Comparative Evaluation of Waist-to-Height Ratio and BMI in Predicting Adverse Cardiovascular Outcome in People With Diabetes: A Systematic Review.

Central obesity is strongly associated with cardiovascular risk in people with diabetes. BMI does not reflect a regional fat distribution. The other anthropometric indices, which are markers of central obesity, like waist circumference and waist-hip ratio, are subject to age, sex, and ethnic variations. An index like waist-to-height ratio (WHtR), which considers central obesity, outperforms BMI in predicting cardiometabolic risk. With a single cut-off of 0.5, irrespective of age, sex, and ethnic variations, WHtR has a wide application in screening obesity in population settings. Previous systematic analyses were conducted in the general population, assessing cardiometabolic risk. The current study is the first systematic analysis to compare the applicability of WHtR and BMI in predicting both cardiovascular risk and adverse cardiovascular outcomes in people with diabetes. It includes prospective cohort studies, cross-sectional studies, and randomized control trials to generate evidence. The summary scores indicate that WHtR is probably a better indicator than BMI to assess cardiovascular risk in people with diabetes. A future meta-analysis will pave the way for more robust evidence.

Clinical Evidence and Practice-Based Guidelines on the Utility of Basal Insulin Combined Oral Therapy (Metformin and Glimepiride) in the Current Era.

BACKGROUND AND AIM: Basal insulin combined oral therapy consisting of insulin and oral anti-diabetic drugs (OADs) is recommended for type 2 diabetes uncontrolled on OADs. There is a lack of clear evidence and recommendations on the combined use of basal insulin analogues to more than one OADs (glimepiride plus metformin) in effective control of glycemic parameters and its safety in terms of reduced hypoglycemic events, weight gain and cardiovascular risk. In this context, a group of clinical experts discussed the utility of basal insulin combined oral therapy with metformin and glimepiride in the current era. METHODS: The clinical experts discussed and provided their inputs virtually. The expert panel included clinical experts comprising endocrinologists and diabetologists from India and Nepal. RESULTS: The panel thoroughly reviewed existing literature on the subject and proposed clinical evidence and practice-based guidelines. CONCLUSION: These current clinical practice guidelines highlight the efficacy and safety of basal insulin combination therapy with various available basal insulins including neutral protamine hagedorn, detemir, glargine and degludec in addition to metformin and glimepiride therapy.

Assessment of determining factors for severity of NeoCOVIDiabetes in India: A pan India multicentric retrospective study.

BACKGROUND AND AIMS: There is a bidirectional relationship between COVID-19 and diabetes. The primary objective of this study was to estimate the prevalence of patients newly detected to have diabetes (NDD) who recovered from COVID-19 in India whilst comparing NDD with patients without diabetes (ND) and those who have known to have diabetes (KD) in terms of glycemic status pre- and post-COVID with disease severity. MATERIALS & METHODOLOGY: There were 2212 participants enrolled from 15 sites, with 1630 active participants after the respective execution of selection criteria. Data collection was done using a specialized Case Record Form (CRF). Planned statistical analysis and descriptive statistics were concluded for significance between patient groups on various parameters. RESULT: The differences in age between the study groups were statistically significant. The average blood glucose at COVID-19 onset was significantly higher in KD than in NDD. Significantly more proportion of NDD (83%) had been hospitalized for COVID management when compared to KD (45%) and ND (55%). The NDD group received higher doses of steroids than the other two groups. On average, patients in the NDD group who received at least one vaccination (one dose or two doses) had a higher High-Resolution Computed Tomography (HRCT) score. Patients who had not been vaccinated in ND and KD groups experienced a higher HRCT score. CONCLUSION: Prospective metabolism studies in post-acute COVID-19 will be required to understand the etiology, prognosis, and treatment opportunities.

Health care delivery model in India with relevance to diabetes care.

The Indian healthcare scenario presents a spectrum of contrasting landscapes. Socioeconomic factors, problems with medical infrastructure, insufficiency in the supply of medical requisites, economic disparities due to major differences in diabetes care delivery in the government and private sectors and difficulty in accessing quality health care facilities challenges effective diabetes care in India. The article gives insights into the practical solutions and the proposed White paper model to resolve major challenges faced by the Indian diabetes care sector for effective diabetes care delivered at Jothydev's Diabetes Educational Forum Global Diabetes Convention 2019.

Corrigendum to: May Measurement Month 2019: an analysis of blood pressure screening results from India.

[This corrects the article DOI: 10.1093/eurheartjsupp/suab047.].

May Measurement Month 2019: an analysis of blood pressure screening results from India.

AIMS: May Measurement Month is a global screening campaign to raise awareness regarding elevated blood pressure (BP). With the growing burden of hypertension, it is imperative to regularly assess the disease's prevalence, risk factors, and awareness levels in a country. The current prevalence of hypertension in India as per the National Family Health Survey Data stands at 25.3%. May Measurement Month mobilizes healthcare professionals and sensitizes them to regularly measure BP, and impart lifestyle modification advice to the community. It also complements the deficiency in screening programmes at a national and international level. METHODS AND RESULTS: May Measurement Month was carried out in May 2019 as an opportunistic screening campaign for adults (≥18 years). It was carried out by over 5000 trained volunteers across approximately 1000 screening sites (hospitals, public places, pharmacies, villages, and malls) in India. A total of 362 708 (57% males and 42.7% females) people were screened, among whom 68.1% had never measured their BP, and 29.4% (n = 106 522) were found to have hypertension. Of these, only 42.0% were on antihypertensive medication and 23.3% had controlled hypertension. CONCLUSION: Almost a third of the screened population had hypertension, and less than half of those with hypertension were aware of it or on treatment for it. Among those on antihypertensive drugs, BP was controlled in only half of them. These results support the need for greater impetus on BP screening initiatives to detect hypertension early in the community and prevent complications due to uncontrolled BP.

Effects of empagliflozin on proinflammatory cytokines and other coronary risk factors in patients with type 2 diabetes mellitus: A single-arm real-world observation.

OBJECTIVE: This single-arm real-world observation aims to examine the effects of empagliflozin (EMPA) on coronary risk factors among subjects with known diabetes. MATERIALS AND METHODS: Records of 63 subjects with type 2 diabetes mellitus, receiving EMPA were drawn for this study. Of 63 patients with diabetes, 6 were excluded, and the remaining 57 received EMPA (25 mg/day) for 24 weeks. Clinical data, dietary intakes, and physical activity were assessed by validated questionnaires. RESULTS: Treatment with EMPA was associated with significant decline in fasting and 2-hour post-prandial blood glucose and Hb1c indicating that this agent has potential antidiabetic effects. Pro-inflammatory cytokines; C-reactive protein, TNF-α, and interleukin-6 showed significant reduction after treatment with EMPA, compared to baseline levels. Apart from these changes, parameters of oxidative stress, thiobarbituric acid reactive substances, malondialdehyde, and diene conjugates as well as uric acid, showed a significant decline with an increase in antioxidant vitamins A, E, and C and beta-carotene as well as nitrite. There was a significant decline in serum uric acid, systolic and diastolic blood pressures, and angiotensin-converting enzyme (ACE), with a non-significant reduction in body weight and body mass index as well as in waist circumference of modest significance, after intervention of 12 weeks compared to baseline levels. Total cholesterol, VLDL cholesterol and triglycerides showed non-significant decline compared to baseline levels. CONCLUSION: It is possible that EMPA administration can cause a significant decline in pro-inflammatory cytokines along with blood glucose, Hb1c, oxidative stress, uric acid, blood pressures, and ACE with an increase in antioxidant vitamins and nitrite. Randomized, controlled intervention trials would be necessary to confirm our findings.

May Measurement Month 2018: an analysis of blood pressure screening campaign results in India.

Hypertension (HTN) is the greatest attributable risk factor for cardiovascular disease in India. Recent studies have reported the crude prevalence of HTN in India to be 25.3%. In the May Measurement Month (MMM) screening campaign of 2017 conducted in India, 31.8% had HTN. In order to ratify earlier results, and further understand the awareness and control levels of HTN in India, organizations that participated in MMM 2017 decided to participate in the MMM global screening initiative of the International Society of Hypertension for a 2nd consecutive year. A total of 345 234 individuals were screened in MMM 2018. There were more than 1000 screening locations that included hospitals, clinics, workplaces, and special health camps organized across the country. After applying multiple imputation, a total of 111 462 (32.3%) individuals had HTN of whom 63 415 (55.6%) were aware of HTN and 61 646 (55.3%) were on antihypertensive medicines, out of which 15 583 (25.3%) were uncontrolled. Overall 57 864 (41.3%) hypertensives were uncontrolled. About half (44.7%) of hypertensive population in India were not on treatment. Around two-thirds (65.7%, n = 226 924) had not measured their blood pressure (BP) in last 12 months and 64% measured their BP for the first time in their life during the campaign, which strongly indicates the need for large scale awareness drives. This study suggests that opportunistic periodic public health screening at a national level is needed to increase HTN detection, treatment, control, and countrywide awareness in highly populated nations like India.

Suboptimal glycemic control among subjects with diabetes mellitus in India: a subset analysis of cross-sectional wave-7 (2016) data from the International Diabetes Management Practices Study (IDMPS).

OBJECTIVE: To assess the real-world management practices of subjects with type 2 diabetes mellitus (T2DM) and type 1 diabetes mellitus (T1DM) in India. METHODS: This cross-sectional study was conducted between 7 March 2016 and 15 May 2016 in India as part of the seventh wave (2016) of the International Diabetes Management Practices Study (IDMPS). Adult subjects with T1DM or T2DM visiting physicians during a 2-week recruitment period were included. RESULTS: A total of 55 physicians included 539 subjects who met eligibility criteria. Of 495 subjects with T2DM, 303 were treated with oral glucose lowering drugs (OGLDs) only, 158 were treated with OGLD + insulin, and 27 received insulin only. Among 44 subjects with T1DM receiving insulin, 13 (29.5%) were also treated with OGLD therapy. The most commonly used insulin regimens were basal alone (69/184; 37.5%) and premixed alone (63/184; 34.2%) in subjects with T2DM, and basal + prandial insulin (24/44; 54.5%) in subjects with T1DM. Proportions of subjects achieving glycemic targets were low [glycated haemoglobin (HbA1c) <7%: T1DM = 7.3% (3/44), T2DM = 25.2% (106/495); as targeted by the treating physician: T1DM = 31.8% (14/44), T2DM = 32.1% (59/185); global target: T1DM = 4.8% (2/42) and T2DM = 1.7% (8/482)]. In subjects with T2DM, HbA1c <7% was noted in 11/22 subjects receiving insulin only and 76/260 receiving only OGLDs. Lack of experience in self-managing insulin dosing, poor diabetes education and failure to titrate insulin dosages were the main reasons for non-achievement of glycemic targets. CONCLUSION: Timely insulinization, education and empowerment of people with diabetes may help improve glycemic control in India.

May Measurement Month 2019: The Global Blood Pressure Screening Campaign of the International Society of Hypertension.

Elevated blood pressure remains the single biggest risk factor contributing to the global burden of disease and mortality. May Measurement Month is an annual global screening campaign aiming to improve awareness of blood pressure at the individual and population level. Adults (≥18 years) recruited through opportunistic sampling were screened at sites in 92 countries during May 2019. Ideally, 3 blood pressure readings were measured for each participant, and data on lifestyle factors and comorbidities were collected. Hypertension was defined as a systolic blood pressure ≥140 mm Hg, or a diastolic blood pressure ≥90 mm Hg (mean of the second and third readings) or taking antihypertensive medication. When necessary, multiple imputation was used to estimate participants' mean blood pressure. Mixed-effects models were used to evaluate associations between blood pressure and participant characteristics. Of 1 508 130 screenees 482 273 (32.0%) had never had a blood pressure measurement before and 513 337 (34.0%) had hypertension, of whom 58.7% were aware, and 54.7% were on antihypertensive medication. Of those on medication, 57.8% were controlled to <140/90 mm Hg, and 28.9% to <130/80 mm Hg. Of all those with hypertension, 31.7% were controlled to <140/90 mm Hg, and 350 825 (23.3%) participants had untreated or inadequately treated hypertension. Of those taking antihypertensive medication, half were taking only a single drug, and 25% reported using aspirin inappropriately. This survey is the largest ever synchronized and standardized contemporary compilation of global blood pressure data. This campaign is needed as a temporary substitute for systematic blood pressure screening in many countries worldwide.

May Measurement Month 2017: an analysis of the blood pressure screening campaign results in India-South Asia.

Elevated blood pressure (BP) is a growing burden worldwide, leading to over 10 million deaths each year. May Measurement Month (MMM) is a global initiative aimed at raising awareness of high BP and to act as a temporary solution to the lack of screening programmes worldwide. A recently conducted study on 1.3 million adults in India showed the prevalence of hypertension to be 25.3%. Raised BP is responsible for 8.5% of the total Disability Adjusted Life Years and is also an important contributor to cardiovascular disease which is the leading cause of deaths in the country. An opportunistic cross-sectional survey of volunteers aged ≥18 was carried out in May 2017. Blood pressure measurement, the definition of hypertension and statistical analysis followed the standard MMM protocol. The study was conducted in over 500 screening sites across the country and involved over 5000 volunteers. Screening sites included health facilities such as hospitals and clinics, as well as a variety of public spaces. A total of 240 376 individuals were screened during MMM17. Out of the 122 685 screenees for whom all three BP readings were available, 38 974 (31.8%) had hypertension based on the mean of second and third reading. Of individuals not receiving antihypertensive medication, 21 679 (17.7%) were hypertensive. Of individuals receiving antihypertensive medication, 14 203 (82.6%) had uncontrolled BP. MMM17 was the largest collaborative BP screening campaign undertaken in India with involvement of the public as well as the private sector. Over two-thirds of the individuals on antihypertensive treatment had uncontrolled BP. Approximately one-fifth of the participants had raised BP and were not on antihypertensive treatment prior to the study. These results suggest that opportunistic screening can identify significant numbers with raised BP.

Uttar Pradesh Association of Physicians of India Position Statement: Betel Quid (Paan) and Diabetes.

Betel quid (paan) chewing is common in India, especially in Uttar Pradesh. Betel quid has multifaceted relationship with health, including metabolic and psychosocial health. The current recommendations have been released keeping in view the public health and clinical importance of this addictive behavior. The objective of this document is to offer clinical guidance for screening, diagnosis and management of co-occurring betel quid chewing among persons with Diabetes Mellitus (DM). The document aims to provide education and guidance to clinicians engaged in care and management of persons with DM, and improve access to treatment for co-occurring betel quid chewing among persons with DM. The current recommendation grades are based on published evidence, and categorized as strong, intermediate, weak and no evidence. The strength of these recommendations is based on the level of evidence.

Quality of Hypertension Management in Type 2 Diabetes in India: A Multisite Prescription Audit.

BACKGROUND AND OBJECTIVE: Renin-angiotensin system (RAS) blockers (angiotensin converting enzyme inhibitors ACEI, angiotensin receptor blockers, ARB) are preferred drugs to control hypertension among diabetic patients. To determine frequency of RAS blocker use in hypertensive patients with type 2 diabetes, we performed a multisite study in India. METHODS: We evaluated physician prescriptions in consecutive patients with type 2 diabetes at 9 sites in India. Details of socio-demographic characteristics, clinical findings and prescription medicines were obtained. Descriptive statistics are reported. RESULTS: Hypertension treatment details were available in 8056 of 8699 diabetic patients (4829 men, 3227 women). No hypertension was in 3300 (40.9%), hypertension in 3625 (45.0%), and hypertension with vascular disease in 1131 (14.0%). In diabetics with no hypertension, hypertension, and hypertension with vascular disease, respectively, prescriptions of antihypertensive drugs was: RAS blockers in 19.4, 48.2 and 58.1%, beta-blockers in 4.8, 31.6 and 38.8%, calcium channel blockers in 0.4, 27.4 and 14.3% and diuretics in 0.6, 36.4 and 17.1%. ACEIs were prescribed more frequently than ARB's in hypertensive diabetics (60.7 vs 39.2%) as well as in diabetics with vascular disease (58.6 vs 41.4%). In diabetics with hypertension (n=3625) prescription of one, two or three antihypertensive drugs was 49.8%, 33.7% and 3.5% while statins were prescribed in 54.1%. CONCLUSION: Use of RAS blockers (ACEI or ARB) in uncomplicated as well as complicated hypertensive patients with type 2 diabetes is sub-optimal. Most of the patients are on one drug and prescription of ≥3 drugs are rare. Statins are prescribed in only a half.

Use of Ambulatory Glucose Profile for Improving Monitoring and Management of T2DM.

AIM: To demonstrate glycemic variability in type 2 diabetic patients and consequent control of the same. METHODS: 108 patients with type 2 diabetes with an HbA1c level of 7.5-8.5% were selected for the study. A Freestyle Libre Pro AGP sensor was applied to the patients after explaining the patient about the same. Next, they were called for follow up at 3rd, 7th, 11th and 14th days. Based on the readings and graph obtained, diet and treatment changes were made on various follow-up days. The sensor was removed at the end of 14 days. RESULTS: Out of the 108 subjects, 106 completed the study. There were no adverse device effects. 98 patients had therapy changes while the rest had diet and lifestyle modifications. The mean HbA1c decreased from 7.96% to 7.03% by the end of 15 days. The glycemic variability curves helped in recognizing and treating masked or asymptomatic hypoglycemic events. It also graphically shows intervals of optimal and sub-optimal glycemia. CONCLUSION: AGP is one of the most recent, innovative developments that are being used to monitor Glycaemic variability in DM patients. AGP is generated from the Flash Glucose Monitoring device which is like a CGM device attached to the patient for a maximum period of 14 days, which checks the ISF glucose at every 15 minutes. We are able to get a Glycaemic variability curve, a median, a modal, various percentiles and statistical data generated through this. AGP study in the patient provides the doctor with an opportunity to have a complete glycemic picture of the patient l. It offers a reliable, predictive, standardized visualization of the glucose data. We were able to not only reduce the Glycaemic variability but were also able to improve their Quality of Life by reducing the frequency of hypos. The data lead to breaking of the clinical inertia and provided a valuable insight into Glycaemic patterns. The achievement of near to normal Glycaemic status at the end of 14 days reflected the use of AGP as an interventional tool.

Evidence-based recommendations for insulin intensification strategies after basal insulin in type 2 diabetes.

Over the time due to progressive nature of diabetes, proactive intensification of the existing insulin therapy becomes imminent as it minimizes patients' exposure to chronic hypo/hyperglycaemia and reduces weight gain while achieving individualized glycaemic targets. This review focuses on the strength of evidence behind various options for intensification, primarily the insulins as also the GLP-1 analogues. The recommendations presented here are meant to serve as a guide for the physician managing type 2 diabetes patients requiring insulin intensification upon failing of basal insulin therapy.

Consensus recommendations on exploring effective solutions for the rising cost of diabetes.

Diabetes remains asymptomatic for a long period of time and its real burden gets noticed only once the complications set in. The number of individuals affected with the disease is also on the rise and more so in the low income countries. This scenario calls for urgent precautionary measures that need to be undertaken to equip ourselves to fight against this chronic disease. Individuals with financial constraints cannot afford to access even the basic treatment facilities and thus stands the most burdened. The International Diabetes Federation calls for 'Eyes on Diabetes' for the society to focus on early screening and early intervention. The rising cost of diabetes results from delayed and denied treatment. The panel discussion organized as a part of 4th Annual global diabetes convention of Jothydev's Professional Education Forum (JPEF, 2016) facilitated a platform to address diabetes as a serious health concern that needs to be given immediate priority by the policymakers as well as public and also to discuss about the feasible measures that will help achieve cost effective and affordable diabetes treatment. This was followed by in-depth literature search and finally a set of recommendations have been arrived at by the key opinion leaders to realize the dream of affordable diabetes care to all deserving individuals.

Efficacy of FurosapTM, a novel Trigonella foenum-graecum seed extract, in Enhancing Testosterone Level and Improving Sperm Profile in Male Volunteers.

Background: Dietary fiber rich fenugreek (Trigonella foenum-graecum) seeds have exhibited cardioprotective, hypolipidemic and other health benefits. Furosap (FS), an innovative, patented, 20% protodioscin-enriched extract was developed in our laboratory from fenugreek seeds. This study examined the free and total testosterone levels, sperm profile and morphology, sexual health, mood and mental alertness, and broad spectrum safety parameters of FS in 50 male volunteers following supplementation over a period of 12 weeks. Methods: Institutional Review Board (IRB) and other regulatory approvals were obtained for our study. This one-arm, open-labelled, multi-center study was conducted in 50 male volunteers (age: 35 to 65 years) over a period of 12 weeks to determine the efficacy of FS (500 mg/day/subject) on free and total testosterone levels, sperm profile, sperm morphology, libido and sexual health, mood and mental alertness, and broad spectrum safety parameters. Results: Free testosterone levels were improved up to 46% in 90% of the study population. 85.4% of the study population showed improvements in sperm counts. Sperm morphology improved in 14.6% of volunteers. Majority of the subjects enrolled in the study demonstrated improvements in mental alertness and mood. Furthermore, cardiovascular health and libido were significantly improved. Extensive safety parameters were evaluated which included blood chemistry data. No significant changes were observed in serum lipid function, cholesterol, triglyceride, HDL and LDL levels, hemogram (CBC), hepatotoxicity and nephrotoxicity. Conclusion: Overall, the results demonstrate that FS, enriched in 20% protodioscin, is safe and effective in attenuating testosterone levels, healthy sperm profile, mental alertness, cardiovascular health and overall performance in human subjects.

Uttar Pradesh Association of Physicians of India Position Statement: Tobacco Use and Metabolic Syndrome.

Tobacco use is one of the main preventable causes of mortality and morbidity worldwide. The global disease burden due to tobacco use is huge with projected mortality of eight million lives per year by 2030. Metabolic syndrome (MS) is defined as a constellation of cardiovascular and endocrine risk factors such as insulin resistance, obesity, raised blood pressure, and abnormal lipid profile. The relationship between tobacco use and MS has been well established. Also, the causal association between tobacco use and development of individual components of MS is well established. The Uttar Pradesh Association of Physicians of India (UP API) has drafted this position statement on managing tobacco use among persons with or at risk of developing Metabolic Syndrome (MS). This position statement presents evidence-based recommendations as described below. Scope and purpose The objective of this position statement is to offer clinical recommendations for screening, diagnosis and management of tobacco use among persons with or at risk of developing Metabolic Syndrome (MS). The purpose of this document is to aid in identification and treatment of maladaptive patterns of tobacco use i.e. tobacco use disorder (tobacco dependence, harmful use, abuse) in person with or at risk of developing MS. Intended Audience The position statement is targeted at the clinicians engaged in care and management of person with or at risk of developing Metabolic Syndrome (MS). This might also be of relevance to the policy makers considering the public health burden of both MS and tobacco use disorders.

Evaluation of statin prescriptions in type 2 diabetes: India Heart Watch-2.

BACKGROUND: Contemporary treatment guidelines advise statin use in all patients with diabetes for reducing coronary risk. Use of statins in patients with type 2 diabetes has not been reported from India. METHODS: We performed a multisite (n=9) registry-based study among internists (n=3), diabetologists (n=3), and endocrinologists (n=3) across India to determine prescriptions of statins in patients with type 2 diabetes. Demographic and clinical details were obtained and prescriptions were audited for various medications with a focus on statins. Details of type of statin and dosage form (low, moderate, and high) were obtained. Patients were divided into categories based on presence of cardiovascular risk into low (no risk factors, n=1506), medium (≥1 risk factor, n=5425), and high (with vascular disease, n=1769). Descriptive statistics are presented. RESULTS: Prescription details were available in 8699 (men 5292, women 3407). Statins were prescribed in 55.2% and fibrates in 9.2%. Statin prescription was significantly greater among diabetologists (64.4%) compared with internists (n=53.3%) and endocrinologists (46.8%; p<0.001). Atorvastatin was prescribed in 74.1%, rosuvastatin in 29.2%, and others in 3.0%. Statin prescriptions were lower in women (52.1%) versus men (57.2%; p<0.001) and in patients aged <40 years (34.3%), versus those aged 40-49 (49.7%), 50-59 (60.1%), and ≥60 years (62.2%; p<0.001). Low-dose statins were prescribed in 1.9%, moderate dose in 85.4%, and high dose in 12.7%. Statin prescriptions were greater in the high-risk group (58.0%) compared with those in the medium-risk (53.8%) and low-risk (56.8%) groups (p <0.001). High-dose statin prescriptions were similar in the high-risk (14.5%), medium-risk (11.8%), and low-risk (13.5%) groups (p=0.31). CONCLUSIONS: Statins are prescribed in only half of the clinic-based patients in India with type 2 diabetes. Prescription of high-dose statins is very low.

Geographic epidemiology of cardiometabolic risk factors in middle class urban residents in India: cross-sectional study.

OBJECTIVE: To determine epidemiology of cardiovascular risk factors according to geographic distribution and macrolevel social development index among urban middle class subjects in India. METHODS: We performed cross-sectional surveys in 11 cities in India during years 2005-2009. 6198 subjects aged 20-75 years (men 3426, women 2772, response 62%) were evaluated for cardiovascular risk factors. Cities were grouped according to geographic distribution into northern (3 cities, n = 1321), western (2 cities, n = 1814), southern (3 cities, n = 1237) and eastern (3 cities, n = 1826). They were also grouped according to human social development index into low (3 cities, n = 1794), middle (5 cities, n = 2634) and high (3 cities, n = 1825). Standard definitions were used to determine risk factors. Differences in risk factors were evaluated using χ(2) test. Trends were examined by least squares regression. FINDINGS: Age-adjusted prevalence (95% confidence intervals) of various risk factors was: low physical activity 42.1% (40.9-43.3), high dietary fat 49.9% (47.8-52.0), low fruit/vegetables 26.9% (25.8-28.0), smoking 10.1% (9.1-11.1), smokeless tobacco use 9.8% (9.1-10.5), overweight 42.9% (41.7-44.1), obesity 11.6% (10.8-12.4), high waist circumference 45.5% (44.3-46.7), high waist-hip ratio 75.7% (74.7-76.8), hypertension 31.6% (30.4-32.8), hypercholesterolemia 25.0% (23.9-26.9), low HDL cholesterol 42.5% (41.3-43.7), hypertriglyceridemia 36.9% (35.7-38.1), diabetes 15.7% (14.8-16.6), and metabolic syndrome 35.7% (34.5-36.9). Compared with national average, prevalence of most risk factors was not significantly different in various geographic regions, however, cities in eastern region had significantly lower prevalence of overweight, hypertension, hypercholesterolemia, diabetes and metabolic syndrome compared with other regions (P < 0.05 for various comparisons). It was also observed that cities with low human social development index had lowest prevalence of these risk factors in both sexes (P < 0.05). CONCLUSIONS: Urban middle-class men and women in eastern region of India have significantly lower cardiometabolic risk factors compared to northern, western and southern regions. Low human social development index cities have lower risk factor prevalence.