Validation of body fat measurement by skinfolds and two bioelectric impedance methods with DEXA - the Chennai Urban Rural Epidemiology Study [CURES-3]

Background and Objective: Although Asian Indians have been shown to have increased body fat compared to Europeans, there have been very few studies in Asian Indians validating the various methods available for body fat measurement. The aim of this study was to test the validity of body fat measured by two commercial impedance analyzers (leg-to-leg and hand-held) as well as by skinfolds with Dual Energy Xray Absorptiometry (DEXA) as the reference method in a population based study in southern India. Methods: Body fat percentage (BF%) was measured in 162 South Indian urban men (n=76) and women (n=86) randomly selected from the "Chennai Urban Rural Epidemiology Study" (CURES), an ongoing population based study of a representative population of Chennai. The mean age of the subjects was 45.1 ± 9.0 years and the body mass index ranged from 16.4 - 34.4 kg/m2. Percentage body fat was measured using DEXA, segmental impedance (leg-to-leg: BF%IMP-LEG; and hand-held BF%IMP-HAND) using the manufacturer's software and skinfolds using the prediction equation from the literature (BF%SKFD). Results: Body fat (%) determined by the leg-to-leg method (BF%IMP-LEG 35.10 ± 7.26) and the skinfolds (BF%SKFD 35.77 ± 6.06) did not differ significantly from the reference method DEXA (BF%DEXA 35.82 ± 8.33), but the hand-held impedance method (BF%IMP-HAND 31.38 ±6.24) showed significant difference (p < 0.001). The bias for estimation of body fat (%) for the bioimpedance leg-to-leg, hand-held and skinfolds were 0.73 ± 5.70, 4.45 ± 4.83 and 0.06 ± 5.86 respectively. All the three methods showed a fairly good correlation with DEXA (BF%IMP-LEG : r = 0.741, p<0.001; BF%IMP-HAND : r = 0.817, p< 0.001; BF%SKFD : r = 0.710, p< 0.001). Conclusion: The study shows that in urban south Indians, measurement of body fat by the leg-to-leg impedance and the skinfold method have better agreement (lower bias) with DEXA than the hand-held impedance. However, all three methods (skinfolds, the leg-to-leg bioelectric impedance and hand-held impedance) show a fairly good correlation with DEXA

Adipocytokines and the expanding 'Asian Indian Phenotype'

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The Chennai Urban Rural Epidemiology Study (CURES) - study design and methodology (Urban Component) (CURES - 1)

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

Prevalence, Awareness and Control of Hypertension in Chennai - The Chennai Urban Rural Epidemiology Study (CURES – 52)

Objective : To study the prevalence, awareness and control of hypertension in Chennai representing Urban South India. Methods : The Chennai Urban Rural Epidemiology Study (CURES) is one of the largest epidemiological studies on diabetes carried out in India, where 26,001 individuals aged ≥ 20 years were screened using systematic random sampling method. Every tenth subject recruited in Phase 1 of CURES was requested to participate in Phase 3 of CURES and the response rate was 2,350/26,001 or 90.4%. An oral glucose tolerance test was performed in all individuals except self-reported diabetic subjects. Anthropometric measurements and lipid estimations were done in all subjects. Hypertension was diagnosed in all subjects who were on drug treatment for hypertension or if the blood pressure ≥ 140/90 mmHg. Results : Hypertension was present in 20% [men:23.2% vs. women:17.1%, p<0.001] of the study population. Isolated systolic hypertension (Systolic BP ≥ 140 and Diastolic BP<90 mmHg) was present in 6.6% while isolated diastolic hypertension (DBP ≥ 90 and SBP<140 mmHg) was present in 4.2% of the population. Among the elderly population (aged ≥ 60 years), 25.2% had isolated systolic hypertension. Age, body mass index, smoking, serum cholesterol and triglycerides were found to be strongly associated with hypertension. Among the total hypertensive subjects, only 32.8% were aware of their blood pressure, of these, 70.8% were under treatment and 45.9% had their blood pressure under control. Conclusion : Hypertension was present in one-fifth of this urban south Indian population and isolated systolic hypertension was more common among elderly population. Majority of hypertensive subjects still remain undetected and the control of hypertension is also inadequate. This calls for urgent prevention and control measures for hypertensio

A simplified Indian diabetes risk score for screening for undiagnosed diabetic subjects

Aim: The aim of this study was to develop and validate a simplified Indian Diabetes Risk Score for detecting undiagnosed diabetes in India. Methods: The risk score was derived from the Chennai Urban Rural Epidemiology Study (CURES), an ongoing epidemiological study on a representative population of Chennai. Phase 1 of CURES recruited 26,001 individuals, of whom every tenth subject was requested to participate in Phase 3 for screening for diabetes using World Health Organization (WHO) 2hour venous plasma glucose criteria [i.e. ≥200 mg/dl]. The response rate was 90.4% (2350/2600). The Indian Diabetes Risk Score [IDRS] was developed based on results of multiple logistic regression analysis. Internal validation was performed on the same data. Results: IDRS used four risk factors: age, abdominal obesity, family history of diabetes and physical activity. Beta co-efficients were derived based on a multiple logistic regression analysis using undiagnosed diabetes as the dependent variable. The beta co-efficients were modified so as to obtain a maximum possible score of 100. Receiver Operating Characteristic [ROC] curves were constructed to identify the optimum value of IDRS for detecting diabetes by WHO consulting group criteria. Area under the curve for ROC was 0.698 (95% confidence interval (CI):0.663 .0.733). An IDRS value . 60 had the optimum sensitivity (72.5%) and specificity (60.1%) for determining undiagnosed diabetes with a positive predictive value of 17.0%, negative predictive value of 95.1%, and accuracy of 61.3%. Conclusion: This simplified Indian Diabetes Risk Score is useful for identifying undiagnosed diabetic subjects in India and could make screening programmes more cost effective

Prevalence of Fibrocalculous Pancreatic Diabetes in Chennai in South India

Fibrocalculous pancreatic diabetes is a form of diabetes secondary to chronic pancreatitis found in tropical, developing countries. There is no population based data on prevalence of fibrocalculous pancreatic diabetes. This paper reports on prevalence of fibrocalculous pancreatic diabetes in Chennai in South India based on the Chennai Urban Rural Epidemiology Study

Incidence of Diabetes and Pre-diabetes in a Selected Urban South Indian Population (Cups - 19)

Abstract Objectives: Several cross-sectional studies have reported on the prevalence of diabetes in India. However, there are virtually no longitudinal population-based studies on the incidence of diabetes from India. The aim of the study was to determine the incidence of diabetes and prediabetes in an urban south Indian population. Methods: The Chennai Urban Population Study [CUPS], an ongoing epidemiological study in two residential colonies in Chennai [the largest city in southern India, formerly called Madras] was launched in 1996; the baseline study was completed in 1997. Follow-up examination was performed after a mean period of 8 years. At follow-up, 501 [47.0%] subjects had moved out of this colonies and were lost to follow-up. Of the remaining 564 individuals, 513 [90.9%] provided blood samples for biochemical analysis. Regression analysis was done using incident diabetes as dependant variable to identify factors associated with development of diabetes or pre-diabetes. Results: Among subjects with normal glucose tolerance (NGT) at baseline [n=476], 64 (13.4%) developed diabetes and 48 (10.1%) developed pre-diabetes (IGT or IFG). The incidence rate of diabetes was 20.2 per 1000 person years and that of pre-diabetes was 13.1 per 1000 person years among subjects with NGT. Of the 37 individuals who were pre-diabetic at baseline, 15 (40.5%) developed diabetes [incidence rate: 64.8 per 1000 person years], 16 (43.2%) remained as pre-diabetic and 6 (16.2%) reverted to normal during the follow-up period. Regression analysis revealed obesity [Odds Ratio (OR): 2.1, p=0.001], abdominal obesity [OR: 2.23, p<0.001] and hypertension [OR: 2.57, p<0.001] to be significantly associated with incident diabetes. The Indian Diabetes Risk Score (IDRS) showed the strongest association with incident diabetes [OR: 5.14, p<0.001]. Conclusion: The study shows that the incidence of diabetes is very high among urban south Indians. While obesity, abdominal obesity and hypertension were associated with incident diabetes, IDRS was th

Association of Small Dense LDL with Coronary Artery Disease and Diabetes in Urban Asian Indians - The Chennai Urban Rural Epidemiology Study (CURES-8)

Objective: Earlier studies in Europeans have identified small dense LDL to be associated with coronary artery disease and diabetes. In this study we assessed the association of small dense LDL with diabetes and CAD in Asian Indians. Methods: Study subjects were selected from the Chennai Urban Rural Epidemiology Study (CURES), a population based study on representative sample of Chennai city in southern India. Group 1:non-diabetic subjects (n=30); Group 2: diabetic subjects without CAD (n=30); Group 3:diabetic subjects with CAD (n=30). LDL subfractions were estimated using LipoPrint LDL system. LDL subfractions 3 and above, defined as small dense LDL was summed up to determine the overall small LDL. 75th percentile of the overall small dense LDL in non-diabetic subjects was used as a cut-off for defining elevated levels of small dense LDL. Results: The mean age of the study subjects was not significantly different among groups. Overall small dense LDL was significantly higher in diabetic subjects with CAD (16.7 ± 11.1 mg/dl, p<0.05) and without CAD (11.1 ± 8.0 mg/dl, p<0.05) compared to non-diabetic subjects without CAD (7.2 ± 6.8 mg/dl). Small dense LDL showed a positive correlation with fasting plasma glucose (r=0.252, p=0.023), HbA1c (r=0.281, p=0.012), total cholesterol (r=0.443, p<0.001), triglycerides(r=0.685, p<0.001), LDL(r=0.342, p=0.002), total cholesterol/HDL ratio (r=0.660, p=<0.001) and triglycerides/HDL ratio(r=0.728, p<0.001) and a negative correlation with HDL cholesterol (r= -0.341, p=0.002) and QUICKI values (r= -0.260, p=0.019). ROC curves constructed to predict elevated small dense LDL ((9.0 mg/dl) revealed that triglycerides/HDL ratio and total cholesterol/HDL ratio had higher AUC values compared to other parameters. A triglycerides/HDL ratio of 3.0 had the optimum sensitivity (80.0%) and specificity (78.0%) for detecting elevated small dense LDL. Conclusion: This data suggests that in Asian Indians, small dense LDL is associated with both diabetes and CAD and that a triglycerides/HDL ratio (3.0 could serve a surrogate marker of small dense LDL

Community empowerment - a successful model for prevention of non-communicable diseases in India - the Chennai Urban population study (CUPS - 17)

Background and objective: Randomized clinical trials have documented that lifestyle changes through physical activity can prevent diabetes. However there is no data whether such strategies are applicable at community level, that is, in a real life setting. This study demonstrates the first attempt in India, to our knowledge, of increasing physical activity through community empowerment in an attempt at primary prevention of non communicable diseases. Methods: The Chennai Urban Population Study [CUPS] was conducted in the year 1996 in two residential areas: a middle income group the Asiad colony at Tirumangalam, and a low income group at Bharathi Nagar in T. Nagar. The Asiad colony was selected for this study. Of the 524 eligible individuals available at baseline in 1998 [age ≥ 20 years], 479 individuals consented for the study (response rate:91.4%). After seven years, in 2004, the number of eligible individuals increased to 712 of whom 705 consented for the study (response rate:99%). Education regarding the benefits of physical activity was provided by mass awareness programmes like public lectures and video clippings. Both at baseline and during follow-up, details about the physical activity were collected using a validated questionnaire, which included job related and leisure time activities, and specific questions on exercise. Study individuals were then graded as having light, moderate and heavy physical activity using a scoring system. Results: In response to the awareness programmes given by our research team, the colony residents constructed a unique public park with their own funds. Though the occupation grades did not change, there was a significant change in the pattern of physical activity. At baseline, only 14.2% of the residents did some form of exercise more than three times a week, which presently increased to 58.7%[p&lt;0.001]. The number of subjects who walked more than three times a week increased from 13.8% at baseline to 52.1% during follow-up [p&lt;0.001]. Conclusion: This study is a demonstration of how community empowerment with increased physical activity could possibly lead to prevention of diabetes and other non communicable diseases at the community level. This study also highlights the importance of sharing the results of research studies with the community

Mortality rates due to diabetes in a selected Urban South Indian population - the Chennai Urban Population Study [CUPS - 16]

Objective: The aim of this study was to determine the mortality rate in diabetic and non-diabetic subjects in urban south India. Methods: The Chennai Urban Population Study is an ongoing epidemiological study in Chennai [formerly Madras, in south India]. All individuals . 20 years of age living in two residential colonies in Chennai were invited to participate in the study. Of the total 1399 eligible subjects, 1262 individuals responded [90.2%] at baseline, and of these, 1140 individuals [90.3%] could be followed annually from 1997 to 2003-04. Mortality rates and causes of death were the main outcome measures. Results: The median follow up period was six years. The overall mortality rate was higher in diabetic compared to non-diabetic subjects [18.9 vs.5.3 per 1000 person-years, p=0.004]. Mortality due to cardiovascular [diabetic subjects, 52.9%; non-diabetic subjects, 24.2%,p=0.042] and renal causes[diabetic subjects, 23.5%; non-diabetic subjects, 6.1%,p=0.072] was higher among diabetic subjects whereas mortality due to gastrointestinal [12.1%], respiratory [9.1%], lifestyle related [6.1%] and unnatural causes [18.2%] were observed only among non-diabetic subjects. Hazards ratio [HR] for all cause mortality for diabetes was 3.6, [95% Confidence Interval [CI]: 2.02-6.53, p&lt;0.001] and this remained significant even after adjusting for age [HR:1.9, 95% CI:1.04-3.45, p=0.038]. Light grade physical activity was associated with higher mortality rate [p=0.008], but the significance disappeared when adjusted for age. Smoking was also associated with increased mortality. Conclusions: In urban India, mortality rates are two fold higher in people with diabetes compared to nondiabetic subjects. Cardiovascular and renal diseases are the commonest causes of death among diabetic subjects