Development and validation of a tool for assessing adherence to gluten free diet in patients with Celiac disease (Celiac Disease: Compliance Assessment Test; CD-CAT).

OBJECTIVE: Life-long adherence to gluten-free diet (GFD) and its assessment is essential for celiac disease (CeD) patients. We have developed and validated a tool for assessing adherence to GFD which can be used by both physicians and dietitians. DESIGN: Phase-I: Development, content validation and assessment of reliability of tool. Phase-II: Validation of tool against standard dietary evaluation (SDE) (gold standard), IgA anti-tissue transglutaminase antibody (IgA-anti-tTG Ab) and gluten immunogenic peptides in urine (Urine-GIP). Overall, 380 biopsy-confirmed CeD patients [Derivation-cohort: n=100(Phase:I), n=210(Phase:II) and Independent validation cohort, n=70)were recruited. RESULTS: Of initial 90-point questionnaire, 84-items (CD-CAT.v1) were retained after content validation and pilot testing. In Phase:I, upon administering CD-CAT.v1on 100 patients, a comprehensive 35-items tool (CD-CAT.v2;α=0.86) was obtained after removing items with low test-retest reliability and item-rest correlation values. In Phase:II, upon administering CD-CAT.v2 on 210patients,22 items were removed having low correlation values (R<0.4) with SDE. Finally, a 13-item tool (CD-CAT.v3;α=0.84) was obtained with high criterion validity with SDE (r=0.806, p<0.001), moderate convergent validity with CDAT (r=0.602, p=0.007) and moderate to weak correlation with urine GIP (r=0.46, p=0.001) and IgA anti-tTG Ab (r=0.39, p=0.008), respectively. The final 13-item tool also strongly correlated with SDE (r=0.78, p<0.001) in an independent validation cohort of 70 CeD patients. Principal component analysis identified three relevant sub-scales with a cumulative-variance of 62%. The sensitivity and specificity of CD-CAT.v3 were 80% and 91%, respectively, with an area under curve of 0.905 with SDE. The obtained cut-off score of <19 from ROC-curve was further categorized as: 13=excellent,14-18=very good, 19-28=average and >28=poor adherence to GFD. CONCLUSION: CD-CAT is a new and rapid tool for monitoring dietary adherence to GFD with high sensitivity and specificity which can be administered by both physicians and dietitians.

Development of a diet pattern assessment tool for coronary heart disease risk reduction.

Objective: Existing diet indices have gaps including neglect of the patterns of intake known to affect the final metabolic impact and use of measurement units prone to reporting error, and have applicability that is limited to specific populations. This study sought to develop a tool for diet-pattern assessment (Prudent Approach to Cardiovascular Epidemic, for Indians - Diet Quality Index (iPACE-DQI)) to reduce diet-related coronary-heart-disease (CHD) risk. Study design: The iPACE-DQI was developed on a 0-100 points scale (higher numeric value healthier). A proof-of-concept analysis was done to examine its construct validity and relation with risk-markers. Methods: Development of iPACE-DQI was partly guided by 'prudent diet' principles, with assessment focus on quality, quantity, and the pattern of intake. In the second part of the study, construct validity was evaluated by association of iPACE-DQI score with nutrients. Further, relationship of the score with risk-markers high-sensitivity C-reactive protein(hs-CRP), body-mass-index(BMI) and body-fat-percent was examined at single-point-in-time (baseline), and predictive ability of score change on hs-CRP change was evaluated in a proof-of-concept 12-weeks pre-post intervention, among free-living Indians (25-44years,n = 55) in an urban setting. Results: The iPACE-DQI consists of eight main components. Associations of iPACE-DQI score with mean daily intake of key nutrients were robust and in expected direction [total-dietary-fiber (r = 0.5, p < 0.001), crude-fiber (r = 0.6, p < 0.001), protein (r = 0.5, p < 0.001), total-fat (r = -0.4, p = 0.002), vitamin-C (r = 0.5, p < 0.001), total-carbohydrate (r = 0.3, p = 0.017)]. Trends of hs-CRP, BMI and body-fat-percent across increasing diet-pattern score showed highest degree of abnormality in lowest tertile (≤35). Logistic regression model indicated higher likelihood for hs-CRP reduction (OR: 1.6, 95% CI 0.5-4.9) among those with ≥20% increase in iPACE-DQI score as compared with <20% increase or no-increase over 12-weeks. Conclusion: The iPACE-DQI is a 100-point scale that assesses diet-pattern with respect to CHD-risk. The proposed tool could be useful for researchers/health practitioners to track diet-pattern change and concomitant CHD-risk reduction.

Validation of Tools to Assess Predictors of Successful Weight Loss Outcome in Individuals With Overweight and Obesity.

OBJECTIVE: To develop and validate questionnaires to assess the behavioral, psychosocial, and environmental predictors of successful weight loss outcomes. DESIGN: Mixed method study. Questionnaires were developed using 5 steps: item generation by literature review and preexisting questionnaires, expert evaluation, pilot testing, factor analysis, and internal consistency. SETTING: Adults with obesity recruited via web-based survey hyperlink. PARTICIPANTS: One hundred participants with a mean body mass index of 28.7 ± 4.4 kg/m2. VARIABLES MEASURED: The questionnaires were generated using 221 items. Establishing content, face and construct validity, and internal consistency. ANALYSIS: Content validity was analyzed using content validity index and content validity ratio, internal consistency through Cronbach α (CA), and structural validity by factor analysis via principal varimax rotation. RESULTS: All three questionnaires had good content validity. The Behavioral Predictor Questionnaire had good internal consistency (CA, 0.7) and excellent structural validity (69.7%). Psychosocial Predictors Questionnaire (CA, 0.8, 67.5%) and Environmental Predictors Questionnaire (CA: 0.8, 72.2%) had excellent internal consistency and structural validity. CONCLUSION AND IMPLICATION: Questionnaires seem to be practical, valid, and reliable tools for baseline assessment of individual-specific factors related to weight loss success.

Identification of instruments for evaluation of behavioural and psychological parameters associated with obesity management: A systematic review with narrative synthesis of the findings.

BACKGROUND AND AIMS: To identify instruments used to evaluate the predictors of successful weight loss across weight loss trials. METHODS: We searched PubMed, PsychInfo, Cochrane Reviews and Scopus for weight loss trials reporting instruments published in the last 16 years. RESULTS: A total of 46 significant behavioral and psychological predictors were identified, of which 32 instruments were finally selected. SF-36 questionnaire and Obesity Related Problem Scale for psychosocial health, TREMORE scale for motivation, Social Support Scale for support, Weight Efficacy Lifestyle Scale for self-efficacy and Body Shape Questionnaire for body image had moderate quality. Barriers to healthy eating questionnaire scale and Dutch Eating Behavior also had moderate quality. CONCLUSION: Use of uniform instruments with optimum quality can benefit clinical and community-based researchers to generate reliable datasets.

Predictors of successful weight loss outcomes amongst individuals with obesity undergoing lifestyle interventions: A systematic review.

Understanding the predictors of weight loss with lifestyle interventions can help to ascertain the probable outcomes of individuals with obesity who undergo such interventions. This systematic review assessed the evidence of predictors of successful weight loss among individuals who are overweight or with obesity undergoing lifestyle interventions. Four electronic databases (PubMed, Cochrane Reviews, PsychInfo and Wiley) were searched to find relevant literature published in the past 20 years. A total of 1351 titles were identified in the initial search, of which 23 studies were finally included. Predictors were synthesized in the domains of socio-demographic factors, anthropometric parameters, psychological and behavioural factors and intervention-based factors. The overall quality of evidence on predictors was then appraised using an adapted GRADE approach. Patient-specific factors such as being male, older in age, having existing cardiometabolic comorbidities and limited fat intake were significantly associated with weight loss success. Amongst intervention specific predictors, greater initial weight loss and higher adherence to lifestyle advice were associated with greater weight loss success. In this review, initial weight loss came out to be as the most important predictor of successful weight loss outcome.

Relevance of the triglyceride-to-high-density lipoprotein cholesterol ratio as an important lipid fraction in apparently healthy, young, and middle-aged Indian men.

CONTEXT: Cardiovascular disease (CVD) is the largest cause of mortality in Indians. Insulin resistance and related dyslipidemia of increased triglyceride (TG), small dense low-density lipoprotein (sd-LDL) particles, and decreased high-density lipoprotein-cholesterol (HDL-C) are associated with increased risk of CVD. TG/HDL-C ratio could be a potential surrogate marker for this South Asian phenotype. Data are scarce on the relevance of TG/HDL-C ratio as a useful lipid marker among Indians. AIMS: To study the prevalence of TG/HDL-C ratio among healthy, young, and middle-aged Indian men (25-44 years) and its relationship with other lipid and nonlipid factors. SUBJECTS AND METHODS: In this cross-sectional analysis, fasting blood samples from 236 healthy participants recruited from an urban community setting were tested for TG/HDL-C ratio, HDL-C, TG, total cholesterol (TC), non-HDL-C, TC/HDL-C, high-sensitivity C-reactive protein, body mass index (BMI), and body fat. RESULTS: Mean (standard deviation) age of participants was 34.7 (7.7) years; median (interquartile range) TG/HDL-C ratio was 4 (2.85-5.2). More than half (51.3%) the participants (n = 121) recorded abnormal TG/HDL-C ratio (≥4.0). Across tertiles of TG/HDL-C ratio, there was a significant trend of higher conventional lipid parameters such as non-HDL-C*, TC/HDL-C ratio*, TG*, HDL-C*, TC**; and non-lipid parameters body-fat* and BMI*** (*P < 0.001, **P = 0.015, ***P = 0.002). LDL-C showed moderate and nonsignificant (P = 0.646) increase across tertiles. CONCLUSION: In a sample of apparently healthy, young, and middle-aged Indian men abnormal TG/HDL-C ratio levels were observed among more than half the participants. The TG/HDL-C ratio was closely associated with other lipid parameters and measures of adiposity, such as BMI and body fat, apart from its previously documented unique association with sd-LDL particles. TG/HDL-C ratio should be evaluated in future for risk prediction of incident CVD among Indians.

Desirable factors for maintaining normal BMI of urban affluent women of Delhi.

The study aimed to identify desirable social, familial, reproductive, dietary, and lifestyle factors for maintaining normal body mass index (BMI) of urban affluent women (25-45 years) in Delhi, India. A total of 387 urban affluent women with at least one living child participated in this cross-sectional study conducted from March 2008 to April 2010. Women were classified into four BMI categories on the basis of World Health Organization (WHO; 2004) classification for Asians. Significant factors for maintaining normal BMI were: Younger age, less parity, nuclear family, normal weight status of parents, postpartum weight gain between 2 and 3 kg, regularity in taking meals, fixed meal size, self-perceived normal weight, and shorter sitting time and television viewing time. Multivariate regression analysis identified five determining factors for maintaining BMI, which are normal weight of father, self-perceived normal weight, fixed meal size, sitting time less than 6 h/day, and television viewing time less than 1 h/day. By small lifestyle modifications, normal BMI can be maintained.

Deficiencies of Serum Ferritin and Vitamin B12, but not Folate, are Common in Adolescent Girls Residing in a Slum in Delhi.

Anemia among adolescent girls is one of the major challenges faced by India. The present study was undertaken to assess the prevalence of anemia and status of other hematological parameters among adolescent girls (11 - 18 years) residing in an urban slum of Delhi. A total of 794 adolescent girls were recruited for the study. The prevalence of anemia was estimated using the cyanmethemoglobin method. Serum levels of ferritin, folic acid and vitamin B12 were estimated for anemic subjects. The prevalence of anemia was reported as 58.7 %, with 31.6 %, 25.7 % and 1.4 % of subjects being mild, moderate and severely anemic. Hemoglobin levels of subjects who had attained menarche were found to be significantly lower than those who had not attained menarche. The prevalence of serum ferritin, folic acid and vitamin B12 deficiency among those who were anemic was reported as 41.1 %, 5.0 % and 63.3 % respectively. A total of 23.5 % anemic subjects had concomitant micronutrient deficiencies of serum vitamin B12 and ferritin. The results indicate that supplemental iron and vitamin B12 may better address the burden of anemia in adolescent girls in Delhi.

Association of leisure-time physical activity with cardiorespiratory fitness in Indian men.

BACKGROUND: The relationship between leisure-time physical activity (LTPA) and cardiorespiratory fitness (CRF) is not clearly understood in Indian men. It is important to elucidate whether the duration or intensity of LTPA is responsible for increasing CRF. This will help in designing better physical activity intervention strategies for improving CRF in Indian men. METHODS: Healthy nondiabetic urban Indian men with no history of coronary heart disease (CHD) were selected (n = 603; aged 22-64 years) and their energy intake and physical activity was determined using a questionnaire. Body fat (percent) was determined by leg-to-leg bioelectrical impedance analysis while CRF was measured on multistage, continuous treadmill test using Bruce protocol. RESULTS: Intensity of physical activity (METs) emerged as the best independent predictor of CRF (ß = 0.217; P < .001). Using univariate General Linear Model, it was found that CRF is more a function of LTPA intensity than LTPA duration, since LTPA duration was not related to CRF when controlled for LTPA intensity. However, LTPA intensity remained significantly associated with CRF even after adjustment for LTPA duration. CONCLUSION: LTPA of preferably higher intensity should be incorporated in the lifestyle to improve CRF and prevent CHD in Indian men.

Pilot-scale technology development, nutritional and consumer assessment of whole-multigrain cookies as influenced by fructan inclusion.

UNLABELLED: The benefits of wholegrain finger millet and sorghum were combined with that of fructan in form of fructoligosaccharide in the pilot-scale production (10 kg) of cookies. Complete nutritional analysis of the cookies was carried out to provide nutritional information to the consumers. Whole-multigrain cookies with fructan can be categorized as "High Fiber" as they suffice 21% daily value (DV) of fiber and a "Good Source" of iron as they suffice 12.8% DV of iron. A total of 300 consumers (M=110 and F=190), aged between 8 and 66 y evaluated cookies. The overall acceptability (OAA) score of 300 consumers was 8.0±0.58 on a 9-point hedonic scale. Females rated cookies significantly (P<0.05) higher than males in terms of flavor, texture, appearance, and OAA. Males rated cookies significantly (P<0.05) higher on color attribute than females. Encouraging response of consumers signified ample scope for viability and marketability of cookies at the commercial scale. PRACTICAL APPLICATION: Consumers are looking at snack and convenience foods to provide increased fiber in their diet and there is a tremendous interest in low-calorie and low-sugar foods. The demand of whole and multigrain products is also on the rise because of the Government's emphasis. The present study would assist in assessing feasibility of commercial production of such novel health foods. Together with this, it will ascertain the marketability and commercial viability of the product by means of the consumer preference trials. Availability of such cookies in the market would offer consumers "health" with "convenience" and "taste."

A case-control study of risk factors for coronary heart disease in urban Indian middle-aged males.

OBJECTIVE: There are few case-control studies on native Indians to explore the reasons for the growing prevalence of coronary heart disease (CHD) in Indians. The present study was undertaken to identify the conventional coronary risk factors in angiographically proven CHD cases by comparing their prevalence in age-and gender-matched healthy controls. METHODOLOGY: A hospital-based case-control study was performed on 197 middle-aged urban males (age 40-64 years) with angiographically proven CHD and 197 age (32 years) and gender-matched healthy controls in a tertiary cardiac care center of New Delhi. Prevalence of coronary risk factors with special emphasis on diet was determined by administration of a pre-tested questionnaire, physical examination, and biochemical estimation of blood lipids and glucose. Odds ratios (OR) and their 95% confidence intervals (CI) for the association of risk factors with CHD and their population attributable risks (PAR) were calculated. RESULTS: Logistic regression analysis showed that history of diabetes mellitus (OR 4.934, 95% CI 2.320-10.494), low education (OR 2.410, 95% CI 1.261-4.608), full cream milk consumption (OR 2.113 95% CI 1.176-3.798), and family history of premature cardiovascular disease (CVD) (OR 1.810, 95% CI 1.064-3.079) were independent risk factors for CHD. High HDL-C (OR 1.055 95% CI 1.025-1.086) and fruit intake (OR 1.473, 95% CI 1.020-2.128) emerged as anti-risk factors. 44.1% of PAR was attributable to low HDL-C (.3%), low education status (6.6%), history of diabetes mellitus (6.0%), family history of premature CVD (4.4%), low fruit consumption (4.3%), tobacco abuse (4.2%), full cream milk consumption (3.6%) or milk intake (3.4%), high fasting blood glucose (2.3%), and history of hypertension (2.07 percent;). CONCLUSIONS: Conventional risk factors are not enough to explain the high prevalence of CHD among native Indians. While efforts must go on to reduce the risk attributable to them, the role of emerging risk factors should be investigated.