Cardiovascular Risk Factors among adolescents of Nepalgunj Municipality in Nepal.

Author(s) Manita Pyakurel 1, Anup Ghimire 2, Paras Pokharel 3.
Affiliation(s) 1Community medicine, Nepalgunj Medical College, Kathmandu, Nepal, 2School of public health and community medicine, B.P.Koirala Institute of Health and sciences, Dharan, Nepal, 3School of public health and community medicine, B.P.Koirala Institute of Health and Sciences, Dharan, Nepal 4.
Country - ies of focus Nepal
Relevant to the conference tracks Education and Research
Summary The aim of this study was to find out the prevalent risk factors of CVD and the association of Metabolic syndrome (MS) with behavioral risk factors (BRF).  A cross sectional study was done among 736 school going adolescents. A Systematic random sampling was done to select the sampling unit. CVD risk factors were assessed by World Health Organization (WHO) STEPwise approach. MS was defined based on National Cholesterol Education Programme (NCEP, 2003) criteria. Chi square test of association and multivariate logistic regression were applied. The prevalence of MS was 23(3.1%). Unprotective HDL and increased TG were the most common metabolic risk factors.
Background Over the centuries we have experienced great transitions in social, economic structures and home environments leading to the shift from agricultural and rural societies to industrial urban societies. These transitions have resulted in major changes in physical activity, eating habits and other lifestyle factors. We now face the rise of non communicable diseases (NCD) in addition to the remaining issues of communicable diseases. As a result low and middle income countries are facing a double burden of the modern risks of NCD. [1]
CVD is responsible for 16.7 million (29.2%) of total global deaths. CVD accounts for approximately 80% of deaths in low and middle income countries. [2] India predicts 64 million cases of CVD in year 2015. [3] In Nepal hypertension has the highest prevalence among the CVD at the tertiary level. [4] Cardiovascular risk factors vary with increasing age, gender, and ethnicity. Behavioral, genetic and metabolic risk factors are established risk factors. [3] In Dharan municipality prevalence of CHD is 57 per 1000. [5] Major behavioral risk factors in Nepal are tobacco smoking 23.3%, physical inactivity 14.2%, high blood sugar 8.4% and obesity 9.1%.[6,7]  Adolescence is the appropriate age range for tracking CVD as the evidence of increased chance of atherosclerosis occurrence increases with age and unhealthy behavioral activities. [8-11]
Objectives General objective.
To determine the prevalence of cardiovascular risk factors among the school going adolescents of the Nepalgunj municipality.Specific objectives:
1. To find out the prevalence of common risk factors of cardiovascular disease among the adolescents.
2. To evaluate the statistical relationship of cardiovascular risk level with sociodemographic variables & lifestyle.Research question.
What is the prevalence of risk factors of cardiovascular disease among the school going adolescents of age 10-19 years?
Methodology 2.1. Study population
A cross sectional study was conducted among a total of 736 adolescents of public and private schools of Nepalgunj municipality of Banke district Nepal from September 2012 to February 2013. Ethical approval was obtained from the institutional review board of B.P.Koirala institute of health sciences. The study was conducted with the financial and logistic support from Nepalgunj medical college. Data collection was done using the STEPS questionnaire of WHO.
2.2. Anthropometric measurements.
Blood pressure was measured with standard mercury sphygmomanometer with adequate cuff size and systolic blood pressure was taken by first heart sound (Kortokoff phase I). Diastolic pressure was recorded at the level when sound disappeared (Kortokoff phase V). Two reading were taken on the right arm at least 5 minutes apart. Before measuring blood pressure the respondent rested for at least 5 minutes or as required. This excluded those who had smoked within the last 30 minutes.
Waist circumference was measured using a nonelastic tape to the nearest 0.1 cm over the unclothed abdomen at smallest diameter between coastal margin & iliac crest. Tape measure was horizontal. Respondent was relaxed with arms held loosely by the side. Measurement was taken at the end of normal breath. Both arterial hypertension and abdominal obesity was categorized according to NCEP (2003) criteria.
2.3. Biochemical tests.
A venous blood sample was collected after fasting 12 hours to assess the serum levels of triglyceride (TG), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C) and fasting blood sugars were collected and brought to biochemistry lab of Nepalgunj medical college. Automated biochemistry analyzer was used to analyze the lipids.
2.4. Diagnostic criteria.
Among the behavioral risk factors dichotomous variable dietary habit was defined as unhealthy for less than 22 minimum score (sum of salt score, frequency of: fruit intake, vegetable intake, food consumed outside). Physical activity was categorized as inactivity for less than minimum score of 77 (sum of moderate / heavy vigorous exercise and sleep). MS was categorized as positive and negative according to NCEP criteria (2003).
Results Analysis was done among 736 adolescents(331 boys,405 girls). The mean age of the study population was 15.22 ±1.79. Among the behavioral risk factors, adolescents who consumed tobacco were 62(8.4%) and alcohol 51(6.9%). Adolescents with unhealthy dietary habit were 726 (98.6%). Physical inactivity was present in 591(80.3%). Also 345 (46.9%) reported stress at any point of time. Among the genetic factors, family history of chronic diseases were present among 547(74.3%) and 1.9% were diagnosed for congenital heart disease. MS was present among 23(3.1%) with 1.3% among male and 1.7% among female.
Baseline characteristics of metabolic risk factors shows mean SBP, DBP of 110.6 ±12.3, 70.3±10.6 and 104.6±11.7, 66.1± 10 mm of Hg among male and female respectively. Level of MS was categorized in 5 levels based on clustering of the risk factors according to sex distribution, described in table no.1, 2 and 3.Bivariate analysis shows no significant association between age, sex, ethnicity, religion and MS. Significant association of 3.9times increased odds of, (95% CI: 1.7-9.2) was established between positive family history and MS as compared with reference category of negative family history.
Multivariate analysis among male adolescents shows positive family history have 10.85 increased odds of (95% CI: 2.42-48.61) MS as compared to its counterpart negative family history. Among the female adolescents non refined oil consumption showed 8.24 increased odds of (95% CI =1.05-64.78) MS as compared to the refined oil consumers. Whereas non stressful adolescents have 4.22 increased odds of (95% CI=1.08-16.4) MS compared to the stressful.
Conclusion From our findings the most prevalent behavioral risk factors were consumption of non refined oil, unhealthy dietary habit, physical inactivity and stress. Among the genetic risk factors, prevalence of 1.9% CHD and positive association of family history with MS were alarming. More than ¾ of adolescents have at least one risk factor of MS. Among the components of MS, dyslipidemia was the most common risk factor affecting the adolescents. Males with positive family history and a non refined oil consumer and non stressed females were important risk factors for identifying adolescents at risk for later CVD onset. The result suggests that preventive measures including consumption of refined oil may be warranted for these adolescents. In conclusion, the presence of behavioral and metabolic risk factors for CVD is an important health problem among the adolescents of Nepalgunj municipality. There is a need for a national programme to control cardiovascular risk factors among these adolescents.

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