The need for obtaining accurate nationwide estimates of diabetes prevalence in India - Rationale for a national study on diabetes.

According to the World Diabetes Atlas, India is projected to have around 51 million people with diabetes. However, these data are based on small sporadic studies done in some parts of the country. Even a few multi-centre studies that have been done, have several limitations. Also, marked heterogeneity between States limits the generalizability of results. Other studies done at various time periods also lack uniform methodology, do not take into consideration ethnic differences and have inadequate coverage. Thus, till date there has been no national study on the prevalence of diabetes which are truly representative of India as a whole. Moreover, the data on diabetes complications is even more scarce. Therefore, there is an urgent need for a large well-planned national study, which could provide reliable nationwide data, not only on prevalence of diabetes, but also on pre-diabetes, and the complications of diabetes in India. A study of this nature will have enormous public health impact and help policy makers to take action against diabetes in India.

Reliability and validity of a modified phq-9 item inventory (Phq-12) as a screening instrument for assessing depression in Asian Indians (Cures - 65).

Objectives: To evaluate the validity and reliability of the modified Patient Health Questionnaire(PHQ) 12 item instrument as a screening tool for assessing depression compared to the PHQ -9 in a representative south Indian urban population. Methods: The Chennai Urban Rural Epidemiology Study [CURES] is a large cross-sectional study conducted in Chennai, South India. In Phase 1 of CURES(urban component), 26,001 individuals aged ≥ 20 years individuals were selected by a systematic sampling technique of whom one hundred subjects were randomly selected, using computergenerated numbers, for this validation study. Two self-reported questionnaires (modified PHQ-12 item and PHQ-9 item) were administered to the subjects to compare their effectiveness in detecting depression. Reliability and validity were assessed and Receiver Operating Characteristic (ROC) curves were plotted. Pearson’s correlation was used to compare the two questionnaires. Results: The mean age of the study was 38.6±11.6 years and 48% were males. Pearson’s correlation coefficient between the modified PHQ-12 and the PHQ-9 item was 0.913 [p<0.0001]. Factor Analysis revealed that the modified PHQ-12 item scale can be used as a unidimensional scale and had excellent internal consistency(Cronbach’s alpha:0.88). A cut point of >4 calculated using the ROC curves for the modified PHQ-12 item had the highest sensitivity (92.0%) and specificity (90.7%) using PHQ-9 as the gold standard. The positive predictive value was 76.7%, and the negative predictive value, 97.1% and the area under the ROC curve, 0.979 (95% Confidence Interval: 0.929 - 0.997, p<0.0001). Conclusion: The modified PHQ-12 item is a valid and reliable instrument for large scale population based screening of depression in Asian Indians and a cut point score of greater than 4 gave the highest sensitivity and specificity. ©

Increased awareness about diabetes and its complications in a whole city: effectiveness of the "prevention, awareness, counselling and evaluation" [PACE] Diabetes Project [PACE-6].

AIMS AND OBJECTIVES: To determine the effectiveness of a large scale multipronged diabetes awareness program provided through community involvement in Chennai. MATERIAL AND METHODS: Mass awareness and free screening camps were conducted between 2004-2007 at various locations of Chennai as part of the Prevention, Awareness, Counselling and Evaluation [PACE] Diabetes Project. During a 3-year period, 774 diabetes awareness camps were conducted to reach the public directly. After the PACE project was completed, 3000 individuals, representative of Chennai, were surveyed in 2007 using a systematic stratified random sampling technique. The results were compared to a similar survey carried out, as part of the Chennai Urban Rural Epidemiology Study [CURES] in 2001-2002, which served as a measure of baseline diabetes awareness. RESULTS: Awareness of a condition called "diabetes" increased significantly from 75.5% in 2001-2002 (CURES) to 81% (p < 0.001) in 2007 (PACE). 74.1% of the citizens of Chennai are now aware that the prevalence of diabetes is increasing as compared to 60.2% earlier [p < 0.001]. Significantly more people felt that diabetes could be prevented (p < 0.001), and that a combination of diet and exercise were needed to do so (p < 0.001). Respondents reporting obesity, family history of diabetes, hypertension and mental stress as risk factors increased significantly after PACE (p < 0.001). More people were able to correctly identify the eyes (PACE 38.1% compared to CURES--16.1%, p < 0.001), kidney (PACE 42.3% compared to CURES 16.10%, p < 0.001), heart (PACE 4.6% compared to CURES 5.8%, p < 0.001) and feet (PACE 35.0% vs. CURES 21.9%, p < 0.001) as the main organs affected by diabetes. CONCLUSION: Through direct public education and mass media campaigns, awareness about diabetes and its complications can be improved even in a whole city. If similar efforts are implemented state-wise and nationally, prevention and control of non-communicable diseases, specifically diabetes and cardiovascular disease, is an achievable goal in India.

Prevention awareness counselling and evaluation (PACE) diabetes project: a mega multi-pronged program for diabetes awareness and prevention in South India (PACE- 5).

OBJECTIVE: The Prevention Awareness Counselling Evaluation (PACE) Diabetes Project is a large scale community based project carried out to increase awareness of diabetes and its complications in Chennai city (population: 4.7 million) through 1) public education 2) media campaigns 3) general practitioner training 4) blood sugar screening and 5) community based "real life" prevention program METHODS: Education took place in multiple forms and venues over the three-year period of the PACE project between 2004-2007. With the help of the community, awareness programs were conducted at residential sites, worksites, places of worship, public places and educational institutions through lectures, skits and street plays. Messages were also conveyed through popular local television and radio channels and print media. The General Practitioners (GPs) program included training in diabetes prevention, treatment and the advantages of early detection of complications. Free random capillary blood glucose testing was done for individuals who attended the awareness programs using glucose meter. RESULTS: Over a three-year period, we conducted 774 education sessions, 675 of which were coupled with opportunistic blood glucose screening. A total of 76,645 individuals underwent blood glucose screening. We also set up 176 "PACE Diabetes Education Counters" across Chennai, which were regularly replenished with educational materials. In addition, we trained 232 general practitioners in diabetology prevention, treatment and screening for complications. Multiple television and radio shows were given and messages about diabetes sent as Short Message Service (SMS) through mobile phones. Overall, we estimate that we reached diabetes prevention messages to nearly two million people in Chennai through the PACE Diabetes Project, making it one of the largest diabetes awareness and prevention programs ever conducted in India. CONCLUSION: Mass awareness and screening programs are feasible and, through community empowerment, can help in prevention and control of non-commuincable diseases such as diabetes and its complications on a large scale.

Diabetic retinopathy: an Indian perspective.

Diabetic retinopathy (DR) can be defined as damage to microvascular system in the retina due to prolonged hyperglycaemia. The prevalence of DR in the Chennai Urban Rural Epidemiology (CURES) Eye Study in south India was 17.6 per cent, significantly lower than age-matched western counterparts. However, due to the large number of diabetic subjects, DR is likely to pose a public health burden in India. CURES Eye study showed that the major systemic risk factors for onset and progression of DR are duration of diabetes, degree of glycaemic control and hyperlipidaemia. Hypertension did not play a major role in this cross-sectional analysis. The role of oxidative stress, atherosclerotic end points and genetic factors in susceptibility to DR has been studied. It was found that DR was associated with increased intima-media thickness and arterial stiffness in type 2 Indian diabetic subjects suggesting that common pathogenic mechanisms might predispose to diabetic microangiopathy. Curcumin, an active ingredient of turmeric, has been shown to inhibit proliferation of retinal endothelial cells in vivo. Visual disability from DR is largely preventable if managed with timely intervention by laser. It has been clearly demonstrated that in type 2 south Indian diabetic patients with proliferative DR who underwent Pan retinal photocoagulation, 73 per cent eyes with good visual acuity (6/9) at baseline maintained the same vision at 1 yr follow up. There is evidence that DR begins to develop years before the clinical diagnosis of type 2 diabetes. Our earlier study demonstrated that DR is present in 7 per cent of newly diagnosed subjects, hence routine retinal screening for DR even at the time of diagnosis of type 2 diabetes may help in optimized laser therapy. Annual retinal examination and early detection of DR can considerably reduce the risk of visual loss in diabetic individuals.

The Chennai Urban Rural Epidemiology Study (CURES)--study design and methodology (urban component) (CURES-I).

The report of World Health Organization (WHO) shows that India tops the world with the largest number of diabetic subjects. This increase is attributed to the rapid epidemiological transition accompanied by urbanization, which is occurring in India. There is very little data regarding the influence of affluence on the prevalence of diabetes and its complications particularly retinopathy in the Indian population. Furthermore, there are very few studies comparing the urban/rural prevalence of diabetes and its complications. The Chennai Urban Rural Epidemiology Study (CURES) is designed to answer the above questions. CURES is initially planned as a cross-sectional study to evolve later into a longitudinal study. Subjects for the urban component of the CURES have been recruited from within the corporation limits of Chennai City. Chennai (formerly Madras), the largest city in Southern India and the fourth largest in India has been divided into 10 zones and 155 wards. 46 wards were selected by a systematic random sampling method to represent the whole of Chennai. Twenty thousand and one individuals were recruited for the study, this number being derived based on a sample size calculation. The study has three phases. Phase one is a door to door survey which includes a questionnaire, anthropometric, fasting capillary blood glucose and blood pressure measurements. Phase two focussed on the prevalence of diabetic complications particularly retinopathy using standardized techniques like retinal photography etc. Diabetic subjects identified in phase one and age and sex matched non-diabetic subjects will participate in these studies. Phase three will include more detailed studies like clinical, biochemical and vascular studies on a sub-sample of the study subjects selected on a stratified basis from phase one. CURES is perhaps one of the largest systematic population based studies to be done in India in the field of diabetes and its complications like retinopathy, nephropathy and neuropathy.

Is the 'rule of halves' in hypertension still valid?--Evidence from the Chennai Urban Population Study.

AIM OF THE STUDY: The aim of the present study was to assess the applicability of the rule of halves in an urban population in South India. METHODS: The Chennai Urban Population Study (CUPS) is an ongoing population based study involving two residential colonies representing a middle and lower socio-economic status in Chennai city. The response rate for the study was 90.1%. Based on a glucose tolerance test (GTT), the study subjects were categorized as having normal glucose tolerance test (NGT), impaired glucose tolerance test (IGT) or diabetes. Blood pressure was measured for all the study subjects and the subjects were classified as hypertensive using the criteria, systolic blood pressure (SBP) > or = 140 mm Hg and/or diastolic blood pressure > or = 90 mmHg and/or known hypertensives and/or treatment with antihypertensive drugs. Controlled hypertension was defined as SBP < 140 mmHg and DBP < 90 mmHg. RESULTS: The overall prevalence of hypertension in this population is 22.1% (279/1262). Of these 279 individuals with hypertension, only 37.3% (104/279) were known hypertensives. Of the 104 known hypertensives, only 52 subjects (50%) were under any kind of antihypertensive therapy. Of these 52 individuals, only 21 (40%) had blood pressure under control. Prevalence of hypertension was higher in subjects with glucose intolerance. Awareness and treatment of hypertension was slightly higher among the diabetic hypertensive subjects. Analysis on the different social classes revealed that the prevalence, awareness and treatment of hypertension to be significantly higher among the middle income group compared to lower income group. CONCLUSION: The rule of halves is still valid in this urban South Indian population and thus the awareness, treatment and control measures for hypertension are still inadequate in this population.

Prevalence and risk factors of hypertension in a selected South Indian population--the Chennai Urban Population Study.

OBJECTIVE: Hypertension is a major public health problem in developing countries. There is however very little population based data particularly in South India. The aim of this study is to determine the prevalence of hypertension and its associated risk factors in an urban South Indian population at Chennai. METHODS: The Chennai Urban Population Study (CUPS) is an epidemiological study involving two residential areas in Chennai in South India. Of the total of 1399 eligible subjects (age > or = 20 years), 1262 (90.2%) participated in the study. All the study subjects underwent a glucose tolerance test (GTT) and were categorized as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT) or diabetes mellitus (DM). Subjects were classified as hypertensive using the criteria, systolic blood pressure (SBP) > or = 140 mm Hg, and/or diastolic blood pressure (DBP) > or = 90 mm Hg and/or treatment with anti-hypertensive drugs. Twelve-lead resting electrocardiography (ECG) was performed in 1175 individuals and peripheral Doppler studies were done in 50% of the individuals (n=631). RESULTS: The overall crude prevalence of hypertension (HTN) in this population is 21.1% (n=266) while the age standardized prevalence is 17.0%. Body mass index (BMI) and waist-hip ratio (WHR) were significantly higher (p < 0.001) in the HTN group compared to the non-hypertensive individuals. The prevalence of diabetes (p < 0.001), obesity (p < 0.001), CAD (p = 0.001) and PVD (p = 0.0055) was higher among the hypertensive compared to normotensive group. Multiple logistic regression analysis revealed HTN to be significantly associated with age (p < 0.001), body mass index (p < 0.001) and glucose intolerance (p = 0.005). CONCLUSION: The prevalence of hypertension appears to be high in this urban South Indian population and this calls for urgent steps for its prevention and control.

Diabetes & coronary artery disease.

Over 20 million people are affected by diabetes in India. These numbers are expected to increase to 57 million by 2025. Diabetic patients are at increased risk of atherosclerosis and its clinical sequelae, particularly coronary artery disease (CAD). CAD remains the most important cause of mortality among diabetic patients. The pathophysiological process of atherosclerosis in diabetic subjects is accelerated by several factors such as hyperglycaemia, insulin resistance, abnormal lipid profile, oxidative modification of lipoproteins, increased blood pressure, altered rate of fibrinolysis, etc. These changes in diabetics render the dormant atherosclerotic plaque vulnerable precipitating an early clinical event. Thus CAD in diabetic subjects carries a worse prognosis than in non-diabetic subjects. This review focuses on the potential role of various risk factors contributing to atherosclerosis in diabetic patients.

The changing scenario of the diabetes epidemic: implications for India.

Diabetes mellitus is one of the main threats to human health in the 21st century. The prevalence of diabetes ranges from nearly 0 per cent in New Guinea to 50 per cent in the Pima Indians. The past two decades have seen an explosive increase in the number of people diagnosed with diabetes world-wide. The World Health Organization (WHO) estimated that there were 135 million diabetics in 1995 and this number would increase to 300 million by the year 2025. India leads the world today with the largest number of diabetics in any given country. In the 1970s, the prevalence of diabetes among urban Indians was reported to be 2.1 per cent and this has now risen to 12.1 per cent. Moreover, there is an equally large pool of individuals with impaired glucose tolerance (IGT), many of whom will develop type 2 diabetes mellitus in the future. Diabetes can affect nearly every organ system in the body. The Chennai Urban Population Study (CUPS) showed that prevalence of diabetic retinopathy, nephropathy and neuropathy is not very different in urban south Indians compared to that reported among Europeans. However, coronary artery disease (CAD) occurs with increased prevalence and at a younger age (premature CAD), while peripheral vascular disease showed the opposite trend, with lower prevalence compared to that reported in Europeans. There is an urgent need for lifestyle intervention, with the incorporation of a healthy diet, an increase in physical activity and weight reduction as a means of preventing diabetes in those who are in the prediabetic stage and thus prevent the diabetes epidemic, which is looming large in our country.