Rationale, Design and Baseline Characteristics of a Randomized Controlled Trial of a Cardiovascular Quality Improvement Strategy in India: The C-QIP Trial.

BACKGROUND: Quality of chronic care for cardiovascular disease (CVD) remains suboptimal worldwide. The Collaborative Quality ImProvement (C-QIP) trial aims to develop and test the feasibility and clinical effect of a multicomponent strategy among patients with prevalent CVD in India. METHODS: The C-QIP is a clinic-based, open randomized trial of a multicomponent intervention versus usual care that was locally developed and adapted for use in Indian settings through rigorous formative research guided by Consolidated Framework for Implementation Research (CFIR). The C-QIP intervention consisted of 5 components: 1) electronic health records and decision support system for clinicians, 2) trained non-physician health workers (NPHW), 3) text-message based lifestyle reminders, 4) patient education materials, 5) quarterly audit and feedback reports. Patients with CVD (ischemic heart disease, ischemic stroke, or heart failure) attending outpatient CVD clinics were recruited from September 2022 to September 2023 and were randomized to the intervention or usual care arm for at least 12 months follow-up. The co-primary outcomes are implementation feasibility, fidelity (i.e., dose delivered and dose received), acceptability, adoption and appropriateness, measured at multiple levels: patient, provider and clinic site-level, The secondary outcomes include prescription of guideline directed medical therapy (GDMT) (provider-level), and adherence to prescribed therapy, change in mean blood pressure (BP) and LDL-cholesterol between the intervention and control groups (patient-level). In addition, a trial-based process and economic evaluations will be performed using standard guidelines. RESULTS: We recruited 410 socio-demographically diverse patients with CVD from four hospitals in India. Mean (SD) age was 57.5 (11.7) years, and 73.0% were males. Self-reported history of hypertension (48.5%) and diabetes (41.5%) was common. At baseline, mean (SD) BP was 127.9 (18.2) /76.2 (11.6) mm Hg, mean (SD) LDLc: 80.3 (37.3) mg/dl and mean (SD) HbA1c: 6.8% (1.6%). At baseline, the GDMT varied from 62.4% for patients with ischemic heart disease, 48.6% for ischemic stroke and 36.1% for heart failure. CONCLUSION: This study will establish the feasibility of delivering contextually relevant, and evidence-based C-QIP strategy and assess whether it is acceptable to the target populations. The study results will inform a larger scale confirmatory trial of a comprehensive CVD care model in low-resource settings. TRIAL REGISTRATION: Clinical Trials Registry India: CTRI/2022/04/041847; Clinicaltrials.gov number: NCT05196659.

Metabolic memory and diabetic retinopathy: Legacy of glycemia and possible steps into future.

The response of retinal pathology to interventions in diabetic retinopathy (DR) is often independent of the glycated hemoglobin (HbA1c) values at the point of care. This is despite glucose control being one of the strongest risk factors for the development and progression of DR. Previous preclinical and clinical research has indicated metabolic memory, whereby past cumulative glucose exposure may continue to impact DR for a prolonged period. Preclinical studies have evaluated punitive metabolic memory through poor initial control of DM, whereas clinical studies have evaluated protective metabolic memory through good initial control of DM. In this narrative review, we evaluate the preclinical and clinical evidence regarding metabolic memory and discuss how this may form the basis of preventive care for DR by inducing "metabolic amnesia" in people with a history of uncontrolled diabetes in the past. While our review suggested mitochondrial biology may be one such target, research is still far from a possible clinical trial. We discuss the challenges in such research.

Landscape of pharmacogenetic variants associated with non-insulin antidiabetic drugs in the Indian population.

INTRODUCTION: Genetic variants contribute to differential responses to non-insulin antidiabetic drugs (NIADs), and consequently to variable plasma glucose control. Optimal control of plasma glucose is paramount to minimizing type 2 diabetes-related long-term complications. India's distinct genetic architecture and its exploding burden of type 2 diabetes warrants a population-specific survey of NIAD-associated pharmacogenetic (PGx) variants. The recent availability of large-scale whole genomes from the Indian population provides a unique opportunity to generate a population-specific map of NIAD-associated PGx variants. RESEARCH DESIGN AND METHODS: We mined 1029 Indian whole genomes for PGx variants, drug-drug interaction (DDI) and drug-drug-gene interactions (DDGI) associated with 44 NIADs. Population-wise allele frequencies were estimated and compared using Fisher's exact test. RESULTS: Overall, we found 76 known and 52 predicted deleterious common PGx variants associated with response to type 2 diabetes therapy among Indians. We report remarkable interethnic differences in the relative cumulative counts of decreased and increased response-associated alleles across NIAD classes. Indians and South Asians showed a significant excess of decreased metformin response-associated alleles compared with other global populations. Network analysis of shared PGx genes predicts high DDI risk during coadministration of NIADs with other metabolic disease drugs. We also predict an increased CYP2C19-mediated DDGI risk for CYP3A4/3A5-metabolized NIADs, saxagliptin, linagliptin and glyburide when coadministered with proton-pump inhibitors (PPIs). CONCLUSIONS: Indians and South Asians have a distinct PGx profile for antidiabetes drugs, marked by an excess of poor treatment response-associated alleles for various NIAD classes. This suggests the possibility of a population-specific reduced drug response in atleast some NIADs. In addition, our findings provide an actionable resource for accelerating future diabetes PGx studies in Indians and South Asians and reconsidering NIAD dosing guidelines to ensure maximum efficacy and safety in the population.

The association of hypertension among married Indian couples: a nationally representative cross-sectional study.

Mounting evidence demonstrates that intimate partners sharing risk factors have similar propensities for chronic conditions such as hypertension. The objective was to study whether spousal hypertension was associated with one's own hypertension status independent of known risk factors, and stratified by socio-demographic subgroups (age, sex, wealth quintile, caste endogamy). Data were from heterosexual married couples (n = 50,023, women: 18-49y, men: 21-54y) who participated in the National Family Health Survey-V (2019-21). Hypertension was defined as self-reported diagnosis of hypertension or average of three blood pressure measurements ≥ 140 systolic or 90 mmHg diastolic BP. Among married adults, the prevalence of hypertension among men (38.8 years [SD: 8.3]) and women (33.9 years [SD: 7.9]) were 29.1% [95%CI: 28.5-29.8] and 20.6% [95%CI: 20.0-21.1] respectively. The prevalence of hypertension among both partners was 8.4% [95%CI: 8.0-8.8]. Women and men were more likely to have hypertension if their spouses had the condition (husband with hypertension: PR = 1.37 [95%CI: 1.30-1.44]; wife with hypertension: PR = 1.32 [95%CI: 1.26-1.38]), after adjusting for known risk factors. Spouse's hypertension status was consistently associated with own status across all socio-demographic subgroups examined. These findings present opportunities to consider married couples as a unit in efforts to diagnose and treat hypertension.

Adapting and scaling a proven diabetes prevention program across 11 worksites in India: the INDIA-WORKS trial.

Background: Delivery of proven structured lifestyle change education for reducing the burden of cardiometabolic diseases such as diabetes at worksites could overcome barriers to program adoption and improve sustainability and reach of these programs; however, tailoring to the worksite setting is essential. Methods: The Integrating Diabetes Prevention in Workplaces (INDIA-WORKS) study tested the implementation and effectiveness of a multi-level program for reducing cardiometabolic disease risk factors at eleven large and diverse worksites across India. Herein, we describe and classify program adaptations reported during in-depth interviews and focus group discussions with worksite managers, program staff, peer educators involved in program delivery, and program participants and drop-outs. We used thematic analysis to identify key themes in the data and classified reported program adaptations using the FRAME classification system. Results: Adaptations were led by worksite managers, peer educators, and program staff members. They occurred both pre- and during program implementation and were both planned (proactive) and unplanned (proactive and reactive). The most frequently reported adaptations to the individual-level intervention were curriculum changes to tailor lessons to the local context, make the program more appealing to the workers at the site, or add exercise options. Other content adaptations included improvements to the screening protocol, intervention scheduling, and outreach plans to tailor participant recruitment and retention to the sites. Environment-level content adaptations included expanding or leveraging healthy food and exercise options at the worksites. Challenges to adaptation included scheduling and worksite-level challenges. Participants discussed the need to continue adapting the program in the future to continue making it relevant for worksite settings and engaging for employees. Conclusion: This study describes and classifies site-specific modifications to a structured lifestyle change education program with worksite-wide health improvements in India. This adds to the literature on implementation adaptation in general and worksite wellness in India, a country with a large and growing workforce with, or at risk of, serious cardiometabolic diseases. This information is key for program scale-up, dissemination, and implementation in other settings. Trial Registration: Clinicaltrial.gov NCT02813668, registered June 27, 2016.

Bidirectionality between Cardiometabolic Diseases and COVID-19: Role of Humoral Immunity.

Cardiometabolic diseases and abnormalities have recently emerged as independent risk factors of coronavirus disease 2019 (COVID-19) severity, including hospitalizations, invasive mechanical ventilation, and mortality. Determining whether and how this observation translates to more effective long-term pandemic mitigation strategies remains a challenge due to key research gaps. Specific pathways by which cardiometabolic pathophysiology affects humoral immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and vice versa, remain unclear. This review summarizes current evidence of the bidirectional influences between cardiometabolic diseases (diabetes, adiposity, hypertension, CVDs) and SARS-CoV-2 antibodies induced from infection and vaccination based on human studies. Ninety-two studies among >408,000 participants in 37 countries on 5 continents (Europe, Asia, Africa, and North and South America) were included in this review. Obesity was associated with higher neutralizing antibody titers following SARS-CoV-2 infection. Most studies conducted prior to vaccinations found positive or null associations between binding antibodies (levels, seropositivity) and diabetes; after vaccinations, antibody responses did not differ by diabetes. Hypertension and CVDs were not associated with SARS-CoV-2 antibodies. Findings underscore the importance of elucidating the extent that tailored recommendations for COVID-19 prevention, vaccination effectiveness, screening, and diagnoses among people with obesity could reduce disease burden caused by SARS-CoV-2.

Couple concordance in diabetes, hypertension and dyslipidaemia in urban India and Pakistan and associated socioeconomic and household characteristics and modifiable risk factors.

BACKGROUND: Concordance in chronic disease status has been observed within couples. In urban India and Pakistan, little is known about couple concordance in diabetes, hypertension, and dyslipidaemia and associated socioeconomic characteristics and modifiable risk factors. METHODS: We analysed cross-sectional data from 2548 couples from the Centre for cArdio-metabolic Risk Reduction in South Asia cohort in Chennai, Delhi and Karachi. We estimated couple concordance in presence of ≥1 of diabetes, hypertension and dyslipidaemia (positive concordance: both spouses (W+H+); negative concordance: neither spouse (W-H-); discordant wife: only wife (W+H-); or discordant husband: only husband (W-H+)). We assessed associations of five socioeconomic and household characteristics, and six modifiable risk factors with couple concordance using multinomial logistic regression models with couples as the unit of analysis (reference: W-H-). RESULTS: Of the couples, 59.4% (95% CI 57.4% to 61.3%) were concordant in chronic conditions (W+H+: 29.2% (95% CI 27.4% to 31.0%); W-H-: 30.2% (95% CI 28.4%- to 32.0%)); and 40.6% (95% CI 38.7% to 42.6%) discordant (W+H-: 13.1% (95% CI 11.8% to 14.4%); W-H+: 27.6% (95% CI 25.9% to 29.4%)). Compared with couples with no conditions (W-H-), couples had higher relative odds of both having at least one condition if they had higher versus lower levels of: income (OR 2.03 (95% CI 1.47 to 2.80)), wealth (OR 2.66 (95% CI 1.98 to 3.58)) and education (wives' education: OR 1.92 (95% CI 1.29 to 2.86); husbands' education: OR 2.98 (95% CI 1.92 to 4.66)) or weight status (overweight or obesity in both spouses ORs 7.17 (95% CI 4.99 to 10.30)). CONCLUSIONS: Positive couple concordance in major chronic conditions is high in urban India and Pakistan, especially among couples with relatively higher socioeconomic position. This suggests that prevention and management focusing on couples at high risk for concordant chronic conditions may be effective and more so in higher socioeconomic groups.

Incidence of obesity across adulthood in the United States, 2001-2017-a national prospective analysis.

BACKGROUND: In the United States, the prevalence of obesity among adults has increased 3-fold since the 1980s, but patterns of incidence of new cases of obesity are not known. OBJECTIVES: To examine the incidence of new cases of obesity: overall, by demographic and educational subgroups, by weight status, and changes during this century. METHODS: We analyzed adult (≥20 y) anthropometric records from the US nationally representative Panel Study of Income Dynamics from 2001 to 2017. Among those not having obesity (body mass index, BMI, ≥30 kg/m2) at first observation, we used Poisson models to estimate the incidence of obesity [cases/1000 person-years (PYs)] and incidence rate ratio (IRR). RESULTS: Among 13,888 adults followed for 115,797 PYs, the incidence of obesity in 2001-2017 was 28.1/1000 PYs (95% CI: 26.7, 29.7). Over the periods 2001-2005, 2005-2009, and 2009-2013, the incidence of obesity was stable, but in 2013-2017 the incidence increased by 18% compared to 2009-2013 [IRR: 1.18 (95% CI: 1.06, 1.30)]. Blacks had higher obesity incidence [47.9/1000 PYs (95% CI: 42.7, 53.1)] than Whites [26.2/1000 PYs (95% CI: 24.6, 27.9)]. Risk was particularly high among Black females [57.9/1000 PYs (95% CI: 49.1, 66.8)] and Black young adults (20-29 y) [65.5/1000 PYs (95% CI: 54.2, 76.7)]. Across race, obesity incidence was highest in young adults (20-29 y) [34.1/1000 PYs (95% CI: 31.5, 36.7)] and declined with age [age 70+ y: 18.9/1000 PYs (95% CI: 16.6, 21.8)]. Those with overweight had an obesity risk 7 times higher than those with normal weight [62.1/1000 PYs (95% CI: 58.8, 65.3) vs. 8.8/1000 PYs (95% CI: 8.1, 9.6)]. Those with less than high-school education had higher obesity incidence than those with education beyond high-school [39.4/1000 PYs (95% CI: 34.4, 44.4) vs. 24.7/1000 PYs (95% CI: 23.1, 26.3)]. CONCLUSIONS: Incidence of obesity was stable over the first 13 y of the last 2 decades but increased by 18% in 2013-2017. Blacks and younger adults were at highest risk, and those with overweight were also at high risk for developing obesity.

HbA1c, blood pressure, and cholesterol control in adults with diabetes: A report card for Kuwait.

AIM: To assess the level of glycemic, blood pressure, and cholesterol control (the 'ABCs') nationally amongst adults with diabetes living in Kuwait. MATERIALS AND METHODS: Using data from two national cross-sectional surveys, the levels of risk factor control were assessed in 1,801 adults with diabetes, aged 18-82 years. Glycemic control was defined as HbA1c < 7%, blood pressure control as systolic and diastolic blood pressures of <140/90 mmHg, and non-HDL cholesterol control as <3.4 mmol/L. RESULTS: The percentage of adults with diabetes achieving control was 39.2% (95% CI, 37.0-41.5) for glycemia, 58.4% (95% CI, 56.0-60.7) for blood pressure, and 28.3% (95% CI, 26.3-30.4) for non-HDL cholesterol. The percentage of adults who were non-smokers was 77.6% (95%, CI 75.6-79.4). The percentage of adults with diabetes achieving control on all three risk factors was 7.4% (95% CI, 6.3-8.8), and only 5.8% (95% CI, 4.8-7.0) achieved ABC control and were nonsmokers. ABC control was 30% higher in women compared with men. Non-Kuwaitis were almost twice as likely to have uncontrolled ABC factors compared with Kuwaitis. CONCLUSIONS: Only 1 in 13 people with diabetes in Kuwait achieved good control of glycemia, blood pressure, and cholesterol. Only 2 in 5 achieved glycemic control, 6 in 10 blood pressure control, and 2 in 7 cholesterol control. A national diabetes quality improvement program is urgently needed to improve the quality of care and to prevent long-term complications.

Trends in depression by glycemic status: Serial cross-sectional analyses of the National Health and Nutrition Examination Surveys, 2005-2016.

AIMS: We examined changes in the prevalence of elevated depressive symptoms among US adults with diabetes, prediabetes, and normal glycemic status during 2005-2016. METHODS: We analyzed data from 32,676 adults in the 2005-2016 National Health and Nutrition Examination Surveys. We defined diabetes as self-reporting a physician diagnosis of diabetes or A1C ≥ 6.5% [48 mmol/mol], and prediabetes as A1C 5.7-6.4% [39-46 mmol/mol]. We used the 9-item Patient Health Questionnaire (PHQ-9) score ≥ 10 or antidepressant use to define 'clinically significant depressive symptoms' (CSDS) and PHQ-9 score ≥ 12 as 'Major Depressive Disorder' (MDD). We calculated prevalence age-standardized to the 2000 US census and used logistic-regression to compute adjusted odds of CSDS and MDD for 2005-2008, 2009-2012, and 2015-2016. We analyzed the prevalence of A1C ≥ 9.0% [75 mmol/mol], systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, non-HDL cholesterol ≥ 130 mg/dL, and current smoking among adults with diagnosed diabetes by depressive status. RESULTS: The prevalence of CSDS increased among individuals with normal glycemic status from 15.0% (13.5-16.2) to 17.3% (16.0-18.7) (p = 0.03) over 2005-2016. The prevalence of CSDS and MDD remained stable among adults with prediabetes (~ 16% and 1%, respectively) and diabetes (~ 26% and ~3%). After controlling for glycemic, sociodemographic, economic, and self-rated health variables, we found 2-fold greater odds of CSDS among unemployed individuals and 3-fold greater odds among those with fair/poor self-rated health across all survey periods. Cardiometabolic care targets for adults with diagnosed diabetes were stable from 2005 to 2016 and similar across depressive status. CONCLUSIONS: One-fourth of adults with diabetes have comorbid CSDS; this prevalence remained stable over 2005-2016 with no change in diabetes care. At the population level, depression does not appear to impact diabetes care, but further research could explore subgroups that may be more vulnerable and could benefit from integrated care that addresses both conditions.

Effectiveness and implementation of a lifestyle modification intervention for women with isolated impaired fasting glucose: Study protocol for a hybrid type 2 study in Kerala, India.

Background: Isolated impaired fasting glucose (i-IFG) constitutes a major group in the prediabetic spectrum among Indians, and thus it is imperative to identify effective diabetes prevention strategies. This study aims to evaluate the effects of an intensive community-based lifestyle modification program on regression to normoglycemia among women with i-IFG, compared to a control group at 24 months. The study also aims to evaluate the implementation of the intervention, via both process and implementation outcomes. Methods: We will use a hybrid design (Effectiveness-implementation hybrid type 2 trial) to test the effectiveness and implementation of the lifestyle modification intervention. Effectiveness is evaluated using a randomized controlled trial among 950 overweight or obese women, aged 30 to 60 years, with i-IFG on an oral glucose tolerance test in the Indian state of Kerala. The intervention involves an intensive lifestyle modification program through group and individually mentored sessions using behavioural determinants and behavioural change techniques.  The intervention group will receive the intervention for a period of 12 months and the control group will receive general health advice through a health education booklet. Data on behavioural, clinical, and biochemical measures will be collected using standard methods at 12 and 24 months. The primary outcome will be regression to normoglycemia at 24 months, as defined by the American Diabetes Association criteria. Discussion: This study will provide the first evidence on the effects of lifestyle interventions on regression to normoglycemia in people with i-IFG among Indians. CTRI registration: CTRI/2021/07/035289 (30/07/2021).

Demographic benchmarks for equitable coverage of the COVID-19 vaccination program among priority populations.

We report the demographic distribution of non-institutionalized populations in the US who are prioritized for COVID-19 vaccination by ethnicity, age and sex and region. The composition of non-institutionalized priority populations was estimated using a nationally representative sample of 25,417 adults interviewed in the National Health Interview Survey (NHIS) in 2018. A relatively large fraction of individuals prioritized for the earliest distribution of the vaccine are women, non-Hispanic Black, and young to middle aged adults. Overall, the study provides a platform to track equity in vaccine coverage and to better tailor health communication strategies.

A Comparison of Lipids and apoB in Asian Indians and Americans.

Background and aims: Apolipoprotein B (apoB) integrates and extends the information from the conventional measures of atherogenic cholesterol and triglyceride. To illustrate how apoB could simplify and improve the management of dyslipoproteinemia, we compared conventional lipid markers and apoB in a sample of Americans and Asian Indians. Methods: Data from the US National Health and Nutrition Examination Survey (NHANES) (11,778 participants, 2009-2010, 2011-2012), and the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) cohort study in Delhi, India (4244 participants), 2011 were evaluated. We compared means and distributions of plasma lipids, and apo B using the Mann-Whitney U test and Fisher's exact test. A p value of < 0.05 was considered significant. Results: The plasma lipid profile differed between Asian Indians and Americans. Plasma triglycerides were greater, but HDL-C lower in Asian Indians than in Americans. By contrast, total cholesterol, non-HDL-C, and LDL-C were all significantly higher in Americans than Asian Indians. However, apoB was significantly higher in Asian Indians than Americans. The LDL-C/apoB ratio and the non-HDL-C/apoB ratio were both significantly lower in Asian Indians than Americans. Conclusion: Whether Americans or Asian Indians are at higher risk from apoB lipoproteins cannot be determined based on their lipid levels because the information from lipids cannot be integrated. ApoB, however, integrates and extends the information from triglycerides and cholesterol. Replacing the conventional lipid panel with apoB for routine follow ups could simultaneously simplify and improve clinical care.

Consequences of access to water from managed aquifer recharge systems for blood pressure and proteinuria in south-west coastal Bangladesh: a stepped-wedge cluster-randomized trial.

BACKGROUND: Drinking-water salinity has been associated with high blood pressure (BP) among communities in south-west coastal Bangladesh. We evaluated whether access to water from managed aquifer recharge (MAR)-a hydrogeological intervention to lower groundwater salinity by infiltrating rainwater into the aquifers-can reduce community BP. METHODS: We conducted a stepped-wedge cluster-randomized trial with five monthly visits between December 2016 and April 2017 in 16 communities. At each visit following baseline, four communities were randomized to access MAR water. Systolic BP was the primary outcome, measured during each visit using Omron® HEM-907 devices. We also measured participants' 24-hour urinary sodium and households' drinking- and cooking-water salinity each visit. We used multilevel regression models to estimate the effects of MAR-water access on participants' BP. The primary analysis was intention-to-treat. RESULTS: In total, 2911 person-visits were conducted in communities randomized to have MAR-water access and 2834 in communities without MAR-water access. Households without MAR-water access predominantly used low-salinity pond water and 42% (range: 26-50% across visits) of households exclusively consumed MAR water when access was provided. Communities randomized to MAR-water access had 10.34 [95% confidence interval (CI): 1.11, 19.58] mmol/day higher mean urinary sodium, 1.96 (95% CI: 0.66, 3.26; p = 0.004) mmHg higher mean systolic BP and 1.44 (95% CI: 0.40, 2.48; p = 0.007) mmHg higher mean diastolic BP than communities without MAR-water access. CONCLUSIONS: Our findings do not support the scale-up of MAR systems as a routine drinking-water source, since communities that shifted to MAR water from the lower-salinity pond-water source had higher urinary sodium and BP.

Do attributes of persons with chronic kidney disease differ in low-income and middle-income countries compared with high-income countries? Evidence from population-based data in six countries.

Kidney biopsies to elucidate the cause of chronic kidney disease (CKD) are performed in a minority of persons with CKD living in high-income countries, since associated conditions-that is, diabetes mellitus, vascular disease or obesity with pre-diabetes, prehypertension or dyslipidaemia-can inform management targeted at slowing CKD progression in a majority. However, attributes of CKD may differ substantially among persons living in low-income and middle-income countries (LMICs). We used data from population or community-based studies from five LMICs (China, urban India, Moldova, Nepal and Nigeria) to determine what proportion of persons with CKD living in diverse regions fit one of the three major clinical profiles, with data from the US National Health Nutrition and Examination Survey as reference. In the USA, urban India and Moldova, 79.0%-83.9%; in China and Nepal, 62.4%-66.7% and in Nigeria, 51.6% persons with CKD fit one of three established risk profiles. Diabetes was most common in urban India and vascular disease in Moldova (50.7% and 33.2% of persons with CKD in urban India and Moldova, respectively). In Nigeria, 17.8% of persons with CKD without established risk factors had albuminuria ≥300 mg/g, the highest proportion in any country. While the majority of persons with CKD in LMICs fit into one of three established risk profiles, the proportion of persons who have CKD without established risk factors is higher than in the USA. These findings can inform tailored CKD detection and management systems and highlight the importance of studying potential causes and outcomes of CKD without established risk factors in LMICs.

Park availability and major depression in individuals with chronic conditions: Is there an association in urban India?

Green space exposure has been positively correlated with better mental-health indicators in several high income countries, but has not been examined in low- and middle-income countries undergoing rapid urbanization. Building on a study of mental health in adults with a pre-existing chronic condition, we examined the association between park availability and major depression among 1208 adults surveyed in Delhi, India. Major depression was measured using the Mini International Neuropsychiatric Interview. The ArcGIS platform was used to quantify park availability indexed as (i) park distance from households, (ii) area of the nearest park; and within one km buffer area around households - the (iii) number and (iv) total area of all parks. Mixed-effects logistic regression models adjusted for socio-demographic characteristics indicated that relative to residents exposed to the largest nearest park areas (tertile 3), the odds [95% confidence interval] of major depression was 3.1 [1.4-7.0] times higher among residents exposed to the smallest nearest park areas (tertile 1) and 2.1 [0.9-4.8] times higher in residents with mid-level exposure (tertile 2). There was no statistically significant association between other park variables tested and major depression. We hypothesized that physical activity in the form of walking, perceived stress levels and satisfaction with the neighborhood environment may have mediating effects on the association between nearest park area and major depression. We found no significant mediation effects for any of our hypothesized variables. In conclusion, our results provide preliminary and novel evidence from India that availability of large parks in the immediate neighborhood positively impacts mental well-being of individuals with pre-existing chronic conditions, at the opportune time when India is embarking on the development of sustainable cities that aim to promote health through smart urban design - one of the key elements of which is the inclusion of urban green spaces.

Development and evaluation of a Nutrition Transition-FFQ for adolescents in South India.

OBJECTIVE: To develop and evaluate a Nutrition Transition-FFQ (NT-FFQ) to measure nutrition transition among adolescents in South India. DESIGN: We developed an interviewer-administered NT-FFQ comprising a 125-item semi-quantitative FFQ and a twenty-seven-item eating behaviour survey. The reproducibility and validity of the NT-FFQ were assessed using Spearman correlations, intra-class correlation coefficients (ICC), and levels of agreement using Bland-Altman and cross-classification over 2 months (NT-FFQ1 and NT-FFQ2). Validity of foods was evaluated against three 24-h dietary recalls (24-HR). Face validity of eating behaviours was evaluated through semi-structured cognitive interviews. The reproducibility of eating behaviours was assessed using weighted kappa (κ w) and cross-classification analyses. SETTING: Vijayapura, India. SUBJECTS: A representative sample of 198 adolescents aged 14-18 years. RESULTS: Reproducibility of NT-FFQ: Spearman correlations ranged from 0·33 (pulses) to 0·80 (red meat) and ICC from 0·05 (fruits) to 1·00 (tea). On average, concordance (agreement) was 60 % and discordance was 7 % for food groups. For eating behaviours, κ w ranged from 0·24 (eating snacks while watching television) to 0·67 (eating lunch at home) with a mean of 0·40. Validity of NT-FFQ: Spearman correlations ranged from 0·11 (fried traditional foods) to 0·70 (tea) and ICC ranged from 0·02 (healthy global foods) to 1·00 (grains). The concordance and discordance were 48 % and 8 %, respectively. Bland-Altman plots showed acceptable agreement between NT-FFQ2 and 24-HR. The eating behaviours had acceptable face validity. CONCLUSIONS: The NT-FFQ has good reproducibility and acceptable validity for food intake and eating behaviours. The NT-FFQ can quantify the nutrition transition among Indian adolescents.

Input of stakeholders on reducing depressive symptoms and improving diabetes outcomes in India: Formative work for the INDEPENDENT Study.

AIMS: Depression and diabetes are highly comorbid, adversely affecting treatment adherence and resulting in poor outcomes. To improve treatment and outcomes for people dually-affected by diabetes and depression in India, we aimed to develop and test an integrated care model. In the formative phase of this INtegrated DEPrEssioN and Diabetes TreatmENT (INDEPENDENT) study, we sought stakeholder perspectives to inform culturally-sensitive adaptations of the intervention. METHODS: At our Delhi, Chennai, and Vishakhapatnam sites, we conducted focus groups for patients with diabetes and depression and interviewed healthcare workers, family members, and patients. These key informants were asked about experiences with diabetes and depression and for feedback on intervention materials. Data were analyzed using a grounded theory approach. RESULTS: Three major themes emerged that have bearing on adaptation of the proposed intervention: importance of family assistance, concerns regarding patient/family understanding of diabetes, and feedback regarding the proposed intervention (e.g. adequate time needed for implementation; training program and intervention should address stigma). CONCLUSIONS: Based on our findings, the following components would add value when incorporated into the intervention: 1) engaging families in the treatment process, 2) clear/simple written information, 3) clear non-jargon verbal explanations, and 4) coaching to help patients cope with stigma.

Diabetes prevention: global health policy and perspectives from the ground.

Type 2 diabetes and other noncommunicable diseases are a growing public health challenge globally. An estimated 285 million people, corresponding to 6.4% of the world's adult population, has diabetes, which is expected to reach 552 million by the International Diabetes Federation in 2030. A much larger segment of the world's population, approximating 79 million individuals in the USA alone, has prediabetes. Globally, a relatively small percentage of those with diabetes or prediabetes are diagnosed with the potential for developing chronic complications. To address this epidemic, governments, in concert with the private sector, need to set policies that promote healthy nutritional and agricultural policies, favor modifications in the environment that encourage greater physical activity and make prevention affordable for all citizens at high risk. The public health sector has the charge of translating evidence-based findings into practical, accessible and cost-effective programs and monitoring the process to continuously improve prevention initiatives. The clinical sector has the formidable challenge of screening and identifying those at high risk and referring them to accredited intervention programs. There is a need to explore additional cost-effective interventions that are customized to meet individual needs that can be offered at the community and clinical levels. Thus, all three sectors, government, public health and clinical, each have a critical role in this process and by working in a partnership, ought to create the necessary synergies essential for making substantial forays in the prevention of Type 2 diabetes.