|Year : 2022 | Volume
| Issue : 3 | Page : 83-89
Study of Prevalence of Lifestyle Diseases and Comparison of their Risk Factors among Serving Personnel of Army
Tripti Agrawal1, Sandeep Bhalla2, Vipul Dutt3
1 Officer Commanding Station Health Organisation Jalandhar Cantt, Comdt Base Hospital, Tezpur, Assam, India
2 Public Health Department, Station Health Organisation Jalandhar Cantt, Comdt Base Hospital, Tezpur, Assam, India
3 MD Community Medicine, Senior Advisor & Colonel Health Southern Command, Pune, India
|Date of Submission||02-Jul-2020|
|Date of Decision||16-Sep-2020|
|Date of Acceptance||06-Oct-2021|
|Date of Web Publication||15-Mar-2022|
(Dr) Tripti Agrawal
Officer Commanding Station Health Organisation, Jalandhar Cantt, Punjab
Source of Support: None, Conflict of Interest: None
Introduction: Lifestyle diseases have multifactorial causation risk factors. Armed forces personnel although constitute healthier sections of society but are not spared from prevalent pandemic of lifestyle diseases in country. This research aims to study the prevalence of lifestyle disease to highlight the importance of keeping suitable preventive measures in place to control the epidemic of lifestyle diseases among the middle-aged army personnel. Materials and Methods: The study is a cross-sectional community-based epidemiological design of 2956 armed forces personnel, aged 35 years and above, selected by multistage random sampling. Data were collected on pretested open-ended questionnaire. Statistical analysis was done using Chi-square test, unpaired t-test, and multiple logistic regression techniques. Results: The study revealed that consistent statistically significant association between major sociodemographic, potential behavioral, and clinical risk factors of lifestyle diseases, especially dietary risk factors, namely snacking in between meals, consumption of energy-dense foods, physical inactivity among tradesman, cooks, clerks contributing to higher prevalence of lifestyle diseases among them. The study indicates that the prevalence of overweight and prehypertensive among study sample is suggestive of alarming proportions. Conclusion: Multi-cross-sectoral-integrated strategies for provisioning of comprehensive health-care and strengthening surveillance mechanism pertaining to prevention and control of lifestyle diseases are the need of the hour. Genuine dietary modifications; improving cooking practices; sustained efforts to be physical active, stringent mechanisms to ensure definite working hours, minimize work-related stress; institutional checks on tobacco, alcohol, substance abuse; screening for lifestyle disease risk factors; addressing common risk factors are desirable lifestyle interventions.
Keywords: Cross-sectoral strategies, differential analysis, lifestyle diseases
|How to cite this article:|
Agrawal T, Bhalla S, Dutt V. Study of Prevalence of Lifestyle Diseases and Comparison of their Risk Factors among Serving Personnel of Army. J Mar Med Soc 2022;24, Suppl S1:83-9
| Introduction|| |
The epidemiological shift, increasing life expectancy, dynamic changes in demographic parameters besides cumulative effects of conventional and emerging risk factors are plausible reasons for pandemic of lifestyle diseases in India as well as other developing nations.,, Armed forces personnel of a country are the healthiest citizens since they are younger and lead a disciplined lifestyle involving routine physical exercise, physical proficiency training, a balanced diet, regular medical examination, and health checkups.,, However, defence services also encompass strenuous working hours, strict disciplinary action, stressful situations, distance from family, unfavorable climatic conditions, and mental stress,,,, and various other biological ill-effects from sustained readiness for enemy at borders are among common risk factors of the various lifestyle disease across different ages and trades.
The present study is, therefore, an attempt to study the prevalence of lifestyle disease, namely ischemic heart diseases, hypertension, diabetes mellitus, obesity, mental stress and differential effect of various risk factors of lifestyle diseases, namely physical inactivity, faulty dietary habits, smoking, alcohol, psychosocial factors among the various trades, namely clerks, storekeepers, cooks, general duty soldiers as well as officers to highlight the importance of keeping suitable preventive measures in place and control the epidemic of lifestyle disease in armed forces.
| Materials and Methods|| |
This study is a community based, cross-sectional, analytical study among various trades of serving male personnel of Indian Army aged 35 years and above, from June 2014 to May 2016, posted to station in Western India, which is the age bracket of high-risk population as per available prevalence studies.,,,,,, Those personnel who were <35 years and that not on duty for the past 14 days or more were excluded from the study. Relevance of 14 days as exclusion criteria was to ensure that the individual returning from leave assumes the delegated task as well as unit normal routine of physical activity and parades which affect the lifestyle.
To obtain an approximate idea of the prevalence of lifestyle diseases, among study population, a pilot study was conducted on 30 participants and 23% cumulative prevalence of lifestyle diseases under study was obtained. Participants of pilot study were not included in the main study. Minimum sample size was calculated on anticipated prevalence of 23% (with level of confidence 95% and error of margin 5%) and it was found to be 2632. It was, therefore, decided to enrol 3000 men in the study (2632 [calculated sample size] + extra 10%) to cater for nonresponse. The sample was selected using “multistage random sampling” procedure. A list of army units in the study area obtained from the military administrative authorities formed the “sampling frame” for the first stage. In the first stage, 1 in 3 samples of the military units were drawn randomly using random number tables. In the second stage, the detailed list of “subunits” of the military units selected in the first stage formed the sampling frame and 1 in 3 samples of these subunits was drawn using random number tables. In the third stage, a list of all army persons aged 35 years and above, in the selected subunits formed the sampling frame. Of the total 43 units with varying strength in the STN, 17 units were randomly selected. Then, 49 subunits were randomly selected within 17 of these units by multistage random sampling. After applying exclusion criteria of the study on the sampling frame of each subunit, 182 were excluded for nonavailability or refusal to get examined. Data on 2956 persons were finally available for collation and statistical analysis which includes 82 officers, 288 JCOs, and 2586 other ranks.
After explaining the purpose of the study, written informed consent was obtained from all eligible participants. The interview was conducted by the principal worker who was assisted by the medical officers and paramedical staff trained for the purpose. Data were collected on pretested close-ended questionnaire which included orally recorded study variables on personal particulars; occupation/trade-related factors; history pertaining to behavioral lifestyle risk factors such as dietary habits; physical exercise; leisure-time physical activity levels diet; tobacco and alcohol use; factors related to perceived stress originating from workplace/family front/personal reasons; past medical history of the individual and family history pertaining to illness with respect to various lifestyle diseases. The study participants then underwent clinical measurements, biochemical measurements, resting ECG measurement, and psychometric tests.
The procedures of epidemiological survey, assessment of physical exercise/energy expenditure levels, anthropometric measurement, laboratory and biochemical methods, ECG recording/assessment, and clinical measurement were as per the standard guidelines given by the WHO. Standing height was measured to the nearest 0.1 cm using a wall-mounted stadiometer. Bodyweight was measured to the nearest 0.1 kg by standardized electronic scale. Body mass index (BMI) was determined by using Quetelet's index in kg/m2 (weight in kg/[height in m]2). Waist circumference was measured with the help of measuring tape to the nearest 0.1 cm at the midpoint between lower most point of the costal margin and highest point of iliac crest with the subject standing, at the end of normal expiration. Measure of less than or equal to 90 cm for men is considered to be healthy. Hip circumference was measured with the help of measuring tape, to the nearest 0.1 cm, taken at the maximum circumference of the hip. Blood pressure was measured on the left arm with the use of an automated blood pressure monitor, after standardization, in a supine position twice after 5 min rest in a quiet room, after ensuring that individual had not consumed coffee or smoked in previous 30 min. The mean of two measurements was taken. Heart rate was measured manually for one full minute by palpating radial artery nearest to 2 per sec. Calibration of all instruments used in the study was carried out before commencement of the study and also intermittently to take care of measurement bias.
The study participants were educated regarding the importance of a fasting blood sample before the day of collection of the sample. Blood was collected after an overnight fasting of 10–12 h for blood sugar profile, blood lipid profile, serum creatinine, uric acid, and hemoglobin. The blood samples were transported to the hospital laboratory maintaining all precautions to prevent hemolysis. Morning sample of urine was also collected for laboratory workup by using test strip for urinalysis. Biochemistry test was done using enzymatic kits on standardized semi-autoanalyzer at nearest military hospital. Hemoglobin is measured by the cyanmethemoglobin method with assistance of trained laboratory staff. LDL was calculated using the Friedewald formula., The intra and inter-assay coefficient of variance established was <2 and <3%, respectively, for cholesterol and 2.5% and 3.5% for triglycerides and HDL cholesterol, respectively. Electrectrocardiogram (ECG) was taken by standardized 12-lead ECG machine and was analyzed by medical specialist at the hospital.
The major biological risk factors identified in the World Health Report 2002 and included in STEPS chronic disease risk factor surveillance; overweight and obesity, raised blood pressure, impaired glucose tolerance, abnormal blood lipids, and its subset raised total cholesterol were studied. The following defining criteria as described by the WHO,,,, were used: ECG evidence of coronary insufficiency was Minnesota codes recommended by the WHO and this serves as proxy indicator of prevalence of ischemic heart disease, an indicator for coronary insufficiency. All individuals found to be having ECG changes other deranged parameters were followed up and managed appropriately. Dyslipidemia, was measured by total cholesterol >200 mg%, HDL <40 mg%, LDL >130 mg%, and triglycerides >150 mg%. Hypertension was diagnosed on the basis of JNC 7, criteria, systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥89 mmHg and prehypertensive if systolic blood pressure 120–139 mmHg and/or diastolic blood pressure 80–89 mmHg. Overweight and obesity were classified as per criteria for Asians (overweight as BMI ≥23 kg/m2 and obesity ≥27.5 kg/m2). Impaired glucose tolerance was defined as fasting blood sugar between 110 and 125 mg/dl and postprandial blood sugar 140–200 mg/dl and diabetes mellitus as fasting blood sugar levels ≥126 mg/dl and/or postprandial blood sugar ≥200 mg/dl. Those smoking ≥1 cigarette or bidi per day were considered active smoker. Data were also obtained for consumption and frequency of any other form of tobacco. Those consuming more than 3 drinks (≥180 ml per week) were considered as active drinkers. Perceived stress originating from workplace/family front/personal reasons was documented in 20 well-studied factors and scaled on scale of 1–10. Dietary history was obtained for diet preferences veg/nonveg, lack of fruits and veg in diet, use of added salt daily, use of butter/ghee daily, eat pickles daily, eating energy-dense food, snacking in between meals. Measuring exercise intensity using metabolic equivalents (MET) is equal to a level at which a person will spend 1 kcal energy per kg body weight per hour and this level usually corresponds to the resting stage. As the level of MET increases, the intensity of exercise increases. For a person weighing 70 kg at rest, activity level of one MET will spend 70 kcal/h. Data were collected on energy spent in leisure-time activity levels as less than or more than recommended 1400 Kcal/day, on most of the days, which is the minimum amount of calories to be expended in programmed physical exercise by the general population as documented by CDC Atlanta and American College of Sports Medicine. All participants currently on antihypertensive or hypoglycemic medications or having written prescriptions of antihypertensive or hypoglycemic drugs were classified as hypertensive or diabetic irrespective of their current blood pressure or blood sugar recordings and recorded to have positive medical history of lifestyle diseases.
Analysis was done using the EPI Info version 6.04 and SPSS (Statistical Package for Social Sciences) Version 21 using standard statistical procedures. Chi-square test was used to test the relation between individual characteristics and potential lifestyle risk factor. Binary logistic regression adjusted for education was executed to separately estimate the independent effect of age, BMI, physical activity, smoking, income categories.
| Results|| |
Total of 2956 armed forces personnel participated in this study which includes 2.8% (82) officers, 9.7% (288) junior commissioned officers, 87.5% (2586) as other ranks, 50.9% were general duty soldiers, 68.5% were educated up to intermediate, 79.2% were of rural origin, 98.8% were married out of which 65.8% were residing in family accommodation. 6.7% (198) gave positive medical history of lifestyle diseases. 8.6% of study participants had suffered ischemic heart disease as analyzed by ECG changes. 18% (95% confidence interval [CI]: 8.3 ± 3.71) were found to have high blood pressure while 3.5% (95% CI: 2.7 ± 1.44) were suffering from frank diabetes, respectively. Dyslipidemia profile – total cholesterol >200 mg/dl (95% CI: 190 ± 32.02); HDL <40 mg/dl (95% CI: 41.8 ± 1.78); LDL <130 mg/dl (95% CI: 120.3 ± 28.51); TRIG >150 mg/dl (95% CI: 151.3 ± 76.39); total Chol/HDL ratio >4.5 (95% CI: 4.5 ± 0.97). It was found that, 17.7% (523) were suffering from perceived stress. The characteristics of study participants are given in [Table 1].
Lifestyle diseases behavioural risk factor profile of the study participants is given in [Table 2]. Association of key risk factors with each lifestyle disease status is presented in [Table 3] while multiple logistic regression analysis of common predictor variables of lifestyle diseases as outcome variables is shown in [Table 4].
|Table 2: Prevalence of lifestyle diseases risk factors among study participants|
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|Table 3: Association of key risk factors with each lifestyle disease status|
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|Table 4: Multiple logistic regression analysis of common predictor variables of lifestyle diseases as outcome variable|
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| Discussion|| |
The present study suggests that there is lesser rate of prevalence of risk factors of lifestyle diseases such as smoking, high body weight, hypertension when compared with existing literature on the subject.,,, On the other hand, the prevalence rate of dietary risk factors, namely high salt intake, snacking in between meals, and physical inactivity with no leisure time activity, alcohol intake, and perceived stress was suggestive of higher proportions. Obesity prevalence was comparable to the WHO statistics for India as per the WHO in 2012,,,,, but the same was quite less as compared to Iran Army and West Bengal Police., The reason for lesser prevalence among the given study group might be due to different age groups of the study population across various research works. Although the study by Varma et al. among healthy armed forces personnel was suggestive of higher prevalence of hypercholesterolemia, diabetes but lower proportions of prehypertension and hypertension when compared to the present study [Table 5].
|Table 5: Comparison of lifestyle disease risk factors with data available from previous studies|
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Lifestyle diseases have multifactorial causation attributable to various genetic as well as modifiable behavioral lifestyle risk factors. Understanding of such impending burden of lifestyle diseases places paramount importance to mass strategy public health approach,, accompanied with ongoing stringent surveillance of lifestyle diseases risk factors. The study brought out that Junior and noncommissioned officers of the age group of 35 years and above being the most vulnerable group for the development of lifestyle diseases for various reasons, namely undue long working hours, uncontrolled dietary habits with consideration to meal timings, amount of food in plate, preferences for fatty, salty nonveg diet, positional/rank effects, etc. The results of the study have genuine bearing for armed forces and the recommendations arising from the study results are as under:
- Mandatory and Stringent Annual or Periodic Medical Examination Waist–Hip Ratio is a better index to predict presence of lifestyle diseases risk factors and its measurement in persons with normal weight holds importance. Lipid profile, waist–hip ratio, and BMI should be included as mandatory laboratory tests as part of Annual Medical Examinations for this age group
- The present study recommends that at least 1400 kcal per week should be expended to achieve some protective effect. The optimum effect of physical exercise comes at intensity level of 6–9 MET. This is in the background of understanding that one may be having normal body weight without exercising optimally
- The study found out those tradesmen, cooks, and clerks are the high-risk trades who participated poorly in PT and organized games. Administrative authorities need to monitor personnel of these trades in particular. All personnel should be compulsorily involved in minimum 45 min or more of moderate-intensity physical activity on most days of the week
- A diet rich in fruits, vegetables, low salt intake, low fat dairy foods with reduced total fat can reduce the prevalence of lifestyle diseases. Unhealthy cooking practices in wet canteens/langars, namely fried snacks with mid-day tea and reuse of left over oil after deep frying should be discarded
- Creating awareness on the link between intake of diets containing high salt, snacking in between meals, and physical inactivity with no leisure time activity, alcohol consumption, and stress is the need of the hour in the prevention of various lifestyle diseases.
Few studies,, had shown that besides other anthropometric parameters, especially BMI and WHR, assessment of visceral fat area should be included as important vital parameters to predict hypertension, diabetes, and syndrome X, especially in high-risk cases. Those with high visceral fat area must be investigated further and monitored closely for developing these lifestyle diseases.
Surprisingly, and despite decades of health campaigns, being overweight and consuming less salt were the least spontaneously cited established and modifiable risk factors.,, The association between overweight and cardiovascular disease is probably less clear to the public since other risk factors such as lack of physical activity, eating too much fat, high blood pressure and/or high blood cholesterol received more attention in health campaigns. The difficulty with salt is that more than 70% of the daily overconsumption is apparently invisible for the consumers. For instance, bread, cheese, soups, ready-to-eat cereals, and meals are rich in salt. It is very difficult to estimate daily salt consumption and adding no or less salt during cooking sessions will have an apparent important impact on consumer's perception of salt intake but a limited impact on total salt consumption. Experiencing stress,, was the fourth most cited cardiovascular risk factor, which is still not a very well-established factor confirmed by other research. Review of literature suggests that being overweight and consuming less salt are among the least documented modifiable risk factors since less number of studies were focussed to establish their attributability. This is also relevant in the background that relatively more weightage was established for risk factors such as lack of physical activity, sedentary habits, eating too much fat, high blood pressure, high blood cholesterol by numerous studies as well as relative importance during health campaigns. It is also highlighted that more than half of daily consumption of salt go unnoticed by consumers in the form of soups, bread, porridge, dal, pickles, chutney, sauces, ready to eat meals, etc. Perceived stress which was studied in the present research is not a very well cited risk factor for lifestyle diseases in review of literature. It is fourth most cited cardio vascular risk factor by few studies,, while not confirmed by many other researches.
Limitations of the study: The study population for the present research consist of armed forces personnel which have few advantages as well disadvantages. Advantages include that since this constitutes organised sector, accurate data collection was administratively convenient including from those who turned nonresponders. However, the same advantage could be seen as disadvantage because varied regional nativity, trade profiles, educational standards, sociodemographic-genetic makeup, etc., constitute the study sample as representative sample for men employed in an organization with varied occupational and trade profiles.
This research study collected the data utilizing a well-tested, open-ended questionnaire vetted by experts in field. The instrument was so drafted keeping research objectives in mind so as to get responses which could inflate the existing understanding on the subject. However, one unavoidable limitation could be that it is unknown how much of the reported history for habits of smoking, alcohol, dietary habits, physical activity, and perceived stress by the participants can be relied as there may be inhibitions by army personnel to share information about such behaviours which may entail some administrative actions for them.
| Conclusion|| |
Multi-cross-sectoral-integrated strategies for provisioning of comprehensive health-care and strengthening surveillance mechanism pertaining to prevention and control of lifestyle diseases among serving armed forces personnel are the need of the hour. Genuine dietary modifications; improving/improvising cooking practices; restriction of diet in relation to energy dense, trans fats, refined, junk foods, snacking in between meals, salt restriction, conserving traditional food constituents; physical activity is the mantra for physical fitness to be ensured equally among all trades including officers; stringent and cross-linked mechanisms to ensure definite working hours, minimize other work-related stress; institutional checks on tobacco, alcohol, substance abuse; 100% compliance with annual medical checks up with thorough screening for lifestyle disease risk factors; follow-up of all suspected/confirmed previous and newly detected cases with both nonpharmacological and pharmacological interventions to avoid future long-term complications; health awareness campaigns addressing different aspects of hitting common risk factors at various levels are the desirable lifestyle interventions required to be in place to show definite benefit in management and prevention of these lifestyle diseases and their common risk factors in timely manner.
Financial support and sponsorship
This study was financially supported by AFMRC project.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]