Cardiovascular disease (CVD) and its associated risk factors among older adults in India: Evidence from LASI Wave 1

Abstract

Background
With the turn of the century, CVDs have become the leading cause of mortality in India. Despite the wide heterogeneous prevalence of risk factors across different regions, CVD is the major cause of death in all parts of India. Therefore, the study aimed to investigate the prevalence of CVDs and its associated risk factors among older adults in India.

Methods
The current study used data from the LASI, Wave 1, the world's largest and India's first longitudinal aging study. The total sample for the analysis was 65562 (45 and above individuals).Statistical analyses were conducted using STATA SE version 14.The self-reported prevalence of CVDs was calculated by considering any one of the self-reported diagnosed conditions of hypertension, stroke, and chronic heart diseases. Binary Logistic regression was carried out between CVD and its associated risk factors like age, sex, place of residence, physical activity, family history of CVD, Diabetes/blood sugar, high cholesterol. P < 0.05 from two-sided statistical tests was regarded statistically significant.

Results
The study indicated that the overall self-reported prevalence of diagnosed CVDs was 29.4% for older adults age 45 and above in India. Age was associated with increased risk of CVD Female older adults were more likely to have CVDs than male.The place of residence also had a stronger association with CVDs.In addition, high cholesterol, diabetes and physical inactivity were key risk factors for CVDs.The study also indicated that Family history was associated with a greater perceived risk for CVDs. The greater prevalence of CVDs risk factors among older adults manifested alarming public health concerns and a future health demand. It creates a threat if health promotion and awareness programs are not well designed.

Full text

Clinical Epidemiology and Global Health 13 (2022) 100937
Available online 17 December 2021
2213-3984/© 2021 Published by Elsevier B.V. on behalf of INDIACLEN. This is an open access article under the CC BY-NC-ND license
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Original article
Cardiovascular disease (CVD) and its associated risk factors among older
adults in India: Evidence from LASI Wave 1
Jhumki Kundu
a
, Sampurna Kundu
a
,
b
,
*
a
International Institute for Population Sciences, Deonar, Mumbai, 400088, India
b
Centre of Social Medicine and Community Health, Jawaharlal Nehru University, Delhi, 110067, India
ARTICLE INFO
Keywords:
CVDs
Risk factors
Older adults
India
ABSTRACT
Background: With the turn of the century, CVDs have become the leading cause of mortality in India. Despite the
wide heterogeneous prevalence of risk factors across different regions, CVD is the major cause of death in all
parts of India. Therefore, the study aimed to investigate the prevalence of CVDs and its associated risk factors
among older adults in India.
Methods: The current study used data from the LASI, Wave 1, the world’s largest and India’s rst longitudinal
aging study. The total sample for the analysis was 65562 (45 and above individuals). The self-reported preva-
lence of CVDs was calculated by considering any one of the self-reported diagnosed conditions of hypertension,
stroke, and chronic heart diseases. Binary Logistic regression was carried out between CVD and its associated risk
factors like age, sex, place of residence, physical activity, family history of CVD, Diabetes/blood sugar, high
cholesterol. P <0.05 from two-sided statistical tests was regarded statistically signicant.
Results: The study indicated that the overall self-reported prevalence of diagnosed CVDs was 29.4% for older
adults age 45 and above in India. Age was associated with increased risk of CVD Female older adults were more
likely to have CVDs than male.The place of residence also had a stronger association with CVDs.In addition, high
cholesterol, diabetes and physical inactivity were key risk factors for CVDs.The study also indicated that Family
history was associated with a greater perceived risk for CVDs. The greater prevalence of CVDs risk factors among
older adults manifested alarming public health concerns and a future health demand. It creates a threat if health
promotion and awareness programs are not well designed.
1. Introduction
India has been experiencing a rapid epidemiological transition in the
last few decades. Along with the increase in life expectancy, there is an
emergence of non-communicable diseases (NCD) which is becoming a
greater public health concern in India. Major four NCDs namely car-
diovascular diseases (CVD), chronic respiratory diseases (CRD), cancers
and Diabetes account for more than 80% of the total premature NCD
deaths .
20
Globally, around 17.9 million people annually die due to
CVDs, followed by cancers (9.3 million), respiratory diseases (4.1
million), and diabetes (1.5 million).
21
More than four out of ve CVD
deaths are due to heart attacks and strokes, and one third of these deaths
occur prematurely in people under 70 years of age.
33
The number of
people with total CVD nearly doubled from 271 million in 1990 to 523
million in 2019, and deaths due to CVD climbed signicantly from 12.1
million in 1990 to 18.6 million in 2019.
28
The majority of NCD deaths occur in low and middle-income coun-
tries including India.
43
As a result of rapid urbanization and change in
lifestyle; the epidemiological health transition has taken place; which
has led to an overall economic rise, but with certain associated ipsides
(risk factors).With growing burden of NCDs and high case fatality rate in
the low and middle income countries; the Unites Nations in 2012
acknowledged that the rising burden of NCDs is one of the serious
challenges to sustainable development in the 21st century.
3,15,25,37,38
The country wise statistics of the WHO on non-communicable dis-
eases (NCDs) estimate that in India, the non-communicable diseases
account for around 53% of the total deaths, among which CVDs have a
major share of 24%.
34
With the turn of the century, cardiovascular
diseases (CVDs) have become the leading cause of mortality in India.
26
The Global Status on NCDs Report (2010) reported that there were more
than 2.5 million deaths from CVD in India in 2008, two-thirds due to
Coronary heart disease (CHD) and one-third due to stroke.
29,35
Studies
* Corresponding author. Centre of Social Medicine and Community Health, Jawaharlal Nehru University, Delhi, 110067, India.
E-mail addresses: jhumkikundu16@gmail.com (J. Kundu), sampurna34@gmail.com (S. Kundu).
Contents lists available at ScienceDirect
Clinical Epidemiology and Global Health
journal homepage: www.elsevier.com/locate/cegh
https://doi.org/10.1016/j.cegh.2021.100937
Received 30 October 2021; Received in revised form 4 December 2021; Accepted 9 December 2021

Clinical Epidemiology and Global Health 13 (2022) 100937
2
show that compared to the people of European ancestry, CVD affects
Indians at least a decade earlier and in their most productive midlife
years.
15,37
CVD prevalence appears to be most closely associated to a country’s
epidemiological transition stage,
24
particularly when high disease rates
in middle age persist into later life. According to a few population based
surveys, the prevalence of CVD in 2003 in rural India was estimated to
be 3–4% and 8–10% in urban areas.
7,10
As per Global burden of disease
study 2010, the age-standardized CVD death rate of 272 per 100 000
population in India is higher than the global average of 235 per 100 000
population.
8
CVD mortality rates vary signicantly by age and gender.
The WHO’s India report shows that age-adjusted CVD mortality rates are
higher for men than women (349 per 100,000 among men and 265 per
100,000 among women).
44
These rates are two to three times higher as
compared to those in the United States, where mortality rate for men are
170 per 100,000 and 108 per 100,000 among women.
36
In India, more
than 10.5 million deaths occur annually, and it was reported that CVD
led to 20.3% of these deaths in men and 16.9% of all deaths in women.
9
A global CVD epidemic is rapidly evolving, with the burden of dis-
ease shifting. CVD currently kills twice as many people in developing
countries as it does in developed countries. Conventional risk factors
account for the great majority of CVD cases.
41
Many epidemiological
studies of cardiovascular risk factors in the mid and late twentieth
century found that the risk factors are higher in upper SES persons than
in lower SES subjects (Sapru, 2006).However, some studies reported
that risk factors could be more in poor, especially where illiteracy is
high.
11
Age plays a vital role in the deterioration of cardiovascular
functionality, resulting in an increased risk of cardiovascular disease
(CVD) in older adults
4
and.
22
However, sex differences are also
frequently perceived in aging adults regarding both onset and preva-
lence of CVD.
6
Diabetes is a major predisposing factor for developing
CVD in the aging population.
12
DCM (diabetic cardiomyopathy) de-
scribes heart disease, which develops primarily due to diabetes.
32
Adults
with diabetes historically have a higher prevalence rate of CVD than
adults without diabetes.
30
The risk of CVD increases continuously with
rising fasting plasma glucose levels, even before reaching levels suf-
cient for a diabetes diagnosis.
31
Some epidemiological evidence also indicates that CVD is associated
with behavioural risk factors like smoking, alcohol use, low physical
activity levels, and insufcient vegetable and fruit intake. In elderly
persons, hypertension has been found to be an independent risk factor
for acute myocardial infarction and stroke.
23,39
There is substantial
epidemiologic evidence for the familial aggregation of CVD. Researchers
from the Framingham Study reported that having CVD in at least one
parent doubled the 8-year risk of CVD among men and increased the risk
among women by 70%.
17
In order to develop and implement an effective strategy for preven-
tion and treatment of CVD in older people, it is necessary to have a more
comprehensive understanding of a wide range of CVD risk factors and
the factors relevant to this population. However, few studies focused on
the older people.
2,16
Therefore, the present study tries to assess the
prevalence of CVD and its attributable risk factors among the older
adults in India.
2. Data & methods
The current study used data from Longitudinal Aging Study in India
(LASI Wave 1), a national survey of scientic investigation of the health,
economics, and social determinants and consequences of population
aging in India. It is the world’s largest and India’s rst longitudinal
aging study. The LASI is designed to simultaneously generate data, raise
awareness of older people’s health issues, and inform public policies in
India and its states. The LASI provides a great opportunity to examine
how different healthcare policies and institutions inuence healthcare
utilization and health outcomes using innovative and comparable
measures of health, including the direct assessment of biological
measures. By the conventional practice for other population-based sur-
veys, the LASI sampling frame included only the household population.
The LASI (Wave 1)2017-18 dataset comprised 72,250 individuals aged
18 years. However, a total of 65562 data of participants aged ≥45 years
were included in the analysis of this study.
2.1. Variable description
Dependent variable: The dependent variable used for the study was
cardiovascular disease for multivariate analysis. Cardiovascular diseases
(CVDs) are a group of disorders of the heart and blood vessels. They
include hypertension, stroke, and chronic heart diseases such as rheu-
matic heart disease, congenital/structural disorder. The self-reported
prevalence of CVDs presented in this section was calculated by consid-
ering any one of the self-reported diagnosed conditions of hypertension,
stroke, and chronic heart diseases.
Independent variable: The following variables are used as under-
lying factors.
Socio-demographic factors: Sex of the respondents (male and fe-
male), age (45–54, 55–64,65-69 and 70+years), place of residence
(Rural and Urban), religion (Hindu, Muslim, Christian, and others),
Caste (SC, ST, OBC, Others), marital status (currently married, widowed,
and others (divorced/separated), education Categorized as Not
educated, up to Primary, up to Secondary, Secondary and above,
working status categorized as currently working worked in the past but
currently not working and never worked, the monthly per-capita quin-
tile (MPCE) characterized as poorest, poor, middle, richer and richest.
Genetic factors: Family history of CVD.
Behavioural factors: Physical activity (categorized as every day, at
least once a month and never worked).
Other risk factors: Diabetes and high cholesterol.
2.2. Statistical methods
Statistical analyses conducted using STATA version 14.2 include bi-
variate analysis and multivariate analysis. The prevalence of self-
reported diagnosed CVD is presented by sex, place of residence, age,
level of education, social group, religion, marital status, monthly per
capita expenditure, Physical activity, family history of CVD in India for
2017–18 pertaining to the Longitudinal aging study in India (LASI),
Wave 1.
Binary Logistic regression was carried out between CVD and its
associated risk factors. The dependent variable, CVD is was dichotomous
(yes/no), and the independent variables were the associated risk factors
of CVD like Sex, place of residence, age, physical activity, family history
of CVD etc. to check the independent effect on CVD. The logistic
regression model is as follows:
Logit (Y) = ln (p/1−p) = ɑ+ß1x1+ß2x2+
Where p is the probability of the event and ɑ is the intercept, β1 are
regression coefcients; xi is set of predictors, and
ε
is an error term.
3. Results
Table 1 presents the self-reported prevalence of diagnosed CVDs
among older adults in India by background characteristics. Overall, the
self-reported prevalence of diagnosed CVDs was 29.4% for older adults
age 45 and above. The prevalence rate increased with age from 22% in
45–54 to 38% in age 70 and above. Among the older adults, the self-
reported prevalence of diagnosed CVDs was higher among women
(32%) than men (26%), and it is much higher among those residing in
urban areas (40%) than in rural areas (25%). The self-reported preva-
lence of diagnosed CVDs increased with the level of education from 26%
among those with no schooling to 34% in those with secondary and
above education.
J. Kundu and S. Kundu

Clinical Epidemiology and Global Health 13 (2022) 100937
3
Similarly, the prevalence of CVD increased with the MPCE quintile
from 23% in the poorest quintile to 38% in the richest quintile. The
prevalence of Cardiovascular disease was higher among the other caste
(35%) compared to scheduled caste, scheduled tribes, and other back-
ward castes (OBC). Inconsistency with the result of Table 1, the preva-
lence of self-reported diagnosed CVD was higher among other religions
(38%) than Hindu, Muslim, and Christians. For instance, the prevalence
of CVD is signicantly low among respondents who reported currently
working (20%). The analysis revealed that older adults with diabetes
(66%) and cholesterol (68%) had a higher prevalence of CVD. However,
there is a graded inverse association between physical activity and the
prevalence of the cardiovascular disease. The prevalence of CVD was
comparatively high among those individuals who never engage in any
activity (35%). However, the analysis revealed that older adults with a
family history of CVD have a higher prevalence of diagnosed CVD
(44%).
Table 2 shows the Odds ratios for the likelihood of CVD by risk
factors. Analysis reveals that respondents of 55–64 age groups were 1.5
times (OR 1.48, 95% CI 1.418–1.553), and respondents of 65–69 and
70+age groups are 2 (OR 2.04, 95% CI 1.932–2.163) and 2.3 times
(OR2.256, 95% CI2.144–2.375) more likely to suffer from CVD than
45–54 age groups. Sex is another inherent risk factor in aging adults,
given that older females are reported to 1.3 times (OR1.35, 95% CI
1.303–1.403)more likely to suffer from CVD than age-matched men. The
analysis also revealed that respondents in the urban area had a signi-
cantly greater risk factor for CVD. Older adults belong to urban area
were 1.5 times (OR 1.46, CI 95% 1.407–1.517)more likely to suffer from
CVD. Physical inactivity has been revealed to be a major cause of CVD.
Diabetes (OR 0.24,95% CI 0.23–0.26)and high cholesterol (OR 0.22, CI
95% CI 0.206–0.253)had a stronger association with CVD among older
adults supporting the nding that patients with diabetes have approxi-
mately twice the risk of stroke than the non-diabetics.
13
Additionally,
the study also revealed that the risk of having CVD was 0.5 times (OR
0.507,95% CI 0.466–0.552) less among individuals without a family
history of CVD.
Table 1
Prevalence of Cardiovascular disease of (45+) older adult population in India by
its background characteristics, LASI (Wave 1, 2017–18), (N =65562).
Background Characteristics CVD Total Chi-
square
Yes No p value
Age-group
45–54 4979
(21.7)
17936
(78.3)
22,914
55–64 5778
(29.5)
13784
(70.5)
19,562
65–69 3373
(35.8)
6050
(64.2)
9,423 0.000
70+5158
(37.8)
8505
(62.3)
13663
Sex
Male 7812
(25.9)
22307
(74.1)
30119 0.000
Female 11476
(32.4)
23967
(67.6)
35443
Place of residence
Rural 11104
(24.7)
33826
(75.3)
44,930 0.000
Urban 8184
(39.7)
12448
(60.3)
20,632
Religion
Hindu 15087
(28.1)
38651
(71.9)
53,738 0.000
Muslim 2769
(36.7)
4780
(63.3)
7,549
Christian 569 (28.2) 1420
(71.4)
1990
Others* 863 (37.8) 1422
(62.2)
2285
Social group
Schedule caste 3318
(26.7)
9119
(73.3)
12,437 0.0000
Schedule tribe 905 (16.2) 4676
(83.8)
5,581
Other backward class (OBC) 8715
(29.5)
20784
(70.5)
29,499
None of the above 5471
(34.8)
10245
(65.2)
15,715
Marital Status
Currently married 13196
(27.4)
34893
(72.6)
48,089
Widowed 5668
(36.4)
9885
(63.6)
15,553 0.000
Others** 424 (22.1) 1496
(77.9)
1,920
Education Level
No schooling 8679
(26.2)
24505
(73.9)
33184
Up to primary 4707
(31.3)
10352
(68.7)
15058
Up to secondary 3629
(34.0)
7044
(66.0)
10673
Secondary & above 2273
(34.2))
4371
(65.8)
6643 0.000
Working status
Currently working 6116
(20.2)
24142
(79.8)
30,258
worked in past but currently
not working
6823
(37.5)
11371
(62.5)
18,194 0.000
never worked 6349
(37.1)
10761
(62.9)
17,110
MPCE
Poorest 3117
(22.8)
10561
(77.2)
13,678
Poorer 3659
(26.3)
10263
(73.7)
13,923 0.000
Middle 3850
(28.7)
9582
(71.3)
13,432
Richer 4147
(32.6)
8587
(67.4)
12,734
Richest 4514
(38.2)
7281
(61.7)
11,796
Table 1 (continued )
Background Characteristics CVD Total Chi-
square
Yes No p value
Ever diagnosed diabetes
Yes 5349
(66.3)
2721
(33.7)
8,070 0.000
No 13970
(24.4)
43341
(75.6)
57,311
Ever diagnosed high cholesterol
Yes 1015
(68.0)
478 (32.0) 1,493 0.000
No 18304
(28.7)
45593
(71.4)
63,897
Physical activity
Everyday 3613
(22.1)
12763
(77.9)
16,377
Atleast once a month 2227
(21.8)
7970
(78.2)
10,197 0.000
Never 13351
(34.8)
25069
(65.3)
38,419
Family history of CVD
Yes 1251
(43.8)
1608
(56.2)
2859
No 17973
(28.9)
44223
(71.1)
62196 0.000
India 19288
(29.4)
46274
(70.6)
65562
Note:Religion; others *(Sikh, Buddhist/neo-Buddhist, Jain, Jewish, Parsi/
Zoroastrian, others) Marital status; others** (Divorced, Separated, Deserted,
Live-in-relationship, never-married.
J. Kundu and S. Kundu

Clinical Epidemiology and Global Health 13 (2022) 100937
4
4. Discussion
The present study tries to present the prevalence of cardiovascular
diseases and (hypertension, heart disease, and stroke) and the pertinent
risk factors among older adults in India. The study indicated that the
prevalence of CVD tended to increase with age. With aging, there is an
incremental acquisition of several CVD risk factors in an individual’s
lifespan.
5
Although CVD remains the leading cause of death of both
women and men in India, there are considerable gender differences in
the prevalence of CVDs. The study indicated that women were more
likely to have CVD than men.This is also line with the study by
40
that
females have died from cardiovascular disease at a higher rate than
males. Despite the fact that women develop heart disease 10 years later
than males, they are more likely to suffer from a heart attack. It is
estimated that 35% of heart attacks in women go unrecognised or
unreported.
This is further supported by the researcher who state that Women
outnumber men in terms of living with and dying from CVD and stroke,
as well as the number of hospital discharges for heart failure and stro-
ke.
27
Sex differences in CVD prevalence largely reect sex differences in
Indian demographics. Because female sex is related to a longer life ex-
pectancy than male, women comprised a larger share of the elderly
population in which the prevalence of CVD is greatest. Along with that
the risk of cardiovascular disease in women is often underestimated due
to the misperception that women are more ‘protected’ than men against
CVD. The neglect of CVD among women leads to less aggressive treat-
ment strategies.
18
The present study showed that the place of residence is signicantly
related to the prevalence of CVD. Older adults residing in rural areas had
a lower chance of having CVD than urban areas. This is further sup-
ported by researchers who state that urban population had higher
prevalence of CVDs as compared to rural population. Risk factor prev-
alence from slum/peri-urban areas lay somewhere in between the urban
and rural population, but more inclined towards urban trends.
42
The study also revealed that high cholesterol, diabetes, were key risk
factors for CVD supporting the nding that adults with diabetes are
about twice as likely to die from heart disease or stroke as people
without diabetes (National diabetes statistical report, 2014).Further
studies have also indicated that Cardiovascular disease (myocardial
infarction, stroke, and peripheral vascular disease) is twofold more
common in people with type 2 diabetes (T2D), and it is the leading cause
of death in T2D patients.
19
The study showed that CVD prevalence was higher among the
physically inactive older adults, and this difference was statistically
signicant (p <0.001).This is line with the study by
1
who stated that
physical inactivity increases a person’s chances of being overweight, of
having high blood pressure and of developing other conditions that
make cardiovascular disease more likely.Regular, moderate to vigorous
physical activity assists in reducing the risk of cardiovascular disease.
Participation in 150 min of physical activity of moderate intensity per
week was estimated to alleviate Ischemic heart disease by about 30%
and diabetes risk by 27% (WHO.2007). The study indicated that most of
the individuals with a signicant family history of heart dis-
ease/stroke/hypertension were more likely to develop CVD them-
selves.
14
in their study found that the individuals with a family history
(FH), perceived their risk for heart disease to be about twice as high as
individuals without a FH (p <0.001).
5. Conclusion
In conclusion, the study provided a representative prevalence of CVD
and relevant risk factors among older adult population in India. The high
prevalence of CVD risk factors among older adults manifested alarming
public health concerns and a future health demand. Implementational
strategies are required for reducing CVD risk among elderly by focussed
promotion of physical activities and early detection of CVDs based on
family history. It creates a threat if health promotion and awareness
programs are not well designed.
Funding
The authors received no nancial support for the research, author-
ship and/or publication of this article.
Availability of data and material
This research work was performed based on secondary data which is
freely available upon request at IIPS, India website (Source of data:htt
ps://www.iipsindia.ac.in/lasi).
Ethics approval & consent to participate
This research does not have an ethical code because this research
work was performed based on secondary data which is freely available
upon request at IIPS, India website (Source of data:https://www.iipsi
ndia.ac.in/lasi) and thus author does not require any ethical clearance
and consent to participate.
Consent for publication
Not applicable.
CRediT authorship contribution statement
Jhumki Kundu: Conceptualization, Methodology, Formal analysis,
Resources, Writing – original draft, Visualization. Sampurna Kundu:
Writing – review & editing, All authors read and approved the nal
manuscript.
Declaration of competing interest
The authors declared no potential conicts of interest concerning the
research, authorship and/or publication of this article.
Table-2
Results of Binary Logistic regression of risk factors of Cardiovascular disease of
(45+) older adult population in India, LASI (WAVE-1,2017–18), (N =65562).
Risk factors of cardiovascular Odds ratio 95% condence interval
Age- group
45–54 ®
55-64 1.484*** [1.418,1.553]
65-69 2.045*** [1.932,2.163]
70+2.256*** [2.144,2.375]
Sex
Male ®
Female 1.353*** [1.303,1.403]
Place of residence
Rural ®
Urban 1.461*** [1.407,1.517]
Diabetes or blood sugar
Yes ®
No 0.246*** [0.234,0.259]
High cholesterol
Yes®
No 0.228*** [0.206,0.253]
Physical activity
everyday ®
Once in a month 1.073* [1.008,1.142]
never 1.379*** [1.315,1.445]
Family history of cardiovascular disease
Yes®
No 0.507*** [0.466,0.552]
Note: ® Reference category,*p <0.05, **p <0.01, ***p <0.001.
J. Kundu and S. Kundu

Clinical Epidemiology and Global Health 13 (2022) 100937
5
Acknowledgements
The authors cordially acknowledge International Institute for Pop-
ulation Sciences (IIPS) for providing us the LASI Wave 1 dataset for
conducting the study.
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