Risk factors profile of coronary heart disease in Nepalese adults and efficacy of counseling

Abstract

The present hospital based study was conducted on Nepalese adults with identified coronary heart disease (CHD). The study was conducted in two phases. During Phase- I baseline survey was carried out on a total 400 samples of both males (n=251) and females (n=149) age ranging from 25-84 years at in-patient ward of Shahid Ganga Lal National Heart Center of Kathmandu. Nepal. Identification of non-modifiable and modifiable coronary risk factors with special emphasis on diet related factors) in CHD subjects was established using personally administered questionnaire cum-interview on demographic factors, biological traits, lifestyle factors, perceived stress and the dietary habits of the subjects. A 24-hour dietary recall was used to assess the nutrient intake of the in-patient diet and a semi-quantitative food frequency questionnaire was used to assess the dietary intake according to food groups. Physical examination was done to collect data on height, weight, waist and hip circumference using standardized techniques and BMI, WHR were calculated. Biochemical records for lipid and blood glucose were taken from hospital records. The subject’s status revealed that the mean age of the male was 57.4±10.2years and 58.7±10.2years of the females. Majority (67%) of them were from urban background and 33%were from rural areas.BMI ?23kg/m2 was found in 67.3%, WC>90cm was found in 33% of male subjects. 75.1% of female subject had WC >80cm. Majority (86.2%) had exceeded the cut-off point of WHR. Raised SBP?140mmHg was in 24.7% and raised DBP?90mmHg was found in 23.2 % of the CHD subjects. History of DM was in15.7%.Lipid record was obtained in total 375 subjects of the study. TC, LDL and TG exceeded in 21%, 42.6% and 44.5% respectively. Low HDL level was found in 82.4% of the total (n=375) CHD subjects. Evaluation of life style status revealed that sedentary worker (75%) and the factor related to low physical activity was found significant in 39.5% of the CHD subjects. 23% continued to smoke >5cigarettee even after the onset of disease and 27% of the CHD subjects reported of drinking alcohol daily. Low intake of fruits was found in 79.5% and low green vegetable intake was found in 51.5% of the subjects. The intake amount of visible vegetable fat was 26.6gm/person /day and salt intake was of 7.8gm/person. The nutrient intake and adequacy rate (NAR) revealed that for energy and total dietary fibre found <66%, NAR of Protein, carbohydrate and calcium was in between 66-100% but it was found >100% for fat,vit A,vit C and iron among the male CHD subjects. Among females the NAR of energy, protein, total dietary fibre, carbohydrate, vitaminB12, calcium and iron <66% and >100% was in fat and vitamin C. The energy % supplied of the nutrients from proximate principle among the in-patient sub-sample (n=44) revealed total calorie obtained from carbohydrate was 63en% in males and 62en% in females. Protein provided 12% in male and 11% in female. Energy % available from fat was 24% in males and 27% in female CHD in-patient. The hospital was not providing food to the patients in order to achieve the nutritional adequacy on nutrient intake of the CHD patients. Hospital needs to provide food services for the management of disease. Risk factors profile was assessed among the subjects and clustering of the associate risk was done. The clustering of risk factors among the subjects was ranged from 1-12 numbers It was found minimum 1-3 risk were present in few subjects and majority of CHD subjects in new and old cases had 96 risk factors. More than 9 risk factors cluster was found in 23 new cases and 20 old CHD cases. In Phase-II of the study involved KAP assessment and individual diet counseling done in Cardiac OPD enrolling another additional 42 new patients with identified CHD cases. Based on the objective of the study to measure the efficacy of diet counseling. The relevant tools were developed and administered. General information of the subjects, assessment of lifestyle practices and dietary assessment were done using the same structured questionnaires and tools as in Phase-I.KAP assessment was done before the intervention of diet counseling. The knowledge score at T0 among the CHD subjects was found in low level on several issues, but it was changed with high score of 12 out of 19 issues on T1 visit. This was four time increase in knowledge level in first post- intervention stage, but in third visit the increase in knowledge was sustained. The attitude score among the subjects revealed that out of ten components had 80% of agreement in both T1 and T2 visits. To conclude that viewing the high score of 80%, the attitude level of the subjects changed with the given counseling in two post intervention session. The result on desirable practices followed by subjects was found in T0 visit (preintervention) with 3 low scores. After two counseling sessions the behavioral and dietary practices has changed. High score at T2visit with the increase of 50% than in T1 visit can measure the change in the dietary intake and life style practices of the CHD subjects with repeated counseling. This revealed the acceptance of given advice and instruction in follow –up visits The scores on seven issues of undesirable practices were mapped. In T1 and T2100% of the score were found in issues like smoking, regular egg and fried food items consumption. This is good indication for CHD subjects to manage their disease after the given counseling with the avoidance of undesirable practices. The repeated counseling helped to increase on the knowledge level of the subjects in most issues when provided with relevant IEC materials. Though the multiple counseling has little impact to bring changes in level of knowledge, but two dietary counseling proved the positive impact on attitude and dietary practices of the CHD subjects. Initiation of diet counseling for the primary and secondary treatment process is lacking in the hospitals of Nepal where study was done. Counseling for diabetic cases is in increasing trend, but for heart patients only preliminary aspects were told on the time of discharge by staff nurse or physician, which is not sufficient for the patient and especially for the care taker .The level, content and the need must be taken in consideration to be a effective and acceptable counseling by all heart patients to bring about behavioral changes with100% compliance. The result of the study suggest that at least two counseling by dietitian and nutritionist is considered necessary and important for the secondary treatment of CHD management as stated in NCEP 2001in effective medical nutrition therapy.