Seema Gulati

Improvement in nutrition-related knowledge and behaviour of urban Asian Indian school children: findings from the 'Medical education for children/Adolescents for Realistic prevention of obesity and diabetes and for healthy aGeing' (MARG) intervention study.

Increasing prevalence of childhood obesity calls for comprehensive and cost-effective educative measures in developing countries such as India. School-based educative programmes greatly influence childrens behaviour towards healthy living. We aimed to evaluate the impact of a school-based health and nutritional education programme on knowledge and behaviour of urban Asian Indian school children. Benchmark assessment of parents and teachers was also done. We educated 40 196 children (aged 8-18 years), 25 000 parents and 1500 teachers about health, nutrition, physical activity, non-communicable diseases and healthy cooking practices in three cities of North India. A pre-tested questionnaire was used to assess randomly selected 3128 children, 2241 parents and 841 teachers before intervention and 2329 children after intervention. Low baseline knowledge and behaviour scores were reported in 75-94 % government and 48-78 % private school children, across all age groups. A small proportion of government school children gave correct answers about protein (14-17 %), carbohydrates (25-27 %) and saturated fats (18-32 %). Private school children, parents and teachers performed significantly better than government school subjects (P < 0.05). Following the intervention, scores improved in all children irrespective of the type of school (P < 0.001). A significantly higher improvement was observed in younger children (aged 8-11 years) as compared with those aged 12-18 years, in females compared with males and in government schools compared with private schools (P < 0.05 for all). Major gaps exist in health and nutrition-related knowledge and behaviour of urban Asian Indian children, parents and teachers. This successful and comprehensive educative intervention could be incorporated in future school-based health and nutritional education programmes.

Secular Trends in Prevalence of Overweight and Obesity from 2006 to 2009 in Urban Asian Indian Adolescents Aged 14-17 Years

The present study examines the secular trends in prevalence of overweight and obesity among urban Asian Indian adolescents in New Delhi (North India). The data were derived from cross-sectional sampling of children, 3493 in year 2006 and 4908 in year 2009, aged 14–17 years studying in privately-funded and government-funded schools. Age, gender and Asian Indian-specific cut offs of body mass index (BMI) were used to define overweight and obesity. The prevalence of obesity increased significantly from 9.8% in 2006 to 11.7% in 2009 (p<0.01), whereas underweight decreased from 11.3% to 3.9% (p<0.001). There was a significantly higher risk of being overweight (OR 1.28; 95% CI, 1.15–1.42) and obese (OR 1.44; 95% CI, 1.24–1.66) in year 2009 than 2006, after adjusting for age, gender and type of school. Males and privately-funded school children had significantly higher increase in prevalence and risk of being overweight and obese over the three years. In conclusion, this study showed an increasing trend in prevalence of overweight and obesity in urban Asian Indian adolescents. More specifically, the study showed the association of this increasing trend of overweight and obesity prevalence with male gender and high socio-economic status, calling for an urgent need for immediate and targeted preventive measures.

The High Burden of Obesity and Abdominal Obesity in Urban Indian Schoolchildren: A Multicentric Study of 38,296 Children

Aims: The objective of this study was to assess the prevalence of overweight, obesity and abdominal obesity and their associated factors in a large sample of urban Indian schoolchildren. Methods: This is a cross-sectional study conducted in 5 cities in India. Height and weight were measured in 38,296 children and waist circumference was measured in 29,244 children aged 8–18 years. The prevalence was compared with respect to age, gender, type of school and city of residence. Results: The mean ± standard deviation for age was 13.3 ± 2.4 years and 18.3 ± 4.3 kg/m2 for BMI. The prevalence of overweight and obesity in 8- to 18-year-old children, respectively, was 14.4 and 2.8% by IOTF cutoffs, 14.5 and 4.8% by CDC cutoffs and 18.5 and 5.3% by WHO cutoffs. When applying the cutoffs specific for Indian ethnicity in 14- to 18-year-old children, the prevalence was higher (21.1 and 12.3%, respectively) as compared to the IOTF, WHO and CDC cutoffs. The overall prevalence of abdominal obesity in urban Indian schoolchildren was 4.5%. The prevalence of overweight and abdominal obesity was significantly higher in females than males (p < 0.001). High socioeconomic status and residing in cities with a population greater than 4 million were independently associated with overweight and abdominal obesity (p < 0.001). On extrapolating these data, more than 15 million children would currently be overweight and 4 million abdominally obese in urban India. Conclusions: There is a substantial burden of childhood obesity in India, which necessitates comprehensive urban-based campaigns for its prevention and control.

High Prevalence of Abdominal, Intra-Abdominal and Subcutaneous Adiposity and Clustering of Risk Factors among Urban Asian Indians in North India

Objective To assess the prevalence of abdominal obesity including intra-abdominal and subcutaneous adiposity along with other cardiometabolic risk factors in urban Asian Indians living in New Delhi. Methods We conducted a cross-sectional epidemiological descriptive study with 459 subjects (217 males and 242 females), representing all socio-economic strata in New Delhi. The anthropometric profile [body mass index (BMI), waist circumference (WC) and skinfold thickness], fasting blood glucose (FBG) and lipid profile were recorded. Percent body fat (%BF), total abdominal fat (TAF), intra-abdominal adipose tissue (IAAT) and subcutaneous abdominal adipose tissue (SCAT) were quantified using predictive equations for Asian Indians. Results The overall prevalence of obesity was high [by BMI (>25 kg/m2), 50.1%]. The prevalence of abdominal obesity (as assessed by WC) was 68.9%, while that assessed by TAF was 70.8%. Increased IAAT was significantly higher in females (80.6%) as compared to males (56.7%) (p = 0.00) with overall prevalence being 69.3%. The overall prevalence of high SCAT was 67.8%, more in males (69.1%) vs. females (66.5%, p = 0.5). The prevalence of type 2 diabetes, the metabolic syndrome and hypertension was 8.5%, 45.3% and 29.2%, respectively. Hypertriglyceridemia, hypercholesterolemia and low levels of HDL-c were prevalent in 42.7%, 26.6% and 37% of the subjects, respectively. The prevalence of hypertriglyceridemia was significantly higher in males (p = 0.007); however, low levels of HDL-c were more prevalent in females as compared to males (p = 0.00). Conclusion High prevalence of generalized obesity, abdominal obesity (by measurement of WC, TAF, IAAT and SCAT) and dysmetabolic state in urban Asian Indians in north India need immediate public health intervention.

Effects of pistachio nuts on body composition, metabolic, inflammatory and oxidative stress parameters in Asian Indians with metabolic syndrome: A 24-wk, randomized control trial

OBJECTIVE The aim of this study was to evaluate the effects of pistachio nuts as an adjunct to diet and exercise on body composition, metabolic, inflammatory, and oxidative stress parameters in Asian Indians with metabolic syndrome. METHODS In this 24-wk randomized control trial, 60 individuals with the metabolic syndrome were randomized to either pistachio (intervention group) or control group (diet as per weight and physical activity profile, modulated according to dietary guidelines for Asian Indians) after 3 wk of a diet and exercise run in. In the first group, unsalted pistachios (20% energy) were given daily. A standard diet and exercise protocol was followed for both groups. Body weight, waist circumference (WC), magnetic resonance imaging estimation of intraabdominal adipose tissue and subcutaneous abdominal adipose tissue, fasting blood glucose (FBG), fasting serum insulin, glycosylated hemoglobin, lipid profile, high-sensitivity C-reactive protein (hs-CRP), adiponectin, free fatty acids (FFAs), tumor necrosis factor (TNF)-α, leptin, and thiobarbituric acid reactive substances (TBARS) were assessed before and after the intervention. RESULTS Statistically significant improvement in mean values for various parameters in the intervention group compared with control group were as follows: WC (P < 0.02), FBG (P < 0.04), total cholesterol (P < 0.02), low-density lipoprotein cholesterol (P < 0.006), hs-CRP (P < 0.05), TNF-α (P < 0.03), FFAs (P < 0.001), TBARS (P < 0.01), and adiponectin levels (P < 0.001). CONCLUSION A single food intervention with pistachios leads to beneficial effects on the cardiometabolic profile of Asian Indians with metabolic syndrome.

Imbalanced Dietary Profile, Anthropometry, and Lipids in Urban Asian Indian Adolescents and Young Adults

Objective: To analyze the macronutrient, micronutrient, food intake pattern, anthropometry, and lipid profile of urban Asian Indian adolescents and young adults and compare it with the nutrient profile of rural Asian Indian and American adolescents. Methods: This was a cross-sectional, epidemiologic descriptive study. Body mass index (BMI), percentage body fat, waist and hip circumferences, skinfold thickness, serum lipids, and dietary intake were assessed in 1236 subjects (607 males, 629 females) aged 13–25 years from schools and colleges of a metropolitan city of India. Results: The mean age and BMI of study subjects were 17.6 ± 2.4 years (range 13–25 years) and 19.8 ± 3.3 kg/m2 (range 11.9–35.9 kg/m2), respectively. The mean daily percentages of total energy contributed by carbohydrates, total fats, proteins, saturated fatty acids (SFAs), monounsaturated fatty acids (MUFAs), polyunsaturated fatty acids (PUFAs), ω-3 PUFAs, ω-6 PUFAs, and trans-fatty acids for all subjects were 53%, 34%, 11%, 11%, 10%, 9%, 1%, 8%, and 0.3%, respectively. The absolute daily intake of total fat was 84 ± 29 g/d in males and 72 ± 21 g/d in females, which was approximately 4 times the recommended dietary allowance for Asian Indians (20–22 g/d). Among food groups, a high intake of milk, milk products, roots, and tubers was observed. In these young individuals, the prevalence of hypercholesterolemia (males ≥169 mg/dl; females ≥181 mg/dl) and overweight (BMI ≥23.1 kg/m2) was 14.4% and ∼16%, respectively. On comparison with rural Asian Indian adolescents, an inappropriately high intake of total fat was observed in our subjects. On the other hand, the percentage of energy intake of SFAs in Asian Indian and American adolescents was at par. Conclusions: High total fat and SFA intake and a low intake of MUFAs and ω-3 PUFAs showed imbalanced nutrition, which could be responsible for the increasing prevalence of obesity and insulin resistance in urban Asian Indian adolescents and young adults. Nutritional strategies for reducing SFA intake and balancing the ω-3/ω-6 PUFAs ratio should be urgently applied in Asian Indian adolescents and are also presented in this paper.

Sugar Intake, Obesity, and Diabetes in India

Sugar and sweet consumption have been popular and intrinsic to Indian culture, traditions, and religion from ancient times. In this article, we review the data showing increasing sugar consumption in India, including traditional sources (jaggery and khandsari) and from sugar-sweetened beverages (SSBs). Along with decreasing physical activity, this increasing trend of per capita sugar consumption assumes significance in view of the high tendency for Indians to develop insulin resistance, abdominal adiposity, and hepatic steatosis, and the increasing “epidemic” of type 2 diabetes (T2DM) and cardiovascular diseases. Importantly, there are preliminary data to show that incidence of obesity and T2DM could be decreased by increasing taxation on SSBs. Other prevention strategies, encompassing multiple stakeholders (government, industry, and consumers), should target on decreasing sugar consumption in the Indian population. In this context, dietary guidelines for Indians show that sugar consumption should be less than 10% of total daily energy intake, but it is suggested that this limit be decreased.

Consensus statement on management of dyslipidemia in Indian subjects.

a Editor, Indian Heart Journal, Sr. Cardiologist, Indo US Superspeciality Hospital, Ameerpet, Hyderabad 500016, India b Senior Consultant e Cardiology, Medanta e The Medicity, Sector 38, Gurgaon, Haryana 122001, India c Head, Department of Cardiology, PRS Hospital, Trivandrum, Akashdeep, TC 17/881, Poojapura, Trivandrum, Kerala 695012, India d Sr. Consultant & HOD, Manipal Hospital, 133, JalaVayu Towers, NGEF Layout, Indira Nagar, Bangalore 560038, India e Head of Medicine and Director Research, Fortis Escorts Hospital, JLN Marg, Malviya Nagar, Jaipur 302017, India f Sr. Cardiologist, Sir Ganga Ram Hospital, New Delhi, India g Westfort H. Hospital, Poonkunnanm, Thrissur 680002, India h Sr. Cardiologist, Krishna Institute of Medical Science, Minister Road, Secunderabad, India i Director, Prof & HOD, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bannerghatta Road, Bangalore 560 069, India j MD DM FACC, Chairman Department of Cardiology, Sir Ganga Ram Hospital, New Delhi, India k Sr. Consultant & Chief Interventional Cardiologist, Sahara India Medical Institute, VirajKhand, Gomti Nagar, Lucknow, Uttar Pradesh 226010, India l Head, Department of Clinical and Preventive Cardiology and Research Centre Arihant Hospital, Indore, MP, India m Prof. of Cardiology, All India Institute of Medical Sciences, New Delhi 110029, India n Chairman, Clinical and Preventive Cardiology, Medanta e The Medicity, Sector 38, Gurgaon, Haryana 122001, India o Professor, Vivekanada Institute of Medical Sciences, Kolkata, India p Chief Co-ordinator, Academic Services (Cardiology), Narayana Hrudayalay, RTIICS, Kolkata, India q Consultant Cardiologist, Fortis Hospital, Kolkata, India r Chief Endocrinologist & CEO, Chellaram Diabetes Institute, Pune 411021, India s Consultant Endocrinology, Bharti Hospital & BRIDE, Karnal, Haryana, India t Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chirag Enclave, New Delhi, India u Head, Public Health, National Diabetes, Obesity and Cholesterol Foundation (N-DOC), Diabetes Foundation (India), New Delhi, India v Head, Nutrition Research Group, Center for Nutrition & Metabolic Research (C-NET) & National Diabetes, Obesity and Cholesterol Foundation (N-DOC), New Delhi, India w Chief Project Officer, Diabetes Foundation (India), C-6/57, Safdarjung Development Area, New Delhi 110 016, India

Body Fat Patterning, Hepatic Fat and Pancreatic Volume of Non-Obese Asian Indians with Type 2 Diabetes in North India: A Case-Control Study

Objective To evaluate body fat patterning and phenotype including hepatic fat and pancreatic volume of non-obese (BMI: < 25 kg/m2) Asian Indians with type 2 diabetes residing in North India. Methods Non-obese patients with type 2 diabetes (n = 93) and non-obese, normo-glycemic subjects (n = 40) were recruited. BMI, waist & hip circumferences, skinfold thickness at 8 sites, body fat, lean mass and detailed abdominal fat evaluation [total abdominal fat, total subcutaneous fat (superficial, deep, anterior, and posterior), total intra-abdominal fat (intra-peritoneal, retroperitoneal)], liver span, grades of fatty liver and pancreatic volume were compared. Results Waist circumference, subscapular skinfolds and total truncal fat (on DEXA) were higher whereas calf, total peripheral skinfolds and total leg fat (on DEXA) lower in patients. Specifically, the following volumes were higher in cases as compared to controls; total abdominal fat (19.4%), total intra-abdominal fat (49.7%), intra-peritoneal fat (47.7%), retroperitoneal fat (70.7%), pancreatic volume (26.6%), pancreatic volume index (21.3%) and liver span (10.8%). In cases, significant positive correlations were observed for pancreatic volume with BMI, waist and hip circumferences, W-HR, subscapular, abdominal and total truncal skinfolds, truncal, total subcutaneous, total intra-abdominal, intra-peritoneal, retroperitoneal fat depots, liver span and fatty liver. Conclusions In non-obese Asian Indians with type 2 diabetes, subcutaneous and intra-abdominal obesity, including fatty liver, and pancreatic volume were higher and peripheral subcutaneous adiposity was lower than BMI matched non-diabetic subjects. Importantly, increased pancreatic volume in patients was highly correlated with multiple measures of abdominal obesity and liver fat.

Impact of Intensive School-Based Nutrition Education and Lifestyle Interventions on Insulin Resistance, β-Cell Function, Disposition Index, and Subclinical Inflammation Among Asian Indian Adolescents: A Controlled Intervention Study

OBJECTIVE The present study was designed to assess the impact of intensive and repetitive nutrition education and lifestyle interventions on insulin resistance, β-cell function, disposition index (DI), and subclinical inflammation in Asian Indian adolescents (15-17 years) residing in North India. METHOD In this prospective study, two matched schools were randomly allocated to the intervention (n = 56; 31 boys and 25 girls) or control group (n = 50; 30 boys and 20 girls). The intervention consisted of seven components: (1) Dissemination of health-related information through lectures and focused group discussions, (2) planning of activities such as quizzes, (3) individual counseling of students, (4) promotion of physical activity, (5) change in the canteen menu to healthier alternatives, (6) conducting health camps involving parents and teachers, and (7) training of student volunteers for sustainability of the program in school. Impact of intervention was studied on surrogate markers of insulin resistance, β-cell function, disposition index, and subclinical inflammation. RESULTS At 6 months follow-up, significantly higher (P = 0.037) mean value of homeostasis model assessment denoting β-cell function (HOMA-βCF) was seen in the intervention group compared to the control group, whereas high sensitivity C-reactive protein (hs-CRP) was significantly lowered (P < 0.001). The increase (30.3 ± 73.4; P < 0.037) observed in the DI in adolescents in the intervention group was significantly higher compared to the control group. The Pearsons coefficient of correlation in the intervention group showed that the Δ-decrease in mean waist circumference was significantly correlated (r = 0.267, P < 0.05) with Δ-decrease in homeostasis model assessment of insulin resistance (HOMA-IR). CONCLUSION The intervention model developed by us could be used for amelioration of insulin resistance with potential of preventing type 2 diabetes mellitus in Asian Indian adolescents.