Indian J Med Res 127, June 2008, pp 555-563

Behavioural risk factors for non communicable diseases among adults in Kerala, India
T.N. Sugathan, C.R. Soman* & K. Sankaranarayanan

Centre for Survey Research & Management Services, Kochi & *Health Action by people Thiruvananthapuram, India

Received May 8, 2006

Background & objectives: Cardiovascular and other chronic diseases are becoming the major causes of morbidity and mortality in most of the third world countries including India, especially in the southern Indian States, like Kerala, where most of the health indicators match closely with those of any developed country. Various behavioural risk factors (BRF) namely smoking, unhealthy diet, stress at home and work place, consumption of alcohol, sedentary life style, etc., are known to be risk factors for many such diseases. The present study was carried out to estimate the prevalence of various behavioural risk factors for chronic diseases, and to identify their biosocial correlates. Methods: A cross-sectional study was done in which the data were collected from a sample of 6579 individuals of age 30 to 74 yr, randomly selected following a stratified multi-stage cluster sampling design covering Kerala State. The important factors investigated include various behavioural risk factors, presenting chronic diseases and family histories among close relatives. The data were analysed using both univariate and multivariate analyses. Results: The two major risk factors observed among males were smoking and alcohol consumption. About two fifths (40%) of them were current smokers as well as current users of alcohol (41%). The median age at initiation was 21 yr for both smoking habits and for alcohol consumption. Nearly a quarter of the target population were inactive (23% males and 22% females) based on work and leisure time activities. More than one-fifth of them (23%) reported stress. Obesity was found more among females (33%) than males (17%). Low socio-economic background was found to be a high predictor (high risk group) for habit of smoking, alcohol consumption, stress and unhealthy diet. Interpretation & conclusions: Substantially high levels of the various behavioural risk factors among adults in Kerala suggests an urgent need for adopting healthy life style modifications among the population in general. The increased risk observed among the younger generation for behavioural risk factors such as smoking and alcohol consumption calls for urgent corrective steps and measures for long-term monitoring of all major risk factors as well as the major chronic disease conditions.

Key words Cox-regression - logistic regression - monitoring - non communicable diseases - prevalence - relative risk - risk factors 555

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Cardiovascular and other non communicable diseases (NCDs) are becoming the major causes of morbidity and mortality in most of the third world countries1. Cardiovascular diseases and stroke represent 31 per cent of all deaths world-wide that is about 15 million deaths a year, of which 11 million (79%) are in developing or transitional countries2. Public health experts have also predicted a global epidemic of cardiovascular disease (CVD) on the basis of current trends. CVDs are the major and growing contributors to morbidity burden in South Asia3. Various behavioural risk factors like smoking, unhealthy diet, stress at home and at the work place, consumption of alcohol, sedentary life style, etc., are known to be the risk factors for various chronic diseases. Most of the behavioural risk factors are potentially modifiable ones4,5. It was estimated that 4.83 million premature deaths in the world was attributed to smoking of which half of them are in developing countries and 3.84 million of these deaths were in men6. It has been documented that regular smoking can increase the risk not only of NCD, but also of many other diseases7. Imbalance in diet is responsible for overnutrition leading to obesity, which in turn is a risk factor for various diseases8. Long use of alcohol may directly cause certain organic diseases, may contribute to the development of cirrhosis of the liver, cancer of the mouth, pharynx, esophagus and pancreas and result in increased risk of accidents and suicide. A history of simultaneous exposure to cigarette smoking and the habit of heavy alcohol intake revealed a very high risk for developing oesophageal cancer, suggesting a synergistic interaction between the two9. Studies on the prevalence of such risk factors are routinely being carried out in the developed countries10. However only a few studies on the prevalence of behavioral risk factors have been carried out in India, most purely localized studies. Kerala is one of the southern States in India with a population of over thirty million. In this State the health indicators are comparable with those of many Western countries, with high life expectancy, very low fertility rate, high literacy among both males and females, and a reasonably good health care system in both government and private sectors. It was reported that 20 per cent of all deaths in Kerala are caused by coronary heart disease (CHD)11,12. Thus the proportion of people with morbidity on account of CVD might be higher than 20 per cent. With favourable conditions for population

ageing, the problem of morbidity burden due to chronic diseases may also be increasing in Kerala. Ramankutty and colleagues13 conducted a study in early nineties on the prevalence of CHD in the rural areas of Thiruvanathapuram district in Kerala. They provided estimates of prevalence rates of four risk factors, viz. hypertension (179/1000), smoking (219/ 1000), diabetes (40/1000) and obesity (50/1000) (BMI>27), which is relatively high. Kannan et al14 in their report on a rural health survey carried out in 1987 noted a high percentage of smokers among males aged 15+ (53%) and a moderate proportion of alcohol users (18%). We undertook this study to estimate the prevalence of various behavioural risk factors prevailing among the population of Kerala State, and also to identify their social correlates. Material & Methods Sampling design: The cross-sectional survey covered whole of Kerala State and the study lasted 16 months, from 1 September 2003 to 31st December 2004. The target population was the residents of Kerala in the age group 30-74 yr. The estimated sample size was a minimum of 6500 covering 8 different age groups and both sexes by using the formula [n=4pq / d2 where d is the allowed error taken as 0.05, p=q=0.5 and with type 1 error () = 0.05] for the individual age and sex groups15. A stratified multi-stage cluster sampling design was adopted for the study. The strata were formed as follows: the cities of Thiruvanathapuram, Kochi and Kozhikode formed strata 1, 2 and 3 respectively. All the 54 Municipalities together constituted stratum 4. All the rural Panchayaths together formed stratum 5. Multistage samples of wards were selected from each stratum using probability proportional to size (PPS) method at each stage. From each sample ward, one or two clusters of households of size 15 were selected at random (Appendix). The investigators visited all households of the selected clusters for data collection. Inclusion and exclusion criteria: All the usual residents, both male and female, in the age group 30 to 74 yr residing presently in the households were included in the survey. The individuals below age 30 or above age 74 yr or those not available for interview on account of their absence of more than a month were excluded. Field procedure: Prior to the interview consent from the respondents was obtained. In each sample

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Appendix
1. Sample design 1.1 A stratified multi-stage sampling design was adopted for the survey. 1.2 Formation of strata: The three largest cities of the state, viz., Thiruvananthapuram, Kochi and Kozhikode, each formed an independent stratum (strata 1, 2, and 3 respectively). All municipalities and the new corporations of Kollam and Trichur together formed on e stratum (stratum 4). Similarly, all the panchayats of the State formed one stratum (stratum 5). The 2001 census list was used as sampling frame at each stage of selection except the last stage in which the houses was obtained from respective Corporation, Municipalities, Panchayat authorities. 1.3 Selection of sample wards in the three cities: 12 wards were selected from each of the three cities systematically with probability proportional to ward population. 1.4 Selection of towns and wards in stratum 4: In stratum 4, 12 towns were selected with probability proportional to town population. From each sample town two wards were selected systematically with equal probability. 1.5 Selection of wards in stratum 5: Wards were selected from stratum 5 in four stages. First, 4 districts were selected (out of 14 districts) systematically with probability proportional to size (pps), size being rural population. From each sample district 4 blocks and from each block 2 panchayaths were selected systematically with pps, size being the number of wards of the respective sampling unit. From each sample panchayaths 2 wards were selected systematically with equal probability. 1.6 Selection of clusters of households: From each sample ward 2 clusters of 15 households were selected at random using the house lists of the sample ward obtainable from the civic authorities (in a few cases only one cluster was selected). 2 Estimated value of standard error (SE ) and design effect (DEFT) R 0.39 0.41 Standard error (SE) 0.016 0.016 No. of cases (N) 2890 2890 Standard error assuming SRS 0.009 0.009 Design effect (DEFT) 1.8 1.8

Risk factor in males Current smoking Current alcohol consumption

household, general information about the household was collected in Schedule 1: (Household particulars). This includes, besides common household particulars such as religion, caste, income, etc., a list of household members and their characteristics such as age, sex, and education. For each eligible person Schedule 2 (Living habits of members aged 30-74 yr) was filled in. The investigators met each of them and got their answers to a set of questions on important classes of behavioural risk factors viz., dietary habits, physical activity, smoking, alcohol consumption and mental stress. Height (correct to 0.1 cm) and weight (correct to 0.5 kg) of respondents were measured. Blood pressure was measured using the mercury sphygmomanometer. Both systolic and diastolic values were taken twice and their average was recorded in the schedule. A person was considered inactive if he/she has always been carrying out only light (sedentary) physical activities. Since work and leisure activities are the two important segments of daily life in which most time is usually spent, a composite index of inactivity was defined by considering the respondent inactive both in the main work as well as in the leisure activities. The

level of activity was also studied with regard to travel, and physical exercise if any, carried out by the respondents. The study also attempted to obtain information on the level of mental stress and tension the respondents experienced. Respondents were asked whether they were feeling any stress or tension in their close environment. Stress was studied in six different areas job, family life, interaction with friends, financial problems, health and marital life (if married). The respondents were asked to score their level of stress in each of these six areas on a 7 point scale, (7 point Likert scale) ranging from -3 (extremely dissatisfied) to +3 (extremely satisfied), with zero if neutral16. This scale is used to get some insight into the presence or absence of any stress, and not for quantifying its level. All the respondents with negative scores were considered stressed in the respective situations. For the purpose of analysis, the respondents were defined as stressed in life if they experienced stress in at least two of the above situations. Information in dietary intake was collected from each respondent. For the purpose of analysis, those who

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took vegetables and fruits less than once daily were considered as having unhealthy diet. Body mass index (BMI) was calculated by dividing weight in kg by square of height in meters. Overweight / obesity was estimated based on BMI > 25.0 kg/m2. High blood pressure was defined based on a systolic blood pressure > 140 mm of Hg or diastolic blood pressure > 90 mm of Hg. Field study team and pilot study: Study team consisted of four investigators and two supervisors with postgraduate qualification in medical social work or in public health. Prior to the finalization of the self designed questionnaire, a pilot study was carried out on a sample of two wards in Kochi which enabled modification of the questionnaires as well as the field interview procedures. The timing of field work was usually in early morning or late in the evening. The duration of field work lasted more than eleven months September 1 st, 2003 to August 31st, 2004. A random quality check of both measurements and data collected by supervisors was a built in procedure in the survey. Statistical analysis: The statistical software SPSS version 7 was used for data analysis. Using the Pearson chi square, variations in prevalence of different risk factors were tested by socio-demographic variables. Relative risk estimation for smoking and alcohol consumption was made using Coxs multivariate proportional hazard method, where the time dependent variable age at initiation of smoking or alcohol consumption was taken as the dependent variable for these habits respectively 17 . Multivariate logistic regression was used for the other risk factors, namely inactivity, stress, risky dietary items and overweight/ obesity. The Step-wise forward procedure was adopted for the above multivariate analysis and relative risk (RR) was obtained for statistically significant factors. The survival method was used to determine the cumulative probability of an event (initiation of smoking/alcohol consumption) at various ages, from 10 yr onwards. P<0.05 was taken as statistically significant. Results The total number of respondents for the study was 6579 persons, 2890 males and 3689 females. The response rate was 95.1 per cent, excluding the nonresidents who were away from their native place, and others working outside the district.

More than half of the respondents (56%) were from the rural areas and the remaining were either from towns (23%) or from cities (21%). The median age of the respondents was 45 yr with an inter-quartile range of 19 yr. Over half of them were Hindus (54%), one fourth Christians (25%) and the rest Muslims (21%). Except 7 per cent, all of them were literate, and more than onefourth possessed college or higher education qualifications. The median monthly household income was INR 6197 (approximately US$ 144), which was higher among city respondents (INR 6901/US$ 160) and the lowest among rural respondents (INR 5883/ US$137). Smoking habits: The survey indicated that 40 per cent of the males were current smokers and 20 per cent former smokers. The prevalence of smoking habit was almost nil among females (0.4%). However, among non smokers, a high proportion of both among males and females, were exposed to passive smoking (62% among males and 43% among females). The median age at smoking initiation was 21 yr. Three-fourths of the current smoking males were heavy smokers (more than 20 cigarettes per day or more than 20 yr of smoking). A small fraction among males and females used other substances for chewing, mainly containing raw tobacco. Alcohol consumption: About 41 per cent of men were current users of alcohol, and 10 per cent were former drinkers. The prevalence of drinking habit was almost nil (0.9%) among females. More than one-tenth (13%) of the current users drank alcohol almost daily and more than a quarter (27%) 1 to 4 times in a week. Physical inactivity: The proportion of individuals physically inactive during work (job) was 31 per cent. The inactivity was 74 per cent during leisure time and 39 per cent during travel. The prevalence of inactivity based on the composite index (work and leisure time) was 23 per cent for males and 22 per cent for females. Stress: Finance was the major source of mental stress for more than one third of the respondents (38%), followed by health (22%). The proportion of people with stress from one or more sources was found to be 54 per cent. For the purpose of the present study, as stated earlier, the respondents were considered stressed if they have been experiencing stress in at least two situations. By this definition 23 per cent, both males and females were found to be under stress. Overweight/obesity: High prevalence of overweight/ obesity was found among females (33%), which was much more than that of males (17%).

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Unhealthy dietary intake: As such 13 per cent of the respondents were having dietary risk factor. Most of the respondents (87%) were not in the habit of taking fruits adequately (at least once daily). As regards vegetables, 13.8 per cent of the respondents were said to have not taken vegetables at a satisfactory level, i.e., at least once daily. About 80 per cent of the respondents were either non vegetarians (29%) or mixed (both vegetarian and non-vegetarian) (51%). The bio-social correlates of various behavioural risk factors were evaluated both in terms of level of prevalence (P) as well as their relative risk (RR) by the multivariate method. For smoking and alcohol consumption, the analysis was restricted to males since the prevalence for these two habits was almost nil among females.

Current smoking habit among males: Educational attainment and occupational status were found to be the two most important and significant determinants in terms of both P and RR. The smoking (current smoking) habit was found to be most prevalent among the least educated (53%) and among the unskilled workers (60%) compared with the well educated (20%) and the professional workers (23%) respectively (Table I). Current alcohol consumption among males: The socioeconomic status based on education and occupation was found to be the most determinant factor for alcohol habit also. The risk in initiating the alcohol habit was found to be 70 per cent higher among younger age group (<45 yr of age) compared to older age group (65 yr or above) (Table I).

Table I. Prevalence and estimated relative risk (RR) of smoking and alcohol consumption by socio-demographic factors Factors No. of cases* Current smoking in males Prevalence SE (%) Age group (yr): 30-34 35-44 45-54 55-64 65-74 All Place of residence: Corporation Municipality Rural Education (years of schooling): <5 5-10 10-12 Higher education Occupation: Professional Skilled Unskilled Others Household income (INR): <2500 2500-4999 5000-9999 >10000 Religion: Hindu Muslims Christian 456 813 716 559 340 2890 602 649 1639 531 1021 966 372 514 1243 641 492 411 940 911 627 1609 559 722 28.3 0.8 41.3 1.0 43.1 1.2 45.6 1.1 34.2 0.9 39.7 1.6 36.0 0.2 35.3 0.1 42.8 2.6 52.7 0.9 48.0 1.3 31.3 1.0 20.2 0.6 22.8 0.5 38.9 1.5 59.6 1.2 33.3 0.6 52.1 1.7 43.4 1.3 37.1 1.0 29.8 0.5 41.0 1.2 42.2 1.7 34.8 2.0 RR ( 95% CI)** 0.5 (0.4-0.7) 0.8 (0.6-1.0) 0.9 (0.7-1.2) 1.0 (0.8-1.3) 1.0 (Ref ) Current alcohol in males Prevalence SE (%) 42.5 1.5 43.9 2.6 43.4 1.7 37.7 1.7 29.4 1.5 40.6 1.6 49.8 0.3 35.3 0.2 39.5 2.6 33.5 2.0 45.7 1.9 42.3 1.6 33.1 1.0 34.2 0.9 45.4 2.2 45.2 1.8 29.4 1.5 39.7 1.4 45.9 2.0 40.1 1.9 34.3 1.2 48.5 1.5 5.0 0.5 50.8 3.4 RR (95% CI)** 1.7 (1.3-2.2) 1.7 (1.3-2.2) 1.5 (1.2-1.8) 1.3 (1.0-1.6) 1.0 (Ref )

0.9 (0.8-1.1) 0.8 (0.7-0.9) 1.0 (Ref ) 3.0 2.5 1.4 1.0 1.0 1.4 2.0 1.2 (2.2-4.0) (1.9-3.3) (1.1-1.9) (Ref ) (Ref ) (1.0-1.6) (1.5-2.5) (1.0-1.6)

1.2 (1.1 - 1.4) 0.9 (0.8 - 1.0) 1.0 (Ref ) 1.9 1.8 1.3 1.0 1.0 1.3 1.5 1.1 (1.4-2.4) (1.4-2.3) (1.0-1.6) (Ref) (Ref) (1.1-1.6) (1.2-1.9) (0.9-1.4)

Not significant

Not significant

Not significant

1.0 (Ref) 0.1 (0.0-0.1) 1.2 (1.0-1.3)

* The total do not add up to the same, due to missing values for some of the factors ** Based on multivariate cox proportional hazard

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Physical inactivity: The high risk groups were the skilled workers (P= 28.5% & RR=3.0) and professionals (P=32% or RR=3.3) compared to unskilled workers. Housewives also had moderately high risk (P=21% & RR=1.7) and the younger age groups (30-54 yr). Stress: Level of education, monthly income and occupational status all had an inverse relation with level of stress (Table II). Overweight / obesity: The high risk groups for acquiring overweight / obesity were females (P=33% & RR=1.8) and the respondents in the high social classes: well educated (P=34% & RR=2.0) and the highest income group (P=34% & RR=2.0) (Table III).

Dietary risk factors: Inadequate intake of both vegetables and fruits (less than once a day) was greater among the lower social class: least educated (P=22%, RR =5.1), lowest monthly income group (P=20% and RR=2.5) and unskilled workers (P=18%, RR=1.5) (Table III). Discussion The present study has revealed a substantially high rate of prevalence of some of the behavioural risk factors among adults in the community, especially the habit of smoking and alcohol consumption among men. The findings clearly indicated that the respondents with lower socio-economic background had a higher rate of

Table II. Prevalence and estimated relative risk (RR) of inactivity and stress by socio-demographic factors Factors No. of cases * Inactivity Prevalence SE (%) 22.9 0.7 21.9 1.0 22.3 0.9 24.7 1.3 23.4 0.8 23.1 0.8 19.7 1.1 18.9 0.7 25.6 0.3 20.7 0.3 21.8 1.4 18.5 0.7 20.4 1.1 24.0 1.1 31.9 0.8 32.0 1.1 28.5 0.5 12.3 0.3 21.2 1.3 18.7 1.0 21.1 1.0 21.3 1.3 21.3 1.0 25.9 0.7 22.2 0.9 20.5 1.1 24.2 2.0 RR ( 95% CI)** 1.0 (Ref ) 1.3 (1.1-1.5) Stress Prevalence SE (%) 23.0 0.8 23.3 0.6 23.1 0.8 16.8 19.7 23.8 27.0 33.9 0.4 0.7 0.8 0.9 1.2 RR (95% CI)** 1.0 (Ref ) 1.3 (1.1-1.6)

Sex: Male Female All Age group (yr): 30-34 35-44 45-54 55-64 65-74 Place of residence: Corporation Municipality Rural Education (years of schooling): <5 5-10 10-12 Higher education Occupation: Professional Skilled Unskilled Housewives Others Household income (INR): <2500 2500-4999 5000-9999 >10000 Religion: Hindu Muslims Christian

2890 3689 6579 1122 1914 1608 1183 752 1354 1510 3715 1521 2257 2079 722 816 1353 942 2349 1119 978 2050 2027 1522 3571 1397 1611

1.0 0.9 0.9 0.7 0.7

(Ref ) (0.7-1.1) (0.8-1.1) (0.6-0.9) (0.6-0.9)

1.0 1.1 1.3 1.3 1.5

(Ref ) (0.9-1.3) (1.0-1.5) (1.1-1.7) (1.2-2.0)

1.1 (0.9-1.3) 0.9 (0.7-1.0) 1.0 (Ref )

22.6 0.2 19.3 0.3 24.9 1.1 35.6 1.1 27.5 1.1 14.8 0.6 7.3 0.3 10.0 0.4 22.6 0.7 32.4 1.0 17.9 0.4 36.5 1.3 35.8 1.3 27.4 1.0 21.1 1.2 12.0 0.3 25.0 1.1 24.6 1.2 17.7 1.0

1.2 (0.9-1.2) 0.8 (0.6-0.9) 1.0 (Ref ) 3.3 2.8 1.6 1.0 (2.3-4.7) (2.0-3.9) (1.1-2.2) (Ref )

Not significant

3.3 (2.5-4.3) 3.0 (2.3-3.8) 1.0 (Ref) 1.7 (1.3-2.1) 1.8 (1.4-2.3)

1.0 (Ref ) 1.5 (1.1-2.1) 1.6 (1.2-2.2) 0.9 (0.6-1.2) 1.9 (1.4-2.5) 2.9 (2.4-3.6) 2.2 (1.8-2.6) 1.7 (1.4-2.1) 1.0 (Ref )

Not significant

Not significant

Not significant

* The total do not add up to the same, due to missing values for some of the factors **Based on Multivariate Logistic regression

SUGATHAN et al: BEHAVIOURAL RISK FACTORS FOR NCDS Table III. Prevalence and estimated relative risk (RR) of overweight/obesity and unhealthy diet by socio-demographic factors Factors No. of cases* Overweight/obesity Prevalence SE (%) 16.9 0.4 32.7 0.5 25.2 0.5 22.1 0.5 28.8 0.6 29.5 0.6 24.2 0.6 18.6 0.4 33.6 0.2 33.0 0.1 30.2 0.7 17.2 0.3 25.9 0.6 29.3 0.8 34.0 1.1 27.1 0.6 19.3 0.3 10.8 0.2 37.2 0.9 21.2 0.6 17.6 22.1 27.5 33.8 0.8 0.6 0.7 0.3 RR ( 95% CI)** 1.0 (Ref ) 1.8 (1.5-2.2) Dietary risk factors Prevalence SE (%) 13.6 0.3 13.1 0.3 13.3 0.2 12.5 0.3 13.6 0.4 13.8 0.4 13.3 0.4 12.6 0.4 8.4 0.1 9.3 0.2 16.7 0.6 22.1 0.6 7.0 0.5 6.5 0.3 2.6 0.1 3.2 0.1 13.5 0.5 17.5 1.0 16.4 0.4 13.3 0.5 20.1 0.8 15.7 0.6 11.9 0.5 7.4 0.4 8.7 0.4 24.1 1.6 14.0 0.8 RR (95% CI)** 1.0 (Ref) 0.8 (0.7-0.95)

561

Sex: Male Female All Age group (yr): 30-34 35-44 45-54 55-64 65-74 Place of residence: Corporation Municipality Rural Education (years of schooling): <5 5-10 10-12 Higher education Occupation: Professional Skilled Unskilled Housewives Others Household income (INR): <2500 2500-4999 5000-9999 >10000 Religion: Hindu Muslims Christian

2890 3689 6579 1122 1914 1608 1183 752 1354 1510 3715 1521 2257 2079 722 816 1353 942 2349 1119 978 2050 2027 1522 3571 1397 1611

1.0 1.6 1.8 1.4 1.1

(Ref ) (1.3-1.9) (1.5-2.2) (1.1-1.8) (0.8-1.4)

1.0 (Ref) 0.95 (0.8-1.2) 0.9 (0.7-1.1) 0.7 (0.5-0.9) 0.6 (0.4-0.8) 0.6 (0.5-0.9) 0.65 (0.5-0.9) 1.0 (Ref) 5.1 (3.02-8.7) 3.86 (2.3-6.4) 1.6 (0.9-2.6) 1.0 (Ref) 1.0 (Ref) 1.9 (1.1-3.1) 1.5 (0.9-2.4) 1.3 (0.8-2.1) 1.8 (1.1-2.9) 2.5 1.9 1.5 1.0 (1.9-3.2) (1.5-2.5) (1.2-1.9) (Ref)

1.8 (1.6-2.1) 1.9 (1.6-2.2) 1.0 (Ref ) 1.0 (Ref ) 1.6 (1.3-1.9) 1.7 (1.3-2.0) 2.0 (1.5-2.6) 1.0 (Ref ) 1.1 (0.9-1.4) 0.7 (0.5-0.9) 1.7 (1.4-2.2) 1.2 (0.9-1.6) 1.0 (Ref ) 1.3 (1.1-1.6) 1.6 (1.3-2.0) 2.0 (1.6-2.5) 1.0 (Ref ) 1.1 (0.9-1.3) 1.4 (1.2-1.6)

24.2 0.6 24.6 1.1 30.5 1.4

1.0 (Ref) 2.6 (2.2-3.1) 1.8 (1.5-2.15)

* The total do not add up to the same, due to missing values for some of the factors ** Based on Multivariate Logistic regression

prevalence of BRFs, except in the case of physical inactivity and obesity. This finding was consistent with findings observed in other countries 18 . Lower occupational class and lower household income categories were found to be associated with higher prevalence of the risk factors such as smoking and alcohol consumption19. This may be a reflection of the lack of awareness about the ill effects of BRFs on health among the people with the low socio-economic background. Smoking and alcohol intake were the two major risk factors observed among men. The prevalence of alcohol consumption observed in the present study was

almost three times that of the prevalence observed in the previous decade14. The Coxs Proportional Hazard method indicated significant variation in relative risk of alcohol use among various age cohorts, with a higher probability of acquiring the habit among men of younger age below 45 yr (70% more) as compared to their older age cohorts. Heavy alcohol consumption can adversely affect the neuralgic, cardiac, gastrointestinal, haematologic, immune, muscular-skeletal and psychiatric systems. Smoking is considered to be a major risk factor for chronic illnesses since it may be responsible for most of the lung cancer, the majority of chronic bronchitis, emphysema and a good portion of

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ischaemic heart diseases in men below 65 yr of age20. In western countries, 20 per cent of deaths among males and 8 per cent among females were attributable to smoking6. Since the incubation period of such diseases is very long (two or more decades), the resultant impact of such habits (smoking & consumption of alcohol) in terms of morbid condition may take a long time. However, the high prevalence of these two risk factors points to a definite likelihood of high morbidity burden occurring in future year. The study further showed that the dietary habits of the majority of the respondents were not healthy. Change in eating habits -less fiber and more fatty food - was influential for many chronic diseases in different countries21. The relationship between the inadequate intakes of high -fiber foods such as vegetables and fruits, and the occurrence of chronic non communicable diseases is well documented22. In the Islamic Republic of Iran, increases in coronary heart disease were indicated on account of a two-fold increase in fat consumption over 30 yr23. According to Pender24, an adult should consume an adequate quantity of fruits and vegetables (at least two servings daily). The inadequate dietary pattern prevailing among the respondents in the present study is likely to impact adversely on the future morbidity burden in the community, especially in the absence of adequate physical activities observed. The inadequate consumption of fruits and vegetables, and inadequate physical activity or exercise is known to enhance disease propensity. Physical activities are of prime importance for lowering the levels of cholesterol and blood pressure, even in a population with dietary practices similar to that of Western countries. Combinations of unhealthy behavioural risk factors are more predictive to describe the lifestyle determinants on chronic diseases and its mortality25. It has been recognized repeatedly in different countries that some of the behavioural risk factors are potentially modifiable5. Cardiovascular diseases, the leading cause of deaths in developed countries, were mainly caused by cigarette smoking, lack of physical activity, obesity, stress, hypertension, etc. 26. The higher prevalence of such risk factors observed in the present study also suggest a high potential for acquiring high morbidity burden for non communicable diseases, in the community especially CVD. With further ageing of the population, the health problem would become more and more acute, both in terms of morbidity burden as well as its burden on

increased medical cost. Ghaffar & Reddy2, stated that India is widely believed to be heading towards an epidemic of coronary heart disease. Studies have also demonstrated that intensive (and positive) lifestyle changes or promotion of healthy lifestyle has resulted in the reduction of diseases associated with high risk life style behaviours27-29. Various behavioural risk factors in midlife and late adulthood are predictors of subsequent disability on account of chronic diseases. Not only do persons with better health habits survive longer, but also in such persons, disability is postponed and compressed into fewer years at the end of life30. In conclusion, our findings indicated a high prevalence of various behavioural risk factors among the population in Kerala State though limitations of cross-sectional studies are applicable here. Public health remedial measures will therefore be urgently needed in order to minimize future morbidity burden, thereby minimizing medical expenditure. Regarding smoking and alcohol consumption, a strict public policy in restricting its use and its distribution may be considered, besides improving the awareness of its ill effects among the masses, especially the high risk groups, mainly the lower social status groups. Acknowledgment
The authors acknowledge the Indian Council of Medical Research (ICMR), New Delhi, for financial support, and thank Dr T.K. Sindu and Miss Simi Elias for supervising and monitoring field work. Authors also thank the Department of Statistics, Cochin University of Science & Technology for allowing to use the computer facilities for multivariate analysis.

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Reprint requests: Dr T.N. Sugathan, Director, Centre for Survey Research & Management Services (CSRMS) C2, Venus Castle, Palarivattom, Kochi 682 025, Kerala, India e-mail: drsugathan@vsnl.net