Review
Correlation of regional cardiovascular disease mortality in India with lifestyle and nutritional factors

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Abstract

Objective

There is a wide disparity in prevalence and cardiovascular disease mortality in different Indian states. To determine significance of various nutritional factors and other lifestyle variables in explaining this difference in cardiovascular disease mortality we performed an analysis.

Methods and results

Mortality data were obtained from the Registrar General of India. In 1998 the annual death rate for India was 840 / 100,000 population. Cardiovascular diseases contribute to 27% of these deaths and its crude mortality rate was 227 / 100,000. Major differences in cardiovascular disease mortality rates in different Indian states were reported varying from 75–100 in sub-Himalayan states of Nagaland, Meghalaya, Himachal Pradesh and Sikkim to a high of 360–430 in Andhra Pradesh, Tamil Nadu, Punjab and Goa. Lifestyle data were obtained from national surveys conducted by the government of India. The second National Family Health Survey (26 states, 92,447 households, 301,984 adults) conducted in 1998–1999 reported on various demographic and lifestyle variables and India Nutrition Profile Study reported dietary intake of 177,841 adults (18 states, 75,229 men, 102,612 women). Cardiovascular disease mortality rates were correlated with smoking, literacy levels, prevalence of stunted growth at 3-years (as marker of fetal undernutrition), adult mean body mass index, prevalence of overweight and obesity, dietary consumption of calories, cereals and pulses, green leafy vegetables, roots, tubers and other vegetables, milk and milk products, fats and oils, and sugar and jaggery. As a major confounder in different states is poverty, all the partial correlation coefficients were adjusted for illiteracy, fertility rate and infant mortality rate. There was a significant positive correlation of cardiovascular disease mortality with prevalence of obesity (R = 0.37) and dietary consumption of fats (R = 0.67), milk and its products (R = 0.27) and sugars (R = 0.51) and negative correlation with green leafy vegetable intake (R =  0.42) (p < 0.05).

Conclusions

There are large disparities in cardiovascular disease mortality in different Indian states. This can be epidemiologically explained by difference in dietary consumption of fats, milk, sugar and green-leafy vegetables and prevalence of obesity.

Introduction

Non-communicable diseases such as cardiovascular disease and cancer are emerging as major causes of death in India [1]. According to the World Health Report (2004) non-communicable diseases caused 6.08 million deaths of which cardiovascular diseases caused 3.31 million deaths in high-child high-adult mortality region of South-East Asia in the year 2002 [2]. In India non-communicable diseases caused 5.10 million deaths, of which cardiovascular diseases were responsible for 2.78 million deaths and cancer 0.75 million [2], [3]. Of the cardiovascular diseases, ischaemic heart disease caused 1.51 million deaths and others deaths were attributed to cerebrovascular disease (0.75 million), rheumatic heart disease (0.10 million), hypertensive heart disease (0.08), and inflammatory heart disease (0.05 million). Assessment of disease burden using the disability adjusted life years (DALYs) methodology revealed that non-communicable diseases resulted in 125.5 million DALYs lost as compared to 139.4 million due to communicable diseases and 39.7 million due to injuries in India [4]. Cardiovascular diseases contributed to 30.5 million DALYs of which the major share was ischaemic heart disease (15.1) and cerebrovascular diseases (7.3). It is apparent that cardiovascular diseases, especially coronary heart disease, are major cause of death in India and absolute mortality due to coronary heart disease shall increase from 1.59 million/year in the year 2000 to 2.03 million in 2010 and 2.58 million by the year 2020 [1].

While it is useful to have global data from a single country for international comparisons, diversities within a country must be recognized. India is a vastly heterogeneous country with large number of genetically, ethnically, socially and geographically separated groups. It is well known that all these factors are important in pathogenesis of cardiovascular diseases and it is difficult to extrapolate data from a single study or even multiple small studies to the country as a whole [4], [5], [6], [7], [8], [9], [10]. Cross-sectional epidemiological studies of prevalence of hypertension [5], [6], diabetes[7], [8], [10] and coronary heart disease [9] in India have shown widely disparate findings. Coronary heart disease prevalence has been reported to be higher in South India as compared to North India in recent studies [9] although a study of railway-workers reported that it was more common among the North Indians [11].

There is a wide disparity in cardiovascular disease (CVD) mortality in different Indian states as reported by the Registrar General of India [12]. To determine significance of various lifestyle variables and nutritional factors in explaining this difference in CVD mortality we performed this study. Data from the second National Family Health Survey (NFHS-2) [13] for lifestyle parameters and India Nutrition Profile study (INP) [14] focusing on nutrition intake in India were used to correlate various lifestyle and nutritional factors with cardiovascular mortality.

Section snippets

Methods

The Office of the Registrar General of India obtains statistics on causes of death from different states and union territories under the aegis of Registration of Births and Deaths Act of 1969. This system of medical certification provides cause-specific mortality profiles and the Office of Registrar General of India publishes annual report on Medical Certification of Causes of Death based on data reported by all states implementing this scheme. In the year 1998 a total of 14.9% deaths in India

Results

The latest causes of death statistics in India are available for 1998 from the Registrar General of India [12]. These causes contribute to 76–93% of all deaths in the states that report these statistics. Cardiovascular diseases form a significant proportion of these causes of deaths and vary from 10% to 42% in different states with the lowest proportion in Meghalaya (10.0%) in eastern India and the highest in Goa (41.2%) in western India (Table 1). Absolute cardiovascular mortality rates per

Discussion

This study shows that there are wide differences in cardiovascular disease mortality in different parts of India. The mortality is the lowest in sub-Himalayan states of Himachal Pradesh, Sikkim, Meghalaya and Nagaland and high in states of Tamil Nadu, Andhra Pradesh, Punjab and Goa. High mortality is not confined to a particular region. The variation in cardiovascular disease mortality can be explained by difference in dietary consumption of fats, sugars, and green-leafy vegetables and the

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