Original Article

Risk factors of type II diabetes among bankers of Kathmandu Metropolitan city: A cross-sectional study

Introduction

Diabetes mellitus, a chronic metabolic condition, and a major public health issue, is the leading cause of mortality and morbidity worldwide.^1,2 Global estimates show the 9.3% prevalence of diabetes in 2019 (463 million) which will be raised to 10.2% (578 million) and 10.9% (700 million) by 2030 and 2045, respectively.³ Moreover, a systematic review states 8.5% prevalence of diabetes in Nepal.⁴ Diabetes is characterized by elevated blood glucose levels resulting from either lacking of the insulin production or insulin resistance.⁵ The most common form of diabetes is type 2 diabetes (T2DM).

Because of rapid mechanization in the agricultural and industrial sectors, most of the physical works have been shifted to less effort-required work. According to the Sedentary Behavior Research Network, the proportion of physical inactivity is increasing among the working population because of their job entity of table work.⁶ Several studies have shown an association between sedentary lifestyle and the development of obesity, cardiovascular diseases, and T2DM.^7-9 In this regard, the working nature of bank employees is both sedentary and involves high levels of stress,¹⁰ increasing the chance of T2DM, and subsequently decreasing the quality of life.¹¹ This group of people spend almost all their working hours sitting in the same place with a high-level of mental stress. The study conducted among bankers of Zambia showed a 15% prevalence of T2DM higher than the government employees in India.¹⁰ Different studies also conducted among bankers and similar sectors of physically less demanding office jobs found overweight, age (45 and older), lack of physical activity, having a family member with T2DM, and stress as major prevalent risk factors for T2DM.^10,12-14 However most of the studies indicating the risk factor of T2DM among bankers have been conducted in developed countries. In this regard, the primary objective of this study is to identify risk factors of T2DM among bank employees of selected banks in Kathmandu metropolitan city, Nepal, one of the least developed countries. Having knowledge of T2DM risk factors among bank employees helps with primary prevention, improving health outcomes and quality of life, as well as reducing the economic burden. Early identification of risk factors helps to increase healthcare-seeking behavior¹⁵ among the employees, which in turn, increases the efficiency within the working station.

Methods

A cross-sectional study was conducted among 348 bank employees from selected banks of Kathmandu Metropolitan City, Nepal. Out of a total of 27 class ‘A’ commercial banks, 3 banks were selected randomly. The number of respondents from each bank was determined using a population proportionate sampling technique and each respondent was selected using a systematic sampling method. All the administrative employees of age group 20-69 were included in the study while pregnant women were excluded from this study.

The research proposal was approved by the Institutional Review Committee (IRC) of the Manmohan Memorial Institute of Health Sciences, Nepal. Written informed consent was taken from each participant and permission for data collection was also taken from each bank. The data was collected from October to December 2020 using a self-administered structured questionnaire which was based on the WHO STEP Instrument¹⁶ and Perceived Stress Scale.¹⁷ Pre-testing of the questionnaire was performed at SBI Bank of Lalitpur Metropolitan City. Also, the questionnaire was prepared in English and translated into Nepali and back-translated to English to ensure linguistic validity by different researchers. Six known risk factors of T2DM (smoking, alcohol consumption, physical activity, dietary habit, family history of diabetes, and stress) along with the socio-demographic characteristics of the respondents were assessed in the study. This study was conducted during a semi-lockdown situation due to the COVID-19 pandemic. In hence, to maintain social distancing and to decrease the risk of COVID-19, BMI could not be assessed, although many studies found it as one of the major risk factors of T2DM. Data was entered, analyzed, and interpreted according to the objective of the study using SPSS version 22.0 software. The results obtained were expressed as mean, frequency, and percentages. Cross tabulation, chi-square test, and binary logistic regression analysis were also utilized to determine the association at 95% level of confidence.

Results

The socio-demographic characteristics of the respondents are shown in Table 1. The mean age of respondents was 34.8 ± 8.951. Out of 348 individuals, 55% were male and 46.8% of the respondents had a post-graduate degree. In addition, 64.1% of them were married and the majority belonged to the Brahmin/Chhetri community (66.7%). 55.7% lived in the nuclear family and almost all of the respondents were above the poverty line (94.5%).

The behavioral characteristics of the respondentshave been shown inTable 2. About 11.8% of all respondents were tobacco users in the form of smoking with the average age of 22.95 years old. Among the total of 348 respondents, 99.4% ate less than five portions of fruit and vegetables a day with 19% of the respondents adding salt to their food.

The association between the demographic variables and the behavioral risk factors is shown in Table 3. Age was found to be associated with tobacco consumption (P < 0.001) and alcohol consumption (P < 0.001). There was no association between tobacco consumption and marital status (P = 0.162), ethnicity (P = 0.628), type of family (P = 0.06), and socio-economic status (P = 0.365). Similarly, a significant association was also found between consumption of alcohol and other socio-demographic variables such as gender (P < 0.001), level of education (P = 0.008), and marital status (P = 0.022). Also, there was no significant association between alcohol consumption and ethnicity, type of family, and socio-economic status. Of note, family history (P = 0.042) was found to be associated with socio-economic status, too. No association was observed between stress and socio-demographic variables (P > 0.05).

Also, Table 4 indicates the binary logistic analysis of socio-demographic with behavioral factors. All the variables with P value < 0.2 were considered for the binary logistic regression analysis. The table shows that ages more than 40 years (OR = 3.834, 95% CI = 1.962-7.494) was highly associated with smoking whereas people living in the joint and extended family (OR = 0.365, 95% CI = 0.173-0.771) was found to be less likely to involved in smoking. The study shows people above the age of 40 years (OR = 2.912, 95% CI = 1.715-4.944), being male (OR = 8.086, 95% CI = 4.102-15.941), post-graduate degree (OR = 3.080, 95% CI = 1.456-6.516), and being married (OR = 2.33, 95% CI = 1.257-4.342), increase the chance of alcohol consumption. Bank employees with a college degree (OR = 2.206, 95% CI = 1.039-4.686) and post-graduate degrees (OR = 2.276, 95% CI = 1.083-4.787) had a higher chance of involving in physical activity in comparison to those with only high school education Results of additional analyses are available at supplementary file.

Figure 1 represents the prevalence of risk factors of T2DM among bankers of Kathmandu Metropolitan City. Almost all the participants were having at least one risk factor for T2DM. Among the total of 348 respondents, 37.4% of them were having four risk factors whereas only 2% had one risk factor.

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Figure 1.

Prevalence of risk factors of Type-II Diabetes

Figure 1.

Prevalence of risk factors of Type-II Diabetes

Discussion

To the best of our knowledge, this is the first study conducted in Nepal to assess the prevalence of risk factors among bank employees. In this study, all of the respondents had at least one risk factor of T2DM. The most common risk factor present was the improper dietary habits like less fruit, and more processed food intake. According to the 2019 STEP Survey of Nepal, 96.7% of Nepalese individuals did not meet the WHO standard, for fruit and vegetable consumption.¹⁶ This might be due to inappropriate food culture among the Nepalese people in addition to the lack of availability and accessibility of fruits and vegetables. As this study was conducted during the semi-lockdown condition, the availability and accessibility might have been affected more.

This study revealed 11.8% prevalence of smoking among bank employees, which is similar to the result of the study conducted in India,¹⁸ but the national rate of prevalence (17.1%) is higher than this study.¹⁶ Results showed a significant association between smoking and increasing age (more than 40 years). Similar result was also demonstrated by the study conducted among bank employees of Zambia,¹⁰ India,¹² and other global data.^19,20 It might be because of the increasing dependency on smoking among people who have initiated it at an early age. Sometimes people might take smoking as a coping strategy for stress, which generally enhances with increasing age. An association between educational level and marital status with smoking was not found. This study found significant association between family type (joint and extended family) and smoking. Those employees who were residing in joint and extended family were less likely to be involved in smoking, which is a well-established risk factor for T2DM,²¹ although a study conducted in Nepal could not find an association between family type and risk of T2DM.²² This indicates that who reside in nuclear families are more vulnerable to smoking. This might be due to the limited number of family members who could give enough time to each other, therefore, people might take smoking as a socializing agent among friends.

The current study found that 24.1% of bank employees were consuming alcohol. Increasingly age (more than 40 years) was significantly associated with alcohol consumption. Alcohol is easily available and acceptable for increasing age people in comparison to young age people. Increasing age accompanied with alcohol consumption increases the chance of developing T2DM,¹² while another study unlike could not establish the association between alcohol consumption and T2DM.¹⁰ Consumption of alcohol was highly associated with females. However, the result showed an inverse relation. Being female decreases the chance of consuming alcohol and increases among males, which increases the chance of developing T2DM. Although the result of this study is supported by other studies,^10,23 one study showed the relationship of being female with increased alcohol consumption and risk of T2DM.^24,25 Being male and consuming alcohol has been accepted as normal in Nepalese society, which might influence males to consume alcohol. A similar result was also found in the case of educational level. Increasing educational status (undergraduate and post-graduate) reduces the chance of involving in the consumption of alcohol. This might be as educational level increases, people become more aware about the harmful effects of alcohol as it increases access to information. The relation between educational status and alcohol consumption²⁶ is well-established, increasing the risk of T2DM.²² In comparison to unmarried, married employees had a double chance of involving in alcohol consumption. The relation between marital status and the risk of T2DM is also well-explained by many studies,^20,27 but unlike, the results of a study conducted in Australia revealed an association between unmarried and alcohol consumption.²⁸ It can be explained that married people are mostly involved in social functions, rituals, and family functions, where they might get involved in alcohol consumption.

This study found that those employees with higher educational status had a higher chance of involving in physical activity. Higher educational levels might have influenced the level of awareness regarding the importance of physical activity. Therefore, a higher level of physical activity, can reduce the risk of T2DM development.¹⁰ It has also shown an increasing risk among bank employees with higher education levels.²⁹ An association between lower socio-economic status and physical activity was also found by this study. Those with lower economic status were less likely to be involved in physical activity than those with higher economic status. Physically less active people are at the risk of developing T2DM. A study conducted in India supports this result.¹² Family history of diabetes was also found to be significantly associated with lower socio-economic status. In addition, 15% of the employees having had a history of diabetes in both parents. This finding is in line with another study conducted among bank employees.¹²

Similarly, an association between post-graduate education and stress status was also found. With an increasing educational level, the stress level also increases among the employees of the bank, which is directly linked with T2DM.^30,31 This is in contrast to the result from another study showing the relation between lower educational level and high stress.³² Higher educational level is usually associated with higher responsibilities within the workstation and other additional responsibilities in the home and society. Therefore, this might have increased the stress level among the bank employees.

Conclusion

The findings of this study reveal that the majority of bank employees of Kathmandu Metropolitan City are living with the risk factors of T2DM. At least one risk factor was observed among all of the employees. The highest prevalence was the improper dietary habit followed by moderate to high levels of perceived stress and lack of sufficient physical activity. Risk factors like age, gender, level of education, marital status, socio-economic status, and family type were associated with the incidence of T2DM. Also, the study showed the urgent need to bring the attention of the concerned authorities to promote a healthy lifestyle, create a stress-free work environment, and awareness about the risk of T2DM among bankers, coming up with public health strategies for its prevention.

Acknowledgments

We would like to express our acknowledgment to all the participants of the study. Special thank goes to all the bank managers who allowed us to conduct this study.

Competing Interests

The authors declare that they have no competing interests.

Ethical Approval

The Institutional Review Committee, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal reviewed and approved the study (registration number, MMIHS-IRC 468). Written informed consent was obtained from all the participants before the collection of data.

Supplementary Files

References

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