Poverty and Stroke in India

Prevalence of stroke and related burden among older people living in Latin America, India and China

OBJECTIVES

Despite the growing importance of stroke in developing countries, little is known of stroke burden in survivors. The authors investigated the prevalence of self-reported stroke, stroke-related disability, dependence and care-giver strain in Latin America (LA), China and India.

METHODS

Cross-sectional surveys were conducted on individuals aged 65+ (n=15 022) living in specified catchment areas. Self-reported stroke diagnosis, disability, care needs and care giver burden were assessed using a standardised protocol. For those reporting stroke, the correlates of disability, dependence and care-giver burden were estimated at each site using Poisson or linear regression, and combined meta-analytically.

RESULTS

The prevalence of self-reported stroke ranged between 6% and 9% across most LA sites and urban China, but was much lower in urban India (1.9%), and in rural sites in India (1.1%), China (1.6%) and Peru (2.7%). The proportion of stroke survivors needing care varied between 20% and 39% in LA sites but was higher in rural China (44%), urban China (54%) and rural India (73%). Comorbid dementia and depression were the main correlates of disability and dependence.

CONCLUSION

The prevalence of stroke in urban LA and Chinese sites is nearly as high as in industrialised countries. High levels of disability and dependence in the other mainly rural and less-developed sites suggest underascertainment of less severe cases as one likely explanation for the lower prevalence in those settings. As the health transition proceeds, a further increase in numbers of older stroke survivors is to be anticipated. In addition to prevention, stroke rehabilitation and long-term care needs should be addressed.

Gender-specific effects of caste and salt on hypertension in poverty: a population-based study

BACKGROUND

Little is known about the risk of developing hypertension in those living in poverty in rural India. We examined gender and caste influences on risk factors for hypertension in a disadvantaged rural community.

METHODS

In 1479 adults living in 12 hamlets in rural Andhra Pradesh, we measured blood pressure, height, weight, waist and hip girth, and used point-of-care devices to measure blood glucose, cholesterol, triglyceride and haemoglobin levels. Information about lifestyle habits was obtained by questionnaire. Multivariable backward stepwise logistic regression was used to determine factors associated with hypertension (blood pressure ≥ 140/90 mmHg).

RESULTS

The mean age was 39.7 years; 46.2% were men, 11.4% were hypertensive, 0.8% were obese and 44.4% were underweight (BMI <18.5 kg/m). Dietary salt intake was more than 40 g/day. Belonging to a forward caste was associated with a greater risk of hypertension in both men and women. The association of caste was eliminated after adjustment for BMI in women [odds ratio (OR) 1.12; 95% confidence interval (CI) 0.61-2.06], but not in men (OR 2.93, 95% CI 1.77-4.86). Similar results were found for educational status. High salt intake was not associated with hypertension in women (OR 0.85, 95% CI 0.44-1.65), but was in men (OR 2.26, 95% CI 1.27-4.02).

CONCLUSION

In this disadvantaged rural community, men are particularly prone to the effects of relative socioeconomic advantage and salt intake on the risk of hypertension. Traditional risk factors may play a greater role in the development of hypertension in men living in poverty than in women.

Caregiver Burden and Quality of Life of Older Persons With Stroke

This article reports a preliminary investigation in India of the association between caregiver burden and quality of life (QOL) in older persons with stroke after controlling for disability, depression, and sociodemographic factors. A cross-sectional analysis was carried out with 46 stroke patients attending a community hospital in India. The primary outcome variable was patient QOL assessed using the World Health Organization Quality of Life questionnaire–short form (WHOQOL-Bref). The primary explanatory variable was caregiver burden, assessed using the Zarit Inventory. Patient economic dissatisfaction ( F = 6.12, p = .04), patient depression ( F = 20.8, p < .001), and caregiver burden ( F = 7.36, p = .009) were found to be associated with lower patient QOL. Caregiver burden was independently associated with lower patient QOL after controlling for patient depression, disability, and economic dissatisfaction (standardized B coefficient = −0.28, p = .03). The level of caregiver burden was a significant correlate of QOL after stroke. Implications for future studies and practice are discussed.

Maternal capital and the metabolic ghetto: An evolutionary perspective on the transgenerational basis of health inequalities

There is particular interest in understanding socioeconomic and ethnic variability in health status. The developmental origins of disease hypothesis emphasize the importance of growth patterns across the life-course in relation to noncommunicable disease risk. The physiological components of cardiovascular risk, collectively termed the metabolic syndrome, derive in part from a disparity between the homeostatic "metabolic capacity" of vital organs and the "metabolic load" induced by large tissue masses, a rich diet and sedentary behavior. From an evolutionary perspective, the risk of such disparity is decreased by maternal physiology regulating offspring growth trajectory during gestation and lactation. Maternal capital, defined as phenotypic resources enabling investment in the offspring, allows effective buffering of the offspring from nutritional perturbations and represents the environmental niche initially occupied by the offspring. Offspring growth patterns are sensitive to the magnitude of maternal capital during early windows of plasticity. Offspring life-history strategy can then respond adaptively to further factors across the life-course, but only within the context of this initial maternal influence on growth. Maternal somatic capital is primarily gained or lost across generations, through variable rates of fetal and infant growth. I argue that the poor nutritional experience of populations subjected to colonialism resulted in a systematic loss of maternal capital, reflected in downward secular trends in stature. Accelerating the recovery of somatic capital within generations overloads metabolic capacity and exacerbates cardiovascular risk, reflected in increased disease rates in urbanizing and emigrant populations. Public health policies need to benefit metabolic capacity without exacerbating metabolic load.

Potential roles of high salt intake and maternal malnutrition in the development of hypertension in disadvantaged populations

1. It has been argued that all major risk factors for cardiovascular disease have been identified. Yet, epidemiological studies undertaken to identify risk factors have largely focused on populations in developed nations or on the urban or relatively affluent rural populations of developing countries. Poor rural populations are seldom studied. 2. Somewhat different risk factors may operate in poor rural populations. Evidence for this is provided by the finding that, in disadvantaged rural India, the prevalence of hypertension is greater than would be expected based on established risk factors in these populations. One risk factor to be considered is a poor intrauterine environment. 3. In animals, maternal macro- and micronutrient malnutrition can lead to reduced nephron endowment. Nephron deficiency, in turn, can render blood pressure salt sensitive. The combination of nephron deficiency and excessive salt intake will predispose to hypertension. 4. Human malnutrition may have similar effects, particularly in regions of the world where malnutrition is endemic and where women are disadvantaged by existing social practices. 5. Moreover, high salt intake is endemic in many parts of Asia, including India. Therefore, we propose that maternal malnutrition (leading to reduced nephron endowment), when combined with excessive salt intake postnatally, will account, at least in part, for the unexpectedly high prevalence of hypertension in disadvantaged rural communities in India and elsewhere.