Socioeconomic Gradients and Distribution of Diabetes, Hypertension, and Obesity in India

Abstract

Importance: Cardiovascular disease and risk factors represent a major and increasing burden of death and disability in India, although socioeconomic aspects have been debated in recent years.

Objective: To conduct a comprehensive equity analysis of the socioeconomic gradients and distribution of diabetes, hypertension, and obesity in India using the latest national data set.

Design, setting, and participants: Cross-sectional study of data originating from the fourth Indian National Family Health Survey collected from January 20, 2015, to December 4, 2016. The study population was based on a nationally representative cross-sectional sample of women aged 15 to 49 years and men aged 15 to 54 years in India, with a response rate of 97% and 92% among eligible women and men, respectively. Biomarker sampling of survey respondents captured height, weight, blood pressure, and random blood glucose levels. Markers of socioeconomic status (SES) were household wealth, education, and social caste. Descriptive analyses and logistic regression models that account for multistage survey design and sampling weights were estimated.

Main outcomes and measures: Diabetes, hypertension, and obesity assessed by predetermined thresholds based on biomarker sampling or current medication were the primary outcomes.

Results: The survey covered 757 958 individuals (weighted prevalence of 51.2% female). The overall prevalence of diabetes, hypertension, and obesity in the sample was 2.9%, 14.4% and 9.7%, respectively. Positive socioeconomic gradients were observed by household wealth, education, and social caste, and in a majority of states. The magnitude of the SES gradient was strongest for obesity (adjusted odds ratio for highest SES quintile vs lowest, 8.76; 95% CI, 7.70-9.95), followed by diabetes (adjusted odds ratio, 2.31; 95% CI, 1.88-2.85) and hypertension (adjusted odds ratio, 1.58; 95% CI, 1.45-1.72) (P < .001 for all associations). Analyses of the socioeconomic distribution indicated that between 70% and 90% of the population burden of diabetes, hypertension, and obesity was among the higher SES groups, and this figure was similar across states.

Conclusions and relevance: Cardiovascular risk factors have an uneven distribution in India. Prevention and treatment strategies should reflect the distribution of the risk factor burden.

Figure 1.. Distribution of Socioeconomic Status (SES) Among Individuals With Diabetes, Hypertension, or Obesity in India From 2015 to 2016

Data are from the fourth Indian National Family Health Survey. High and low SES groupings defined for wealth (quintiles 1-2 vs quintiles 3-5), education (no education vs primary and above), and social caste (scheduled castes and scheduled tribes vs others). Combined marker represents low SES on all 3 dimensions.

Figure 2.. Adjusted Odds Ratios and 95% Confidence Intervals for the Social Gradients in Wealth, Education, and Social Caste for Diabetes, Hypertension, and Obesity in India From 2015 to 2016

Data are from the fourth Indian National Family Health Survey. OBC indicates other backward class; Q, quintile; SC, scheduled caste; and ST, scheduled tribe.

Figure 3.. State-Specific Age-Adjusted Odds Ratios for Social Gradients and Distribution of Higher Socioeconomic Status

The box plots show state-specific age-adjusted odds ratios for social gradients (A) and distribution of higher socioeconomic status (B) by wealth, education, and social caste for diabetes, hypertension, and obesity in India. The boxes indicate first and third quartiles with median lines at the center. Whiskers indicate first quartile − 1.5 × interquartile range and third quartile + 1.5 × interquartile range. Values outside the whiskers are shown as dots. Data are from the fourth Indian National Family Health Survey (2015-2016).