Summary
Ageing is an inevitable natural process usually related to declining health conditions. There are no universal criteria for healthy ageing but can be broadly regarded as the maintenance of robust physical, mental, and social health, leading to overall well-being [1]. The demographic and epidemiological transition in low-and-middle-income countries (LMICs) has led to a rise in the co-existence of two or more long-term conditions known as multimorbidity [2]. Estimates suggest that adults aged 45 or more will constitute over 40 percent of the Indian population by 2050 [3]. Recently, Puri et al. [4] reported the results of a descriptive study aimed at determining the magnitude and correlates of early onset of multimorbidity and explore its linkages with selected indicators of health-related quality of life (HRQoL) among mid-aged women from India. The authors used for the analysis data of a total of 23,951 women aged 45-65 from the first round of the Longitudinal Ageing Study in India (LASI, 2017-2019). Ordered logistic regression was conducted and proportional odds reported to identify the correlates of multimorbidity. Multimorbidity was reported in 29.8% of the mid-aged cohort. Punjab state and Chandigarh, its capital, reported the highest prevalence of multimorbidity (52.8 per 100 women and 54.8 per 100 women, respectively). Women with multimorbidity reported compromised HRQoL indicators such as self-rated health, work-limiting health conditions, mobility, and daily living activities. The authors conclude that multimorbidity is increasingly prevalent in mid-aged women and associated with impaired quality of life. Recommendation is that reproductive health programs should be carried out for women, focusing on mid-life multimorbidity and overall well-being.
Commentary
During the female menopausal transition there are a series of physiological changes (i.e aging per se and estrogen decrease) that occur which lead to various conditions such as vasomotor symptoms, obesity, osteoporosis, depression, and urinary incontinence. All these conditions place them at a higher risk of having multimorbidity which in turn is usually related to poorer quality of mid-life, leading to deteriorated work productivity and associated economic loss. Life expectancy in India has increased from 42 years in 1960 to 69 years in 2017 mainly due to advances in the quality of healthcare. Despite this, inequality in life expectancy across gender makes women outlive men. In this sense, due to socio-economic and cultural barriers, women from LMICs, such as India, fall under the vulnerable and disadvantaged section of society; hindering their comprehensive development. Therefore, an increase in life expectancy does not necessarily guarantee a healthy life. As mentioned above, poorer quality of life during midlife can impair work productivity and will be associated to economic loss. The present commented study was conducted to provide healthcare professionals and policymakers with evidence on multimorbidity among mid-aged women, basically based on the nationally representative data from the LASI in India. Mean age of surveyed women was 54.4 years, around 70% lived in rural areas. Nearly sixty-two percent received no education and 61.3 percent were unemployed. Top five non-communicable diseases (NCDs) where hypertension, gastrointestinal disorders, bone and joint problems, obesity and diabetes (27.1, 17.9, 16.9 10.9 and 10.7%, respectively). According to findings, more than a half of women had single (only one NCD) or multimorbidity (two or more NCDs) in 28.8% and 29.8%, respectively. As expected, as age increases, the cumulative number of chronic conditions also does, leading to an overall rise in the prevalence of multimorbidity. Findings of the authors suggest that in this mid-aged female cohort, age, place of residence, religion, social group, level of education, occupation, wealth, tobacco consumption, waist-hip ratio, and experienced menopause in family were significantly associated with single morbidity. For a one-year increase in age, the odds of multimorbidity versus the combined single and no morbidity were 1.02 times greater. Equally, for urban residence, the odds of multimorbidity versus the combined single and no morbidity were 1.56 times greater than rural residence. For women who had multimorbidity, the odds of reporting poor self-rated health versus the combined good and fair self-rated health were almost two times higher than those who had single morbidity. In addition, five indicators of HRQoL such as poor self-rated health, work-limiting health conditions, mobility, activities of daily living and, instrumental activities of daily living were significantly found to be associated with multimorbidity. As the authors state, these findings correlate with those reported in the US by other authors, indicating that impaired HRQoL can be attributed to stress related to the poverty conditions in which they live, the non-accessibility to health care, among other factors. Although these are expected findings, the strength of the study is that it provides evidence based on nationally representative information, employing a list of seventeen NCDs in order to generate empirical evidence on single and multimorbidity of mid-aged women from India. Moreover, the study highlighted patterns and sub-national level variation in the burden of single and multimorbidity, linking these with selected indicators of HRQoL. As for the limitations of the study one can mention the fact that it is based on self-reported data, which could have caused misclassification bias in the research estimates and also due to its descriptive/cross sectional design causality could not be determined.
I agree with the authors with the fact that adopting a healthy lifestyle in midlife has substantial overall health benefits and that healthcare needs for countering NCD multimorbidity are usually unmet among women. Risk factors found in this study need to be targeted and reduced. Health promotion through behavioral changes should be encouraged such as the abstinence of tobacco and alcohol consumption and the increase in physical activity. These are cost-effective ways to improve quality of life. In conclusion, this study suggests that multimorbidity is increasingly prevalent in mid-aged women and related to impaired quality of life. There is a need for further studies to deeper explore correlates of multimorbidity among mid-aged women.
Peter Chedraui, MD, PhD
Instituto de Investigación e Innovación en Salud Integral
Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
References
- Peel N, Bartlett H, McClure R. Healthy ageing: how is it defined and measured? Australas J Ageing. 2004;23(3):115–9.
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1741-6612.2004.00035.x - Lee JT, Hamid F, Pati S, Atun R, Millett C. Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis. PLoS One. 2015;10(7):e0127199.
https://pubmed.ncbi.nlm.nih.gov/26154083/ - United Nations (2019) World Population Prospects 2019.
https://population.un.org/wpp/Download/Standard/Population/ - Puri P, Sinha A, Mahapatra P, Pati S. Multimorbidity among midlife women in India: well-being beyond reproductive age. BMC Womens Health. 2022;22(1):117.
https://pubmed.ncbi.nlm.nih.gov/35413903/
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