Naval Kishore Vikram

High prevalence of diabetes, obesity and dyslipidaemia in urban slum population in northern India

BACKGROUND AND AIMS: In this study, a prevalence survey of various atherosclerosis risk factors was carried out on hitherto poorly studied rural–urban migrants settled in urban slums in a large metropolitan city in northern India, with the aim of studying anthropometric and metabolic characteristics of this population in socio-economic transition.DESIGN: A cross-sectional epidemiological descriptive study.SUBJECTS: A total of 532 subjects (170 males and 362 females) were included in the study (response rate approximately 40%).METHODS AND RESULTS: In this study, diabetes mellitus was recorded in 11.2% (95% CI 6.8–16.9) of males and 9.9% (95% CI 7.0–13.5) of females, the overall prevalence being 10.3% (95% CI 7.8–13.2). Based on body mass index (BMI), obesity was more prevalent in females (15.6%; 95% CI 10.7–22.3) than in males (13.3%; 95% CI 8.5–19.5). On the other hand, classifying obesity based on percentage body fat (%BF), 10.6% (95% CI 6.4–16.2) of males and 40.2% (95% CI 34.9–45.3) of females were obese. High waist–hip ratio (WHR) was observed in 9.4% (95% CI 5.4–14.8) of males and 51.1% (95% CI 45.8–56.3) of the females. All individual skinfolds and sum of skinfolds were significantly higher in females (P<0.001). In both males and females above 30 y of age, there was a steep increase in the prevalence of high WHR, and in females, %BF was very high (particularly in %BF quartile>30%). Furthermore, total cholesterol and low-density lipoprotein cholesterol were high in both males and females. Stepwise multiple linear regression analysis showed that for both males and females BMI, WHR and %BF were positive predictors of biochemical parameters, except for HDL-c, for which these parameters were negatively associated.CONCLUSIONS: Appreciable prevalence of obesity, dyslipidaemia, diabetes mellitus, substantial increase in body fat, generalised and regional obesity in middle age, particularly in females, need immediate attention in terms of prevention and health education in such economically deprived populations.

BMI does not accurately predict overweight in Asian Indians in northern India

Asian Indians are at high risk for the development of atherosclerosis and related complications, possibly initiated by higher body fat (BF). The present study attempted to establish appropriate cut-off levels of the BMI for defining overweight, considering percentage BF in healthy Asian Indians in northern India as the standard. A total of 123 healthy volunteers (eighty-six males aged 18--75 years and thirty-seven females aged 20--69 years) participated in the study. Clinical examination and anthropometric measurements were performed, and percentage BF was calculated. BMI for males was 21.4 (sd 3.7) kg/m(2) and for females was 23.3 (sd 5.5) kg/m(2). Percentage BF was 21.3 (sd 7.6) in males and 35.4 (sd 5.0) in females. A comparison of BF data among Caucasians, Blacks, Polynesians and Asian ethnic groups (e.g. immigrant Chinese) revealed conspicuous differences. Receiver operating characteristic (ROC) curve analysis showed a low sensitivity and negative predictive value of the conventional cut-off value of the BMI (25 kg/m(2)) in identifying subjects with overweight as compared to the cut-off value based on percentage BF (males >25, females >30). This observation is particularly obvious in females, resulting in substantial misclassification. Based on the ROC curve, a lower cut-off value of the BMI (21.5 kg/m(2) for males and 19.0 kg/m(2) for females) displayed the optimal sensitivity and specificity, and less misclassification in identification of subjects with high percentage BF. Furthermore, a novel obesity variable, BF:BMI, was tested and should prove useful for interethnic comparison of body composition. In the northern Indian population, the conventional cut-off level of the BMI underestimates overweight and obesity when percentage BF is used as the standard to define overweight. These preliminary findings, if confirmed in a larger number of subjects and with the use of instruments having a higher accuracy of BF assessment, would be crucial for planning and the prevention and treatment of various obesity-related metabolic diseases in the Asian Indian population.

Waist circumference cutoff points and action levels for Asian Indians for identification of abdominal obesity

Objective:To test the validity of internationally accepted waist circumference (WC) action levels for adult Asian Indians.Design:Analysis of data from multisite cross-sectional epidemiological studies in north India.Subjects:In all, 2050 adult subjects >18 years of age (883 male and 1167 female subjects).Measurements:Body mass index (BMI), WC, waist-to-hip circumference ratio, blood pressure, and fasting samples for blood glucose, total cholesterol, serum triglycerides, and high-density lipoprotein cholesterol.Results:In male subjects, a WC cutoff point of 78 cm (sensitivity 74.3%, specificity 68.0%), and in female subjects, a cutoff point of 72 cm (sensitivity 68.7%, specificity 71.8%) were appropriate in identifying those with at least one cardiovascular risk factor and for identifying those with a BMI >21 kg/m2. WC levels of ⩾90 and ⩾80 cm for men and women, respectively, identified high odds ratio for cardiovascular risk factor(s) and BMI level of ⩾25 kg/m2. The current internationally accepted WC cutoff points (102 cm in men and 88 cm in women) showed lower sensitivity and lower correct classification as compared to the WC cutoff points generated in the present study.Conclusion:We propose the following WC action levels for adult Asian Indians: action level 1: men, ⩾78 cm, women, ⩾72 cm; and action level 2: men, ⩾90 cm, women, ⩾80 cm.

High prevalence of insulin resistance in postpubertal Asian Indian children is associated with adverse truncal body fat patterning, abdominal adiposity and excess body fat.

OBJECTIVE: The objectives were to study the relationships of insulin resistance with generalized and abdominal obesity, and body fat patterning in urban postpubertal Asian Indian children.DESIGN: Cross-sectional, population-based epidemiological study.SUBJECTS: In all, 250 (155 males and 95 females) healthy urban postpubertal children.MEASUREMENTS: Anthropometric profile, percentage of body fat (%BF), fasting serum insulin, and lipoprotein profile.RESULTS: Fasting insulin correlated significantly with body mass index (BMI), %BF, waist circumference (WC), central and peripheral skinfold thicknesses and sum of four skinfold thicknesses (∑4SF) in both sexes, and with systolic blood pressure and waist–to hip circumference ratio (W–HR) in males only. Consistent increase in fasting insulin was noted with increasing values of central skinfold thickness at each tertile of peripheral skinfold thickness, WC, and %BF. Central skinfold thickness correlated with fasting insulin even after adjusting for WC, W–HR, and %BF. The odds ratios (OR) (95% CI) of hyperinsulinemia (fasting insulin concentrations in the highest quartile) were 4.7 (2.4–9.4) in overweight subjects, 8 (4.1–15.5) with high %BF, 6.4 (3.2–12.9) with high WC, 3.7 (1.9–7.3) with high W–HR, 6.8 (3.3–13.9) with high triceps skinfold thickness, 8 (4.1–15.7) with high subscapular skinfold thickness, and 10.1 (5–20.5) with high ∑4SF. In step-wise multiple logistic regression analysis, %BF [OR (95% CI): 3.2 (1.4–7.8)] and ?4SF [OR (95% CI): 4.5 (1.8–11.3)] were independent predictors of hyperinsulinemia, similar to insulin resistance assessed by HOMA (homeostatic model of assessment) in the study.CONCLUSION: A high prevalence of insulin resistance in postpubertal urban Asian Indian children was associated with excess body fat, abdominal adiposity, and excess truncal subcutaneous fat. Primary prevention strategies for coronary heart disease and diabetes mellitus in Asian Indians should focus on the abnormal body composition profile in childhood.

Effect of Supervised Progressive Resistance-Exercise Training Protocol on Insulin Sensitivity, Glycemia, Lipids, and Body Composition in Asian Indians With Type 2 Diabetes

OBJECTIVE—To evaluate the effect of supervised progressive resistance-exercise training (PRT) protocol on insulin sensitivity, glycemia (blood glucose and A1C levels), lipids, and body composition in Asian Indians with type 2 diabetes. RESEARCH DESIGN AND METHODS—Thirty patients with type 2 diabetes underwent 12 weeks of PRT of six muscle groups (two sets, 10 repetitions each). The subjects were evaluated with detailed anthropometry and with measurements of the disappearance of glucose per unit time (K) during the short insulin tolerance test (KITT) for assessment of insulin sensitivity; of fasting blood glucose, A1C, lipids, and high-sensitivity C-reactive protein (hsCRP); of total body fat, regional fat, and lean body mass by dual-energy X-ray absorptiometry; and of cross-sectional skeletal muscle area of upper arm and thigh by computed tomography scan. RESULTS—Insulin sensitivity improved significantly from mean ± SD KITT 1.22 ± 0.73 to 2.13 ± 0.75 (P < 0.0001) after the intervention. Significant decline (mean difference ± SD) from baseline was recorded in levels of the following parameters: A1C (0.54 ± 0.4%, P < 0.001), fasting blood glucose (2.7 ± 2.2 mmol/l, P < 0.001), total cholesterol (0.39 ± 0.7 mmol/l, P = 0.003), serum triglycerides (0.39 ± 0.5 mmol/l, P < 0.001), and truncal and peripheral subcutaneous adipose tissue compartments (SCAT) (P < 0.001). However, no significant changes were noticed in BMI or levels of total body fat, truncal fat, lean body mass, cross-sectional skeletal muscle area of the extremities, or hsCRP levels. CONCLUSIONS—Moderate-intensity PRT for 3 months resulted in significant improvement in insulin sensitivity, glycemia, lipids, and truncal and peripheral SCAT in patients with type 2 diabetes. Resistance training should be an integral part of exercise regimen in Asian Indians with type 2 diabetes.

Subcutaneous abdominal adipose tissue is associated with the metabolic syndrome in Asian Indians independent of intra-abdominal and total body fat

Hypothesis Subcutaneous abdominal adipose tissue (SCAT) compared with intra-abdominal adipose tissue (IAAT) would be more significantly associated with the metabolic syndrome in Asian Indians. Design Cross-sectional study. Setting Tertiary care medical institution. Subjects 100 healthy adults without known heart disease or diabetes. Interventions Magnetic resonance imaging to measure cross-sectional areas of abdominal adipose tissue compartments at the L3–L4 intervertebral level. Dual energy x-ray absorptiometry to measure fat percentage (BF%) and lean mass of total body, trunk, legs and arms. Results Subjects with the metabolic syndrome (n=35) had a significantly higher BF%, SCAT and IAAT than those without it. Both SCAT and IAAT showed a significant correlation with blood pressure and triglycerides. One SD increase in IAAT (odds ratio (OR) 3.43; 95% CI 1.78 to 6.63) or SCAT area (OR 6.35; 95% CI 2.75 to 14.7) was significantly associated with the metabolic syndrome. On comparing them in the same model, SCAT was the only significant factor associated with the metabolic syndrome (OR 4.92; 95% CI, 1.95 to 12.38). In receiver operating characteristic curve analysis, significant areas under the curves (AUC) were noted for IAAT (0.77) and SCAT (0.89). On comparing the equality of AUC by C statistics, SCAT was a more significant predictor of the metabolic syndrome than IAAT (p=0.009). Only SCAT was significantly associated with the metabolic syndrome after adjusting for BF%, lean body mass or trunk lean mass. Conclusion SCAT is a more important predictor of the metabolic syndrome in Asian Indians than IAAT. The significance of SCAT in the pathogenesis of atherosclerosis and diabetes needs to be investigated further in Asian Indians.

Correlates of Type 2 diabetes mellitus in children, adolescents and young adults in north India: a multisite collaborative case-control study

Aims  In this study we describe the clinical, anthropometric and biochemical characteristics of patients with early onset Type 2 diabetes mellitus (T2DM) (< 30 years of age) and compare them with healthy, non‐diabetic individuals.

The Role of Lipids in the Development of Diabetic Microvascular Complications

Dyslipidemia is a major factor responsible for coronary heart disease and its reduction decreases coronary risk in patients with diabetes mellitus. However, the association of dyslipidemia with microvascular complications and the effect of intervention with lipid-lowering therapy in diabetes have been less investigated. We present the systematic review of association and intervention studies pertaining to dyslipidemia and microvascular disease in diabetes and also review possible mechanisms. Dyslipidemia may cause or exacerbate diabetic retinopathy and nephropathy by alterations in the coagulation-fibrinolytic system, changes in membrane permeability, damage to endothelial cells and increased atherosclerosis. Hyperlipidemia is associated with faster decline in glomerular filtration rate and progression of albuminuria and nephropathy. Recent evidence also suggests a role of lipoprotein(a) in progression of retinopathy and nephropathy in patients with diabetes mellitus. Lipid-lowering therapy, using single agents or a combination of drugs may significantly benefit diabetic retinopathy and diabetic nephropathy. In particular, hydroxymethyl glutaryl coenzyme A reductase inhibitors may be effective in preventing or retarding the progression of microvascular complications because of their powerful lipid-lowering effects and other additional mechanisms. However, most of the data are based on short-term studies, and need to be ascertained in long-term studies. Until more specific guidelines are available, aggressive management of diabetic dyslipidemia, according to currently accepted guidelines, should be continued for the prevention of macrovascular disease which would also benefit microvascular complications.

High prevalence and low awareness, treatment and control of hypertension in Asian Indian women

Hypertension is an important public health problem in India. To determine its prevalence, awareness, treatment and control among women, we performed a nationwide study. Population-based studies among women aged 35–70 years were performed in four urban and five rural locations. Stratified sampling was performed and we enrolled 4608 (rural 2604 and urban 2004) of the targeted 8000 (57%). Demographic details, medical history, diet, physical activity, anthropometry and blood pressure (BP) were recorded. Descriptive statistics are reported. Logistic regression was performed to determine the association of hypertension and its awareness, treatment and control with socioeconomic factors. Age-adjusted prevalence of hypertension (known or BP⩾140/⩾90 mm Hg) was observed in 1672 women (39.2%) (rural 746, 31.5%; urban 926, 48.2%). Significant determinants of hypertension were urban location, greater literacy, high dietary fat, low fibre intake, obesity and truncal obesity (P<0.01). Hypertension awareness was noted in 727 women (42.8%), more in urban (529, 56.8%) than in rural (198, 24.6%). Of these, 38.6% of the women were on treatment (urban 35.7, rural 46.5) and of those treated, controlled blood pressure (<140 and <90 mm Hg) was observed in 21.5% (urban 28.3 vs 10.2). Among hypertensive subjects, treatment was noted in 18.3% (rural 13.1, urban 22.5) and control in 3.9% (rural 1.3, urban 5.9). A significant determinant of low awareness, treatment and control was rural location (multivariate-adjusted P<0.05). There is a high prevalence of hypertension in middle-aged Asian Indian women. Very low awareness, treatment and control status are observed.

Vitamin D Insufficiency Is Associated with Abdominal Obesity in Urban Asian Indians Without Diabetes in North India

OBJECTIVE We evaluated the associations of serum 25-hydroxyvitamin D [25(OH) D] levels with clinical, biochemical, and anthropometric profiles and total abdominal adipose tissue (TAAT), subcutaneous abdominal adipose tissue (SCAT), and intraabdominal adipose tissue (IAAT) depots in Asian Indians without diabetes residing in north India. SUBJECTS AND METHODS In this cross-sectional study (n=137; 74 males and 63 females; 18-60 years of age), anthropometric (body mass index, waist and hip circumferences, and skinfold thickness at four sites) and biochemical (fasting plasma glucose, lipid profile, and fasting insulin levels) assessments were done. Measurement of percentage body fat was done by dual energy x-ray absorptiometry, and areas of TAAT, SCAT and IAAT were measured at the L2-L3 intervertebral level by single-slice magnetic resonance imaging. Levels of 25(OH) D were measured by radioimmunoassay. Correlation analysis was used to assess relationships among clinical, biochemical, and anthropometric profiles, areas of TAAT, SCAT, and IAAT, and 25(OH) D levels. RESULTS The mean concentration of 25(OH) D was 40.5 ± 8.6 ng/mL. Overall, 6.6% had vitamin D deficiency (<10 ng/mL), 87.6% had insufficiency (<30 ng/mL), and 5.8% had a sufficient level (>30 ng/mL). Levels of 25(OH) D did not correlate with demographic, biochemical, and anthropometric profiles or with abdominal fat depots (TAAT, SCAT, and IAAT). In the correlation regression model, 25(OH) D was associated with TAAT in obese subjects. CONCLUSIONS In obese urban Asian Indians without diabetes, higher values of total abdominal fat at the L2-L3 intervertebral level were associated with low 25(OH) D levels.