Estimated glomerular filtration rate trajectories in south Asians: Findings from the cardiometabolic risk reduction in south Asia study

Background

Few longitudinal data characterize kidney function decline among South Asians, one of the world's largest population groups. We aimed to identify estimated glomerular filtration rate (eGFR) trajectories in a population-based cohort from India and assess predictors of rapid kidney function decline.

Methods

We used 6-year longitudinal data from participants of a population-representative study from Delhi and Chennai, India who had at least two serum creatinine measures and baseline CKD-EPI eGFR> 60 ml/min/1.73m² (n=7779). We used latent class trajectory modeling to identify patterns of kidney function trajectory (CKD-EPI eGFR) over time. In models accounting for age, sex, education, and city, we tested the association between 15 hypothesized risk factors and rapid kidney function decline.

Findings

Baseline mean eGFR was 108 (SD 16); median eGFR was 110 [IQR: 99-119] ml/min/1.73m². Latent class trajectory modeling and functional characterization identified three distinct patterns of eGFR: class-1 (no decline; 58%) annual eGFR change 0.2 [0.1, 0.3]; class-2 (slow decline; 40%) annual eGFR change -0.2 [-0.4, -0.1], and class-3 (rapid decline; 2%) annual eGFR change -2.7 [-3.4, -2.0] ml/min/1.73m². Albuminuria (>30 mg/g) was associated with rapid eGFR decline (OR for class-3 vs class-1: 5.1 [95% CI: 3.2; 7.9]; class-3 vs. class-2: 4.3 [95% CI:2.7; 6.6]). Other risk factors including self-reported diabetes, cardiovascular disease, peripheral arterial disease, and metabolic biomarkers such as HbA1c and systolic blood pressure were associated with rapid eGFR decline phenotype but potential 'non-traditional' risk factors such as manual labor or household water sources were not.

Interpretation

Although mean and median eGFRs in our population-based cohort were higher than those reported in European cohorts, we found that a sizeable number of adults residing in urban India are experiencing rapid kidney function decline. Early and aggressive risk modification among persons with albuminuria could improve kidney health among South Asians.

Funding

The CARRS study has been funded with federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, under Contract No. HHSN2682009900026C and P01HL154996. Dr. Anand was supported by NIDDK K23DK101826 and R01DK127138.

Correction: Cardiovascular Health in India - a Report Card from Three Urban and Rural Surveys of 22,144 Adults

[This corrects the article DOI: 10.5334/gh.1137.].

Cardiometabolic risk factors in young Indian men and their association with parameters of insulin resistance and beta-cell function

BACKGROUND

There is an unmet need to evaluate the burden of cardiometabolic risk factors in young South Asian adults, who are not preselected for glycaemia.

AIM

To evaluate young North Indian men (aged 20-50 years) for burden of cardiometabolic risk factors, in relation to parameters of homeostatic model assessment for insulin resistance (HOMA-IR) and beta-cell function (oral disposition index [oDI]).

METHODS

Study participants were invited in a fasting state. Sociodemographic, anthropometric, and medical data were collected, and 75 g oral glucose tolerance test was performed with serum insulin and plasma glucose estimation at 0, 30, and 120 min. Participants were divided into quartiles for HOMA-IR and oDI (category 1: Best HOMA-IR/oDI quartile; category 3: Worst HOMA-IR/oDI quartile) and composite HOMA-IR/oDI phenotypes (phenotype 1: Best quartile for both HOMA-IR and oDI; phenotype 4: Worst quartile for both HOMA-IR and oDI) were derived.

RESULTS

We evaluated a total of 635 men at a mean (± SD) age of 33.9 ± 5.1 years and body mass index of 26.0 ± 3.9 kg/m². Diabetes and prediabetes were present in 34 (5.4%) and 297 (46.8%) participants, respectively. Overweight/obesity, metabolic syndrome, and hypertension were present in 388 (61.1%), 258 (40.6%), and 123 (19.4%) participants, respectively. The prevalence of dysglycaemia, metabolic syndrome, and hypertension was significantly higher in participants belonging to the worst HOMA-IR and oDI quartiles, either alone (category 3 vs 1) or in combination (phenotype 4 vs 1). The adjusted odds ratios for dysglycaemia (6.5 to 7.0-fold), hypertension (2.9 to 3.6-fold), and metabolic syndrome (4.0 to 12.2-fold) were significantly higher in individuals in the worst quartile of HOMA-IR and oDI (category 3), compared to those in the best quartile (category 1). The adjusted odds ratios further increased to 21.1, 5.6, and 13.7, respectively, in individuals with the worst, compared to the best composite HOMA-IR/oDI phenotypes (phenotype 4 vs 1).

CONCLUSION

The burden of cardiometabolic risk factors is high among young Asian Indian men. Our findings highlight the importance of using parameters of insulin resistance and beta-cell function in phenotyping individuals for cardiometabolic risk.

Anxiety and depression among adult tobacco users during the COVID-19 restrictions in India

Background

The world witnessed a highly contagious and deadly disease, COVID-19, toward the end of 2019. India is one of the worst affected countries. We aimed to assess anxiety and depression levels among adult tobacco users and people who recently quit tobacco during COVID-19 lockdown in India.

Materials and methods

The study was conducted across two Indian cities, Delhi and Chennai (July-August, 2020) among adult tobacco users (n = 801). Telephonic interviews were conducted using validated mental health tools (Patient Health Questionnaire-PHQ-9 and Generalized Anxiety Disorder-GAD-7) to assess the anxiety and depression levels of the participants. Descriptive analysis and multiple logistic regression were used to study the prevalence and correlates of depression and anxiety.

Results

We found that 20.6% of tobacco users had depression symptoms (3.9% moderate to severe); 20.7% had anxiety symptoms (3.8% moderate to severe). Risk factors associated with depression and anxiety included food, housing, and financial insecurity.

Conclusion

During COVID-19 lockdown, mental health of tobacco users (primarily women) was associated with food, housing and financial insecurity. The Indian Government rightly initiated several health, social and economic measures to shield the most vulnerable from COVID-19, including a ban on the sale of tobacco products. It is also necessary to prioritize universal health coverage, expanded social security net, tobacco cessation and mental health services to such vulnerable populations during pandemic situations.

Macronutrient Recommendations for Remission and Prevention of Diabetes in Asian Indians Based on a Data-Driven Optimization Model: The ICMR-INDIAB National Study

OBJECTIVE

To derive macronutrient recommendations for remission and prevention of type 2 diabetes (T2D) in Asian Indians using a data-driven optimization approach.

RESEARCH DESIGN AND METHODS

Dietary, behavioral, and demographic assessments were performed on 18,090 adults participating in the nationally representative, population-based Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study. Fasting and 2-h postglucose challenge capillary blood glucose and glycosylated hemoglobin (HbA1c) were estimated. With HbA1c as the outcome, a linear regression model was first obtained for various glycemic categories: newly diagnosed diabetes (NDD), prediabetes (PD), and normal glucose tolerance (NGT). Macronutrient recommendations were formulated as a constrained quadratic programming problem (QPP) to compute optimal macronutrient compositions that would reduce the sum of the difference between the estimated HbA1c from the linear regression model and the targets for remission (6.4% for NDD and 5.6% for PD) and prevention of progression in T2D in PD and NGT groups.

RESULTS

Four macronutrient recommendations (%E- Energy) emerged for 1) diabetes remission in NDD: carbohydrate, 49-54%; protein, 19-20%; and fat, 21-26%; 2) PD remission to NGT: carbohydrate, 50-56%; protein,18-20%; fat, 21-27%; 3 and 4) prevention of progression to T2D in PD and NGT: carbohydrate, 54-57% and 56-60%; protein, 16-20% and 14-17%, respectively; and fat 20-24% for PD and NGT.

CONCLUSIONS

We recommend reduction in carbohydrates (%E) and an increase in protein (%E) for both T2D remission and for prevention of progression to T2D in PD and NGT groups. Our results underline the need for new dietary guidelines that recommend appropriate changes in macronutrient composition for reducing the burden due to diabetes in South Asia.

Cardiovascular Health in India - a Report Card from Three Urban and Rural Surveys of 22,144 Adults

Background

Markers of ideal cardiovascular health (CVH) predict cardiovascular events. We estimated the prevalence of ideal CVH markers in two levels of cities and villages in India.

Methods

We did pooled analysis of individual-level data from three cross sectional surveys of adults ≥ 30 years over 2010-14 (CARRS: Centre for cArdiometabolic Risk Reduction in South Asia; UDAY and Solan Surveillance Study) representing metropolitan cities; smaller cities and rural areas in diverse locations of India. We defined ideal CVH using modified American Heart Association recommendations: not smoking, ≥ 5 servings of fruits and vegetables (F&V), high physical activity (PA), body mass index (BMI) <25 Kg/m2, blood pressure (BP) <120/80 mm Hg, fasting plasma glucose (FPG) <100 mg/dl, and total cholesterol (TC) <200 mg/dL. We estimated (1) age-and sex-standardized prevalence of ideal CVH and (2) prevalence of good (≥6 markers), moderate (4-5), and poor CVH (≤3) adjusted for age, sex, education, and stratified by setting and asset tertiles.

Results

Of the total 22,144 participants, the prevalence of ideal CVH markers were: not smoking (76.7% [95% CI 76.1, 77.2]), consumed ≥5 F&V (4.2% [3.9, 4.5]), high PA (67.5% [66.8, 68.2]), optimum BMI (59.6% [58.9, 60.3]), ideal BP (34.5% [33.9, 35.2]), FPG (65.8% [65.1, 66.5]) and TC (65.4% [64.7, 66.1]). The mean number of ideal CVH metrics was 3.7(95% CI: 3.7, 3.8). Adjusted prevalence of good, moderate, and poor CVH, varied across settings: metropolitan (3.9%, 41.0%, and 55.1%), smaller cities (7.8%, 49.2%, and 43%), and rural (10.4%, 60.9%, and 28.7%) and across asset tertiles: Low (11.0%, 55.9%, 33.1%), Middle (6.3%, 52.2%, 41.5%), and High (5.0%, 46.4%, 48.7%), respectively.

Conclusion

Achievement of ideal CVH varied, with higher prevalence in rural and lower asset tertiles. Multi-sectoral and targeted policy and program actions are needed to improve CVH in diverse contexts in India.

Effectiveness and Safety of Ayurvedic Medicines in Type 2 Diabetes Mellitus Management: A Systematic Review and Meta-Analysis

Introduction: Many Ayurvedic medicines have the potential for managing type 2 diabetes mellitus (T2DM), with previous systematic reviews demonstrating effectiveness and safety for specific Ayurvedic medicines. However, many of the reviews need updating and none provide a comprehensive summary of all the Ayurvedic medicines evaluated for managing T2DM.

Objective: The objective of this systematic review was to evaluate and synthesize evidence on the effectiveness and safety of Ayurvedic medicines for managing T2DM.

Inclusion criteria: Published and unpublished RCTs assessing the effectiveness and safety of Ayurvedic medicines for managing T2DM in adults.

Methods: The JBI systematic review methodology was followed. A comprehensive search of sources (including 18 electronic databases) from inception to 16 January 2021 was made. No language restrictions were applied. Data synthesis was conducted using narrative synthesis and random effects meta-analyses, where appropriate. Pooled results are reported as mean differences (MD) with 95% confidence intervals (CI).

Results: Out of 32,519 records identified from the searches, 219 articles were included in the systematic review representing 199 RCTs (21,191 participants) of 98 Ayurvedic medicines. Overall, in the studies reviewed the methodology was not adequately reported, resulting in poorer methodological quality scoring. Glycated hemoglobin (HbA1c) was reduced using Aegle marmelos (L.) Corrêa (MD -1.6%; 95% CI −3 to −0.3), Boswellia serrata Roxb. (−0.5; −0.7 to −0.4), Gynostemma pentaphyllum (Thunb.) Makino (−1; −1.5 to −0.6), Momordica charantia L. (−0.3; −0.4 to −0.1), Nigella sativa L. (−0.4; −0.6 to −0.1), Plantago ovata Forssk. (−0.9; −1.4 to −0.3), Tinospora cordifolia (Willd.) Hook.f. and Thomson (−0.5; −0.6 to −0.5), Trigonella foenum-graecum L. (−0.6; −0.9 to −0.4), and Urtica dioica L. (−1.3; −2.4 to −0.2) compared to control. Similarly, fasting blood glucose (FBG) was reduced by 4–56 mg/dl for a range of Ayurvedic medicines. Very few studies assessed health-related quality of life (HRQoL). Adverse events were not reported in many studies, and if reported, these were mostly none to mild and predominately related to the gastrointestinal tract.

Conclusion: The current evidence suggests the benefit of a range of Ayurvedic medicines in improving glycemic control in T2DM patients. Given the limitations of the available evidence and to strengthen the evidence base, high-quality RCTs should be conducted and reported.

A multi-center pediatric to adult care transition intervention program to improve clinic visit adherence and clinical outcomes among adolescents and emerging adults with type 1 diabetes mellitus [PATHWAY]: Protocol for a randomized controlled trial

OBJECTIVE

This multi-center randomized controlled trial aims to evaluate the effectiveness of a context-specific transition intervention program to improve clinic visit adherence and clinical outcomes among emerging adults with type 1 diabetes mellitus (T1DM) in Delhi, India.

METHODS

We will recruit patients with T1DM of duration ≥1 year and age 15-19.5 years from the participating pediatric sites. After a baseline assessment and a "basic introductory session", which apprises participants about the concept of transition, study participants (proposed sample size =156) will be randomly allocated into an intervention and control arm. Participants in the intervention arm will receive a structured transition program delivered over a period of 15 months. On the other hand, control arm participants will continue to receive usual care from the pediatric site till the time of transfer to the adult site. The study assessments will be done at baseline, at the time of transfer, and at 1 and 2 years following the transfer. The primary outcome is the difference in clinic attendance rate between intervention and control arms at the end of 1-year post-transfer.The secondary outcomes include the difference in clinic attendance rate at the end of 2 years, difference in proportion of participants with a minimum of 4 visits in the first follow-up year, and process indicators such as diabetes knowledge and self-management skills, diabetes treatment satisfaction, overall quality of life, diabetes-related distress, hospitalization for acute complications and screening for chronic diabetes complications, and HbA1c.

CONCLUSION

This study will provide important new evidence about a potential strategy to improve clinical care among adolescents and emerging adults with T1DM in lower resource contexts during the vulnerable phase of transition from pediatric to adult healthcare. The trial is registered on the Clinical Trials Registry of India (http://ctri.nic.in) under the CTRI registration number CTRI/2020/10/028379.

CGMS profile of women diagnosed as GDM by IADPSG criteria and labelled as normoglycemic by alternate criteria in early pregnancy

AIMS/INTRODUCTION

We aimed to evaluate and compare CGMS-based glycemic parameters in women in early pregnancy (<20 weeks of gestation) who were classified as: a) GDM by IADPSG but normoglycemia by alternate (UK NICE, CDA and DIPSI) criteria, and b) normoglycemia by both (IADPSG and alternate) criteria.

MATERIAL AND METHODS

In this cross-sectional study, eligible women underwent standard 75-g OGTT, followed by the placement of a CGMS. Glycemia-related parameters were calculated using the standard approach for CGMS data in pregnancy.

RESULTS

We enrolled 96 women at 14.0 ± 3.2 weeks of gestation. Of the women diagnosed as GDM by IADPSG criteria, 34.2%, 26.3% and 44.7% were classified as normoglycemic by UK NICE, CDA and DIPSI criteria, respectively. Mean 1-h postprandial glucose and time above range were significantly higher in women who were GDM by IADPSG, but normoglycemia by CDA criteria, compared to women with normoglycemia using both criteria. Similarly, mean 1-h postprandial glucose, 2-h postprandial glucose, peak postprandial glucose, 1-hr postprandial glucose excursion and time above range were significantly higher in women who were not identified as GDM by UK NICE criteria. Finally, women missed by DIPSI criteria had significantly higher mean 1-h postprandial glucose, 2-h postprandial glucose, peak postprandial glucose, postprandial glucose excursion, 24-h glucose, and time above range parameters.

CONCLUSIONS

More than a quarter of women diagnosed as GDM by IADPSG criteria are not identified by alternate criteria. Such women are significantly different from normoglycemic women in terms of several CGMS-based glycemic parameters of clinical significance.

Burden, patterns, and impact of multimorbidity in North India: findings from a rural population-based study

Aim

To estimate the prevalence, socio-demographic determinants, common disease combinations, and health impact of multimorbidity among a young rural population.

Methods

We conducted a cross-sectional survey among participants aged ≥30 years in rural Punjab, North India, from Jan 2019 to April 2019. Multimorbidity was defined as the coexistence of ≥two conditions using a 14-condition tool validated in India. We also calculated a multimorbidity-weighted index (MWI), which provides a weight to each disease based on its impact on physical functioning. Logistic regression was conducted to evaluate the association with sociodemographic variables, mental health (PHQ-9), physical functioning (ADL scale), and self-rated health (SRH).

Results

We analyzed data from 3213 adults [Mean age 51.5 (±13), 54% women]. Prevalence of single chronic condition, multimorbidity, and MWI was 28.6, 18% and − 1.9 respectively. Age, higher wealth index and ever use alcohol were significantly associated with multimorbidity. Overall, 2.8% of respondents had limited physical functioning, 2.1% had depression, and 61.5% reported low SRH. Poorer health outcomes were more prevalent among the elderly, women, less educated, and those having lower wealth index and multimorbidity, were found to be significantly associated with poor health outcomes.

Conclusions

The burden of multimorbidity was high in this young rural population, which portends significant adverse effects on their health and quality of life. The Indian health system should be reconfigured to address this emerging health priority holistically, by adopting a more integrated and sustainable model of care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13495-0.

Achievement of guideline recommended diabetes treatment targets and health habits in people with self-reported diabetes in India (ICMR-INDIAB-13): a national cross-sectional study

BACKGROUND

There is little information on comprehensive diabetes care comprising glycaemic, lipid, and blood pressure control in India; therefore, we aimed to assess the achievement of treatment targets among adults with self-reported diabetes.

METHODS

The Indian Council of Medical Research (ICMR)-India Diabetes (INDIAB) study is a cross-sectional, population-based survey of adults aged 20 years or older in all 30 states and union territories of India. We used a stratified multistage sampling design, sampling states in a phased manner, and selected villages in rural areas and census enumeration blocks in urban areas. We used a three-level stratification method on the basis of geography, population size, and socioeconomic status for each state. For the outcome assessment, good glycaemic control was defined as HbA_1c of less than 7·0% (A), blood pressure control was defined as less than 140/90 mm Hg (B), and the LDL cholesterol target was defined as less than 100 mg/dL (C). ABC control was defined as the proportion of individuals meeting glycaemic, blood pressure, and LDL cholesterol targets together. We also performed multiple logistic regression to assess the factors influencing achievement of diabetes treatment targets.

FINDINGS

Between Oct 18, 2008, and Dec 17, 2020, 113 043 individuals (33 537 from urban areas and 79 506 from rural areas) participated in the ICMR-INDIAB study. For this analysis, 5789 adults (2633 in urban areas and 3156 in rural areas) with self-reported diabetes were included in the study population. The median age was 56·1 years (IQR 55·7-56·5). Overall, 1748 (weighted proportion 36·3%, 95% CI 34·7-37·9) of 4834 people with diabetes achieved good glycaemic control, 2819 (weighted proportion 48·8%, 47·2-50·3) of 5698 achieved blood pressure control, and 2043 (weighted proportion 41·5%, 39·9-43·1) of 4886 achieved good LDL cholesterol control. Only 419 (weighted proportion 7·7%) of 5297 individuals with self-reported diabetes achieved all three ABC targets, with significant heterogeneity between regions and states. Higher education, male sex, rural residence, and shorter duration of diabetes (<10 years) were associated with better achievement of combined ABC targets. Only 951 (weighted proportion 16·7%) of the study population and 227 (weighted proportion 36·9%) of those on insulin reported using self-monitoring of blood glucose.

INTERPRETATION

Achievement of treatment targets and adoption of healthy behaviours remains suboptimal in India. Our results can help governments to adopt policies that prioritise improvement of diabetes care delivery and surveillance in India.

FUNDING

Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare.

Improving care for hypertension and diabetes in india by addition of clinical decision support system and task shifting in the national NCD program: I-TREC model of care

Background

The growing burden of hypertension and diabetes is one of the major public health challenges being faced by the health system in India. Clinical Decision Support Systems (CDSS) that assist with tailoring evidence-based management approaches combined with task-shifting from more specialized to less specialized providers may together enhance the impact of a program. We sought to integrate a technology “CDSS” and a strategy “Task-shifting” within the Government of India’s (GoI) Non-Communicable Diseases (NCD) System under the Comprehensive Primary Health Care (CPHC) initiative to enhance the program’s impact to address the growing burden of hypertension and diabetes in India.

Methods

We developed a model of care “I-TREC” entirely calibrated for implementation within the current health system across all facility types (Primary Health Centre, Community Health Centre, and District Hospital) in a block in Shaheed Bhagat Singh (SBS) Nagar district of Punjab, India. We undertook an academic-community partnership to incorporate the combination of a CDSS with task-shifting into the GoI CPHC-NCD system, a platform that assists healthcare providers to record patient information for routine NCD care. Academic partners developed clinical algorithms, a revised clinic workflow, and provider training modules with iterative collaboration and consultation with government and technology partners to incorporate CDSS within the existing system.

Discussion

The CDSS-enabled GoI CPHC-NCD system provides evidence-based recommendations for hypertension and diabetes; threshold-based prompts to assure referral mechanism across health facilities; integrated patient database, and care coordination through workflow management and dashboard alerts. To enable efficient implementation, modifications were made in the patient workflow and the fulcrum of the use of technology shifted from physician to nurse.

Conclusion

Designed to be applicable nationwide, the I-TREC model of care is being piloted in a block in the state of Punjab, India. Learnings from I-TREC will provide a roadmap to other public health experts to integrate and adapt their interventions at the national level.

Trial registration

CTRI/2020/01/022723.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08025-y.

Association of family history of cardiometabolic diseases (CMDs) and individual health behaviours: Analysis of CARRS study from South Asia

Objectives

Family history is considered as an important predictor of cardiovascular diseases (CVDs) and diabetes. Available research findings suggest that family history of chronic diseases is associated with perceived risk of disease and adoption of healthy behaviours. We examined the association between family history of cardio-metabolic diseases (CMDs) and healthy behaviours among adults without self-reported CMDs.

Methods

Cross-sectional data of 12,484 adults, without self-reported CMDs, from the baseline survey of Centre for cArdiometabolic Risk Reduction in South-Asia (CARRS) cohort study were analysed.

Results

Family history was positively associated with non-smoking and high fruits & vegetables consumption in the age group of 45–64 years and moderate to high physical activity in the age group ≥65 years after adjusting for sex, education, wealth index, city and body mass index.

Conclusions

Understanding perceived risks and cultural or psychological factors related to family history through ethnographic studies may deepen understanding of these associations.

Feasibility Trial of Yoga Programme for Type 2 Diabetes Prevention (YOGA-DP) among High-Risk People in India: A Qualitative Study to Explore Participants' Trial- and Intervention-Related Barriers and Facilitators

Yoga-based interventions can be effective in preventing type 2 diabetes mellitus (T2DM). We developed a Yoga programme for T2DM prevention (YOGA-DP) and conducted a feasibility randomised controlled trial (RCT) among high-risk people in India. This qualitative study's objective was to identify and explore participants' trial- and intervention-related barriers and facilitators. The feasibility trial was conducted at two Yoga centres in New Delhi and Bengaluru, India. In this qualitative study, 25 trial participants (13 intervention group, 12 control group) were recruited for semi-structured interviews. Data were analysed using deductive logic and an interpretative phenomenological approach. Amongst intervention and control participants, key barriers to trial participation were inadequate information about recruitment and randomisation processes and the negative influence of non-participants. Free blood tests to aid T2DM prevention, site staff's friendly behaviour and friends' positive influence facilitated trial participation. Amongst intervention participants, readability and understanding of the programme booklets, dislike of the Yoga diary, poor quality Yoga mats, difficulty in using the programme video, household commitment during home sessions, unplanned travel, difficulty in practising Yoga poses, hesitation in attending programme sessions with the YOGA-DP instructor of the opposite sex and mixed-sex group programme sessions were key barriers to intervention participation. Adequate information was provided on T2DM prevention and self-care, good venue and other support provided for programme sessions, YOGA-DP instructors' positive behaviour and improvements in physical and mental well-being facilitated intervention participation. In conclusion, we identified and explored participants' trial- and intervention-related barriers and facilitators. We identified an almost equal number of barriers (n = 12) and facilitators (n = 13); however, intervention-related barriers and facilitators were greater than for participating in the trial. These findings will inform the design of the planned definitive RCT design and intervention and can also be used to design other Yoga interventions and RCTs.

Cardiovascular disease risk profile of Indian young adults with type 1 diabetes compared to general population - A sub-study from the Young Diabetes Registry (YDR), India

OBJECTIVE

We estimated the prevalence of traditional CVD risk factors among young adults with type 1 diabetes and compared them with the general population without diabetes.

METHODS

Participants were young adults (aged 20 years and above) with type 1 diabetes, from the Delhi and Chennai sites of the ICMR -Young Diabetes Registry (YDR) and their age, gender and location matched controls, without diabetes from the CARRS (Cardio metabolic Risk Reduction in South Asia) cohort. YDR and CARRS used similar standard methodologies to quantify the CVD risk factors. Linear and logistic regression models were used to compare the adjusted means and proportions of risk factors.

RESULTS

Individuals with type 1 diabetes had lower levels of mean BMI (21.9 kg/m2 vs 24.3 kg/m2), waist circumference (76.8 cm vs 82.1 cm), favourable lipid profile (lower LDL and higher HDL), higher mean systolic blood pressure (122.1 mmHg vs 118.7 mmHg) and hypertension (29.2% vs 21.0%), compared to controls. The extent of clustering of two or more traditional CVD risk factors was higher among general population compared to people with type 1 diabetes.

CONCLUSION

We found that young adults with type 1 diabetes have relatively low prevalence and clustering of traditional CVD risk factors compared to general population.

Infant Young Child Feeding Practices in an Indian Maternal-Child Birth Cohort in Belagavi, Karnataka

Poor infant young child feeding (IYCF) practices result in malnutrition, poor psychosocial development, poor school performance and less productivity in later life, thereby perpetuating a vicious cycle. The current study aims to characterize the IYCF practices during the first year of life in a maternal–child birth cohort (DHANI) in Belagavi, Karnataka, India. We collected data from the dyad at birth, 6 and 12 months postpartum. We examined dietary diversity among these infants at 12 months using WHO criteria. A total of 902 live births were recorded, and 878 mother–child pairs completed the 12-month follow up. The overall prevalence of early (within 1 h of delivery) initiation of breastfeeding (EIBF) was 77.9%, and that of exclusive breastfeeding (EBF) at 6 months was 52.4%. At 12 months, most (90%) infants were breastfed, while 39% also received formula. The large majority (94.4%) of infants met minimum meal frequency (MMF), but only 55% of infants were receiving a minimum acceptable diet (MAD). The mean dietary diversity (DD) score was 4.7 ± 1.1. Only 21.9% of infants consumed egg and/or flesh food. A large proportion (33.8%) of infants received no vegetables and/or fruits till 12 months of age. Consumption of sweet beverage was 4.8%, but consumption of ultra-processed foods high in trans-fats, sugars and salt was high (85.8%). High-quality, sustainable and scalable interventions to enhance knowledge and support positive behaviour change for adopting and implementing better IYCF practices may be urgently needed in low- and middle-income group settings to improve diet diversity and overall nutritional intake amongst young children.

How to promote a healthy lifestyle among schoolchildren: Development of an intervention module (i-PROMISe)

Objective

Lifestyle preferences are inculcated in childhood and once established, persist into adulthood. The Project PROMoting Health LIteracy in School (i-PROMISe) aims to promote a healthy lifestyle among students for the universal prevention of non-communicable diseases (NCDs) like diabetes.

Study design

Qualitative study using focus-group-discussions (FGDs) and In-Depth Interviews (IDI).

Method

Project was undertaken in two-phases in two private schools in New Delhi, India. In phase-one, FGDs with students (grades IV to VIII) and IDIs with teachers were conducted to ascertain their perceptions of diabetes prevention and management according to the Health Belief Model. The data was analyzed using a thematic framework method. In phase-two, the resources were pre-tested and participants’ feedback was requested on the duration, quality, and understanding of the resources.

Results

In total, 89 students and 17 teachers participated in phase-one (n = 54 [in FGDs] and n = 5 [in IDIs]) and phase-two (n = 35 students and n = 12 teachers in FGDs). In phase-one, themes that emerged included: diabetes was considered a disease of the elderly; misconceptions about susceptibility to these diseases were common; children were largely aware of measures to prevent these diseases, but barriers to adopting a healthy lifestyle existed. Based on the findings, a comprehensive module was developed, which consisted of a teacher's manual with interactive activities and short films. The resources (teacher's manual and short films) were well received and contributed to a better understanding of diabetes and other NCDs; myths/misconceptions were clarified.

Conclusion

Development of resources using participatory approach can be effective in promoting and reinforcing healthy behaviours among school going children to prevent and control NCDs in schools.

Overt Diabetes in Pregnancy

AIMS

Overt diabetes in pregnancy is defined as hyperglycemia first recognized during pregnancy which meets the diagnostic threshold of diabetes in non-pregnant adults. This case-based narrative review aims to describe this unique condition and discuss the potential implications for its accurate diagnosis and management.

METHODS AND RESULTS

We conducted a literature search in PubMed for relevant articles published in English language up to January 2022. Women with overt diabetes have a higher risk for adverse pregnancy outcomes and postpartum diabetes, compared to their counterparts with gestational diabetes mellitus (GDM). Such women often need aggressive management, including early and prompt initiation of insulin therapy, and a close follow-up during pregnancy and in the postpartum period. Not all pregnant women with overt diabetes have persistent diabetes in the postpartum period. Early diagnosis, especially during the first trimester, and fasting plasma glucose elevation (≥ 126 mg/dl or 7 mmol/L) at the time of initial diagnosis are predictors of postpartum diabetes.

CONCLUSIONS

Both GDM and overt diabetes in pregnancy are hyperglycemic conditions first recognized during pregnancy, but the two conditions differ in severity; the latter is a more severe form of hyperglycemia associated with worse maternal and fetal outcomes, and a higher risk of postpartum diabetes.

Evaluation of Cognitive Deficits in Adults with Type 1 Diabetes Stratified by the Age of Diabetes Onset: A Cross-Sectional Study

INTRODUCTION

Type 1 diabetes (T1DM) is associated with cognitive deficits, and age at diagnosis is thought to play a substantial role. However, there are limited data for the cognitive performance in young adults, in relation to the age of diabetes onset. The lack of information is particularly striking in the context of developing regions.

METHODS

This cross-sectional study was performed from August 2018 to July 2020. We included adult participants with T1DM, stratified by the age of diabetes onset (till 6 years of age, between 7 to 12 years of age, and 13 to < 18 years of age) and compared them with the control group (no diabetes or pre-diabetes). We filled a structured case record proforma for all participants and recorded relevant socio-demographic and medical details. Detailed neuropsychological assessment with 13 psychological tests representing four cognitive domains was carried-(1) attention, working memory and executive functions; (2) learning and memory; (3) visuoperceptual functions; and (4) information processing speed.

RESULTS

We evaluated 100 individuals, 73 (men 48.0%) with T1DM and 27 (men 51.9%) without T1DM. After adjustment for age, gender and education, the mean differences in composite Z scores (for the four cognitive domains) between participants with T1DM and without T1DM were 0.08 for attention, working memory and executive functions (p = 0.614); 0.07 for learning and memory (p = 0.694); 0.05 for visuoperceptual (p = 0.784); and 0.22 for information processing speed (p = 0.305). No significant differences were found for the three subgroups of individuals with T1DM, when compared with the control group. Effect size (Cohen's d) for the individual tests (n = 13) ranged from - 0.36 to + 0.39, and none of the comparisons were statistically significant. Amongst the participants with T1DM, higher education had a significant positive association with three of the four cognitive domains evaluated.

CONCLUSIONS

To conclude, our findings suggest minimal differences in the cognitive functioning of patients with T1DM with different age of onset of diabetes compared to healthy controls, when evaluated in early adulthood. This is possibly the first study from South Asia with an in-depth and comprehensive assessment of cognitive functions in patients with T1DM, using a detailed neuropsychological battery.

Bone microarchitecture, bone mineral density and bone turnover in association with glycemia and insulin action in women with prior gestational diabetes

OBJECTIVE

The aim of this cross-sectional study was to comprehensively assess bone health in women with prior gestational diabetes mellitus, including bone microarchitecture (TBS), bone mineral density (BMD, DXA) and bone turnover (osteocalcin).

DESIGN, PATIENTS AND MEASUREMENTS

Study participants underwent a detailed anthropometric, biochemical and hormone assessment, including insulin and osteocalcin measurement. BMD was measured at lumbar spine, femur neck and total hip using DXA and TBS derived from lumbar spine DXA images using TBS iNsight software.

RESULTS

A total of 240 women (mean age: 33.3 ± 5.0 years; median postpartum duration: 34 [interquartile range 13.0-54.5] months were evaluated. At the current visit, 115 (47.9%) and 36 (15%) women had prediabetes and diabetes, respectively. Women with dysglycemia (diabetes/prediabetes) had a higher BMD at all three sites, compared to those with normoglycemia; however, the difference was not statistically significant. Women with dysglycemia had a significantly lower TBS (1.32 ± 0.09 vs. 1.35 ± 0.09; p = .038). In the fully adjusted model, the odds ratio for association between diabetes and low TBS was 2.92 (95% confidence interval: 1.20, 7.08; p = .018). Women with dysglycemia had significantly lower serum osteocalcin levels (18.6 ± 8.5 ng/ml vs. 21.5 ± 9.7 ng/ml; p = .018). HOMA-IR (r = -.285, p < .001) was negatively correlated, while Matsuda index (r = .274, p < .001) and disposition index (r = .159, p = .016) were positively correlated with serum osteocalcin levels.

CONCLUSIONS

Bone health is affected early in the natural history of diabetes and is associated with an overall low bone turnover state.

Effects of a Lifestyle Intervention to Prevent Deterioration in Glycemic Status Among South Asian Women With Recent Gestational Diabetes: A Randomized Clinical Trial

IMPORTANCE

Women with recent gestational diabetes (GDM) have increased risk of developing type 2 diabetes.

OBJECTIVE

To investigate whether a resource-appropriate and context-appropriate lifestyle intervention could prevent glycemic deterioration among women with recent GDM in South Asia.

DESIGN, SETTING, AND PARTICIPANTS

This randomized, participant-unblinded controlled trial investigated a 12-month lifestyle intervention vs usual care at 19 urban hospitals in India, Sri Lanka, and Bangladesh. Participants included women with recent diagnosis of GDM who did not have type 2 diabetes at an oral glucose tolerance test (OGTT) 3 to 18 months postpartum. They were enrolled from November 2017 to January 2020, and follow-up ended in January 2021. Data were analyzed from April to July 2021.

INTERVENTIONS

A 12-month lifestyle intervention focused on diet and physical activity involving group and individual sessions, as well as remote engagement, adapted to local context and resources. This was compared with usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was worsening category of glycemia based on OGTT using American Diabetes Association criteria: (1) normal glucose tolerance to prediabetes (ie, impaired fasting glucose or impaired glucose tolerance) or type 2 diabetes or (2) prediabetes to type 2 diabetes. The primary analysis consisted of a survival analysis of time to change in glycemic status at or prior to the final patient visit, which occurred at varying times after 12 months for each patient. Secondary outcomes included new-onset type 2 diabetes and change in body weight.

RESULTS

A total of 1823 women (baseline mean [SD] age, 30.9 [4.9] years and mean [SD] body mass index, 26.6 [4.6]) underwent OGTT at a median (IQR) 6.5 (4.8-8.2) months postpartum. After excluding 160 women (8.8%) with type 2 diabetes, 2 women (0.1%) who met other exclusion criteria, and 49 women (2.7%) who did not consent or were uncontactable, 1612 women were randomized. Subsequently, 11 randomized participants were identified as ineligible and excluded from the primary analysis, leaving 1601 women randomized (800 women randomized to the intervention group and 801 women randomized to usual care). These included 600 women (37.5%) with prediabetes and 1001 women (62.5%) with normoglycemia. Among participants randomized to the intervention, 644 women (80.5%) received all program content, although COVID-19 lockdowns impacted the delivery model (ie, among 644 participants who engaged in all group sessions, 476 women [73.9%] received some or all content through individual engagement, and 315 women [48.9%] received some or all content remotely). After a median (IQR) 14.1 (11.4-20.1) months of follow-up, 1308 participants (81.2%) had primary outcome data. The intervention, compared with usual care, did not reduce worsening glycemic status (204 women [25.5%] vs 217 women [27.1%]; hazard ratio, 0.92; [95% CI, 0.76-1.12]; P = .42) or improve any secondary outcome.

CONCLUSIONS AND RELEVANCE

This study found that a large proportion of women in South Asian urban settings developed dysglycemia soon after a GDM-affected pregnancy and that a lifestyle intervention, modified owing to the COVID-19 pandemic, did not prevent subsequent glycemic deterioration. These findings suggest that alternate or additional approaches are needed, especially among high-risk individuals.

TRIAL REGISTRATION

Clinical Trials Registry of India Identifier: CTRI/2017/06/008744; Sri Lanka Clinical Trials Registry Identifier: SLCTR/2017/001; and ClinicalTrials.gov Identifier: NCT03305939.