and methods Biochemical measurements (STEP 3): Blood samples were drawn on individuals after 10-12 h fasting. Laboratory measurements of blood glucose and lipids were made using standard automated procedures. Statistical methods: Considering the unequal distribution of age, sex and residence in the population, appropriate sampling weights were used for all data analyses. Data were analyzed using SPSS version 11.5.

8. Results VariablesgroupsUrbanRuralSlumTotal Age15-24 25-34 35-44 45-54 55-64 491(19.8) 499(20.2) 498(20.1) 494(20) 493(19.9) 501(20) 539(21.5) 493(19.6) 497(19.8) 480(19.1) 498(20.2) 494(20.0) 497(20.2) 492(20.0) 483(19.6) 1490 (20.0) 1532 (20.6) 1488 (20.0) 1483 (19.9) 1456 (19.5 SexMales Females 1229(49.7) 1246(50.3) 1186(47.3) 1324(52.7) 1227(49.8) 1237(50.2) 3642 (48.9) 3807 (51.1) Education<10yrs >10 yrs 698(28.2) 1771(71.8) 1070(42.6) 1440(57.4) 1420(57.6) 1044(42.4) 3188 (42.8) 4261 (57.2) Occupatio n Clericle Skilled/Unskille Housewieves Unemployed 517(20.9) 443(17.9) 879(35.5) 636(25.7) 2475 246(9.8) 751(29.9) 1030(41.1) 483(19.2) 2510 218(8.8) 931(37.8) 866(35.1) 449(18.2) 2464 981 (13.2) 2125 (28.5) 2775 (37.3) 1568 (21.0) 7449

9. Results: VariablegroupsUrbanRuralSlumTotal Tobacco useNon users Users 1915 (77.4) 560 (22.6) 1901 (75.7) 609 (24.3) 1545 (62.7) 919 (37.3) 5361(72.0) 2088 (28.0) Alcohol useNon users Users 2148 (86.8) 327 (13.2) 2257 (89.9) 253 (10.1) 1894 (76.9) 570 (23.1) 6299 (84.6) 1150 (15.4) Diet habits (Fruits and Vegetables) <5 servings ≥5 servings 940 (38.0) 1535 (62.0) 1012 (40.3) 1498 (59.7) 1549 (62.9) 915 (37.1) 3501 (47.0) 3948 (53.0) Physical Activity Inactive Moderate Vigorous 236 (9.5) 1956 (79.0) 283 (11.4) 159 (6.3) 1782 (71.0) 569 (22.7) 110 (4.5) 1439 (58.4) 915 (37.1) 505 (6.8) 5177 (69.5) 1767 (23.7)

10. Results Table III. Prevalence of risk factors in urban, rural, slum and the total population by sex Variable Urban M F Total Rural M F Total Slum M F Total Behaviioral RF Tobacco use Alcohol use Dietary habits Phy. Inactivity 43.0 2.6 22.6* 26.5 0.1 13.2* 36.5 39.4 38.0 10.4 8.7 9.5 45.2 5.5 24.3 20.9 0.4 10.1 35.1 45.0 40.3 4.7 7.8 6.3 62.6 12.2 37.3 45.4 1.0 23.1 56.9 68.8 62.9 4.1 4.9 4.5 Anthropometric RF Overweight Abdominal Obesity Hypertension 27.9 44.8 36.3 30.0 53.7 41.9 36.2 33.6 34.9 13.7 27.4 20.9 17.8 48.4 33.9 34.4 30.8 32.5 29.7 41.0 35.3 29.7 42.4 52.2 31.0 30.6 31.6 Biochemical Risk Diabetes Mellitus Hyper cholestremia LDL Cholesterol Hypertriglyceridemia 12.3 17.1 14.8 59.1 62.9 61.0 57.4 34.3 45.6* 30.2 13.9 21.9* 19.0 22.0 20.6 45.9 64.8 56.0 42.9 22.3 31.9 22.1 15.9 18.8 11.4 14.5 13.1 48.8 57.2 53.6 51.2 33.3 41.1 18.5 15.9 17.0

11. Results Table IV. Mean values of NCD risk factors (continuous variables) by sex and place of residence Variables Urban Rural Slum Men Women Total Men Women Total Men Women Total Body mass index (kg/m2) 22.5±4.0 24.2±4.3 23.4±4.2* 20.9±3.5 22.3±4.2 21.7±3.9* 22.7±3.9 24.0±4.5 23.4±4.2* Waist circumference (cm) 83.7±11.5 85.8±11.1 84.8±11.4* 79.4±10.4 84.4±11.0 82.0±11.0* 83.0±11.4 86.3±12.4 84.7±11.8* Systolic BP (mm Hg) 130.2±17.1 126.4±19.0 128.2±18.2* 129.5±17.0 125.9±17.5 127.6±17.3* 128.7±18.3 123.4±19.0 125.9±18.5* Diastolic BP (mm Hg) 79.2±11.7 78.8±10.7 79.0±11.2 78.7±11.5 79.0±10.5 78.8±11.0 78.3±12.6 78.3±11.4 78.3±11.8 Blood glucose (mg/dl) 84.9±24.4 98.1±47.9 91.7±39.0* 98.5±39.3 111.4±48.2 105.3±44.6* 94.9±51.8 102.4±49.4 98.8±44.7 Total cholesterol (mg/dl) 209.7±42.5 208.3±36.9 209.0±39.7 191.4±38.6 210.5±39.5 201.3±40.2* 196.6±52.1 202.2±52.5 199.5±46.2 HDL cholesterol (mg/dl) 38.7±9.9 44.8±9.8 41.9±10.3* 41.1±8.0 48.4±11.1 44.9±10.4* 39.9±12.7 43.6±12.0 41.8±11.0* Triglycerides (mg/dl) 135.6±78.2 94.3±52.1 114.9±69.0* 112.6±67.3 101.1±55.4 106.6±61.6* 108.4±76.6 92.9±61.8

12. Results: STEP2 STEP 1 Overweight Prevalence OR(95% CI) Abdominal Obesity Prevalence OR(95% CI) Hypertension Prevalence OR(95% CI) AGE 15-24 25-34 35-44 45-54 55-64 9.4 Referent 24.8 3.4(2.81-4.14) 34.2 5.6(4.64-6.81) 32.5 5.2(4.25-6.37) 30.3 4.4(3.55-5.57) 12.1 Referent 33.0 3.9(3.31-4.72) 45.0 7.7(6.49-9.30) 47.0 8.8(7.3-10.7) 48.2 8.7(7.12-10.84) 11.4 Referent 19.1 1.8(1.57-2.26) 33.1 4.02(3.36-4.8) 44.0 6.41(5.34-7.71) 60.7 12.51(10.19-15.57) SEX Male Female 18.1 REFERENT 31.3 1.71(1.49-1.96) 20.0 REFERENT 47.8 3.03(2.66-3.46) 30.9 REFERENT 26.8 0.67(0.59-0.77) Area Urban Rural Slum 34.8 Referent 19.7 0.4(0.41-0.52) 33.3 1.1(0.48-2.64) 38.5 Referent 31.0 0.71(0.64-0.80) 39.3 1.24(0.52-2.95) 30.0 Referent 28.2 1.0(0.89-1.12) 25.9 0.9( 0.36-2.26) Tobacco Users non user 26.9 Referent 17.6 0.6(0.54-0.78) 38.5 Referent 19.6 0.5(0.42-0.60) 27.7 Referent 32.7 0.7(0.64-0.88) Alcohol Users non user 25.4 Referent 20.8 01.2(1.01-1.56) 35.7 Referent 23.6 1.4(1.2-1.84) 28.2 Referent 33.7 1.23(1.01-1.48) Phy. Act Inactive Mod. Act Vig. Act 33.8 2.51(1.94-3.25) 27.5 1.80(1.50-2.16) 12.3 Referent 46.6 2.79(2.18-3.57) 38.2 1.79(1.51-2.13) 16.0 Referent 34.0 1.64(1.28-2.09) 29.8 1.47(1.26-1.71) 23.3 Referent

13. STEP3 STEP 1 Diabetes Mellitus Prevalence OR(95% CI) Hypercholestremia Prevalence OR(95% CI) Low HDL Cholesterol Prevalence OR(95% CI) Hypertriglycerdaemia Prevalence OR(95% CI) AGE 15-24 25-34 35-44 45-54 55-64 2.9 Referent 4.1 1.5(0.69-3.4) 15.0 6.46(3.27-12.75) 31.4 17.79(9.13-34.66) 30.2 30.23(15.06-60.71) 29.8 Referent 49.9 2.38(1.75-3.23) 64.4 4.39(3.18-6.08) 73.1 6.78(4.7-9.78) 71.2 6.02(3.95-9.20) 11.4 Referent 19.1 1.01(0.73-1.38) 33.1 1.40(1.02-1.93 ) 44.0 0.89(0.63-1.28) 60.7 0.93(0.61-1.40) 9.8 Referent 18.3 2.06(1.33-3.19) 25.9 3.21(2.09-4.94) 21.6 2.5(1.57-1.98) 24.4 2.94(1.76-4.92) SEX Male Female 13.4 REFERENT 16.0 0.87(0.6-1.26) 48.1 REFERENT 59.6 1.64(1.26-2.13) 30.9 REFERENT 26.8 0.67(0.59-0.77) 24.9 Referent 13.5 0.49(0.35-0.67) Area Urban Rural Slum 11.3 Referent 16.6 1.8(1.31-2.70) 16.7 1.08(0.54-21.77) 58.9 Referent 51.7 0.74(0.58-0.94) 50.0 0.63(0.1-3.87) 30.0 Referent 28.2 1.0(0.89-1.12) 25.9 0.9( 0.36-2.26) 20.9 Referent 18.0 0.84(0.63—1.11) 16.7 0.63(0.05-7.12) Tobacco Users non user 15.1 Referent 13.5 0.7(0.45-1.14) 54.5 Referent 52.3 0.9(0.64-1.25) 27.7 Referent 32.7 0.7(0.64-0.88) 17.3 Referent 25.4 0.85(0.58-1.23) Alcohol Users Non Users 15.5 Referent 7.8 0.37(0.17-0.77) 54.0 Referent 53.9 1.11(0.73-1.68) 36.1 Referent 44.0 0.79(0.53-1.19) 17.5 Referent 33.3 1.57((1.01-2.44) Phy. Act Inactive Mod. Act Vig. Act 16.9 1.34(0.63-2.86) 15.6 1.5490.97-2.42) 11.5 Referent 54.0 1.24(0.73-2.11) 55.4 1.04(0.77-1.39) 48.5 Referent 34.0 1.15(0.68-1.94) 29.8 0.96(0.72-1.28) 23.3 Referent 21.1 1.19(0.64-2.21) 17.6 0.93(0.66-1.30) 23.1 Referent

14. Results STEP3 STEP 2 Diabetes Mellitus Prevalence OR(95% ) Hypercholestremia Prevalence OR(95%) Low HDL Cholesterol Prevalence OR(95% ) Hypertriglycerdaemia Prevalence OR(95% ) Overweight Yes NO 11.9 Referent 24.2 1.16(0.79-1.70) 49.5 Referent 68.9 1.22(0.89-1.68) 34.4 Referent 44.9 1.47(1.08-2.1) 14.2 Referent 34.3 2.45(1.72-3.50) Abdominal Obesity Yes NO 9.0 Referent 26.2 2.82(1.95-4.06) 46.0 Referent 70.0 2.29(1.72—3.03) 35.6 Referent 39.5 0.88(0.66-1.17) 14.4 Referent 28.2 1.25(0.89-1.77) Hypertension Yes NO 9.6 Referent 26.8 2.79(2.05-3.8) 50.2 Referent 63.0 1.39(1.09-1.76) 34.2 Referent 43.2 1.41(1.11-1.79) 15.3 Referent 27.5 1.72(1.29-2.29) Area Urban Rural Slum 1.74 Referent 16.6 1.74(1.23-2.46) 16.7 0.83(0.04-15.09) 58.9 Referent 51.7 0.77(0.61-0.97) 50.0 0.62(0.10-3.65) 44.9 Referent 32.7 0.60(0.48-0.76) 40.0 0.92(0.16-5.28) 20.9 Referent 18.0 0.94(0.70-1.25) 16.7 0.63(0.05-7.05)

15. Results Area Hypertension Treated Aware Treated Controlled Control Diabetes Mellitus Treated Aware Treated Controlled Control Urban Males Female Total 36.2 41.3 38.7 26.5 34.6 30.4 6.7 11.7 9.1 25.4 33.8 30.0 89.7 88.1 88.7 86.2 85.7 85.9 58.6 28.6 40.8 68.0 33.3 47.5 Rural Males Female Total 27.9 43.4 35.7 20.3 29.7 25.0 6.9 8.8 7.8 33.7 29.8 31.4 59.1 67.2 63.7 56.8 65.5 61.8 25.0 8.6 15.7 44.0 13.1 25.3 Slum Male Female Total 24.2 48.3 36.2 15.3 34.7 24.9 4.7 13.1 8.9 31.0 37.7 35.6 70.8 65.0 67.2 54.2 60.0 57.8 8.3 10.0 9.4 15.3 16.6 16.2 Total Male Female Total 29.8 44.2 36.9 21.0 32.9 26.9 6.2 11.1 8.6 29.3 33.8 32.1 71.1 72.9 72.2 30.9 15.0 21.2 30.9 15.0 21.5 47.6 21.4 31.6

16. Discussion: The prevalence of smoking among men in the present study (42%) The prevalence of overweight (men – 23.9%, women – 37.5%) In terms of behavioural risk factors (STEP 1), a fifth of the sample used tobacco products, and a tenth consumed alcohol, and two-fifths consumed a diet low in fruit and vegetable content High blood pressure was observed in nearly 30 per cent of individuals evaluated The study observed a suboptimal cholesterol level in over half of the sample The prevalence of all NCD risk factors increased with age. women had a higher prevalence of overweight and abdominal obesity, they had a lower prevalence of hypertension and dyslipidaemia and a similar prevalence of diabetes (compared to men)

17. Discussion: Physical inactivity was associated with greater prevalence of overweight, abdominal obesity and hypertension, but was not related to prevalence of diabetes and dyslipidaemia. Smoking was associated with a lower prevalence of overweight, abdominal obesity and hypertension, but was unrelated to prevalence of diabetes and dyslipidaemia. In analyses relating STEP 3 variables to STEP 2 variables in an attempt to understand causal pathways, indices of excess adiposity were associated with diabetes mellitus and dyslipidaemia Overall, these observations suggest that though presence of overweight or obesity is a marker of greater metabolic and NCD risk factor burden, the relations among behavioural, anthropometric and biochemical risk factors is complex. The odds ratio noted for relating STEP 2 variables to STEP 3 variables were modest, suggesting that STEP 2 factors may not be useful surrogates for biochemical risk factors for population screening purposes.

18. Conclusion: In conclusion, in this community-based study in Kerala, a high burden of NCD risk factors was observed Association of socio-demographic and behavioural risk factors with biochemical risk factors were seen

19. Thank You !