risk factors and prevention strategies of ...

Pakistan Journal of Public Health, 2014 ( September )

Pak J Public Health Vol. 4, No. 3, 2014

Review Article

RISK FACTORS AND PREVENTION STRATEGIES OF CARDIOVASCULAR DISEASES IN BANGLADESH: A SCOPING REVIEW OF CURRENT RESEARCH AND POLICY DOCUMENTS Samira Anjum1, Tuhin Biswas 2 and Anwar Islam 3 1

Research Fellow, Centre for Control of Chronic Diseases (CCCD), icddr,b, 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali Dhaka 1212, Bangladesh. 2Research Ofcer, Centre for Control of Chronic Diseases (CCCD), icddr,b, 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali Dhaka 1212, Bangladesh.3Adjunct Professor, School of Health Policy and Management, York University, Toronto, Ontario, M3J1P3, Canada. ( Correspondence to Anjum S: [email protected]) Abstract Background: Along with other developing countries Bangladesh is also going through an epidemiological transition from infectious diseases to chronic non communicable diseases (NCDs). In Bangladesh, NCDs are estimated to account for 52% of all deaths. Cardiovascular diseases (CVDs) alone account for 27% of these deaths. Our aim was to conduct a scoping review of literature to ascertain what is known about risk factors and prevention strategies to reduce the burden of CVDs in Bangladesh. Methodology: Based on York methodology based scoping review, a comprehensive search of published academic articles, conference processing and grey literature was carried out through pub Med, BanglsJOL, Google and Google scholar. We summarized risk factors and diseases outcomes and as well as Prevention strategies of CVDs among adults (? 18 years) in both urban and rural area of Bangladesh. Result: After conducting scoping review and as well as considering inclusion criteria we found 9 studies that fulll study objectives. Among all the studies 4 were cross sectional, 2 were case control, 1 was population-based prospective study, one was retrospective observational study and another one was survey. The most common risk factors of CVDs, as identied by these studies, were tobacco consumption, hypertension (HTN), Diabetes mellitus, dyslipidemia, animal protein-rich diet and sedentary lifestyle. Only 3 papers were found related to prevention strategies. It is unfortunate that except tobacco consumption there were no papers related to chronic disease prevention strategies. Conclusion: CVDs are considered as a major public health concern in a resource poor country like Bangladesh. Addressing the risk factors sustainable interventions could be designed and implemented on a larger scale to prevent the rise of CVDs in Bangladesh.(Pak J Public Health 2014; 4(3):23-28) Key words: CVDs, Risk factors, Prevention strategy. Introduction Cardiovascular diseases are caused by disorders of the heart and blood vessels and include coronary heart disease (heart attacks), cerebrovascular disease (stroke), raised blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital heart disease and heart failure. Cardiovascular diseases (CVDs) are the leading cause of death globally. Approximately 17.3 million people died from CVDs in 2008 which represents 30% of all global deaths. Among them an estimated 7.3 million deaths were due to coronary heart disease and 6.2 million were due to stroke. Among all the CVD deaths 80% take place in low- and middle-income countries and occur almost equally among men and women. It is estimated that by 2030, almost 23.6 million people will die from CVDs, mainly heart disease and stroke (WHO, 2011).

According to World Health Organization the most important behavioral risk factors of CVDs are unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol. These risk factors are responsible for about 80% of coronary heart disease and cerebrovascular disease (WHO, 2011). People in low- and middle-income countries are more exposed to risk factors such as tobacco, leading to CVDs and other non -communicable diseases. At the same time they often do not have the benet of prevention programs compared to people in high-income countries. People in low- and middle-income countries who suffer from CVDs and other non -communicable diseases have less access to effective and equitable health care services which respond to their needs (including detection of diseases at early stage). As a result, many people in lowand middle-income countries die younger from CVDs and other non -communicable diseases, often in their

23


most productive years. Unlike other developing countries, Bangladesh is also experiencing an epidemiological transition from infectious, communicable diseases to chronic, noncommunicable diseases (NCDs) like cardiovascular diseases, diabetes, cancer, chronic respiratory diseases, and injury (BDHS, 2011).According to WHO (2011) in Bangladesh, NCDs were estimated to account for 52% of all deaths and among them 27% were due to CVDs. In a recent study it was projected that death rate from CVDs would be 4 times higher in 2010 and 21 times higher by 2025 (Karar et Al.2009) (16). According to World Health Rankings (2011), coronary artery disease was ranked as the rst and stroke was the third leading cause of death which accounts for 17.11% and 8.57% respectively. CVDs are emerging as an epidemic in a resource poor country like Bangladesh. So it will be better if we can prevent the risk factors of CVDs. So risk factor identication is the only way to achieve this goal. In this regard my study will nd out the risk factors and prevention strategies of CVDs that are needed to develop effective national health policy to prevent and manage them. This way, we can reduce morbidity and mortality among CVD patients and alleviate the burden of CVDs. This paper explored the availability of literature on risk factors and prevention strategies of CVDs in Bangladesh through a scoping review which, unlike a systematic review, offers a much broader perspective in the respective eld which makes it more appropriate method to assess the risk factors and prevention strategies of CVDs in Bangladesh. Methodology The main objective of our study was to identify the unique risk factors associated with major CVDs and to identify prevention strategies that could be implemented in Bangladesh with a view to reduce the burden cardiovascular diseases) as well as NCDs. A scoping review was performed based on the York methodology outlined by Arksey and O' Malley from the University of York, United Kingdom. The 'York framework' suggested ve stages that we have followed for this review: (Fig1)

Initially, we dened research questions and developed search strategy and discussed them in a team meeting. Relevant literatures were then identied through a comprehensive search across different databases including Pubmed, Google, Google scholar and Bangladesh's country specic search engine (BanglaJOL). We categorized the search terms according to location, methodology and outcomes: (1) Location: "Bangladesh." (2) Method: "prevalence, cross-sectional, cohort studies, case control, survey." (3) Outcome: "Cardiovascular diseases mainly ischemic heart disease, cerebrovascular disease/ stroke, myocardial infarction, hypertension/ high blood pressure, coronary artery disease and peripheral artery disease". The "AND" Boolean operator was used to combine search terms across the categories and the "OR" was used to combine within the categories. Further, we limited the search to studies that only involved Bangladeshi people, stayed here and were published between January 1, 1998 and December 31, 2013. We screened the studies using the following inclusion and exclusion criteria: language (English), dates (between '1st January 2000 and 31st December 2013'), Species (Humans) and Age: 18+ years and the studies that are most recent and nationally representative will be included At this stage studies will be excluded based on the following exclusion criteria: Being conned to a specic age group, Studies reporting the results of larger studies as duplications and Studies conducted among Bangladesh are residing elsewhere. Data extraction We extracted the following information for each reviewed study: (1) Authors and publication year, (2) Title and journal, (3) Study location (urban or rural), (4), Study design, (6) Sample size, (7) Sample characteristics such as age and gender, (8) Disease type: CVD [Hypertension (HTN), Ischemic Heart Disease (IHD), Coronary heart disease (CHD), Stroke,], (9) Outcome assessment (objective or subjective), (10) Risk factors signicantly associated with CVD and (11) Prevention strategies for CVD in Bangladesh. Methods use for data searching is describe in gure 2.

Figure 1: Steps of scoping review 24


Methodology used for data searching

Table 1: Risk Factors of CVDs in Bangladesh.

(9)

(13)

(01)

(07)

(02)

(15)

(11)

(18)

Figure 2: Steps of the method used to sort out relevant literatures for reviewing

Results After reviewing the published existing online articles we found 14 articles fullled the eligible criteria. All these studies analyzed the risk factors by using/through different logistic regression model e.g. multivariate or binary logistic regression or by using correlation coefcient. The Table 1 showed the summary ndings of the existing reviewed articles. Among all the studies 56 % were related to heart disease, 22% were related to stroke and 22% conducted on CVDs as a whole. According to the majority of the Risk factor studies the signicant risk factors of heart diseases were smoking, higher BMI, dietary habit such as animal protein rich diet, previous history of diabetes, hypertension, higher age, educational and economic etc. One of the study found that tobacco consumption was more prevalent among young (60.06%) compared to older people (48.43%). According to Zama et. al in 2004 (18) found male tobacco users used any form of tobacco on average 11 times in a day while females used 8 times in a day. The proportion of tobacco use was higher in older age groups in both sexes. Betel quid and arsenic were signicant risk factor among the 2 studies. According to another study hypertension, Smoking, lipid disorder, heart diseases,

diabetes mellitus, and previous history of stroke, patients who were on irregular use of antihypertensive drug were the signicant risk factors of Stroke. The most concerned outcome of this study was that majority of the patient had two modiable risk factors. After searching prevention strategies of CVDs in Bangladesh we have found 3 relevant papers (Table 2). Table 2: Prevention strategies of CVDs in Bangladesh

(03)

(08)

(16)

25


Among them one was review paper, one was policy brief of NCD and another was a cross sectional study to nd out the inuence of attitude, subjective norms, perceived behavioral control on intention to perform CVDs preventive behaviors among young adults in Bangladesh. The outcome of these studies is given in the following table. Though it is found that there are many risk factors still there is only law as prevention strategy on smoking and tobacco control exists. Since 1978 treatments were only available in tertiary care hospitals. Heart 'camps' throughout rural parts of the country to treat and educate cardiac patients; published booklets and educational materials to build awareness of CVD prevention. From 2007 Upazilla NCD Project is working to develop NCD capacity among public and private providers and No communicable Disease Control and Public Health Intervention Program of the Directorate General for Health Services are working to spread awareness on NCDs and NCDs care. Discussion Cardiovascular diseases have been studied extensively in many other countries but in Bangladesh studies related to risk factors and prevention strategies are relative scarce. From searching literatures I found that this is the rst and only review that has been conducted on this topic in Bangladesh. In this review it has also been found that though the outcome diseases were different in different studies, there were similarities between the risk factors of those diseases. However as the study site were different and the outcome disease was also different so it was difcult to compare across the studies and predict the trends of these factors in different context. It had been observed that there were scarcity of data in urban and rural setting differently and also in different socioeconomic status and different age groups. According this review the most signicant risk factors for stroke were hypertension, tobacco consumption, diabetes mellitus, lipid disorder, heart diseases, previous history of stroke and irregular use of antihypertensive drugs. This nding is similar to a study conducted in India, where it is found that metabolic disorders and smoking were signicantly associated with ischemic stroke (Sridharan, 1992) (14). Another study conducted in India found ve risk factors of Ischaemic Stroke - hypertension, serum total cholesterol, use of anticoagulants and antiplatelet agents, past history of transient Ischaemic attack and alcohol intake (Zodpey, Tiwari & Kulkarni, 2000) (19). From this review it was found that Hypertension, tobacco consumption and abdominal obesity were signicantly associated with Coronary heart disease. Another study found that dislipidemia was signicantly associated with CHD among aged people 9over 40).

According to this review the most common risk factors of Ischaemic heart disease were increased body weight, higher body mass index, previous history of other diseases like diabetes, hypertension, family history of cardiac diseases, smoking habit and sedentary life style. Another study found an animal protein rich diet as risk factor of heart diseases. Study conducted in an urban population of India similarly found that smoking, physical inactivity, hypertension, hypercholesterolemia, diabetes and obesity were signicantly with CHD (Gupta et al. 2001) (5). Another study conducted in India found that diets rich in vegetables and use of mustard oil could the lower risk of IHD among Indians (Rastogi et al. 2004) (12). In this review it was found that there was only prevention strategy has been implemented in Bangladesh that was restriction of tobacco smoking in public places and advertisement. A national strategic plan for Tobacco control also has been adopted. According to this review we found that there are two tertiary care hospital in Bangladesh for the emergency cardiac care, and promote prevention and treatment of cardiovascular diseases. Another Upazilla NCD project is going on to develop NCD capacity among public and private providers in project sites. Noncommunicable Disease Control and Public Health Intervention Program of the Directorate General for Health Services are going on since 2007 to develop awareness of NCDs among senior citizens and provide equipment for improving the quality of NCD care. This review has some limitations. Unlike a systematic review it was not possible to assess the quality of the studies included in this review. Due to lack of available studies on CVDs we reviewed all the study related to different kinds of CVDs. It might be possible to miss some information due to inaccessibility of certain databases. In addition, there might have been other unpublished studies that are not available on internet which could not be revealed. Moreover, information on certain groups, such as tribal or ethnic minorities, is missing. Nevertheless, the ndings of this review provide useful insights for future research needs in this area. Conclusion This review found a noticeable published literature gap regarding risk factors and prevention strategies of CVDs in Bangladesh. Now CVDs are considered as a major public health concern in a resource poor country like Bangladesh. Addressing the risk factors it could be possible to design sustainable interventions which could be implemented on a larger scale to prevent the rise of CVDs in Bangladesh. It has been also found from this review that there are no strong policies for preventing CVDs in this country.

26


Reference 1.

2.

3.

4.

5.

6.

7.

Haque AFMS, Siddiqui AR, Rahman S MM , Iqbal SA, Fatema NN, Khan Z. Acute Coronary Syndrome in the Young - Risk Factors and Angiographic Pattern. Cardiovascular Journal 2010; 2(2):175-178. Retrieved 5th May 2014 from http://www.banglajol.info/index.php/CARDIO /article/view/6635/5100 Badiuzzaman M, Mohammed FR, Chowdhury FR, Bari MS, Alam MB, & Ahasan HN. Prevalence of modiable risk factors among stroke patients in a tertiary care hospital in dhaka. Journal of Medicine 2 0 0 9 ; 1 0 ( 3 ) , 1 8 - 2 1 . F r o m h t t p : / / w w w. b a n g l a j o l . i n f o /bd/index.php/JOM/article/view/2011/1879 Bleich SN, Koehlmoos TL, Rashid M, P e t e r s D H , & A n d e r s o n G . Noncommunicable chronic disease in Bangladesh: Overview of existing programs and priorities going forward. Health Policy 2011; 100(2): 282-289.Retrieved 2 April, 2014 from h t t p : / / w w w. s c i e n c e d i r e c t . c o m / s c i e n c e /article/pii/S0168851010002654. Chen Y, McClintock TR, Segers S, Parvez F, I s l a m T, A h m e d A , & A h s a n H . Prospective investigation of major dietary patterns and risk of cardiovascular mortality in Bangladesh. International journal of cardiology 2013; 167(4): 1495-1501. Gupta R, Gupta VP, Sarna M, Bhatnagar S , T h a n v i J , S h a r m a V, & K a u l V. Prevalence of coronary heart disease and risk factors in an urban Indian population: Jaipur Heart Watch-2. Indian heart journal 2001; 54(1): 5 9 - 6 6 . R e t r i e v e d 1 8 M a y, 2 0 1 4 f r o m http://test.europepmc.org/abstract/MED /11999090/reload=0;jsessionid=285AD57C29 E691EA5C1E9BE8BEB91664 Jafar TH, Jafary FH, Jessani S, & Chaturvedi N. Heart disease epidemic in Pakistan: women and men at equal risk. American heart journal 2005; 150(2): 221-226. R e t r i e v e d 1 8 M a y, 2 0 1 4 f r o m http://www.ahjonline.com/article/S0002 -8703%2804%2900657-X/abstract. Khandakar MR, Ahsan R, & Haque MJ. Socio-economic Status and Risk of Coronary Heart Disease (CHD) in a Northern Urban Community of Bangladesh. Dinajpur Med Col J 2010; 3(2):67-75. Retrieved 2nd May 2014 f r o m h t t p : / / w w w. d i n a j m c . o r g / j o u r n a l /djmcj_v3_i2/09_djmcj_v3i2_Raihan_Khandk

8.

9.

10.

11.

12.

13.

14.

15.

ar_Socio.pdf Khatun J, Boonyasopun U, & Jittanoon P. Inuence of Attitude, Subjective Norms, Perceived Behavioral Control on Intention to Perform Cardiovascular Disease Preventive Behaviors among Young Adults in Bangladesh. 2010. Retrieved 4 April, 2014 from http://fs.libarts.psu.ac.th/research/conference /Proceedings2/article/7pdf/004.pdf. Mateen FJ, Carone M, Alam N, Streateld PK, & Black RE. A population based case-control study of 1250 stroke deaths in rural Bangladesh. European Journal of Neurology 2012; 19(7):999-1006. Retrieved 6 April, 2014 http://onlinelibrary.wiley.com/doi/10.1111 /j.1468-1331.2012.03666.x/pdf MIT Libraries: Database Search Tips: Boolean operators. Retrieved 28 April, 2014 from http://libguides.mit.edu/content.php?pid= 36863&sid=271372. R a h m a n M A , & Z a m a n M M . Smoking and smokeless tobacco consumption: Possible risk factors for coronary heart disease among young patients attending a tertiary care cardiac hospital in Bangladesh. Public Health 2008; 122(12):1331-1338. Retrieved from http://www.sciencedirect.com/science/article /pii/S0033350608001662# Rastogi T, Reddy KS, Vaz M, Spiegelman D, Prabhakaran D, Willett WC,& Ascherio A. Diet and risk of ischemic heart disease in India. The American journal of clinical nutrition 2004; 79(4): 582-592. Retrieved 1 8 M a y , 2 0 1 4 f r o m http://scholar.google.com/scholar?start=10 &q=risk+factors+of+iscahemic+heart+diseas e+in+india&hl=en&as_sdt=0,5 Sayeed MA, Mahtab H, Sayeed S, Begum T, Khanam PA, & Banu A. Prevalence and risk factors of coronary heart disease in a rural population of Bangladesh. Ibrahim Medical College Journal 2010; 4(2): 37-43. Retrieved http://www.banglajol.info/index.php/IMCJ /article/view/6494/4980 Sridharan R. Risk factors for ischemic s t r o k e : a c a s e c o n t r o l analysis. Neuroepidemiology 1992;11(1):24-30. Retrieved 17 May 2014 from http://jnnp.bmj.com/content/78/9/959.short Sultana R, Anisuzzaman SM, Begum AA, Chowdhury SS, Akter T, & Chowdhury AS. Risk factors for ischemic heart disorder patients: Outcome of a survey c o n d u c t e d i n D h a k a c i t y, Bangladesh. International Current Pharmaceutical Journal 2012; 1(4): 68-70.

27


16.

17.

18.

19.

R e t r i e v e d f r o m h t t p : / / w w w. i c p j o n l i n e .com/documents/Vol1Issue4/02.pdf The World Bank, South Asia Human Development, Health Nutrition, and Population, NCD policy Brief Bangladesh. 2011. Retrieved 1 0 M a y , 2 0 1 4 f r o m http://citeseerx.ist.psu.edu/viewdoc /download?doi=10.1.1.405.5611&rep=rep1&t ype=pdf The World Bank, South Asia Human Development, Health Nutrition, and Population NCD policy Brief Bangladesh. 2011. Retrieved 1 0 M a y , 2 0 1 4 f r o m http://citeseerx.ist.psu.edu/viewdoc/download ?doi=10.1.1.405.5611&rep=rep1&type=pdf Zaman MM, Choudhury SR, Ahmed J, N u m a n S M , I s l a m M S , & Yo s h i i k e N . Non-biochemical risk factors for cardiovascular disease in general clinic-based rural population of Bangladesh. J Epidemiology 2004; 14(2): 63-68. Retrieved 2 April, 2014 from http://www.researchgate.net/prole/Sharker _Numan2/publication/236685328_Nonbioch emical_Risk_Factors_for_Cardiovascular_Di sease_in_General_Clinicbased_Rural_Popula tion_of_Bangladesh/le/72e7e5190efd422220 .pdf Zodpey SP, Tiwari RR, & Kulkarni HR. Risk factors for haemorrhagic stroke: a case-control study. Public Health 2000; 114(3): 177-182. Retrieved 18 May, 2014 from http://www.sciencedirect.com/science/article /pii/S0033350600003310

28