Cardiovascular health through a sex and gender lens in six South Asian countries: Findings from the WHO STEPS surveillance

Background Sex and gender-based differences in cardiovascular health (CVH) has been explored in the context of high-income countries. However, these relationships have not been examined in low- and middle-income countries. The main aim of this study was to examine how sex and gender-related factors are associated with cardiovascular risk factors of people in South Asian countries.Methods We conducted a retrospective analysis of the World Health Organization's "STEPwise approach to surveillance of risk factors for non-communicable disease" or "STEPS" from six South Asian countries, surveys conducted between 2014-2019. The main outcomes were CVH as measured by a composite measure of STEPS-HEART health index (smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes and hypertension), values ranging from 0 (worst) to 6 (best or ideal) and self-reported occurrence of cardiovascular disease (ie, heart attack and stroke). Multivariate linear and logistic regression models were performed. Multiple imputation with chained equations was performed.Results The final analytic sample consisted of 33106 participants (57.5% females). The mean STEPS-HEART index score in the South Asian population was 3.43 [SD: 0.92]. Female sex (beta: 0.05, 95% confidence interval (CI)=0.01-0.08, P<0.05) was significantly associated with better CVH compared to males. Being married (beta(male)=-0.30, 95% CI-0.37, -0.23 vs beta(female)=-0.23, 95% CI=-0.29, -0.17; P<0.001) and having a household size >= 5 (beta(male=)-0.15, 95% CI=-0.24, -0.06 vs beta(male)=-0.11, 95% CI= -0.16, -0.04; P<0.01) were associated with poorer CVH, more so in males. Being married was also associated with high risk of CVD (ORmale =2.54, 95% CI=1.68-3.86, P<0.001 vs ORfemale =1.19, 95% CI=0.84-1.68, P=0.31), significant in males.Conclusions Among the South Asian population, being female may be advantageous in having an ideal CVH. However, gender-related factors such as marital status and large household size were associated with poorer CVH and greater risk of CVD, regardless of sex.