Prevalence Study of Hypertension, Diabetes, and Depression in Vanni Anjali Arulanandan, Kavitha Kanagarayer, Kalaivani Subramaniam, Meera Bala, Gayanthini Nadesalingham
ABSTRACT In the Vanni region of northern Thamileelam, many diseases with relatively simple cures are going untreated due to the poor standard of available medical care. We seek to gather information on the prevalence of hypertension, diabetes, and depression. We believe the information will be useful for fellow researchers, volunteers, and medical enthusiasts visiting the region to treat affected patients. By testing patients at two local hospitals in Vanni, we found that hypertension and depression are areas potentially affecting a large percentage of the population, with a disproportionate number of women suffering from depression. More attention should be devoted to these diseases, both through increased access to medical care and further epidemiological study. While diabetes did not seem to be a major concern for most patients, our results indicate that valuable information can be gained from further investigation of the prevalence of common diseases in this community. Additional studies must be done to further improve the standard of healthcare in this region. INTRODUCTION Diseases such as hypertension, diabetes, and depression are common problems in primary care medicine affecting all societies to varying degrees, yet data on their prevalence in developing countries is often lacking. In developed Western countries, such conditions are often effectively detected and treated when patients visit medical professionals for well check-ups or during acute illness, in part because clinicians are keenly aware of their relatively high prevalence among certain patient populations. Hypertension, or high blood pressure, is a condition in which the force of blood against the artery walls is too strong. When blood pressure remains too high for many years, it can have deleterious effects on several parts of the body; the brain, heart, arteries, and kidneys can all be damaged. Chronic hypertension can lead to severe complications including heart attack, stroke, ruptured aneurysm, and kidney failure. Hypertension is often referred to as a “silent killer” because symptoms, unless highly severe, are not evident in most cases. Because of this, it is also easy for hypertension to go untreated until it is too late for the patient. Evidence-based guidelines for the diagnosis and treatment of hypertension are published periodically by the United States government’s National Institutes of Health. Diabetes is a disorder of metabolism, affecting the way the body absorbs sugar from digested food. Usually the pancreas will produce the right amount of insulin to move glucose from the blood into cells. In people with Type 2 diabetes however, the pancreas either produces too little insulin, or the body’s cells do not respond appropriately to the insulin that is produced by the pancreas. Diabetes can generally be diagnosed simply by testing blood sugar, but if these measurements are not taken the disease can go unnoticed for a long period of time. The complications of long-term diabetes are even more serious than that of hypertension. In addition to causing heart attack, stroke, and kidney failure, diabetes can also cause blindness, nerve problems, decreased ability to fight infection, and intestinal problems. Guidelines for diagnosis and treatment of diabetes are available in the annual position statement of the American Diabetes Association. Depression is classified as a mood disorder, and symptoms include low energy, prolonged unhappiness or irritability, and a lack of interest in daily activities. The causes of depression are not known for certain, but the disease can be triggered by a variety of causes including chemical imbalances in the brain or by stressful situations such as living in a warzone. Depression can very adversely affect the productivity of affected individuals, as well as those who care for them. Acceptance of depression as a
medical illness and the judicious use of psychotherapy and antidepressant medication can help to mitigate the profound societal impact of the illness. Several tools for quick screening of depression in a primary care setting have been verified through research, including the Patient Health Questionnaire (PHQ-9). In developing countries, identification of the aforementioned illnesses may be overlooked despite relatively simple tests for their diagnosis. Medical assessment of common problems may not be readily available due to a shortage of manpower and resources, or in part the result of a poor knowledge base among medical staff. In the Vanni region of northern Thamileelam, where much of the area has been affected by a long civil war spanning more than two decades, medical infrastructure has suffered greatly. The number of medical college graduates per capita is exceedingly low, and the quantity of medical supplies reaching the region is not sufficient to meet the needs of the population. Unlike in many parts of the more developed world, the general population in Vanni does not go to the hospital for regular medical checkups. Only when the patient suffers from an ailment does he/she visit the doctor and seek treatment, and even during these visits, basic medical checkups are not performed completely. Instead, a focused history and physical are performed, and patient encounters rarely last more than 5 minutes. With the proper materials and experience, diseases such as diabetes and hypertension are relatively easy to diagnose; however, in the Vanni region of Thamileelam where basic tests are not performed during most patient visits, these conditions may be underdiagnosed. Despite the slow rebuilding of the medical system in the Vanni since the signing of the Ceasefire Agreement 3 years ago, the current situation is substandard by any measure. This is especially true since the tsunami natural disaster of December 2004. While the contributions of medical professionals and benefactors living outside of Sri Lanka has gone a long way to alleviating the plight of the medical system in Thamileelam, there is an even longer way to go. One area of expertise that has been underdeveloped to date is research on the prevalence of specific diseases in the Vanni population. With their experience in research analysis and design, volunteers from foreign countries can gather data on common medical conditions in Vanni. These data would be an important resource to guide the planning, development, and implementation of future medical projects in the region. OBJECTIVES This study is a cursory survey of prevalence of hypertension, diabetes and depression in the district of Vanni in Thamileeelam. The primary objective of the study is to provide healthcare professionals from overseas, who might be keen on working in the Vanni, with background information on the prevalence of diseases there. The same data could potentially influence the delivery of healthcare by local medical professionals operating in Vanni. Of note, the study was carried out by visiting undergraduate student volunteers (who reside outside of Sri Lanka), and secondary objectives included the following: • provide an example of how volunteers without a medical background can make significant contributions to knowledge of healthcare needs in Vanni • motivate other youth living around the world to work on projects that benefit the population in the north and east of Sri Lanka • show that research on healthcare problems in Vanni can be conducted to provide significant results • encourage future medical research endeavors in Vanni by youth and adults METHODS Background
Subjects were interviewed and data were gathered to determine the prevalence of hypertension, diabetes, and depression at the private Dr. Ponnampalam Memorial Hospital in the town of Puthukkudiyiruppu and the government hospital in the village of Dharmapuram. The study was conducted during the last week of May 2005 at Dharmapuram hospital and the first week of June 2005 at Ponnampalam Memorial Hospital. Each day, interview sessions began at nine in the morning and ended around noon or one in the afternoon. At both the Dharmapuram and Ponnampalam Memorial hospitals, patients above the age of twenty who visited the outpatient department were brought by the triage nurse to be interviewed for the study. Patients were brought for interviews in the order they arrived at the clinic. Selection of patients was determined exclusively by the triage nurse. Despite instructions to the contrary, for the first few days some outpatients were selected for study inclusion by the triage nurse solely because the patient had a prior history of hypertension or diabetes. The number of patients excluded from the survey was not recorded. Selected patients were brought to a separate room and interviewed by three of our researchers. In both hospitals, the room was situated adjacent to the outpatient clinic, and interviews were conducted with the doors open to the hospital waiting area. The duration of each interview was approximately 10 minutes. After the interview, the patients were thanked and sent back to the outpatient waiting area. Demographics First, a general interview was conducted and basic patient demographic information was recorded including name, age, sex, occupation, reason for hospital visit. Hypertension All patients were then tested for hypertension through a single measurement of brachial artery blood pressure using a manual, analog sphygnomanometer. A single, standard cuff size was used for all patients. The blood pressure cuff was marked to indicate whether it was the appropriate size for the arm being tested, and patients were not tested if their arm was too small. Type 2 Diabetes Patients’ body mass index (BMI) was calculated after measuring their height and weight. Body mass index = weight (kg) / height2 (m) Patients above forty years old with a BMI of greated than 25 were then given a fingerstick blood glucose test using a glucometer and test strips from the United States. To determine if they were fasting, patients were asked if they had eaten any breakfast that morning. Because the finger stick blood glucose value as determined by a glucometer is +/- 10% of the serum blood glucose, the criteria for detecting diabetes in this patient population was modified slightly. A finger stick blood glucose value of 140 mg/dL (7.8 mmol/L) in fasting patients and a value of 220 mg/dL (12.2 mmol/L) in nonfasting patients were used to make a diagnosis of diabetes, because these values are approximately 10% higher than the cut-off values for serum blood glucose. Of note, patients were not queried about previous diagnoses of diabetes or hypertension. Depression Patients were first asked two screening questions: “Over the last 2 weeks, how often have you been bothered by any of the following problems? 1) Little interest or pleasure in doing things 2) Feeling down, depressed, or hopeless.� Patients who answered positively to at least one of the two screening questions for depression were further questioned with seven additional questions as part of the PHQ-9 depression survey. The screening questions and entire survey were translated to Thamil, and survey question #9 was slightly modified due to negative cultural perceptions regarding suicide (Annexure 1). These depression questions were asked of all patients by the same interviewer in order to minimize variability.
RESULTS Patient Demographics Fifty-nine women and forty-one men ages 22-88 years (mean, 47 years) were included in the study. Hypertension One patient was excluded from blood pressure measurement, because the arm was too small for the blood pressure cuff. Fifty percent of the subjects fell into the category of Prehypertension, while 21% and 4% were categorized as Stage 1 and Stage 2 hypertension, respectively (Table 1). The distribution of men and women among the different categories appeared similar (Figure 1). Table 1. JNC-7 Categories of Hypertension Stage SBP DBP (mm Hg) (mm Hg) Normal < 120 And < 80 Prehypertension 120-139 Or 80-89 Stage 1 hypertension 140-159 Or 90-99 Stage 2 hypertension â&#x2030;Ľ160 Or â&#x2030;Ľ 100
n (%) 26 (26) 48 (48) 21 (21) 4 (4)
30 25 20
Females
15
Males
10 5 0
n io ns
io 2 ge St a
St a
ge
1
H yp
H yp
er
er te
te
ns
ns i te yp er Pr eh
N or m
n
on
c al
Number of Patients
Figure 1. Sex-specific plot of blood pressure.
Blood pressure categories
Diabetes A total of 10 subjects had a BMI value above 25 and were tested with a finger stick blood glucose measurement (Table 2). Of these, 3 subjects fit the criteria for Type 2 diabetes. Table 2. Patients Screened for Diabetes with Finger-Stick Blood Glucose Sex Age BMI Breakfast? Finger stick Diagnosis Blood glucose Female 66 22.7 no 163 Type 2 Diabetes Female 57 25.5 yes 170 Female 56 26.7 yes 85
Female Male Male Male Male Male Male
47 65 47 45 37 86 70
26.8 19.3 19.3 22.1 32.7 29.1 27.5
no no yes no yes yes yes
68 302 179 273 114 121 127
Type 2 Diabetes Type 2 Diabetes
Body Mass Index The majority of subjects had a normal body mass index, with 8% being classified as underweight (Table 3). This distribution was the same for both sexes (Figure 3). Table 3. Body Mass Index Classification Body Mass Index Underweight Below 18.5 Normal 18.5-24.9 Overweight 25.0-29.9 Obese 30.0 and above
n (%) 8 (8) 60 (60) 20 (20) 12 (12)
Figure 3. Sex-specific plot of Body Mass Index 40 Number of Patients
35 30 25 Females
20
Males
15 10 5 0 Below 18.5
18.5 - 24.9
25.0 - 29.9
30.0 and above
Body Mass Index
Depression Fifty-seven percent of subjects were screened for depression. Approximate depression severity is given for each score in Table 4. Women appeared more likely than men to be screened, with 39 of the 59 women undergoing screening compared to only 18 of 41 men (Figure 4). Only women had the most severe types of depression. Table 4. PHQ-9 Depression Screening Score Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression
Women 7 17 11
Men 6 10 2
15-19 20-27
Moderately severe depression Severe depression
2 2
0 0
45 40 35 30 25 20 15 10 5 0
Females
Se v
er e
er od M
od
er
at
el y
M
Se v
e at
ild M
al M
in
im
ne ee Sc r
er e
Males
d
Number of Patients
Figure 4. Sex-specific plot of Depression Screening
Type of Depression
LIMITATIONS Selection bias of patients is a major drawback to this study design, because subjects were chosen in an arbitrary fashion by the triage nurse who was not blinded. The triage nurse selected only relatively well-appearing patients, excluding those with severe conditions. This bias prevented the entire range of patients from being interviewed. Ideally, this study would be conducted among a random segment of the population, or at least among a consecutive series of all patients seeking medical care at the outpatient departments. In measuring values of blood pressure, the values could have been performed on both arms and by two different operators to minimize errors. Measurements of blood glucose could be limited to those patients who have been fasting. Serum blood glucose measurements could also be performed, though this test is not available in all places. Cultural factors may have prevented some subjects from giving honest answers to the questions in the depression survey. This may be especially true of the male subjects, since all investigators were female. Also, the location of the interview area may have affected the results. Since subjects were not interviewed in an isolated area, lack of privacy could have discouraged them from answering truthfully. DISCUSSION Hypertension The results for hypertension indicate that 74% of the subjects assessed need an alteration of diet or need medical attention to lower blood pressure. Figure 2 indicates that hypertension is not sex specific. Given the large public health impact when hypertension is untreated at the population level and the relatively low cost of routine screening, it would be advisable for routine blood pressure screening to be performed on all patients seeking medical attention. If the doctors do not have enough time to measure patientsâ&#x20AC;&#x2122; blood pressure themselves, the task can be delegated to nurses who have undergone proper training. This is the standard practice in most developed countries. With only 26% of the surveyed population having a â&#x20AC;&#x153;Normalâ&#x20AC;? blood pressure by JNC 7 criteria, blood pressure should be addressed by medical professionals working in Vanni for every patient, regardless of chief complaint.
Diabetes The measured prevalence of diabetes in our study population was not high, with only 10 (10%) subjects even meeting our screening criteria for finger-stick blood glucose and only 3 of those with Type 2 diabetes. This may be due in part to the increased level of exercise seen in the developing world when compared to industrialized countries. However, the results may have been quite different had all patients been tested with finger-stick blood glucose. Depression A positive answer to at least one depression screening question was found in more than half of patients (57 of 100), requiring the more formal assessment with the Thamil version of the PHQ-9 depression survey. This may have been due in part to the translation of the screening questions, or an inherently high level of depression among the population in Vanni. A cursory look at the data without formal statistical analysis seems to indicate that women suffer more from depressive symptoms than men, with 15 of 59 women displaying symptoms of moderate to severe depression. This may be due in large part to the role of women in society. The actual causes of the depressive symptoms were not analyzed in this study, but no doubt social, economic, and environmental factors play a large role. This would be an interesting area of research in a more formal future research study. Given the potential for a high prevalence of depression among this population and several anecdotal accounts of depressed patients, it seems that foreign medical professionals should concentrate resources on targeting depression as a high priority area for future intervention. At the very least, patients should be routinely screened for depression during visits for acute medical care. This applies to women especially. All patients with a positive screen should have access to further counseling or professional mental health. CONCLUSION Healthcare in the Vanni region of Thamileelam is suffering due to the lack of professionals and of basic information regarding the status of healthcare in the community. This simple survey of patients has provided previously unknown data regarding the prevalence of hypertension, diabetes, and depression. The results suggest that more resources and research need to be focused on hypertension and depression. We hope the work done in this study can guide others who will use this research to gain a better understanding of the current situation in this region and motivate them to carry out similar projects of their own.
REFERENCES The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) http://www.nhlbi.nih.gov/guidelines/hypertension/ PHQ-9 Depression Scale http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/ Standards of Medical Care in Diabetes American Diabetes Association Diabetes Care 2005 28: S4-36 http://care.diabetesjournals.org/cgi/content/full/28/suppl_1/s4 Diagnosis and Classification of Diabetes Mellitus American Diabetes Association Diabetes Care 2005 28: S37-42. http://care.diabetesjournals.org/cgi/content/full/28/suppl_1/s37 Body Mass Index Centers for Disease Control Department of Health and Human Services http://www.cdc.gov/nccdphp/dnpa/bmi/index.htm