B.C. Das

Prevalence and risk factors for metabolic syndrome in Asian Indians: A community study from urban Eastern India

Objectives: To determine the prevalence of metabolic syndrome and to identify predictors for the same, specific to an underdeveloped urban locale of Eastern India. Materials and Methods: Study design: Population-based cross-sectional study, with multistage random sampling technique. Setting: Urban city-dwellers in Orissa one of the poorest states of Eastern India bordering a prosperous state of Andhra Pradesh of Southern India. Participants: 1178 adults of age 20–80 years randomly selected from 37 electoral wards of the urban city. Definition of Metabolic Syndrome: We followed a unified definition of the metabolic syndrome by joint interim statement of five major scientific organizations – the International Diabetes Federation, the National Heart, Lung, and Blood Institute, the American Heart Association, the World Heart Federation, the International Atherosclerosis Society, and the International Association of the Study of Obesity. Individuals who meet at least three of five clinical criteria of abdominal obesity, hypertriglyceredimia, low HDL, hypertension, and hyperglycemia are diagnosed as having the condition; presence of none of these criteria is mandatory. Explicit cut points are defined for all criteria, except elevated waist circumference, which must rely on population and country-specific definitions. Main Outcome Measure: Prevalence and significant predictors of metabolic syndrome. Statistical Analysis: Both descriptive and multivariable logistic regression analyses. Results: Age-standardized prevalence rates of metabolic syndrome were 33.5% overall, 24.9 % in males and 42.3% in females. Older age, female gender, general obesity, inadequate fruit intake, hypercholesterolemia, and middle-to-high socioeconomic status significantly contributed to increased risk of metabolic syndrome. Conclusion: Metabolic syndrome is a significant public health problem even in one of the poorest states of India that needs to be tackled with proven strategies.

Physical inactivity : A cardiovascular risk factor

Evidence regarding health benefits of physical activity is overwhelming and plays a critical role in both the primary and secondary prevention of coronary artery disease (CAD). Epidemiological investigations show approximately half the incidence of CAD in active compared to sedentary persons. A sedentary lifestyle is considered by various national and international organizations to be one of the most important modifiable risk factors for cardiovascular morbidity and mortality. Fortunately, a moderate level of occupational or recreational activity appears to confer a significant protective effect. Once coronary artery disease has become manifest, exercise training can clearly improve the functional capacity of patients and reduce overall mortality by decreasing the risk of sudden death. Well-designed clinical investigations, supported by basic animal studies, have demonstrated that the beneficial effects of exercise are related to direct and indirect protective mechanisms. These benefits may result from an improvement in cardiovascular risk factors, enhanced fibrinolysis, improved endothelial function, decreased sympathetic tone, and other as-yet-undetermined factors. Hence physical fitness, more than the absence of ponderosity or other factors, is the major determinant of cardiovascular and metabolic risk and long-term disease-free survival, in effect linking health span to life span. It is obviously in every individuals interest to assume the responsibility for his or her own health and embrace this extremely effective, safe, and inexpensive treatment modality. The need for a comprehensive review of this particular topic has arisen in view of the high prevalence of physical inactivity and overwhelming evidence regarding CVD risk reduction with regular physical activity.

Smoking and cardiovascular health: A review of the epidemiology, pathogenesis, prevention and control of tobacco

The causal associations between cigarette smoking and human diseases are irrefutable. In this review, we focus on the epidemiological pattern of cigarette smoking on cardiovascular risk, the underlying mechanistic process of such a causal link, how to prevent premature cardiovascular morbidity and mortality particularly through smoking cessation, and the health benefits of such cessation measures. Finally, we conclude our review summarizing a few of the proven evidence-based tobacco control strategies and policies from across the globe. We did not conduct a systematic review but followed a similar structure. We abstracted the most relevant published literature on the electronic databases, namely, PubMed, Embase and the Cochrane Library applying specific search terms. We also searched gray literature and consulted experts in the field for cross-references. Smoking has been estimated to cause about 11% of all deaths due to cardiovascular disease. Smoking contributes to the pathogenesis of coronary artery disease and sudden death through a variety of mechanisms, including the promotion of atherosclerosis, the triggering of coronary thrombosis, coronary artery spasm, and cardiac arrhythmias, and through reduced capacity of the blood to deliver oxygen. Smoking cessation also confers substantial benefits on people with serious heart disease. Smoking cessation should be viewed as therapeutic rather than preventive intervention, similar to treating asymptomatic hypertension. Smoking cessation is highly cost-effective relative to other frequently used medical and surgical interventions. Tobacco related illnesses are important public health issues worldwide. It has been estimated that there are 1.1 billion smokers worldwide and 250 million of them live in India.

Abdominal obesity, an independent cardiovascular risk factor in Indian subcontinent: A clinico epidemiological evidence summary.

Evidence is emerging that obesity-associated cardiovascular disorders (CVD) show variations across regions and ethnicities. However, it is unclear if there are distinctive patterns of abdominal obesity contributing to an increased CVD risk in South Asians. Also, potential underlying mechanistic pathways of such unique patterns are not comprehensively reported in South Asians. This review sets out to examine both. A comprehensive database search strategy was undertaken, namely, PubMed, Embase and Cochrane Library, applying specific search terms for potentially relevant published literature in English language. Grey literature, including scientific meeting abstracts, expert consultations, text books and government/non-government publications were also retrieved. South Asians have 3-5% higher body fat than whites, at any given body mass index. Additional distinctive features, such as South Asian phenotype, low adipokine production, lower lean body mass, ethno-specific socio-cultural and economic factors, were considered as potential contributors to an early age-onset of obesity-linked CVD risk in South Asians. Proven cost-effective anti-obesity strategies, including the development of ethno-specific clinical risk assessment tools, should be adopted early in the life-course to prevent premature CVD deaths and morbidity in South Asians.

Prevalence and risk factors for diabetes and impaired glucose tolerance in Asian Indians: A community survey from urban Eastern India

OBJECTIVES To determine the prevalence of diabetes and impaired glucose tolerance (IGT) and to identify risk factors for the same specific to an underdeveloped urban locale of Eastern India. METHODS Study design. Population based cross-sectional study, with multistage random sampling technique. Setting. Urban city-dwellers in Orissa one of the poorest states of Eastern India bordering a prosperous state of Andhra Pradesh of Southern India. Participants. 1178 adults of 20-80 years age randomly selected from 37 electoral wards of urban populace. Definition and diagnosis of diabetes mellitus and IGT. These were based on a Report of a World Health Organization/International Diabetes Federation Consultation of 2006. Main outcome measure. Prevalence and significant risk factors for Diabetes and IGT. Statistical analysis. Both descriptive and multivariable logistic regression analyses. RESULTS The crude rates of diabetes and IGT in the study population were 15.7% and 8.8%, respectively. Similarly age-standardized rates of diabetes and IGT were 11.1% and 6.7%, respectively. Both diabetes and IGT had shown a male preponderance. CONCLUSION Diabetes and IGT were very highly prevalent in this urban populace. Cardiometabolic risk factors like older age, central obesity, inadequate fruit intake, hypertension, hypertriglyceridemia and socio economic status were found to be significant predictors of diabetes in this study.

Childhood cardiovascular risk factors in South Asians: A cause of concern for adult cardiovascular disease epidemic.

Cardiovascular risk factors in children are increasing at an alarming rate in the western world. However, there is limited information regarding these in the South Asian children. This review attempts at summarizing such evidence. South Asians are remarkable for the earlier onset of adult cardiovascular disease (CVD) by almost a decade compared to the Caucasians. We identified published literature, mainly on PubMed, Embase and Cochrane library using specific search terms such as lipid abnormalities, high blood pressure, hyperglycemia, tobacco use, obesity, physical inactivity, and unhealthy dietary practices. Atherosclerotic CVD processes begin early in childhood and are influenced over the life course by genetic and potentially modifiable risk factors and environmental exposure. 80% of adult CVD burden will fall on the developing nations by 2020. The concept of primordial prevention is fast emerging as a necessary prevention tool to curb adult CVD epidemic. Established guidelines and proven preventive strategies on cardiovascular health exist; however, are always implemented half-heartedly. Composite screening and prediction tools for adults can be adapted and validated in children tailored to South Asian population. South Asian children could be at a greater risk of developing cardiovascular risk factors at an earlier stage, thus, timely interventions are imperative.

Prevalence and predictors of adult hypertension in an urban eastern Indian population

Objective To determine the prevalence of hypertension and to identify predictors of adult hypertension specifically in an underdeveloped urban region of eastern India. Study design Population-based cross-sectional study, with multi-stage random sampling technique. Settings A main urban city located in South Orissa in eastern India. Participants 1178 adults 20–80 years of age randomly selected from 37 electoral wards of an urban locale. Statistical methods Descriptive and multivariable logistic regression analyses. Results The prevalence of hypertension was 36%. Significant predictors of hypertension were age, central obesity, inadequate fruit intake, diabetes, low high-density lipoprotein level and physical inactivity. Conclusions One-third of the adults in this urban population of eastern India are reported to be hypertensive and the classical risk factors have been found to contribute to the increased burden, which reinforces the importance of preventive cardiovascular interventions in tackling this burden.

Appropriate anthropometric indices to identify cardiometabolic risk in South Asians

Background: South Asians show an elevated cardiometabolic risk compared to Caucasians. They are clinically metabolically obese but are considered normal weight based on current international cut-off levels of several anthropometric indices. This study has two main objectives: (i) to predict the most sensitive anthropometric measures for commonly studied cardiometabolic risk factors, and (ii) to determine optimal cut-off levels of each of the anthropometric indices in relation to these cardiometabolic risk factors in South Asians. Methods: The study was conducted on a random sample of 1178 adults of 20–80 years of age from an urban population of eastern India. Obesity, as evaluated by standard anthropometric indices of BMI (body mass index), WC (waist circumference), WHpR (waist-to-hip ratio) and WHtR (waist-to-height ratio), was individually correlated with cardiometabolic risk factors. Receiver operating characteristic (ROC) curve analyses were performed which includes: (i) the area under the receiver operating characteristic curve (AUROC) analysis to assess the predictive validity of each cardiometabolic risk factor; and (ii) Youden index to determine optimal cut-off levels of each of the anthropometric indices. Results: Overall, AUROC values for WHtR were the highest, but showed variations within the sexes for each of the cardiometabolic risk factors studied. Further, WHpR cut-offs were higher for men (0.93–0.95) than women (0.85–0.88). WC cut-offs were 84.5–89.5 cm in men and 77.5–82.0 cm in women. For both sexes the optimal WHtR cut-off value was 0.51–0.55. The optimal BMI cut-offs were 23.4–24.2 kg/m2 in men and 23.6–25.3 kg/m2 in women. Conclusion: WHtR may be a better anthropometric marker of cardiometabolic risks in South Asian adults than BMI, WC or WHpR.

Subclinical atherosclerosis and silent myocardial ischaemia in patients with type 2 diabetes: a protocol of a clinico-observational study

Introduction Atherosclerotic cardiovascular disease is a significant modifiable complication in patients with diabetes and subclinical atherosclerosis is considered a surrogate marker of future vascular events. The clustering of cardiometabolic-risk factors in patients with diabetes and cardiovascular disease is increasingly being recognised. Recent evidence indicates that 20–50% of asymptomatic patients with diabetes may have silent coronary heart disease. However, the identification of subclinical atherosclerosis and silent myocardial ischaemia in patients with diabetes has been less well-explored, especially in low-resource population settings where cost-effective non-invasive clinical tools are available. The objective of this study is to identify patients with physician-diagnosed diabetes who are at risk of developing future cardiovascular events measured as subclinical atherosclerosis and silent myocardial ischaemia in an urban population of Eastern India. Methods and analysis This is a cross-sectional clinico-observational study. A convenience sampling of approximately 350 consecutive patients with type 2 diabetes based on predefined inclusion and exclusion criteria will be identified at an urban diabetes center. This estimated sample size is based on an expected prevalence of silent myocardial ischaemia of 25% (± 5%), we computed the required sample size using OpenEpi online software assuming an α level of 0.05 (95% CI) to be 289. On factoring 20% non-response the estimated sample size is 350. Previously validated questionnaire tools and well-defined clinical, anthropometric and biochemical measurements will be utilised for data collection. The two primary outcomes—subclinical atherosclerosis and silent myocardial ischaemia will be measured using carotid intima-media thickness and exercise tolerance testing, respectively. Descriptive and multivariate logistic regression statistical techniques will be employed to identify ‘at risk’ patients with diabetes, and adjusted for potential confounders. Ethics and dissemination Ethical approval was granted by the institutional review board of Kalinga Institute of Medical Sciences, Bhubaneshwar, India. Data will be presented at academic fora and published in peer-reviewed journals.

Neurodevelopmental disorders in children aged 2–9 years: Population-based burden estimates across five regions in India

Background Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden. Methods and findings We assessed 3,964 children (with almost equal number of boys and girls distributed in 2–<6 and 6–9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6–9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2–<6 year olds ranged from 2.9% (95% CI 1.6–5.5) to 18.7% (95% CI 14.7–23.6), and for any of nine NDDs in the 6–9-year-old children, from 6.5% (95% CI 4.6–9.1) to 18.5% (95% CI 15.3–22.3). Two or more NDDs were present in 0.4% (95% CI 0.1–1.7) to 4.3% (95% CI 2.2–8.2) in the younger age category and 0.7% (95% CI 0.2–2.0) to 5.3% (95% CI 3.3–8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5–11.2) and 13.6% (95% CI 11.3–16.2) in children of 2–<6 and 6–9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6–9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population. Conclusions The study identifies NDDs in children aged 2–9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.