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Prevalence of risk factors for noncommunicable diseases among adult population in an urban slum of Pune, India


1 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Hospital Administration, Military Hospital, Leimakhong, Manipur, India
3 Station Health Organisation, Srinagar, Jammu and Kashmir, India
4 Hospital Administration, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission14-Jul-2020
Date of Decision09-Sep-2020
Date of Acceptance22-Sep-2020

Correspondence Address:
Ananta Kumar Naik,
Department of Hospital Administration, Armed Forces Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_387_20

  Abstract 


Introduction: India is experiencing health transition with a rising burden of noncommunicable diseases (NCDs). There is a need to study risk factors of NCDs among poor and underprivileged section of the society. Methodology: A cross-sectional study was done among adults in an urban slum in Pune using the World Health Organization's STEP wise approach to surveillance (STEPS). Two hundred individuals selected by simple random sampling participated in this study. Information regarding dietary habits, physical activity, and tobacco and alcohol consumption was obtained. Physical measurements of height, weight, waist and hip circumference, and blood pressure were also done. Nominal and numerical variables in different groups were compared by Fisher's exact test and Student's t-test, respectively. Logistic regression was used to determine the association of various factors with high blood pressure. Results: Tobacco and alcohol consumption was observed in 22.5% (95% confidence interval [CI]: 16.9%–28.9%) and 11.5% (95% CI: 7.4%–16.8%) of individuals, which was significantly higher among males. 40.0% (95% CI: 33.2%–47.1%) of participants were doing less than recommended physical activity. 47% (95% CI: 40.0%–54.2%) of individuals were overweight or obese. The prevalence of high blood pressure was found to be 43.9% (95% CI: 36.6%–51.3%). Significant positive correlation was observed among different anthropometric variables. Multivariable logistic regression showed that there was significant positive association of high blood pressure with age (adjusted odds ratio [aOR] = 1.05 [95% CI: 1.02–1.08]) and waist hip ratio (aOR = 1.45 [95% CI: 1.01–2.09]). Conclusions: There is a high prevalence of risk factors for NCDs among residents of urban slum. Behavior change communication is required for adoption of healthy lifestyle and prevents NCDs in urban slums.

Keywords: Noncommunicable disease, risk factor, STEPS methodology, urban slum



How to cite this URL:
Ghildiyal A, Joshi RK, Dutt SK, Mopagar V, Naik AK. Prevalence of risk factors for noncommunicable diseases among adult population in an urban slum of Pune, India. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=322313




  Introduction Top


The global burden of chronic, noncommunicable diseases (NCDs) such as heart disease, stroke, cancer, and diabetes is increasing rapidly and has significant social, economic, and health consequences. India is also experiencing a rapid health transition with a rising burden of NCDs. Overall, NCDs are emerging as the leading cause of mortality and disability-adjusted life year (DALY) loss in India, accounting for over 42% of all deaths.[1],[2] There is a shift in the disease spectrum from communicable to NCDs with urbanization and socioeconomic transition. The leading risk factors for NCDs are tobacco use, harmful alcohol consumption, physical inactivity, raised blood pressure, obesity, and unhealthy diet including high salt and sodium intake.[3],[4],[5] Regular studies of these risk factors in the community are required to plan and implement preventive strategies.

Various studies carried in across the globe have reported high prevalence of these risk factors in the population. Studies[6],[7],[8],[9] in different Asian and African countries have found more than 70% prevalence of NCD risk factors. Similarly, high prevalence of risk factors such as unhealthy diet, over weight/obesity, tobacco/alcohol consumption, and high blood pressure was reported in studies carried out in different states of India.[10],[11],[12],[13],[14] However, only very few studies[15],[16],[17],[18] have been done to evaluate prevalence of these risk factors in urban slums of India. Slum areas in India are characterized by overcrowded and poor living conditions with limited access to educational and health-care facilities. We carried out this study to estimate prevalence of NCD risk factors in a selected urban slum of Pune, Maharashtra, India.


  Methodology Top


This cross-sectional study was conducted in the year 2018 among adult population (18–60 years) residing in an urban slum in Pune. Minimum sample size required for our study was calculated to estimate prevalence of various risk factors with 95% confidence level and 7% error of margin. As per the previous study carried out in urban slum of Mumbai,[18] prevalence of different risk factors varies from 14.75% to 83.75%. Among sample sizes calculated for different risk factors, sample size of 187 participants was the highest for estimating prevalence of high blood pressure considering it to be 39%.[18] Assuming 15% nonresponse, we selected 218 individuals to participate in the study using simple random sampling. The sampling frame of all the adult residents of the selected slum (2992 individuals) was prepared after obtaining details of residents from the administrative office of the locality. Random numbers were generated using R software to select 218 individuals. Of these 18 residents (8.26%) refused to participate while 200 individuals participated in the study.

The prevalence of risk factors was studied using the WHO STEP wise approach to surveillance (STEPS).[19],[20] The standard WHO STEPS questionnaire was translated into local Hindi language and was pretested before the study. In Step 1, demographic information and behavioral data about consumption of tobacco, alcohol, fruit, vegetables, and physical activity were obtained using interviewer administered questionnaire. One cup of raw leafy vegetables or half cup of other vegetables (cooked or chopped raw) was considered one serving of vegetables. One medium-sized piece of fruit or half cup of chopped/cooked fruit was considered as one serving of fruits. In Step 2, physical measurements were taken maintaining the privacy of the participants. Height was measured in centimeters using stadiometer. Weight was recorded using a digital weighing scale. Body mass index (BMI) was categorized according to the WHO classification into following categories: underweight < 18.5, normal 18.5–24.9, overweight 25–29.9, and obesity ≥ 30.[21] Waist circumference (in cm) was measured at midpoint between lower rib and iliac crest at the end of normal expiration and hip circumference was measured at the maximum circumference over the buttocks.[22] Blood pressure was recorded using standard protocol three times in sitting position, on the right arm, using a digital automatic blood pressure monitor. The mean of the second and third readings was calculated and taken as the final reading. High blood pressure was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or those being treated for hypertension.[20]

Data were summarized by calculating mean, standard deviation (SD), range, proportions and 95% confidence intervals (CIs). Numerical variables in two groups were compared using Student's “t-test” while nominal variables were compared by Fisher's exact test. Pearson's correlation coefficients were calculated to find correlation between different anthropometric variables. Logistic regression was used to determine association of high blood pressure with other socio-demographic and anthropometric variables. Variables with significant association in bivariate analysis were included for multivariable analysis. Two-tailed tests were used and P < 0.05 was considered to be statistically significant. R software version 3.5.1 was used for statistical analysis.

Approval of Institutional Ethics Committee was obtained for this study. Informed consent from all participants was taken and confidentiality of study participants was ensured. Study participants were informed about healthy lifestyle to prevent NCDs after data collection was done.


  Results Top


There were 102 male and 98 female participants in this study. The study participants had mean (SD) age of 41.9 (12.6) years. 42 (21%) participants belonged to 18–30 years of age group, 56 (28%) participants were between 31 and 40 years of age, 40 (20%) individuals were of 41–50 years age group and 62 (31%) participants were more than 50 years of age. The median (range) family income was Rs. 13,000 (Rs. 2500–122,000). Forty-one (20.5%) participants were illiterate and 81 (40.5%) had not completed their secondary school (<10th standard).

Tobacco and alcohol consumption

The prevalence of current tobacco consumption was 22.5% (95% CI: 16.9%–28.9%) while alcohol consumption in last 1 year was reported to be 11.5% (95% CI: 7.4%–16.8%). Betel nut (Areca Nut) consumption prevalence was 2.5% (95% CI: 0.8%–5.7%). Tobacco and alcohol use were found to be higher among males as compared to females [Table 1]. Most of these participants started tobacco consumption during their young age. The median age for starting smoking bidi, cigarette, and chewing tobacco was 17, 22, and 20 years, respectively. Among bidi smokers, median (range) daily consumption of bidi was 1.5 (1–2) packs while cigarette users were consuming 1 (0.4–6) packs/day. Chewable tobacco and alcohol were consumed on an average 3 (range: 1–7) times/day and 3 times/week (range: once a day - once a month), respectively.
Table 1: Consumption of addictive substances

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Fruits and vegetables consumption

Fruits and vegetables were consumed on an average for 3 (range: 0–7) days and 7 (range: 0–7) days in a week. The median number of servings of fruit and vegetables consumed daily was 1 (range: 0–4) and 2 (range: 0–4), respectively. Only 7% (95% CI: 3.9%–11.5%) slum residents consumed minimum 5 servings of fruits and vegetables.

Physical activity

56.0% (95% CI: 48.8%–63.0%) of individuals were doing moderate physical activity and only 11.5% (95% CI: 7.4%–16.8%) were resorting to vigorous physical activity. Physical activity of 40.0% (95% CI: 33.2%–47.1%) of individuals was less than recommended 600 MET-minutes in a week. Higher proportion of males were involved in vigorous activity (males - 19.6%, females - 3.1%, P < 0.001) in comparison to females who predominantly were involved in moderate activity (males - 46.1%, females - 66.3%, P = 0.005).

Anthropometry findings

The prevalence of overweight (BMI 25–29.99 kg/m2) was 34.0% (95% CI: 27.5%–41.0%) while obesity (BMI ≥ 30 kg/m2) prevalence was 13.0% (95% CI: 08.7%–18.5%). Females had higher hip circumference and lower height, weight, and waist–hip ratio as compared to males [Table 2].
Table 2: Anthropometric findings

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High blood pressure

In our study, the prevalence of high blood pressure was 43.9% (95% CI: 36.6%–51.3%). Mean (SD) heart rate of study participants was 84.0 (12.5) beats/min and mean (SD) systolic and diastolic BP was 131.0 (21.3) and 86.2 (12.5) mm of Hg, respectively. The prevalence of high blood pressure was greater among males (47.4, 95% CI: 37.0%–57.9%) as compared to females (40.2%, 95% CI: 30.1%–51.0%), though the difference was statistically not significant. Many of anthropometry variables were found to be correlated with each other as well as with blood pressure [Figure 1]. We found that age, BMI, and waist–hip ratio were positively associated with high blood pressure while moderate or vigorous physical activity was inversely associated with high blood pressure. In multi-variable analysis, high blood pressure was found to be associated with age and waist–hip ratio [Table 3].
Figure 1: Correlation matrix between anthropometry, heart rate, and blood pressure (size and color density of circle is proportionate to correlation between two variables. Blue color indicates positive correlation and red color is for negative correlation)

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Table 3: Factors associated with High blood pressure

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  Discussion Top


Regular studies on the prevalence of common NCD risk factors are essential for prevention and control of NCDs in the community. STEPS methodology used in this study is a widely accepted method to study NCD risk factors across the world. Standardized questions and protocols of STEPS assist in monitoring trends of NCD risk factors within country as well as for making between-country comparisons. In our study, we observed high prevalence of NCD risk factors in slum area. Other studies carried out in slum population in different parts of India had also reported similar high prevalence of these risk factors for NCD.[15],[16],[17],[18]

We observed that consumption of any form of tobacco was higher among males (35.3%) than females (9.2%), which is similar to the data provided by NFHS-4[12] and study by Bhagyalaxmi et al.[13] However, tobacco consumption in our study was less than the one reported in a study done in North India (at 48.3% and 11.9%).[17] It was also observed that chewable tobacco was the predominant form of tobacco consumption among females while among males, smokeless tobacco as well as smoking were equally common. This can be due to the fact that smoking of any kind is associated with something only men do and is considered taboo for women to be seen smoking, especially in low socio-economic strata. The prevalence of alcohol consumption in the study population was 13.5% with 24.5% males and 2.04% females giving history that they have consumed alcohol. These proportion among males is similar to what has been reported for males in Haryana at 28.9%[23] and urban Maharashtra 22.8%[12] but is higher for females in comparison to same studies at 0% and 0.2% respectively. These high levels of tobacco and alcohol consumption in urban slums are matter of concern as it is not only harming their health but also aggravating their financial problems. These people are spending part of their limited earnings for purchasing these harmful substances leading to lesser availability of money for proper nutrition as well as for education of their children. Our study also found that people in urban slum were not consuming enough fruits and vegetables. This may be due to low purchasing power of people staying in urban slum as well as due to poor awareness about importance of vegetable and fruit consumption for healthy life. Hence, it is important to carry out regular information, education and communication campaigns against NCD risk factors in slum areas to achieve behavior change among slum residents.

In our study, 34% of participants were overweight while 13% were obese. These findings were similar to other studies in India[10],[14] which have also found around 35–40% prevalence of overweight/obesity. This high prevalence levels of overweight and obesity depicts rise in unhealthy lifestyle even in urban slum areas. Unhealthy diet as well as sedentary life style are the main factors responsible for overweight problem of slum residents. In our study, around 40% of participants were doing less than adequate physical activity. This shows that unhealthy sedentary lifestyle is becoming more common in slum areas also.

We also found high levels of prevalence of high blood pressure among slum dwellers. Similar prevalence levels were reported from slums in Mumbai[18] and Punjab,[11] however, studies in Haryana,[10],[16] have reported lower prevalence levels of high blood pressure (16%–26%). Unhealthy diet including high salt consumption, inadequate consumption of fruit and vegetables, central obesity and sedentary lifestyle contributes to raised blood pressure. High blood pressure is the leading cause of mortality and DALY in India[1] and efforts are required to address this problem in slum areas.

One of the major limitations of our study is that we could carry out study in one slum area only and hence, our study has limited external validity. Second, we could not study biochemical measurements of blood glucose and lipid profile among study participants. Nonetheless, the findings of our study bring out important aspect of high prevalence of risk factors for NCDs in slum population. These risk factors are now not restricted to high socio-economic strata of society but are becoming important public health problem in slum areas also. We recommend that regular awareness campaigns should be carried out in slums to educate slum dwellers about prevention of NCDs. Regular surveillance should also be done in slums to study change in NCD risk factor prevalence over time and its determinants.


  Conclusions Top


Unhealthy diet, inadequate physical activity, consumption of tobacco and alcohol, overweight and high blood pressure are common NCD risk factors prevalent in slum population. There is a definite need to focus on prevention of NCDs in poor socio-economic strata of Indian society. Specific behavior change communication strategies are required to be developed to address unhealthy lifestyle in urban slums.

Financial support and sponsorship

This study was supported by MUHS Short Term Research Grant for Under-graduate Students.

Conflicts of interest

There are no conflicts of interest.



 
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