Evaluation of Madras Diabetes Research Foundation-Indian Diabetes Risk Score in detecting undiagnosed diabetes in the Indian population: Results from the Indian Council of Medical Research-INdia DIABetes population-based study (INDIAB-15)

Background & objectives: Screening of individuals for early detection and identification of undiagnosed diabetes can help in reducing the burden of diabetic complications. This study aimed to evaluate the performance of Madras Diabetes Research Foundation (MDRF)-Indian Diabetes Risk Score (IDRS) to screen for undiagnosed type 2 diabetes in a large representative population in India. Methods: Data were acquired from the Indian Council of Medical Research–INdia DIABetes (ICMR–INDIAB) study, a large national survey that included both urban and rural populations from 30 states/union territories in India. Stratified multistage design was followed to obtain a sample of 113,043 individuals (94.2% response rate). MDRF-IDRS used four simple parameters, viz. age, waist circumference, family history of diabetes and physical activity to detect undiagnosed diabetes. Receiver operating characteristic (ROC) with area under the curve (AUC) was used to assess the performance of MDRF-IDRS. Results: We identified that 32.4, 52.7 and 14.9 per cent of the general population were under high-, moderate- and low-risk category of diabetes. Among the newly diagnosed individuals with diabetes [diagnosed by oral glucose tolerance test (OGTT)], 60.2, 35.9 and 3.9 per cent were identified under

Effects of Intermittent Fasting on Weight Loss in Asian Indian Adults with Obesity

Background: Worldwide, obesity has nearly tripled since 1975 and has become a major healthcare challenge today. Intermittent fasting (IF) is gaining popularity as a weight loss strategy in recent times. This study aimed to study the role of IF as a modern-day weight-loss strategy in obese adults through a real-world pilot experiment conducted at a nutrition clinic in Mumbai. Methodology: To understand the effects of IF on weight loss, 32 overweight/obese [body mass index (BMI) ?23 kg/m2] adults from a nutrition clinic in Mumbai, were assigned consecutively to an IF plan and followed up for 3 months. Their demographic, anthropometric, and dietary assessments were done pre- and post-intervention. Qualitative interviews were done at the end of the study to record the participants’ overall well-being, experience, and sustainability of IF. Results: 56% of study participants were males and their mean age was 35.6 ± 8.9 years. 65.6% of participants were able to maintain 14–16 hours of fasting and 53% managed all 7 days of IF. Analysis of post-intervention data showed a significant reduction in mean body weight (88.5 ± 19 to 83.8 ± 17.6 kg), waist circumference (M: 108.2 ± 11.3 to 103.6 ± 4.4 cm, F: 98.9 ± 8.8 to 93.3 ± 3.3 cm), BMI (31.4 ± 5.3 to 29.6 ± 5.1 kg/m2), daily calories (1782 ± 237 to 1388 ± 243 kcal/day), carbohydrate intake (267 ± 18.4 to 164 ± 4.0 g/day), and an increase in protein intake (39 ± 11 to 55 ± 11 g/day). Participants reported positive experiences of practicing IF such as improved fitness, sleep cycle, and adoption of healthy eating habits. Conclusion: The study demonstrates that IF could aid in weight loss and adoption of a healthier lifestyle.

Remission of Type 2 Diabetes: How, When, and for Whom?

Type 2 diabetes (T2DM) is conventionally considered a progressive disorder, with most patients requiring increasingly intensive therapy to control hyperglycemia over time. Recently, there has been a major paradigm shift towards trying to reverse T2DM. Emerging evidence suggests that remission of T2DM is feasible in a subset of patients. Identification and careful selection of candidates for remission are crucial for the success of these programs. Among various dietary strategies, low-calorie diets (LCDs) and low-carbohydrate diets (LCBDs) have been demonstrated as being effective in facilitating remission of T2DM in a targeted population within a clinical setting. Remission with LCBDs may be maintained in the absence of weight loss, however, long-term evidence is limited and remission may not be maintained without long-term carbohydrate restriction, which poses major challenges. In very low-calorie diets (VLCDs), weight loss of 15 kg or greater and maintenance of weight loss is the main driver and predictor of remission. However, most individuals with T2DM were unable to maintain remission beyond 2 years, despite being on VLCDs. More data are required on the long-term sustainability of remission in an ethnically diverse population like Asian Indians with T2DM who have less obesity and hence less weight to lose. Moreover, “re-reversal” or “relapse” of diabetes can occur in a large percentage of individuals who discontinue the dietary restrictions. Hence, regular follow-up by a multi-disciplinary team to ensure sustainability of the lifestyle modification is crucial to the maintenance of remission of T2DM.

Carbohydrate profiling & glycaemic indices of selected traditional Indian foods

Background & objectives: Consumption of high glycaemic index (GI) food is associated with a high risk for diabetes. There is a felt need to understand the GI of common Indian traditional foods using standard GI protocols. The present study was aimed to analyse the carbohydrate profile of common traditional Indian food preparation and to determine their GI using standardized protocols. Methods: Twelve food preparations made of millets, wheat, maize and pulses were evaluated for nutrient composition including detailed carbohydrate profiling and tested for GI in healthy volunteers using standard methodology. Capillary blood glucose responses for the test foods containing 50 g available carbohydrates were recorded and compared to the reference food (50 g glucose). GI was calculated from the incremental area under the curve (IUAC) for the test and reference foods. Results: Available carbohydrate content of the food preparations ranged between 13.6 and 49.4 g per cent. Maize roti showed the highest total dietary fibre (7.5 g%). White chick pea ‘sundal’ showed highest resistant starch content (3.95 g%). Amongst the 12 test foods, five fell in the high GI category (finger millet balls, sorghum, pearl millet and maize roti), four in the medium GI category (sorghum idli, wheat dosa, methi roti and adai) and three in the low GI category (broken wheat upma, white peas sundal and white chick peas sundal). Interpretation & conclusions: Merely being a whole grain-based food does not qualify for a lower GI. The method of processing, food structural integrity and preparation could influence the GI. The type and quality of fibre are important than the quantity of fibre alone. Judicious planning of accompaniments using low GI legumes may favourably modify the glycaemic response to high GI foods in a meal.

Effects of Metabolic Surgery on Diabetic Kidney Disease and Diabetic Retinopathy Among Obese Asian Indians with Type 2 Diabetes

Introduction: To evaluate the effect of metabolic surgery on microvascular changes associated with diabetic retinopathy (DR) and diabetic kidney disease (DKD) in obese Asian Indians with type 2 diabetes (T2DM), one year after metabolic surgery. Methods: This is a follow up study in 21 obese Asian Indians with T2DM who underwent metabolic surgery (MS). Diabetic microvascular complications were assessed before and one-year post surgery using urinary albumin, protein creatinine ratio, eGFR, retinal colour photography and Optical coherence tomography (OCT). Results: Microalbuminuria (54±26 vs 28±16 vs 21±6 ?g/mg, p<0.001) and protein creatinine ratio (0.4±0.1 vs 0.2±0.03 vs 0.1±0.02, p<0.05) reduced significantly 6 months and one year after Metabolic surgery (MS) respectively compared to baseline values. Estimated Glomerular Filtration (eGFR) rate and creatinine was stable and there was no decline in renal function one year after MS. DR was present in eight individuals at baseline. After metabolic surgery, 12 % of individuals achieved regression of DR and 12% individuals showed a one step regression from severe to moderate non proliferative DR while 12 % individuals progressed from moderate to severe non proliferative DR. Of the 14 (53.8%) individuals who had micro or macroalbuminuria at baseline, 43% individuals reverted back to normoalbuminuria. There was also a reduction in the usage of anti- hypertensive medications after MS. Conclusion: In obese Asian Indians with T2DM, metabolic surgery reduced urinary microalbuminuria and protein creatinine ratios at one-year post MS. MS resulted in stable D. Retionpathy status one-year post surgery. MS may help to improve in stabilisation of the microvascular complications in obese patients with T2DM.

Comparison of dietary profile of a rural south Indian population with the current dietary recommendations for prevention of non-communicable diseases (CURES 147).

Background & objectives: Despite the rising prevalence of non-communicable diseases (NCDs) in rural India, data on the dietary profile of the rural Indian population in relation to the recommendations for prevention of NCDs are scarce. This study was conducted to assess the dietary intake of a rural south Indian population in relation to the current dietary recommendations for the prevention of NCDs. Methods: The dietary profiles of 6907 adults aged ≥ 20 yr, from a cluster of 42 villages in Kancheepuram district of Tamil Nadu State in southern India, were assessed using a validated food frequency questionnaire. Results: The prevalence of general obesity was 27.4 per cent and that of abdominal obesity, 14.0 per cent among this rural population. The median daily energy intake of the population was 2034 (IQR 543) kcals. More than 3/4th of the calories (78.1%) were provided by carbohydrates. Refined cereals, mainly polished rice, was the major contributor to total calories. About 45 per cent of the population did not meet WHO recommendation for protein due to low intake of pulses, flesh foods and dairy products and more than half (57.1%) exceeded the limit of salt intake; 99 per cent of the population did not meet WHO recommendations for fruits and vegetables and 100 per cent did not meet the requirement of n-3 poly unsaturated fatty acids. Interpretation & conclusions: The dietary profile of this rural south Indian population reflected unhealthy choices, with the high consumption of refined cereals in the form of polished white rice and low intake of protective foods like fruits, vegetables, n-3 poly and monounsaturated fatty acids. This could potentially contribute to the increase in prevalence of NCDs like diabetes, hypertension and cardiovascular diseases in rural areas and calls for appropriate remedial action.

Slowing the diabetes epidemic in the World Health Organization South-East Asia Region: the role of diet and physical activity.

The nutrition transition occurring in the World Health Organization South-East Asia Region, as a result of rapid urbanization and economic development, has perhaps made this region one of the epicentres of the diabetes epidemic. This review attempts to evaluate the role of diet and physical inactivity in the South-East Asia Region in promoting this epidemic and points to strategies to slow it down by lifestyle modification. The emerging new food-production technologies and supermarkets have made energy-dense foods more easily available. This includes refined carbohydrate foods like those with added sugars, and refined grains and unhealthy fats. In addition, increased availability of modern technology and motorized transport has led to decreased physical activity. South Asian diets tend to be based on high-carbohydrate foods, with a predominance of refined grains. All of these accentuate the risk of diabetes in people of this region, who already have a unique “south Asian phenotype”. However, there is increasing evidence that altering diet by replacing refined cereals like white rice with whole grains (e.g. brown rice) and increasing physical activity can help to prevent diabetes in highrisk individuals. An urgent, concerted effort is now needed to improve diet quality and encourage physical activity, by introducing changes in policies related to food and built environments, and improving health systems to tackle noncommunicable diseases like diabetes.

Epidemiology of childhood overweight & obesity in India: A systematic review.

Background & objectives: Childhood obesity is a known precursor to obesity and other non-communicable diseases (NCDs) in adulthood. However, the magnitude of the problem among children and adolescents in India is unclear due to paucity of well-conducted nationwide studies and lack of uniformity in the cut-points used to define childhood overweight and obesity. Hence an attempt was made to review the data on trends in childhood overweight and obesity reported from India during 1981 to 2013. Methods: Literature search was done in various scientific public domains from the last three decades using key words such as childhood and adolescent obesity, overweight, prevalence, trends, etc. Additional studies were also identified through cross-references and websites of official agencies. Results: Prevalence data from 52 studies conducted in 16 of the 28 States in India were included in analysis. The median value for the combined prevalence of childhood and adolescent obesity showed that it was higher in north, compared to south India. The pooled data after 2010 estimated a combined prevalence of 19.3 per cent of childhood overweight and obesity which was a significant increase from the earlier prevalence of 16.3 per cent reported in 2001-2005. Interpretation & conclusions: Our review shows that overweight and obesity rates in children and adolescents are increasing not just among the higher socio-economic groups but also in the lower income groups where underweight still remains a major concern.

Prevalence of generalized & abdominal obesity in urban & rural India- the ICMR-INDIAB study (Phase-I) [ICMR-INDIAB-3].

Background & objectives: Overweight and obesity are rapidly increasing in countries like India. This study was aimed at determining the prevalence of generalized, abdominal and combined obesity in urban and rural India. Methods: Phase I of the ICMR-INDIAB study was conducted in a representative population of three states [Tamil Nadu (TN), Maharashtra (MH) and Jharkhand (JH)] and one Union Territory (UT)[Chandigarh (CH)] of India. A stratified multi-stage sampling design was adopted and individuals ≥20 yr of age were included. WHO Asia Pacific guidelines were used to define overweight [body mass index (BMI) ≥23 kg/m2 but <25 kg/m2], generalized obesity (GO, BMI≥25kg/m2), abdominal obesity (AO, waist circumference ≥90 cm for men and ≥80cm for women) and combined obesity (CO, GO plus AO). Of the 14,277 participants, 13,800 subjects (response rate, 96.7%) were included for the analysis (urban: n=4,063; rural: n=9737). Results: The prevalence of GO was 24.6, 16.6, 11.8 and 31.3 per cent among residents of TN, MH, JH and CH, while the prevalence of AO was 26.6, 18.7, 16.9 and 36.1 per cent, respectively. CO was present in 19.3, 13.0, 9.8 and 26.6 per cent of the TN, MH, JH and CH population. The prevalence of GO, AO and CO were significantly higher among urban residents compared to rural residents in all the four regions studied. The prevalence of overweight was 15.2, 11.3, 7.8 and 15.9 per cent among residents of TN, MH, JH and CH, respectively. Multiple logistic regression analysis showed that female gender, hypertension, diabetes, higher socio-economic status, physical inactivity and urban residence were significantly associated with GO, AO and CO in all the four regions studied. Age was significantly associated with AO and CO, but not with GO. Interpretation & conclusions: Prevalence of AO as well as of GO were high in India. Extrapolated to the whole country, 135, 153 and 107 million individuals will have GO, AO and CO, respectively. However, these figures have been estimated from three States and one UT of India and the results may be viewed in this light.

Prevalence of Overweight and Obesity Among School Children and Adolescents in Chennai.

Objectives: To determine the prevalence of overweight and obesity among children and adolescents in Chennai, India, using national and international age- and sex- specific body mass index (BMI) cut-off points. Methods: The Obesity Reduction and Awareness and Screening of Non communicable diseases through Group Education in Children and Adolescents (ORANGE) project is a cross-sectional study carried out on 18,955 children (age 6-11 years) and adolescents (age 12-17 years) across 51 schools (31 private and 20 government) of Chennai. Overweight and obesity was classified by the International Obesity Task Force (IOTF 2000) and Khadilkar’s criteria (2012), and Hypertension by the IDF criteria (in children ≥10 years and adolescents). Results: The prevalence of overweight/obesity was significantly higher in private compared to government schools both by the IOTF criteria [private schools: 21.4%, government schools: 3.6%, (OR: 7.4, 95% CI:6.3-8.6; P<0.001) and by Khadilkar criteria (private school: 26.4%, government schools: 4.6% OR: 6.9, 95% CI:6.2-7.8; P<0.001). Overweight/obesity was higher among girls (IOTF: 18%, Khadilkar: 21.3%) compared to boys (IOTF: 16.2%, Khadilkar: 20.7%) and higher among adolescents (IOTF: 18.1%, Khadilkar: 21.2%) compared to children (IOTF: 15.5%, Khadilkar: 20.7%). Prevalence of hypertension was 20.4% among obese/ overweight and 5.2% among non-obese (OR 4.7, 95%CI: 4.2-5.3, P<0.001). Conclusion: The prevalence of overweight and obesity is high among private schools in Chennai, and hypertension is also common.