Smokeless tobacco and public health in Bangladesh.

Despite the high prevalence of smokeless tobacco (SLT) use among adults in Bangladesh, SLT was not included in the Tobacco Control Law till 2013. Information on SLT use among Bangladeshi people is inadequate for policymaking and implementing effective control measures. With the aim to identify the prevalence and trends of different SLT products, health and economic impacts, manufacture, and sale of and policies related to SLT in Bangladesh, we carried out a literature review, which involved literature search, data extraction, and synthesis. Evidence suggests that in Bangladesh, SLTs range from unprocessed to processed or manufactured products including Sada Pata, Zarda, Gul, and Khoinee. Over 27% of Bangladeshi adults aged 15 years and older use SLT in one form or other. SLT use is associated with age, sex, education, and socioeconomic status. SLT consumption has reportedly been associated with increased prevalence of heart diseases, stroke, and oral cancer and led to around 320,000 disability adjusted life years lost in Bangladesh in 2010. No cessation service is available for SLT users in public facilities. Compared to cigarettes, taxation on SLT remains low in Bangladesh. The amendment made in Tobacco Control Law in 2013 requires graphic health warnings to cover 50% of SLT packaging, ban on advertisement of SLT products, and restriction to sale to minors. However, implementation of the law is weak. As the use of SLT is culturally accepted in Bangladesh, culturally appropriate public awareness program is required to curb SLT use along with increased tax and cessation services.

Clustering of non-communicable diseases risk factors in Bangladeshi adults: An analysis of STEPS survey 2013.

BACKGROUND: Non-communicable diseases (NCDs) have already become major killers in Bangladesh. Once NCDs are developed, they become chronic health and economic problems. Their primary prevention is linked to their common risk factors. This study was conducted to determine the prevalence of NCD risk factors with a focus on their clustering in Bangladeshi adults. METHODS: This nationally representative study was done in 4,073 (1,812 men and 2,261 women) adults aged 25 years or older selected from rural and urban households. Multistage cluster sampling design was used. Selected variables were in line with steps I and II of WHO stepwise surveillance except alcohol. RESULTS: Forty-four percent used tobacco in any form. Almost 93% did not consume adequate fruit and vegetables (5 servings or more). Thirty eight percent had low physical activity level (<600 MET-minutes/week). One-quarter (26%) were overweight (body mass index > =25 kg/m^2). Twenty-one percent had hypertension (blood pressure > =140/90 mmHg or medication) and about 5% had documented diabetes. Upon examination of risk factor clustering, we observed that 38% had at least three risk factors. After this threshold, clustering suddenly dropped down to a fairly low level. Using this threshold as a cut-off, clustering of risk factors was associated with age, male gender, urban residence, educational levels and quality of house in multivariate analysis. CONCLUSION: Prevalence of NCD risk factors is fairly high in Bangladeshi adults with a tendency of clustering. If a risk factor such as hypertension is detected, a closer look for other risk factors has to be given in both at clinical and public health settings. Clustering raises risk by more than a summation of risk factors. Our findings, therefore, suggest that Bangladesh could expect a significant increase in NCDs in near future.

Prevalence of blindness and its determinants in Bangladeshi adult population: results from a national cross-sectional survey.

OBJECTIVE: The objective of this study was to determine the prevalence of blindness and its determinants in Bangladeshi adult population. STUDY DESIGN: A cross-sectional population-based survey conducted at household level with national representation. Samples were drawn from the 2011 national census frame using a multistage stratified cluster sampling method. SETTING AND PARTICIPANTS: The survey was done in urban and rural areas in 2013 using a probability proportionate to size sampling approach to locate participants from 72 primary sampling units. One man or one woman aged ≥40 years was randomly selected from their households to recruit 7200. In addition to sociodemographic data, information on medication for hypertension and diabetes was obtained. Blood pressure and capillary blood glucose were measured. Eyelids, cornea, lens, and retina were examined in addition to visual acuity and refraction testing. PRIMARY OUTCOME MEASURES: The following definition was used to categorise subjects having (1) blindness: visual acuity <3/60, (2) low vision: ≥3/60 to <6/60 and (3) normal vision: ≥6/12 after best correction. RESULTS: We could recruit 6391 (88.8%) people among whom 2955 (46.2%) were men. Among them, 1922 (30.1%) were from urban and 4469 (69.9%) were from rural areas. The mean age was 54.3 (SD 11.2) years. The age-standardised prevalence, after best correction, of blindness and low vision was 1.0% (95% CI 0.5% to 1.4%) and 12.1% (95% CI 10.5% to 13.8%), respectively. Multivariable logistic regression indicated that cataract, age-related macular degeneration and diabetic retinopathy were significantly associated with low vision and blindness after adjustment for age and sex. Population attributable risk of cataract for low vision and blindness was 79.6%. CONCLUSIONS: Low vision and blindness are common problems in those aged 40 years or older. Extensive screening and eye care services are necessary for wider coverage engaging all tiers of the healthcare system especially focusing on cataract.

Estimation of total cardiovascular risk using the 2019 WHO CVD prediction charts and comparison of population-level costs based on alternative drug therapy guidelines: a population-based study of adults in Bangladesh.

OBJECTIVE: The objective of this study was to estimate the population distribution of 10-year cardiovascular disease (CVD) risk among Bangladeshi adults aged 40 years and above, using the 2019 WHO CVD risk prediction charts. Additionally, we compared the cost of CVD pharmacological treatment based on the total CVD risk (thresholds ≥30%/≥20%) and the single risk factor (hypertension) cut-off levels in the Bangladeshi context. STUDY DESIGN: Cross-sectional, population-based study. SETTING AND PARTICIPANTS: From 2013 to 2014, we collected data from a nationally representative cross-sectional survey of adults aged ≥40 years from urban and rural areas of Bangladesh (n=6189). We estimated CVD risk using the 2019 WHO CVD risk prediction charts and categorised as very low (<5%), low (5% to <10%), moderate (10% to <20%), high (20% to <30%) and very high risk (≥30%). We estimated drug therapy costs using the lowest price of each drug class available (aspirin, thiazide diuretics, statins and ACE inhibitors). We compared the total cost of drug therapy using the total CVD risk versus single risk factor approach. PRIMARY OUTCOME MEASURES: Our primary outcome was 10-year CVD risk categorised as very low (<5%), low (5% to <10%), moderate (10% to <20%), high (20% to <30%) and very high risk (≥30%). RESULTS: The majority of adults (85.2%, 95% CI 84.3 to 86.1) have a 10-year CVD risk of less than 10%. The proportion of adults with a 10-year CVD risk of ≥20% was 0.51%. Only one adult was categorised with a 10-year CVD risk of ≥30%. Among adults with CVD risk groups of very low, low and moderate, 17.4%, 27.9% and 41.4% had hypertension (blood pressure (BP) ≥140/90) and 0.1%, 1.7% and 2.9% had severe hypertension (BP ≥160/100), respectively. Using the total CVD risk approach would reduce drug costs per million populations to US$144 540 (risk of ≥20%). CONCLUSION: To reduce healthcare expenditure for the prevention and treatment of CVD, a total risk approach using the 2019 WHO CVD risk prediction charts may lead to cost savings.

Sex differences in prevalence and determinants of hypertension among adults: a cross-sectional survey of one rural village in Bangladesh.

OBJECTIVE: Prevention of mortality due to cardiovascular disease (CVD) through control of hypertension is a public health priority in Bangladesh. Our objective was to assess sex differences in prevalence and determinants of hypertension among adults in one rural area of Bangladesh. STUDY DESIGN: Cross-sectional. SETTING AND PARTICIPANTS: From January 2014 to December 2015, we conducted a cross-sectional study of 2600 men and women aged ≥18 years located in one rural district of Bangladesh. We collected data on demographics, behavioural factors, physical measurements and health history. PRIMARY OUTCOME MEASURES: Our primary outcome was hypertension (systolic blood pressure ≥140 or diastolic blood pressure ≥90 mm Hg). RESULTS: The average age of participants was 41.6 years and 53.7% were women. Hypertension prevalence was 6.9% (95% CI 5.9 to 7.9), and was significantly higher among women (8.9%) than men (4.5%). The highest prevalence of hypertension was observed among women aged ≥60 years at 21.3% (95% CI 16.6 to 26.7). A higher proportion of men with hypertension were aware of their condition (72.2%) compared with women (52.4%). Determinants of hypertension included older age, higher education, current tobacco use, increasing body mass index, and hyperglycaemia. CONCLUSION: Our research suggests that hypertension prevalence is higher among women than men in rural Bangladesh. Sex-specific interventions should be developed to inform adults of the necessary lifestyle changes that may reduce the risk of hypertension and subsequent CVDs.

Prevalence of musculoskeletal conditions and related disabilities in Bangladeshi adults: a cross-sectional national survey.

BACKGROUND: Nationally representative data on burden of musculoskeletal conditions (MSK) in Bangladesh are not available. The objective of this study was to determine the prevalence of MSK conditions and related disabilities in the adult population of Bangladesh. METHODS: A total of 2000 individuals aged 18 years or older were targeted from 20 primary sampling units (urban and rural) of all former seven divisions of Bangladesh in 2015. Structured interviews were done using the modified Community Oriented Program for Control of Rheumatic Disorders questionnaire to detect positive respondents. Standard criteria were used for diagnosing MSK conditions by rheumatology residents. In case of uncertainty, opinion was taken from senior rheumatologists. A Bangla version of the Health Assessment Questionnaire was used to determine disability. RESULTS: A total of 1843 (92.1%) participated. Among them, 892 men and 951 women participated from rural (n = 716) and urban (n = 1127) areas. Their mean age was 40.5 (standard deviation 14.7) years. Almost a third did not have any formal schooling. Overall, 30.4% (95% confidence interval, 28.3-32.5) had MSK conditions. Low back pain (18.6%, 16.9-20.5), knee osteoarthritis (7.3%, 6.1-8.5) and soft tissue rheumatism 3.8% (2.9-4.7) were the three top-ranking MSK conditions. Rheumatoid arthritis (1.6%, 1.0-2.1), spondyloarthritis (1.2%, 7-1.8) and adhesive capsulitis (1.4%, 0.9-1.9) were relatively uncommon. Among those who had MSK conditions, 24.8% (21.3-28.6) had some degree of disability. Of them, 24.4% (21.0-28.1) had history of work loss during last 12 months. CONCLUSIONS: The high burden of MSK conditions and related disabilities in Bangladesh warrants greater attention of the health system. Further studies are needed to estimate the impact of this group of conditions particularly addressing related disabilities and loss of work.

Epidemiology of hypertension among Bangladeshi adults using the 2017 ACC/AHA Hypertension Clinical Practice Guidelines and Joint National Committee 7 Guidelines.

In 2017, the American College of Cardiology (ACC) and American Heart Association (AHA) released updated guidelines on the definition of hypertension, and blood pressure thresholds for initiation of antihypertensive medication. Our objective was to assess the change in prevalence of hypertension, risk factors, and identify populations recommended for treatment among Bangladeshi adults, based on the 2017 ACC/AHA guidelines. Data for this analysis were collected from a population-based nationally representative sample of 1843 Bangladeshi adults, aged ≥18 years in 2015. Hypertension was defined based on two definitions: the JNC 7 guidelines (SBP ≥ 140 or DBP ≥ 90 mmHg), and the 2017 ACC/AHA guidelines (SBP ≥ 130 mmHg, or DBP ≥ 80 mmHg), or a self-reported diagnosis of hypertension. Based on the 2017 ACC/AHA guidelines, the prevalence of hypertension was 40.7% (95% CI: 38.5-43.0). The prevalence of JNC 7 definition of hypertension was 17.9% (95% CI: 16.2-19.7), indicating a 22.8% increase in prevalence. Based on both definitions, urban residents, older adults, adults with low physical activity, obese, abdominally obese, and diabetic adults were more likely to have hypertension. Based on current JNC 7 guidelines, only half of hypertensive adults were aware of having hypertension. Among those aware of their condition, 75% were taking medication based on self-report. Using the 2017 ACC/AHA guidelines, the prevalence of hypertension will more than double in Bangladesh. Newly diagnosed hypertensive adults will be considered high-risk for cardiovascular disease leading to a larger burden on Bangladesh's health system. However, implementation of the ACC/AHA guidelines may improve prevention efforts where lifestyle changes are appropriate.

Prevalence, treatment patterns, and risk factors of hypertension and pre-hypertension among Bangladeshi adults.

In Bangladesh, morbidity and mortality due to non-communicable diseases (NCDs) has increased over the last few decades. Hypertension is an important risk factor for NCDs, specifically cardiovascular disease. The objective of this study was to assess prevalence and risk factors for hypertension and pre-hypertension among adults in Bangladesh. Data for this analysis were collected during the national NCD Risk Factor Survey of Bangladesh conducted in 2010 from a representative sample of men and women, aged 25 years or above. The survey adopted a multistage, geographically clustered, probability-based sampling approach. WHO STEPS questionnaire was used to collect data on demographics, behavioral risk factors, and physical measurements. Overall, 20% of the study population were hypertensive at study measurement. The prevalence of hypertension increased with age and body mass index (BMI). Twelve percent of the population were previously diagnosed with hypertension. Among these individuals, nearly half were not taking any medications to control their hypertension. Additionally, the prevalence of pre-hypertension was 43%, with higher levels among males, older age groups, and those with higher education, higher wealth index and high BMI. Predictors of hypertension, included older age, high BMI, and diabetes comorbidity. Based on this study, we estimate that 1 out of 5 Bangladeshi adults have hypertension. The risk of hypertension increases with older age and high BMI. Additionally, prevalence of pre-hypertension is high in Bangladesh in both rural and urban areas. Findings from this study can be used to inform public health programming to control the spread of NCDs in Bangladesh.

Prevalence of ischemic heart disease in a rural population of Bangladesh.

Bangladeshi people, as other South Asians, have high susceptibility to ischemic heart disease (IHD) but population-based data are lacking in Bangladesh. We investigated for IHD burden in a rural population of Bangladesh in 2001. Information was sought on use of medications for IHD and electrocardiogram was done in 447 adults (157 men and 290 women) aged 20 years or older (mean 40 years). Prevalence of IHD defined by presence of pathological Q wave on electrocardiogram or current medication for IHD is 3.4% (95% confidence interval, 1.7% to 5.1%). Prevalence in men (4.6%, 1.3% to 7.9%) was almost twice than in women (2.7%, 0.8% to 4.6%). However, this sex-difference should be cautiously interpreted because of small sample size for men. It appears that IHD is an important problem even in this traditional rural population of Bangladesh.

Alcohol consumption among adults in Bangladesh: Results from STEPS 2010.

Background Alcohol use is a risk factor for the development of noncommunicable diseases. National data are needed to assess the prevalence of alcohol use in the Bangladeshi population. The objective of this study was to describe the prevalence and patterns of alcohol use among men and women of rural and urban areas of Bangladesh. Additionally, predictors of ever alcohol use were also identified. Methods A nationally representative cross-sectional survey (STEPS 2010) was conducted on 9275 adults between November 2009 and April 2010. Participants were selected using multi-stage random cluster sampling. Data on several risk factors for noncommunicable diseases, including alcohol use, were collected by an interviewer-administered questionnaire. Results Among the total population, 5.6% (n = 519) reported to have ever drunk alcohol and 94.4% (8756) were lifetime abstainers; 2.0% (n = 190) of participants reported to have drunk alcohol within the last 12 months. Of these, 94.7% (n = 180) were men. Only 0.9% (n = 87) of the total population had drunk alcohol within the last 30 days and were categorized as current drinkers. Among current drinkers, 77.0% (n = 67) were defined as binge drinkers, having had at least one episode of heavy drinking in this time period; 92.0% (n = 80) were current smokers and 59.8% (n = 52) had either no formal education or less than primary school education. Ever alcohol use was more common among men, those who live in urban areas and smokers. Conclusion Alcohol use is low in Bangladesh; however, those who do use alcohol frequently binge drink, which is a public health concern. Targeted efforts should be made on these specific groups, to control and prevent the continued use of alcohol in Bangladesh.

Sociodemographic Determinants of Low Fruit and Vegetable Consumption Among Bangladeshi Adults: Results From WHO-STEPS Survey 2010.

This study aimed to investigate factors affecting fruit and vegetables (FAVs) intake among Bangladeshi adults. Dietary data of 9275 adults from the Bangladesh Noncommunicable Disease Risk Factor Survey 2010 were analyzed. The mean age of the respondents was 42.4 (±13.5) years. Multistage cluster sampling was applied to identify samples. Demographics, personal habits, physical activity, diet, and anthropometric data were collected using the WHO-STEPs questionnaire. Average daily intake of <5 servings of FAVs combined was considered to be low FAV consumption, and its prevalence was 82.8%. A mixed-effect logistic regression model was fitted to assess association of factors with low FAV intake. Higher educational attainment, greater wealth, female sex, low physical activity, body mass index >25 kg/m2, and smokeless tobacco consumption were significantly associated with higher FAV consumption. Frequency of low FAV intake increased with increasing age and decreased with increasing educational attainment. Programs targeting people at risk of low FAV consumption are needed to promote consumption.

Prevalence of disability in Manikganj district of Bangladesh: results from a large-scale cross-sectional survey.

OBJECTIVE: To conduct a comprehensive survey on disability to determine the prevalence and distribution of cause-specific disability among residents of the Manikganj district in Bangladesh. METHODS: The survey was conducted in Manikganj, a typical district in Bangladesh, in 2009. Data were collected from 37 030 individuals of all ages. Samples were drawn from 8905 households from urban and rural areas proportionate to population size. Three sets of interviewer-administered questionnaires were used separately for age groups 0-1 years, 2-10 years and 11 years and above to collect data. For the age groups 0-1 years and 2-10 years, the parents or the head of the household were interviewed to obtain the responses. Impairments, activity limitations and restriction of participation were considered in defining disability consistent with the International Classification of Functioning, Disability and Health framework. RESULTS: Overall, age-standardised prevalence of disability per 1000 was 46.5 (95% CI 44.4 to 48.6). Prevalence was significantly higher among respondents living in rural areas (50.2; 95% CI 47.7 to 52.7) than in urban areas (31.0; 95% CI 27.0 to 35.0). Overall, female respondents had more disability (50.0; 95% CI 46.9 to 53.1) than male respondents (43.4; 95% CI 40.5 to 46.3). Educational deprivation was closely linked to higher prevalence of disability. Commonly reported prevalences (per 1000) for underlying causes of disability were 20.2 for illness, followed by 9.4 for congenital causes and 6.8 for injury, and these were consistent in males and females. CONCLUSIONS: Disability is a common problem in this typical district of Bangladesh, which is largely generalisable. Interventions at community level with special attention to the socioeconomically deprived are warranted.

Blood glucose and cholesterol levels in adult population of Bangladesh: Results from STEPS 2006 survey.

BACKGROUND: A nationally representative survey was carried out to determine the distribution of blood glucose and cholesterol in adult population of Bangladesh in the absence of existing data. METHODS: The study adopted a multistage and geographically clustered sampling technique of households. A total of 2610 individuals (1444 men and 1166 women) aged 25-64 years were selected from rural and urban areas. Capillary blood glucose and total cholesterol levels were measured using an overnight fasting state. RESULTS: The mean age of the participants was 41 years [standard deviation (SD), 11 years]. Half of them (49%) were from urban areas. Half of them (51%) had primary or higher education. Mean glucose was 74mg/dL (SD 23mg/dL). Men had higher mean glucose levels (79mg/dL) than women (67mg/dL). Age-standardized prevalence of diabetes (blood glucose level ≥126mg/dL and/or use of anti-diabetic medication) was 5.5%. In men, it was almost two-and-half times (7.6%) compared with women (2.8%). It was also double in urban areas (7.8%) compared with rural areas (3.4%). Mean cholesterol level among all participants was 167mg/dL (SD 26mg/dL). Men and women had almost similar levels (169mg/dL versus 166mg/dL, respectively). Prevalence of high cholesterol level (≥240mg/dL) was very low (1.3%) in both men (2.2%) and women (0.5%). However, the prevalence of borderline high cholesterol was substantial (5.8%) in this sample. CONCLUSION: The prevalence of high hypercholesterolemia is low, whereas there is a high prevalence of borderline high cholesterol and diabetes in the adult population of Bangladesh. This warrants population-based interventions to tackle this problem.

Emerging Burden of Cardiovascular Diseases in Bangladesh.

As a result of an epidemiological transition from communicable to non-communicable diseases for last few decades, cardiovascular diseases (CVD) are being considered as an important cause of mortality and morbidity in many developing countries including Bangladesh. Performing an extensive literature search, we compiled, summarized, and categorized the existing information about CVD mortality and morbidity among different clusters of Bangladeshi population. The present review reports that the burden of CVD in terms of mortality and morbidity is on the rise in Bangladesh. Despite a few non-communicable disease prevention and control programs currently running in Bangladesh, there is an urgent need for well-coordinated national intervention strategies and public health actions to minimize the CVD burden in Bangladesh. As the main challenge for CVD control in a developing country is unavailability of adequate epidemiological data related to various CVD events, the present review attempted to accumulate such data in the current context of Bangladesh. This may be of interest to all stakeholder groups working for CVD prevention and control across the country and globe.

Prevalence of rheumatic fever and rheumatic heart disease in Bangladeshi children.

BACKGROUND: Recent prevalence data on rheumatic fever (RF) and rheumatic heart disease (RHD) are lacking in Bangladeshi population. AIM: We have done this national level cross-sectional survey to determine the prevalence of RF and RHD in Bangladeshi children. METHODS: Samples were drawn from three out of seven divisions of Bangladesh from both urban and rural areas. Trained and experienced enumerators visited households to suspect cases of RF or RHD in 5-19 years children by asking structured questions on symptoms and signs of RF and RHD (n = 56,827). Then trained doctors again took history and examined them for RF/RHD. RF was defined according to the Modified Jones Criteria 1992. Doppler echocardiography was done to confirm the diagnosis in all suspected cases of RF/RHD. RESULTS: A total of 36 RF cases (new and old) and 16 Doppler echocardiography confirmed RHD cases were identified. Prevalence of RF and RHD was 0.9 per 1000 (95% confidence interval: 0.7-1.2) while prevalence of RF was 0.6 per 1000 (95% CI: 0.4-0.9) and RHD 0.3 per 1000 (95% CI: 0.2-0.5). CONCLUSION: Observed prevalence of RF and RHD indicates that RF/RHD is disappearing from Bangladesh. However, studies using new technology of portable echocardiographic screening are needed.

Burden of Cardio- and Cerebro-vascular Diseases and the Conventional Risk Factors in South Asian Population.

Similar to most populations, South Asian countries are also witnessing the dramatic transitions in health during the last few decades with the major causes of adverse health shifting from a predominance of nutritional deficiencies and infectious diseases to chronic diseases such as cardio and cerebrovascular disease (CVD). We summarized the available information of the burden of CVD and risk factors in the South Asian populations. The prevalence of conventional cardiovascular has been increasing among all South Asian populations. Extensive urbanization, shift in dietary pattern and sedentary daily life style is contributing towards the worsening of the CVD risk factor scenario. The burdens of the chronic cardiovascular risk factors are much prevalent in the South Asian populations. These are also rising alarmingly which ought to influence the already existed heavy CVD burden. Similar to the rest of the world, management for the conventional cardiovascular risk factors is very important for the prevention of CVD in South Asia.