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��ࡱ�>��	14����./0�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������_�	��C�bjbj,E,E	7�N/N/z
���������FFFFF����ZZZ8��fZh60�����qqq�5�5�5�5�5�5�5$�7�J:<�5QFqqqqq�5FF���"6�$�$�$q.F�F��5�$q�5�$�$��/h�0�����@�7��������!.�/�5860h60��:�$�: �0�:F�0�qq�$qqqqq�5�5�$qqqh6qqqq���������������������������������������������������������������������:qqqqqqqqq� :	@MENOPAUSE AS AN INDICATOR FOR DETERMINING CARDIOVASCULAR RISK FACTORS: A CROSS SECTIONAL STUDY AMONG GADDI TRIBE OF HIMACHAL PRADESH, INDIA
AUTHORS: SIMI KHAN, K N SARASWATHY, M.P. SACHDEVA, SUNIL K THAKUR
Authors�Affiliation: Department of Anthropology, University of Delhi
Keywords: Menopause, cardiovascular risk factors, dyslipidemia, hypertension, altitude
ABSTRACT:  Introduction: Menopause may affect certain physiological events of the female and further lead to many complex disorders. The present study attempts to understand the association between menopause and cardio vascular adversities among the Gaddi tribe. Methodology: This is a cross sectional household study on 363 ever married females of Gaddi tribe aged 25-70 years. The current study deals with the effect of menopause on cardiovascular risk factors among the altitude based tribal population. Results: The mean age at menopause is found to be 42.98 years. A higher percentage of women fall under premenopausal category (55.37%) followed by natural menopause (36.36%) and hysterectomy (8.2%). Almost all the lipid parameters showed significantly increased levels in postmenopausal women. Women with natural menopause were observed to have a 1-fold risk of succumbing to central obesity (WC and WHR) and hypertension. Women with hysterectomy were at a 1 fold significant risk for hyperglycemia. Post-menopausal women (both with natural menopause and hysterectomy) were at 1 fold significant risk for succumbing to metabolic syndrome. Conclusion: It can be assumed though not confirmed, that higher altitude Gaddi women are prone to an early age risk for cardio vascular adversities owing to their menopausal age which is indicative of development of certain screening strategies for the post-menopausal women for their early protection.
INTRODUCTION
Menopause marks the cessation of menstruation and is hence considered as an important transition period. [1] There are three phases of menopause, Pre-menopause, Peri-menopause and post menopause. Menopause may affect certain physiological events of the female by either accelerating or deaccelerating the functioning of different organs via decreased estrogen levels. [2] This may further lead to the incidence of varied diseases, hypertension, osteoporosis, heart disease, diabetes, breast cancer and autoimmune disease. [3, 4, 5, 6] 
With the increase in the life expectancy attributed to various social and physical factors, the females are found to spend most of their life in postmenopausal state. Cardiovascular adversities are reportedly the reason for much of the morbidity in this stage. Infact, surgical and natural menopause both are considered to be independent risk factors for the cardiovascular adversities. Many studies have shown an increased risk of CVDs after menopause. The Framingham study has substantiated that a 4 fold increased risk has been observed in CVD in 10 years after a natural menopause. Surgically induced menopause has also lead to an increased risk for CVD. [8]. A significant change has been observed in the lipoprotein levels of postmenopausal females attributable to the estrogen deficiency. Although estrogen deficiency also has a direct effect on the cardiovascular risk through central obesity, insulin sensitivity, arterial wall and fibrinolysis [9, 10]
Studies have been conducted on the age at menopause of various ethnic groups, including Gaddis, of India residing on a higher altitude and also otherwise. The present study attempts to understand the association between menopause and cardio vascular risk factors or adversities like abnormal BMI, obesity, dyslipedimia, metabolic syndrome and hypertension among the Gaddis of Himachal Pradesh.

METHODOLOGY
2.1 Subjects 
This is a cross sectional household based study conducted on ever married females of Gaddi tribe which is an endogamous group, from year 2011-2013. A total of 363 women aged 25-70 years were selected. The women were enrolled from two districts of Himachal Pradesh, North India viz. Chamba and Kangra.  (The altitude of the study area was 900m-3000m considered as higher altitude).[7] The study was approved by Institutional review board of Department of Anthropology, University of Delhi. Written informed consents were obtained prior to the participation in the study.
2.2 Collection of Data
Retrospective data of reproductive history and prospective data of tobacco use, marital status and family planning measures were obtained through structured interview schedule. The perimenopausal women were excluded from the study. Anthropometric data such as height, weight, waist circumference were collected from all the subjects. Blood pressure was taken twice in right arm in sitting position using standard sphygmomanometer and stethoscope from each subject, with a time gap of a minimum 10-15 minutes of first reading and second reading was used for the analysis to avoid false reading due to increased palpitations
Overnight fasting 5 ml intravenous blood sample was collected from the participants to perform the lipid profiling. The serum lipids and fasting glucose were tested for at the Red Cross lab, Chamba and Nurpur lab, Kangra, Himachal Pradesh.
MetS and its components were identified by NCEP ATPIII criteria [11]. 
Among the non-traditional risk factors, non-High Density Lipoprotein cholesterol (non-HDL-C) was calculated by subtracting HDL-C from total cholesterol [12] and Hypertriglycerademic waist (HTGW) was derived as per the National Health and Nutrition Survey. [13].
2.3 Statistical analysis
The mean�SD and frequency of variables analyzed with descriptive statistics. Binary logistic regression was used to calculate the odds ratio and confidence interval. All these analysis were done using SPSS version 16.0.

RESULTS
The mean age at menopause of the presently studied population is found to be 42.98 years. Of the total of 363 females recruited for the study, a higher percentage of women fall under premenopausal category (55.37%) followed by those having natural menopause (36.36%) and hysterectomy (8.2%). the postmenopausal women had a higher percentage of literacy and smoking. The age at enrolment differed significantly among the three groups viz. premenopausal and postmenopausal (natural menopause and hysterectomy). (Table 1)
Table 1: Baseline characteristics of the study population
Premenopausal (1)Natural Menopause(2)Hysterectomy(3)p1(1 vs.2) �p2(1 vs.3) �Number (%)201 (55.37%)132 (36.36%)30 (8.2%)Age at enrolment(in years)33.73 �4.79350.93� 7.32749.97� 9.2490.000.00Illiterate N (%)75 (41.4%)93 (82.3%)23 (76.7%)0.000.52Agriculturalists & other work N (%)34 (20.4%)13 (12%)3 (10.7%)0.120.11Smokers N (%)8 (4.3%)7 (5.8%)1 (3.6%)0.540.20
When checked for the mean levels of the cardiovascular factors of the population, the premenopausal and postmenopausal women did not differ with respect to generalized obesity (BMI), but differed significantly with respect to abdominal obesity with postmenopausal women having increased waist circumference. The highest waist circumference was of the women who had surgical menopause. Both systolic and diastolic blood pressure was significantly increased in postmenopausal women than premenopausal women who were further narrowed down to higher blood pressure in women with hysterectomy than those having a natural menopause. A significantly higher level of fasting blood glucose was observed in natural menopausal women as compared to premenopausal women. 

The lipoprotein levels among the postmenopausal women, especially those having natural menopause had significantly higher levels of total cholesterol than premenopausal woman.  While the low HDL levels was significantly increased in premenopausal women, the other lipid parameters viz. LDL, VLDL and non HDL showed significantly increased levels in postmenopausal women. (Table 2)

Table2. Distribution of mean levels of traditional and non-traditional risk factors among premenopausal and postmenopausal (natural and hysterectomy) women
Premenopausal
(1)Natural menopause
(2)Hysterectomy (3)p 1 �
(1 vs. 2) p 2 �
(1 vs. 3)a. Generalized             Obesity (BMI) (kg/m2)21.17  �3.6521.60 � 4.2721.88 � 3.960.310.366b. Abdominal Obesity
(Waist Circumference)(cm)70.71 � 15.5475.77 � 16.3678.51 � 13.2720.000.00Waist Hip Ratio (WHR)0.73+0.270.766+0.2820.727+0.2540.200.05c. Blood PressureSystolic Blood Pressure(mm/Hg)120.97 � 9.479128.76 � 14.83125.67 � 12.0120.000.01Diastolic Blood Pressure(mm/Hg)80.41 � 7.13584.87 � 9.48283.20 � 9.5060.000.00   d. DyslipidemiaFasting Blood Glucose(mg/dl)83.96 � 14.2493.15  �22.9781.33 � 12.2370.000.00Cholesterol(mg/dl)165.38 � 21.340182.42 � 30.188180.60 � 25.0840.000.24Triglyceride(mg/dl)126.11 � 28.591141.85 � 36.971135.97 � 46.0340.000.01High Density Lipoprotein (HDL)(mg/dl)48.51 � 6.35148.17 � 4.94148.30 � 7.8550.000.00Low Density Lipoprotein (LDL)(mg/dl)92.22 � 19.87105.23 � 27.314105.21 � 21.6940.000.10Very Low Density Lipoprotein (VLDL)(mg/dl)25.22 � 5.71728.40 � 7.39327.20 � 9.2080.000.01e. Nontraditional risk factorsNon HDL-C(mg/dl)116.97 � 21.329134.98 � 30.017132.30  �24.3250.000.27
Women with abnormal waist circumference, abnormal waist hip ratio, hypertension, and abnormal cholesterol, TG, non HDL C and LDL are significantly higher in postmenopausal women, specifically in those with natural menopause as compared to premenopausal women. Prehypertensive women are significantly increased in premenopausal women. Further, women with metabolic syndrome and HTGW are significantly higher in women with natural menopause. (Table 3)

Table3. Distribution of traditional and non-traditional risk factors among premenopausal and postmenopausal (natural and hysterectomy) women

Premenopausal
(1)Natural menopause
(2)Hysterectomy (3)p 1 �
(1 vs. 2) p 2 �
(1 vs. 3)a. BMIUnderweight(<18.5 kg/m2)102 (49.3%)68 (45%)13 (43.3 %)0.520.42Overweight (23-24.9 kg/m2)28 (13.5%)28 (18.5%)6 (20%)0.220.21Obese (e"25 kg/m2)34 (16.4%)28 (18.5%)6 (20%)0.220.12b. Abdominal ObesityWaist Circumference(e"80 cm)66 (31.9%)67 (44.4%)15 (50%)0.010.23Waist Hip Ratio(<0.8)128 (61.4%)110(72.8%)25 (83.3%)0.020.00c. Blood PressureHypertensive(e"140/90mm/Hg)24 (11.6%)50 (33.3%)9 (30%)0.000.00d. Blood Glucose and DyslipidemiaHyperglycemia(>110 mg/dl)16 (7.9%)15 (10.8%)1 (3.3%)0.020.03Cholesterol(>200mg/dl)19 (9.4%)42 (30.2%)8 (26.7%)0.000.91Triglyceride(150mg/dl)38 (18.7%)55 (39.6%)9 (30%)0.000.20High Density Lipoprotein (HDL) (<45mg/dl)101 (44.5%)70 (50.4%)18 (60%)0.910.48Low Density Lipoprotein (LDL) (>130mg/dl)6 (3%)24 (17.3%)3 (10%)0.000.27Very Low Density        Lipoprotein                          (VLDL) (>30mg/dl)4 (2%)4 (2.9%)3 (10%)0.190.18e. Nontraditional risk factorsPre hypertensive(120-139/80-89mm/Hg)122 (58.9%)79 (52.7%)14 (46.7%)0.020.08Non HDL-C(e"130mg/dl)49 (24.3%)67 (50%)16 (53.3%)0.000.53Metabolic Syndrome23 (13.1%)43 (38.4%)12 (41.4%)0.000.81Hypertriglyceridemia Waist(TGe"2mmol/L;WC>80cm)3 (1.5%) `9 (6.7%)3 (10%)0.010.88
Among women in both the categories of postmenopausal women, a 1-fold risk for increased waist hip ratio and central obesity was observed in both adjusted and unadjusted odds ratio, though the risk was relatively increased in the women who had hysterectomy. A similar risk is observed for dyslipidemia in postmenopausal women. An increased risk for hyperglycemia, though not significant, was also seen among women with hysterectomy as compared to the women with natural menopause. A significant 1-fold risk for hypertension was seen in women with natural menopause adjusted for present age. Among the non-traditional risk factors, naturally menopausing women had significant risk of raised non HDL-C. No risk was seen for hypertriglyceridemic waist among women with natural menopause or hysterectomy. But both of these women (adjusted for age/ unadjusted), were subjected to risk for metabolic syndrome. (Table 4)

Table4. Crude and Age adjusted odds ratio for traditional and non-traditional risk factors.
Natural  Menopause(1)Hysterectomy (2)Premenopausal women(3)P1 �
(1 vs. 3)P2 �
(2 vs.  3)Traditional Risk Factors
Waist Hip RatioUnadjusted1.656 (1.050-2.611)3.086 (1.135-8.391)0.0300.027Age adjusted1.036 (0.996-1.077)1.057 (1.003-1.115)0.0790.039Waist CircumferenceUnadjusted1.704 (1.104-2.630)2.136(0.986- 4.268)0.0160.054Age adjusted1.055 (1.017-1.095)1.083 (1.028-1.141)0.0040.003HyperglycemiaUnadjusted1.414 (0.674-2.963)1.606 (0.000)0.3590.997Age adjusted0.347(0.092-1.312)1.789(0.000)0.1190.997HypercholesterolemiaUnadjusted4.193(2.313- 7.603)3.522(1.380-8.987)0.0000.008Age adjusted1.069 (1.022-1.118)1.084 (1.010-1.163)0.0030.025HypertriglyceridemiaUnadjusted2.843 (1.742-4.640)1.861 (0.790-4.384)0.0000.155Age adjusted2.277 (0.999-5.189)1.027 (0.971-1.087)0.0500.349High LDLUnadjusted6.852 (2.721-17.258)3.648 (0.862-15.445)0.0000.079Age adjusted1.063 (1.007-1.123)1.184 (1.044-1.343)0.0260.009High VLDLUnadjusted1.474(0.362-5.996)5.528 (1.173-26.043)0.5880.031Age adjusted1.635 (0.151-17.745)8.715 (0.866-87.674)0.9160.066HypertensionUnadjusted6.052 (3.021-12.124)3.268 (1.093-9.767)0.0000.034Age adjusted1.088 (1.021-1.158)1.048 (0.965-1.141)0.0090.266Nontraditional risk factors
Pre-hypertensionUnadjusted1.881 (1.063-3.329)0.995 (0.945-1.047)00.0300.995Age adjusted1.853(0.706-4.864)1.00(0.384-2.606)0.9701.000Non HDL-CUnadjusted3.122 (1.957-4.981)3.569(1.626-7.832)0.0000.002Age adjusted1.052 (1.011-1.095)1.018 (0.967-1.072)0.0120.489Metabolic SyndromeUnadjusted4.146 (2.230-7.409)4.696(1.989- 11.088)0.0000.00Age adjusted1.092 (1.040-1.146)1.085 (1.015-1.610)0.0000.017HTGWUnadjusted4.776(1.269-17.980)7.7370(1.414-38.378)0.0210.018Age adjusted5.064 (0.703-36.491)1.016 (0.907-1.139)0.1070.780


DISCUSSION
Within the menopausal women, almost one fifth have attained menopause through hysterectomy which seems to be quite high in Indian context. The occurrence of hysterectomy is found to be high in the present population when compared with other north Indian populations where it is reported to be as low as 4.2% [14] and 6% [15, 16]. The most common cause to attain hysterectomy in the population is found to be ovarian cyst. The mean age at menopause for both groups, ones who had natural menopause and others who had hysterectomy, are similar and this could be possibly because almost 63% women attain menopause naturally at the age of less than 45 years and also 70% of the women undergoes hysterectomy at the age less than 45 years.
As the women who have attained menopause either naturally or through hysterectomy is found to be significantly older than premenopausal women. This is contrast to some reported studies where hysterectomy is usually done in relatively younger age groups. ([17] The older females are expected to be illiterate who is substantiated in the present study.
Though the present population is not susceptible to general obesity (abnormal BMI) but increased abdominal obesity (WC and WHR), both with respect to mean levels and incidence, is increased among the post menopausal women. This increase is more aggravated in women who have had hysterectomy. These concords with few previous studies [18, 19] which have also reported an increase in abdominal obesity with respect to waist circumference. This is attributable to the fact that decreasing estrogen in post-menopausal state leads to a transition in the distribution of fat to the abdominal region and hence causing an increase in the same. [20]. Further an increased systolic and diastolic blood pressure is observed in the postmenopausal women both natural and hysterectomy which is further substantiated by significant risk of hypertension in the same. This increase is in concordance of the other studies, [21, and 22].  This is also supported by the fact that Asian Pacific populations are moving towards the progression of cardiovascular adversities, diabetes, hyperetension at not too high BMI than the other ethnic populations owing to their tendency of having higher central adiposity and no general obesity [23]
Dyslipidemia is found to increase with menopause, whether it is natural or hysterectomy. Females undergoing surgical menopause under the age of 45 years have been observed to be at increased risk of mortality from cardio vascular diseases. [24]. This clearly confirms the substantial role of menopause in the lipid metabolism imbalance. The progressive rise of CVD risk factors might be due to the ovarian failure, or due to the metabolic consequences of central adiposity accompanied by estrogen deficiency. [19] All the parameters (TC, TG, HDL, VLDL, LDL) are found to increase significantly with menopause. This is in line with other studies conducted, [25, 26, 27, and 28]. Both the post-menopausal states (natural and hysterectomy), are found to exert similar influence on the lipid parameters. Thus it can be said, though not concluded that, the present population is influenced merely by the transitioning to the menopausal status and not by how they have attained the same. This is further supported by a study which has shown that low estrogen in the circulating form, leads to a reduced activity of apolipoprotein A and hepatic lipase.  The menopause also reduces the activity of LDL receptors, [29, and 30]. In the present study, a relatively stable mean levels of HDL C is observed with menopause, though the prevalence of the low HDL C is found to increase with menopause. Also many studies have depicted that with menopause sometimes HDL cholesterol fall slightly [3, 31, 32], or they remain unchanged [10] But few studies have also shown an increasing HDL C levels with menopause [33, 34, 19] 
An increased insulin resistance is observed in post menopausal women as compared to premenopausal women [35]. However there are studies which have shown reduced insulin resistance with menopause. [36, 37]. The present study has also shown significantly increased mean levels of fasting blood glucose with an increase in hyperglycemic individuals in women post menopause (natural menopause). Further, pathophysiology of metabolic syndrome is linked to hyperglycemia [38, 39, 40, 41]. In this study it can be henceforth said that insulin resistance is related to cause the occurrence of metabolic syndrome as also confirmed by 19.
Among the non-traditional risk factors, all the parameters are depicting an increased distribution in the post menopausal women specifically those having natural menopause. Further an increased risk is also observed in the women with natural menopause for all the non-traditional risk factors in the unadjusted model. This is in concordance with other studies like [42, 43, and 44]. But when adjusted for age, only pre hypertension and HTGW was not affected by the menopausal status, i.e. no significant risk was observed. The increased risk of metabolic syndrome is attributed to the fact that though, the estrogen levels are reduced but there is progressive increase in the androgen hormone which then increases Metabolic syndrome [45]
However a higher CVD risk is observed in the present population via the abnormal lipids and abnormal anthropometry, it is still not clear if higher risk in postmenopausal women is owing to estrogen decline, ageing or a combination of transitioning to menopausal state with the higher altitude environment. Altitude has a significant effect on cardiac volume, pulmonary pressure and blood viscosity [46, 47]. Further, high altitude is also reported to increase hypertension [48]. There might be many compensatory mechanisms which have been evolved to enable these populations to live in such harsh environments, where there is restricted physical activity, difficult breathing etc. but due to the changing lifestyle, food habits and educational status, they are now subject to development of cardio vascular adversities.
Thus it can be assumed though not confirmed that higher altitude Gaddi women are prone to an early age risk for cardio vascular adversities owing to their menopausal age which is indicative of development of certain screening strategies for the post menopausal women for protecting them from such complex disorders. 
Acknowledgements: The authors would like to pay their sincere thanks to Prof. PK Ghosh and Prof. VR Rao (Dept. of Anthropology, University of Delhi) for their technical inputs and DU-DST Purse grant for the financial support to carry out the research.
The authors have no conflict of interest.	
Author�s contributions: All authors have read and approved the manuscript. KNS made significant contribution to the conceptualization of the study. MPS was involved in the design of the study. SK and ST were involved in data collection. SK was involved in analysis and interpretation of the data along with drafting of the manuscript and revising it critically.

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46 Pe�aloza, Dante, et al. "Pulmonary hypertension in healthy men born and living at high altitudes."�The American Journal of Cardiology, 1963: 11.2 ,150-157.
47 Frisancho, A. Roberto.�Human adaptation and accommodation. 1993, University of Michigan Press.
48 Sun, S.Epidemiology of hypertension on the Tibetan Plateau.Human biology, 1986, 507-515.











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