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Chronic disease risk factor and physical activity patterns: Findings from Sri Lanka

Author(s) Shreenika DE Silva Weliange1, Dulitha Fernando2, Jagath Gunathilake3.
Affiliation(s) Community Medicine, University of Colombo, Colombo, Sri Lanka, Department of Community Medicine- retired, University of Colombo, Colombo, Sri Lanka, 3Department of Geology, University of Peradeniya, Kandy, Sri Lanka.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Chronic Diseases
Summary There is a tremendous increase in chronic diseases worldwide. A similar pattern is observed in Sri Lanka. Physical inactivity contributes to 6% of deaths globally and is identified as the fourth leading risk factor for mortality due to chronic diseases. There is sparse knowledge of the profile of the risk factors of chronic diseases as well as inadequate knowledge of the pattern of physical activity in Sri Lanka. The objective of this study was to assess the risk factors of chronic disease and the association with physical activity for adults in the Colombo Municipal Council (CMC) area.
Background 'The Global Strategy on Diet, Physical Activity and Health' endorsed at the 57th World Health Assembly states that a “profound shift in the balance of the major causes of morbidity and mortality has already occurred in the developed countries and is underway in many developing countries”. The World Health Report 2002, 'Reducing Risks, Promoting Healthy Life', shows that few risks are responsible for a large number of premature deaths and account for a big share of the global burden of disease. The immediate risk factors for chronic diseases are raised blood glucose, high blood pressure, high concentrations of cholesterol in the blood and overweight or obesity. Physical inactivity and tobacco use, along with poor diet, are the common modifiable risk factors. In Sri Lanka a changing trend in the pattern of disease burden is observed. Trend analysis using Registrar General’s data shows that chronic disease mortality rates are increasing rapidly during the past decades. In 2001, 71% of all deaths in Sri Lanka were due to chronic diseases. Chronic disease mortality is reported to be 20-30% higher in Sri Lanka than in many developed countries. According to the Annual Health statistics, coronary heart disease was the leading cause of hospital deaths in Sri Lanka since 1997.
Objectives Urbanisation and other socio economic changes have led to changes in individuals’ lifestyle thereby causing an increase in the intermediate risk factors of chronic diseases, such as raised blood pressure, raised blood glucose, abnormal blood lipids and overweight/obesity. However, to further understand the problem it is necessary to study these intermediate risk factors and the common modifiable risk factors in the most urbanized part of Sri Lanka namely the CMC area. This study aims to assess these risk factors and the association of physical activity for adults in the CMC area.
Methodology Study design and area: This was a cross sectional study of a representative sample of adults aged 20-59 (both inclusive) years living in the CMC area in which has the highest population density, and covers most of the metropolitan and the economic area in Sri Lanka. Study population: All adults living in the area for a continued period of not less than six months were the study population. The exclusion criteria were: institutionalised adults, adult visitors to the study area, pregnant females up to postpartum period of 3 months, adults with severe psychiatric illness and those not providing consent. Sampling: Four hundred adults were selected using a probability proportionate to size cluster sampling method. The Primary Sampling Unit was a ward in the CMC area which is similar to a village structure. The Grama Niladhari (village headman) in each ward helped the data collectors to locate the selected houses. Within the household an adult was selected using a random procedure. Only one eligible individual was selected from a household so as to minimize cluster effect, as members of the same household share similar life styles. Recruitment was done irrespective of the availability of the study participants in the house at the time of the first visit to the households. The cluster was considered as complete when 40 consenting eligible people were identified and interviewed.Measurements: An interviewer administered questionnaire consisting of socio-demographic, economic characteristics was used to collect data. Medically trained officers interviewed individuals and assessed the disease status by questioning and going through medical records. Physical activity was assessed using the validated long version of the international physical activity questionnaire and individuals were classified into ‘sufficient activity’ and ‘insufficient activity. Trained personnel took anthropometric measures of height and weight from all participants.Ethics: All participants received an information sheet about the study and signed a consent form if they agreed to participate. Ethical clearance was obtained from the Ethics Review Board of the Faculty of Medicine, University of Colombo. The provincial and the district government authorities gave permission to carry out the study in their area.

Statistical analysis: Descriptive analysis was done using chi square tests. All analysis were conducted using SPSS software version 17.

Results Out of the 400 participants 43% (n=172) were males and 57% (n=228) were females. Only 46% (n=184) had a G.C.E. ordinary level education or more and 86.3% (n=345) had an income of less than Rupees 30,000. Fifty four percent were between 40-59 years of age while the rest (46%) were between 20-49 years of age.
The self-reported prevalence of type 2 diabetes mellitus was 12.3% (n=49) while the prevalence of raised blood pressure and abnormal lipds were 13.3% (n=53) and 5.5% (n=22) respectively. The majority (60.5%, n=242) were overweight while another 7% (n=28) were underweight. More than half (64.5%, n=258) of the participants had at least one immediate risk factor for NCD, and out of them 110 (27.5%) were 40 years or less. Of the sample 11.8% were current smokers and 14.5% were previous smokers.
Seventy two precent (n=288) of the participants were in the ‘sufficiently active’ category, with activity accumulated mainly through household, travel and job related behaviours. However, 85.8% (n=343) reported no leisure-time PA, and 21.3% (n=85) reported that they did not walk either for travel or leisure for more than 10 minutes a week. No active transport (walking/cycling) methods were used by 23.5 % (n=94). Of those who were had at least one immediate risk factor 85.6% (n=221) had no leisure activity while 21.3% (n=55) and 93.4% (n=240) reported no walking or cycling during the previous week.
Having an immediate risk factor for chronic disease was not statistically significantly associated with socioeconomic or demographic characteristics of the individuals. This study also did not find a strong evidence of association between the presence of at least one immediate risk factor and physical activity.
Conclusion An alarming percentage of immediate risk factors were observed in the CMC area although no particular socioeconomic and demographic group was more affected than the others. The major contributors to energy expenditure in the local setting according to this study were housework, transportation and job related activities. This is different to the pattern seen in the developed countries. Being active while attending to day to day chores should be encouraged and promoted in the developing countries since it is already their habitual practice. Special concern is necessary due to the counteracting forces of rapid urbanisation taking place in Sri Lanka which makes it more convenient and fashionable for people to use mechanical equipment for housework, to seek sedentary jobs and use motorised vehicles for transport. Since it is seen that most of the participants in the present study enacted their activity from transportation it is necessary to promote active transportation. Thus the importance of an activity friendly physical environment with good street structure to facilitate walking and cycling, traffic and general safety, access and connectivity needs to be highlighted.
Strength and limitations: This study explored the burden of risk factors in the most urban part of Sri Lanka and its association with physical activity. Physical activity measurement, although validated for Sri Lanka, was carried out through self-reports. Thus there was a possibility for recall bias and for over-reporting or under-reporting the number of occasions and time spent on physical activity in different domains. This is due to various reasons such as social norms determining socially acceptable answers. A cross sectional study design had to be used. Therefore causal interferences cannot be made because of the inability to determine the temporal sequence.