Cardiovascular disease, mortality, and their associations with modifiable risk factors in a multi-national South Asia cohort: a PURE substudy.

AIM: To examine the incidence of cardiovascular disease (CVD), of death, and the comparative effects of 12 common modifiable risk factors for both outcomes in South Asia. METHODS AND RESULTS: Prospective study of 33 583 individuals 35-70 years of age from India, Bangladesh, or Pakistan. Mean follow-up period was 11 years. Age and sex adjusted incidence of a CVD event and mortality rates were calculated for the overall cohort, by urban or rural location, by sex, and by country. For each outcome, mutually adjusted population attributable fractions (PAFs) were calculated in 32 611 individuals without prior CVD to compare risks associated with four metabolic risk factors (hypertension, diabetes, abdominal obesity, high non-HDL cholesterol), four behavioural risk factors (tobacco use, alcohol use, diet quality, physical activity), education, household air pollution, strength, and depression. Hazard ratios were calculated using Cox regression models, and average PAFs were calculated for each risk factor or groups of risk factors. Cardiovascular disease was the most common cause of death (35.5%) in South Asia. Rural areas had a higher incidence of CVD (5.41 vs. 4.73 per 1000 person-years) and a higher mortality rate (10.27 vs. 6.56 per 1000 person-years) compared with urban areas. Males had a higher incidence of CVD (6.42 vs. 3.91 per 1000 person-years) and a higher mortality rate (10.66 vs. 6.85 per 1000 person-years) compared with females. Between countries, CVD incidence was highest in Bangladesh, while the mortality rate was highest in Pakistan. The modifiable risk factors studied contributed to approximately 64% of the PAF for CVD and 69% of the PAF for death. Largest PAFs for CVD were attributable to hypertension (13.1%), high non-HDL cholesterol (11.1%), diabetes (8.9%), low education (7.7%), abdominal obesity (6.9%), and household air pollution (6.1%). Largest PAFs for death were attributable to low education (18.9%), low strength (14.6%), poor diet (6.4%), diabetes (5.8%), tobacco use (5.8%), and hypertension (5.5%). CONCLUSION: In South Asia, both CVD and deaths are highest in rural areas and among men. Reducing CVD and premature mortality in the region will require investment in policies that target a broad range of health determinants.

Personal and household PM2.5 and black carbon exposure measures and respiratory symptoms in 8 low- and middle-income countries.

BACKGROUND: Household air pollution (HAP) from cooking with solid fuels has been associated with adverse respiratory effects, but most studies use surveys of fuel use to define HAP exposure, rather than on actual air pollution exposure measurements. OBJECTIVE: To examine associations between household and personal fine particulate matter (PM2.5) and black carbon (BC) measures and respiratory symptoms. METHODS: As part of the Prospective Urban and Rural Epidemiology Air Pollution study, we analyzed 48-h household and personal PM2.5 and BC measurements for 870 individuals using different cooking fuels from 62 communities in 8 countries (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Self-reported respiratory symptoms were collected after monitoring. Associations between PM2.5 and BC exposures and respiratory symptoms were examined using logistic regression models, controlling for individual, household, and community covariates. RESULTS: The median (interquartile range) of household and personal PM2.5 was 73.5 (119.1) and 65.3 (91.5) µg/m3, and for household and personal BC was 3.4 (8.3) and 2.5 (4.9) x10-5 m-1, respectively. We observed associations between household PM2.5 and wheeze (OR: 1.25; 95%CI: 1.07, 1.46), cough (OR: 1.22; 95%CI: 1.06, 1.39), and sputum (OR: 1.26; 95%CI: 1.10, 1.44), as well as exposure to household BC and wheeze (OR: 1.20; 95%CI: 1.03, 1.39) and sputum (OR: 1.20; 95%CI: 1.05, 1.36), per IQR increase. We observed associations between personal PM2.5 and wheeze (OR: 1.23; 95%CI: 1.00, 1.50) and sputum (OR: 1.19; 95%CI: 1.00, 1.41). For household PM2.5 and BC, associations were generally stronger for females compared to males. Models using an indicator variable of solid versus clean fuels resulted in larger OR estimates with less precision. CONCLUSIONS: We used measurements of household and personal air pollution for individuals using different cooking fuels and documented strong associations with respiratory symptoms.

Association of estimated sleep duration and naps with mortality and cardiovascular events: a study of 116 632 people from 21 countries.

AIMS: To investigate the association of estimated total daily sleep duration and daytime nap duration with deaths and major cardiovascular events. METHODS AND RESULTS: We estimated the durations of total daily sleep and daytime naps based on the amount of time in bed and self-reported napping time and examined the associations between them and the composite outcome of deaths and major cardiovascular events in 116 632 participants from seven regions. After a median follow-up of 7.8 years, we recorded 4381 deaths and 4365 major cardiovascular events. It showed both shorter (≤6 h/day) and longer (>8 h/day) estimated total sleep durations were associated with an increased risk of the composite outcome when adjusted for age and sex. After adjustment for demographic characteristics, lifestyle behaviours and health status, a J-shaped association was observed. Compared with sleeping 6-8 h/day, those who slept ≤6 h/day had a non-significant trend for increased risk of the composite outcome [hazard ratio (HR), 1.09; 95% confidence interval, 0.99-1.20]. As estimated sleep duration increased, we also noticed a significant trend for a greater risk of the composite outcome [HR of 1.05 (0.99-1.12), 1.17 (1.09-1.25), and 1.41 (1.30-1.53) for 8-9 h/day, 9-10 h/day, and >10 h/day, Ptrend < 0.0001, respectively]. The results were similar for each of all-cause mortality and major cardiovascular events. Daytime nap duration was associated with an increased risk of the composite events in those with over 6 h of nocturnal sleep duration, but not in shorter nocturnal sleepers (≤6 h). CONCLUSION: Estimated total sleep duration of 6-8 h per day is associated with the lowest risk of deaths and major cardiovascular events. Daytime napping is associated with increased risks of major cardiovascular events and deaths in those with >6 h of nighttime sleep but not in those sleeping ≤6 h/night.

Urbanization, Human Development and Literacy and Syndemics of Obesity, Hypertension and Hyperglycemia in Rajasthan: National Family Health Survey-4.

OBJECTIVE: Non-communicable diseases (NCDs) are the new epidemic in India. District-specific prevalence of various NCD risk factors and their macrolevel determinants is unknown. We used National Family Health Survey-4 (NFHS-4) data to map the syndemics of obesity, hypertension and hyperglycemia in Rajasthan, the largest state of the country, and correlated their prevalence with selected social determinants of health- urbanization, human development index (HDI) and literacy. METHODOLOGY: Data on location-adjusted prevalence of various NCD risk factors among women (15-49y) and men (15-54y) were obtained from NFHS-4 data sheets. Heat maps were created to determine geographic distribution of obesity (body mass index, BMI ≥25 kg/m2), hypertension (known and/or BP ≥140/≥90 mmHg) and hyperglycemia (random glucose >140 mg/dl) in all the districts (n=33). We determined correlation of various social determinants with NCD risk factors. RESULTS: Significant geographic variation was observed in prevalence of obesity, hypertension and hyperglycemia in women and men. High prevalence of obesity and hypertension was observed in central and northwestern districts of the state. In women and men respectively, there was a significant positive correlation of obesity with urbanization (r=0.68, 0.51), HDI (r=0.70, 0.66) and female literacy (r=0.46, 0.34). Prevalence of hypertension also showed significant correlation with urbanization (r=0.18, 0.33), HDI (r=0.38, 0.52) and literacy (r=0.32, 0.21) while no correlation was observed with hyperglycemia. CONCLUSION: There is significant geographic variation in prevalence of obesity, hypertension and hyperglycemia in Rajasthan. Significant correlation of obesity and hypertension with urbanization, human development and female literacy is observed..

Cervical Cancer in SAARC Countries.

Purvish M. ParikhIn the year 2020, a total of 342 000 women were estimated to die of cervical cancer, of which 90%) were expected amongst low- and middle-income countries (LMIC). Globally incidence of cervical cancer has reduced as a result of improved personal hygiene, better living conditions and higher application of opportunistic screening programs. Yet GLOBOCAN shows that absolute number of cases are still increasing. We therefore conducted a 21 question multiple choice questionnaire online survey in Jan 2023 amongst 9 SAARC countries. A total of 367 replies were received and the representative answers for each country are being reported in this manuscript. A good possibility of achieving World Health Assembly target (Nov 17, 2020) was felt only by Bhutan and Nepal. For screening, most countries (Bhutan, India, Myanmar, Nepal, Pakistan and Sri Lanka) recommend for all asymptomatic eligible patients. Public health experts have suggested VIA / VILI as the best solution for LMICs. However, a dual screening strategy (HPV DNA plus) cytology was preferred by doctors in Afghanistan, Bhutan, India, Myanmar, Pakistan and Sri Lanka. Screening, triage and then treatment was the preferred by Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, Sri Lanka. HPV vaccination was recommended in all girls between ages 10 to 26 years in Bangladesh, India, Myanmar, Nepal, Pakistan and Sri Lanka. All the 9 countries would use HPV vaccination to all eligible patients if the cost of the vaccine was reasonably low. Our survey clearly outlines challenges faced in tackling cervical cancer in SAARC countries. We also provide consensus regarding several potential solutions that can be used in both public and private cervical cancer control programs.

Persistent high prevalence of cardiovascular risk factors in the urban middle class in India: Jaipur Heart Watch-5.

BACKGROUND AND OBJECTIVE: Urban subjects have high burden of cardiovascular risk factors, therefore, to evaluate risk factors in middle socioeconomic subjects and to study secular trends we performed an epidemiological study. METHODS: The study was performed at urban middle class locations defined according to municipal records in years 2009-10. Stratified random sampling using house-to-house survey was performed. Details of medical history, anthropometry and clinical examination were recorded and biochemical tests performed for estimation of fasting glucose and lipids. Current definitions were used for risk factor classification. Descriptive statistics are provided. Trends were calculated using ANOVA or Mantel Haenszel chi-square. Univariate and multivariate logistic regression was performed to assess risk factor determinants. To determine secular trends we compared risk factors with previous cross-sectional studies performed in same locations in years 2002-3 and 2004-5 in subjects 20-59 years age. RESULTS: We evaluated 739 subjects (men 451, women 288, response 67%). Age-adjusted prevalence (%) of risk factors in men and women respectively was smoking 95 (21.1) and 12 (4.2), low physical activity 316 (69.6) and 147 (52.3), high fat intake > or = 20 gm/day 278 (73.4) and 171 (68.7), low fruits and vegetables intake < 3 helpings/day 249 (70.3) and 165 (76.4), overweight/obesity 205 (46.2) and 142 (50.7), high waist size 58 (12.9) and 76 (26.6), high waist:hip 143 (31.9) and 154 (53.9), hypertension 177 (39.5) and 71 (24.6), high total cholesterol > or = 200 mg/ dl 148 (33.0) and 93 (32.7), low HDL cholesterol < 40/50 mg/dl 113 (25.1) and 157 (55.3), diabetes 62 (15.5) and 25 (10.8) and metabolic syndrome 109 (25.1) and 61 (22.0). Age-associated increase was observed in body mass index, waist size, waist ratio:hip, systolic blood pressure and fasting and total cholesterol, non-HDL cholesterol and triglycerides in women (Ptrend < 0.01). Age related increase was also observed in prevalence of obesity, truncal obesity, hypertension, diabetes and metabolic syndrome (Ptrend < 0.01). On univariate analysis significant determinants of risk factors were low educational and socioeconomic status for smoking, high fat diet for obesity and hypertension, low fruits and vegetables intake for metabolic syndrome, and low physical activity or obesity but on age-and sex-adjusted multivariate analysis only association was high fat diet with obesity and hypertension (logistic regression analysis p < 0.05). Compared to studies performed at similar locations in years 2002-03 and 2005-06 there was increasing trend in prevalence of high non-HDL cholesterol and hypertriglyceridemia (Ptrend < 0.05) while other risk factors did not change significantly. CONCLUSIONS: There is a high prevalence of multiple cardiovascular risk factors in Indian middle class individuals. Secular trends demonstrate a persistent high prevalence and increasing non-HDL cholesterol and triglycerides over 8-year period.

Measuring and predicting personal and household Black Carbon levels from 88 communities in eight countries.

Black Carbon (BC) is an important component of household air pollution (HAP) in low- and middle- income countries (LMICs), but levels and drivers of exposure are poorly understood. As part of the Prospective Urban and Rural Epidemiological (PURE) study, we analyzed 48-hour BC measurements for 1187 individual and 2242 household samples from 88 communities in 8 LMICs (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Light absorbance (10-5 m-1) of collected PM2.5 filters, a proxy for BC concentrations, was calculated via an image-based reflectance method. Surveys of household/personal characteristics and behaviors were collected after monitoring. The geometric mean (GM) of personal and household BC measures was 2.4 (3.3) and 3.5 (3.9)·10-5 m-1, respectively. The correlation between BC and PM2.5 was r = 0.76 for personal and r = 0.82 for household measures. A gradient of increasing BC concentrations was observed for cooking fuels: BC increased 53% (95%CI: 30, 79) for coal, 142% (95%CI: 117, 169) for wood, and 190% (95%CI: 149, 238) for other biomass, compared to gas. Each hour of cooking was associated with an increase in household (5%, 95%CI: 3, 7) and personal (5%, 95%CI: 2, 8) BC; having a window in the kitchen was associated with a decrease in household (-38%, 95%CI: -45, -30) and personal (-31%, 95%CI: -44, -15) BC; and cooking on a mud stove, compared to a clean stove, was associated with an increase in household (125%, 95%CI: 96, 160) and personal (117%, 95%CI: 71, 117) BC. Male participants only had slightly lower personal BC (-0.6%, 95%CI: -1, 0.0) compared to females. In multivariate models, we were able to explain 46-60% of household BC variation and 33-54% of personal BC variation. These data and models provide new information on exposure to BC in LMICs, which can be incorporated into future exposure assessments, health research, and policy surrounding HAP and BC.

Multinational prediction of household and personal exposure to fine particulate matter (PM2.5) in the PURE cohort study.

INTRODUCTION: Use of polluting cooking fuels generates household air pollution (HAP) containing health-damaging levels of fine particulate matter (PM2.5). Many global epidemiological studies rely on categorical HAP exposure indicators, which are poor surrogates of measured PM2.5 levels. To quantitatively characterize HAP levels on a large scale, a multinational measurement campaign was leveraged to develop household and personal PM2.5 exposure models. METHODS: The Prospective Urban and Rural Epidemiology (PURE)-AIR study included 48-hour monitoring of PM2.5 kitchen concentrations (n = 2,365) and male and/or female PM2.5 exposure monitoring (n = 910) in a subset of households in Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania and Zimbabwe. PURE-AIR measurements were combined with survey data on cooking environment characteristics in hierarchical Bayesian log-linear regression models. Model performance was evaluated using leave-one-out cross validation. Predictive models were applied to survey data from the larger PURE cohort (22,480 households; 33,554 individuals) to quantitatively estimate PM2.5 exposures. RESULTS: The final models explained half (R2 = 54%) of the variation in kitchen PM2.5 measurements (root mean square error (RMSE) (log scale):2.22) and personal measurements (R2 = 48%; RMSE (log scale):2.08). Primary cooking fuel type, heating fuel type, country and season were highly predictive of PM2.5 kitchen concentrations. Average national PM2.5 kitchen concentrations varied nearly 3-fold among households primarily cooking with gas (20 µg/m3 (Chile); 55 µg/m3 (China)) and 12-fold among households primarily cooking with wood (36 µg/m3 (Chile)); 427 µg/m3 (Pakistan)). Average PM2.5 kitchen concentration, heating fuel type, season and secondhand smoke exposure were significant predictors of personal exposures. Modeled average PM2.5 female exposures were lower than male exposures in upper-middle/high-income countries (India, China, Colombia, Chile). CONCLUSION: Using survey data to estimate PM2.5 exposures on a multinational scale can cost-effectively scale up quantitative HAP measurements for disease burden assessments. The modeled PM2.5 exposures can be used in future epidemiological studies and inform policies targeting HAP reduction.

The high burden of obesity and abdominal obesity in urban Indian schoolchildren: a multicentric study of 38,296 children.

AIMS: The objective of this study was to assess the prevalence of overweight, obesity and abdominal obesity and their associated factors in a large sample of urban Indian schoolchildren. METHODS: This is a cross-sectional study conducted in 5 cities in India. Height and weight were measured in 38,296 children and waist circumference was measured in 29,244 children aged 8-18 years. The prevalence was compared with respect to age, gender, type of school and city of residence. RESULTS: The mean ± standard deviation for age was 13.3 ± 2.4 years and 18.3 ± 4.3 kg/m(2) for BMI. The prevalence of overweight and obesity in 8- to 18-year-old children, respectively, was 14.4 and 2.8% by IOTF cutoffs, 14.5 and 4.8% by CDC cutoffs and 18.5 and 5.3% by WHO cutoffs. When applying the cutoffs specific for Indian ethnicity in 14- to 18-year-old children, the prevalence was higher (21.1 and 12.3%, respectively) as compared to the IOTF, WHO and CDC cutoffs. The overall prevalence of abdominal obesity in urban Indian schoolchildren was 4.5%. The prevalence of overweight and abdominal obesity was significantly higher in females than males (p < 0.001). High socioeconomic status and residing in cities with a population greater than 4 million were independently associated with overweight and abdominal obesity (p < 0.001). On extrapolating these data, more than 15 million children would currently be overweight and 4 million abdominally obese in urban India. CONCLUSIONS: There is a substantial burden of childhood obesity in India, which necessitates comprehensive urban-based campaigns for its prevention and control.

Erratum to "Escalating Ischemic Heart Disease Burden among Women in India: Insights from GBD, NCDRisC and NFHS Reports" [American Journal of Preventive Cardiology 2C (2020) 100035].

[This corrects the article DOI: 10.1016/j.ajpc.2020.100035.].

Improvement in nutrition-related knowledge and behaviour of urban Asian Indian school children: findings from the 'Medical education for children/Adolescents for Realistic prevention of obesity and diabetes and for healthy aGeing' ( MARG) intervention study.

Increasing prevalence of childhood obesity calls for comprehensive and cost-effective educative measures in developing countries such as India. School-based educative programmes greatly influence children's behaviour towards healthy living. We aimed to evaluate the impact of a school-based health and nutritional education programme on knowledge and behaviour of urban Asian Indian school children. Benchmark assessment of parents and teachers was also done. We educated 40 196 children (aged 8-18 years), 25 000 parents and 1500 teachers about health, nutrition, physical activity, non-communicable diseases and healthy cooking practices in three cities of North India. A pre-tested questionnaire was used to assess randomly selected 3128 children, 2241 parents and 841 teachers before intervention and 2329 children after intervention. Low baseline knowledge and behaviour scores were reported in 75-94 % government and 48-78 % private school children, across all age groups. A small proportion of government school children gave correct answers about protein (14-17 %), carbohydrates (25-27 %) and saturated fats (18-32 %). Private school children, parents and teachers performed significantly better than government school subjects (P < 0.05). Following the intervention, scores improved in all children irrespective of the type of school (P < 0.001). A significantly higher improvement was observed in younger children (aged 8-11 years) as compared with those aged 12-18 years, in females compared with males and in government schools compared with private schools (P < 0.05 for all). Major gaps exist in health and nutrition-related knowledge and behaviour of urban Asian Indian children, parents and teachers. This successful and comprehensive educative intervention could be incorporated in future school-based health and nutritional education programmes.

Escalating ischemic heart disease burden among women in India: Insights from GBD, NCDRisC and NFHS reports.

OBJECTIVE: To determine trends in ischemic heart disease (IHD) mortality and burden among women in India we performed a study. METHODS: Data were obtained from three publicly available resources. Cardiovascular disease (CVD) and IHD mortality were obtained from 2017 Global Burden of Diseases (GBD) Study. Metabolic risk factor data (body-mass index, blood pressure and diabetes) were obtained from Non-Communicable Disease Risk Factor Collaboration (NCDRiSC) and lifestyle factors were obtained from National Family Health Surveys (NFHS). Descriptive statistics are reported. RESULTS: GBD study reported that in year 2017 in India CVD caused 2.64 million deaths (women 1.18, men 1.45 million) and IHD 1.54 million (women 0.62, men 0.92 million). Burden of IHD related disability adjusted life years (DALYs) was 36.99 million (women 13.80, men 23.19 million). From 2000 to 2017 annual IHD mortality increased from 0.85 to 1.54 million (+81.1%) with greater increase in women 0.32 to 0.62 million (+93.7%) compared to men (0.53-0.92 million, +73.6%). Increase in age-adjusted IHD mortality rate/100,000 was also more in women (62.9-92.7, +47.4%) than men (97.5-129.5, +32.8%). Trends in cardiometabolic risk factors from 2000 to 2015 showed greater increase in body-mass index, diabetes, tobacco-use and periodontal infections among women than men. CONCLUSION: IHD is increasing more rapidly among women than men in India and there is sex-associated convergence. This is associated with greater increase in overweight, diabetes, tobacco use and periodontal infections in women.

Household and personal air pollution exposure measurements from 120 communities in eight countries: results from the PURE-AIR study.

BACKGROUND: Approximately 2·8 billion people are exposed to household air pollution from cooking with polluting fuels. Few monitoring studies have systematically measured health-damaging air pollutant (ie, fine particulate matter [PM2·5] and black carbon) concentrations from a wide range of cooking fuels across diverse populations. This multinational study aimed to assess the magnitude of kitchen concentrations and personal exposures to PM2·5 and black carbon in rural communities with a wide range of cooking environments. METHODS: As part of the Prospective Urban and Rural Epidemiological (PURE) cohort, the PURE-AIR study was done in 120 rural communities in eight countries (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Data were collected from 2541 households and from 998 individuals (442 men and 556 women). Gravimetric (or filter-based) 48 h kitchen and personal PM2·5 measurements were collected. Light absorbance (10-5m-1) of the PM2·5 filters, a proxy for black carbon concentrations, was calculated via an image-based reflectance method. Surveys of household characteristics and cooking patterns were collected before and after the 48 h monitoring period. FINDINGS: Monitoring of household air pollution for the PURE-AIR study was done from June, 2017, to September, 2019. A mean PM2·5 kitchen concentration gradient emerged across primary cooking fuels: gas (45 µg/m3 [95% CI 43-48]), electricity (53 µg/m3 [47-60]), coal (68 µg/m3 [61-77]), charcoal (92 µg/m3 [58-146]), agricultural or crop waste (106 µg/m3 [91-125]), wood (109 µg/m3 [102-118]), animal dung (224 µg/m3 [197-254]), and shrubs or grass (276 µg/m3 [223-342]). Among households cooking primarily with wood, average PM2·5 concentrations varied ten-fold (range: 40-380 µg/m3). Fuel stacking was prevalent (981 [39%] of 2541 households); using wood as a primary cooking fuel with clean secondary cooking fuels (eg, gas) was associated with 50% lower PM2·5 and black carbon concentrations than using only wood as a primary cooking fuel. Similar average PM2·5 personal exposures between women (67 µg/m3 [95% CI 62-72]) and men (62 [58-67]) were observed. Nearly equivalent average personal exposure to kitchen exposure ratios were observed for PM2·5 (0·79 [95% 0·71-0·88] for men and 0·82 [0·74-0·91] for women) and black carbon (0·64 [0·45-0·92] for men and 0·68 [0·46-1·02] for women). INTERPRETATION: Using clean primary fuels substantially lowers kitchen PM2·5 concentrations. Importantly, average kitchen and personal PM2·5 measurements for all primary fuel types exceeded WHO's Interim Target-1 (35 µg/m3 annual average), highlighting the need for comprehensive pollution mitigation strategies. FUNDING: Canadian Institutes for Health Research, National Institutes of Health.

Qualitative Study of Barriers to Adherence to Antihypertensive Medication among Rural Women in India.

OBJECTIVE: There is poor adherence to antihypertensive therapies among women in India. To determine its socioeconomic barriers we performed a qualitative study on Indian rural women with hypertension. METHODS: In-depth interviews with women having hypertension and presenting to outpatient department at a teaching hospital were performed in 30 women aged 35-65 years, using a questionnaire focused on reasons for nonadherence and poor lifestyle modification. Low to medium adherence was observed in two-thirds of women. RESULTS: Majority of women were from low socioeconomic status and were illiterate. Awareness of hypertension and its complications was poor. Knowledge and practices of cessation of smoking and tobacco use and salt restriction in hypertension were low. Efforts to increase physical activity and decrease dietary fat and sugar intake were largely absent. Local follow-up at rural community health centres was not practiced due to physician nonavailability and about half used alternative systems of medicine. None had health insurance or access to free medicines. All the women had to pay out-of-pocket for medicines and were concerned with cost of therapy as well as pill burden. Half of the women borrowed money from relatives or friends to reach the hospital and pay for medicines. CONCLUSIONS: Socioeconomic barriers for low adherence to antihypertensive medication in women in India are low awareness of hypertension and complications, poor access to care, out-of-pocket payments, borrowing money, lack of insurance, and cost of medicines.

Household, Community, Sub-National and Country-level Predictors of Primary Cooking Fuel Switching in Nine Countries from the PURE Study.

INTRODUCTION: Switching from polluting (e.g. wood, crop waste, coal) to clean cooking fuels (e.g. gas, electricity) can reduce household air pollution (HAP) exposures and climate-forcing emissions. While studies have evaluated specific interventions and assessed fuel-switching in repeated cross-sectional surveys, the role of different multilevel factors in household fuel switching, outside of interventions and across diverse community settings, is not well understood. METHODS: We examined longitudinal survey data from 24,172 households in 177 rural communities across nine countries within the Prospective Urban and Rural Epidemiology (PURE) study. We assessed household-level primary cooking fuel switching during a median of 10 years of follow up (~2005-2015). We used hierarchical logistic regression models to examine the relative importance of household, community, sub-national and national-level factors contributing to primary fuel switching. RESULTS: One-half of study households (12,369) reported changing their primary cooking fuels between baseline and follow up surveys. Of these, 61% (7,582) switched from polluting (wood, dung, agricultural waste, charcoal, coal, kerosene) to clean (gas, electricity) fuels, 26% (3,109) switched between different polluting fuels, 10% (1,164) switched from clean to polluting fuels and 3% (522) switched between different clean fuels. Among the 17,830 households using polluting cooking fuels at baseline, household-level factors (e.g. larger household size, higher wealth, higher education level) were most strongly associated with switching from polluting to clean fuels in India; in all other countries, community-level factors (e.g. larger population density in 2010, larger increase in population density between 2005-2015) were the strongest predictors of polluting-to-clean fuel switching. CONCLUSIONS: The importance of community and sub-national factors relative to household characteristics in determining polluting-to-clean fuel switching varied dramatically across the nine countries examined. This highlights the potential importance of national and other contextual factors in shaping large-scale clean cooking transitions among rural communities in low- and middle-income countries.

Association of Household Wealth Index, Educational Status, and Social Capital with Hypertension Awareness, Treatment, and Control in South Asia.

OBJECTIVE: Hypertension control rates are low in South Asia. To determine association of measures of socioeconomic status (wealth, education, and social capital) with hypertension awareness, treatment, and control among urban and rural subjects in these countries we performed the present study. METHODS: We enrolled 33,423 subjects aged 35-70 years (women 56%, rural 53%, low-education status 51%, low household wealth 25%, low-social capital 33%) in 150 communities in India, Pakistan, and Bangladesh during 2003-2009. Prevalence of hypertension and its awareness, treatment, and control status and their association with wealth, education, and social capital were determined. RESULTS: Age-, sex-, and location-adjusted prevalence of hypertension in men was 31.5% (23.9-40.2%) and women was 32.6% (24.9-41.5%) with variations in prevalence across study sites (urban 30-56%, rural 11-43%). Prevalence was significantly greater in urban locations, older subjects, and participants with more wealth, greater education, and lower social capital index. Hypertension awareness was in 40.4% (urban 45.9, rural 32.5), treatment in 31.9% (urban 37.6, rural 23.6), and control in 12.9% (urban 15.4, rural 9.3). Control was lower in men and younger subjects. Hypertension awareness, treatment, and control were significantly lower, respectively, in lowest vs. highest wealth index tertile (26.2 vs. 50.6%, 16.9 vs. 44.0%, and 6.9 vs. 17.3%, P < 0.001) and lowest vs. highest educational status tertile (31.2 vs. 48.4%, 21.8 vs. 42.1%, and 7.8 vs. 19.2%, P < 0.001) while insignificant differences were observed in lowest vs. highest social capital index (38.2 vs. 36.1%, 35.1 vs. 27.8%, and 12.5 vs. 9.1%). CONCLUSIONS: This study shows low hypertension awareness, treatment, and control in South Asia. Lower wealth and educational status are important in low hypertension awareness, treatment, and control.

Effects of bidi smoking on all-cause mortality and cardiorespiratory outcomes in men from south Asia: an observational community-based substudy of the Prospective Urban Rural Epidemiology Study (PURE).

BACKGROUND: Bidis are minimally regulated, inexpensive, hand-rolled tobacco products smoked in south Asia. We examined the effects of bidi smoking on baseline respiratory impairment, and prospectively collected data for all-cause mortality and cardiorespiratory events in men from this region. METHODS: This substudy of the international, community-based Prospective Urban Rural Epidemiology (PURE) study was done in seven centres in India, Pakistan, and Bangladesh. Men aged 35-70 years completed spirometry testing and standardised questionnaires at baseline and were followed up yearly. We used multilevel regression to compare cross-sectional baseline cardiorespiratory symptoms, spirometry measurements, and follow-up events (all-cause mortality, cardiovascular events, respiratory events) adjusted for socioeconomic status and baseline risk factors between non-smokers, light smokers of bidis or cigarettes (≤10 pack-years), heavy smokers of cigarettes only (>10 pack-years), and heavy smokers of bidis (>10 pack-years). FINDINGS: 14 919 men from 158 communities were included in this substudy (8438 non-smokers, 3321 light smokers, 959 heavy cigarette smokers, and 2201 heavy bidi smokers). Mean duration of follow-up was 5·6 years (range 1-13). The adjusted prevalence of self-reported chronic wheeze, cough or sputum, dyspnoea, and chest pain at baseline increased across the categories of non-smokers, light smokers, heavy cigarette smokers, and heavy bidi smokers (p<0·0001 for association). Adjusted cross-sectional age-related changes in forced expiratory volume in 1 s (FEV1) and FEV1/forced vital capacity (FVC) ratio were larger for heavy bidi smokers than for the other smoking categories. Hazard ratios (relative to non-smokers) showed increasing hazards for all-cause mortality (light smokers 1·28 [95% CI 1·02-1·62], heavy cigarette smokers 1·59 [1·13-2·24], heavy bidi smokers 1·56 [1·22-1·98]), cardiovascular events (1·45 [1·13-1·84], 1·47 [1·05-2·06], 1·55 [1·17-2·06], respectively) and respiratory events (1·30 [0·91-1·85], 1·21 [0·70-2·07], 1·73 [1·23-2·45], respectively) across the smoking categories. INTERPRETATION: Bidi smoking is associated with severe baseline respiratory impairment, all-cause mortality, and cardiorespiratory outcomes. Stricter controls and regulation of bidis are needed to reduce the tobacco-related disease burden in south Asia. FUNDING: Population Health Research Institute, Canadian Institutes of Health Research, and Heart and Stroke Foundation of Ontario.

Trends in Coronary Heart Disease Epidemiology in India.

Cardiovascular diseases, especially coronary heart disease (CHD), are epidemic in India. The Registrar General of India reported that CHD led to 17% of total deaths and 26% of adult deaths in 2001-2003, which increased to 23% of total and 32% of adult deaths in 2010-2013. The World Health Organization (WHO) and Global Burden of Disease Study also have highlighted increasing trends in years of life lost (YLLs) and disability-adjusted life years (DALYs) from CHD in India. In India, studies have reported increasing CHD prevalence over the last 60 years, from 1% to 9%-10% in urban populations and <1% to 4%-6% in rural populations. Using more stringent criteria (clinical ± Q waves), the prevalence varies from 1%-2% in rural populations and 2%-4% in urban populations. This may be a more realistic prevalence of CHD in India. Case-control studies have reported that important risk factors for CHD in India are dyslipidemias, smoking, diabetes, hypertension, abdominal obesity, psychosocial stress, unhealthy diet, and physical inactivity. Suitable preventive strategies are required to combat this epidemic.

Disparities in Prevalence of Cardiometablic Risk Factors in Rural, Urban-Poor, and Urban-Middle Class Women in India.

OBJECTIVE: Urbanization is an important determinant of cardiovascular disease (CVD) risk. To determine location-based differences in CVD risk factors in India we performed studies among women in rural, urban-poor and urban middle-class locations. METHODS: Population-based cross-sectional studies in rural, urban-poor, and urban-middle class women (35-70 y) were performed at multiple sites. We evaluated 6853 women (rural 2616, 5 sites; urban-poor 2008, 4 sites; urban middle-class 2229, 11 sites) for socioeconomic, lifestyle, anthropometric and biochemical risk factors. Descriptive statistics are reported. RESULTS: Mean levels of body mass index (BMI), waist circumference, waist-hip ratio (WHR), systolic BP, fasting glucose and cholesterol in rural, urban-poor and urban-middle class women showed significantly increasing trends (ANOVAtrend, p <0.001). Age-adjusted prevalence of diabetes and risk factors among rural, urban-poor and urban-middle class women, respectively was, diabetes (2.2, 9.3, 17.7%), overweight BMI ≥25 kg/m2 (22.5, 45.6, 57.4%), waist >80 cm (28.3, 63.4, 61.9%), waist >90 cm (8.4, 31.4, 38.2%), waist hip ratio (WHR) >0.8 (60.4, 90.7, 88.5), WHR>0.9 (13.0, 44.3, 56.1%), hypertension (31.6, 48.2, 59.0%) and hypercholesterolemia (13.5, 27.7, 37.4%) (Mantel Haenszel X2 ptrend <0.01). Inverse trend was observed for tobacco use (41.6, 19.6, 9.4%). There was significant association of hypertension, hypercholesterolemia and diabetes with overweight and obesity (adjusted R2 0.89-0.99). CONCLUSIONS: There are significant location based differences in cardiometabolic risk factors in India. The urban-middle class women have the highest risk compared to urban-poor and rural.

Cardiometabolic risk factors in the Agarwal business community in India: Jaipur Heart Watch-6.

BACKGROUND: Agarwal is one of the largest business communities in India. To determine prevalence of cardiovascular risk factors and their distribution according to educational status (ES) in this community we performed a study. METHODS: 1781 (men 1039, women 742) of 2500 selected subjects (71.2%) were evaluated and fasting blood sample obtained in 1130. RESULTS: Age-adjusted prevalence of risk factors was tobacco use 12.2%, sedentary habits 54.2%, overweight/obesity 54.4%, obesity 19.5%, abdominal obesity 61.2%, hypertension 36.0%, diabetes 19.2%, hypercholesterolemia ≥200 mg/dl 25.8%, low HDL cholesterol 29.2%, hypertriglyceridemia 32.8% and metabolic syndrome 22.3%. Low ES subjects had significantly greater prevalence of sedentary habits, low fruit/vegetable intake, hypertension, low HDL cholesterol and diabetes. CONCLUSIONS: Cardiometabolic risk factors are highly prevalent in the Agarwal business community. Prevalence is greater in subjects with low educational status.