Overall Findings
This study identified significant factors affecting the risk of cardio-metabolic diseases in patients with TB. More than two out of five patients had at least one cardio-metabolic risk factor and males were more at risk than females including the behaviors related to consumption of tobacco, and alcohol. Nevertheless, the proportion of developing hypertension and obesity was higher in females compared to males. Sex, geographic location and patients’ education level were significantly associated with the risk of cardio-metabolic diseases.
Males and cardio-metabolic risk
The preponderance of males in bearing cardio-metabolic risk factors highlights their higher proportion of developing TB and thus cardio-metabolic risk factors. The predominance of males in developing TB echoes with the global and national reports [5, 6] which may partially explain the risk of cardio-metabolic diseases among these patients. Nonetheless, the socio-cultural role of males in Nepalese society where their increased exposure to work and occupation, food and life-style related behavior compared to females who may not have similar exposure, further explains the higher risk of cardio-metabolic risk factors [31]. One associated factor within this study that sheds light on male’s increased risk of cardio-metabolic diseases is the higher consumption of tobacco and alcohol more than females [31, 32]. Socio-culturally in Nepal, males are at the forefront of earning money and managing the household expenditure. Availability of cash money, together with the cultural benefits due to patriarchy in Nepalese society can further explain the increased leeway for males that conduces the affordability for consumption of alcohol and tobacco [32]. These high-risk behaviors are further predicated on other factors such as level of education, occupation and the individual motivation towards healthy life style. The significantly higher odds of having at least one risk to cardio-metabolic diseases in male patients with tuberculosis further support our argument.
Females, obesity and hypertension
The proportion of female patients with TB in this study who had higher risk of developing hypertension and diabetes resonates with the nationally representative survey where females were found to be the vulnerable population in developing cardio-metabolic diseases [33], and can be explained by the socio-cultural entanglements of female’s role in Nepalese society. Similar to other South Asian nations, females are often housebound, particularly those who are unemployed or are in poor-socio-economic status, and are found to have higher rates of obesity and cardio-metabolic risks than male counterparts [34-36]. Females are culturally repressed in their outdoor activities often because of threats of sexual harassments and violence. Such cultural restrictions are further aggravated by lack of urban green spaces, parks and exercise places conducive for physical exercise in South Asia [37]. Embedded in the patriarchal culture of Nepal [38], females are not only burdened by household chores such as cooking, they are also vulnerable to delayed and irregular eating. Delayed and irregular eating generally stems from cultural and traditional niceties of serving the male members of the family first. In addition, wasting of cooked food in traditional Nepali family (usually devoid of refrigerator) is considered ‘ominous’ which can add pressure to the female members to finish the remaining portion of food. The latter can aggravate irregular and over eating. Women in Nepal are also vulnerable to fasting based on religious and cultural practices. The ramifications of delayed, irregular (over and under) eating and fasting are established to increase the risk of developing obesity, diabetes and hypertension [39]. These socio-culturally shaped behaviors contribute to higher prevalence of cardio-metabolic risks in females in Nepal. Though female had significantly lower odds of having at least one cardio-metabolic risk factor in this study as compared to males, the greater risk of hypertension and overweight/obesity cannot be neglected.
Socio-demographic factors and cardio-metabolic risk
Other socio-demographic factors that affect higher risk to cardio-metabolic diseases are equally important. Although the population from Gandaki province had lower risk of developing cardio-metabolic risk, causal explanations are hard to draw from the geographic location alone. Nevertheless, this may have been due to the socio-demographic characteristics of the population in Gandaki province, such as higher education level, relatively higher affluence, organized urban planning with adequate space for exercise, increased awareness in regards to food and behavior and other socio-ecological factors.
In this study, literate patients with TB showed reduced risk of cardio-metabolic diseases and echoes with previous studies from Nepal [36]. Our findings are also consistent with South African study where the risk of cardio-metabolic disorders were higher among men, and was lower in those with higher education and socio-economic status [40]. The fact that higher education in general might have led to increased awareness regarding the NCDs such as diabetes and hypertension and thus the personal modification in food and life style related behavior could be one of the mechanisms to explain the finding.
Limitations and further area of research
This cross-sectional study relied on questionnaire-based survey at 12 DOTS center across Nepal and the results are largely representative for eight districts in Nepal. Nevertheless, by virtue of the study being cross-sectional and dependent on quantitative assessment, causal explanations of the association for cardio-metabolic risks among TB patients could not be adequately explained. In future, qualitative studies using in-depth interviews and focus group discussions with the patients with TB can yield a rich set of data to explain the associated factors with cardio-metabolic diseases in this study. Also, further studies can build to explore how the current DOTS centers can increasingly collaborate in management of co-morbid cardio-metabolic conditions with evidence suggesting that risk factors of death among patients with TB die are non-infectious co-morbidities as well as alcohol and substance abuse [41]. As TB and HIV prevalence continue to decline in Nepal, operational and health system research may provide useful insights on how to integrate a major infectious disease, TB with rising trend of NCDs.