Development and validation of a novel cardiovascular risk score for screening undiagnosed cardiovascular disease (CVD) in Sri Lankan adults

Main Applicant: Thilina Samarathunga
Principal Investigator: Prof. Prasad Katulanda, University of Colombo (Sri Lanka)
Reference No. GHRU/2023/007
Approval Date: 20th November 2023

Lay Summary

The growing burden of non-communicable diseases (NCDs), particularly cardiovascular disease (CVD), requires accurate risk assessment and prevention strategies in Sri Lanka. However, existing global CVD risk prediction tools may estimate risk poorly within the diverse Sri Lankan population due to variations in genetics, lifestyle and socio-cultural factors. This study aims to develop and validate a novel cardiovascular risk score tailored to Sri Lankan adults. We hypothesise that this novel tool will more accurately predict the 5-year likelihood of fatal/non-fatal CVD compared to established scores. Key objectives include identifying predictive CVD risk factors specific to Sri Lanka, constructing a population-specific risk score, and internal validation of its performance in undiagnosed Sri Lankan adults. With a high prevalence of CVD-related mortality and rising healthcare costs, this study addresses the need for accurate risk assessment in Sri Lanka. By facilitating improved doctor-patient communication, adherence and informed decision making, the novel risk score aims to address the unique challenges of primary prevention of CVD in Sri Lankan adult population.

Risk prediction of hypertension and impaired lung function among South Asian adults

Main Applicant: Dilakshe Lekamge
Principal Investigator: Prof. K.T.A.A. Kasturiratne, University of Kelaniya (Sri Lanka)
Reference No. GHRU/2023/006
Approval Date: 21st August 2023

Lay Summary

Hypertension is an increasingly important public health burden worldwide and a leading contributory factor for major cardiovascular events and mortality. Association between decline of lung function and high blood pressure has been widely studied in Europe, whereas little is known of how impaired lung function associates with hypertension in South Asian countries. Therefore, the aim of the study is to investigate the association between impaired lung function and hypertension among adults in South Asia. This study will be based on the demographic, anthropometric, blood pressure, spirometry, physical activity, dietary intake, health and lifestyle and biochemistry data obtained from GHRU surveillance cohorts in Bangladesh, India, Pakistan and Sri Lanka. South Asian adults ≥18 years would be included and people with cancer or other serious illness expected to reduce life expectancy to less than 12 months, people who are unable or unwilling to give consent and pregnant women will be excluded from this study. Statistical analysis including descriptive statistics and multivariate regression analysis are to be performed using the R studio software package to determine association between impaired lung function and hypertension as well as to determine factors associated with hypertension, impaired lung function and hypertension with impaired lung function among adults in Bangladesh, India, Pakistan and Sri Lanka. ArcGIS 10.8 software would be used to map and identify the spatial distribution of hypertensive South Asians with impaired lung function. This study could be used to predict those at risk of hypertension and impaired lung function among South Asian adults and thereby providing information for preventing major cardiovascular events and mortality in South Asia.

Identification of fasting blood glucose level associated with the nadir level of cardiometabolic risk markers and end organ complications in the GHRU cohort

Main Applicant: Prof Khadija Irfan Khawaja
Principal Investigator: Prof Khadija Irfan Khawaja, Services Institute of Medical Science, Lahore (Pakistan)
Reference No. GHRU/2023/005
Approval Date: 20th March 2023

Lay Summary

Levels of fasting glycaemia used to define diabetes and prediabetes have been declining over the years. The diagnosis of diabetes is hampered by the fact that the parameter used to diagnose diabetes, viz blood glucose level, is not specific for the disease state known as diabetes, and, to state the obvious, is also present in the individuals not identified as diabetic. Furthermore, there is no single acceptable marker which is unique to diabetes (i.e. not found in any other disease state).

At present, the only known clinical sign which may be considered pathognomonic of diabetes is diabetic retinopathy, and the fasting blood glucose level currently accepted for the diagnosis of diabetes was identified as the approximate level at which retinopathy seemingly begins to appear. However, fasting blood glucose is a continuous variable which may be expected to be normally distributed in the population. At present, a line has been drawn across this continuum to artificially demarcate a diabetic state, when, in fact, the fasting blood glucose level exists as a continuum, and any increase beyond the “normal” would be expected to be associated with markers of cardiovascular risk and end organ changes incrementally. Similarly, at the other end of the population curve, blood glucose levels in the hypoglycaemic range may be expected to correlate with increased risk of morbidity and mortality. Thus, the most challenging part of this problem is identifying what is the blood glucose level which correlates with the nadir level of cardiometabolic risk and microvascular complications.

The GHRU surveillance cohort provides an excellent opportunity to examine the relationship of fasting blood glucose with several cardiometabolic risk markers. Additionally, the end organ data available in the form of retinal images can be used to identifying the nadir level of blood glucose at which the changes of retinopathy are absent.

We hope that analysis of the surveillance data will help identify the blood glucose level at which cardiometabolic risk is at the lowest level. This may help in identifying a lower intervention threshold and may indicate a need to revise the diagnostic cut-offs of diabetes and pre-diabetes.

Undiagnosed Diabetes in adult South Asian population: Epidemiology, Determinants and Prediction

Main Applicant: Dr Saira Burney
Principal Investigator: Prof Khadija Irfan Khawaja, Services Institute of Medical Science, Lahore (Pakistan)
Reference No. GHRU/2023/004
Approval Date: 20th February 2023

Lay Summary

Many people living with diabetes remain undiagnosed, with diagnosis usually occurring long after signs and symptoms are present or complications have set in. Detecting people living with diabetes is crucial for timely management and improving disease prognosis as delays in diagnosis lead to suboptimal care. The South Asian region has one of the highest susceptibilities to diabetes mellitus in the world but there is little quantitative evidence on the proportion of undiagnosed diabetes in this population. Our main aim is to determine the prevalence of undiagnosed diabetes and study its correlation with clinical correlates and socio-demographic determinants.

Association of Sedentary Time with Adiposity and Cardiometabolic Risk Factors in South-Asian Population

Main Applicant: Dr Asma Salam
Principal Investigator: Prof. Dr Tania A Shakoori, Department of Physiology, University of Health Sciences, Lahore (Pakistan)
Reference No. GHRU/2023/003
Approval Date: 20th February 2023

Lay Summary

South Asians represent 23% of the global population, corresponding to 1.8 billion people. They are considerably at a higher risk of cardiometabolic diseases as compared with most of other ethnicities. The unhealthy lifestyle and the unique body composition of South Asians are the major factors contributing to this escalating risk. Among the modifiable life-style risk factors, sedentary behaviour plays a significant role. Increasing sedentary time leads to adverse health outcomes leading to an increased all-cause mortality, cardiovascular disease mortality, cancer risk, and risks of metabolic disorders.

This study aims to determine the prevalence of sedentary behaviour in the South Asian region and also measure the association of sedentary time with adiposity and cardiometabolic risk factors in the indigenous population of South Asia. It will be a crosssectional, comparative study including the healthy subjects residing in South Asia. Sedentary time will be objectively measured using accelerometer. Adiposity will be measured using body fat analyser and cardiometabolic risk factors including Body mass index (BMI), Waist Circumference (WC), Serum Lipids, Blood pressure (BP), Heart Rate (HR) and Fasting Glucose levels (FBS) will be measured. Association of sedentary time with psychological traits i.e., anxiety and food intake will be measured. This study will be conducted on a larger scale including both male and female, with age-group of 18 plus from the local general population of South Asian countries. Previously, there were studies conducted on migrant South Asians, however, there is a scarcity of data in the indigenous population. Therefore, we shall be able to evaluate the local risk factors in the indigenous population of the region which contribute to such life-style changes. The results of our study will help us formulate policies for preventing non-communicable diseases in the region.

Associations between the built environment and socioeconomic inequalities in health outcomes related to noncommunicable diseases (NCDs)

Main Applicant: Petya Atanasova
Principal Investigator: Prof Marisa Miraldo, Imperial College Business School (UK)
Reference No. GHRU/2023/002
Approval Date: 20th February 2023

Lay Summary

Globally, many studies have documented that lower socioeconomic status is associated with behavioural risk factors (e.g., unhealthy diet and alcohol consumption, tobacco smoking, low physical inactivity) that lead to metabolic/physiological changes (raised blood pressure, obesity, raised blood glucose) contributing to noncommunicable diseases (NCDs). NCDs are complex and multifactorial and affected by a range of factors at the individual, area level and national level. There is scant evidence on the determinants of socioeconomic inequalities in NCDs related risk factors.

Further, factors within the built environment have been found to be significant contributors to NCDs related risk factors. For example, people with lower socioeconomic status and living in rural areas have been found to have lower access to healthy food, and/or health care for NCDs diagnosis and treatment compared to those with higher socioeconomic status and living in urban areas. Thus, built environments tend to vary across areas that may be more affluent or poor and therefore can be contributing factor to the socioeconomic inequalities in NCDs related risk factors. Therefore, the aim of this study is to assess the associations between the built environment and socioeconomic inequalities in dietary quality, anthropometrics (weight, BMI and waist circumference), cardiovascular disease (systolic and diastolic blood pressure) and diabetes (fasting blood glucose; high blood glucose; diagnosed diabetes).

Prevalence of diabetes, prediabetes and associated factors in South Asians: the South Asia Biobank study

Main Applicant: Prof John Chambers
Principal Investigator: Prof John Chambers, Epidemiology and Biostatistics/Imperial College London (UK)
Reference No. GHRU/2023/001
Approval Date: 16th January 2023

Lay Summary

Diabetes is a major and increasing public health problem globally. South Asians have higher prevalence of diabetes than other ethnic groups probably due to both biologic and lifestyle factors. The aim of this study is to evaluate the prevalence of diabetes and prediabetes and its associated factors using the data from South Asia Biobank study.

Association of residential green space exposure and walkability with travel behaviour, physical activity and health in South Asia

Main Applicant: Dr Louise Foley
Principal Investigator: Prof Nick Wareham, MRC Epidemiology Unit, University of Cambridge (UK)
Reference No. GHRU/2022/010
Approval Date: 21st November 2022

Lay Summary

Residential neighbourhoods have the potential to shape behaviours and health. Currently, the research in this area is drawn almost entirely from Europe and North America. In this analysis, we will investigate if features of the built environment (walkability and green space) are related to walking, physical activity and better wellbeing and health, at scale, in the South Asian context for the first time. Because cultural, climatic, geographic and other factors are likely to differ across South Asia, we will explore how these relationships vary by country.

Association of Smokeless Tobacco Use with Cardiovascular Disease Risk Factors in South Asian Population: Evidence from the South Asia Biobank

Main Applicant: Dr Wubin Xie
Principal Investigator: Prof John Chambers, School of Public Health, Imperial College London (UK)
Reference No. GHRU/2022/009
Approval Date: 19th September 2022

Lay Summary

Smokeless tobacco (ST) use is highly prevalent in South Asia. India alone is home to 66.6% of the world’s 356 million ST users. While cigarette smoking prevalence declined in recent years, smokeless tobacco use has increased in many South Asian countries. ST products in South Asia are often homemade or manufactured by small business, a virtually unregulated market.

ST products contain more than 30 harmful or potentially harmful constituents (HPHCs), many of which are cardiovascular toxicants. Many ST products found in South Asia contain higher levels of HPHCs compared with Swedish snus. While abundant evidence supports the association between cigarette smoking and cardiovascular disease, the cardiovascular effects of smokeless tobacco (ST) remain unclear. Existing epidemiological studies assessing ST use and cardiovascular diseases and risk factors (i.e., hypertension, dyslipidaemia, hyperglycaemia) reported inconsistent findings, with geographic variations indicating higher risks in Asia than in Sweden or in Europe.

Little data are available from South Asia. The existing SA studies were limited by small, local samples, with limited characterization by ST product type, user characteristics, and using patterns. The present study aims to address these gaps by assessing the association between ST use and CV risk factors in a well-characterized South Asian population.

To determine the prevalence and predictors of depression and anxiety among adults with NCDs in South Asia

Main Applicant: Dr. Swati Waghdhare Pandit
Principal Investigator: Dr Vinitaa Jha, Max Healthcare (India)
Reference No. GHRU/2022/008
Approval Date: 20th June 2022

Lay Summary

There is a steep rise in the Non-Communicable Disease (NCD) epidemic and mental health disorders. The co-occurrence of these health burdens in transitioning populations, particularly in low-income countries, makes it increasingly imperative to quantify the burden of comorbid NCDs and mental illness in order to be able to conceptualise frameworks to improve the understanding of risk factors and better design and implementation of holistic prevention and intervention programmes and address these comorbidities amongst patients. Therefore, this study must be conducted to determine the prevalence of depression and generalised anxiety disorder among a population with diabetes and/or cardiovascular disease and explore the associated risk factors.

Understanding the Prevalence and Risk Factors of Type 2 Diabetes Mellitus (T2DM) and Prediabetes among Bangladeshi Adults and Level of Care Available for T2DM Patients in Bangladesh: Epidemiological Analysis of a Nationally Representative Survey Data

Main Applicant: Dr. Ipsita Sutradhar
Principal Investigator: Dr Malay Mridha, BRAC James P Grant School of Public Health, BRAC University (Bangladesh)
Reference No. GHRU/2022/007
Approval Date: 20th June 2022

Lay Summary

Type 2 Diabetes Mellitus (T2DM) is one of the leading causes of death and disability across the globe. According to the World Health Organization, 451 million adults around the world lived with diabetes in 2019. Historically diabetes has been considered as the ‘disease of rich’ mostly affecting the developed nations. However, currently, the disease disproportionately affects the lower middle-income countries of Asia and Africa. Like other South Asian countries, Bangladesh is experiencing a high burden of T2DM. A recently published scoping review found that the prevalence of T2DM among Bangladeshi adults was 7.4%. Despite being greatly affected by the disease, a comprehensive investigation of T2DM hardly took place in Bangladesh. Additionally, the situation of diagnosis and management of T2DM has not been carefully investigated in Bangladesh yet. We, therefore, aim to conduct this study to identify the prevalence and determinants of T2DM and prediabetes among ≥18 years old Bangladeshi adults and to investigate the level of care available for Bangladeshi diabetic patients. The findings of this study will offer a strong insight to the pertinent stakeholders on the current situation of T2DM, which eventually will aid them in designing target specific interventions for prevention and control of T2DM.

Associations between the quantity and type of dietary carbohydrate consumption and cardiometabolic disease risk in South Asia

Main Applicant: Anwesha Lahiri
Principal Investigator: Prof Nita Gandhi Forouhi, MRC Epidemiology Unit, University of Cambridge (UK)
Approval Date: 18th April 2022
Reference No. GHRU/2022/006

Lay Summary

South Asians are known to have a much higher risk of developing serious medical conditions such as being twice as likely to suffer from heart diseases and three times more likely to have diabetes, compared to European people. Our diet and nutrition are important risk factors, and there has been a lot of research exploring dietary factors that can raise or reduce the risk of developing diabetes or heart disease in European populations. However, we have a limited understanding of whether these risk factors have the same effect in people from different ethnic and geographic or regional backgrounds. For example, on research based in western countries the existing dietary guidance advises to lower the consumption of saturated fat, but it is possible that carbohydrates may be more relevant than fat because of generally higher carbohydrate-rich foods in South Asians diets. The type of dietary carbohydrate consumed may also be relevant, such as starch, sugar or fibre. We will study the relevance of quantity and type of carbohydrates and their food sources with risk of developing diabetes and heart disease in South Asians.  

Regional, demographic, and seasonal differences in fruit and vegetable consumption in South Asia

Main Applicant: Anwesha Lahiri
Principal Investigator: Prof Nita Gandhi Forouhi, MRC Epidemiology Unit, University of Cambridge (UK)
Reference No. GHRU/2022/005
Approval Date: 18th April 2022

Lay Summary

Most governments recommend that their populations should consume a diet that is high in fruit and vegetables for good health. In fact the World Health Organization advises that people should eat five or more servings per day of fruit and vegetables. However, this evidence is primarily based on decades of research in European populations, and a particular challenge is lack of understanding of the patterns of fruit and vegetable intake in other groups like South Asians, and how that would influence risk of medical problems. In South Asia Biobank, we will study how fruit and vegetable consumption can vary across different countries or regions in South Asia, and identify factors that contribute to such variation, including but not limited to income or education. This knowledge will aid in consideration of policies, programmes and actions that might be undertaken to improve the diet quality of South Asians and reduce the burden of chronic diseases like diabetes and heart diseases. 

Ultra-processed food consumption and cardio-metabolic health in adults living in South Asia

Main Applicant: Divya H Bhagtani
Principal Investigator: Prof Nita Gandhi Forouhi, MRC Epidemiology Unit, University of Cambridge (UK)
Reference No. GHRU/2022/004
Approval Date: 21st February 2022

Lay Summary

The sale of industrially manufactured or ultra-processed foods (UPFs) has been rapidly rising in South Asia where there has been a shift from traditional home-cooked meals to foods high in fat, sugar, salt, and low in fibre. UPFs include items such as crisps, candies, cake, fizzy drinks and others that are made in industries using food processing and additives to prolong food shelf-life. Research in other world regions suggests that higher consumption of UPFs is linked to greater risk of conditions such as obesity and diabetes, but this has hardly been studied in South Asia.
In our proposed research we will quantify UPF consumption, identify the characteristics of individuals with varying levels of UPF consumption and assess its associations with health status.

Findings from this research will enable understanding of the distribution, determinants and health impacts of UPF consumption in South Asia and will inform development of future interventions to reduce the burden of diseases.

Description of the development, evaluation and performance assessment of a digital technology based 24-hour dietary recall tool in Bangladesh, India, Pakistan and Sri Lanka: The South Asia Biobank

Main Applicant: Divya H Bhagtani
Principal Investigator: Prof Nita Gandhi Forouhi, MRC Epidemiology Unit, University of Cambridge (UK)
Reference No. GHRU/2022/003
Approval Date: 21st February 2022

Lay Summary

In South Asia there has been relatively little research into what makes-up a healthy or optimal diet for the prevention of chronic diseases such as diabetes or heart disease. Part of the reason for this is the lack of suitable methods and tools to measure the consumption of foods and overall diets specific to the local and regional types of eating.

Working together in close collaboration, the Cambridge Diet Assessment Team and colleagues in the regional teams of the Global Health Research Unit have adapted and implemented an instrument – ‘Intake24’ – for the collection of dietary information in South Asia. This comprehensive tool collects details from study participants on what foods and drinks they consumed in the previous 24 hours and in what quantities, aided by pictures to indicate the portion sizes consumed. Data collection by trained interviewers enables participation of people with varying literacy and digital accessibility.

Our proposed research will describe the tool and evaluate its’s performance. Our goal will be to make the tool available for researchers wishing to collect dietary data in South Asia.

Seasonal and regional differences in physical activity in South Asia

Main Applicant: Dr Soren Brage
Principal Investigator: Dr Soren Brage, MRC Epidemiology Unit, University of Cambridge (UK)
Reference No. GHRU/2022/002
Approval Date: 16th May 2022

Lay Summary

This project will describe variation in physical activity between population subgroups and across time. Physical activity is measured by self-report in the full sample (n~100k) and by wrist accelerometry in a subsample (n~20k). Population subgroups will include age, sex and occupation and will be stratified by geographical setting. This project also serves to fully document the underlying methods for deriving physical activity estimates from wrist acceleration records, including calibration to local gravity and classification of wear and non-wear time.

Relationship between food and physical activity environments and diabesity in adults from Chennai, South India

Main Applicant: Aarthi Garudam Raveendiran
Principal Investigator: Dr R. M. Anjana & Dr R. Guha Pradeepa, Madras Diabetes Research Foundation (India)
Reference No. GHRU/2022/001
Approval Date: 21st February 2022

Lay Summary

The global prevalence of diabetes has reached epidemic proportions and is considered to be a major public health problem in India. Obesity is a major risk factor for diabetes and studies have shown a growing link between diabetes and obesity, termed as “Diabesity”. The term ‘diabesity’ expresses their close relationship, as both metabolic disorders are characterized by insulin action defects. Obesity and diabetes are linked by two path physiologic factors: insulin resistance and insulin deficiency. According to the World Health Organization, the plan, design and build of a city can have a great influence on public health, in particular, on diabetes and obesity. Recent studies have shown that development of diabetes and obesity is influenced by built environment, which refers to man-made surroundings that provide space for human activity. Many studies have revealed a gap in evaluating the importance of the food and physical activity environment on diabesity. The aim of the study is to understand the relationship between food and physical environments on diabesity among adults residing in Chennai. In this study it is planned to assess the prevalence of diabesity and also intends to assess the food and physical activity environments through audits and data collection using Geographical Information system for the first time in Chennai. This study integrates accelerometer data and GPS coordinates using Geographical Information system which will aid in understanding the relationship between behavioral patterns and the availability of physical activity environments.