Association of pro-inflammatory cytokines, adipokines and hepatokine with incident diabetes in India: a nested case-control study within CARRS cohort.

AIMS: To study the association of pro-inflammatory markers with incident diabetes in India. METHODS: We did a nested case-control study within the CARRS (Centre for Ardiometabolic Risk Reduction in South Asia) cohort. Of the 5739 diabetes-free individuals at the baseline, 216 participants with incident diabetes and 432 age-, gender- and city-matched controls at 2-year follow-up were included. We measured high sensitive C-reactive protein (hsCRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), monocyte chemoattractant protein-1 ( MCP-1), adiponectin, leptin and fetuin-A in the stored baseline blood samples. We did multivariate conditional logistic regression to estimate association of inflammatory markers (as quartiles) and incident diabetes. Covariates were baseline fasting plasma glucose (FPG) and lipids, body mass index (BMI), family history of diabetes, smoking and alcohol use. RESULTS: Baseline hsCRP and TNF-α were higher, and IL-6 and adiponectin were lower among cases vs. controls. In multivariate conditional logistic regression models, only quartile-3 (odds ratio [OR]: 2.96 [95% CI:1.39, 6.30]) and quartile-4 (OR: 2.58 [95% CI: 1.15, 5.79]) of TNF-α and quartile-4 of MCP-1 (OR: 2.55 [95% CI: 1.06, 6.16]) were positively associated with diabetes after adjusting for baseline FPG and BMI. These associations did not remain after adjusting for family history. High level (quartile-4) of IL-6 was negatively associated with diabetes after adjusting for all factors (OR: 0.18 [95% CI: 0.06, 0.55]). CONCLUSIONS: Higher TNF-α and MCP-1 levels and lower IL-6 were associated with higher risk of developing diabetes. Better understanding and potential methods of addressing these biomarkers, especially in relation to family history, are needed to address diabetes in South Asians.

Cardiovascular Health in India - a Report Card from Three Urban and Rural Surveys of 22,144 Adults.

Background: Markers of ideal cardiovascular health (CVH) predict cardiovascular events. We estimated the prevalence of ideal CVH markers in two levels of cities and villages in India. Methods: We did pooled analysis of individual-level data from three cross sectional surveys of adults ≥ 30 years over 2010-14 (CARRS: Centre for cArdiometabolic Risk Reduction in South Asia; UDAY and Solan Surveillance Study) representing metropolitan cities; smaller cities and rural areas in diverse locations of India. We defined ideal CVH using modified American Heart Association recommendations: not smoking, ≥ 5 servings of fruits and vegetables (F&V), high physical activity (PA), body mass index (BMI) <25 Kg/m2, blood pressure (BP) <120/80 mm Hg, fasting plasma glucose (FPG) <100 mg/dl, and total cholesterol (TC) <200 mg/dL. We estimated (1) age-and sex-standardized prevalence of ideal CVH and (2) prevalence of good (≥6 markers), moderate (4-5), and poor CVH (≤3) adjusted for age, sex, education, and stratified by setting and asset tertiles. Results: Of the total 22,144 participants, the prevalence of ideal CVH markers were: not smoking (76.7% [95% CI 76.1, 77.2]), consumed ≥5 F&V (4.2% [3.9, 4.5]), high PA (67.5% [66.8, 68.2]), optimum BMI (59.6% [58.9, 60.3]), ideal BP (34.5% [33.9, 35.2]), FPG (65.8% [65.1, 66.5]) and TC (65.4% [64.7, 66.1]). The mean number of ideal CVH metrics was 3.7(95% CI: 3.7, 3.8). Adjusted prevalence of good, moderate, and poor CVH, varied across settings: metropolitan (3.9%, 41.0%, and 55.1%), smaller cities (7.8%, 49.2%, and 43%), and rural (10.4%, 60.9%, and 28.7%) and across asset tertiles: Low (11.0%, 55.9%, 33.1%), Middle (6.3%, 52.2%, 41.5%), and High (5.0%, 46.4%, 48.7%), respectively. Conclusion: Achievement of ideal CVH varied, with higher prevalence in rural and lower asset tertiles. Multi-sectoral and targeted policy and program actions are needed to improve CVH in diverse contexts in India.

Association of family history of cardiometabolic diseases (CMDs) and individual health behaviours: Analysis of CARRS study from South Asia.

OBJECTIVES: Family history is considered as an important predictor of cardiovascular diseases (CVDs) and diabetes. Available research findings suggest that family history of chronic diseases is associated with perceived risk of disease and adoption of healthy behaviours. We examined the association between family history of cardio-metabolic diseases (CMDs) and healthy behaviours among adults without self-reported CMDs. METHODS: Cross-sectional data of 12,484 adults, without self-reported CMDs, from the baseline survey of Centre for cArdiometabolic Risk Reduction in South-Asia (CARRS) cohort study were analysed. RESULTS: Family history was positively associated with non-smoking and high fruits & vegetables consumption in the age group of 45-64 years and moderate to high physical activity in the age group ≥65 years after adjusting for sex, education, wealth index, city and body mass index. CONCLUSIONS: Understanding perceived risks and cultural or psychological factors related to family history through ethnographic studies may deepen understanding of these associations.

Potassium Intake in India: Opportunity for Mitigating Risks of High-Sodium Diets.

INTRODUCTION: Most Indians are vegetarian or eat very little meat, which could imply high potassium intake. Because a high-potassium diet could counterbalance the adverse health effects of high-sodium intake, this study aimed to describe potassium relative to sodium intake and investigate the relationship between blood pressure and potassium intake relative to sodium intake in rural and urban India. METHODS: Investigators collected 24-hour urines from 1,445 participants in a subset of 2 population-based surveys in North India in 2012-2013. Standardized questionnaires were used to collect information on demography, behaviors (tobacco, alcohol consumption, physical activity, and diet [food frequency and 24-hour recall]), and medical history. After evaluating expected versus measured creatinine excretion, the authors calculated median urine potassium excretion and sodium/potassium ratio, according to sex and urban or rural residence, and estimated least square means for the urine measures by participant demographics and comorbidities, after accounting for caloric intake. Two-year blood pressure follow-up data were available in the urban study, and ANCOVA regression was used to determine the association with urine measures. All the statistical analyses of the data were done in January 2019. RESULTS: Acceptable 24-hour urine collections were available in 1,397 participants (rural, n=730). Median urine potassium excretions were 1,492 (IQR=1,012-2,063) and 975 (615-1,497) mg/day; sodium/potassium ratios met the recommended target of <1 in 2.9% rural and 6.6% urban participants. Rural participants did not have higher potassium or lower (better) sodium/potassium ratios when diagnosed with hypertension or other cardiovascular conditions. Higher potassium excretion was associated with lower blood pressure during follow-up among the urban participants (mean systolic blood pressure, 129 vs 133 mm Hg in highest vs lowest potassium excretion tertiles; p=0.029). CONCLUSIONS: Low potassium intake in India warrants dietary policies promoting intake of potassium-rich foods to improve heart health. This approach may be more acceptable than programs focused on sodium reduction alone.

Prevalence of dyslipidaemia and factors associated with dyslipidaemia among South Asian adults: The Center for Cardiometabolic Risk Reduction in South Asia Cohort Study.

Background: . The pattern of dyslipidaemia in South Asia is believed to be different from that in other parts of the world. Nonetheless, limited population-based data are available from the region. We assessed the prevalence, types of, and factors associated with dyslipidaemia among South Asians. Methods: . We used baseline data (2010-11) of the Center for Cardiometabolic Risk Reduction in South Asia (CARRS) cohort of 16 287 representative urban adults aged ≥20 years from Chennai and Delhi in India and Karachi in Pakistan. Total cholesterol (TC) was measured by the enzymatic-cholesterol oxidase peroxidase method, high-density lipoprotein-cholesterol (HDL-C) by the direct homogeneous method and triglycerides (TG) by enzymatic methods. Low-density lipoprotein-cholesterol (LDL-C) was calculated using Friedewald's formula. We defined high TC ≥200 mg/dl or on medication; hypertriglyceridaemia ≥150 mg/dl, high LDL-C ≥130 mg/dl or on medication and low HDL-C <40 mg/dl for males, <50 mg/dl for females. Multivariate logistic regression was carried out to assess the factors associated with dyslipidaemia. Results: . The prevalence of any dyslipidaemia was 76.4%, 64.3% and 68.5% among males and 89.3%, 74.4% and 79.4% among females in Chennai, Delhi and Karachi, respectively. The prevalence of elevated TC was higher in Chennai compared to Delhi and Karachi (31.3%, 28.8% and 22.9%, respectively); males had a significantly greater prevalence of high TG, whereas females had a greater prevalence of low HDL-C in all the three cities. The most common lipid abnormality in all three cities was low HDL-C, which was seen in 67.1%, 49.7% and 61.3% in Chennai, Delhi and Karachi, respectively. Only 2% of the participants were on lipid-lowering drugs. Adjusted for other factors, dyslipidaemia was positively associated with age, female sex, obesity, hypertension, diabetes and tobacco use. Discussion: . Overall, almost seven in ten adults in urban South Asia have some form of dyslipidaemia, and the predominant subtypes were low HDL-C and high TG.

Effect of workplace physical activity interventions on the cardio-metabolic health of working adults: systematic review and meta-analysis.

BACKGROUND: Adults in urban areas spend almost 77% of their waking time being inactive at workplaces, which leaves little time for physical activity. The aim of this systematic review and meta-analysis was to synthesize evidence for the effect of workplace physical activity interventions on the cardio-metabolic health markers (body weight, waist circumference, body mass index (BMI), blood pressure, lipids and blood glucose) among working adults. METHODS: All experimental studies up to March 2018, reporting cardio-metabolic worksite intervention outcomes among adult employees were identified from PUBMED, EMBASE, COCHRANE CENTRAL, CINAHL and PsycINFO. The Cochrane Risk of Bias tool was used to assess bias in studies. All studies were assessed qualitatively and meta-analysis was done where possible. Forest plots were generated for pooled estimates of each study outcome. RESULTS: A total of 33 studies met the eligibility criteria and 24 were included in the meta-analysis. Multi-component workplace interventions significantly reduced body weight (16 studies; mean diff: - 2.61 kg, 95% CI: - 3.89 to - 1.33) BMI (19 studies, mean diff: - 0.42 kg/m2, 95% CI: - 0.69 to - 0.15) and waist circumference (13 studies; mean diff: - 1.92 cm, 95% CI: - 3.25 to - 0.60). Reduction in blood pressure, lipids and blood glucose was not statistically significant. CONCLUSIONS: Workplace interventions significantly reduced body weight, BMI and waist circumference. Non-significant results for biochemical markers could be due to them being secondary outcomes in most studies. Intervention acceptability and adherence, follow-up duration and exploring non-RCT designs are factors that need attention in future research. Prospero registration number: CRD42018094436.

High prevalence of prediabetes among the family members of individuals with diabetes. Findings from targeted screening program from south India.

AIM: We aimed to screen for prediabetes, diabetes and other cardiovascular risk factors among family members of people with diabetes registered for care in a primary health centre in South India. METHODS: During 2017-2018, we screened eligible family members of individuals with diabetes at their homes. We measured fasting capillary blood glucose (FCBG); for those with FCBG≥126 mg/dl, we confirmed the diagnosis of diabetes with fasting plasma glucose (FPG). We defined prediabetes as FCBG between 100 and 125 mg/dl; diabetes as both FCBG and FPG ≥126 mg/dl. We assessed non-communicable disease risk factors using WHO STEPS questionnaire. RESULTS: Of total 884 participants, 873 (99%) underwent screening; 280 (32%) had prediabetes, and 19 (2.2%) were confirmed with diabetes. Of newly diagnosed, 17 (90%) were initiated on treatment. Of 873 participants, 180 (20.6%) were newly diagnosed with hypertension. Of the total, 7.3%, 5.2% and 16% reported tobacco use, alcohol use and high salt intake respectively. Nearly half (48%) had overweight. CONCLUSION: Though the yield for diabetes is modest (3%), the house to house approach was able to screen 99% of eligible population. High prevalence of prediabetes and undiagnosed hypertension emphasize the need for screening and life style modifications.

Association between full service and fast food restaurant density, dietary intake and overweight/obesity among adults in Delhi, India.

BACKGROUND: The food environment has been implicated as an underlying contributor to the global obesity epidemic. However, few studies have evaluated the relationship between the food environment, dietary intake, and overweight/obesity in low- and middle-income countries (LMICs). The aim of this study was to assess the association of full service and fast food restaurant density with dietary intake and overweight/obesity in Delhi, India. METHODS: Data are from a cross-sectional, population-based study conducted in Delhi. Using multilevel cluster random sampling, 5364 participants were selected from 134 census enumeration blocks (CEBs). Geographic information system data were available for 131 CEBs (n = 5264) from a field survey conducted using hand-held global positioning system devices. The number of full service and fast food restaurants within a 1-km buffer of CEBs was recorded by trained staff using ArcGIS software, and participants were assigned to tertiles of full service and fast food restaurant density based on their resident CEB. Height and weight were measured using standardized procedures and overweight/obesity was defined as a BMI ≥25 kg/m2. RESULTS: The most common full service and fast food restaurants were Indian savory restaurants (57.2%) and Indian sweet shops (25.8%). Only 14.1% of full service and fast food restaurants were Western style. After adjustment for age, household income, education, and tobacco and alcohol use, participants in the highest tertile of full service and fast food restaurant density were less likely to consume fruit and more likely to consume refined grains compared to participants in the lowest tertile (both p < 0.05). In unadjusted logistic regression models, participants in the highest versus lowest tertile of full service and fast food restaurant density were significantly more likely to be overweight/obese: odds ratio (95% confidence interval), 1.44 (1.24, 1.67). After adjustment for age, household income, and education, the effect was attenuated: 1.08 (0.92, 1.26). Results were consistent with further adjustment for tobacco and alcohol use, moderate physical activity, and owning a bicycle or motorized vehicle. CONCLUSIONS: Most full service and fast food restaurants were Indian, suggesting that the nutrition transition in this megacity may be better characterized by the large number of unhealthy Indian food outlets rather than the Western food outlets. Full service and fast food restaurant density in the residence area of adults in Delhi, India, was associated with poor dietary intake. It was also positively associated with overweight/obesity, but this was largely explained by socioeconomic status. Further research is needed exploring these associations prospectively and in other LMICs.

Is the "South Asian Phenotype" Unique to South Asians?: Comparing Cardiometabolic Risk Factors in the CARRS and NHANES Studies.

BACKGROUND: In the context of rising obesity in South Asia, it is unclear whether the "South Asian phenotype"(described as high glucose, low high-density lipoprotein cholesterol, and high triglycerides at normal ranges of body weight) continues to be disproportionately exhibited by contemporary South Asians relative to other race/ethnic groups. OBJECTIVES: We assessed the distinctiveness of the South Asian cardiometabolic profile by comparing the prevalence of combined high glucose, high triglycerides, and low high-density lipoprotein cholesterol (combined dysglycemia and dyslipidemia) in resident South Asians with 4 race/ethnic groups in the United States (Asians, black persons, Hispanics, and white persons) overall and by body mass index (BMI) category. METHODS: South Asian data were from the 2010 to 2011 Center for Cardiometabolic Risk Reduction in South Asia Study, representative of Chennai and New Delhi, India and Karachi, Pakistan. U.S. data were from the 2011 to 2012 National Health and Nutrition Examination Survey, representative of the U.S. POPULATION: Combined dysglycemia and dyslipidemia was defined as fasting blood glucose ≥126 mg/dl and triglyceride/high-density lipoprotein cholesterol ratio >4. Logistic regression was used to estimate the relative odds and 95% confidence intervals of combined dysglycemia and dyslipidemia associated with each race/ethnic group (referent, U.S. white persons). Models were estimated among adults aged 20 to 79 years by sex and BMI category and accounted for age, education, and tobacco use. Data from 8,448 resident South Asians, 274 U.S. Asians, 404 U.S. black persons, 308 U.S. Hispanics, and 703 U.S. white persons without previously known diabetes were analyzed. RESULTS: In the normal body weight range of BMI 18.5 to 24.9 kg/m(2), the prevalence of combined dysglycemia and dyslipidemia among men and women, respectively, was 33% and 11% in resident South Asians, 15% and 1% in U.S. Asians, 5% and 2% in U.S. black persons, 11% and 2% in U.S. Hispanics, and 8% and 2% in U.S. white persons. Compared with U.S. whites persons, South Asians were more likely to present with combined dysglycemia and dyslipidemia at all categories of BMI for men and at BMI 18.5 to 29.9 for women in adjusted models. The most pronounced difference between South Asians and U.S. white persons was observed at normal weight (adjusted odds ratio: 4.98; 95% confidence interval: 2.46 to 10.07 for men) (adjusted odds ratio: 9.09; 95% confidence interval: 2.48 to 33.29 for women). CONCLUSIONS: Between 8% and 15% of U.S. men and 1% and 2% of U.S. women of diverse race/ethnic backgrounds exhibited dysglycemia and dyslipidemia at levels of body weight considered "healthy," consistent with the cardiometabolic profile described as the "South Asian Phenotype." Urban South Asians, however, were 5 to 9 times more likely to exhibit dysglycemia and dyslipidemia in the "healthy" BMI range compared with any other U.S. race/ethnic group.

Socioeconomic status and cardiovascular risk in urban South Asia: The CARRS Study.

BACKGROUND: Although South Asians experience cardiovascular disease (CVD) and risk factors at an early age, the distribution of CVD risks across the socioeconomic spectrum remains unclear. METHODS: We analysed the 2011 Centre for Cardiometabolic Risk Reduction in South Asia survey data including 16,288 non-pregnant adults (≥20 years) that are representative of Chennai and Delhi, India, and Karachi, Pakistan. Socioeconomic status (SES) was defined by highest education (primary schooling, high/secondary schooling, college graduate or greater); wealth tertiles (low, middle, high household assets) and occupation (not working outside home, semi/unskilled, skilled, white-collar work). We estimated age and sex-standardized prevalence of behavioural (daily fruit/vegetables; tobacco use), weight (body mass index; waist-to-height ratio) and metabolic risk factors (diabetes, hypertension, hypercholesterolaemia; hypo-HDL; and hypertriglyceridaemia) by each SES category. RESULTS: Across cities, 61.2% and 16.1% completed secondary and college educations, respectively; 52.8% reported not working, 22.9% were unskilled; 21.3% were skilled and 3.1% were white-collar workers. For behavioural risk factors, low fruit/vegetable intake, smoked and smokeless tobacco use were more prevalent in lowest education, wealthy and occupation (for men only) groups compared to higher SES counterparts, while weight-related risks (body mass index 25.0-29.9 and ≥30 kg/m(2); waist-to-height ratio ≥0.5) were more common in higher educated and wealthy groups, and technical/professional men. For metabolic risks, a higher prevalence of diabetes, hypertension and dyslipidaemias was observed in more educated and affluent groups, with unclear patterns across occupation groups. CONCLUSIONS: SES-CVD patterns are heterogeneous, suggesting customized interventions for different SES groups may be warranted. Different behavioural, weight, and metabolic risk factor prevalence patterns across SES indicators may signal on-going epidemiological transition in South Asia.

A cross-sectional study of the prevalence and correlates of tobacco use in Chennai, Delhi, and Karachi: data from the CARRS study.

BACKGROUND: Tobacco burdens in India and Pakistan require continued efforts to quantify tobacco use and its impacts. We examined the prevalence and sociodemographic and health-related correlates of tobacco use in Delhi, Chennai (India), and Karachi (Pakistan). METHODS: Analysis of representative surveys of 11,260 participants (selected through multistage cluster random sampling; stratified by gender and age) in 2011 measured socio-demographics, tobacco use history, comorbid health conditions, and salivary cotinine. We used bivariate and multivariate regression analyses to examine factors associated with tobacco use. RESULTS: Overall, 51.8 % were females, and 61.6 % were below the age of 45 years. Lifetime (ever) tobacco use prevalence (standardized for world population) was 45.0 %, 41.3 %, and 42.5 % among males, and 7.6 %, 8.5 %, and 19.7 % among females in Chennai, Delhi, and Karachi, respectively. Past 6 month tobacco use prevalence (standardized for world population) was 38.6 %, 36.1 %, and 39.1 % among males, and 7.3 %, 7.1 %, and 18.6 % among females in Chennai, Delhi, and Karachi, respectively. In multivariable regression analyses, residing in Delhi or Karachi versus Chennai; older age; lower education; earning less income; lower BMI; were each associated with tobacco use in both sexes. In addition, semi-skilled occupation versus not working and alcohol use were associated with tobacco use in males, and having newly diagnosed dyslipidemia was associated with lower odds of tobacco use among females. Mean salivary cotinine levels were higher among tobacco users versus nonusers (235.4; CI: 187.0-283.8 vs. 29.7; CI: 4.2, 55.2, respectively). CONCLUSION: High prevalence of tobacco use in the South Asian region, particularly among men, highlights the urgency to address this serious public health problem. Our analyses suggest targeted prevention and cessation interventions focused on lower socioeconomic groups may be particularly important.