Electrocardiogram abnormalities and renal impairment in patients with type 2 diabetes mellitus: A healthcare facilities-based cross-sectional study in Dang district of Nepal.

AIMS/INTRODUCTION: The global burden of diabetes mellitus is rising substantially, with a further increase in cardiovascular and kidney disease burden. These public health problems are highly prevalent in low- and middle-income countries, including Nepal. However, there is limited evidence on cardiac and renal conditions among patients with type 2 diabetes mellitus. We determined the status of electrocardiogram (ECG) abnormalities and renal impairment among patients with type 2 diabetes mellitus in Nepal. METHODS: We carried out a cross-sectional study in Tulsipur Sub-Metropolitan City of Nepal using a multistage stratified sampling technique to recruit patients with type 2 diabetes mellitus. We used World Health Organization stepwise approach to surveillance (WHO STEPS) questionnaires and carried out resting ECG to collect data of 345 patients with type 2 diabetes mellitus. Logistic regression analysis assessed the factors associated with ECG abnormalities and renal impairment. RESULTS: The study showed that 6.1% of participants had major ECG abnormalities (95% confidence interval [CI] 3.8-8.6%), which were associated with hypertension (P = 0.01%) and low socioeconomic status (P = 0.01). The proportion of major and/or minor ECG abnormalities was 47.8% (95% CI 40.5-51%), and were significantly associated with age (odds ratio [OR] 1.04, 95% CI 1.01-1.07), higher education (OR 3.50, 95% CI 1.31-9.33), unemployment (OR 3.02, 95% CI 1.08-8.48), body mass index (OR 1.09, 95% CI 1.02-1.17) and duration of type 2 diabetes mellitus >5 years (OR 2.42, 95% CI 1.19-4.93). The proportion of renal impairment was 3.5% (95% CI 1.5-4.5%) which was associated with older age (OR 1.08, 95% CI 1.00-1.17) and hypertension (OR 12.12, 95% CI 1.07-138.22). CONCLUSION: A significant proportion of patients with type 2 diabetes mellitus had ECG abnormalities and renal impairment, which were significantly associated with hypertension. Therefore, hypertension management and early screening are essential to prevent future cardiorenal complications among patients with type 2 diabetes mellitus.

Poor glycemic control, cardiovascular disease risk factors and their clustering among patients with type 2 diabetes mellitus: A cross-sectional study from Nepal.

BACKGROUND: Cardiovascular disease (CVD) is the most common complication of diabetes mellitus (DM). To prevent morbidity and mortality among patients with type 2 diabetes mellitus (T2DM), optimization of glycemic status and minimizing CVD risk factors is essential. As Nepal has limited data on these CVD risk parameters, we assessed the prevalence of poor glycemic control, CVD risk factors, and their clustering among patients with T2DM. METHODS: Using a cross-sectional study design, we collected data of 366 patients with T2DM. We applied a multistage cluster sampling technique and used the WHO STEPS tools. Binary logistic and Poisson regression was applied to calculate odds and prevalence ratio of clustering of risk factors, considering P< 0.05 statistically significant. RESULTS: The mean age of participants was 54.5±10.7 years and 208 (57%) were male. The prevalence of poor glycemic control was 66.4% (95% C.I: 61.5-71.2). The prevalence of smoking, alcohol users, inadequate fruit and vegetables intake and physical inactivity were 18% (95% C.I:14 to 21.9), 14.8% (95% C.I:11.1 to 18.4), 98.1% (95% C.I: 96.7-99.4), and 9.8% (95% C.I:6.7-12.8), respectively. Overall, 47.3% (95% C.I: 42.1-52.4) were overweight and obese, 59% (95% C.I: 52.9-63) were hypertensive, and 68% (95% C.I: 63.2-72.7) had dyslipidemia. Clustering of two, three, four, five and more than five risk factors was 12.6%, 30%, 30%,19%, and 8.7%, respectively. Four or more risk factors clustering was significantly associated with gender, age, level of education, T2DM duration, and use of medication. Risk factors clustering was significantly higher among males and users of anti-diabetic medications with prevalence ratio of 1.14 (95% C.I:1.05-1.23) and 1.09 (95% C.I: 1.09-1.18)], respectively. CONCLUSIONS: The majority of the patients with T2DM had poor glycemic control and CVD risk factors. Policies and programs focused on the prevention and better management of T2DM and CVD risk factors should be implemented to reduce mortality in Nepal.

Effectiveness of community-based health education and home support program to reduce blood pressure among patients with uncontrolled hypertension in Nepal: A cluster-randomized trial.

BACKGROUND: Hypertension is a major global public health problem. Elevated blood pressure can cause cardiovascular and kidney diseases. We assessed the effectiveness of health education sessions and home support programs in reducing blood pressure among patients with uncontrolled hypertension in a suburban community of Nepal. METHODS: We conducted a community-based, open-level, parallel-group, cluster randomized controlled trial in Birendranagar municipality of Surkhet, Nepal. We randomly assigned four clusters (wards) into intervention and control arms. We provided four health education sessions, frequent home and usual care for intervention groups over six months. The participants of the control arm received only usual care from health facilities. The primary outcome of this study was the proportion of controlled systolic blood pressure (SBP). The analysis included all participants who completed follow-up at six months. RESULTS: 125 participants were assigned to either the intervention (n = 63) or the control (n = 62) group. Of them, 60 participants in each group completed six months follow-up. The proportion of controlled SBP was significantly higher among the intervention participants compared to the control (58.3% vs. 40%). Odds ratio of this was 2.1 with 95% CI: 1.01-4.35 (p = 0.046) and that of controlled diastolic blood pressure (DBP) was 1.31 (0.63-2.72) (p = 0.600). The mean change (follow-up minus baseline) in SBP was significantly higher in the intervention than in the usual care (-18.7 mmHg vs. -11.2 mmHg, p = 0.041). Such mean change of DBP was also higher in the intervention (-10.95 mmHg vs. -5.53 mmHg, p = 0.065). The knowledge score on hypertension improved by 2.38 (SD 2.4) in the intervention arm, which was significantly different from that of the control group, 0.13 (1.8) (p<0.001). CONCLUSIONS: Multiple health education sessions complemented by frequent household visits by health volunteers can effectively improve knowledge on hypertension and reduce blood pressure among uncontrolled hypertensive patients at the community level in Nepal. TRIAL REGISTRATION: ClinicalTrial.gov: NCT02981251.

Effects of a health worker-led 3-month yoga intervention on blood pressure of hypertensive patients: a randomised controlled multicentre trial in the primary care setting.

BACKGROUND: Hypertension control remains a major challenge globally. A recent systematic review suggested that yoga has beneficial effects on reducing blood pressure. However, the role of yoga in hypertension management in primary health care has received little attention, and no studies have evaluated the impact of a yoga program fully delivered by health care staff on hypertension. This study, therefore, assessed the effects of a health worker-led yoga intervention on blood pressure reduction among hypertensives patients in the primary care setting. METHODS: This was a multicentric, two-arm, randomised trial conducted among hypertensive patients in seven Ayurveda Health Centres in Nepal between March 2017 and June 2018. One hundred and twenty-one participants who were on or without medications were randomised to intervention (n = 61) and wait-list control (n = 60) groups using stratified block randomisation. Participants in the intervention arm received an intervention consisting of an initial five-day structured yoga training at the centres and then a further home-based practice of yoga for five days a week for the following 90 days. Both intervention and control groups also participated in a 2-h health education session. The primary outcome of this trial was systolic blood pressure at 90-day follow-up. Data were analysed on an intention-to-treat basis using linear mixed-effects regression models. RESULTS: We included all 121 study participants (intervention/control = 61/60) in the primary analysis (52.1% males; mean ± SD age = 47.8 ± 10.8 years). The difference in systolic blood pressure between the intervention group and the control group was - 7.66 mmHg (95% CI: - 10.4, - 4.93). For diastolic blood pressure, the difference was - 3.86 mmHg (95% CI: - 6.65, - 1.06). No adverse events were reported by the participants. CONCLUSIONS: A yoga program for hypertensive patients consisting of a five-day training in health centres and 90 days of practice at home is effective for reducing blood pressure. Significant benefits for hypertensive patients could be expected if such programmes would become a part of the standard treatment practice. TRIAL REGISTRATION: This trial was prospectively registered with the Clinical Trial Registry of India [ CTRI/2017/02/007822 ] on 10/02/2017.

Impact of a structured yoga program on blood pressure reduction among hypertensive patients: study protocol for a pragmatic randomized multicenter trial in primary health care settings in Nepal.

BACKGROUND: Hypertension control remains a major global challenge. The behavioral approaches recommended for blood pressure reduction are stress reduction, increased exercise and healthy dietary habits. Some study findings suggest that yoga has a beneficial effect in reducing blood pressure. However, the role of yoga on blood pressure has received little attention in existing health care practices in developing countries. This study will be conducted in primary health care facilities in Nepal to assess the effectiveness of a pragmatic yoga intervention to complement standard practice in further reducing blood pressure. METHODS: This will be multicentric, two arms, randomized, nonblinded, pragmatic trial. It will be conducted in seven District Ayurveda Health Centers (DAHCs) in Nepal between July 2017 and June 2018. The study participants will consist of hypertensive patients with or without antihypertensive medication attending to the outpatient department (OPD). One hundred and forty participants will be randomized to treatment or control groups by using a stratified block randomization. At the study site, the treatment arm participants will receive an intervention consisting of five days of structured yoga training and practice of the same package at home with a recommendation of five days a week for the following 90 days. Both the intervention and control groups will receive two hours of health education on lifestyle modifications. The primary outcome of this trial will be the change in systolic blood pressure and it will be assessed after 90 days of the intervention. DISCUSSION: This study will establish the extent to which a yoga intervention package can help reduce blood pressure in hypertensive patients. If proven effective, study findings may be used to recommend the governing bodies and other stakeholders for the integration of yoga in the national healthcare system for the treatment and control of hypertension. TRIAL REGISTRATION: Clinical Trial Registry- India (CTRI); CTRI Reg. No- CTRI/2017/02/007822 . Registered on 10/02/2017.

Prevalence and clustering of cardiovascular disease risk factors in rural Nepalese population aged 40-80 years.

BACKGROUND: Cardiovascular diseases (CVD) are the main cause of mortality in low- and middle-income countries like Nepal. Different risk factors usually cluster and interact multiplicatively to increase the risk of developing acute cardiovascular events; however, information related to clustering of CVD risk factors is scarce in Nepal. Therefore, we aimed to determine the prevalence of CVD risk factors with a focus on their clustering pattern in a rural Nepalese population. METHODS: A community-based cross-sectional study was conducted among residents aged 40 to 80 years in Lamjung District of Nepal in 2014. A clustered sampling technique was used in steps. At first, four out of 18 wards were chosen at random. Then, one person per household was selected randomly (n = 388). WHO STEPS questionnaires (version 2.2) were used to collect data. Chi-square and independent t-test were used to test significance at the level of p < 0.05. RESULTS: A total 345 samples with complete data were analyzed. Smoking [24.1% (95% CI: 19.5-28.6)], harmful use of alcohol [10.7% (7.4-13.9)], insufficient intake of fruit and vegetable [72% (67.1-76.6)], low physical activity [10.1% (6.9-13.2)], overweight and obesity [59.4% (54.2-64.5)], hypertension [42.9% (37.6-48.1)], diabetes [16.2% (14.0-18.3)], and dyslipidemia [56.0% (53.0-58.7)] were common risk factors among the study population. Overall, 98.2% had at least one risk factor, while 2.0% exhibited six risk factors. Overall, more than a half (63.4%) of participants had at least three risk factors (male: 69.4%, female: 58.5%). Age [OR: 2.3 (95% CI: 1.13-4.72)] and caste/ethnicity [2.0 (95% CI: 1.28-3.43)] were significantly associated with clustering of at least three risk factors. CONCLUSIONS: Cardiovascular risk factors and their clustering were common in the rural population of Nepal. Therefore, comprehensive interventions against all risk factors should be immediately planned and implemented to reduce the future burden of CVD in the rural population of Nepal.

Development of scoring system for risk stratification in clinical medicine: a step-by-step tutorial.

Risk scores play an important role in clinical medicine. With advances in information technology and availability of electronic healthcare record, scoring systems of less commonly seen diseases and population can be developed. The aim of the article is to provide a tutorial on how to develop and validate risk scores based on a virtual dataset by using R software. The dataset we generated including numeric and categorical variables and firstly the numeric variables would be converted to factor variables according to cutoff points identified by the LOESS smoother. Then risk points of each variable, which are related to the coefficients in logistic regression, are assigned to each level of the converted factor variables and other categorical variables. Finally, the total score is calculated for each subject to represent the prediction of the outcome event probability. The original dataset is split into training and validation subsets. Discrimination and calibration are evaluated in the validation subset. R codes with explanations are presented in the main text.

Prevalence, associated factors, awareness, treatment, and control of hypertension: Findings from a cross sectional study conducted as a part of a community based intervention trial in Surkhet, Mid-western region of Nepal.

BACKGROUND: Hypertension is one of the leading public health problems globally. About half of the deaths from cardiovascular diseases were attributed to hypertension in 2008. Reduction of blood pressure to normal range is one of the major challenges in preventing complications and future burden of cardiovascular diseases. Therefore, this study aims to determine prevalence, awareness, treatment and control of hypertension and its associated factors in Nepal. METHODS: This was a community based cross-sectional study conducted as a part of a community based intervention trial in Birendranagar Municipality of Surkhet district located at the Mid-western region of Nepal. We enrolled 1159 subjects aged 30 years and above. Out of 12 wards (administrative unit), four wards were selected randomly. Three hundred participants were recruited from each selected ward. Trained enumerator collected socio-demographic, anthropometric, and clinical data using standard STEPS questionnaires. RESULTS: Out of all participants, women were 71% and mean age was 47±12.6 years. The overall prevalence of hypertension was 38.9% (95% CI: 36-41.7) while age and sex adjusted prevalence was 40.6%. The hypertension was present in 48.1% (95% CI: 45.2-50.9) of men and 35.2% (95% CI: 32.4-37.9)] of women. Male gender (OR = 1.49), older age (OR = 1.04 per year), Dalit caste (OR = 1.71), past history of cigarettes smoking (OR = 2.78), current alcohol consumption (OR = 1.75), and raised body mass index (OR = 1.17 per unit) were identified as significant factors associated with hypertension. Of total hypertensive respondents, 53.4% (95% CI: 48.7-58) were aware, 29% (95% CI: 24.8-33.1) were receiving treatment for high blood pressure, and 8.2% (95% CI: 5.6-10.7) had controlled blood pressure. The awareness, treatment, and control status were worse in younger participants. CONCLUSIONS: The study revealed high prevalence with low awareness, treatment, and control of hypertension in Nepal. Gender, age, ethnicity, smoking, drinking alcohol, and body mass index were associated with hypertension. Immediate public health and individual measures are warranted to reduce future burden of cardiovascular diseases. TRIAL REGISTRATION: ClinicalTrial.gov (NCT02981251).

Total cardiovascular risk for next 10 years among rural population of Nepal using WHO/ISH risk prediction chart.

BACKGROUND: Cardiovascular diseases (CVD) are the leading cause of morbidity and mortality globally. Primary prevention of CVD based on total CVD risk approach using WHO/ISH risk prediction chart would be more effective to stratify population under different risk levels, prioritize and utilize the scarce resources of low and middle-income countries. This study estimated total 10-year CVD risk and determined the proportion of population who need immediate drug therapy among the rural population of Nepal. METHODS: A community based cross-sectional study conducted among 345 participants aged 40-80 years in rural villages of Lamjung District of Nepal. They were selected randomly from total eighteen wards. Data were collected using WHO STEPS questionnaires. WHO/ISH risk prediction chart for SEAR D was used to estimate total cardiovascular risk. Chi-square and independent t-test were used to test significance at the level of p < 0.05 in SPSS version 16.0. RESULTS: Of the total participants, 55.4% were female. The mean age (standard deviation) of the participants was 53.5 ± 10.1 years. According to WHO/ISH chart proportions of low, moderate and high CVD risk were 86.4%, 9.3%, and 4.3%, respectively. Eleven percent of participants were in need of immediate pharmacotherapy. Age (p = 0.001), level of education (p = 0.01) and occupation (p = 0.001) were significantly associated with elevated CVD risk. CONCLUSION: A large proportion of Nepalese rural population is at moderate and high CVD risk. Immediate pharmacological interventions are warranted for at least one in every ten individuals along with lifestyle interventions. Both population-wise and high-risk approaches are required to minimize CVD burden in the future.

Prevalence of cardiovascular health risk behaviors in a remote rural community of Sindhuli district, Nepal.

BACKGROUND: Cardiovascular disease (CVD) is emerging as a public health menace among low and middle income countries. It has particularly affected the poorest. However, there is paucity of information about CVD risk factors profile among Nepalese rural communities where the majority of people live in poverty. Therefore, this study aimed to identify the prevalence of cardiovascular health risk behaviors in an outback community of Nepal. METHODS: We conducted a descriptive cross-sectional study in Tinkanya Village Development Committee (VDC), Sindhuli between January and March, 2014. Total 406 participants of age 20 to 50 years were selected randomly. Data were collected using WHO-NCD STEPwise approach questionnaires and analyzed with SPSS V.16.0 and R i386 2.15.3 software. RESULT: The mean age of participants was 36.2 ± 9 years. Majority of participants (76.3%) were from lower socio-economic class, Adibasi/Janajati (63.1%), and without formal schooling (46.3%). Smoking was present in 28.6%, alcohol consumption in 47.8%, insufficient fruits and vegetables intake in 96.6%, insufficient physical activity in 48.8%; 25.6% had high waist circumference, 37.4% had overweight and obesity. Average daily salt intake per capita was 14.4 grams ±4.89 grams. Hypertension was detected in 12.3%. It had an inverse relationship with education and socio-economic status. In binary logistic regression analysis, age, smoking, body mass index (BMI) and daily salt intake were identified as significant predictors of hypertension. CONCLUSION: Present study showed high prevalence of smoking, alcohol consumption, insufficient fruit and vegetable intake, daily salt intake, overweight and obesity and hypertension among remote rural population suggesting higher risk for developing CVD in future. Nepalese rural communities, therefore, are in need of population-wide comprehensive intervention approaches for reducing CVD health risk behaviors.