Institutional and behaviour-change interventions to support COVID-19 public health measures: a review by the Lancet Commission Task Force on public health measures to suppress the pandemic.

The Lancet COVID-19 Commission Task Force for Public Health Measures to Suppress the Pandemic was launched to identify critical points for consideration by governments on public health interventions to control coronavirus disease 2019 (COVID-19). Drawing on our review of published studies of data analytics and modelling, evidence synthesis and contextualisation, and behavioural science evidence and theory on public health interventions from a range of sources, we outline evidence for a range of institutional measures and behaviour-change measures. We cite examples of measures adopted by a range of countries, but especially jurisdictions that have, thus far, achieved low numbers of COVID-19 deaths and limited community transmission of severe acute respiratory syndrome coronavirus 2. Finally, we highlight gaps in knowledge where research should be undertaken. As countries consider long-term measures, there is an opportunity to learn, improve the response and prepare for future pandemics.

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.

Relative contribution of diet and physical activity to increased adiposity among rural to urban migrants in India: A cross-sectional study.

BACKGROUND: In common with many other low- and middle-income countries (LMICs), rural to urban migrants in India are at increased risk of obesity, but it is unclear whether this is due to increased energy intake, reduced energy expenditure, or both. Knowing this and the relative contribution of specific dietary and physical activity behaviours to greater adiposity among urban migrants could inform policies for control of the obesity epidemic in India and other urbanising LMICs. In the Indian Migration Study, we previously found that urban migrants had greater prevalence of obesity and diabetes compared with their nonmigrant rural-dwelling siblings. In this study, we investigated the relative contribution of energy intake and expenditure and specific diet and activity behaviours to greater adiposity among urban migrants in India. METHODS AND FINDINGS: The Indian Migration Study was conducted between 2005 and 2007. Factory workers and their spouses from four cities in north, central, and south of India, together with their rural-dwelling siblings, were surveyed. Self-reported data on diet and physical activity was collected using validated questionnaires, and adiposity was estimated from thickness of skinfolds. The association of differences in dietary intake, physical activity, and adiposity between siblings was examined using multivariable linear regression. Data on 2,464 participants (median age 43 years) comprised of 1,232 sibling pairs (urban migrant and their rural-dwelling sibling) of the same sex (31% female) were analysed. Compared with the rural siblings, urban migrants had 18% greater adiposity, 12% (360 calories/day) more energy intake, and 18% (11 kilojoules/kg/day) less energy expenditure (P < 0.001 for all). Energy intake and expenditure were independently associated with increased adiposity of urban siblings, accounting for 4% and 6.5% of adiposity difference between siblings, respectively. Difference in dietary fat/oil (10 g/day), time spent engaged in moderate or vigorous activity (69 minutes/day), and watching television (30 minutes/day) were associated with difference in adiposity between siblings, but no clear association was observed for intake of fruits and vegetables, sugary foods and sweets, cereals, animal and dairy products, and sedentary time. The limitations of this study include a cross-sectional design, systematic differences in premigration characteristics of migrants and nonmigrants, low response rate, and measurement error in estimating diet and activity from questionnaires. CONCLUSIONS: We found that increased energy intake and reduced energy expenditure contributed equally to greater adiposity among urban migrants in India. Policies aimed at controlling the rising prevalence of obesity in India and potentially other urbanising LMICs need to be multicomponent, target both energy intake and expenditure, and focus particularly on behaviours such as dietary fat/oil intake, time spent on watching television, and time spent engaged in moderate or vigorous intensity physical activity.

Prevalence and incidence of hypertension: Results from a representative cohort of over 16,000 adults in three cities of South Asia.

BACKGROUND: Despite high projected burden, hypertension incidence data are lacking in South Asian population. We measured hypertension prevalence and incidence in the Center for cArdio-metabolic Risk Reduction in South Asia (CARRS) adult cohort. METHODS: The CARRS Study recruited representative samples of Chennai, Delhi, and Karachi in 2010/11, and socio-demographic and risk factor data were obtained using a standard common protocol. Blood pressure (BP) was measured in the sitting position using electronic sphygmomanometer both at baseline and two year follow-up. Hypertension and control were defined by JNC 7 criteria. RESULTS: In total, 16,287 participants were recruited (response rate=94.3%) and two year follow-up was completed in 12,504 (follow-up rate=79.2%). Hypertension was present in 30.1% men (95% CI: 28.7-31.5) and 26.8% women (25.7-27.9) at baseline. BP was controlled in 1 in 7 subjects with hypertension. At two years, among non-hypertensive adults, average systolic BP increased 2.6mm Hg (95% CI: 2.1-3.1), diastolic BP 0.7mm Hg (95% CI: 0.4-1.0), and 1 in 6 developed hypertension (82.6 per 1000 person years, 95% CI: 80.8-84.4). Risk for developing hypertension was associated with age, low socio-economic status, current alcohol use, overweight, pre-hypertension, and dysglycemia. Risk of incident hypertension was highest (RR=2.95, 95% CI: 2.53-3.45) in individuals with pre-hypertension compared to normal BP. Collectively, 4 modifiable risk factors (pre-hypertension, overweight, dysglycemia, and alcohol use) accounted for 78% of the population attributable risk of incident hypertension. CONCLUSION: High prevalence and poor control of hypertension, along with high incidence, in South Asian adult population call for urgent preventive measures.

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.

Legume consumption and its association with fasting glucose, insulin resistance and type 2 diabetes in the Indian Migration Study.

OBJECTIVE: Legume consumption is associated with lower fasting glucose (FG) and insulin levels in nutrition trials and lower CVD mortality in large-scale epidemiological studies. In India, legumes are widely consumed in various preparations, yet no epidemiological study has evaluated the association of legumes with FG levels, insulin resistance and diabetes risk. The present study aimed to fill this gap. DESIGN: Fasting blood samples, in-person interviews to obtain information on demographic/socio-economic factors, physical activity, alcohol and tobacco use, and anthropometric measurements were collected. Dietary intakes were assessed by an interviewer-administered, validated, semi-quantitative FFQ. SETTING: Lucknow, Nagpur, Hyderabad and Bangalore, India. SUBJECTS: Men and women (n 6367) aged 15-76 years - urban residents, urban migrants and their rural siblings. RESULTS: In multivariate random-effects models adjusted for age, BMI, total energy intake, macronutrients, physical activity and rural/migration status, daily legume consumption was not associated with FG (P-for-trend=0·78), insulin resistance (homeostasis model assessment score; P-for-trend=0·73) or the prevalence of type 2 diabetes mellitus (P-for-trend=0·41). Stratified analyses by vegetarian diet and migration status did not change the findings. Inverse associations between legumes and FG emerged for participants with lower BMI and higher carbohydrate, protein, fat and sugar intakes. CONCLUSIONS: Although legumes are essential in traditional Indian diets, as well as in prudent and Mediterranean diets in the West, we did not find an association between legumes and markers of glycaemic control, insulin resistance or diabetes, except for subgroups based on BMI and macronutrient intake. The ubiquitous presence and complexity of legume preparations in Indian diets may contribute to these findings.

Associations Between Sociodemographic Characteristics, Pre Migratory and Migratory Factors and Psychological Distress Just After Migration and After Resettlement: The Indian Migration Study.

BACKGROUND/OBJECTIVES: Migration is suspected to increase the risk for psychological distress for those who enter a new cultural environment. We investigated the association between sociodemographic characteristics, premigratory and migratory factors and psychological distress in rural-to-urban migrants just after migration and after resettlement. METHODS: Data from the cross-sectional sib-pair designed Indian Migration Study (IMS, 2005-2007) were used. The analysis focused on 2112 participants aged ≥18 years from the total IMS sample (n = 7067) who reported being migrant. Psychological distress was assessed based on the responses of the 7-questions in a five-point scale, where the respondents were asked to report about their feelings now and also asked to recall these feelings when they first migrated. The associations were analyzed using multiple logistic regression models. RESULTS: High prevalence of psychological distress was found just after migration (7.3%; 95% confidence interval [CI]: 6.2-8.4) than after settlement (4.7%; 95% CI: 3.8-5.6). Push factors as a reason behind migration and not being able to adjust in the new environment were the main correlates of psychological distress among both the male and female migrants, just after migration. CONCLUSIONS: Rural-urban migration is a major phenomenon in India and given the impact of premigratory and migratory related stressors on mental health, early intervention could prevent the development of psychological distress among the migrants.

The association between a vegetarian diet and cardiovascular disease (CVD) risk factors in India: the Indian Migration Study.

BACKGROUND: Studies in the West have shown lower cardiovascular disease (CVD) risk among people taking a vegetarian diet, but these findings may be confounded and only a minority selects these diets. We evaluated the association between vegetarian diets (chosen by 35%) and CVD risk factors across four regions of India. METHODS: Study participants included urban migrants, their rural siblings and urban residents, of the Indian Migration Study from Lucknow, Nagpur, Hyderabad and Bangalore (n = 6555, mean age-40.9 yrs). Information on diet (validated interviewer-administered semi-quantitative food frequency questionnaire), tobacco, alcohol, physical history, medical history, as well as blood pressure, fasting blood and anthropometric measurements were collected. Vegetarians ate no eggs, fish, poultry or meat. Using robust standard error multivariate linear regression models, we investigated the association of vegetarian diets with blood cholesterol, low density lipoprotein (LDL), high density lipoprotein (HDL), triglycerides, fasting blood glucose (FBG), systolic (SBP) and diastolic blood pressure (DBP). RESULTS: Vegetarians (32.8% of the study population) did not differ from non-vegetarians with respect to age, use of smokeless tobacco, body mass index, and prevalence of diabetes or hypertension. Vegetarians had a higher standard of living and were less likely to smoke, drink alcohol (p<0.0001) and were less physically active (p = 0.04). In multivariate analysis, vegetarians had lower levels of total cholesterol (ß =  -0.1 mmol/L (95% CI: -0.03 to -0.2), p = 0.006), triglycerides (ß =  -0.05 mmol/L (95% CI: -0.007 to -0.01), p = 0.02), LDL (ß =  -0.06 mmol/L (95% CI: -0.005 to -0.1), p = 0.03) and lower DBP (ß =  -0.7 mmHg (95% CI: -1.2 to -0.07), p = 0.02). Vegetarians also had decreases in SBP (ß =  -0.9 mmHg (95% CI: -1.9 to 0.08), p = 0.07) and FBG level (ß =  -0.07 mmol/L (95% CI: -0.2 to 0.01), p = 0.09) when compared to non-vegetarians. CONCLUSION: We found beneficial association of vegetarian diet with cardiovascular risk factors compared to non-vegetarian diet.

Nutritional profile of Indian vegetarian diets--the Indian Migration Study (IMS).

BACKGROUND: The cardiovascular and other health benefits and potential harms of protein and micronutrient deficiency of vegetarian diets continue to be debated. METHODS: Study participants included urban migrants, their rural siblings and urban residents (n = 6555, mean age - 40.9 yrs) of the Indian Migration Study from Lucknow, Nagpur, Hyderabad and Bangalore. Information on diet (validated interviewer-administered semi-quantitative food frequency questionnaire), tobacco, alcohol, physical activity, medical histories, as well as blood pressure, fasting blood and anthropometric measurements were collected. Nutrient databases were used to calculate nutrient content of regional recipes. Vegetarians ate no eggs, fish, poultry and meat. Using multivariate linear regression with robust standard error model, we compared the macro- and micro-nutrient profile of vegetarian and non-vegetarian diets. RESULTS: Vegetarians, (32.8% of the population), consumed greater amounts of legumes, vegetables, roots and tubers, dairy and sugar, while non-vegetarians had a greater intake of cereals, fruits, spices, salt (p < 0.01), fats and oils. Vegetarians had a higher socioeconomic status, and were less likely to smoke, drink alcohol (p < 0.0001) and engage in less physical activity (p = 0.04). On multivariate analysis, vegetarians consumed more carbohydrates (ß = 7.0 g/day (95% CI: 9.9 to 4.0), p < 0.0001), vitamin C (ß = 8.7 mg/day (95% CI: 4.3 to13.0), p < 0.0001) and folate (ß = 8.0 mcg/day (95% CI: 3.3 to 12.7), p = 0.001) and lower levels of fat (ß = -1.6 g/day (95% CI: -0.62 to -2.7), p = 0.002), protein (ß = -6.4 g/day (95% CI: -5.8 to -7.0), p < 0.0001), vitamin B12 (ß = -1.4 mcg/day (95% CI: -1.2 to -1.5), p < 0.0001) and zinc (ß = -0.6 mg/day (95% CI: -0.4 to -0.7), p < 0.0001). CONCLUSION: Overall, Indian vegetarian diets were found to be adequate to sustain nutritional demands according to recommended dietary allowances with less fat. Lower vitamin B12 bio-availability remains a concern and requires exploration of acceptable dietary sources for vegetarians.

Early accelerated senescence of circulating endothelial progenitor cells in premature coronary artery disease patients in a developing country - a case control study.

BACKGROUND: The decreased number and senescence of circulating endothelial progenitor cells (EPCs) are considered markers of vascular senescence associated with aging, atherosclerosis, and coronary artery disease (CAD) in elderly. In this study, we explore the role of vascular senescence in premature CAD (PCAD) in a developing country by comparing the numerical status and senescence of circulating EPCs in PCAD patients to controls. METHODS: EPCs were measured by flow cytometry in 57 patients with angiographically documented CAD, and 57 controls without evidence of CAD, recruited from random patients ≤ 50 years of age at All India Institute of Medical Sciences. EPC senescence as determined by telomere length (EPC-TL) and telomerase activity (EPC-TA) was studied by real time polymerase chain reaction (q PCR) and PCR- ELISA respectively. RESULT: The number of EPCs (0.18% Vs. 0.039% of total WBCs, p < 0.0001), and EPC-TL (3.83 Vs. 5.10 kb/genome, p = 0.009) were markedly lower in PCAD patients compared to controls. These differences persisted after adjustment for age, sex, BMI, smoking and medications. EPC-TA was reduced in PCAD patients, but was statistically significant only after adjustment for confounding factors (1.81 Vs. 2.20 IU/cell, unadjusted p = 0.057, adjusted p = 0.044). CONCLUSIONS: We observed an association between increased vascular cell senescence with PCAD in a sample of young patients from India. This suggests that early accelerated vascular cell senescence may play an important mechanistic role in CAD epidemic in developing countries like India where PCAD burden is markedly higher compared to developed countries.

Associations between active travel to work and overweight, hypertension, and diabetes in India: a cross-sectional study.

BACKGROUND: Increasing active travel (walking, bicycling, and public transport) is promoted as a key strategy to increase physical activity and reduce the growing burden of noncommunicable diseases (NCDs) globally. Little is known about patterns of active travel or associated cardiovascular health benefits in low- and middle-income countries. This study examines mode and duration of travel to work in rural and urban India and associations between active travel and overweight, hypertension, and diabetes. METHODS AND FINDINGS: Cross-sectional study of 3,902 participants (1,366 rural, 2,536 urban) in the Indian Migration Study. Associations between mode and duration of active travel and cardiovascular risk factors were assessed using random-effect logistic regression models adjusting for age, sex, caste, standard of living, occupation, factory location, leisure time physical activity, daily fat intake, smoking status, and alcohol use. Rural dwellers were significantly more likely to bicycle (68.3% versus 15.9%; p<0.001) to work than urban dwellers. The prevalence of overweight or obesity was 50.0%, 37.6%, 24.2%, 24.9%; hypertension was 17.7%, 11.8%, 6.5%, 9.8%; and diabetes was 10.8%, 7.4%, 3.8%, 7.3% in participants who travelled to work by private transport, public transport, bicycling, and walking, respectively. In the adjusted analysis, those walking (adjusted risk ratio [ARR] 0.72; 95% CI 0.58-0.88) or bicycling to work (ARR 0.66; 95% CI 0.55-0.77) were significantly less likely to be overweight or obese than those travelling by private transport. Those bicycling to work were significantly less likely to have hypertension (ARR 0.51; 95% CI 0.36-0.71) or diabetes (ARR 0.65; 95% CI 0.44-0.95). There was evidence of a dose-response relationship between duration of bicycling to work and being overweight, having hypertension or diabetes. The main limitation of the study is the cross-sectional design, which limits causal inference for the associations found. CONCLUSIONS: Walking and bicycling to work was associated with reduced cardiovascular risk in the Indian population. Efforts to increase active travel in urban areas and halt declines in rural areas should be integral to strategies to maintain healthy weight and prevent NCDs in India. Please see later in the article for the Editors' Summary.

Association between milk and milk product consumption and anthropometric measures in adult men and women in India: a cross-sectional study.

BACKGROUND: The nutritional aetiology of obesity remains unclear, especially with regard to the role of dairy products in developing countries. OBJECTIVE: To examine whether milk/milk product consumption is associated with obesity and high waist circumference among adult Indians. METHODS: Information on plain milk, tea, curd and buttermilk/lassi consumption assessed using a Food Frequency Questionnaire was obtained from the cross-sectional sib-pair designed Indian Migration Study (3698 men and 2659 women), conducted at four factory locations across north, central and south India. The anthropometric measures included were Body Mass Index (BMI) and Waist Circumference (WC). Mixed-effect logistic regression models were conducted to accommodate sib-pair design and adjust for potential confounders. RESULTS: After controlling for potential confounders, the risk of being obese (BMI ≥ 25 kg/m(2)) was lower among women (OR = 0.57;95%CI:0.43-0.76;p ≤ 0.0001) and men (OR = 0.67;95%CI: 0.51-0.87;p = 0.005), and the risk of a high WC (men: >90 cm; women: >80 cm) was lower among men (OR = 0.71;95%CI:0.54-0.93;p = 0.005) and women (OR = 0.79;95%CI:0.59-1.05;p>0.05) who consume ≥1 portions of plain milk daily than those who do not consume any milk. The inverse association between daily plain milk consumption and obesity was also confirmed in sibling-pair analyses. Daily tea consumption of ≥ 1 portion was associated with obesity (OR = 1.51;95%CI:1.00-2.25;p>0.050) and high WC (OR = 1.65;95%CI:1.08-2.51;p>0.019) among men but not among women but there was no strong evidence of association of curd and buttermilk/lassi consumption with obesity and high waist circumference among both men and women. CONCLUSIONS: The independent, inverse association of daily plain milk consumption with the risk of being obese suggests that high plain milk intake may lower the risk of obesity in adult Indians. However, this is an observational finding and uncontrolled confounding cannot be excluded as an explanation for the association. Therefore, confirmatory studies are needed to clarify this relationship.

Association study of 25 type 2 diabetes related Loci with measures of obesity in Indian sib pairs.

Obesity is an established risk factor for type 2 diabetes (T2D) and they are metabolically related through the mechanism of insulin resistance. In order to explore how common genetic variants associated with T2D correlate with body mass index (BMI), we examined the influence of 25 T2D associated loci on obesity risk. We used 5056 individuals (2528 sib-pairs) recruited in Indian Migration Study and conducted within sib-pair analysis for six obesity phenotypes. We found associations of variants in CXCR4 (rs932206) and HHEX (rs5015480) with higher body mass index (BMI) (ß=0.13, p=0.001) and (ß=0.09, p=0.002), respectively and weight (ß=0.13, p=0.001) and (ß=0.09, p=0.001), respectively. CXCR4 variant was also strongly associated with body fat (ß=0.10, p=0.0004). In addition, we demonstrated associations of CXCR4 and HHEX with overweight/obesity (OR=1.6, p=0.003) and (OR=1.4, p=0.002), respectively, in 1333 sib-pairs (2666 individuals). We observed marginal evidence of associations between variants at six loci (TCF7L2, NGN3, FOXA2, LOC646279, FLJ39370 and THADA) and waist hip ratio (WHR), BMI and/or overweight which needs to be validated in larger set of samples. All the above findings were independent of daily energy consumption and physical activity level. The risk score estimates based on eight significant loci (including nominal associations) showed associations with WHR and body fat which were independent of BMI. In summary, we establish the role of T2D associated loci in influencing the measures of obesity in Indian population, suggesting common underlying pathophysiology across populations.

Serum Omega-6/Omega-3 Ratio and Risk Markers for Cardiovascular Disease in an Industrial Population of Delhi.

High omega-6/omega-3 ratio intake promotes development of many chronic diseases. Secondary prevention studies though have demonstrated a decline in progression of many such diseases after reducing the intake, specific biochemical indices of cardiovascular disease risk markers have not been evaluated. We have evaluated the circulating levels of omega-6/omega-3 ratio and its effect on cardiovascular risk markers in India. Present study was conducted in industrial setting where employees were randomly selected. Data on their demographic characteristics were collected using pre-tested questionnaire. Fasting blood samples were collected from all the participants. Serum was separated and stored at -80°C till the time of analysis. Lipids were estimated using standard kits. Fatty acids in serum were estimated by Gas chromatography. The identified Omega-3 fatty acid included were 18:3 (Alpha-linolenic acid), 20:5 (Eicosapentenoic acid) & 22:6 (Docosahexenoic acid). Among omega-6 included were 18:2 (linoleic acid), 18:3 (gamma-linolenic acid) & 20:4 (Arachidonic acid). Complete data was available for 176 participants (89% males and 11% females) with mean age of 47.23 ± 6.00 years. The bmi of the participants was 24.88 ± 3.43 Kg/m2 and waist circumference was 91.50 ± 9.56 cm. The median of omega-6/omega-3 ratio in the study population was 36.69 (range: 6.21 - 183.69). The levels of total cholesterol, triglycerides, ldl-cholesterol and cholesterol/hdl ratio and apo B correlated significantly with omega-6/3 ratio. There was no correlation observed with hsCRP and LDL-particle size. A direct relationship of omega-6/omega-3 ratio with dyslipidemia was observed in our study.

LDL particle heterogeneity, and its association with other established cardiovascular risk factors in a young Indian industrial population.

OBJECTIVE: Low density lipoprotein (LDL) particles are heterogeneous in terms of size, density, chemical composition and electric charge with certain particle of LDL being more atherogenic than the others. The present study aimed to look at the LDL particle heterogeneity, particle size and association with other cardiovascular disease (CVD) risk factors in young Indian industrial population. METHODOLOGY: 600 employees of an industry of Delhi, aged 20-39 years were selected for the study. Data on demographics, individual characteristics associated with major risk factors of CVD, past medical history, clinical and anthropometric profile was collected. Fasting glucose, lipid profile, apolipoprotein (A1, B, and E), lipoprotein (a), high sensitive C-reactive protein (hsCRP) and insulin were estimated. LDL particle size was determined in ethylenediamminetetraacetate (EDTA) plasma by 3% polyacrylamide gel electrophoresis. RESULT: We found a prevalence of small dense LDL phenotype (LDL size ≤ 26.3) in 27.4% of males and 24.0% of females. The mean waist circumference, blood pressure, triglycerides (TAG), cholesterol, hsCRP, apolipoprotein (A1, B and E) and insulin were higher in males whereas mean high density lipoprotein was higher in females. Females also had a significantly higher mean LDL particle diameter as compared to males. CONCLUSION: TAG, physical activity and lipoprotein (a) correlated with small dense LDL in this young Indian population.

Socio-demographic patterning of physical activity across migrant groups in India: results from the Indian Migration Study.

OBJECTIVE: To investigate the relationship between rural to urban migration and physical activity (PA) in India. METHODS: 6,447 (42% women) participants comprising 2077 rural, 2,094 migrants and 2,276 urban were recruited. Total activity (MET hr/day), activity intensity (min/day), PA Level (PAL) television viewing and sleeping (min/day) were estimated and associations with migrant status examined, adjusting for the sib-pair design, age, site, occupation, education, and socio-economic position (SEP). RESULTS: Total activity was highest in rural men whereas migrant and urban men had broadly similar activity levels (p<0.001). Women showed similar patterns, but slightly lower levels of total activity. Sedentary behaviour and television viewing were lower in rural residents and similar in migrant and urban groups. Sleep duration was highest in the rural group and lowest in urban non-migrants. Migrant men had considerably lower odds of being in the highest quartile of total activity than rural men, a finding that persisted after adjustment for age, SEP and education (OR 0.53, 95% CI 0.37, 0.74). For women, odds ratios attenuated and associations were removed after adjusting for age, SEP and education. CONCLUSION: Our findings suggest that migrants have already acquired PA levels that closely resemble long-term urban residents. Effective public health interventions to increase PA are needed.

Association between urban life-years and cardiometabolic risk: the Indian migration study.

Urban living is associated with an increase in cardiometabolic risks, but the speed at which these risks are accrued over time is unknown. Using a cross-sectional sibling-pair design, the authors surveyed migrant factory workers and their spouses from 4 cities in India together with their rural-dwelling siblings and examined the associations between urban life-years and cardiometabolic risk factors. Data on 4,221 participants (39% women; mean age = 41 years) were available (2005-2007). In regression models, a 2-slope pattern for body fat (with a marked shift at 10 years) was found, whereas a common slope could be accepted for other risk factors. In men, the regression coefficients (per decade of urban life) were 2.5% in the first decade and 0.1% thereafter for body fat; 1.4 mm Hg for systolic blood pressure; and 7% for fasting insulin. Age, gender, marital status, household structure, and occupation did not influence the patterns appreciably; however, stronger gradients for adiposity were noted in migrants from lower socioeconomic positions. The findings suggest that body fat increases rapidly when one first moves to an urban environment, whereas other cardiometabolic risk factors evolve gradually. Public health interventions focused on the control of obesity in newer migrants to urban areas, particularly those from lower socioeconomic positions, may be beneficial.

Childhood body mass index and adult pro-inflammatory and pro-thrombotic risk factors: data from the New Delhi birth cohort.

OBJECTIVE: Weight gain and growth in early life may influence adult pro-inflammatory and pro-thrombotic cardiovascular risk factors. METHODS: Follow-up of a birth cohort in New Delhi, India, whose weight and height were measured every 6 months until age 21 years. Body mass index (BMI) at birth, during infancy (2 years), childhood (11 years) and adulthood (26-32 years) and BMI gain between these ages were analysed in 886 men and 640 women with respect to adult fibrinogen, high-sensitivity C-reactive protein (hsCRP) and plasminogen activator inhibitor-1 (PAI-1) concentrations. RESULTS: All the pro-inflammatory/pro-thrombotic risk factors were higher in participants with higher adiposity. In women, BMI at birth and age 2 years was inversely related to fibrinogen (P = 0.002 and 0.05) and, after adjusting for adult adiposity, to hsCRP (P = 0.02 and 0.009). After adjusting for adult adiposity, BMI at 2 years was inversely related to hsCRP and PAI-1 concentrations (P < 0.001 and 0.02) in men. BMI gain between 2 and 11 years and/or 11 years to adulthood was positively associated with fibrinogen and hsCRP in women and with hsCRP and PAI-1 in men. CONCLUSIONS: Thinness at birth or during infancy, and accelerated BMI gain during childhood/adolescence are associated with a pro-inflammatory/pro-thrombotic state in adult life. An altered inflammatory state could be one link between small newborn/infant size and adult cardiovascular disease. Associations between pro-inflammatory markers and childhood/adolescent BMI gain are probably mediated through adult adiposity.