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Abstract Background The associations of vegetarian diets with risks for site-specific cancers have not been estimated reliably due to the low number of vegetarians in previous studies. Therefore, the Cancer Risk in Vegetarians Consortium was established. The aim is to describe and compare the baseline characteristics between non-vegetarian and vegetarian diet groups and between the collaborating studies. Methods We harmonised individual-level data from 11 prospective cohort studies from Western Europe, North America, South Asia and East Asia. Comparisons of food intakes, sociodemographic and lifestyle factors were made between diet groups and between cohorts using descriptive statistics. Results 2.3 million participants were included; 66% women and 34% men, with mean ages at recruitment of 57 (SD: 7.8) and 57 (8.6) years, respectively. There were 2.1 million meat eaters, 60,903 poultry eaters, 44,780 pescatarians, 81,165 vegetarians, and 14,167 vegans. Food intake differences between the diet groups varied across the cohorts; for example, fruit and vegetable intakes were generally higher in vegetarians than in meat eaters in all the cohorts except in China. BMI was generally lower in vegetarians, particularly vegans, except for the cohorts in India and China. In general, but with some exceptions, vegetarians were also more likely to be highly educated and physically active and less likely to smoke. In the available resurveys, stability of diet groups was high in all the cohorts except in China. Conclusions Food intakes and lifestyle factors of both non-vegetarians and vegetarians varied markedly across the individual cohorts, which may be due to differences in both culture and socioeconomic status, as well as differences in questionnaire design. Therefore, care is needed in the interpretation of the impacts of vegetarian diets on cancer risk.

Introduction: Region-specific data on individual factors associated with uptake of breast and cervical cancer screening or early testing in diverse Indian populations are limited. Aim: To assess the prevalence and individual determinants of uptake of breast and/or cervical cancer screening or testing among women aged 30–69 years in regionally representative populations of two large Indian cities: New Delhi and Chennai. Methods: We conducted an analysis of the cross-sectional data (2016–2017) nested within the Centre for Cardiometabolic Risk Reduction in South Asia cohort, established in 2010–2011 with 12,271 participants (5365 in New Delhi; 6906 in Chennai). Among 3310 women participants, we evaluated the associations of demographic, socioeconomic, lifestyle, medical, psychosocial, and reproductive factors with breast and/or cervical cancer screening or testing using multivariable logistic regression models with results expressed as adjusted odds ratios (OR) and 95% confidence intervals (CI). Results: At any point prior to 2016–2017, 193 women self-reported having undergone evaluations for breast and/or cervical cancer. The reasons for evaluation were ‘general examination’ or ‘physician’s advice’ (i.e., screening) or ‘being symptomatic’ (i.e., early testing). The overall prevalence was 5.8% for screening or testing and 2.5% for screening alone. Formal education (OR:1.88; 95% CI:1.12–3.15), high monthly household income (OR:2.27; 95% CI:1.59–3.25) and less ‘fear-of-judgement’ (OR:1.65; 95% CI:1.05–2.58) were positively associated with screening or testing uptake. When screening uptake was analysed separately, the results were generally similar. Conclusion: Our findings may have important implications for interventions at community-level (e.g., reducing ‘fear-of-judgement’, increasing awareness to screening programs and early symptoms) and health-system level (e.g., opportunistic screening).

Abstract Background Structured lifestyle change education reduces the burden of cardiometabolic diseases such as diabetes. Delivery of these programs at worksites could overcome barriers to program adoption and improve program sustainability and reach; however, tailoring to the worksite setting is essential. Methods The Integrating Diabetes Prevention in Workplaces (INDIA-WORKS) study tested the implementation and effectiveness of a multi-level program for reducing cardiometabolic disease risk factors at 11 large and diverse worksites across India. Herein, we describe and classify program adaptations reported during in-depth interviews and focus group discussions with worksite managers, program staff, and peer educators involved in program delivery, and program participants and drop-outs. We used thematic analysis to identify key themes in the data and classified reported program adaptations using the FRAME classification system. Results Adaptations were led by worksite managers, peer educators, and program staff members. They occurred both pre- and during program implementation and were both planned (proactive) and unplanned (proactive and reactive). The most frequently reported adaptations to the individual-level intervention were curriculum changes to tailor lessons to the local context, make the program more appealing to the workers at the site, or add a wider variety of exercise options. Other content adaptations included improvements to the screening protocol, intervention scheduling, and outreach plans to tailor participant recruitment and retention to the sites. Environment-level content adaptations included expanding or leveraging healthy food and exercise options at the worksites. Challenges to adaptation included scheduling and worksite-level challenges. Participants discussed the need to continue adapting the program in the future to continue making it relevant for worksite settings and engaging for employees. Conclusion This study describes and classifies site-specific modifications to a structured lifestyle change education program with worksite-wide health improvements in India. This adds to the literature on implementation adaptation in general and worksite wellness in India, a country with a large and growing workforce with, or at risk of, serious cardiometabolic diseases. This information is key for program scale-up, dissemination, and implementation in other settings. Trial registration Clinicaltrials.gov NCT02813668. Registered June 27, 2016

Abstract Background The variability in the effectiveness of type 2 diabetes (T2D) preventive interventions highlights the potential to identify the factors that determine treatment responses and those that would benefit the most from a given intervention. We conducted a systematic review to synthesize the evidence to support whether sociodemographic, clinical, behavioral, and molecular factors modify the efficacy of dietary or lifestyle interventions to prevent T2D. Methods We searched MEDLINE, Embase, and Cochrane databases for studies reporting on the effect of a lifestyle, dietary pattern, or dietary supplement interventions on the incidence of T2D and reporting the results stratified by any effect modifier. We extracted relevant statistical findings and qualitatively synthesized the evidence for each modifier based on the direction of findings reported in available studies. We used the Diabetes Canada Clinical Practice Scale to assess the certainty of the evidence for a given effect modifier. Results The 81 publications that met our criteria for inclusion are from 33 unique trials. The evidence is low to very low to attribute variability in intervention effectiveness to individual characteristics such as age, sex, BMI, race/ethnicity, socioeconomic status, baseline behavioral factors, or genetic predisposition. Conclusions We report evidence, albeit low certainty, that those with poorer health status, particularly those with prediabetes at baseline, tend to benefit more from T2D prevention strategies compared to healthier counterparts. Our synthesis highlights the need for purposefully designed clinical trials to inform whether individual factors influence the success of T2D prevention strategies.

Self-stigma-the internalization of negative community attitudes and beliefs about a disease or condition-represents an important barrier to improving patient care outcomes for people living with common mental disorders and diabetes. Integrated behavioral healthcare interventions are recognized as evidence-based approaches to improve access to behavioral healthcare and for improving patient outcomes, including for those with comorbid diabetes, yet their impact on addressing self-stigma remains unclear. Using secondary data from the Integrating Depression and Diabetes Treatment (INDEPENDENT) study-a trial that aimed to improve diabetes outcomes for people with undertreated and comorbid depression in four urban Indian cities via the Collaborative Care Model-we longitudinally analyzed self-stigma scores and evaluated whether change in total self-stigma scores on diabetes outcomes is mediated by depressive symptom severity. Self-stigma scores did not differ longitudinally comparing Collaborative Care Model participants to enhanced standard-of-care participants (mean monthly rate of change in Self-Stigma Scale for Chronic Illness-4 Item scores; B = 0.0087; 95% CI: -0.0018, 0.019, P = .10). Decreases in total self-stigma scores over 12 months predicted diabetes outcomes at 12 months (HbA1c, total effect; B = 0.070 95%CI: 0.0032, 0.14; P < .05), however depressive symptoms did not mediate this relationship (average direct effect; B = 0.064; 95% CI: -0.0043, 0.13, P = .069). Considering the local and plural notions of stigma in India, further research is needed on culturally grounded approaches to measure and address stigma in India, and on the role of integrated care delivery models alongside multi-level stigma reduction interventions. Trial registration : ClinicalTrials.gov, NCT02022111. https://clinicaltrials.gov/study/NCT02022111.

[This corrects the article DOI: 10.1371/journal.pone.0278919.].

Abstract Background Diabetic retinopathy (DR) is a major sight-threatening microvascular complication in individuals with diabetes. Systemic inflammation combined with oxidative stress is thought to capture most of the complexities involved in the pathology of diabetic retinopathy. A high level of neutrophil–lymphocyte ratio (NLR) is an indicator of abnormal immune system activity. Current estimates of the association of NLR with diabetes and its complications are almost entirely derived from cross-sectional studies, suggesting that the nature of the reported association may be more diagnostic than prognostic. Therefore, in the present study, we examined the utility of NLR as a biomarker to predict the incidence of DR in the Scottish population. Methods The incidence of DR was defined as the time to the first diagnosis of R1 or above grade in the Scottish retinopathy grading scheme from type 2 diabetes diagnosis. The effect of NLR and its interactions were explored using a competing risks survival model adjusting for other risk factors and accounting for deaths. The Fine and Gray subdistribution hazard model (FGR) was used to predict the effect of NLR on the incidence of DR. Results We analysed data from 23,531 individuals with complete covariate information. At 10 years, 8416 (35.8%) had developed DR and 2989 (12.7%) were lost to competing events (death) without developing DR and 12,126 individuals did not have DR. The median (interquartile range) level of NLR was 2.04 (1.5 to 2.7). The optimal NLR cut-off value to predict retinopathy incidence was 3.04. After accounting for competing risks at 10 years, the cumulative incidence of DR and deaths without DR were 50.7% and 21.9%, respectively. NLR was associated with incident DR in both Cause-specific hazard (CSH = 1.63; 95% CI: 1.28–2.07) and FGR models the subdistribution hazard (sHR = 2.24; 95% CI: 1.70–2.94). Both age and HbA1c were found to modulate the association between NLR and the risk of DR. Conclusions The current study suggests that NLR has a promising potential to predict DR incidence in the Scottish population, especially in individuals less than 65 years and in those with well-controlled glycaemic status.

Abstract Maturity Onset Diabetes of the Young (MODY) is a monogenic form of diabetes which is detected by genetic testing. We looked at clinical and biochemcial variables that could help detect possible MODY among Asian Indians with youth-onset diabetes. From the diabetes electronic medical records of a diabetes care centre in Chennai in southern India, demographic, anthropometric, and biochemical details of 34 genetically confirmed MODY participants were extracted. They were compared with patients with type 1 diabetes (T1D) (n = 1011) and type 2 diabetes (T2D) (n = 1605), diagnosed below 30 years of age. Clinical and biochemical variables including body mass index (BMI), glycated hemoglobin, HDL cholesterol, and C-peptide (fasting and stimulated) were analyzed to determine whether cut points could be derived to identify individuals who could be sent for genetic testing to diagnose or rule out MODY in this ethnic group. The age at diagnosis was higher for T2D (26.5 ± 4.0 years) compared to T1D (18.2 ± 6.1 years) and MODY (17.8 ± 6.0 years). Individuals with MODY had BMI, glycated hemoglobin, total cholesterol, triglycerides, HDL cholesterol, and C-peptide levels which were intermediate between T1D and T2D. The identified probable parameters and their cut points to identify cases for MODY genetic screening were BMI 21.2–22.7 kg/m2, glycated hemoglobin 7.2–10%, HDL cholesterol 43–45 mg/dl, fasting C -peptide, 1.2–2.1 ng/ml and stimulated C-peptide, 2.1–4.5 ng/ml. Asian Indians with MODY have clinical features that are intermediate between T1D and T2D and selected biochemical parameters, especially stimulated C peptide cut points were the most useful to diagnose MODY.

Introduction Exposure to fine particulate matter has been associated with several cardiovascular and cardiometabolic diseases. However, such evidence mostly originates from low-pollution settings or cross-sectional studies, thus necessitating evidence from regions with high air pollution levels, such as India, where the burden of non-communicable diseases is high.Research design and methods We studied the associations between ambient PM2.5 levels and fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1c) and incident type 2 diabetes mellitus (T2DM) among 12 064 participants in an adult cohort from urban Chennai and Delhi, India. A meta-analytic approach was used to combine estimates, obtained from mixed-effects models and proportional hazards models, from the two cities.Results We observed that 10 μg/m3 differences in monthly average exposure to PM2.5 was associated with a 0.40 mg/dL increase in FPG (95% CI 0.22 to 0.58) and 0.021 unit increase in HbA1c (95% CI 0.009 to 0.032). Further, 10 μg/m3 differences in annual average PM2.5 was associated with 1.22 (95% CI 1.09 to 1.36) times increased risk of incident T2DM, with non-linear exposure response.Conclusions We observed evidence of temporal association between PM2.5 exposure, and higher FPG and incident T2DM in two urban environments in India, thus highlighting the potential for population-based mitigation policies to reduce the growing burden of diabetes.

Aims: The purpose of this study is to explore the perceptions and practices of diabetes management through focus group discussions (FGDs) among adults with diabetes in rural Tamil Nadu. Materials and Methods: A qualitative study was conducted among individuals with diabetes who were part of the Telemedicine pRoject for screENing Diabetes and its complications in rural Tamil Nadu (TREND). A total of 16 FGDs were conducted using a semi-structured FGD guide that elicited perceptions of the different aspects of diabetes management and knowledge about diabetes prevention. The sample size was based on the attainment of thematic saturation. All FGDs were audio-recorded and transcribed verbatim. The textual data was then coded into meaning units and grouped into themes. Data were analyzed using NVIVO software version 10.0. Results: There were varied responses with respect to diet, medication adherence, regularity of follow-up, knowledge about diabetes, and diabetes prevention. Most participants had limited knowledge of the disease and did not have regular hospital visits. Several participants were unable to adhere to the diet prescribed by healthcare providers, as they lived alone or were dependent on someone in the family for dietary needs. Most participants were unaware that diabetes could be prevented. Some participants were interested in serving as “Diabetes ambassadors” to educate rural societies about diabetes. Conclusions: Understanding the perceptions and practices about diabetes management and prevention strategies could help primary healthcare workers effectively treat, manage, and prevent diabetes in underserved rural populations.

Context: Collaborative care models for depression have been successful in a variety of settings, but their success may differ by patient engagement. We conducted a post-hoc analysis of the INDEPENDENT trial to investigate the role of differential engagement of participants on health outcomes over 3 years. Settings and Design: INDEPENDENT study was a parallel, single-blinded, randomised clinical trial conducted at four socio-economically diverse clinics in India. Participants were randomised to receive either active collaborative care or usual care for 12 months and followed up for 24 months. Method: We grouped intervention participants by engagement, defined as moderate (≤7 visits) or high, (8 or more visits) and compared them with usual care participants. Improvements in composite measure (depressive symptoms and at least one of three cardio-metabolic) were the primary outcome. Statistical Analysis: Mean levels of depression and cardio-metabolic measures were analysed over time using computer package IBM SPSS Statistics 25. Results: The composite outcome was sustained the highest in the moderate engagers [27.5%, 95% confidence interval (CI): 19.5, 36.7] and the lowest in high engagers (15.8%, 95% CI: 8.1, 26.8). This pattern was observed for individual parameters – depressive symptoms and glycosylated haemoglobin. Progressive reductions in mean depressive symptom scores were observed for moderate engagers and usual care group from baseline to 36 months. However, in high engagers of collaborative care, mean depressive symptoms were higher at 36 months compared to 12 months. Conclusion: Sustained benefits of collaborative care were larger in participants with moderate engagement compared with high engagement, although a majority of participants relapsed on one or more outcome measures by 36 months. High engagers of collaborative care for co-morbid depression and diabetes may need light touch interventions for longer periods to maintain health and reduce depressive symptoms.

Background and Objectives: “Adai” is a traditional South Indian breakfast prepared using the wet ground batter of white rice and pulses. Convenience foods are gaining popularity and owing to the increasing prevalence of noncommunicable diseases such as diabetes, there is a need for food products with lower glycemic index (GI). The current study aimed to develop an instant adai mix using brown rice, millets, pulses, and spices. Materials and Methods: The instant adai mix was prepared by blending pulverized brown rice, sorghum, and pulses (green gram, horse gram, decorticated and split red gram, black gram, and chickpea) along with roasted cumin, red chilies, and salt. The nutritional composition of the instant adai mix was analyzed, and GI of “adai” was evaluated in healthy human volunteers using International organization for standardization protocol. Results: The instant adai mix was rich in whole grains (48%) and pulses (45%). Nutritional profiling of the instant adai mix revealed that it is rich in protein and dietary fiber. One hundred grams of instant adai mix fulfill 27.8% of protein and 29.6% of dietary fiber requirements of recommended dietary allowance of adult male. Likewise, 100 g of instant adai mix fulfill 34.9% of protein requirements of the estimated average requirement of an adult male. The “adai” prepared from the instant mix exhibited medium GI (65.1). Conclusion: The instant “adai” mix was found to be nutritionally superior, and the adai prepared from the mix showed a medium GI. It can be a healthy option compared with instant mixes containing refined grains such as white rice. More formulation trials are needed to prepare an adai mix to achieve a low GI. Reformulation of traditional foods with nutritious ingredients and achieving a lower GI can expand the healthier food choices for this vulnerable population who are at risk for type 2 diabetes.

Aim: Type 1 diabetes mellitus (T1DM) is a chronic metabolic disorder that makes self-care challenging for T1DM individuals and their caregivers. This qualitative study aimed to explore the perceived benefits of the Back to Basics-Diabesties (B2B) session among T1DM individuals and their caregivers in India. Materials and Methods: The B2B session is a structured intervention provided through telephonic peer counseling, aimed at enhancing the understanding of T1DM that provides practical knowledge of diabetes management, insulin administration, blood glucose monitoring, diet, exercise, and psychosocial aspects of living with T1DM. Overall, more than 1560 participants (T1DM/caregivers/family/friends) have opted for B2B session. A qualitative telephonic interview was conducted (n = 96) using a semistructured open-ended questionnaire to collect data on the perceived benefits of B2B session. The information obtained was then coded, and grouped to form themes. Results: According to T1DM individuals, B2B sessions enhanced diabetes knowledge and confidence, self-management abilities, increased sense of community and peer support, and easy accessibility. Caregivers reported that the B2B session provided emotional support, disease knowledge, shared experiences, practical ideas, and coping strategies. Most widely appreciated salient feature of B2B session was the peer counselors were themselves with T1DM or caregivers of T1DM, which created unbreakable trust among the study participants. Clinical evidence after B2B session showed a 23% of improvement in the glycated hemoglobin (

Purpose: The study was conducted to compare the compliance to intravitreal injection treatment and follow-up in patients with center-involving diabetic macular edema (CI-DME) and treatment outcomes between a tertiary eye care facility and a tertiary diabetes care center. Methods: A retrospective review was conducted on treatment naïve DME patients who had received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections in 2019. Participants were people with type 2 diabetes who were under regular care at the eye care center or the diabetes care center in Chennai. The outcome measures were noted at months 1, 2, 3, 6, and 12. Results: A review of 136 patients treated for CI-DME (72 from the eye care center and 64 from a diabetes care center) was carried out. The severity of diabetic retinopathy (DR) was similar in both centers. There was no statistically significant (P > 0.05) difference in the choice of initial intravitreal drug in the two centers. At 12-month follow-up, only 29.16% came for a follow-up in the eye center vs. 76.56% in a diabetes care center (P = 0.000). The multivariate logistic regression showed increasing age was associated with non-compliance in both the groups (eye care center: odds ratio [OR] 0.91; 95% confidence interval [CI] 0.82–1.21; P = 0.044) and diabetes care center (OR 1.15; 95% CI 1.02–1.29; P = 0.020). Conclusion: The follow-up rate between eye care and diabetic care center with DME showed a significant disparity. By providing comprehensive diabetes care for all complications under one roof, compliance with follow-up can be improved in people with DME.

Aim: The aim of this study was to develop and validate the situational anxiety scale (SAS) during COVID-19 among adults with type 2 diabetes attending a tertiary diabetes center in Southern India. Materials and Methods: A total of 100 individuals aged from 18 to 65 years with type 2 diabetes attending a tertiary care diabetes center completed a structured SAS at two visits. The first visit (visit 1) survey was conducted in April 2021 and the second visit (visit 2) survey was conducted in March 2022. The SAS was administered to all 100 individuals. The State Trait Anxiety Inventory Scale (STAI-S) consisting of 20 questions was administered to the same 100 individuals in addition to the SAS during Visit 2. Results: The SAS showed good internal consistency for visit 1 (α = 0.855) and visit 2 (α = 0.795). Exploratory factor analysis showed four factors and explained 69% of variance. The four factors identified were as follows: (1) fear, (2) desire for COVID-free state, (3) lack of interest and energy, and (4) financial worries. A weak positive correlation was observed between SAS visit 2 and STAI-S, and it was statistically significant (r = 0.223; P = 0.026). Conclusion: The SAS is a valid and reliable tool for measuring situational anxiety during pandemics and post-COVID anxiety levels, which can help in the development of a holistic approach.

Background: The nutritional importance of brown rice (BR) is well established. Despite several nutritional benefits of BR, its consumption remains limited due to long cooking time and limited shelf-life. BR can be subjected to processing to improve shelf-life. Gamma irradiation is one such strategy, but it could induce changes in the grain and thus affect its glycemic properties. Aims and objectives: The aim of this study was to look at the 24-h glycemic response of irradiated and non-irradiated BR-based iso-caloric diets in Asian Indians. Methods: Fifteen (mean body mass index: 24 ± 2.6 kg/m2) Asian Indian adults without diabetes, aged 25–39 years, participated in this randomized cross-over study. Iso-caloric diets were prepared with two varieties (ADT 43 and Swarna) of parboiled gamma-irradiated brown rice with 750–820 Gy dosage (IBR) and non-irradiated brown rice (NIBR). After the participants consumed these diets, 24-h glycemic responses were recorded using a continuous glucose monitoring system. The mean positive change from baseline glucose concentration was calculated as the incremental area under the curve (IAUC) for both the diets. Results: The percentage difference in 24-h average IAUC was 10% lower in the IBR diets when compared with NIBR diets, irrespective of the variety of BR (P = 0.56). In the case of ADT 43 rice variety, both IBR and NIBR diets showed similar IAUC (P = 0.68). However, the IBR of Swarna rice variety showed 21% lower IAUC when compared with the NIBR diet (P = 0.21). Comparing the IBR varieties, Swarna showed 21% lower IAUC than ADT 43 (P = 0.21), whereas between NIBR varieties, only 0.79% difference was observed between ADT 43 and Swarna (P = 0.93). Conclusions: Gamma irradiation of parboiled BR did not produce significant differences in the 24-h glycemic responses for BR-based diets. Swarna variety was better than ADT 43 with regard to glycemic response. Judicious application of radiation technology to BR varieties may help in shelf-life extension without affecting the glycemic properties.

Background: A large number of epidemiologic studies across the world indicate a growing link between obesity and diabetes. The metropolitan city of Chennai in South India is experiencing an alarming increase in diabetes and obesity. Aim: The aim of this study was to determine the prevalence of and risk factors for diabetes and obesity together termed as “diabesity” among adults in urban Chennai. Materials and Methods: This was a community-based cross-sectional door-to-door study done as part of a large National Institute of Health and Care Research (NIHR)––a funded project aimed to understand patterns and determinants of health in South Asia. Of the 200 wards in Chennai, 34 wards were surveyed in the main project and two wards were selected randomly for this substudy. Five community enumeration blocks were selected using a systematic sampling technique. Participants aged ≥18 years were selected using a consecutive sampling method. Results: Of the 1138 participants studied, the prevalence of diabesity was found to be 34.3%(n = 390). Of the study participants, 74.8% had obesity (61.9%––generalized obesity; 68.5%––abdominal obesity) and 43.0% had diabetes. As age increased, the diabesity risk also increased gradually from 30 to 39 years (odds ratio [OR]: 3.6[95%, confidence interval [CI]: 1.4–8.9]) to 50–59 years (OR: 5.4[95%, CI: 2.2–13.2]), whereas there was a slight decrease in risk after 60 years (OR: 5.1[95%, CI: 2.1–12.3]). Females had nearly twice the risk of diabesity compared to men (OR: 1.8, P < 0.001), and physically inactive individuals had 1.7 times increased risk (P < 0.001). Conclusion: We report in this study that the prevalence of the dual metabolic defect (diabesity) is alarmingly high in urban Chennai. This study was an attempt to understand the epidemiology of diabesity.

A clinical trial is the most foolproof method to evaluate the efficacy of a new intervention. Successful completion of clinical trials depends on the retention of the participants enrolled. Poor participant retention can lead to significant time and cost burden and have potentially adverse biases on the results. A high retention rate of participants is an important criterion for the validity and credibility of randomized controlled clinical trials. Many long-term trials fail due to low retention of study participants. Efforts at participant retention should start even before the first participant is recruited into the study. Retention is not only the responsibility of the investigators but also all other stakeholders in a clinical trial. In recent years, retention materials, participant camps, and introduction of national study coordinators have helped in improving retention. Quality of the relationship developed between the research staff and the study participant is a key factor for success of any trial. In our experience, in the context of resource-challenged low- and middle-income countries, we have found that it is possible to achieve high retention rates, 95%–100%. The rapport built between the investigating team and the participant plays a vital role in retention. In addition, personalized care, including listening to the participant's problems and enabling to contact investigators or study team at any time of the day, has shown benefits in retention.

Background: This project aimed to assess the impact of yoga on stress, metabolic parameters and cognition (attention & concentration) in adolescents, aged 13–15 years from public and private schools in two cities (Chennai and New Delhi) in India. Methods: The study recruited 2000 adolescents from 24 schools in a cluster randomized controlled trial design. The yoga group participants underwent 17 yoga sessions, which included: pranayama, basic asanas, meditation and relaxation exercises. Yoga sessions, were held in the school premises once a week. A total of five awareness talks on healthy lifestyle were delivered once a month to the education group. ADOlescence Stress Scale (ADOSS), salivary cortisol, metabolic and clinical parameters and Letter Cancellation Test (LCT) score were measured at baseline and post-intervention (5–6 months). Results: The yoga group showed statistically significant differences in the mean ADOSS score, metabolic parameters, salivary cortisol, and LCT scores compared to the education group. In the intention- to- treat analysis, a significant reduction [5.11, 95% CI (4.78, 5.36), p = 0.001] in ADOSS score was seen in the yoga group compared to education. Conclusion: Implementation of a 17-week standardized yoga program at the school level significantly decreased stress, improved attention and concentration, metabolic and clinical parameters in Indian adolescents. Trial registration: This trial was registered at Clinical Trials Registry, India (CTRI/2017/08/009203).

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.

Objectives This study provides an estimate of the annual cost of blindness and moderate to severe visual impairment (MSVI) among people with diabetes aged 40 years and above in India in the year 2019.Design A cost of illness study.Setting India.Participants People with diabetes aged 40 years and above in India in the year 2019.Primary and secondary outcome measures Estimates are provided for the total costs of screening for most common vision-threatening eye conditions, treatment of these conditions, economic activity lost by these people and their family carers whose ability to work is affected, and loss of quality of life experienced by people with diabetes and blindness or MSVI.Results It is estimated that for people with diabetes aged 40 years or above, annual screening followed by eye examination where required would cost around 42.3 billion Indian rupees (INR) (4230 crores) per year; treating sight problems around 2.87 billion INR (287 crores) per year if 20% of those needing treatment receive it; and lost economic activity around 472 billion INR (47 200 crores). Moreover, 2.86 million (0.286 crores) quality-adjusted life years (QALYs) are lost annually due to blindness and MSVI. The estimate of lost production is highly sensitive to the proportion of people with MSVI able to work and how their output compares with that of a person with no visual impairment.Conclusions This is the first study to estimate the cost of blindness and MSVI for people aged 40 years and over with diabetes in India. The annual cost to the Indian economy is substantial. This cost will be expected to fall if a successful screening and treatment plan is introduced in India. Further work is suggested using more robust data, when available, to estimate the loss of productivity and loss of QALYs, as this would be worthwhile.

BackgroundHNF1A is an essential component of the transcription factor network that controls pancreatic β-cell differentiation, maintenance, and glucose stimulated insulin secretion (GSIS). A continuum of protein malfunction is caused by variations in the HNF1A gene, from severe loss-of-function (LOF) variants that cause the highly penetrant Maturity Onset Diabetes of the Young (MODY) to milder LOF variants that are far less penetrant but impart a population-wide risk of type 2 diabetes that is up to five times higher. Before classifying and reporting the discovered variations as relevant in clinical diagnosis, a critical review is required. Functional investigations offer substantial support for classifying a variant as pathogenic, or otherwise as advised by the American College of Medical Genetics and Genomics (ACMG) and the Association for Molecular Pathology (AMP) ACMG/AMP criteria for variant interpretation.ObjectiveTo determine the molecular basis for the variations in the HNF1A gene found in patients with monogenic diabetes in India.MethodsWe performed functional protein analyses such as transactivation, protein expression, DNA binding, nuclear localization, and glucose stimulated insulin secretion (GSIS) assay, along with structural prediction analysis for 14 HNF1A variants found in 20 patients with monogenic diabetes.ResultsOf the 14 variants, 4 (28.6%) were interpreted as pathogenic, 6 (42.8%) as likely pathogenic, 3 (21.4%) as variants of uncertain significance, and 1 (7.14%) as benign. Patients harboring the pathogenic/likely pathogenic variants were able to successfully switch from insulin to sulfonylureas (SU) making these variants clinically actionable.ConclusionOur findings are the first to show the need of using additive scores during molecular characterization for accurate pathogenicity evaluations of HNF1A variants in precision medicine.

Background: Stress levels increase tremendously in adolescence. Indian adolescents derive much of their stress from school and family pressures. Developing a standardized tool to assess adolescent stress can help early diagnosis. This article aimed to assess the reliability and validity of the ADOlescence Stress Scale (ADOSS). Methods: ADOSS was administrated by trained interviewers to 100 adolescents (10–17 years) of both sexes in Chennai, South India. Salivary cortisol was used as an objective measure of stress in 40 adolescents. Reliability was assessed within a two weeks interval. Exploratory factor analysis was done for the baseline ADOSS scores. The internal consistency (Cronbach’s alpha and spilt-half correlation), test-retest agreement (Kappa value), and inter-rater reliability (ICC) were assessed. Pearson correlation between salivary cortisol and ADOSS score was done. Results: The inter-factor correlation between the inherent four ADOSS factors (personal, academic, family, and social) was between 0.73 and 0.87, and split-half correlation was between 0.70 and 0.83, showing that the factors are reliable and coherent. Test-retest agreement was Kappa: 0.63, P = 0.001, and ICC was 0.84. Pearson correlation showed a statistically significant positive correlation between cortisol levels and ADOSS scores ( r = 0.87, P = 0.001). Conclusion: ADOSS is a reliable and valid tool to assess the overall stress of Indian adolescents in the age group of 10–17 years.

Objectives Our study aimed to systematically review the literature and synthesise findings on potential associations of built environment characteristics with type 2 diabetes (T2D) in Asia.Design Systematic review of the literature.Data sources Online databases Medline, Embase and Global Health were used to identify peer-reviewed journal articles published from inception to 23 January 2023.Eligibility criteria Eligible studies included cohort, cross-sectional and case–control studies that explored associations of built environment characteristics with T2D among adults 18 years and older in Asia.Data extraction and synthesis Covidence online was used to remove duplicates and perform title, abstract and full-text screening. Data extraction was carried out by two independent reviewers using the OVID database and data were imported into MS Excel. Out of 5208 identified studies, 28 studies were included in this systematic review. Due to heterogeneity in study design, built environment and outcome definitions, a semiqualitative analysis was conducted, which synthesised results using weighted z-scores.Results Five broad categories of built environment characteristics were associated with T2D in Asia. These included urban green space, walkability, food environment, availability and accessibility of services such as recreational and healthcare facilities and air pollution. We found very strong evidence of a positive association of particulate matter (PM2.5, PM10), nitrogen dioxide and sulfur dioxide (p

Objectives In resource-constrained settings, cancer epidemiology research typically relies on self-reported diagnoses. To test a more systematic alternative approach, we assessed the feasibility of linking a cohort with a cancer registry.Setting Data linkage was performed between a population-based cohort in Chennai, India, with a local population-based cancer registry.Participants Data set of Centre for Cardiometabolic Risk Reduction in South-Asia (CARRS) cohort participants (N=11 772) from Chennai was linked with the cancer registry data set for the period 1982–2015 (N=140 986).Methods and outcome measures Match*Pro, a probabilistic record linkage software, was used for computerised linkages followed by manual review of high scoring records. The variables used for linkage included participant name, gender, age, address, Postal Index Number and father’s and spouse’s name. Registry records between 2010 and 2015 and between 1982 and 2015, respectively, represented incident and all (both incident and prevalent) cases. The extent of agreement between self-reports and registry-based ascertainment was expressed as the proportion of cases found in both data sets among cases identified independently in each source.Results There were 52 self-reported cancer cases among 11 772 cohort participants, but 5 cases were misreported. Of the remaining 47 eligible self-reported cases (incident and prevalent), 37 (79%) were confirmed by registry linkage. Among 29 self-reported incident cancers, 25 (86%) were found in the registry. Registry linkage also identified 24 previously not reported cancers; 12 of those were incident cases. The likelihood of linkage was higher in more recent years (2014–2015).Conclusions Although linkage variables in this study had limited discriminatory power in the absence of a unique identifier, an appreciable proportion of self-reported cases were confirmed in the registry via linkages. More importantly, the linkages also identified many previously unreported cases. These findings offer new insights that can inform future cancer surveillance and research in low-income and middle-income countries.

BackgroundAsian Indians have an increased susceptibility to type 2 diabetes and premature coronary artery disease. Nuts, like almonds, are rich in unsaturated fat and micronutrients with known health benefits.ObjectivesThis study aimed to assess the efficacy of almonds for reduction of insulin resistance and improving lipid profile in overweight Asian Indian adults.MethodsThis parallel-arm, randomized, controlled trial was conducted in Chennai, India on 400 participants aged 25–65 years with a body mass index ≥ 23 kg/m2. The intervention group received 43 g of almonds/day for 12 weeks, while the control group was advised to consume a customary diet but to avoid nuts. Anthropometric, clinical, and dietary data were assessed at periodic intervals. Glucose tolerance, serum insulin, glycated hemoglobin, C-peptide and lipid profile were assessed at baseline and end of the study. Insulin resistance (homeostasis assessment model-HOMA IR) and oral insulin disposition index (DIo) were calculated.ResultsA total of 352 participants completed the study. Significant improvement was seen in DIo [mean (95% CI) = + 0.7 mmol/L (0.1, 1.3); p = 0.03], HOMA IR (−0.4 (−0.7, −0.04; p = 0.03) and total cholesterol (−5.4 mg/dl (−10.2, −0.6); p = 0.03) in the intervention group compared to the control group. Incremental area under the curve (IAUC) and mean amplitude of glycemic excursion (MAGE) assessed using continuous glucose monitoring systems were also significantly lower in the intervention group. Dietary 24-h recalls showed a higher significant reduction in carbohydrate and increase in mono unsaturated fatty acid (MUFA) and polyunsaturated fatty acids (PUFA) intake in the intervention group compared to the control group.ConclusionDaily consumption of almonds increased the intake of MUFA with decrease in carbohydrate calories and decreases insulin resistance, improves insulin sensitivity and lowers serum cholesterol in Asian Indians with overweight/obesity. These effects in the long run could aid in reducing the risk of diabetes and other cardiometabolic disease.

Background: A city’s planning, design, and construction can have a profound influence on health, specifically on non-communicable diseases such as diabetes and obesity, which are often referred to as “diabesity.” This study describes the designs and methods to understand the relationship between food and physical activity environments on diabesity. Materials and Methods: This study was a community-based cross-sectional door-to-door survey conducted as part of a large National Institute of Health and Care Research-funded surveillance project. For this study, two wards in Chennai were selected randomly. In each ward, five community enumeration blocks were selected using systematic random sampling technique. A consecutive sampling approach was used to select the study participants. Two categories of data were collected: (1) health data and (2) built environment (BE) data. Health and lifestyle questionnaires, anthropometric, and biochemical data were collected from all the study participants. For categorizing BE, an online questionnaire was developed using the KoBo toolbox to collect information about food and physical activity environments, as well as geographic locations. Expected Outcome: This study is expected to reveal data on the relationship between food and physical activity environments and diabesity. It will help policy-makers to understand the importance of access to healthy foods and spaces for physical activity in prevention and control of diabesity. It can also enable community-based interventions to improve health outcomes and help urban planners to plan cities that promote active lifestyles for its residents.

Brown rice (whole grain, BR) has lower glycemic index (GI), is a healthy replacement for white rice (WR). However, BR has a short shelf life, is susceptible to pest infestation. Gamma irradiation is a safe approach to prevent the latter. This study examines effect of gamma irradiation on the physical, cooking, nutritional, shelf life and glycemic properties of three Indian parboiled BR. Parboiled BR of ADT-43, BPT-5204, and Swarna rice varieties were packed in polyester and polypropylene pouches (60 µ thickness) and subjected to gamma irradiation [750–820 Gy] (IR). Appropriate controls without irradiation (NIR) were maintained. Irradiation did not induce major changes in the physical and nutritional properties, except for resistant starch which significantly increased after irradiation in ADT-43 and BPT-5204. Irradiation reduced the cooking time, increased loss of solids in the cooking water and decreased apparent water uptake (particularly in BPT-5204). IR varieties exhibited longer shelf life (8–9 months) compared to 6 months shelf life of NIR varieties. The shelf stability of IR Swarna rice was superior in terms of delayed rancidity development compared to all other rice. All BR samples exhibited the ranking of ‘like moderately’ in the sensory acceptability tests at 6 months of storage and scores decreased subsequently. Irradiation did not affect GI [all showed medium GI, except a high GI for IR BPT 5204] and helped in shelf life extension of parboiled BR by preventing insect infestation.

Background and Aims: The impact of a chronic illness like diabetes on physical and mental wellbeing has been gaining more focus in the last few decades. This study aimed to investigate the association of stress, depression, and anxiety among individuals with type 2 diabetes mellitus (T2DM) and microvascular complications. Materials and Methods: This cross-sectional study included 315 participants aged ≥20 years with T2DM seen at a tertiary care diabetes centre who were screened for diabetic retinopathy, nephropathy, and neuropathy and assessed for stress, depression, and anxiety using the Depression, Anxiety Stress Scale 21 (DASS 21). Diabetic retinopathy was classified according to the Early Treatment Diabetic Reinopathy Study grading system diagnosed using retinal photography [Early Treatment DR Study grading system] i.e., presence of at least one distinct microaneurysm; nephropathy, if urinary albumin excretion was ≥30 mg/μg of creatinine; and neuropathy, if vibration perception threshold of the big toe using biothesiometry was ≥20 V. Results: Prevalence of stress was higher in those with neuropathy (60% vs 40%, P < 0.001), nephropathy (61% vs 39%, P < 0.001) and retinopathy (57% vs 43%, P < 0.05) compared to those without. Prevalence of depression was also higher in individuals with neuropathy (66% vs 34%,P < 0.001), nephropathy (58% vs 42%, P < 0.001) and retinopathy (55% vs 45%, P < 0.05). In multiple regression analysis, stress was significantly associated with retinopathy (OR=3.13,CI:1.75–5.58, P < 0.000), neuropathy (OR=2.50, CI:1.42–4.39,P < 0.001) and nephropathy (OR=2.06,CI:1.19–3.56, P < 0.010),depression was also significantly associated with retinopathy (OR=1.97,CI:1.04–3.73, P < 0.037), neuropathy (OR=2.77,CI:1.45–5.30,P < 0.002) and nephropathy (OR=2.59,CI:1.42–4.70,P < 0.002). Conclusions: Individuals with microvascular complications of diabetes should be screened for stress, depression,and anxiety so that proper counselling can be given.

Aim: To study the health and socioeconomic impact of the COVID-19 pandemic and to assess the barriers to self-management of diabetes during the lockdown, in rural South India. Materials and Methods: Details of demographic, social, economic, migration and health status were collected using a structured questionnaire from participants aged ≥18 years belonging to the 21 villages of Chengalpattu and Kancheepuram districts of Tamil Nadu state in south India as part of the Telemedicine pRoject for screENing Diabetes and its complications in rural Tamil Nadu (TREND) study. From the 11,249 TREND participants, a random list of 25% (n = 2812) was system-generated using random numbers and 2812 participants were contacted for the study, of whom 2511 individuals participated. Telephonic interviews were conducted during the lockdown from June to August 2020. Further, qualitative interviews(Focus group discussions) were conducted among 27 individuals with diabetes between September and December 2020. Data were analyzed using thematic analysis. Results: The mean age of the study population was 43 ± 14 years and 50.4% were women. Diabetes was present in 14.7%, hypertension in 31.9%, generalized and abdominal obesity in 33.3% and 46.5% respectively. When the lockdown was implemented in March 2020, 37% had migrated from urban to rural areas. Lack of daily wage jobs (68%), price of essential commodities (41.7%), social distancing/curfew (34.8%), mental fatigue/depression (14.7%), and loss of job (7.1%) were some reasons stated for their adverse social and financial circumstances. People with diabetes stated that they had to avoid or cut down their regular hospital visits due to travel restrictions. Many of the patients took the same medications for almost a year. Conclusion: Unemployment, poor mental health, and reduced household income were the most significant negative impacts faced by rural residents during the lockdown due to COVID-19. People with diabetes experienced disruptions in diabetes management due to the pandemic.

Background and Objectives: Beaten or flattened rice (flakes) is very popular in India for preparing the meal “upma.” Commonly marketed rice flakes are fiber depleted, starchy, and may be nutritionally poor. Hence, this study aimed at preparing brown rice flakes (BRF) for such “upma” preparation and compared the nutritional and glycemic properties of it with those of white rice flakes (WRF). Materials and Methods: Flakes were prepared from brown rice (BR, ADT-45 variety) by steaming and flattening using a roller flaker. The BRF and commercial WRF were analyzed for nutrient composition, and upma prepared from both the flakes was evaluated for glycemic index (GI) in normal healthy volunteers by using a validated protocol. Results: BRF contained significantly higher (6.2 g%) dietary fiber as compared with WRF (1.8 g%, P < 0.001). Stereo-zoom microscopic examination of BRF revealed retention of bran and germ. BRF was thicker, firmer, and had a lower surface area compared with WRF. BRF upma exhibited medium GI (63.3 ± 6.2), whereas WRF upma showed high GI (70.4 ± 5.6), though the GI values were not statistically significant. Interpretation and Conclusions: BRF upma, a medium GI category meal choice, could be considered a healthier option compared to high GI WRF upma considering the nutritional profile. The BRF described in the study is easy to cook and suitable enough to replace WRF. More trials are required to design and devise innovative protocols for the preparation of BRF with significantly lower glycemic properties.

Type 1 diabetes (T1D) is emerging as a major healthcare challenge impacting a significant percentage of the population. Management of T1D remains a concern in India with the diversity in socio-economic backgrounds, poor literacy levels, and inadequate resources and facilities which impact timely diagnosis, treatment, and management of this condition. All over the world in general, and in India, many peer support groups have come into existence and are even blossoming. A peer support system instils a sense of security, allows for better care practices, and builds quality relationships and a sense of belonging which can help improve their glycemic control and self-confidence and help them live a good quality of life. There are more than 40 T1D peer support groups in India offering emotional and financial support, knowledge, clinic services, matrimonial support as well as guidance in specialized areas of need such as celiac disease, sports, etc. While there is a need to understand and evaluate the most effective way to deliver these programs to effectually meet the various needs of people with T1D, there is also a need to integrate the various T1D peer support programs in India as there are many good practices that one group can learn and emulate from the other. The aim of this review article is to share the experience of the authors and to review available literature on T1D peer support groups to understand the role and impact of peer support groups in improving health outcomes and quality of life in people with T1D.

Diabetes is a chronic disease and to see the long-term glycemic control, most commonly glycosylated hemoglobin (HbA1c) is estimated. Presently, the most common method used to do HbA1c is high-performance liquid chromatography (HPLC) method. But in some cases unusually, low HbA1c is recorded by the HPLC method if hemoglobin variants are present. So in those cases, alternative methods of HbA1c estimation can be used to see the long-term glycemic status. So the presence of variants must be kept in mind and should be investigated properly so that when similar cases are encountered, it can be taken care appropriately.

Aims and Objectives: Diabetes is a chronic health condition proving to be a major health challenge globally. Being a lifestyle-related disorder, psychosocial and behavioral factors are critical for its management, among which stress plays a contributory role. Diabetes is associated with increased risk of depression, anxiety, and stress due to its debilitating nature and complications. Stress not only affects glycemic control through biological pathways but also leads to unhealthy behavior such as binge eating, smoking, and alcohol. This study attempts to fill the lacuna between clinical and psychosocial aspects of stress and thereby determines the prevalence and impact of stress among type 2 diabetes individuals in a clinic population. Materials and Methods: This is a cross-sectional, case–control study that includes individuals with type 2 diabetes mellitus (T2DM) as well as those with normal glucose tolerance. Assessment of stress was done using a validated tool, the Depression Anxiety Stress Scale-21 (stress component). Sociodemographic characteristics, anthropometry, blood pressure, and biochemical parameters were collected in all the participants. Data were analyzed using Statistical Package for Social Sciences statistical software. Results: The prevalence of stress was significantly higher in T2DM compared to normal glucose tolerance (NGT; 43% vs 13%, P < .001). Both among T2DM and NGT, stress levels were higher in younger individuals with higher education, higher income levels, and professionals. Stress scores decreased with age at diagnosis of T2DM (16.6 [≤25 years] vs 15.6 [≥26–40 years] vs 12.7 [≥41 years], P < .001). T2DM was significantly associated with stress after adjusting for confounding factors. Conclusion: Individuals with T2DM had significantly higher prevalence of stress. Regular screening of stress could lead to better glycemic control.

Aim: Diabetes is a chronic progressive disease. A healthy eating pattern is essential to achieve good glycemic control (HbA1c 7%) which aids in delaying and preventing diabetes-related complications. The pivotal role of diet, a modifiable risk factor for type 2 diabetes has not been understood completely especially in India where carbohydrate consumption is high. This study, therefore, aims to identify major dietary patterns associated with uncontrolled diabetes by using data reduction methods. Objective: To study and compare the association of dietary patterns with elevated HbA1c among known diabetic adults using three data reduction methods (principal component analysis (PCA), reduced rank regression (RRR), and partial least-squares (PLS) regression). Materials and Methods: The Chennai Urban Rural Epidemiological followed up study (CURES) was completed in 2410 adults. Adults with diabetes (both genders, aged >20years), 573 were selected for the present analysis. Dietary intake was assessed using food frequency questionnaire. Results: The PCA derived the non-vegetarian and vegetarian pattern. Both showed positive association with the risk of high HbA1c. The first pattern of RRR and PLS showed a positive association with many foods especially those contributing to increased intakes of total calories. Whereas the 2nd pattern of RRR and PLS scores both showed an inverse association with HbA1c especially with the reduction in rice-based recipes and total calories. Conclusions: The low intake of certain foods, especially white rice, directly decreased the total calories, total carbohydrate, glycemic load, and glycemic index which has a beneficial effect on glycemic control among those with diabetes.

Diabetes is one of the leading causes of death globally. India is home to the second-largest population suffering from diabetes. This underscores the need to build capacity of primary care physicians (PCPs) for better disease management. This narrative review article aims to describe the emergence of diabetes education and capacity-building programs for PCPs and its current situation in India. The review highlighted that major emphasis on diabetes was given only when the WHO estimated that morbidity and mortality due to diabetes would increase to 35% in India. As a result, National Diabetes Control Program was launched in 1987. Yet, very little attention was paid to diabetology in under-graduation. In the last decade, few public and private institutions have developed diabetes related capacity-building programs for PCPs independently or in collaborations. These programs include 16 fellowships, 4 diplomas, 12 certificate programs, and 6 other diabetes training programs, which have their own pros and cons. As medical science is changing rapidly, PCPs need to upgrade their skills and knowledge regularly to manage NCDs such as diabetes more effectively and efficiently. This can be possible only if scientific, evidence-based, and quality-oriented capacity-building programs are provided to the healthcare workforce.

AimMetabolic syndrome (MS) refers to a group of co-morbidities which include central obesity, hypertension, hyperglycemia and dyslipidemia. Previously, we reported that childhood lymphatic filariasis (LF) confers significant protection against type-1 and type-2 forms of diabetes, by means of immunomodulation. In the present study, we studied the effect of LF on endocrine dysfunction in MS and Non-MS patients in baseline and after 10 years of follow-up.MethodsWe quantified the serum levels of pancreatic hormones (insulin and glucagon), incretins (Ghrelin, GIP and GLP-1) and adipokines (leptin, adiponectin, adipsin, visfatin, PAI-1 and resistin) by multiplex bead array system.ResultsMS (both LF- and LF+) subjects had increased insulin levels compared to NMS (both LF- and LF+) subjects. MS-LF+ subjects had significantly increased levels of glucagon, ghrelin, GIP and GLP-1 and decreased levels of adipsin, compared to MS-LF- subjects. Interestingly this effect was short-lived and was not seen in the follow-up samples.ConclusionOverall, LF infection might confer limited short-term beneficial effects against MS, by means of modulating the incretin levels,either directly or indirectly.

Summary: 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.

Objective Intake of white rice has been associated with elevated risk for type 2 diabetes (T2D), while studies on brown rice are conflicting. To inform dietary guidance, we synthesised the evidence on white rice and brown rice with T2D risk.Design Systematic review and meta-analysis.Data sources PubMed, EMBASE and Cochrane databases were searched through November 2021.Eligibility criteria Prospective cohort studies of white and brown rice intake on T2D risk (≥1 year), and randomised controlled trials (RCTs) comparing brown rice with white rice on cardiometabolic risk factors (≥2 weeks).Data extraction and synthesis Data were extracted by the primary reviewer and two additional reviewers. Meta-analyses were conducted using random-effects models and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias was assessed using the Newcastle Ottawa Scale for prospective cohort studies and the Cochrane Risk of Bias Tool for RCTs. Strength of the meta-evidence was assessed using NutriGrade.Results Nineteen articles were included: 8 cohort studies providing 18 estimates (white rice: 15 estimates, 25 956 cases, n=5 77 426; brown rice: 3 estimates, 10 507 cases, n=1 97 228) and 11 RCTs (n=1034). In cohort studies, white rice was associated with higher risk of T2D (pooled RR, 1.16; 95% CI: 1.02 to 1.32) comparing extreme categories. At intakes above ~300 g/day, a dose–response was observed (each 158 g/day serving was associated with 13% (11%–15%) higher risk of T2D). Intake of brown rice was associated with lower risk of T2D (pooled RR, 0.89; 95% CI: 0.81 to 0.97) comparing extreme categories. Each 50 g/day serving of brown rice was associated with 13% (6%–20%) lower risk of T2D. Cohort studies were considered to be of good or fair quality. RCTs showed an increase in high-density lipoprotein-cholesterol (0.06 mmol/L; 0.00 to 0.11 mmol/L) in the brown compared with white rice group. No other significant differences in risk factors were observed. The majority of RCTs were found to have some concern for risk of bias. Overall strength of the meta-evidence was moderate for cohort studies and moderate and low for RCTs.Conclusion Intake of white rice was associated with higher risk of T2D, while intake of brown rice was associated with lower risk. Findings from substitution trials on cardiometabolic risk factors were inconsistent.PROSPERO registration number CRD42020158466.

Summary: Background: Delayed diagnosis and treatment of sight threatening diabetic retinopathy (STDR) is a common cause of visual impairment in people with Type 2 diabetes. Therefore, systematic regular retinal screening is recommended, but global coverage of such services is challenging. We aimed to develop and validate predictive models for STDR to identify ‘at-risk’ population for retinal screening. Methods: Models were developed using datasets obtained from general practices in inner London, United Kingdom (UK) on adults with type 2 Diabetes during the period 2007–2017. Three models were developed using Cox regression and model performance was assessed using C statistic, calibration slope and observed to expected ratio measures. Models were externally validated in cohorts from Wales, UK and India. Findings: A total of 40,334 people were included in the model development phase of which 1427 (3·54%) people developed STDR. Age, gender, diabetes duration, antidiabetic medication history, glycated haemoglobin (HbA1c), and history of retinopathy were included as predictors in the Model 1, Model 2 excluded retinopathy status, and Model 3 further excluded HbA1c. All three models attained strong discrimination performance in the model development dataset with C statistics ranging from 0·778 to 0·832, and in the external validation datasets (C statistic 0·685 – 0·823) with calibration slopes closer to 1 following re-calibration of the baseline survival. Interpretation: We have developed new risk prediction equations to identify those at risk of STDR in people with type 2 diabetes in any resource-setting so that they can be screened and treated early. Future testing, and piloting is required before implementation. Funding: This study was funded by the GCRF UKRI (MR/P207881/1) and supported by the NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology.

This article details a correction to: Shivashankar R, Singh K, Kondal D, Gupta R, Perel P, Kapoor D, et al.. Cardiovascular Health in India – a Report Card from Three Urban and Rural Surveys of 22,144 Adults. Global Heart. 2022; 17(1): 52. DOI: http://doi.org/10.5334/gh.1137

BackgroundThe 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 methodsThe 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.ResultsWe 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.ConclusionDuring 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.

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)

This paper discusses the importance of investigating DR using machine learning and a computational method to rank DR risk factors by importance using different machine learning models. The dataset was collected from four large population-based studies conducted in India between 2001 and 2010 on the prevalence of DR and its risk factors. We deployed different machine learning models on the dataset to rank the importance of the variables (risk factors). The study uses a t-test and Shapely additive explanations (SHAP) to rank the risk factors. Then, it uses five machine learning models (K-Nearest Neighbor, Decision Tree, Support Vector Machines, Logistic Regression, and Naive Bayes) to identify the unimportant risk factors based on the area under the curve criterion to predict DR. To determine the overall significance of risk variables, a weighted average of each classifier’s importance is used. The ranking of risk variables is provided to machine learning models. To construct a model for DR prediction, the combination of risk factors with the highest AUC is chosen. The results show that the risk factors glycosylated hemoglobin and systolic blood pressure were present in the top three risk factors for DR in all five machine learning models when the t-test was used for ranking. Furthermore, the risk factors, namely, systolic blood pressure and history of hypertension, were present in the top five risk factors for DR in all the machine learning models when SHAP was used for ranking. Finally, when an ensemble of the five machine learning models was employed, independently with both the t-test and SHAP, systolic blood pressure and diabetes mellitus duration were present in the top four risk factors for diabetic retinopathy. Decision Tree and K-Nearest Neighbor resulted in the highest AUCs of 0.79 (t-test) and 0.77 (SHAP). Moreover, K-Nearest Neighbor predicted DR with 82.6% (t-test) and 78.3% (SHAP) accuracy.

This study aimed to compare the clinical and biochemical profiles as well as the complications in males and females with type 2 diabetes (T2DM) presenting to a private tertiary diabetes care centre in India. This is a retrospective study, conducted between 1 January 2017 and 31 December 2019, and included 72,980 individuals with T2DM, aged ≥ 18 years (age and sex-matched—males—36,490; females—36,490). Anthropometric measurements, blood pressure, fasting plasma glucose (FPG), post-prandial plasma glucose (PPPG), glycated haemoglobin (HbA1c), lipids, urea, and creatinine were measured. Retinopathy was screened using retinal photography, neuropathy using biothesiometry, nephropathy measuring urinary albumin excretion, peripheral vascular disease (PVD) using Doppler, and coronary artery disease (CAD) based on the history of myocardial infarction and/or drug treatment for CAD and/or electrocardiographic changes. Obesity (73.6% vs. 59.0%) rates were significantly higher in females compared to males. FPG, PPPG, and HbA1c were higher among younger age groups among both sexes, with males having higher values compared to females. However, after the age of 44 years, control of diabetes was worse among females. In addition, only 18.8% of the females achieved glycemic control (HbA1c < 7%) compared to 19.9% in males (p < 0.001). Males had higher prevalence of neuropathy (42.9% vs. 36.9%), retinopathy (36.0% vs. 26.3%), and nephropathy (25.0% vs. 23.3%) compared to females. Males had 1.8- and 1.6-times higher risk of developing CAD and retinopathy compared to females. Hypothyroidism (12.5% vs. 3.5%) and cancers (1.3% vs. 0.6%) were significantly higher in females compared to males. In this large sample of T2DM seen at a chain of private tertiary diabetes centres, females had higher prevalence of metabolic risk factors and poorer diabetes control compared to males, emphasizing the need for better control of diabetes in females. However, males had higher prevalence of neuropathy, retinopathy, nephropathy, and CAD compared to females.

Abstract Background People with chronic conditions are disproportionately prone to be affected by the COVID-19 pandemic but there are limited data documenting this. We aimed to assess the health, psychosocial and economic impacts of the COVID-19 pandemic on people with chronic conditions in India. Methods Between July 29, to September 12, 2020, we telephonically surveyed adults (n = 2335) with chronic conditions across four sites in India. Data on participants’ demographic, socio-economic status, comorbidities, access to health care, treatment satisfaction, self-care behaviors, employment, and income were collected using pre-tested questionnaires. We performed multivariable logistic regression analysis to examine the factors associated with difficulty in accessing medicines and worsening of diabetes or hypertension symptoms. Further, a diverse sample of 40 participants completed qualitative interviews that focused on eliciting patient’s experiences during the COVID-19 lockdowns and data analyzed using thematic analysis. Results One thousand seven hundred thirty-four individuals completed the survey (response rate = 74%). The mean (SD) age of respondents was 57.8 years (11.3) and 50% were men. During the COVID-19 lockdowns in India, 83% of participants reported difficulty in accessing healthcare, 17% faced difficulties in accessing medicines, 59% reported loss of income, 38% lost jobs, and 28% reduced fruit and vegetable consumption. In the final-adjusted regression model, rural residence (OR, 95%CI: 4.01,2.90–5.53), having diabetes (2.42, 1.81–3.25) and hypertension (1.70,1.27–2.27), and loss of income (2.30,1.62–3.26) were significantly associated with difficulty in accessing medicines. Further, difficulties in accessing medicines (3.67,2.52–5.35), and job loss (1.90,1.25–2.89) were associated with worsening of diabetes or hypertension symptoms. Qualitative data suggest most participants experienced psychosocial distress due to loss of job or income and had difficulties in accessing in-patient services. Conclusion People with chronic conditions, particularly among poor, rural, and marginalized populations, have experienced difficulties in accessing healthcare and been severely affected both socially and financially by the COVID-19 pandemic.

Abstract Background Recent studies have indicated an association of gut microbiota and microbial metabolites with type 2 diabetes mellitus (T2D). However, large-scale investigation of the gut microbiota of “prediabetic” (PD) subjects has not been reported. Identifying robust gut microbiome signatures of prediabetes and characterizing early prediabetic stages is important for the understanding of disease development and could be crucial in early diagnosis and prevention. Methods The current study performed amplification and sequencing on the variable regions (V1–V5) of the 16S rRNA genes to profile and compare gut microbiota of prediabetic individuals (N = 262) with normoglycemic individuals (N = 275) from two cohorts in India and Denmark. Similarly, fasting serum inflammatory biomarkers were profiled from the study participants. Results After correcting for strong country-specific cohort effect, 16 operational taxonomic units (OTUs) including members from the genera Prevotella9, Phascolarctobacterium, Barnesiella, Flavonifractor, Tyzzerella_4, Bacteroides, Faecalibacterium, and Agathobacter were identified as enriched in normoglycaemic subjects with respect to the subjects with prediabetes using a negative binomial Wald test. We also identified 144 OTUs enriched in the prediabetic subjects, which included members from the genera Megasphaera, Streptococcus, Prevotella9, Alistipes, Mitsuokella, Escherichia/Shigella, Prevotella2, Vibrio, Lactobacillus, Alloprevotella, Rhodococcus, and Klebsiella. Comparative analyses of relative abundance of bacterial taxa revealed that the Streptococcus, Escherichia/Shigella, Prevotella2, Vibrio, and Alloprevotella OTUs exhibited more than fourfold enrichment in the gut microbiota of prediabetic subjects. When considering subjects from the two geographies separately, we were able to identify additional gut microbiome signatures of prediabetes. The study reports a probable association of Megasphaera OTU(s) with impaired glucose tolerance, which is significantly pronounced in Indian subjects. While the overall results confirm a state of proinflammation as early as in prediabetes, the Indian cohort exhibited a characteristic pattern of abundance of inflammatory markers indicating low-grade intestinal inflammation at an overall population level, irrespective of glycemic status. Conclusions The results present trans-ethnic gut microbiome and inflammation signatures associated with prediabetes, in Indian and Danish populations. The identified associations may be explored further as potential early indicators for individuals at risk of dysglycemia.

Abstract Background Type 2 diabetes (T2D), a multifactorial disease influenced by host genetics and environmental factors, is the most common endocrine disease. Several studies have shown that the gut microbiota as a close-up environmental mediator influences host physiology including metabolism. The aim of the present study is to examine the compositional and functional potential of the gut microbiota across individuals from Denmark and South India with a focus on T2D. Many earlier studies have investigated the microbiome aspects of T2D, and it has also been anticipated that such microbial associations would be dependent on diet and ethnic origin. However, there has been no large scale trans-ethnic microbiome study earlier in this direction aimed at evaluating any “universal” microbiome signature of T2D. Methods 16S ribosomal RNA gene amplicon sequencing was performed on stool samples from 279 Danish and 294 Indian study participants. Any differences between the gut microbiota of both populations were explored using diversity measures and negative binomial Wald tests. Study samples were stratified to discover global and country-specific microbial signatures for T2D and treatment with the anti-hyperglycemic drug, metformin. To identify taxonomical and functional signatures of the gut microbiota for T2D and metformin treatment, we used alpha and beta diversity measures and differential abundances analysis, comparing metformin-naive T2D patients, metformin-treated T2D patients, and normoglycemic individuals. Results Overall, the gut microbial communities of Danes and Indians are compositionally very different. By analyzing the combined study materials, we identify microbial taxonomic and functional signatures for T2D and metformin treatment. T2D patients have an increased relative abundance of two operational taxonomic units (OTUs) from the Lachnospiraceae family, and a decreased abundance of Subdoligranulum and Butyricicoccus. Studying each population per se, we identified T2D-related microbial changes at the taxonomic level within the Danish population only. Alpha diversity indices show that there is no significant difference between normoglycemic individuals and metformin-naive T2D patients, whereas microbial richness is significantly decreased in metformin-treated T2D patients compared to metformin-naive T2D patients and normoglycemic individuals. Enrichment of two OTUs from Bacteroides and depletion of Faecalibacterium constitute a trans-ethnic signature of metformin treatment. Conclusions We demonstrate major compositional differences of the gut microbiota between Danish and South Indian individuals, some of which may relate to differences in ethnicity, lifestyle, and demography. By comparing metformin-naive T2D patients and normoglycemic individuals, we identify T2D-related microbiota changes in the Danish and Indian study samples. In the present trans-ethnic study, we confirm that metformin changes the taxonomic profile and functional potential of the gut microbiota.

Background: The aim of this study was to evaluate the changes in body composition, central obesity (visceral and liver fat), and pro-inflammatory markers after bariatric surgery in obese Asian Indians with prediabetes and diabetes. Materials and Methods: This is 1-year follow-up study of 30 obese patients (BMI of 30–40 kg/m2) with prediabetes and diabetes who underwent bariatric surgery at tertiary diabetes center in South India. HbA1c, adiponectin, liver enzymes, ferritin, and high-sensitivity C-reactive protein (hs-CRP) were tested before surgery and at 6 and 12 months postoperatively. Body composition analysis and ultrasound hepatic fat grading were done before and at 6 and 12 months’ post-surgery. Results: The baseline HbA1c were 8.3 ± 1.8% which reduced to 6.1 ± 0.8% at 12 months. The percent body fat, visceral fat area, and slim lean mass reduced significantly at 12 months compared with baseline (P < 0.001). Hepatic steatosis and liver enzymes also significantly reduced at 12 months compared with baseline. hs-CRP and ferritin significantly reduced (P < 0.05) at 12 months post-op [2.9 ± 2.8 mg/L, 39 ± 29 ng/mL] compared with baseline [7.5 ± 3.5 mg/L, 61 ± 44 ng/mL], respectively. Serum adiponectin levels significantly increased from 26.4 ± 1.4 to 67 ± 3.5 ng/mL after the surgery. Conclusion: Bariatric surgery is effective in reducing total body fat and visceral fat area, hepatic steatosis with an improvement in liver enzyme levels after bariatric surgery. hs-CRP, ferritin, and adiponectin also significantly improved following surgery.