Discriminating Bangladesh Adults by the Prevalence of Diabetic Elevated Blood Pressure

The analytical results presented here were based on data collected from 960 adults of ages 18 years and above residing in both urban and rural areas of Bangladesh. The data were collected by some doctors and nurses from and nearby their working places according to quota sampling plan. The objective of the study was to investigate the impacts of different socioeconomic variables on simultaneous sufferings of adults from diabetes and high blood pressure and to identify the most responsible variables to discriminate the sufferer and non-sufferer adults. The analysis indicated that 5.4 percent adults were simultaneously suffering from both diabetes and elevated high pressure. The most responsible variable for the diseases was duration of the disease followed by wasting time by sedentary activities, body mass index, age, habit of taking can food and restaurant food, etc. These variables were identified by discriminant analysis.


Introduction
Diabetes is one of the riskiest health hazards which can enhance many non-communicable diseases like cardiovascular diseases, hypertension, kidney diseases, retinopathy, sensory system and so -fourth. Again, hypertension and or elevated blood pressure, though it is curable NCDs, is the primary risk factor for cardiovascular disease including stroke, heart failure, heart attack and aneurysm [1][2][3][4][5][6][7][8]. The elevated blood pressure is considered if systolic blood pressure is greater than or equal to 140 mmHg and diastolic blood pressure is greater than or equal to 90 mmHg [9,10]. In 2015, I in 4 men and 1 in 5 women had hypertension Number of adults with hypertension increased from 594 million in 1975 to 1.13 billion in 2015 [11]. The increase was noted in low-and middle-income countries. The prevalence rate was 28.6 percent among adults of ages 18 years and above [3]. Prevalence was increased significantly with age, ranging from 6.8 percent among individuals aged 18 to 39 years to 30.4 percent in those aged 40 to 59 years and 66.7 percent in individuals aged 60 years and above [ 4]. In Bangladesh, according to JNC 7 guidelines the prevalence of hypertension was 17.9 percent [10].
Urban adults, elderly adults, adults with physical inactivity, obese and diabetic adults were more likely to have hypertension [10].
People with both diabetes and hypertension have approximately twice the risk of cardiovascular diseases compared to the people with non-diabetic hypertension [12]. The prevalence of hypertension among diabetic patients is around three times compared to the people of non-diabetic hypertension [13]. Diabetes is the targeted disease by WHO as it has some social and economic consequences [14][15][16][17]. Accordingly, the problem is addressed to reduce the prevalence of the disease. Still, upward trend in deaths due to diabetes is noted [16]. This is true for both home and abroad. It was reported that, approximately 463 million adults of ages 20-79 years worldwide were diabetic [17]. This figure will be increased up to 700 million in 2045. In a separate report, it was mentioned that 1 in 5 diabetic patients were at the age above 65 years and 2 in 3 were urban residents [18,19].
In one study, it was observed that most of the Bangladeshi urban adults (36.3%) were suffering from diabetes [20]. Both diabetes and hypertension are in alarming stage for elderly people in both home and abroad. Thus, the simultaneous impact of diabetes and elevated blood pressure needs to be considered and how these diseases are influenced by different socioeconomic variables are needed to be studied. For this reason, the objective

Methodology
The present work was done by analysing the data collected from adults of ages 18 years and above residing in both urban and rural areas of Bangladesh. The investigated adults were 960. They were available for investigation nearby the working places of some doctors and nurses when they were doing their Master of Public Health degree in American International University-Bangladesh during the academic session 2017 -18. These adults were investigated by quota sampling method to cover around 70% diabetic patients [21]. The objective to cover this number of diabetic patients was to ensure a good amount of elevated blood pressure people simultaneously suffering from diabetes [1]. For comparative study, a good number of normal subjects were also investigated. Finally, 960 adults were interviewed, and data were recorded through a pre-designed and pre-tested questionnaire.
The questionnaire contained different questions related to different socioeconomic variables of the respondents and of the families. The main questions for families were related to the monthly family income and monthly family expenditure. The questions for the diabetic adults were related to the duration of disease, disease related health hazard, i.e. eye problem, kidney problem, heart problem, blood pressure, blood sugar, treatment stage of disease, admission into hospital, etc. Beside these, the other questions were related to personal habit, viz. food habit, working habit, physical activity, utilization of time, etc. The collected personal information were residence, religion, marital status, age, height, weight, education, and occupation. Some of the above-mentioned variables were qualitative and some are quantitative in nature. All the recorded variables were measured in nominal scale by assigning numbers. Height and weight were used to measure the level of obesity and level of obesity was measured by the value of BMI, where BMI was calculated by weight (in kg) divided by height (in meter 2 ). The respondents were classified as underweight (BMI < 20), normal (BMI = 20 and above but less than 25), overweight (BMI = 25 and above but less than 30) and obese (BMI ≥ 30).
At the first step of analysis, association of level of prevalence of diabetes and prevalence of elevated blood pressure [if diastolic blood pressure ≥ 90 mmHg and systolic blood pressure ≥ 140 mmHg] was investigated. The association of socioeconomic variables and prevalence of diabetes and high blood pressure were investigated by Chi-square test, where significant association was decided if the p-value of Chi-square statistic is less than or equal to 0.05. Some diabetic adults were at higher risk of elevated blood pressure compared to others. To study this characteristic the risk ratio ( R.R.) along with standard error of ln(R.R.) for a particular level of a social variable compared to the level of the variable which did not create problem for the disease was calculated. Discriminant analysis was done to discriminate the adults suffering simultaneously from diabetes and high blood pressure from other group of adults. Important variables were detected by the higher value of correlation coefficient in absolute form of a variable with the discriminant function scores in discriminating adults [22,23]. The analysis was done using the SPSS [ Version 25].

Results
The investigated adults were classified into two groups according to the prevalence of diabetes. There were 33.1 percent diabetic respondents and 16.4 percent of them were suffering from high blood pressure also [ Table 1]. The prevalence of diabetes and prevalence of high blood pressure were significantly associated as is observed by Chi-square test [ 2 χ = 37,97, p -value = 0.000 ].
The diabetic patients were at higher risk of high blood pressure by 17 percent compared to the risk of non-diabetic adults [ R.R =1.17, S.E. ln (R.R.) = 0.05]. It was also observed that 5.4 percent adults were suffering from elevated blood pressure and diabetes. They were suffering for different periods. Eight of them were sufferings for less than 5 years, 18 were suffering for 5 but less than 10 years, 11 were suffering for 10 to less than 15 years and 15 were suffering for 15 years and above. In the sample, the rural adults were 43.5 percent and 6.5 percent of them were simultaneously suffering from diabetes and high blood pressure [ Table 2]. Among urban adults the percentage of sufferers from both the diseases was 4.6. This differential in proportions was not statistically significant  The females are usually housewives. But this study indicated that most of the females were not housewives as the number of adults in this group was 331. In this group students and employed adults were also included. This group are usually not involved in physical labour and for that reason they have the more risk of affecting by diabetes and diabetes related disease. This fact was noted in different studies [24][25][26]. The present study also supported the fact ,though there was no significant association between occupation and prevalence of the diseases under study [ In studying different aspects of non-communicable diseases using the same set of data it was noted that the diseases were

Journal of Endocrinology and Thyroid Research
prevalent among elderly people [24,25,27]. The same phenomena were noted in this case also. The prevalence of diabetes higher blood pressure was significantly different among adults of different ages [ 2 χ = 11.731, p -value = 0.019]. The rate of prevalence was in increasing trend with the increase in ages of adults and this rate was higher (9.4%) among adults of ages 50 years and above. The elderly adults of ages 40 years and above had 69 percent more risk of suffering from the disease compared to the risk of younger adults [ R.R.= 1.69, S.E. ln (R.R.) = 0.29]. Higher proportion of illiterate (11.1%) and primary educated adults (11.6%) were suffering from diabetes and high blood pressure. The different proportions of adults suffering from the disease was significantly different [ 2 χ = 10.849, p value = 0.013].
In the sample the higher educated adults were 562 and 5.2 percent of them were suffering from the disease. The percentages of illiterate and primary educated adults suffering from the disease were 11.1 and 9.6, respectively. The illiterate and primary educated adults had more than two times risk of the diseases compared to the risk of secondary and higher educated adults [ R.R.= 2.27, S.E. ln (R.R.) = 0.28]. The percentage of adults coming from highest income group (Tk. 100.00 thousand and above) of families was 11.6 and 8.9 percent of them were suffering from the disease. Lowest proportion of affected adults (4.2%) were noted in lower income families (income < Tk. 60.00 thousand). The present analysis indicated that 34.7 percent adults were involved in sedentary activities and 9.9 percent of them were affected by diabetes and elevated blood pressure. Another big group (25.7%) of adults were also passing their time watching television but they did household work also. A smaller proportion (2.5%) of them were suffering from diabetes high blood pressure.

Discriminant Analysis
The analytical results presented above gave the evidence that some of the socioeconomic variables, viz. age, education, utilization of time, level of obesity, food habit and use of can food were significantly associated with the prevalence of diabetes elevated blood pressure. But the study of this association did not indicate the most responsible factor in enhancing the afore mentioned health problem. To identify the most responsible factor for the prevalence of the disease among adults, discriminant analysis was done to discriminate the adults who were suffering from the disease from the adults who were not suffering. Analysis was done using all the data available for the study variables. It was already mentioned that the adults were classified into two groups.
Some of the socioeconomic variables were significantly different for two groups of adults. It was noted by F-test, the results of which were presented in Table 3. The results indicated that the duration of disease was the most responsible variable for the prevalence of diabetes elevated blood pressure among the adults, followed by utilization of time, body mass index, age, habit of taking can food and restaurant food, etc . These variables were identified by the larger values of correlation coefficient of variables with discriminant function scores in doing discriminant analysis.

Discussion
The different results discussed in this paper was derived from the data collected from 960 adults of ages 18 years and above residing in both urban and rural areas of Bangladesh. Most of the investigated adults (56.5%) were from urban area as the data were collected by some doctors and nurses from and nearby their working places. Among the investigated adult's 5.4 percent were suffering simultaneously from diabetes and high blood pressure, though the percentage of diabetic patients in the sample was higher (33.1%). In urban area higher percentage of diabetic adults were noted in some earlier studies also [20,21,24,25] and these adults were suffering from different types of non-communicable diseases.
In this analysis, no significant association between residence and prevalence was observed but rural adults were at higher risk (40% higher) of affecting by the disease compared to the risk of urban adults. This risk was higher (55% higher) among the female adults. But prevalence of the disease was independent of the gender. Similar findings were noted in other studies [24,25]. The independence was observed in studying the association of prevalence of the disease with religion and marital status of the adults. In different studies, in both home and abroad, aged males and females were at higher risk of different types of noncommunicable diseases including higher blood pressure [28][29][30][31][32][33][34]. This study also indicated that with the increase in ages there was significant increase in the prevalence rate of diabetes and high blood pressure.
The adults of ages 40 years and above had the higher risk of affecting by the disease compared to the risk of younger adults. With the increase in level of education of adults there was a downward shift in the prevalence rate of diabetes elevated blood pressure. The risk of illiterate adults of affecting by the disease was more than two times than the risk of educated adults. Housewives, students, and unemployed adults were not directly doing any physical labour and this physical inactivity was the important cause of higher risk of affecting by the disease. In other studies, also it was observed that this group of adults were more exposed to different types of non-communicable diseases [24,25]. However, level of occupation was independent of level of prevalence of the disease.
Physical inactivity and involvement in sedentary activities are two risk factors for many types of NCDs. It was noted in both home and abroad [27][28][29][30]. This study also indicated that the adults involved in sedentary activities had more than 8 times risk of facing the problem of diabetes and high blood pressure simultaneously. Obesity is one of the highly risk factor for NCDs. It was noted in both home and abroad [28][29][30][31][32][33]. This analysis provided the evidence that with the increase in level of BMI there was a significant increase in the rate of prevalence of diabetes elevated blood pressure. The obese adults had more than 3 times risk of facing the problem of diabetes and high blood pressure compared to the risk of other adults.
In earlier studies it was noted that habit of taking restaurant food and can food be the risk factors for NCDs [24][25]. The

Journal of Endocrinology and Thyroid Research
present analysis showed that majority (51.4%) of the adults were habituated in taking restaurant food and can food (60.8%). Both these two groups of adults had more than two times risk of affecting by the disease compared to the risk of adults who were not taking either restaurant food or can food.

Conclusion
The present paper was prepared with an objective to study the impacts of different socioeconomic variables on the prevalence of diabetes and high blood pressure among adults of ages 18 years and above. The targeted adults were investigated by some doctors and nurses from their working places using quota sampling plan to cover 70 percent diabetic patients so that some of the diabetic adults were suffering from other non-communicable diseases also. But during data collection, only 33.1 percent diabetic adults were interviewed, and total investigated adults were 960. Among these diabetic adults, 16.4 percent were suffering from both diabetes and elevated blood pressure for different periods. These adults were classified into 4 groups according to their sufferings for less than 5 years, 5 -< 10 years, 10 -< 15 years and 15 years and above. The number of total diabetic adults belonging to these 4 periods were significantly different as was observed during discriminant analysis.
Among the investigated adults 43.5 percent were from rural area , 44.8 percent were females, 17.4 percent were non-Muslims, 69.8 percent were currently married, 54.2 percent were of ages 40 years and above, 5.6 percent were illiterate, 34.5 percent were housewives, students and unemployed adults. In each case of these demographic characteristics higher proportion of the adults were suffering from diabetes and high blood pressure simultaneously compared to the proportions of sufferers of their counterparts. The adults possessing these demographic characteristics were at higher risk of the diseases under consideration. So far economy concerns the adults belonging to families of highest level of income and highest level of expenditure were at higher risk of the disease compared to the risk of adults of other families. Among the adult's 34.7 percent were involved in sedentary activities, 63.4 percent were physically inactive. Both these groups of adults were at higher risk of the disease compared to the risk of adults involved in some sort of physical activities.
So far food habit concern, 51.4 percent were habituated in taking restaurant food and 60.8 percent were used to take can food. Both these groups of adults were at higher risk of the disease compared to the risk of their counter parts. Obese adults (9.6%) were at higher risk of the disease compared to the risk of nonobese adults. In the above illustration, it was clear that some of the adults of different socioeconomic characteristics were at higher risk of diabetes and elevated blood pressure. But prevalence of the disease was not significantly associated with all the socioeconomic variables. Some of the variables had high influencing impacts on the prevalence of the disease. Thus, the most responsible variables for which the adults were affected were identified by discriminant analysis. The analysis indicated that duration of the disease, utilization of time, body mass index, age, habit of taking restaurant food and can food be the responsible variables for enhancing the prevalence of diabetes and high blood pressure simultaneously.
As the prevalence of the disease is associated with maximum socioeconomic variables, the problem of prevalence cannot be avoided but intensity of the problem can be reduced if some plans related to proper health care can be formulated and action is taken to implement those plans. The following steps can be taken for healthy society and reduced rate of NCDs affected people. i.
People should be encouraged to maintain healthy body weight or to reduce the BMI. ii.
People should be advised to eat heart-healthy food and food free of much sugar and salt. iii.
People should be encouraged to take more fresh vegetables and fruits. iv.
Elderly people should consult the doctor for proper medication regularly so that blood pressure is properly controlled. v.
Each one should do some sort of physical work whenever it is possible. vi.
Everyone at least walks a while whenever it is possible. vii.
Everyone should avoid sedentary activities as per as possible. viii.
Health authority in both urban and rural areas can provide a service free of cost to check up the blood pressure, blood sugar and body weight at least twice a year. This can be done by forming different charitable trusts in the community or forming social workers groups.