Is India's public health care system prepared for cervical cancer screening?: Evaluating facility readiness from the fourth round of the District Level Household and Facility Survey (DLHS-4).

India's cervical cancer screening program was launched in 2016. We evaluated baseline facility readiness using nationally representative data from the 2012-13 District Level Household and Facility Survey on 4 tiers of the public health care system - 18,367 sub-health centres (SHCs), 8540 primary health centres (PHCs), 4810 community health centres and 1540 district/sub-divisional hospitals. To evaluate facility readiness we used the Improving Data for Decision Making in Global Cervical Cancer Programmes toolkit on six domains - potential staffing, infrastructure, equipment and supplies, infection prevention, medicines and laboratory testing, and data management. Composite scores were created by summing responses within domains, standardizing scores across domains at each facility level, and averaging across districts/states. Overall, readiness scores were low for cervical cancer screening. At SHCs, the lowest scores were observed in 'infrastructure' (0.55) and 'infection prevention' (0.44), while PHCs had low 'potential staffing' scores (0.50) due to limited manpower to diagnose and treat (cryotherapy) potential cases. Scores were higher for tiers conducting diagnostic work-up and treatment/referral. The highest scores were in 'potential staffing' except for PHCs, while the lowest scores were in 'infection & prevention' and 'medicines and laboratory'. Goa and Maharashtra were consistently among the top 5 ranking states for readiness. Substantial heterogeneity in facility readiness for cervical cancer screening spans states and tiers of India's public healthcare system. Infrastructure and staffing are large barriers to screening at PHCs, which are crucial for referral of high-risk patients. Our results suggest focus areas in cervical cancer screening at the district level for policy makers.

Pensions, consumption and health: evidence from rural South Africa.

BACKGROUND: Increasing numbers of older people in sub-Saharan Africa are gaining access to pension benefits and it is often claimed that these benefits promote healthy forms of consumption, which contribute to significant improvements in their health status. However, evidence to support these claims is limited. METHODS: The paper uses data for 2701 people aged 60 or over who participated in a population-based study in rural north-eastern South Africa. It analyses effects of receiving a pension on reported food scarcity, body mass index and patterns of consumption. RESULTS: The paper finds that living in a pension household is associated with a reduced risk of reported food scarcity and with higher levels of consumption of food and drink. The paper does not find that living in a pension household is associated with a higher prevalence of current smoking nor current alcohol consumption. However, the paper still finds that tobacco and alcohol make up over 40% of reported food and drink consumption, and that the correlation between reported food scarcity and body mass index status is imperfect. CONCLUSIONS: The paper does not show significant associations between pension receipt and the selected risk factors. However, the context of prevalent obesity and high shares of household spending allocated to tobacco and alcohol call into question widely-made claims that pensions enhance healthy consumption among older people in low and middle-income countries.

Functional Measures of Sarcopenia: Prevalence, and Associations with Functional Disability in 10,892 Adults Aged 65 Years and Over from Six Lower- and Middle-Income Countries.

Identification of sarcopenia in lower- and middle-income countries (LMICs) is limited by access to technologies that assess muscle mass. We investigated associations between two functional measures of sarcopenia, grip strength and gait speed (GS), with functional disability in adults from six LMICs. Data were extracted from the World Health Organization (WHO) Study on global AGEing and adult health Wave 1 (2007-2010) for adults (≥ 65 years) from China, Mexico, Ghana, India, Russia and South Africa (n = 10,892, 52.8% women). We calculated country-specific prevalence of low grip strength, slow GS (≤ 0.8 m/s), and both measures combined. Using multivariable negative binomial regression, we separately assessed associations between low grip strength, slow GS, and both measures combined, with the WHO Disability Assessment Schedule 2.0, accounting for selected socioeconomic factors. In women, low grip strength ranged from 7 in South Africa to 51% in India; in men, it ranged from 17 in Russia to 51% in Mexico. Country-specific proportions of slow GS ranged from 77 in Russia, to 33% in China. The concomitant presence of both was the lowest in South Africa and the highest in India (12.3% vs. 33%). Independent of age, those with both low grip strength and slow GS had between 1.2- and 1.5-fold worse functional disability scores, independent of comorbidities, low education, and low wealth (all country-dependent). Low grip strength, slow GS, and the combination of both, were all associated with higher levels of functional disability, thus indicating these objective measures offer a reasonably robust estimate for potential poor health outcomes.

Establishing Baseline Cervical Cancer Screening Coverage - India, 2015-2016.

Cervical cancer is the second leading cause of new cancer cases and cancer-related deaths among women in India, with an estimated 96,922 new cases and 60,078 deaths each year.* Despite the availability of effective low-cost screening options in India, limited access to screening and treatment services, diagnosis at a later stage, and low investment in health care infrastructure all contribute to the high number of deaths (1). In 2016 the Ministry of Health and Family Welfare of India recommended cervical cancer screening using visual inspection with acetic acid every 5 years for women aged 30-65 years (per World Health Organization [WHO] guidelines) (2,3). To establish a baseline for cervical cancer screening coverage, survey data were analyzed to estimate the percentage of women aged 30-49 years who had ever been screened for cervical cancer (defined as ever having had a cervix examination). Cervical cancer screening was estimated using data from the Fourth National Family Health Survey† (NFHS-4), a nationally representative survey conducted at the district level during 2015-2016, which included 699,686 Indian women aged 15-49 years. Lifetime cervical cancer screening prevalence was low (29.8%) and varied by geographic region, ranging from 10.0% in the Northeast Region to 45.2% in the Western Region. Prevalence of screening was higher among women with higher levels of education and household wealth, those who had ever been married, and urban residents. This screening prevalence can be used as a baseline indicator for cervical cancer screening in India in accordance with the WHO Noncommunicable Diseases Global Monitoring Framework during state-based programmatic rollout and program evaluation (4).

Association between empirically derived dietary patterns with blood lipids, fasting blood glucose and blood pressure in adults - the India migration study.

BACKGROUND: Dietary patterns (DPs) in India are heterogenous. To date, data on association of indigenous DPs in India with risk factors of nutrition-related noncommunicable diseases (cardiovascular disease and diabetes), leading causes of premature death and disability, are limited. We aimed to evaluate the associations of empirically-derived DPs with blood lipids, fasting glucose and blood pressure levels in an adult Indian population recruited across four geographical regions of India. METHODS: We used cross-sectional data from the Indian Migration Study (2005-2007). Study participants included urban migrants, their rural siblings and urban residents and their urban siblings from Lucknow, Nagpur, Hyderabad and Bangalore (n = 7067, mean age 40.8 yrs). Information on diet (validated interviewer-administered, 184-item semi-quantitative food frequency questionnaire), tobacco consumption, alcohol intake, physical activity, medical history, as well as anthropometric measurements were collected. Fasting-blood samples were collected for estimation of blood lipids and glucose. Principal component analysis (PCA) was used to identify major DPs based on eigenvalue> 1 and component interpretability. Robust standard error multivariable linear regression models were used to investigate the association of DPs (tertiles) with total cholesterol (TC), low density lipoprotein-cholesterol (LDL-C), high density lipoprotein-cholesterol (HDL-C), triglycerides, fasting-blood glucose (FBG), systolic and diastolic blood pressure (SBP and DBP) levels. RESULTS: Three major DPs were identified: 'cereal-savoury' (cooked grains, rice/rice-based dishes, snacks, condiments, soups, nuts), 'fruit-vegetable-sweets-snacks' (Western cereals, vegetables, fruit, fruit juices, cooked milk products, snacks, sugars, sweets) and 'animal food' (red meat, poultry, fish/seafood, eggs) patterns. High intake of the 'animal food' pattern was positively associated with levels of TC (ß = 0.10 mmol/L; 95% CI: 0.02, 0.17 mmol/L; p-trend = 0.013); LDL-C (ß = 0.07 mmol/L; 95% CI: 0.004, 0.14 mmol/L; p-trend = 0.041); HDL-C (ß = 0.02 mmol/L; 95% CI: 0.004, 0.04 mmol/L; p-trend = 0.016), FBG: (ß = 0.09 mmol/L; 95% CI: 0.01, 0.16 mmol/L; p-trend = 0.021) SBP (ß = 1.2 mm/Hg; 95% CI: 0.1, 2.3 mm/Hg; p-trend = 0.032); DBP: (ß = 0.9 mm/Hg; 95% CI: 0.2, 1.5 mm/Hg; p-trend = 0.013). The 'cereal-savoury' and 'fruit-vegetable-sweets-snacks' patterns showed no association with any parameter except for a positive association with diastolic blood pressure for high intake of 'fruits-vegetables-sweets-snacks' pattern. CONCLUSION: Our results indicate positive associations of the 'animal food' pattern with cardio-metabolic risk factors in India. Further longitudinal assessments of dietary patterns in India are required to validate the findings.

Dietary patterns and non-communicable disease risk in Indian adults: secondary analysis of Indian Migration Study data.

OBJECTIVE: Undernutrition and non-communicable disease (NCD) are important public health issues in India, yet their relationship with dietary patterns is poorly understood. The current study identified distinct dietary patterns and their association with micronutrient undernutrition (Ca, Fe, Zn) and NCD risk factors (underweight, obesity, waist:hip ratio, hypertension, total:HDL cholesterol, diabetes). DESIGN: Data were from the cross-sectional Indian Migration Study, including semi-quantitative FFQ. Distinct dietary patterns were identified using finite mixture modelling; associations with NCD risk factors were assessed using mixed-effects logistic regression models. SETTING: India. SUBJECTS: Migrant factory workers, their rural-dwelling siblings and urban non-migrants. Participants (7067 adults) resided mainly in Karnataka, Andhra Pradesh, Maharashtra and Uttar Pradesh. RESULTS: Five distinct, regionally distributed, dietary patterns were identified, with rice-based patterns in the south and wheat-based patterns in the north-west. A rice-based pattern characterised by low energy consumption and dietary diversity ('Rice & low diversity') was consumed predominantly by adults with little formal education in rural settings, while a rice-based pattern with high fruit consumption ('Rice & fruit') was consumed by more educated adults in urban settings. Dietary patterns met WHO macronutrient recommendations, but some had low micronutrient contents. Dietary pattern membership was associated with several NCD risk factors. CONCLUSIONS: Five distinct dietary patterns were identified, supporting sub-national assessments of the implications of dietary patterns for various health, food system or environment outcomes.

Dietary patterns in India: a systematic review.

Dietary patterns analysis is an emerging area of research. Identifying distinct patterns within a large dietary survey can give a more accurate representation of what people are eating. Furthermore, it allows researchers to analyse relationships between non-communicable diseases (NCD) and complete diets rather than individual food items or nutrients. However, few such studies have been conducted in developing countries including India, where the population has a high burden of diabetes and CVD. We undertook a systematic review of published and grey literature exploring dietary patterns and relationships with diet-related NCD in India. We identified eight studies, including eleven separate models of dietary patterns. Most dietary patterns were vegetarian with a predominance of fruit, vegetables and pulses, as well as cereals; dietary patterns based on high-fat, high-sugar foods and more meat were also identified. There was large variability between regions in dietary patterns, and there was some evidence of change in diets over time, although no evidence of different diets by sex or age was found. Consumers of high-fat dietary patterns were more likely to have greater BMI, and a dietary pattern high in sweets and snacks was associated with greater risk of diabetes compared with a traditional diet high in rice and pulses, but other relationships with NCD risk factors were less clear. This review shows that dietary pattern analyses can be highly valuable in assessing variability in national diets and diet-disease relationships. However, to date, most studies in India are limited by data and methodological shortcomings.

Legume consumption and its association with fasting glucose, insulin resistance and type 2 diabetes in the Indian Migration Study.

OBJECTIVE: Legume consumption is associated with lower fasting glucose (FG) and insulin levels in nutrition trials and lower CVD mortality in large-scale epidemiological studies. In India, legumes are widely consumed in various preparations, yet no epidemiological study has evaluated the association of legumes with FG levels, insulin resistance and diabetes risk. The present study aimed to fill this gap. DESIGN: Fasting blood samples, in-person interviews to obtain information on demographic/socio-economic factors, physical activity, alcohol and tobacco use, and anthropometric measurements were collected. Dietary intakes were assessed by an interviewer-administered, validated, semi-quantitative FFQ. SETTING: Lucknow, Nagpur, Hyderabad and Bangalore, India. SUBJECTS: Men and women (n 6367) aged 15-76 years - urban residents, urban migrants and their rural siblings. RESULTS: In multivariate random-effects models adjusted for age, BMI, total energy intake, macronutrients, physical activity and rural/migration status, daily legume consumption was not associated with FG (P-for-trend=0·78), insulin resistance (homeostasis model assessment score; P-for-trend=0·73) or the prevalence of type 2 diabetes mellitus (P-for-trend=0·41). Stratified analyses by vegetarian diet and migration status did not change the findings. Inverse associations between legumes and FG emerged for participants with lower BMI and higher carbohydrate, protein, fat and sugar intakes. CONCLUSIONS: Although legumes are essential in traditional Indian diets, as well as in prudent and Mediterranean diets in the West, we did not find an association between legumes and markers of glycaemic control, insulin resistance or diabetes, except for subgroups based on BMI and macronutrient intake. The ubiquitous presence and complexity of legume preparations in Indian diets may contribute to these findings.

Food Price Spikes Are Associated with Increased Malnutrition among Children in Andhra Pradesh, India.

BACKGROUND: Global food prices have risen sharply since 2007. The impact of food price spikes on the risk of malnutrition in children is not well understood. OBJECTIVE: We investigated the associations between food price spikes and childhood malnutrition in Andhra Pradesh, one of India's largest states, with >85 million people. Because wasting (thinness) indicates in most cases a recent and severe process of weight loss that is often associated with acute food shortage, we tested the hypothesis that the escalating prices of rice, legumes, eggs, and other staples of Indian diets significantly increased the risk of wasting (weight-for-height z scores) in children. METHODS: We studied periods before (2006) and directly after (2009) India's food price spikes with the use of the Young Lives longitudinal cohort of 1918 children in Andhra Pradesh linked to food price data from the National Sample Survey Office. Two-stage least squares instrumental variable models assessed the relation of food price changes to food consumption and wasting prevalence (weight-for-height z scores). RESULTS: Before the 2007 food price spike, wasting prevalence fell from 19.4% in 2002 to 18.8% in 2006. Coinciding with India's escalating food prices, wasting increased significantly to 28.0% in 2009. These increases were concentrated among low- (χ(2): 21.6, P < 0.001) and middle- (χ(2): 25.9, P < 0.001) income groups, but not among high-income groups (χ(2): 3.08, P = 0.079). Each 10.0 rupee ($0.170) increase in the price of rice/kg was associated with a drop in child-level rice consumption of 73.0 g/d (ß: -7.30; 95% CI: -10.5, -3.90). Correspondingly, lower rice consumption was significantly associated with lower weight-for-height z scores (i.e., wasting) by 0.005 (95% CI: 0.001, 0.008), as seen with most other food categories. CONCLUSION: Rising food prices were associated with an increased risk of malnutrition among children in India. Policies to help ensure the affordability of food in the context of economic growth are likely critical for promoting children's nutrition.

The Psychosocial Factors Related to Obesity: A Study Among Overweight, Obese, and Morbidly Obese Women in India.

Psychosocial factors among overweight, obese, and morbidly obese women in Delhi, India were examined. A follow-up survey was conducted of 325 ever-married women aged 20-54 years, systematically selected from 1998-99 National Family Health Survey samples, who were re-interviewed after 4 years in 2003. Information on day-to-day problems, body image dissatisfaction, sexual dissatisfaction, and stigma and discrimination were collected and anthropometric measurements were obtained from women to compute their current body mass index. Three out of four overweight women (BMI between 25 and 29.9 kg/m(2)) were not happy with their body image, compared to four out of five obese women (BMI of 30 kg/m(2) or greater), and almost all (95 percent) morbidly obese women (BMI of 35 kg/m(2) or greater) (p < .0001). It was found that morbidly obese and obese women were five times (adjusted odds ratio [aOR] 5.29, 95% confidence interval [CI] 2.02-13.81, p < .001) and two times (aOR 2.30, 95% CI 1.20-4.42, p < .001), respectively, as likely to report day-to-day problems; twelve times (aOR 11.88, 95% CI 2.62-53.87, p < .001) and three times, respectively, as likely (aOR 2.92, 95% CI 1.45-5.88, p = .001) to report dissatisfaction with body image; and nine times (aOR 9.41, 95% CI 2.96-29.94, p < .001) and three times (aOR 2.93, 95% CI 1.03-8.37, p = .001), respectively, as likely to report stigma and discrimination as overweight women.

Women's health in India: the role of body mass index.

We examined the health status of women in relation to their body mass indices and waist-to-hip ratio (WHR) by analyzing data from a follow-up study of 325 women, selected from the Indian National Family Health Survey (NFHS-2/1998-99) Delhi samples, reinterviewed after 4 years (2003). Obese women were five times more likely (OR = 4.87; p <.0001) and women with a higher WHR (> 0.90) were two times more likely (OR = 1.70; p =.050) to perceive their health condition as worse than others. Arthritis, hypertension, and shortness of breath were found to be higher among obese women and women with a high WHR. Healthy lifestyle choices must be promoted to contain the growing burden of obesity-related health problems among Indian women.

Averting obesity and type 2 diabetes in India through sugar-sweetened beverage taxation: an economic-epidemiologic modeling study.

BACKGROUND: Taxing sugar-sweetened beverages (SSBs) has been proposed in high-income countries to reduce obesity and type 2 diabetes. We sought to estimate the potential health effects of such a fiscal strategy in the middle-income country of India, where there is heterogeneity in SSB consumption, patterns of substitution between SSBs and other beverages after tax increases, and vast differences in chronic disease risk within the population. METHODS AND FINDINGS: Using consumption and price variations data from a nationally representative survey of 100,855 Indian households, we first calculated how changes in SSB price alter per capita consumption of SSBs and substitution with other beverages. We then incorporated SSB sales trends, body mass index (BMI), and diabetes incidence data stratified by age, sex, income, and urban/rural residence into a validated microsimulation of caloric consumption, glycemic load, overweight/obesity prevalence, and type 2 diabetes incidence among Indian subpopulations facing a 20% SSB excise tax. The 20% SSB tax was anticipated to reduce overweight and obesity prevalence by 3.0% (95% CI 1.6%-5.9%) and type 2 diabetes incidence by 1.6% (95% CI 1.2%-1.9%) among various Indian subpopulations over the period 2014-2023, if SSB consumption continued to increase linearly in accordance with secular trends. However, acceleration in SSB consumption trends consistent with industry marketing models would be expected to increase the impact efficacy of taxation, averting 4.2% of prevalent overweight/obesity (95% CI 2.5-10.0%) and 2.5% (95% CI 1.0-2.8%) of incident type 2 diabetes from 2014-2023. Given current consumption and BMI distributions, our results suggest the largest relative effect would be expected among young rural men, refuting our a priori hypothesis that urban populations would be isolated beneficiaries of SSB taxation. Key limitations of this estimation approach include the assumption that consumer expenditure behavior from prior years, captured in price elasticities, will reflect future behavior among consumers, and potential underreporting of consumption in dietary recall data used to inform our calculations. CONCLUSION: Sustained SSB taxation at a high tax rate could mitigate rising obesity and type 2 diabetes in India among both urban and rural subpopulations.

Frequency of fish intake and diabetes among adult Indians.

OBJECTIVES: Recent studies have shown that the choice of foods plays a role in diabetes prevention. However, little empirical evidence on this association exists in developing countries. We aimed to examine the association between frequency of fish intake and self-reported diabetes status among adult men and women in India. METHODS: Analysis of cross-sectional data from participants in India's third National Family Health Survey conducted during 2005-2006 was performed. Associations between fish intake, determined by frequency of consumption (daily, weekly, occasionally, and never), and self-reported diabetes were estimated using multivariable-adjusted models in 99,574 women, 56,742 men, and 39,257 couples aged 20-49 years after adjusting for frequency of consumption of other food items, body mass index (BMI) status, tobacco smoking, alcohol drinking, watching television, age, education, living standard of the household, and place of residence. RESULTS: After adjustment for other dietary, lifestyle, and socioeconomic and demographic characteristics, odds of diabetes were 2 times higher (odds ratio [OR]: 2.02; 95% confidence interval [CI], 1.59-2.57; p < 0.0001) among those who reported consuming fish daily compared to those who never consumed fish. Weekly fish intake was also associated with a higher odds of having diabetes (OR: 1.55; 95% CI, 1.25-1.93; p < 0.0001). The adjusted effect of daily fish intake on diabetes was greater among men (OR: 2.46; 95% CI, 1.66-3.65) than among women (OR: 1.72; 95% CI, 1.26-2.33). In cross-spousal sensitivity analysis, the odds of a husband having diabetes was also associated with wife's daily/weekly consumption of fish (OR: 1.36; 95% CI, 0.92-2.01) and the odds of a wife having diabetes was also associated with husband's daily/weekly consumption of fish (OR: 1.21; 95% CI, 0.87-1.68). CONCLUSIONS: In a large nationally representative sample of adult men and women in India, daily or weekly fish intake was positively associated with the presence of diabetes. However, this is an observational finding and uncontrolled confounding cannot be excluded as an explanation for the association. More epidemiological research with better measures of food intake and clinical measures of diabetes is needed in a developing country setting to validate the findings.

Occupations with an increased prevalence of self-reported asthma in Indian adults.

OBJECTIVES: Occupational asthma remains relatively under-recognized in India with little or no information regarding preventable causes. We studied occupations with an increased prevalence of self-reported asthma among adult men and women in India. METHODS: Analysis is based on 64,725 men aged 15-54 years and 52,994 women aged 15-49 years who participated in India's third National Family Health Survey, 2005-2006, and reported their current occupation. Prevalence odds ratios (ORs) for specific occupations and asthma were estimated using multivariate logistic regression, separately for men and women, adjusting for age, education, household wealth index, current tobacco smoking, cooking fuel use, rural/urban residence and access to healthcare. RESULTS: The prevalence of asthma among the working population was 1.9%. The highest odds ratios for asthma were found among men in the plant and machine operators and assemblers major occupation category (OR: 1.67; 95% CI: 1.14-2.45; p = 0.009). Men working in occupation subcategories of machine operators and assemblers (OR: 1.85; 95% CI: 1.24-2.76; p = 0.002) and mining, construction, manufacturing and transport (OR: 1.33; 95% CI: 1.00-1.77; p = 0.051) were at the highest risk of asthma. Reduced odds of asthma prevalence in men was observed among extraction and building trades workers (OR: 0.72; 95% CI: 0.53-0.97; p = 0.029). Among women none of the occupation categories or subcategories was found significant for asthma risk. Men and women employed in high-risk occupations were not at a higher risk of asthma when compared with those in low-risk occupations. CONCLUSIONS: This large population-based, nationally representative cross-sectional study has confirmed findings from high income countries showing high prevalence of asthma in men in a number of occupational categories and subcategories; however, with no evidence of increased risks for women in the same occupations.

Association between smoke-free workplace and second-hand smoke exposure at home in India.

BACKGROUND: The implementation of comprehensive smoke-free laws has been associated with reductions in second-hand smoke exposure at home in several high income countries. There is little information on whether these benefits extend to low income and middle income countries with a growing tobacco-related disease burden such as India. METHODS: State and individual-level analysis of cross-sectional data from the Global Adult Tobacco Survey India, 2009/2010. Associations between working in a smoke-free indoor environment and living in a smoke-free home were examined using correlation at the state level, and multivariate logistic regression at the individual level. RESULTS: The percentage of respondents employed indoors (outside the home) working in smoke-free environments who lived in a smoke-free home was 64.0% compared with 41.7% of those who worked where smoking occurred. Indian states with higher proportions of smoke-free workplaces had higher proportions of smoke-free homes (rs=0.54, p<0.005). In the individual-level analysis, working in a smoke-free workplace was associated with a significantly higher likelihood of living in a smoke-free home (adjusted OR=2.07; 95% CI 1.64 to 2.52) after adjustment for potential confounders. CONCLUSIONS: Implementation of smoke-free legislation in India was associated with a higher proportion of adults reporting a smoke-free home. These findings further strengthen the case for accelerated implementation of Article 8 of the Framework Convention on Tobacco Control (FCTC) in low and middle income countries.

Type of vegetarian diet, obesity and diabetes in adult Indian population.

BACKGROUND: To investigate the prevalence of obesity and diabetes among adult men and women in India consuming different types of vegetarian diets compared with those consuming non-vegetarian diets. METHODS: We used cross-sectional data of 156,317 adults aged 20-49 years who participated in India's third National Family Health Survey (2005-06). Association between types of vegetarian diet (vegan, lacto-vegetarian, lacto-ovo vegetarian, pesco-vegetarian, semi-vegetarian and non-vegetarian) and self-reported diabetes status and measured body mass index (BMI) were estimated using multivariable logistic regression adjusting for age, gender, education, household wealth, rural/urban residence, religion, caste, smoking, alcohol use, and television watching. RESULTS: Mean BMI was lowest in pesco-vegetarians (20.3 kg/m2) and vegans (20.5 kg/m2) and highest in lacto-ovo vegetarian (21.0 kg/m2) and lacto-vegetarian (21.2 kg/m2) diets. Prevalence of diabetes varied from 0.9% (95% CI: 0.8-1.1) in person consuming lacto-vegetarian, lacto-ovo vegetarian (95% CI:0.6-1.3) and semi-vegetarian (95% CI:0.7-1.1) diets and was highest in those persons consuming a pesco-vegetarian diet (1.4%; 95% CI:1.0-2.0). Consumption of a lacto- (OR:0.67;95% CI:0.58-0.76;p < 0.01), lacto-ovo (OR:0.70; 95% CI:0.51-0.96;p = 0.03) and semi-vegetarian (OR:0.77; 95% CI:0.60-0.98; p = 0.03) diet was associated with a lower likelihood of diabetes than a non-vegetarian diet in the adjusted analyses. CONCLUSIONS: In this large, nationally representative sample of Indian adults, lacto-, lacto-ovo and semi-vegetarian diets were associated with a lower likelihood of diabetes. These findings may assist in the development of interventions to address the growing burden of overweight/obesity and diabetes in Indian population. However, prospective studies with better measures of dietary intake and clinical measures of diabetes are needed to clarify this relationship.

A study on body-weight perception, future intention and weight-management behaviour among normal-weight, overweight and obese women in India.

OBJECTIVE: We examined the socio-economic differential in the self-perception of body weight, future intention for weight management and actual weight-management behaviour among normal-weight, overweight and obese women in India. DESIGN: A population-based follow-up survey of ever-married women, systematically selected from the second round of the National Family Health Survey (NFHS-2, 1998-99) samples, who were re-interviewed after four years in 2003. SETTING: Information on women's perception about their own weight, intention of weight management and actual weight-management behaviour were collected through personal interview. Anthropometric measurements were obtained from women to compute their current BMI. SUBJECTS: Three hundred and twenty-five ever-married women aged 20-54 years residing in the national capital territory of Delhi in India. RESULTS: Discrepancy between self-perceived body weight and women's actual body weight was reported. One-quarter of overweight women and one in ten obese women perceived themselves as normal weight. Although a majority of overweight and obese women wanted to reduce their weight, a significant proportion of overweight (one in four) and 4 % of obese women also wanted to maintain their weight as it is. Only one in three overweight and one in four obese women were performing any physical activity to reduce their weight. CONCLUSIONS: These findings are important for public health interventions in obesity care. Implementation of health promotion and health education in the community should use effective school education and mass-media programmes to raise awareness of appropriate body weight to combat the growing level of obesity among Indian women.

Non communicable disease multimorbidity and associated health care utilization and expenditures in India: cross-sectional study.

BACKGROUND: Non communicable disease (NCD) multimorbidity is increasingly becoming common in high income settings but little is known about its epidemiology and associated impacts on citizens and health systems in low and middle-income countries (LMICs). We aim to examine the socio-demographic distribution of NCD multimorbidity (≥2 diseases) and its implications for health care utilization and out-of-pocket expenditure (OOPE) in India. METHODS: We analyzed cross-sectional nationally representative data from the World Health Organisaion Study on Global Ageing and Adult Health (WHO-SAGE), conducted in India during 2007. Multiple logistic regression was used to determine socio-demographic predictors of self-reported multimorbidity. A two part model was used to assess the relationship between number of NCDs and health care utilization including OOPE. RESULTS: 28.5% of the sample population had at least one NCD and 8.9% had NCD multimorbidity. The prevalence of multimorbidity increased from 1.3% in 18-29 year olds to 30.6% in those aged 70 years and above. Mean outpatient visits in the preceding 12 months increased from 2.2 to 6.2 and the percentage reporting an overnight hospital stay in the past 3 years increased from 9% to 29% in those with no NCD and ≥2 NCDs respectively (p <0.001).OOPE incurred during the last outpatient visit increased from INR 272.1 (95% CI = 249.0-295.2) in respondents with no NCDs to INR 454.1 (95% CI = 407.8-500.4) in respondents with ≥2 NCDs. However, we did not find an increase in OOPE during the last inpatient visit with number of NCDs (7865.9 INR for those with zero NCDs compared with 7301.3 for those with ≥2 NCDs). For both outpatient and inpatient OOPE, medicine constitutes the largest proportion of spending (70.7% for outpatient, 53.6% for inpatient visit), followed by spending for health care provider (14.0% for outpatient, 12.2% for inpatient visit). CONCLUSION: NCD multimorbidity is common in the Indian adult population and is associated with substantially higher healthcare utilization and OOPE. Strategies to address the growing burden of NCDs in LMICs should include efforts to improve the management of patients with multimorbidity and reduce associated financial burden to individuals and households.

Associations between active travel to work and overweight, hypertension, and diabetes in India: a cross-sectional study.

BACKGROUND: Increasing active travel (walking, bicycling, and public transport) is promoted as a key strategy to increase physical activity and reduce the growing burden of noncommunicable diseases (NCDs) globally. Little is known about patterns of active travel or associated cardiovascular health benefits in low- and middle-income countries. This study examines mode and duration of travel to work in rural and urban India and associations between active travel and overweight, hypertension, and diabetes. METHODS AND FINDINGS: Cross-sectional study of 3,902 participants (1,366 rural, 2,536 urban) in the Indian Migration Study. Associations between mode and duration of active travel and cardiovascular risk factors were assessed using random-effect logistic regression models adjusting for age, sex, caste, standard of living, occupation, factory location, leisure time physical activity, daily fat intake, smoking status, and alcohol use. Rural dwellers were significantly more likely to bicycle (68.3% versus 15.9%; p<0.001) to work than urban dwellers. The prevalence of overweight or obesity was 50.0%, 37.6%, 24.2%, 24.9%; hypertension was 17.7%, 11.8%, 6.5%, 9.8%; and diabetes was 10.8%, 7.4%, 3.8%, 7.3% in participants who travelled to work by private transport, public transport, bicycling, and walking, respectively. In the adjusted analysis, those walking (adjusted risk ratio [ARR] 0.72; 95% CI 0.58-0.88) or bicycling to work (ARR 0.66; 95% CI 0.55-0.77) were significantly less likely to be overweight or obese than those travelling by private transport. Those bicycling to work were significantly less likely to have hypertension (ARR 0.51; 95% CI 0.36-0.71) or diabetes (ARR 0.65; 95% CI 0.44-0.95). There was evidence of a dose-response relationship between duration of bicycling to work and being overweight, having hypertension or diabetes. The main limitation of the study is the cross-sectional design, which limits causal inference for the associations found. CONCLUSIONS: Walking and bicycling to work was associated with reduced cardiovascular risk in the Indian population. Efforts to increase active travel in urban areas and halt declines in rural areas should be integral to strategies to maintain healthy weight and prevent NCDs in India. Please see later in the article for the Editors' Summary.

Association between legume intake and self-reported diabetes among adult men and women in India.

BACKGROUND: It is postulated that a diet high in legumes may be beneficial in preventing diabetes. However, little empirical evidence on this association exists in developing countries. We aimed to examine the association between legume intake and self-reported diabetes status in adult men and women in India. METHODS: The analysis is based on a population-based cross sectional study of 99,574 women and 56,742 men aged 20-49 years included in India's third National Family Health Survey conducted in 2005-06. Association of legume intake, determined by the frequency of consumption of pulses and beans (daily, weekly and occasionally or never), with the reported prevalence of diabetes were estimated using multiple logistic regression after adjusting for frequency of consumption of other food items, BMI status, tobacco smoking, alcohol drinking, watching television, age, education, living standard of the household, residence and geographic regions. RESULTS: Daily (OR: 0.71; 95% CI: 0.59-0.87; p=0.001) and weekly (OR: 0.66; 95% CI: 0.54-0.80; p<0.001) legumes intake were associated with a significantly reduced prevalence of diabetes among adult Indian women even after controlling for the effects of potentially confounding factors, whereas non-significant inverse associations were observed in men. CONCLUSION: Daily or weekly intake of legumes was inversely associated with presence of diabetes in the Indian population. However, this is an observational finding and uncontrolled confounding cannot be excluded as an explanation for the association. More epidemiological research with better measures of legumes intake and clinical measures of diabetes is needed to clarify this relationship.