| VOLUME 20, NUMBER 3 |
MAY/JUNE 2007 |
Original Articles 115
Are the urban poor vulnerable to non-communicable diseases? A
survey of risk factors for non-communicable diseases in urban
slums of Faridabad
K.
Anand, Bela Shah, Kapil Yadav, Ritesh Singh, Prashant Mathur,
Eldho Paul, S. K. Kapoor
ABSTRACT
Background. Non-communicable
diseases have modifiable risk factors, which are easy to
measure and can help in planning effective interventions. We
established a community-based sentinel surveillance to
estimate the prevalence and level of common risk factors for
major non-communicable diseases as part of a joint Indian
Council of Medical Research/WHO initiative.
Methods. This survey was done from
February 2003 to June 2004 and included 1260 men and 1304
women 15–64 years of age living in urban slum areas of
Ballabgarh block, Faridabad district, Haryana. A list of all
slums in Ballabgarh block was obtained from the Municipal
Corporation of Faridabad. Slums were selected by stratified
cluster sampling. All households in the selected slums were
visited and men and women interviewed in alternate households.
The study instrument was based on the STEPS approach of WHO.
It included questions related to tobacco use, alcohol intake,
diet, physical activity, and history of treatment for
hypertension and diabetes mellitus. Height, weight,
waist circumference and blood pressure were measured. To
estimate prevalence at the population level, age adjustment
was done using the urban Faridabad population structure from
the 2001 Census of India.
Results. The age-adjusted prevalence of
smoking among men was 36.5% compared with 7% in women. Bidi
was the predominant form of smoked tobacco used. The use of
smokeless tobacco was reported by 10.2% of men and 2.9% of
women. While 26% of men reported consuming alcohol in the past
1 year, none of the women did. The mean number of servings per
day of fruits and vegetables was 2.7 for men compared with 2.2
for women. Overall, only 7.9% and 5.4% of men and women,
respectively took >5 servings per day of fruits and
vegetables. Women were more likely to be
physically inactive compared with men (14.8% v. 55%);
67% of men and 22.8% of women reported mean physical activity
>150 minutes per week. The mean body mass index (BMI) was
lower in men than in women (20.9 v. 21.9 kg/m2).
The prevalence of overweight (BMI > 25 kg/m2))
was 16% among men and 21.9% among women. The prevalence of
hypertension (blood pressure >140/>90 mmHg or on
an antihypertensive drug) was 17.2% in men and 15.8% in women.
Conclusion. The high prevalence of
risk factors for non-communicable diseases across all age
groups in this urban slum community indicates the likelihood
of a high future burden of illness. Immediate action for
prevention and control is required to prevent the situation
from worsening.
Natl Med J India 2007;20:115–20
INTRODUCTION
Non-communicable diseases (NCDs) are
responsible for a high proportion of deaths and disabilities.
WHO estimated that, in 2000, NCDs and mental disorders caused
59% of deaths and 46% of the global burden of disease.1
Based on available trends, by 2020 NCDs are predicted to
account for 73% of deaths and 60% of disease burden. 2
Much of the projected rise in NCDs is preventable,
particularly those related to smoking, poor diet, physical
inactivity and obesity. Economic development in wealthy
countries was accompanied by the emergence of NCDs as the
predominant health problem. As a result, NCDs are often
referred to as ‘diseases of affluence’—a misleading term. A
more accurate label is ‘diseases of urbanization’. Several
studies from developing countries have shown increased levels
of high blood pressure and the presence of other risk factors
for NCDs in urban compared with rural populations.
In 2001, 28% of the total population in India was living in
urban areas, which was projected to increase to about 50%
(605–618 million) by 2021–25.3
Demographic trends show that while the urban average growth
rate stabilized at 3% over the past decade (1991–2001), the
slum growth rate doubled. An alarming feature of the growth of
the urban population is the proportion of people living in
poverty; official estimates place it at 32%. Projections
suggest that while the urban population will double in the
next 10 years, the urban poor will double in just 5 years.4
It is evident that the urban poor have the worst of both
worlds—they adopt a more urbanized lifestyle which places them
at a higher risk for NCDs and have poor access to healthcare,
partly related to their poor purchasing ability.
It is important to assess the prevalence of risk factors
for NCDs in a community and monitor their trend over a period
of time so as to identify areas for intervention as well as
evaluate the effectiveness of interventions. The Indian
Council of Medical Research (ICMR) and WHO Country Office,
India jointly initiated sentinel surveillance centres in 5
sites, of which Ballabgarh was one. We present the results of
the first survey documenting the prevalence of risk factors
for NCDs among urban adult slum dwellers in Faridabad
district, which is adjacent to Delhi and falls within the
National Capital Region.
METHODS
The survey protocol was based on the STEPS
approach of WHO,5 according to which a
minimum sample of 250 individuals was to be interviewed for
each 10-year age group. Five such age groups were included for
both sexes (15–24 years, 25–34 years, 35–44 years, 45–54 years
and 55–64 years). Thus, a total of 2500 individuals were to be
interviewed. A list of all the slums in Ballabgarh block was
obtained from the Municipal Corporation of Faridabad. The
slums were selected from each of the 4 wards based on the
probability proportion to size in Ballabgarh block. All the
households were visited in the selected slums and men and
women interviewed in alternate households. Within a household,
a list was made of eligible members in the various age groups
and as per gender requirements and one member selected
randomly (using the last digit of the serial number of a
currency note). After the selected slums were covered, the
numbers in the age group 15–24 and the older age groups of
45–54 and 55–64 years were found to be insufficient.
Therefore, additional areas were selected from the uncovered
sampling units and in these areas only respondents for these
age groups were recruited for interview.
The study instrument included a questionnaire based on the
STEPS5 approach of WHO, suitably
modified and translated in the local language. This had 5
parameters related to tobacco and alcohol use, diet, physical
activity and history related to treatment of hypertension and
diabetes. According to the STEPS questionnaire physical
activity was divided into 3 grades of vigorous, moderate and
inactive continued for >10 minutes.
|
Definitions
Current daily
smokers: Currently smoking cigarettes, bidis or
hookah daily.
Current daily smokeless tobacco users: Currently using
chewable tobacco products such as gutka, naswar,
khaini or zarda paan daily.
Current alcohol drinkers: Report consuming alcohol
within the past 1 year.
One standard drink: Equivalent to consuming 1 standard
bottle of regular beer (285 ml), one single measure of
spirits (30 ml) or one medium size glass of wine (120 ml).
One serving of vegetable:
1 cup of raw green leafy vegetables, ½ cup of other
vegetables (cooked or chopped raw) or ½ cup of vegetable
juice.
One serving of fruit:
1 medium size piece of apple, banana or orange, ½ cup of
chopped, cooked, canned fruit or ½ cup of fruit juice, not
artificially flavoured.
Physical inactivity:
Less than 10 minutes of activity at a stretch during
leisure, work or transport.
Overweight: Body mass
index >25 kg/m2
Obesity: Body mass
index >30 kg/m2
Hypertension: Blood pressure >140/>90
mmHg or currently on antihypertensive drugs.
Source: WHO STEPS manual5 |
Vigorous activity was defined as activity
that made the person feel breathless and have palpitations;
moderate activity as not much breathlessness; and inactive or
least active as no felt variation in heart rate and
respiratory rate. These three grades of activity were measured
separately under three domains—occupation (including housework
for women), transport and leisure.
Height, weight and waist measurements were taken using
SECA instruments. The weight was measured to the nearest
0.1 kg and height to the nearest 1 cm. The body mass index
(BMI) was calculated. The weight instrument was regularly
calibrated against a standard weight. Waist was defined as the
mid-point between the lower margin of the rib and upper border
of the iliac crest in the mid-axillary plane. The blood
pressure was measured with a digital sphygmomanometer
(OMRAN-MX2 with adult size cuff) and two recordings were taken
in the sitting position at an interval of 5 minutes. If the
difference in the readings was >10 mmHg, a third reading was
taken. The mean of 2 (or 3) readings was taken as the final
measurement. All measurements were taken at home.
Three men and women workers each were trained in a 3-day
workshop at Ballabgarh to conduct the interviews, fill up the
schedules and take various measurements. The site
investigators (KA, SKK) had been previously trained in the
STEPS methodology. Field-testing of the schedule was
done in a different area with each worker covering
around 50 houses. The investigators checked the filled formats
and the problem areas were identified and re-training provided
in these areas.
Data were collected from April 2003 to January 2004.
Supervision of the survey was done from time to time by the
investigators and the ICMR team. A re-training session was
held for 1 day in the month of September 2003.
Each individual interviewed was explained in detail the
purpose of the study and written informed consent was taken.
The ethics committee of the All India Institute of Medical
Sciences (AIIMS) approved the study. The common queries by the
participants were answered by the field workers and those who
wanted further information or were identified to have problems
were referred to the Civil hospital, Ballabgarh which is run
by AIIMS.
Statistical analysis
Data entry was done in visual basic. An independent data
entry operator re-entered 10% of the data and a discrepancy
was detected in only 3.2% of cases. Data analysis was done
using
|
Table
I. Prevalence (95% CI) of smoked tobacco use, smokeless
tobacco use and alcohol consumption by age and sex |
|
Age (in
years) |
Men (n=1258)
|
Women* (n=1304) |
| |
Tobacco
use (%) |
Alcohol
consumption
(%) |
Tobacco
use (%) |
|
Smoked |
Smokeless |
|
Smoked
|
Smokeless |
| 15–24
|
12.0
(7.9–16.0) |
5.6 (2.7–8.4) |
12.8
(8.6–16.9) |
0 |
1.2 (0.1–2.5) |
| 25–34
|
37.5
(31.5–43.5) |
15.0
(10.5–19.4) |
32.0
(26.2–37.8) |
4.4 (2.0–6.7) |
3.4
(1.3–5.4) |
| 35–44
|
53.2
(46.9–59.3) |
10.3
(6.5–14.0) |
36.9
(30.9–42.9) |
11.7
(7.7–15.6) |
2.7 (0.7–4.7) |
| 45–54 |
56.6
(50.3–62.7) |
12.4
(8.2–16.4) |
30.7
(24.9–36.4) |
14.4
(10.0–18.7) |
2.0 (2.5–3.7) |
| 55–64 |
62.6
(56.6–68.5) |
9.4
(5.8–13.0) |
20.1
(15.1–25.0) |
24.8
(19.4–30.1) |
7.6
(4.2–10.9) |
Age-adjusted
prevalence† |
36.5
(33.7–39.1) |
10.2
(8.5–11.9) |
25.9
(23.5–28.3) |
7.0 (5.5–8.3)
|
2.7 (1.7–3.5) |
|
* none of the women reported alcohol consumption †Adjusted
to urban Faridabad age strata (Census 2001) |
SPSS version 11 (SPSS Inc., Chicago) and
Stata version 8 (Statacorp, Texas).
Since the exact age and sex distribution of the slum
population of Ballabgarh block was not available, the age
distribution of the total urban population of Faridabad
Municipal Corporation according to the 2001 Census of India6
was used to calculate the weightage to be used to obtain the
summary measure from the age- and sex-specific rates.
Results
Of the 2564 individuals interviewed for the study, 1304
were women; 114 women (4.4% of the sample) were found to be
pregnant and were excluded from anthropometric examination.
The mean (SD) number of years spent in school was 9.5 (4.5)
years for men compared with 5.4 (4.9) years for women. Among
men 7.5% had never attended school compared with 38.7% women.
The main employment of men was clerical/medium business
(37.6%) followed by the self-employed/skilled group (34.7%)
whereas women were mainly housewives (89.6%).
Tobacco use
Smoking was more prevalent among men
(36.5%) compared with women (7%) (Table I). Among men, the use
of smoked tobacco increased significantly from 12% in the
15–24 years age group to 37.5% in the 25–34 years age group
(Fig. 1) and stabilized at around 50% after 35 years of age.
The mean age of starting to smoke was 21 years for men (median
20 years) and 30.9 years for women (median 22 years). Among
women, none of the respondents in the 15–24 years age group
reported smoking and an increase was seen from 14.8% to 24.8%
after the age of 54 years. The mean duration of smoking was
17.9 years for men and 12.8 years for women. Bidi was
the predominant form of smoked tobacco used by both men and
women (around 90%) followed by cigarettes (13.6%) among men
and hookah (22%) among women.
The use of smokeless tobacco was reported by 10.2% of men
and 2.9% of women. Trends across age were similar to those
seen for the use of smoked tobacco. The predominant form of
smokeless tobacco used by men was khaini (68.9%)
followed by gutkha (31%), whereas among women khaini,
gutkha and chewed tobacco were each used by about
one-third.
Alcohol consumption
About a quarter of the men (25.9%) reported
consuming alcohol in the past 1 year and none of the women
reported ever consuming alcohol (Table I). Only 12.8% of men
in the 15–24 years age group consumed alcohol. This increased
to 36.9% in the 34–45 years age group. Overall, 31.6% of men
reported ever consuming alcohol and the difference between the
prevalence of ever consumption and current consumption of
alcohol increased significantly after the age of 45 years (a
difference of 2% in the 15–24 years age group compared with a
difference of 13% in the 55–64 years age group). Among men
respondents who had consumed alcohol in the past 1 year, 25%
had consumed alcohol at least once a week and the mean number
of drinks per drinking session was 3.2. Among those who
reported alcohol consumption in the past 1 week (10.5%), the
mean number of drinks consumed per day was 1.6; 11.8% of these
consumed more than 4 standard drinks per day (high risk group)
and 3.5% consumed more than 10 standard drinks per day (very
high risk group).
Dietary habits
The mean number of servings per day of
fruits and vegetables for men was 2.7 compared with 2.2 for
women (Table II). No significant trend was seen across age
groups for both men and women except in the 55–64 years age
group where it decreased. Overall, only 7.9% and 5.4% men and
women, respectively, consumed a mean of >5 servings/day
of fruits and vegetables. The mean number of servings of
vegetables was greater than fruits across all age groups in
both sexes. About 95% of the study population irrespective of
sex reported the most commonly consumed type of oil to be
refined/unhydrogenated oil. The next most common oil consumed
was hydrogenated vegetable oil (2.1%) followed by butter or
ghee (1.8%).
Physical activity
Women were found to be more physically
inactive compared with men (55% v. 14.8%; Table III).
An increasing trend of physical inactivity with age was seen
among men whereas among women,
extremes of age reported maximum physical
inactivity and the 35–44 years age group reported the least
physical inactivity. While 77.5% of men and 41.9% women
reported any moderate activity, only 7.8% of men and 3.2% of
women reported any vigorous activity. The mean duration of
physical activity per day was 95.2 minutes for men and 54.1
minutes for women; 67% of men and 22.8% of women reported mean
physical activity >150 minutes per week. Among men, 7.4%
reported any leisure time activity, 13.8% reported any work
time activity and 81.6% reported any transport activity (Fig.
2). The percentage reporting leisure time activity was maximum
at the extremes of age among men (11% in the 15–24 years and
55–64 years age groups compared with 5.1% for the 35–44 years
age group). However, no such trend with age was seen among
women. The mean activity per week by domain among men who
reported being physically active in that domain was 323.77
minutes for work, 35.90 minutes for leisure and 202.13 minutes
for transport time activity. The corresponding values reported
by women were 74.10 minutes, 44.44 minutes and 52.51 minutes
per week. Thus, although the majority of respondents of both
sexes reported transport as the main domain of physical
activity, it was lesser in terms of duration of physical
activity.
BMI and waist circumference
The mean BMI was lower in men compared with women (20.9
kg/m2 v.
21.9 kg/m2). This
difference was observed across all age groups with the
difference widening after the age of 35 years (Tables IV and
V). Among both sexes, the mean BMI increased with age and
declined only in the 55–64 years age group. The percentage of
overweight men in the study population (BMI >25 kg/m2)
was 16% and women 21.9%. This increased to 26.7% and 34%,
respectively, if a cut-off of 23 kg/m2
was used. Among
 |
women, the prevalence of overweight
increased significantly after 25 years of age and was 35% in
the 35–44 years age group and 49.7% in the 45–54 years age
group. Fewer women were overweight than men up to the age of
34 years after which there was a significant increase among
women (Fig. 3). Also, 29% of men and 21.2% of women were
underweight (BMI <18.5 kg/m2).
The mean waist circumference of men was 79 cm and of women
76.2 cm. In men the percentage with a waist circumference >102
cm was 3.5%, being maximum in the 45–54 years age group. The
prevalence of waist circumference >88 cm was 20.6% in women,
with the 45–54 years age group having the highest prevalence
(45.5%).
Blood pressure and diabetes
A total of 22.4% men and 48.8% women reported having had a
blood pressure measurement taken in the past 12 months and
3.9% of men and 9.5% of women reported having been diagnosed
to be hypertensive in the past 12 months (Table VI). Only 2.1%
of men
and 4.2% of women were currently on
antihypertensive drugs, indicating a treatment gap of around
50%.
The prevalence of hypertension (blood pressure >140/>90
mmHg) was 17.2% in men and 15.8% in women (those currently on
antihypertensive treatment were classified as hypertensive
irrespective of their blood pressure values). In both sexes
the prevalence of hypertension increased with age. The mean
systolic blood pressure was 122.7 mmHg in men and 117.8 mmHg
in women. The mean diastolic blood pressure was 75.6 mmHg in
men and 74.2 mmHg in women.
The self-reported prevalence of diabetes mellitus over the
past 1 year was 1.4% in men and 1.3% in women. The prevalence
showed an increasing trend with age, more so in women. Only
9.5% of men and 12.5% of women reported having had their blood
sugar levels measured in the past 1 year.
Discussion
Our study documents a high prevalence of risk factors for
NCDs in an urban slum population of Haryana. Almost one-third
of the study population had at least one risk factor. While
data from these slums cannot be generalized to the rest of the
country, it does
indicate that this segment of the
population is also vulnerable to NCDs. A limited number of
studies have been done to assess the prevalence of risk
factors for NCDs in urban slum residents. 12-15
The STEPS instrument focuses on collecting good quality
data that is comparable across countries. The questions
included in the core section can be collected easily under
field conditions and have been validated for use across
different countries. The assessment of diet and physical
inactivity is the most difficult. The section on food asks
questions about quantification, fruit and vegetable intake,
and type of cooking medium used. The Global Physical Activity
Questionnaire (GPAQ) used as a part of STEPS has been found to
be a reliable and valid tool. This instrument assesses
physical activity across three domains: work, transport and
leisure.7 However,
measuring physical activity using the questionnaire imposes
restrictions. We feel this instrument underestimates regular
physical activity at work, especially housework and leisure
time activity.
The National Family Health Survey-2 (NFHS-2) provides data
on tobacco and alcohol use though the methods of assessment
and age groups studied were different.8
The reported smoked tobacco use among men and women in Haryana
was 40.4% and 3.5%, respectively.
Different cut-off points have been used in different
studies to indicate the risk from alcohol consumption, e.g.
>30 g of absolute alcohol per day is quantified as moderate
risk by the British Medical Association (1995)9
and >40 g by English et al.10
In our study, 36% of the population had ever consumed alcohol
in the 7 days prior to the study. Most of them had consumed
1–40 g of ethanol (low risk). However, 4.4% of current
drinkers had consumed >60 g of ethanol during the past 7 days,
which put them in the high and very high risk groups. Gupta
et al.11
assessed the prevalence and pattern of alcohol use in men >45
years of age from the lower and lower–middle sections of the
general population in Mumbai and showed that 18.8% currently
consumed alcoholic beverages. The highest number of those
consuming alcohol was in the 55–59 years age group (21.5%). In
our study, current consumption of alcohol was relatively
higher in the younger age groups (36.9% of current consumers
of alcohol were in the 35–44 years age group). This may have
adverse economic implications for the community and the
country.
The consumption of an inappropriate diet is associated with
many NCDs. However, few Indian studies have quantified the
consumption of fruits and vegetables in the general
population. We found that >95% (96.9% men and 95.6% women) of
respondents used refined vegetable oil for cooking.
For individuals, regular and adequate daily physical
activity is an effective and powerful means of preventing
chronic diseases; for nations, it can provide a cost-effective
way of improving public health. We found that women were less
active than men. Physical activity for transportation was low
suggesting that motorized transport was the main mode of
travel.
Our study shows that both undernutrition and overnutrition
coexist in the same population. Mishra et al. found the
prevalence of obesity in urban slums to be 15.6% in women and
13.3% in men.12 A large cross-sectional
study among men and women aged >35 years from in Mumbai
found that 19% of men and 30% of women were overweight (BMI
>25 kg/m2).13
Although hypertension is more prevalent in men as a
group, the gap between men and women decreases as age
advances. Among the older age groups, women had a higher mean
blood pressure. Gurav et al. studied the prevalence of
hypertension in the >35 years age group in an urban slum
community in Mumbai14 and found that 12%
of men and 22.6% of women had a blood pressure >140/>90
mmHg. In Delhi, Chadha et al.15
observed that the mean blood pressure in the 25–64 years age
group was 127.5 per 1000 (116.6 per 1000 in men and 136.8 per
1000 in women). Gupta reviewed the recent studies on
prevalence of hypertension in different communities.16
Using systolic blood pressure >140 and/or diastolic
>90 mmHg as the criteria for hypertension they found a
high prevalence of hypertension among urban adults in Jaipur
(men 30%, women 33%), Mumbai (men 44%, women 45%),
Thiruvananthapuram (31%, women 36%) and Chennai (14%). Our
findings are similar.
Conclusion
Our study shows a high prevalence of risk
factors for NCDs in an urban slum of Haryana. The population
residing in these slums is generally poor and thought to be at
low risk for lifestyle diseases. Our results show that many
risk factors were prevalent at levels higher than in urban
areas. With little or no social and health systems to support
them, this group needs urgent intervention. To tackle the
emerging epidemic of NCDs the government has started the
Integrated Disease Surveillance Programme (IDSP) to provide a
rational basis for decision-making and implementing public
health interventions.17 The sampling
design adopted for the IDSP has to ensure that it generates
information for slums as well.
Combating NCDs requires action at the community, local and
national levels. At the national level, framing appropriate
policies for tobacco and alcohol control, and promotion of a
good diet and adequate physical activity is needed.
Simultaneously, there is a need to reorient and strengthen the
health system to address the challenge of NCDs. At the
community level, we need to create an environment that
promotes the adoption of healthy behaviours.
The results of our survey have been shared with the
district-level authorities as well as the community. A
community-based alliance called ‘Friends of City’ has been
formed to carry out community-based activities with the
technical support of our team.
ACKNOWLEDGEMENTS
This work
presents the results of one of five sites of the multisite
initiative of ICMR and we acknowledge the contribution of the
investigators of the other four sites (Drs J. C. Mahanta, K.
Thankappan, V. Mohan and Prashant Joshi) in its planning and
design. We also acknowledge the technical guidance provided by
WHO, particularly Drs Cherian Varghese (WHO India), Jerzy
Leowski (WHO/SEARO) and Ruth Bonita (formerly with WHO/HQ) and
ICMR (Drs D. K. Shukla and Geeta Menon).
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