Prevalence and Correlates of Vitamin D Deficiency among Adult Population in Urban and Rural Areas of the National Capital Region of Delhi, India.

ABSTRACT: High prevalence of Vitamin D deficiency has been reported among selective population, but its population prevalence from representative adult population is lacking in India. The aim of this study was to estimate the prevalence and identify the correlates of Vitamin D deficiency among urban and rural areas of the National Capital Region (NCR) of Delhi, India. Serum Vitamin D levels of 1403 adults (aged 30 years above), 702 from urban and 701 from rural NCR of Delhi, who participated in a representative cross-sectional survey were measured using the quantitative chemiluminescent immunoassay method. The prevalence of Vitamin D deficiency was classified as severe deficient, and insufficient at three serum levels of 25-hydroxyvitamin D-<10, 10-<20, and 20-<30 ng/mL, respectively. The median (interquartile range) 25-hydroxyvitamin D levels in urban and rural areas were 7.7 (5.2, 10.8) ng/mL and 16.2 (10.9, 22.3) ng/mL, respectively. The prevalence of Vitamin D severe deficiency, deficiency, and insufficiency in urban areas were 71%, 27%, and 2%, respectively. The corresponding prevalence in rural areas was 20%, 47%, and 25%. Urban location (odds ratio [OR] [95% confidence interval [CI]: 11.7 [8.6, 15.9]), female gender (OR [95% CI]: 1.5 [1.1, 2.2]), and abdominal obesity (OR [95% CI]:1.5 [1.1, 2.0]) were independently associated with severe deficiency. This study revealed a high prevalence of severe vitamin deficiency among the adult living in NCR, more so among urban areas, women, and obese.

A multi-center pediatric to adult care transition intervention program to improve clinic visit adherence and clinical outcomes among adolescents and emerging adults with type 1 diabetes mellitus [PATHWAY]: Protocol for a randomized controlled trial.

OBJECTIVE: This multi-center randomized controlled trial aims to evaluate the effectiveness of a context-specific transition intervention program to improve clinic visit adherence and clinical outcomes among emerging adults with type 1 diabetes mellitus (T1DM) in Delhi, India. METHODS: We will recruit patients with T1DM of duration ≥1 year and age 15-19.5 years from the participating pediatric sites. After a baseline assessment and a "basic introductory session", which apprises participants about the concept of transition, study participants (proposed sample size =156) will be randomly allocated into an intervention and control arm. Participants in the intervention arm will receive a structured transition program delivered over 15 months. On the other hand, control arm participants will continue to receive usual care from the pediatric site till the time of transfer to the adult site. The study assessments will be done at baseline, at the time of transfer, and at 1 and 2 years following the transfer. The primary outcome is the difference in clinic attendance rate between intervention and control arms at the end of 1 year post-transfer. The secondary outcomes include the difference in clinic attendance rate at the end of 2 years, the difference in proportion of participants with a minimum of 4 visits in the first follow-up year, and process indicators such as diabetes knowledge and self-management skills, diabetes treatment satisfaction, overall quality of life, diabetes-related distress, hospitalization for acute complications and screening for chronic diabetes complications, and HbA1c. CONCLUSION: This study will provide important new evidence about a potential strategy to improve clinical care among adolescents and emerging adults with T1DM in lower resource contexts during the vulnerable phase of transition from pediatric to adult healthcare. The trial is registered on the Clinical Trials Registry of India (http://ctri.nic.in) under the CTRI registration number CTRI/2020/10/028379.

Cardiovascular disease risk profile of Indian young adults with type 1 diabetes compared to general population - A sub-study from the Young Diabetes Registry (YDR), India.

OBJECTIVE: We estimated the prevalence of traditional CVD risk factors among young adults with type 1 diabetes and compared them with the general population without diabetes. METHODS: Participants were young adults (aged 20 years and above) with type 1 diabetes, from the Delhi and Chennai sites of the ICMR -Young Diabetes Registry (YDR) and their age, gender and location matched controls, without diabetes from the CARRS (Cardio metabolic Risk Reduction in South Asia) cohort. YDR and CARRS used similar standard methodologies to quantify the CVD risk factors. Linear and logistic regression models were used to compare the adjusted means and proportions of risk factors. RESULTS: Individuals with type 1 diabetes had lower levels of mean BMI (21.9 kg/m2 vs 24.3 kg/m2), waist circumference (76.8 cm vs 82.1 cm), favourable lipid profile (lower LDL and higher HDL), higher mean systolic blood pressure (122.1 mmHg vs 118.7 mmHg) and hypertension (29.2% vs 21.0%), compared to controls. The extent of clustering of two or more traditional CVD risk factors was higher among general population compared to people with type 1 diabetes. CONCLUSION: We found that young adults with type 1 diabetes have relatively low prevalence and clustering of traditional CVD risk factors compared to general population.

Development and design of the first structured clinic-based program in lower resource settings to transition emerging adults with type 1 diabetes from pediatric to adult care.

INTRODUCTION: Type 1 diabetes (T1D) is increasing in young people worldwide and more children in resource limited settings are living into adulthood. There is a need for rigorous testing and reporting of evidence-based and stakeholder-informed strategies that transition individuals with T1D from pediatric to adult care. We present the development of and design of the first structured transition program in Delhi, India, to inform similar efforts in India and resource limited settings. METHODS: The intervention development team included clinicians and researchers with expertise in T1D and the implementation context. To select intervention outcomes, establish intervention targets, and design session modules, we drew upon formative research conducted at prospective intervention implementation sites, consensus guidelines, and previous care transition and behavior change research conducted in developed settings. We used the Template for Intervention Description and Replication and GUIDance for the rEporting of intervention Development checklists to report the intervention and development process. RESULTS: The 15-month program ("PATHWAY") includes five quarterly ~30 minute sessions delivered predominantly by diabetes educators at pediatric and adult clinics, which coincide with routine care visits. Primary program components include educational and behavioral sessions that address psychosocial drivers of clinic attendance and self-management, diabetes educators as transition coordinators and counselors, and a one-year "overlap period" of alternating visits between pediatric and adult providers. CONCLUSIONS: We followed a systematic and transparent process to develop PATHWAY, which facilitated rich description of intervention context, guiding principles, targets, and components. Dependence on previously published program examples to design PATHWAY may have introduced challenges for program feasibility and effectiveness, underscoring the importance of input gathering from prospective intervention actors at multiple points in the development process. This detailed report in combination with future evaluations of PATHWAY support efforts to increase rigorous development and testing of strategies to improve outcomes among emerging adults with T1D.

SARS-CoV-2 Seroprevalence in Individuals With Type 1 and Type 2 Diabetes Compared With Controls.

OBJECTIVE: Data for the association between diabetes and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) susceptibility are conflicting. We aimed to evaluate this association using an analytical cross-sectional study design. METHODS: Study participants were recruited from endocrine clinics of our hospital and belonged to 3 groups: group 1 (type 1 diabetes mellitus [T1DM]), group 2 (type 2 diabetes mellitus [T2DM]), and group 3 (controls). All participants submitted blood samples for SARS-CoV-2 S1/S2 immunoglobulin G antibody test (LIAISON; DiaSorin) and were interviewed for a history of documented infection. RESULTS: We evaluated a total of 643 participants (T1DM, 149; T2DM, 160; control, 334; mean age, 37.9 ± 11.5 years). A total of 324 (50.4%) participants were seropositive for SARS-CoV-2. The seropositivity rate was significantly higher in the T1DM (55.7% vs 44.9%, P = .028) and T2DM (56.9% vs 44.9%, P = .013) groups than in the control group. The antibody levels in seropositive participants with T1DM and T2DM were not significantly different from those in seropositive controls. On multivariable analysis, low education status (odds ratio [OR], 1.41 [95% CI, 1.03-1.94]; P = .035), diabetes (OR, 1.68 [95% CI, 1.20-2.34]; P = .002), and overweight/obesity (OR, 1.52 [95% CI, 1.10-2.10]; P = .012) showed a significant association with SARS-CoV-2 seropositivity. The association between diabetes and SARS-CoV-2 seropositivity was found to further increase in participants with coexisting overweight/obesity (adjusted OR, 2.63 [95% CI, 1.54-4.47]; P < .001). CONCLUSION: SARS-CoV-2 seropositivity, assessed before the onset of the national vaccination program, was significantly higher in participants with T1DM and T2DM than in controls. The antibody response did not differ between seropositive participants with and without diabetes. These findings point toward an increased SARS-CoV-2 susceptibility for patients with diabetes, in general, without any differential effect of the diabetes type.

Diabetic ketoacidosis at diagnosis among youth with type 1 and type 2 diabetes: Results from SEARCH (United States) and YDR (India) registries.

BACKGROUND: There is significant global variation in the prevalence of diabetic ketoacidosis (DKA) at diagnosis among youth with type 1 diabetes (T1D). However, data for youth with type 2 diabetes (T2D) are limited, even in developed countries. We compared the prevalence of DKA at diagnosis among individuals with T1D and T2D from the SEARCH for Diabetes in Youth (SEARCH) and the Registry of Youth Onset Diabetes in India (YDR) registries. METHODS: We harmonized the SEARCH and YDR registries to the structure and terminology in the Observational Medical Outcome Partnership Common Data Model. Data used were from youth with T1D and T2D diagnosed before 20 years and newly diagnosed between 2006 and 2012 in YDR and 2009 and 2012 in SEARCH. RESULTS: There were 5366 US youth (4078 with T1D, 1288 with T2D) and 2335 Indian youth (2108 with T1D, 227 with T2D). More than one third of T1D youth enrolled in SEARCH had DKA at diagnosis which was significantly higher than in YDR (35.3% vs 28.7%, P < .0001). The burden of DKA in youth with T1D was significantly higher among younger age groups; this relationship was similar across registries (P = .4). The prevalence of DKA among T2D in SEARCH and YDR were 5.5% and 6.6% respectively (P = .4). CONCLUSIONS: There is significant burden of DKA at diagnosis with T1D among youth from United States and India, especially among the younger age groups. The reasons for this high prevalence are largely unknown but are critical to developing interventions to prevent DKA at diagnosis.

Clinical profile at diagnosis with youth-onset type 1 and type 2 diabetes in two pediatric diabetes registries: SEARCH (United States) and YDR (India).

BACKGROUND: Over the last decades, diabetes in youth has increased in both India and the United States, along with the burden of long-term complications and healthcare costs. However, there are limited standardized population-based data in contemporary youth cohorts for comparison of clinical and demographic characteristics of diabetes for both type 1 (T1D) and type 2 (T2D). METHODS: In partnership, we harmonized demographic and clinical data from the SEARCH for Diabetes in Youth (SEARCH) registry in the United States and the Registry of People with Diabetes with Youth Age at Onset (YDR) in India to the structure and terminology of the Observational Medical Outcomes Partnership Common Data Model. Data were from youth with T1D and T2D, aged <20 years and newly diagnosed between 2006 and 2010. We compared key characteristics across registries using χ2 tests and t-tests. RESULTS: In total, there were 9650 youth with T1D and 2406 youth with T2D from 2006 to 2012. SEARCH youth were diagnosed at younger ages than YDR youth for T1D and T2D (10.0 vs 10.5 years, P < .001 and 14.7 vs 16.1 years, P < .001, respectively). For T2D, SEARCH had a higher proportion of females and significantly lower proportion of youth of high socioeconomic status compared to YDR. For T1D and T2D, SEARCH youth had higher BMI, lower blood pressure, and lower A1c compared to YDR youth. CONCLUSIONS: These data offer insights into the demographic and clinical characteristics of diabetes in youth across the two countries. Further research is needed to better understand why these differences exist.

Demographic and clinical profile of youth onset diabetes patients in India-Results from the baseline data of a clinic based registry of people with diabetes in India with young age at onset-[YDR-02].

BACKGROUND: We here report the demographic and clinical profile of the patients enrolled in the Indian Council of Medical Research funded Registry of people with diabetes in India with young age at onset (YDR) from 1 January 2000 to 31 July 2011. METHODS: The YDR registry recruits all diabetes cases (newly diagnosed or treated) reporting on or after 1 January 2000 with age of diagnosis ≤25 years, and residing within the assigned geographical area of the reporting centres. A baseline proforma was used to obtain information on demographic and clinical details at registration. RESULTS: The registry has enrolled 5546 patients (49.5% male; 50.5% female) with youth onset diabetes from 205 reporting centres linked to 8 regional collaborating centres (RCC) across India. T1DM (63.9%; n = 3545) and T2DM (25.3%; n = 1401) were the commonest variants of youth onset diabetes, though their relative proportion varied across RCCs. The mean (SD) age at diagnosis for T1DM was 12.9 (6.5) years, while that for T2DM was 21.7 (3.7) years. Nearly half the T1DM patients were registered within 6 months of the onset of disease. Most cases of T2DM (47.3%) were registered after 3 years from their date of diagnosis. 56.1% of patients had at least one episode of hospitalization at registration. CONCLUSION: The observations from YDR registry indicate the need to establish a surveillance system in India to monitor diabetes in youth, not only to understand its complex etiology and natural history but also due to its detrimental socio economic impact.

Treatment regimens and glycosylated hemoglobin levels in youth with Type 1 and Type 2 diabetes: Data from SEARCH (United States) and YDR (India) registries.

OBJECTIVE: To compare treatment regimens and glycosylated hemoglobin (A1c) levels in Type 1 (T1D) and Type 2 diabetes (T2D) using diabetes registries from two countries-U.S. SEARCH for Diabetes in Youth (SEARCH) and Indian Registry of youth onset diabetes in India (YDR). METHODS: The SEARCH and YDR data were harmonized to the structure and terminology in the Observational Medical Outcomes Partnership Common Data Model. Data used were from T1D and T2D youth diagnosed <20 years between 2006-2012 for YDR, and 2006, 2008, and 2012 for SEARCH. We compared treatment regimens and A1c levels across the two registries. RESULTS: There were 4003 T1D (SEARCH = 1899; YDR = 2104) and 611 T2D (SEARCH = 384; YDR = 227) youth. The mean A1c was higher in YDR compared to SEARCH (T1D:11.0% ± 2.9% vs 7.8% ± 1.7%, P < .001; T2D:9.9% ± 2.8% vs 7.2% ± 2.1%, P < .001). Among T1D youth in SEARCH, 65.1% were on a basal/bolus regimen, whereas in YDR, 52.8% were on once/twice daily insulin regimen. Pumps were used by 16.2% of SEARCH and 1.5% of YDR youth with T1D. Among T2D youth, in SEARCH and YDR, a majority were on metformin only (43.0% vs 30.0%), followed by insulin + any oral hypoglycemic agents (26.3% vs 13.7%) and insulin only (12.8% vs 18.9%), respectively. CONCLUSION: We found significant differences between SEARCH and YDR in treatment patterns in T1D and T2D. A1c levels were higher in YDR than SEARCH youth, for both T1D and T2D, irrespective of the regimens used. Efforts to achieve better glycemic control for youth are urgently needed to reduce the risk of long-term complications.

Comparison of the incidence of diabetes in United States and Indian youth: An international harmonization of youth diabetes registries.

OBJECTIVE: Incidence of youth-onset diabetes in India has not been well described. Comparison of incidence, across diabetes registries, has the potential to inform hypotheses for risk factors. We sought to compare the incidence of diabetes in the U.S.-based registry of youth onset diabetes (SEARCH) to the Registry of Diabetes with Young Age at Onset (YDR-Chennai and New Delhi regions) in India. METHODS: We harmonized data from both SEARCH and YDR to the Observational Medical Outcomes Partnership (OMOP) Common Data Model. Data were from youth registered with incident diabetes (2006-2012). Denominators were from census and membership data. We calculated diabetes incidence by averaging the total cases across the entire follow-up period and dividing this by the estimated census population corresponding to the source population for case ascertainment. Incidence was calculated for each of the registries and compared by type and within age and sex categories using a 2-sided, skew-corrected inverted score test. RESULTS: Incidence of type 1 was higher in SEARCH (21.2 cases/100 000 [95% CI: 19.9, 22.5]) than YDR (4.9 cases/100 000 [95% CI: 4.3, 5.6]). Incidence of type 2 diabetes was also higher in SEARCH (5.9 cases/100 000 [95% CI: 5.3, 6.6] in SEARCH vs 0.5/cases/100 000 [95% CI: 0.3, 0.7] in YDR). The age distribution of incident type 1 diabetes cases was similar across registries, whereas type 2 diabetes incidence was higher at an earlier age in SEARCH. Sex differences existed in SEARCH only, with a higher rate of type 2 diabetes among females. CONCLUSION: The incidence of youth-onset type 1 and 2 diabetes was significantly different between registries. Additional data are needed to elucidate whether the differences observed represent diagnostic delay, differences in genetic susceptibility, or differences in distribution of risk factors.

Change in prevalence of Coronary Heart Disease and its risk between 1991-94 to 2010-12 among rural and urban population of National Capital Region, Delhi.

OBJECTIVES: We aimed to measure the change in prevalence of Coronary Heart Disease (CHD) and Cardiovascular Diseases (CVDs) risk among those aged 35-64 years in urban and rural areas of National Capital Region (NCR) of Delhi, between 1991-1994 (survey 1) and 2010-2012 (survey 2). METHODS: Both surveys used similar sampling methodology and mean ages of participants were similar. A total of 3048 and 2052 subjects were studied in urban Delhi and 2487 and 1917 participants recruited from rural Ballabgarh in survey 1 and in survey 2 respectively. CHD was diagnosed based on a Minnesota coded ECG and Rose angina questionnaire. Data on behavioural, physical, clinical and biochemical parameters were collected using standard methods. CVD Risk of participants was calculated using the gender specific Framingham risk equation. RESULTS: The age and sex standardised prevalence of CHD in urban Delhi increased from 10.3% (95% CI: 9.2-11.4) to 14.1% (95% CI: 12.6-15.6) between the two surveys as compared to an increase from 6.0% (95% CI: 5.0-6.9) to 7.4% (95% CI: 6.3-8.6) in rural Ballabgarh. The highest increase in the prevalence of CHD was reported among urban women (10.1% to 16.6%).The proportion of population with high 10-year CVD risk increased to 4.1% from 1.2% in rural areas as compared to 4.8% from 2.5% in urban areas. CONCLUSIONS: The CHD and CVD risk has increased over 20 years period in and around Delhi and the increase was more in rural population and women, traditionally considered to be at low risk.

Yoga-Based Cardiac Rehabilitation After Acute Myocardial Infarction: A Randomized Trial.

BACKGROUND: Given the shortage of cardiac rehabilitation (CR) programs in India and poor uptake worldwide, there is an urgent need to find alternative models of CR that are inexpensive and may offer choice to subgroups with poor uptake (e.g., women and elderly). OBJECTIVES: This study sought to evaluate the effects of yoga-based CR (Yoga-CaRe) on major cardiovascular events and self-rated health in a multicenter randomized controlled trial. METHODS: The trial was conducted in 24 medical centers across India. This study recruited 3,959 patients with acute myocardial infarction with a median and minimum follow-up of 22 and 6 months. Patients were individually randomized to receive either a Yoga-CaRe program (n = 1,970) or enhanced standard care involving educational advice (n = 1,989). The co-primary outcomes were: 1) first occurrence of major adverse cardiovascular events (MACE) (composite of all-cause mortality, myocardial infarction, stroke, or emergency cardiovascular hospitalization); and 2) self-rated health on the European Quality of Life-5 Dimensions-5 Level visual analogue scale at 12 weeks. RESULTS: MACE occurred in 131 (6.7%) patients in the Yoga-CaRe group and 146 (7.4%) patients in the enhanced standard care group (hazard ratio with Yoga-CaRe: 0.90; 95% confidence interval [CI]: 0.71 to 1.15; p = 0.41). Self-rated health was 77 in Yoga-CaRe and 75.7 in the enhanced standard care group (baseline-adjusted mean difference in favor of Yoga-CaRe: 1.5; 95% CI: 0.5 to 2.5; p = 0.002). The Yoga-CaRe group had greater return to pre-infarct activities, but there was no difference in tobacco cessation or medication adherence between the treatment groups (secondary outcomes). CONCLUSIONS: Yoga-CaRe improved self-rated health and return to pre-infarct activities after acute myocardial infarction, but the trial lacked statistical power to show a difference in MACE. Yoga-CaRe may be an option when conventional CR is unavailable or unacceptable to individuals. (A study on effectiveness of YOGA based cardiac rehabilitation programme in India and United Kingdom; CTRI/2012/02/002408).

Screening model for diabetic retinopathy among patients with type 1 diabetes attending a tertiary care setting in India.

Diabetic retinopathy (DR) is a common microvascular complication in young individuals with type 1 diabetes. It is recommended to implement structured screening programs and adopt an appropriate referral mechanism at all levels of the health system to prevent vision loss in this disease. We developed and pilot-tested the feasibility of a comprehensive DR screening model at a tertiary care diabetes clinic in India. The model comprised an affordable DR screening facility at the diabetes clinic, structured education sessions, and annual inhospital diabetes complication screening camps. Over the span of 2 years, we screened 413 eligible patients with type 1 diabetes and 17.4% (n = 72) had any form of DR in at least one eye. Half of the retinopathy positive patients had mild DR. However, only one-third of newly diagnosed patients reported to the eye care facility for DR management. Based on this study, it is feasible to screen all patients with type 1 diabetes for DR by increasing awareness and providing opportunities for DR screening at a tertiary care diabetes clinic. Our model combined with formal referral and follow-up systems would be a potentially scalable approach for DR prevention and management at diabetes care facilities in India.

Development of a Yoga-Based Cardiac Rehabilitation (Yoga-CaRe) Programme for Secondary Prevention of Myocardial Infarction.

Cardiac rehabilitation (CR) after myocardial infarction is highly effective. It is unavailable in public hospitals in India due to limited resources. Our objective was to develop a scalable model of CR for India based on yoga, which could also appeal to some groups with low uptake of CR (e.g., ethnic minorities, women, and older people) globally. The intervention was developed using a structured process. A literature review and consultations with yoga experts, CR experts, and postmyocardial infarction patients were conducted to systematically identify and shortlist appropriate yoga exercises and postures, breathing exercises, meditation and relaxation practices, and lifestyle changes, which were incorporated into a conventional CR framework. The draft intervention was further refined based on the feedback from an internal stakeholder group and an external panel of international experts, before being piloted with yoga instructors and patients with myocardial infarction. A four-phase yoga-based CR (Yoga-CaRe) programme was developed for delivery by a single yoga instructor with basic training. The programme consists of a total of 13 instructor-led sessions (2 individual and 11 group) over a 3-month period. Group sessions include guided practice of yoga exercises and postures, breathing exercises, and meditation and relaxation practices, and support for the lifestyle change and coping through a moderated discussion. Patients are encouraged to self-practice daily at home and continue long-term with the help of a booklet and digital video disc (DVD). Family members/carers are encouraged to join throughout. In conclusion, a novel yoga-based CR programme has been developed, which promises to provide a scalable CR solution for India and an alternative choice for CR globally. It is currently being evaluated in a large multicentre randomised controlled trial across India.

Effectiveness and cost-effectiveness of a Yoga-based Cardiac Rehabilitation (Yoga-CaRe) program following acute myocardial infarction: Study rationale and design of a multi-center randomized controlled trial.

BACKGROUND: Cardiac rehabilitation (CR) is a standard treatment for secondary prevention of acute myocardial infarction (AMI) in high income countries (HICs), but it is inaccessible to most patients in India due to high costs and skills required for multidisciplinary CR teams. We developed a low-cost and scalable CR program based on culturally-acceptable practice of yoga (Yoga-CaRe). In this paper, we report the rationale and design for evaluation of its effectiveness and cost-effectiveness. METHODS: This is a multi-center, single-blind, two-arm parallel-group randomized controlled trial across 22 cardiac care hospitals in India. Four thousand patients aged 18-80 years with AMI will be recruited and randomized 1:1 to receive Yoga-CaRe program (13 sessions supervised by an instructor and encouragement to self-practice daily) or enhanced standard care (3 sessions of health education) delivered over a period of three months. Participants will be followed 3-monthly till the end of the trial. The co-primary outcomes are a) time to occurrence of first cardiovascular event (composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke and emergency cardiovascular hospitalization), and b) quality of life (Euro-QoL-5L) at 12 weeks. Secondary outcomes include need for revascularization procedures, return to pre-infarct activities, tobacco cessation, medication adherence, and cost-effectiveness of the intervention. CONCLUSION: This trial will alone contribute >20% participants to existing meta-analyses of randomized trials of CR worldwide. If Yoga-CaRe is found to be effective, it has the potential to save millions of lives and transform care of AMI patients in India and other low and middle income country settings.

Changes in hypertension prevalence, awareness, treatment and control rates over 20 years in National Capital Region of India: results from a repeat cross-sectional study.

BACKGROUND AND OBJECTIVES: Despite being one of the leading risk factors of cardiovascular mortality, there are limited data on changes in hypertension burden and management from India. This study evaluates trend in the prevalence, awareness, treatment and control of hypertension in the urban and rural areas of India's National Capital Region (NCR). DESIGN AND SETTING: Two representative cross-sectional surveys were conducted in urban and rural areas (survey 1 (1991-1994); survey 2 (2010-2012)) of NCR using similar methodologies. PARTICIPANTS: A total of 3048 (mean age: 46.8±9.0 years; 52.3% women) and 2052 (mean age: 46.5±8.4 years; 54.2% women) subjects of urban areas and 2487 (mean age: 46.6±8.8 years; 57.0% women) and 1917 (mean age: 46.5±8.5 years; 51.3% women) subjects of rural areas were included in survey 1 and survey 2, respectively. PRIMARY AND SECONDARY OUTCOME MEASURES: Hypertension was defined as per Joint National Committee VII guidelines. Structured questionnaire was used to measure the awareness and treatment status of hypertension. A mean systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg was defined as control of hypertension among the participants with hypertension. RESULTS: The age and sex standardised prevalence of hypertension increased from 23.0% to 42.2% (p<0.001) and 11.2% to 28.9% (p<0.001) in urban and rural NCR, respectively. In both surveys, those with high education, alcohol use, obesity and high fasting blood glucose were at a higher risk for hypertension. However, the change in hypertension prevalence between the surveys was independent of these risk factors (adjusted OR (95% CI): urban (2.3 (2.0 to 2.7)) rural (3.1 (2.4 to 4.0))). Overall, there was no improvement in awareness, treatment and control rates of hypertension in the population. CONCLUSION: There was marked increase in prevalence of hypertension over two decades with no improvement in management.

20-Year Trend of CVD Risk Factors: Urban and Rural National Capital Region of India.

BACKGROUND: The World Health Organization and the Government of India have set targets to reduce burden of noncommunicable diseases. Information on population level trend of risk factors would provide insights regarding the possibility of achieving them. OBJECTIVE: This study aimed to determine the population trends of cardiovascular disease risk factors in the National Capital Region of Delhi over 2 decades. METHODS: Two representative cross-sectional surveys were conducted among men and women ages 35 to 64 years, residing in the urban and rural areas (survey 1 [1991 to 1994] and survey 2 [2010 to 2012]) using similar methodology. The urban sample was collected from the Municipal Corporation of Delhi, and the rural sample was from the Ballabgarh block of the adjoining state of Haryana. A total of 3,048 and 2,052 subjects of urban areas and 2,487 and 1,917 subjects of rural areas were surveyed in surveys 1 and 2, respectively. Behavioral (smoking and alcohol use), physical (overweight, abdominal obesity, and raised blood pressure), and biochemical risk factors (raised fasting blood glucose and raised total cholesterol) were measured using standard tools. RESULTS: Urban and rural prevalence of overweight, alcohol use, raised blood pressure, and blood glucose increased with increases in age-standardized mean body mass index (urban: 24.4 to 26.0 kg/m2; rural: 20.2 to 23.0 kg/m2), systolic blood pressure (urban: 121.2 to 129.8 mm Hg; rural: 114.9 to 123.1 mm Hg), diastolic blood pressure (urban: 74.3 to 83.9 mm Hg; rural: 73.1 to 82.3 mm Hg), and fasting glucose (urban: 101.2 to 115.3 mg/dl; rural: 83.9 to 103.2 mg/dl). The smoking prevalence increased in the rural male population. Raised total cholesterol declined in urban and increased significantly in rural populations. CONCLUSIONS: The study indicates an overall worsening of population levels of all cardiovascular disease risk factors in National Capital Region over past 20 years, though some signs of stabilization and reversal are seen in urban Delhi.

Registry of Youth Onset Diabetes in India (YDR): Rationale, Recruitment, and Current Status.

BACKGROUND: With the aim of addressing the relative scarcity of information on youth-onset diabetes in India, the Indian Council of Medical Research (ICMR) decided to establish the Registry of People with Diabetes with Young Age at Onset (YDR) in 2006. The major objectives of YDR are to generate information on disease pattern or types of youth-onset diabetes including their geographical variations within India and to estimate the burden of diabetes complications. METHODS: YDR is an observational multicenter clinic based registry enlisting physician diagnosed diabetes in individuals below 25 years of age. Diabetes was classified using symptom based clinical criteria. YDR data collection is coordinated through regional collaborating centers and their interacting reporting centers across India. A baseline and an annual follow-up proformas are used to obtain information on sociodemographic details, clinical profile, and anthropometric and laboratory measurements of the patients. RESULTS: In phase 1, the registry has enrolled 5546 patients, in which type 1 diabetes mellitus (T1DM) was the most prevalent (63.9%), followed by youth-onset type 2 diabetes mellitus (T2DM) (25.3%). CONCLUSION: This registry provides a unique opportunity to study the natural history of youth-onset diabetes in India.

Childhood obesity and type 2 diabetes in India.

India is witnessing an increase in the burden of childhood obesity, especially among the upper socioeconomic strata and in urban areas. Emerging literature suggests a link between childhood obesity and the diabetes epidemic in India. Asian-Indian children and adolescents are increasingly susceptible to a high percentage of body fat and abdominal adiposity. Further, they are exposed to an obesogenic environment, created by rapid urbanization and nutrition transition in India. Obese children have a higher risk of developing abnormalities that are recognized as precursors to diabetes, such as subclinical inflammation, insulin resistance and metabolic syndrome, which often track to adulthood. A review of the literature suggests the need for more longitudinal studies to improve understanding of the long-term consequences of childhood obesity in India. A life-course approach with a combination of population- and risk-based strategies is warranted, to prevent childhood obesity and curtail its consequences in adulthood.

Cardiovascular disease risk factors: a childhood perspective.

Atherosclerotic cardiovascular disease (CVD) is one of the leading causes of death and disability worldwide including in developing countries like India. Indians are known to be predisposed to CVD, which occur almost a decade earlier in them. Though these diseases manifest in the middle age and beyond, it is now clear that the roots of CVD lie in childhood and adolescence. Many of the conventional risk factors of CVD such as high blood pressure, dyslipidemia, tobacco use, unhealthy diet and obesity have their beginnings in childhood and then track overtime. It is thus important to screen and identify these risk factors early and treat them to prevent onset of CVD. Similarly community based strategies to prevent onset of these risk factors is imperative to tackle this burgeoning public health crisis especially in countries like ours with limited resources.