|Year : 2014 | Volume
| Issue : 1 | Page : 25-29
Heart health risk factors in Punjabi early teens
Elizabeth Mary John, Clarence James Samuel
Department of Community Medicine, Christian Medical College, Ludhiana, Punjab, India
|Date of Web Publication||11-Feb-2014|
Clarence James Samuel
Department of Community Medicine, Christian Medical College, Ludhiana 141 008, Punjab
Source of Support: None, Conflict of Interest: None
Context: India is experiencing an epidemiological health transition characterized by rapid decline in nutritional and parasitic diseases (pre-transitional diseases) with an alarming rise in cardiovascular diseases, mainly coronary heart disease and stroke (post-transitional diseases). Many of these risk factors manifesting themselves as diseases in adults can be found during adolescence. Aims: To determine the prevalence of risk factors of heart disease among urban high-school students aged 13-15 yrs in Ludhiana city. Materials and Methods: This cross-sectional study included 330 high school-going early teens aged 13-15 years using a pretested questionnaire. Details regarding food habits, physical activity, and family history were collected along with anthropometric measures and blood pressure recordings. Statistical Analysis Used: Data was analysed using frequencies and proportion. Chi-square was the test of significance. Results: The prevalence of at least one risk factor in the population was 48.5%. Family history with prevalence of at least one coronary artery disease risk factor was of 27.4%, diabetic parents 12.2%, hypertension 17.6%, and heart disease was 1.8%. Physical inactivity as a risk factor showed an overall prevalence of 73%. Nearly 50% of the students consumed some junk food every day. Only 18.2% consume 3-5 servings of fruits per day, 11.2% do not take any fruits at all. Prevalence of overweight was 11.2% and 4.6% of them were obese. Hypertension was seen in 20.1% of subjects. Conclusions: The present generation of early teens are at high risk of future cardiovascular disease and schools and society need to address these issues urgently.
Keywords: Adolescent health, BMI, childhood obesity, diabetes, early teens, heart health, hypertension, playtime, school health
|How to cite this article:|
John EM, Samuel CJ. Heart health risk factors in Punjabi early teens. CHRISMED J Health Res 2014;1:25-9
| Introduction|| |
India is experiencing an epidemiological health transition characterized by rapid decline in nutritional and parasitic diseases (pre-transitional diseases) with an alarming rise in cardiovascular diseases, mainly coronary heart disease, and stroke (post-transitional diseases).  It is predicted that coronary artery disease (CAD) will become the leading cause of death by the year 2020 in people aged 35-65 year. , Cardiovascular diseases (CVD) will be the leading cause of death worldwide by 2030.  Many of these disease have their origins in childhood but manifest later in life.
We grapple with this problem of plenty such as childhood obesity while we are still fighting under-nutrition problems and infectious diseases.  In Punjab, weight is an indicator of status and health; therefore, typically "well" built, overweight and obese individuals are referred to as "healthy". This study was undertaken to look at the prevalence of cardiovascular risk factors in a vulnerable and impressionable age group.
| Materials and Methods|| |
This cross-sectional study was conducted within a 2-month period in Urban Ludhiana, Punjab. Four schools were selected and divisions/sections of classes 8 and 9 were selected by simple random sampling. High-school children of both sexes aged 13-15 year, who gave assent after written parental consent were included. Details regarding food habits, physical activity, and family history were obtained using a semi-structured questionnaire. Weights of the children were recorded using a bathroom scale which was checked by calibration with standard weights. For measuring height, the subject was made to stand erect looking straight on a level surface with heels together and toes apart, without shoes. Height was read to the nearest of 0.5 cm. Waist circumference was measured at the level of the iliac crest with a plastic tape to the nearest 1 mm. Waist/height ratio was calculated and compared with the standards. The waist circumference and height of children increases continuously as they age, the same boundary value WHTR = 0.5 could be used to indicate increased risk across all age group. Body mass index was calculated by the formula BMI = Weight (kg)/[Height (m)] 2 and the results where compared with the percentile charts to identify obese and overweight children. The American Obesity Association uses the 85 th percentile of BMI for age and sex as a reference point for overweight and the 95 th percentile for obesity in children. Systolic and diastolic blood pressure were recorded by using electronic blood pressure apparatus and compared with the gender, age, height percentile charts from the 4 th report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents:  A reading >95 percentile were regarded as abnormal readings and between 90-95 percentile as high normal blood pressure.
For type I error of 5% and power of 80%, with a prevalence of 25% and a precision of 20% the sample size was calculated as 300 using the formula
N = p*q (Zα + Zβ) 2/ d 2
The results was entered in Microsoft excel and analyzed using SPSS 16 version for frequencies and proportions. Chi-square was the test of significance.
| Results|| |
Four hundred subjects were recruited for participation, 370 gave consent to the study and 40 subjects were rejected as they were over the age group proposed earlier. The remaining was 330 students were included in the study. Out of the 330 high-school early teens, 49.4% were males 50.6% females. The age-wise break up was 107 (32.4%) 13-year olds, 122 (37%) were 14-year olds, and 101 (30.3%) were 15-years olds.
Family history of diabetes was seen in 42 (12.7%) subjects [Fathers 33 (10%), Mothers 14 (4.2%), and 5 (1.5%) both parents]. There were 58 (17.6%) early teens with a family history of hypertension [Fathers (6.9%), Mothers (11.5%) and both parents (0.9%)].
There were 6 (1.8%) teens who had a parental history of CAD, of these 5 (1.5%) fathers, 1 (0.3%) mother and both the parents of one had history of CAD. [Table 1] shows the prevalence of genetic risk factor of heart health in early teens.
The average number of hours of play by the early teens was 1.51 hrs SD ±1.466 while the average hours of TV viewing were 1.91 ± 1.086 SD. There were 61 (18.5%) children who did not play at all, while majority 210 (63.5%) played for 1-2 hours per day. There were 52 (15.8%) who played for 3-5 hours and 7 (2.1%) children played for more than 5 hours.
The reasons for reduced vigorous physical activity are listed in [Table 2]. Among the reasons cited for not playing was "to study" followed by "no park" available in the community or to play area/grounds in the neighbourhood, no play mates/friends to play with, parents prohibiting them to go out and play, extreme weather and the teens do not like sports/physical activity.
Television (TV) watching as a risk factor of physical inactivity or sedentary life style was assessed. The group was divided into four groups, those watching TV less than 1 hour, 1-2 hours, 3-5 hours and those watching TV for more than 5 hours. The majority 69.7% of the early teens watched TV for 1-2 hours/day, 26.4% watched for 3-5 hours/day and the 0.6% watched for greater than 5 hours daily, and only 3.3% of the children claimed to have watched TV for less than an hour per day.
Junk food consumption was nearly equal, with 50.9% of the early teens claimed they did not eat any, 36.4% ate 1-2 junk foods per day and 12.7% ate more than three junk food meals/snacks per day. In a week, nearly 66.9% of the early teens consumed 1-5 junk food per week, 9.1% did not eat any junk food and 23.9% ate more than 5 junk foods per week.
Fruit consumption was good with nearly 70.2% of the early teens consuming 1-2 serving of fruits per day, 18.2% consumed 3-5 servings, 11.2% did not take any and none consumed greater than 5 servings per day.
Of the 330 early teens 74.3% had normal BMI for age and gender, while 11.2% were overweight and 4.5% where obese. Gender comparison revealed that 57.9% females had abdominal obesity as compared to 47.9% males (P = 0.04) [Table 3].
Blood pressure was abnormal in 15.8% of subjects [Table 4] and [Table 5]. Systolic BP increased with age (Chi-square for trend 5.63 and P value 0.02) but there was no significant trend for diastolic BP (Chi-square for trend 0.03 and P value 0.86).
| Discussion|| |
Family history is a non-modifiable risk factor for CAD. Familial clustering is common in many forms of heart diseases. It may occur not only on a genetic basis but also may be related to familial dietary or behavior pattern such exercise, ingestion of salt and calories or cigarette smoking.  India is in the midst of a rapidly escalating epidemic of type 2 diabetes and more families will have a history of diabetes in either one or both parents.  Our study had a prevalence of 12.2% of diabetes in either or of both parents which is approximately the same as the current prevalence in India. There was more diabetes among the father's side (10%) as compared to the mother's side (4.2%) while there was increased prevalence of hypertension among the mothers side (10.6%) as compared to the fathers side (6.2%). Similar findings have been reported in the study in Poland by Chiel-Polez et al.
In India, the appearance of CAD and diabetes is 10-15 years earlier compared to those in the Western world. The low prevalence of parents with heart disease can be due to the fact that the parents would be in their late 30's or early 40's, the manifestation of CAD is the usually in 5 th decade of life. In this study, the history of smoking in the family was low 6.1% as compared to other parts of the country. Studies have shown that smoking is highest in Chandigarh and lowest in Punjab; this is because the Sikh religion forbids smoking. The consumption of alcohol by parents is around 21.1%. This section of questions was filled with consultation of the parents at home and there is possibility of a bias in the responses to the question regarding tobacco and alcohol use.
There were no students who gave history of smoking or consumption of alcohol. The questionnaire was filled at home and had parental supervision hence the answers would not have been forthcoming. None of the students claimed to have ever smoked tobacco or consumed tobacco in any form or have any friends or classmates who smoke.
There is no clear data on the extent of smoking in Indian youth. The prevalence of tobacco usage in North India varied between 2.9 and 8.5% in boys and 1.5-9.8% in girls.  Between 16 and 46% of students were exposed to the habit of tobacco among parents or friends. There were 10-34% students who were passively exposed to environmental tobacco smoke. In a similar survey from south India about 10% of students aged 13-15 in Tamil Nadu had ever used tobacco.  In a study done in the North-eastern states of India tobacco users ranged from 75.3% (Mizoram) to 40.1% (Assam).
Physical activity is now recognized as an important health enhancing behavior. Physical activity is a key determinant of energy expenditure, and thus is fundamental to energy balance and weight control. Individuals who are more physically active appear to have lower rates of all-cause mortality, probably due to a decrease in chronic diseases including CAD.
Studies have shown that TV viewing of less than 2 hours per day is protective, more than 2 hours is a surrogate for obesogenic lifestyle. Average of 60 minutes of good physical activity per day is protective against heart disease for all ages. The number of students who participate in less than 1 hour of play per day is around 18% which is quite high. The reasons given by the subjects for not playing showed that most of the reasons for not playing were due to academic pursuits (55.5%). The students had to study as they were in senior classes which determined their future course. The lack of adequate play areas (28.3%) was the next common reason. This may probably be due to the overcrowding in the cities and high-rise apartments with no playgrounds or maidans.
Improper eating habits are developed during childhood and have its effects in adult life. Food rich in trans fats and cholesterol have a major role in atherosclerosis, this study was targeted at the eating habits, mainly consumption of "junk food" versus the consumption of fruits. There are no definite studies quantifying the risk by the intake of junk food. In our study, we found that nearly 50% of the students consumed some junk food per day (36.4% eat 1-2 junk foods per day and 12.7% eat more than 3 junk food per day). This is probably due to the availability of junk food at the school canteens, road side eateries, etc. The consumption of junk food at any time during the week is high with 66.9% of the children consuming 1-5 junk food per week, and 23.9% eat more than 5 junk foods per week, the remaining 9.1% did not eat any junk food, this can be due to increased health consciousness in the group.
The consumption of fruits is considered protective against CAD. There are no studies to show the consumption of fruits in this age group. Fruits were consumed less by our subjects. The reason for this could be the cost of fruits in the months of the survey was very exorbitant. The lack of knowledge of the protective benefits of fruits and the availability of cheaper "junk foods" to satisfy the child have lead on to a group of students with highly improper eating habits making them predisposed to CAD.
Obesity in adolescence is a known risk for obesity in adulthood and with it the risk of CAD. Our study with 4.5% obesity was comparable to the study in Ludhiana which had 3.4% obesity.  In Egypt, 14% of adolescents and 25% of 6-11-year-old children in Cyprus were reported to be overweight or obese.  According to a report from urban South India, 17.8% of boys and 15.8% of girls aged 13-18 years were overweight or obese.  Overweight is comparable to similar studies in India.
The prevalence of high blood pressure was 15.8% showed abnormal systolic blood pressure readings while 4.2% showed high normal or at risk systolic blood pressure readings. This is comparable to other studies. Most of the students identified with abnormally high blood pressure readings at first contact would have to be screened again. As per the recommendation three blood pressure reading in different sittings are required to label it as abnormally high blood pressure reading. In a recent study in the USA, to find out the prevalence of hypertension in school-aged children that included mostly minority school children, the prevalence of BP >95 th percentile was 17% at the first screening. , Similarly, in a study in Texas, to find out the prevalence of high BP in school children, 16% of children had SBP >95 th percentile, (with or without DBP >95 th percentile), and 2% had DBP >95 th percentile (with or without SBP >95 th percentile) at the first screening. The results of these studies suggest that BP >95 th percentile is not rare in children. Females showed a slightly higher risk of BP >95 th percentile than males. 
In a Polish study, although 17.61% of respondents (mostly boys 64.70%) found increasing incidence of hypertension, and 82.35% were related to systolic BP. In the group of people with higher BP systolic hypertension demonstrated itself in 35.72% of positive cases, while diastolic hypertension related to 16.66% of the population and was present mainly among adolescence girls. 
Interventions to prevent CAD should be started in adolescent age group itself. The emphasis on increased and improved physical activity would be able prevent CAD in adulthood. The modifiable risk factor like physical activity, right diet, prevention of obesity, smoking should have a targeted approach in adolescence. The need to improve physical activity - walking to school, or cycling, playing for at least 60 minutes per day, and minimizing TV viewing to less than 2 hours per day should be advised to the parents as well. The lifestyle and habits that are there in a household determine the majority of CAD risk factors. Society needs to make changes by building more parks and designated play areas to develop a heart healthy culture.
| Acknowledgments|| |
Indian Council of Medical Research (ICMR) Short Term Studentship Grant 2009.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]