Epidemiology of Non-CommunicableDisease in RuralNepal: the NCD Nepal Study

Background:

Non-communicable diseases (NCD), including cardiovascular disease (CVD) are a leading cause of death from low to middle-income countries (LMIC), yet there are limited high-quality data from remote areas of LMIC, like rural Nepal.

Methods:

We designed a prospective epidemiological and implementation study (the NCD Nepal Study) of 40-75 years old individuals from GhorahiSub-Metropolitan Wards 3,4,6,7, which is 406kilometers West of the capital of Nepal, Kathmandu(total target population 7052). We conducted screening for NCDs and provided treatment for common NCDs using mobile monthly health clinic. Persons with NCDs had labs and were invited for continuity of care and treatment using the United States and the World Health Organizationbasedprotocols. Individuals without NCDs are followed up every 1-2 years. Here,we report data of first 1119participantsfromtheirinitial visit.

Results:

The mean age was 54years, 64% were women. Approximately 50% described having a monthly income of <10,000 Nepalese Rupee and about 50% had < 5thgrade education(Table). The mean body mass index, waist circumference and blood pressure were 24.0kg/m2, 82.1 cm, and 124/77mmHg, respectively. Mean daily intake of salt, fruits and vegetables were 13.2 gram, 1.1 serving and 1.6 serving, respectively. About 48% performed <30 min/daily vigorous physical activity.In general, women were younger, had lower education, higher body mass index but lower waist circumference, lower daily intake of vegetables and lower vigorous physical activity compared with men (Table). Random glucose was 126 mg/dL (N= 702) and fasting glucose was 124 mg/dL(N= 417)[Figure 1].Mean total cholesterol(N=401), high-density lipoprotein cholesterol(N=401), triglycerides(N=401), serum creatinine (N=400) and hemoglobin A1C (N=77) are166 mg/dL, 48 mg/dL, 214 mg/dL, 0.8 mg/dl and 7.1 %, respectively (Figure 1).Approximately 20% used unhealthy level of alcohol, 14% were current smokers and among 245people selected using a predefined protocol, the estimated 10-year risk of having heart attack and stroke was 8.5% (atherosclerotic cardiovascular disease, ASCVD risk, Figure 2). Hypertension and diabetes were prevalent in 30.8% and 30.5% respectively. Prevalent cases were identified using self-reported diagnosis and on-site diagnosis and laboratory tests. Undiagnosed hypertension was present in 16.8%, while elevated glucose(fasting ≥126 mg/dL or random ≥200 mg/dL)was present in 20.6%. Among those who had hemoglobin A1C checked (N=77), diabetes criteria (hemoglobin A1C≥6.5%) was met in 40% of individuals. Overall, the burden of coronary artery disease, stroke, heart failure and peripheral artery disease was low (Figure 2), but this could have been underestimated.

Conclusions:

In rural Nepal, modifiable NCD risk factors are highly prevalent and a high proportion of people are unaware of having diabetes and hypertension. Well-designed community-based prospective studies with active surveillance and treatment of NCDs like the NCD Nepal Study are urgently needed in LMIC like Nepal to better understandNCD epidemiology and to assess the effect of inexpensive, locally appropriate interventions before fully manifest complications of NCDs develop. Academic institutions, non-profit and philanthropic organizations, international professional societies, biomedical industry, local government including Nepal government and Nepalese diaspora can contribute in various ways to alleviate NCD burden.