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Urban rural differences in diet, physical activity and obesity in India: are we witnessing the great Indian equalisation? Results from a cross-sectional STEPS

survey

Jaya Prasad Tripathy, J.S. Thakur, Gursimer Jeet, Sohan Chawla, Sanjay Jain and Rajendra Prasad

Tripathy et al. BMC Public Health (2016) 16:816DOI 10.1186/s12889-016-3489-8

INTRODUCTION

1. Non-communicable diseases (Burden) : • Increasing prevalence of NCD deaths • 52 million deaths by 2030

2. Unhealthy dietary practices, sedentary lifestyle and obesity

3. Nations’ economic, demographic and nutrition transition

4. Studies from western countries on diet and levels of physical activity in population

5. Limited information available

OBJECTIVE

• Study planned to document urban rural differences in dietary

practices, levels of physical activity and obesity in a North

Indian state of Punjab.

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STROBE check list

Recommendation Report

Title and abstract

a)Study’s design in the title or the abstractb)Informative and balanced summary in the abstract

Yes

Introduction Background/rationaleObjectives with hypothesis Yes

MATERIALS AND METHODSStudy design: Cross sectional

Study setting: Punjab – Urban and rural areas Study period:

Study tool:

Sampling method:

2014-2015

WHO STEP Surveillance (STEPS) questionnaire

Multistage stratified cluster sampling

Sample size: 5400 (Prevalence of physical activity as 50%, 95% confidence interval, 0.05 margin of error and 85% response rate)

Study subjects: Individuals in the age group 18-69 years residing in the selected households

Punjab

RuralUrban

Multistage stratified geographically clustered sampling

*PPS: Probability Proportional to Size CEB: Census Enumeration Block

Selection of villages

Selection of wards

*CEB

Selection of households

Selection of households

PPS sampling PPS sampling

Random sampling

Systematic random sampling Systematic random sampling

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STROBE check listMethodology

Study design Study design No

Setting Study Setting , locations, and relevant dates, including periods & data collection

Yes

Participants Eligibility criteriaSources and methods of selection

Yes

Variables Outcomes, exposures, predictors, potential confounders & diagnostic criteria

Yes

Data sources/measurement

Sources of data and detailsComparability of assessment methods

Yes

Recommendation ReportBias Potential sources of bias No

Study size Sample size calculation YesQuantitative variables

How quantitative variables were handled in the analyses

Yes

Statistical methods

1. Describe all statistical methods, including those used to control for confounding

2. Describe any methods used to examine subgroups and interactions

3. Explain how missing data were addressed

Yes

STROBE check list…

PARAMETERS STUDIED1. Socio-demographic profile and

Behavioural information (Tobacco and alcohol use, diet, physical activity, H/O chronic diseases, family H/O chronic conditions, health screening and health care costs)

2. Physical measurementsa) Weight: SECA electronic weighing scale to nearest 100gb) Height: SECA adult portable stadiometer to the nearest 0.1cmc) Waist circumference: SECA constant tension tape to the nearest

0.1cm Midway between the lowest rib margin and the iliac crest

d) BMI: Categorised as normal, overweight and obese

PARAMETERS STUDIED..3. Dietary practices • 1 serving of vegetable – 1 cup of raw green leafy vegetables / ½

cup of other vegetables (cooked/chopped raw) • 1 serving of fruit – 1 medium size piece of apple, banana or

orange, ½ cup of chopped, canned fruit / ½ cup of fruit juice

PARAMETERS STUDIED..4. Levels of physical activity • GPAQ (Global Physical Activity Questionnaire) developed by WHO • 3 domains – work, transport & during leisure time in a normal

active week • Activities – vigorous, moderate & light • Minimum duration of physical activity/week recommended by

WHO → 150 min of moderate intensity physical activity / 75 min of vigorous intensity physical activity

(OR) Equivalent combination of moderate + vigorous

intensity physical activity at least 600 MET with each activity performed in bouts of at least 10 min duration

PARAMETERS STUDIED..4. Obesity • Asian cut off < 18.5 → Underweight 18.5 – 23 → Normal weight 23 – 27.5 → Pre-obese > 27.5 → Obese • WHO cut off < 18.5 → Underweight 18.5 – 24.9 → Normal weight 25 – 29.9 → Pre-obese / Overweight 30 – 34.9 → Class 1 obesity 35 – 39.9 → Class 2 obesity > 40 → Class 3 obesity

RESULTSTotal 5400 eligible individuals - (5127 studied)

RESULTS

Table 1: Socio-demographic profile of study participants in STEPS Survey, Punjab, India

Table 2: Urban rural differences in dietary practices, STEPS Survey, Punjab, India 2014-2015

Table 3: Urban rural differences in levels of physical activity, STEPS Survey, Punjab, India 2014-2015

Table 3: Urban rural differences in body mass index and abdominal obesity, STEPS Survey, Punjab, India 2014-2015

Table 4: Socio-demographic characteristics associated with obesity and lack of physical activity, STEPS Survey, Punjab, India 2014-2015

Recommendation Report

Results

Participants 1. Report numbers of individuals at each stage of study

2. Give reasons for non-participation at each stage

3. Consider use of a flow diagram

Yes

Descriptive data

1. Characteristics of study participants, number of participants with missing data (Give information separately if applicable, for exposed and unexposed groups in cohort studies)

2. Indicate number of participants with missing data for each variable of interest

3. Summarise follow-up time (eg, average and total amount)

Yes

Outcome data Numbers of outcome events or summary measures over time

Yes

STROBE check list…

Recommendation Report

Results 1. Unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, 95% confidence interval)

2. Report category boundaries when continuous variables were categorized

3. If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period

Yes

Other results Report other analyses done—eg analyses of subgroups and interactions, and sensitivity analyses

STROBE check list…

DISCUSSIONDiet and physical activity:• Present study - Minimal urban rural differences in dietary habits

and levels of physical activity• Other studies- Higher physical inactivity in urban areas and poor

intake of fruits and vegetables in the rural areas• Similar survey conducted in 2005 in India reported 6.8% of overall

inactivity levels• Recent studies reports 38 to 70% of higher levels of physical

inactivity in India – indicating declining physical activity levels in recent times

DISCUSSION...

Obesity:• Present study – Urban females had higher proportion of

obesity compared to rural counterparts• Previous study have highlighted significant urban rural

differences in prevalence of overweight and obesity with urban dwellers being more overweight and obese

DISCUSSION...

Recreational physical activity:• Current study – 90% of individuals in both urban and rural

areas reports no physical activity during leisure time• Other studies in India and Vietnam – inactivity in the

recreational domain to be as high as 90%

RECOMMENDATIONS

Multi-pronged strategic approach :• For promoting healthy diet• Restricting the use of unhealthy diet

Regulations to control the content of salt, sugar, saturated fats and trans fats in dietary products

STRENGHTS

• Multi-stage stratified sampling approach• Involved whole state of Punjab• Followed standard methodology of STEPS survey

LIMITATIONS

• Self-reported survey• Inherent bias• Validity- GPAQ

STROBE check list…Recommendation Report

DiscussionKey results Key results with reference to study

objectivesYes

Limitations Limitations of the study

Sources of potential bias

Yes

Yes Interpretation Overall interpretation of results

considering objectives, limitationsResults from similar studies

Yes

Generalizability External validity of the study results No

Other information

Source of funding and the role of the funders for the present study

Yes