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PHFI

Working towards a healthier India
PHFI is helping to build institutional and systems capacity in India for strengthening education, training, research and policy development in the area of Public Health.

Projects under CVD PDF Print

Cardiovascular diseases

CVD is a class of various forms that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs are stroke, hypertensive heart disease, rheumatic heart disease, cardiomyopathy, heart arrhythmia, congenital heart disease, endocarditis, aortic aneurysms, peripheral artery disease and venous thrombosis.

The burden of chronic diseases has reached epidemic proportion in India along with the penitence of preternatural diseases. It is now experiencing a polarized and protracted double burden of disease. At the present stage of India’s health transition, chronic diseases contribute to an estimated 53% of deaths and 44% of disability-adjusted life-years lost.

  • Cardiovascular diseases and diabetes are highly prevalent in urban areas.

  • Hypertension and dyslipidaemia, although common, are inadequately detected and treated.

  • Demographic and socioeconomic factors are hastening the health transition, with sharp escalation of chronic disease burdens expected over the next 20 years.

Despite this broad knowledge, the biomedical research community faces formidable challenges in understanding the dynamics, determinants and dimension of chronic diseases. The chronic care paradigm encompasses preventive and therapeutic care, and both must incorporate risk-factor management. To address the growing burden of CVDs, CCCI is involved in:

  • carefully designed, comprehensive, policy and practice relevant research

  • development of evidence based guidelines, which leave ample room for local adaptation and create an important base to realise the full potential of research

  • development of innovative, scalable and sustainable solutions to control and prevent chronic cardiovascular diseases

  • training, policy development and advocacy programmes for chronic diseases

ACS QUICK

Name Funding Body Duration Status Team
Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) National Heart Lung Blood Institute (NHLBI). 2 Years; Nov 2014-Nov 2016 On-going PI-Dr. Dorairaj Prabhakaran Project Coordinator- Raji Devarajan

 

About

The Acute Coronary Syndrome Quality Improvement in Kerala (ACS QUIK) study is a cluster randomized, stepped wedge clinical trial assessing implementation and effect of a locally-developed quality improvement toolkit for patients with ACS in Kerala, India. Participating hospitals are randomly assigned to one of five steps. Every four months, a new step implements a quality improvement toolkit. Those hospitals continue to use the quality improvement toolkit through the end of the trial for all ACS patients. The aim of this study is to evaluate, in comparison to usual care, the effect of a locally-developed, evidence-based health care quality improvement toolkit on 30-day major adverse cardiovascular events (MACE). The primary outcome is 30-day major adverse cardiovascular events (MACE) rates, defined as death, myocardial infarction, stroke, and major bleeding defined by GUSTO criteria. The trial enrolled over 9,000 participants in November 2015 and aims to complete a total recruitment of 18,000 participants by November 2016. CCDC, now part of CCCI is the National Coordinating Centre for the trial.

Website: http://www.acsquik.org/

Andhra Pradesh Children And Parents Study (APCAPS)

Name Funding Body Duration Status Team
Andhra Pradesh Children And Parents Study(APCAPS) Wellcome Trust 2010-2016 On-going PI: Dr. Sanjay Kinra

 

About

APCAPS is a trans-generational extension of Hyderabad Nutrition Trial which was conducted by National Institute of Nutrition (NIN, ICMR) in 1987-1990 in 29 villages of Rangareddy district of Andhra Pradesh (Telangana). The participants (N~7000) have been intensely phenotyped foe various cardiometabolic risk factors varying from lifestyle factors, anthropometric measures, bioelectric impedance, DEXA scans, lung function, vascular measures and serological & biochemical indices.

The study has also surveyed the entire population of these 29 villages (N~85,000) for basic household characteristics. As a part of this survey data on children (less than 6 years of age) for immunization records and anthropometry measures was also collected and verbal autopsy questionnaires for the deaths that occurred in last 5 years in each household were administered.

The study is also examining the built-in-environment of these villages focusing to assess the availability and accessibility of healthy food and physical exercise and air pollution levels in these areas.

Collaborating partners

  • Public Health foundation of India
  • National Institute of Nutrition, Indian council of Medical research
  • London School of Hygiene and Tropical Medicine
  • University of Bristol

Impact

APCAPS has helped in establishing a trans generational cohort in rural South India which can address numerous research questions related to cardiometabolic and respiratory outcomes. Since, this population is undergoing urbanization it can also help in examining related environmental and lifestyle risk factors of cardiometabolic and respiratory health.

  1. Kinra S, Radha Krishna KV, Kuper H, Rameshwar SarmaKV, Prabhakaran P, GuptaV,Walia GK,et al. Cohort Profile: Andhra Pradesh Children and Parents Study(APCAPS).International Jouranal of Epidemiology. 2014 ;43(5) 1417-24.
  2. Gupta V, Millett C , Walia GK , Kinra S , Aggarwal A , Prabhakaran P, Bhogadi S, Kumar A, et al. Socio-economic patterning of Cardiometabolic risk factors in rural and peri-urban India: Andhra Pradesh Children and Parents Study(APCAPS). Journal of Public Health.2015;23(3):129-136.
  3. Matsuzaki M1, Kuper HKulkarni BPloubidis GBWells JCRadhakrishna KVPrabhakaran PGupta VWalia GKAggarwal APrabhakaran DRameshwar Sarma KVDavey Smith GBen-Shlomo YKinra S. Adolescent undernutrition and early adulthood bone mass in an urbanizing rural community in India. Arch Osteoporos. 2015;10:232.
  4. Molinari FGupta VPrabhakaran PMeiburger KMSaba LAcharya URLedda GRadha Krishna KVWalia GKKinra SNicolaides AEbrahim SSuri JS. Automated IMT estimation and BMI correlation using a low-quality carotid ultrasound image database from India. Conf Proc IEEE Eng Med Biol Soc. 2013;2013:3343-6.

Website: http://apcaps.lshtm.ac.uk

Center of Excellence - Center for CArdio-metabolic Risk Reduction in South Asia (CARRS)

Name Funding Body Duration Status Team
Center of Excellence - Center for CArdio-metabolic Risk Reduction in South Asia National Heart Lung Blood Institute (USA) and United Health (USA)- through Centre for Excellence (COE)- CARRS

Emory University (USA)- through South Asian Health and Wellness Tracking Program-
2010-2016 On-going PI Dr. Dorairaj Prabhakaran, Dr. Srinath Reddy,
Dr. Nikhil Tandon, Dr. Vishwanathan Mohan,
Dr. Masood Kadir , Dr. Venkat Narayan and Dr. Mohammed Ali

 

About

CARRS - Surveillance is an on-going cohort-modelled, community based surveillance capturing cardio-metabolic diseases (CMDs) and its risk factors in three major metropolitan cities in South Asia (Delhi and Chennai from India and Karachi from Pakistan). In 2010-11, the CARRS cohort-1 from these cities recruited 16,287 adults aged ≥20 years. More than 80% of these participants were fully phenotyped for cardio-metabolic risk factors and a bio bank of DNA, sera, and urine was created. Participants at present are being followed up annually for incidence of CMDs, changes in risk factors and mortality with nearly 70% response rate till date. In 2015, an additional 15,000 adults ≥20 years were recruited in the same cities to measure trends. This cohort is a rich platform for students and fellows to develop sub studies and for future genetic studies. The results of the study has been published in many reputed international journals and presented in international conferences.

Publications

1. Anand S, Shivashankar R, Ali MK, Kondal D, Binukumar B, Montez-Rath ME, Ajay VS, Pradeepa R, Deepa M, Gupta R, Mohan V, Narayan KM, Tandon N, Chertow GM, Prabhakaran D. Prevalence of chronic kidney disease in two major Indian cities and projections for associated cardiovascular disease: the Cardiometabolic Risk Reduction in South Asia surveillance study Kidney Int. 2015 Jul;88(1):178-85.

2. Mendenhall E, Shivashankar R, Tandon N, Ali MK, Narayan KMV, Prabhakaran D. Stress and Diabetes in Socioeconomic Context: A Qualitative Study of Urban Indians. Soc Sci Med. Dec 2012; 75(12): 2522–2529.

3. Patel SA, Shivashankar R, Ali MK, Anjana RM, Mohan D, Kapoor D, Kondal D, Rautela G, Mohan V, Narayan KMV, Kadir MM, Fatmi Z, Prabhakaran D, and Tandon N, on behalf of the CARRS investigators Is the “South Asian Phenotype” Unique to South Asians? Comparing Cardiometabolic Risk Factors in the CARRS and NHANES studies Global heart (Accepted)

4. Ali MK, Bhaskarapillai B, Shivashankar R, Mohan D, Fatmi ZA, Pradeepa R, Masood Kadir M, Mohan V, Tandon N, Venkat Narayan KM, Prabhakaran D; CARRS investigators. Socioeconomic status and cardiovascular risk in urban South Asia: The CARRS Study. Eur J Prev Cardiol. 2015 Apr 27 pii: 2047487315580891

5. Nair M, Ali MK, Ajay VS, Shivashankar R, Mohan V, Pradeepa R, Deepa M, Khan HM, Kadir MM, Fatmi ZA, Reddy KS, Tandon N, Narayan KM, Prabhakaran D. CARRS Surveillance study: design and methods to assess burdens from multiple perspective. BMC Public Health 2012, 12:701

6. Finzer LE, Ajay VS, Ali MK, Shivashankar R, Goenka S, Sharma P, Pillai DS, Khandelwal S, Tandon N, Reddy KS, Narayan KM, Prabhakaran D. Fruit and Vegetable Purchasing Patterns and Preferences in South Delhi Ecol Food Nutr. 2013; 52(1):1-20. doi: 10.1080/03670244.2012.705757.

7. Mohan D, Mundu G, Bhaskarapillai B, Pradeepa , Shivashankar R, Khan HM , Fatmi Z, Kadir MM, Naeem I, Ajay VS, Anjana RM, Ali MK, Prabhakaran D, Tandon N, Mohan V, Narayan KMV – For the CARRS Surveillance Research Group, High burden of prediabetes and diabetes in three large cities in South Asia: The Center for Cardio-metabolic Risk Reduction in South Asia (CARRS) Study Diabetes Res Clin Pract. 2015 Sep 25. pii: S0168-8227(15)00378-2. doi: 10.1016/j.diabres.2015.09.005. [Epub ahead of print]

8. Berg CJ, Ajay VS, Ali MK, Kondal D, Khan HM, Shivashankar R, Pradeepa R, Mohan D, Fatmi Z, Kadir MM, Tandon N, Mohan V, Narayan KM, Prabhakaran D A cross-sectional study of the prevalence and correlates of tobacco Use in Chennai, Delhi, and Karachi: data from the CARRS study. BMC Public Health. 2015 May 11; 15:483.

9. Patel SA , Ali MK , Alam D, Yan LL, Levitt NS, Bernabe-Ortiz A, Checkley W, Wu Y, Irazola V, Gutierrez L, Rubinstein A , Shivashankar R, Li X, Miranda JJ, Chowdhury MAH, Siddiquee AT, Gaziano TA, Kadir MM , Prabhakaran D, Obesity and its relation with diabetes and hypertension: a cross-sectional study across four low- and middle-income country regions Global heart (Accepted)

10. Kelly L, Patel SA, Narayan KMV, Prabhakaran D, Cunningham SA Measuring Social Networks for Medical Research in Lower-Income Settings PLoS One. 2014 Aug 25;9(8):e105161

Website: www.coecarrs.org

Developing and Testing Integrated, Multi-factorial Cardiovascular Disease Risk Reduction Strategies in South Asia (CARRS Translation Trial)

Name Funding Body Duration Status Team
Developing and Testing Integrated, Multi-factorial Cardiovascular Disease Risk Reduction Strategies in South Asia (CARRS Translation Trial) National Heart, Lung and Blood Institute and UnitedHealth Group Jan 2011-Jul 2014; Trial Extension: Aug 2014-Jul 2018 On-going PI: Dr. Dorairaj Prabhakaran
Co-I: Dr. Nikhil Tandon, Dr. Venkat Narayan, Dr. Mohammed K Ali
Project Coordinator: Kavita Singh, Raji Devarajan

 

About

CARRS Translation Trial is a randomized, controlled multi-site translation trial to evaluate low-cost, multifactorial, multi-faceted, innovative, scalable and sustainable delivery improvement strategies for cardiovascular risk reduction. This trial is testing a multi-faceted delivery intervention (non-physician care coordinator and decision-support software) in diabetes patients with inadequate control of blood sugar and at least one other risk factor. The CARRS Translation Trial is a multi-site, individually randomized, controlled translation trial of a cardiovascular risk reduction intervention in 1,146 Type 2 diabetes patients attending 10 established out-patient clinics in South Asia, for a mean follow-up of 30 months. Half of the patients were randomized to the intervention, which utilizes a combination of health care management strategies: (1) a web-enhanced decision-support software that serves to store patient health records; provide patient management advice; and prompt and remind care providers and participants of recommended care processes; and (2) a non-physician care coordinator to facilitate patient self-management and provider adherence to evidence-based management guidelines, which includes regular 3-monthly visits for patient evaluation. The care coordinator is the main person who interacts with the decision-support software, collecting and inputting all intervention data into the decision support software and providing management prompts to the study physician. The control group received the standard care existing at the clinical site. All study physicians have equal access to the evidence-based management guidelines. The trial participant recruitment was completed in August 2012 and end of study visits were completed in July 2014. The trial was coordinated by COE-CARRS, Public Health Foundation of India and CCDC was the Research Coordinating Centre.

Publications

  1. CARRS Trial Writing Group, Shah S, Singh K, Ali MK, Mohan V, Kadir MM, Unnikrishnan AG, Sahay RK, Varthakavi P, Dharmalingam M, Viswanathan V, Masood Q, Bantwal G, Khadgawat R, Desai A, Sethi BK, Shivashankar R, Ajay VS, Reddy KS, Narayan KM, Prabhakaran D, Tandon N. Improving diabetes care: multi-component cardiovascular disease risk reduction strategies for people with diabetes in South Asia--the CARRS multi-center translation trial. Diabetes Res Clin Pract. 2012 Nov;98(2):285-94

Abstracts presented at national & international conferences:

  1. K Singh, M K Ali, R Devarajan et al. Effects Of A Multifaceted Health System Intervention On Cardiometabolic Risk Profiles In Patients With Diabetes: The CARRS Trial. American Diabetes Association. 75th Scientific Sessions.
  2. K Singh, M K Ali, R Devarajan et al. Cost Implications of a Multifactorial Diabetes Care Improvement Strategy: The CARRS Trial. American Diabetes Association. 75th Scientific Sessions.
  3. K Singh, M K Ali, R Devarajan et al. The Utility and Acceptability of Decision Support Electronic Health Records (DS-EHR) In Diabetes Care: The CARRS Translation Trial. American Diabetes Association. 74th Scientific Sessions June 2014.
  4. K Singh, D Kondal, R Devarajan et al. Impact of a multifaceted intervention on health utility and treatment satisfaction in diabetes patients: The CARRS Trial. International Diabetes Federation- World Diabetes Congress 2015
  5. K. Singh, M.K. Ali, D. Kondal, R. Devarajan. Effects of a multifaceted intervention on cardiometabolic risk by subgroups in type 2 diabetes patients: The CARRS Trial. International Diabetes Federation- World Diabetes Congress 2015

Website : http://www.carrstrial.org/phfi/

The CARRS - Surveillance Study

Name Funding Body Duration Status Team
The CARRS - Surveillance Study National Heart Lung Blood Institute (USA) and United Health (USA)- through Centre for Excellence (COE)- CARRS, Emory University (USA)- through South Asian Health and Wellness Tracking Program 2010-2016 On-going PI: Dr. Dorairaj Prabhakaran, Dr. Srinath Reddy, Dr. Nikhil Tandon, Dr. Venkat Narayan and Dr. Mohammed Ali

 

About

CARRS - Surveillance is an ongoing cohort-modelled, community based surveillance capturing cardio-metabolic diseases (CMDs) and its risk factors i in three major metropolitan cities in South Asia- Delhi (India), Chennai (India) and Karachi (Pakistan). In 2010-11, the CARRS cohort-1 recruited 16,287 adults aged ≥20 years, representative of the three cities. More than 80% of these participants were fully phenotyped for cardio-metabolic risk factors and a bio bank of DNA, sera, and urine was created. Participants are being followed up annually for incidence of CMDs, changes in risk factors and mortality with nearly 70% response rate till date. In 2015, an additional 15,000 adults ≥20 years are being recruited in the same cities to measure trends. This cohort is a rich platform for students and fellows to develop sub studies and for future genetic studies.  The results of the study has been published in many reputed international journals and presented in international conferences.

The study partners are PHFI, Emory University, AIIMS, Aga Khan University Karachi and Madras Diabetic Research Foundation, Chennai.

Publications

  1. Anand S, Shivashankar R, Ali MK, Kondal D, Binukumar B, Montez-Rath ME, Ajay VS, Pradeepa R, Deepa M, Gupta R, Mohan V, Narayan KM, Tandon N, Chertow GM, Prabhakaran D. Prevalence of chronic kidney disease in two major Indian cities and projections for associated cardiovascular disease: the Cardiometabolic Risk Reduction in South Asia surveillance study Kidney Int. 2015 Jul;88(1):178-85.
  2. Mendenhall E, Shivashankar R, Tandon N, Ali MK, Narayan KMV, Prabhakaran D.  Stress and Diabetes in Socioeconomic Context: A Qualitative Study of Urban Indians. Soc Sci Med. Dec 2012; 75(12): 2522–2529.
  3. Patel SA, Shivashankar R, Ali MK, Anjana RM, Mohan D, Kapoor D, Kondal D, Rautela G, Mohan V, Narayan KMV, Kadir MM, Fatmi Z, Prabhakaran D, and Tandon N, on behalf of the CARRS investigators Is the “South Asian Phenotype” Unique to South Asians? Comparing Cardiometabolic Risk Factors in the CARRS and NHANES studies Global heart (Accepted)
  4. Ali MK, Bhaskarapillai B, Shivashankar R, Mohan D, Fatmi ZA, Pradeepa R, Masood Kadir M, Mohan V, Tandon N, Venkat Narayan KM, Prabhakaran D; CARRS investigators. Socioeconomic status and cardiovascular risk in urban South Asia: The CARRS Study. Eur J Prev Cardiol. 2015 Apr 27 pii: 2047487315580891
  5. Nair M, Ali MK, Ajay VS, Shivashankar R, Mohan V, Pradeepa R, Deepa M, Khan HM, Kadir MM, Fatmi ZA, Reddy KS, Tandon N, Narayan KM, Prabhakaran D. CARRS Surveillance study: design and methods to assess burdens from multiple perspective. BMC Public Health 2012, 12:701
  6. Finzer LE, Ajay VS, Ali MK, Shivashankar R, Goenka S, Sharma P, Pillai DS, Khandelwal S, Tandon N, Reddy KS, Narayan KM, Prabhakaran D. Fruit and Vegetable Purchasing Patterns and Preferences in South Delhi Ecol Food Nutr. 2013; 52(1):1-20. doi: 10.1080/03670244.2012.705757.
  7. Mohan D, Mundu G, Bhaskarapillai B, Pradeepa , Shivashankar R, Khan HM , Fatmi Z, Kadir MM,   Naeem I, Ajay VS, Anjana RM, Ali MK, Prabhakaran D, Tandon N, Mohan V, Narayan KMV – For the CARRS Surveillance Research Group, High burden of prediabetes and diabetes in three large cities in South Asia: The Center for Cardio-metabolic Risk Reduction in South Asia (CARRS) Study Diabetes Res Clin Pract. 2015 Sep 25. pii: S0168-8227(15)00378-2. doi: 10.1016/j.diabres.2015.09.005. [Epub ahead of print]
  8. Berg CJ, Ajay VS, Ali MK, Kondal D, Khan HM, Shivashankar R, Pradeepa R, Mohan D, Fatmi Z, Kadir MM, Tandon N, Mohan V, Narayan KM, Prabhakaran D A cross-sectional study of the prevalence and correlates of tobacco Use in Chennai, Delhi, and Karachi: data from the CARRS study. BMC Public Health. 2015 May 11; 15:483.
  9. Patel SA , Ali MK , Alam D, Yan LL, Levitt NS, Bernabe-Ortiz A, Checkley W, Wu Y, Irazola V, Gutierrez L, Rubinstein A , Shivashankar R, Li X, Miranda JJ, Chowdhury MAH, Siddiquee AT, Gaziano TA, Kadir MM , Prabhakaran D, Obesity and its relation with diabetes and hypertension: a cross-sectional study across four low- and middle-income country regions Global heart (Accepted)
  10. Kelly L, Patel SA, Narayan KMV, Prabhakaran D, Cunningham SA Measuring Social Networks for Medical Research in Lower-Income Settings PLoS One. 2014 Aug 25;9(8):e105161

Website : www.coecarrs.org

Oral health, habits and risk factors in urban India: The CARRS-Oral health study

Name Funding Body Duration Status Team
Oral health, habits and risk factors in urban India: The CARRS-Oral health study National Heart Lung Blood Institute (USA) and United Health (USA)- through Centre for Excellence (COE)- CARRS, Emory University (USA)- through South Asian Health and Wellness Tracking Program July 2014-August 2015 On-going Prof D Prabhakaran
Col Prof Nikhil Tandon, Prof KM Venkat Narayan, Dr Safraj S Hameed, Dr Ajay VS, Dr Roopa S.

 

About

The overall goal was to develop and integrate an oral health component into the established Cardio Metabolic Disease (CMD) Surveillance system. The aim is to recruit a total of 1970 randomly selected participants of age 20 years or above from Delhi site of the CARRS cohort II. The cross sectional study is in accordance with the WHO STEP wise approach and includes both; a questionnaire and clinical examination. Clinical examination is conducted by qualified and trained dentists at camp settings established at neighbourhood locations. Arrangements have been made for referral of participants to nearby dental care facility whenever required. The study would help us estimate the levels of oral diseases and oral habits in the population and ascertain the prevalence of oral diseases in participants with CMDs such as diabetes.

CARRS- GIS study

Name Funding Body Duration Status Team
CARRS- GIS study NHLBI 2013- 2015 Completed Technical Consultant: Prof Atiqur Rahman, Department of Geography. Jamia Milia Islamia University
Project Manager: Safraj

 

About

The Geographical Information System (GIS) component of CARRS surveillance study aims to investigate whether neighbourhood built environment characteristics such as access to parks and other recreational facilities are associated with CMD and risk factors. We proposed to spatially locate CARRS study households numbering over 8000, capture location details of select neighbourhood built environment features and perform GIS analysis of participant data overlaid on geographic data.

Publications

Atiqur Rahman, Safraj Shahul Hameed, Mohammed Tayyab, Nikhil Tandon, Dorairaj Prabhakaran (2015). Built Environment, Cardio Metabolic Diseases and Their Risk Factors in South Asia: The CARRS-GIS Study, Source Book of Management of the Public Infrastructure, (Eds.) Sigamani Panneer, N U Khan, G Ramachandran, Bloomsbury Publishing, New Delhi, ISBN: 978-93-84898-79-9, pp. 362-363

Health and environmental implications of low-carbon, climate-change resilient diets in India

Name Funding Body Duration Status Team
Health and environmental implications of low-carbon, climate-change resilient diets in India Wellcome Trust, UK Nov 2014-Oct 2016 ongoing Alan Dangour (LSHTM, UK), Rosemarry Green (LSHTM, UK)

 

About

This project involves experts in health, nutrition, environment, agriculture and mathematical modelling working together to develop an extremely complex and accurate model to analyse climate change resilients low carbon content dietary pattern in India.

Publications

Atiqur Rahman, Safraj Shahul Hameed, Mohammed Tayyab, Nikhil Tandon, Dorairaj Prabhakaran (2015). Built Environment, Cardio Metabolic Diseases and Their Risk Factors in South Asia: The CARRS-GIS Study, Source Book of Management of the Public Infrastructure, (Eds.) Sigamani Panneer, N U Khan, G Ramachandran, Bloomsbury Publishing, New Delhi, ISBN: 978-93-84898-79-9, pp. 362-363

Media Coverage

Nature Climate Change 5, 405–407 (2015) doi:10.1038/nclimate2630 http://www.nature.com/nclimate/journal/v5/n5/full/nclimate2630.html

Papers in progress

Systematic review of dietary patterns in India

Systematic review of environmental impacts of sustainable diets

Systematic review /analysis of determinants of processed food consumption in India

Indian dietary patterns and their health impacts

Environmental impacts of Indian dietary patterns

Estimating greenhouse gas emissions for Indian food items

Estimating water footprints for Indian food items

Website: http://www.wellcome.ac.uk/Funding/Strategic-funding/Our-planet-our-health/Funded-projects/Global-food-systems-and-health/WTS058414.htm

DISHA Study - Diet and Lifestyle InterventionS for Hypertension Risk-reduction through Anganwadi Workers and Accredited Social Health Activists

Name Funding Body Duration Status Team
Scientific Title: “Effectiveness of diet and lifestyle intervention through Information Education Communication (IEC) tools with Angan Wadi Centres (AWCs) as the centre of knowledge dissemination for hypertension (including hypercholesterolemia and diabetes) risk reduction – a cluster randomised controlled trial” ICMR 3 years Ongoing PI: Dr D Prabhakaran
CoI: Dr P Jeemon
Project Coordinator: Kashvi Kahol
Bio Statistician: Dr Dimple Kondal
Data Manager: Mumtaz Ali

 

About

This ICMR-funded multi-centre cluster randomised controlled trial aims to assess the effectiveness of diet and lifestyle intervention through Information Education Communication (IEC) tools with Angan Wadi Centres (AWCs) as the centre of knowledge dissemination for Non-communicable Disease risk reduction. This Cluster RCT comprises of 3 parts: i) Baseline Survey ii) Intervention Phase iii) Repeat Survey/End Line Survey. With the primary objective of the study being to assess the effectiveness of intense versus usual IEC interventions on diet and lifestyle modifications delivered by existing community-level health-workers (ASHA or equivalent) on population level blood pressure. The study also aims to assess the operational feasibility of integrating NCD risk reduction in community health programs, usefulness of trained healthcare workers to affect changes in dietary fat, fibre and salt, tobacco and alcohol consumption and increasing physical activity and to assess the efficacy of these interventions to evaluate changes in lipid levels and glycemia.

Participants

The study is being implemented in two phases, with each phase having 5 sites each. With ICMR being the funding body, we are the central coordinating centre for the study. In phase we centrally coordinate the following centres

  1. Sri Aurbindo Institute of Medical Sciences, Indore
  2. Aga Khan Health Services, Mumbai (the work is being implemented in Junagadh)
  3. Pondicherry Institute of Medical Sciences, Puducherry
  4. Indra Gandhi Medical College, Shimla
  5. Rajendra Prasad Government Medical College, Tanda

We are running in the 3 part of the study, which is the end-line survey. In Phase II we coordinate 5 sites and the study is now beginning with the second part which is the intervention phase.

  1. Regional Medical Research Centre, Bhubaneswar
  2. National Institute of Nutrition, Hyderabad
  3. Desert Medical Research Centre, Jodhpur
  4. Rajendra Memorial Research Institute of Medical Sciences, Patna and Rajendra Institute of Medical Sciences (RIMS) Ranchi
  5. Regional Institute of Medical Research, Dibrugarh

Effect of Docosa-hexaenoic acid (DHA) Supplementation during pregnancy on Newborn outcomes in India – DHANI trial

Name Funding Body Duration Status Team
Effect of Docosa-hexaenoic acid (DHA) Supplementation during pregnancy on Newborn outcomes in India – the DHANI randomized controlled trial 1st Dec 2015-December, 2020 Ongoing Principal Investigator - Dr. Shweta Khandelwal

Co-Investigator (S) –
  • Prof Nikhil Tandon, AIIMS, New Delhi, India
  • Prof Aryeh Stein, EMORY, Atlanta, USA
  • Prof Reynaldo Martorell, EMORY, Atlanta, USA (CHAIR)
  • Dr Usha Ramakrishnan, EMORY, Atlanta, USA
  • Prof D Prabhakaran, CCDC/PHFI, New Delhi, India
  • Prof K Srinath Reddy, PHFI, New Delhi, India (CO-CHAIR)

 

About

Docosahexaenoic acid (DHA), a long chain omega-3 fatty acid is an important structural component of membranes in brain and retina. Indian diets are typically deficient in DHA. Recent evidence suggests prenatal DHA supplementation could enhance birth outcomes. Therefore the present study was designed as a double-blinded placebo-controlled RCT which aims to examine the effect of prenatal DHA supplementation on the offspring neurodevelopment (primary outcome), gestational age and anthropometry (birth-weight, length and head circumference) and morbidity patterns through 12 months. This trial will be carried out at the Prabhakar Kore Hospital (PKH) under the Jawaharlal Nehru Medical College (JNMC), Belgaum, Karnataka. Objectives – Primary Objectives – To compare the effect of supplementing pregnant women (from ≤20 weeks of gestation through 6 months postpartum) with a daily dose of 400mg DHA supplements against placebo on the birth weight and gestational age of their newborn. Infant neurodevelopment at ages 6- and 12-months using validated the Development Assessment Scale for Indian Infants. Secondary Objectives - To compare other anthropometric measurements in the newborn (i.e, crown-heel length and head circumference). In addition to comparing APGAR score at 1 and 5 min between the two groups. Infant body size and morbidity patterns through 12 months.

Impact

The proposed RCT will be the first to examine the effects of in-utero and early life DHA exposure (through maternal supplementation from mid-pregnancy through 6 months postpartum) on postnatal neurodevelopment and body-size of Indian infants. Results of this trial will lead to advanced understanding of the role of maternal DHA supplementation on in-utero and early-life cognitive and motor development among their infants.

Genomic and life style predictors of foetal outcome relevant to diabetes and obesity and their relevance to prevention strategies in south Asian people (GIFTS)

Name Funding Body Duration Status Team
Genomic and life style predictors of foetal outcome relevant to diabetes and obesity and their relevance to prevention strategies in south Asian people (GIFTS) European Union 2012-2015 (six months extension) Ongoing PI: Sanjay Kinra

 

About

This project aims to investigate lifestyle predictors of foetal outcome to diabetes and obesity in South Asian people. For this, SANCD, now part of CCCI as a collaborator is developing low cost nutritional assays using micro-quantities of serum, plasma or blood.

Partners

Queen Mary and Westfield College, University of Oslo Norway; King Edward Memorial Hospital Research Centre Pune India;  Baqai Medical University Pakistan University; Bangladesh Institute of Health Sciences; Public Health Foundation of India; University of Southampton UK; London School of Hygiene and Tropical Medicine; University of Bristol UK; University of Exeter UK;  Centre for Cellular and Molecular Biology India;Technische Universitat Dresden Germany; University of Helsinki Finland; University of East London UK; University College London UK

Impact

We have standardized assays like fatty acids using gas chromatography, homocysteine using ELISA and Vitamin D from dried blood spots. The assays have been validated against standard methods.

We have also standardized high quality DNA isolation from dried blood spots. The isolated DNA was also tested for medium and high through put genotyping platforms like Sequenom Mass Spectrometer, Illumina iScan and Fluidigm. This will help in conducting genetic research in large epidemiological studies by collecting comparatively less invasive and economical biological samples (Dry blood samples instead of intravenous blood).

mWellcare - An integrated mHealth system for the prevention and care of chronic conditions

Name Funding Body Duration Status Team
mWellcare - An integrated mHealth system for the prevention and care of chronic conditions Wellcome Trust 3 Years Recruitment will start from March/April 2016 Principal Investigators:
Prof. D Prabhakaran (PHFI)
Prof. Vikram Patel (LSHTM)

Co-Investigators:
Prof. K Srinath Reddy (PHFI)
Prof. Nikhil Tandon (AIIMS)
Dr Pablo Perel (LSHTM)
Dr Ambuj Roy (AIIMS)

 

About

Cardiovascular diseases (CVDs) account for a third of total mortality in India and are projected to increase dramatically. Common modifiable risk factors for CVDs can be detected early and can be controlled by cost effective, widely available interventions. The major barriers to controlling these conditions in India and elsewhere are low detection rates, inadequate use of evidence based interventions and low adherence with these interventions. Common mental disorders such as anxiety and depression are frequently co-morbid with CVD risk factors and often contribute to failure to follow treatment plans. Primary health care is the appropriate setting for improving the prevention and management of these chronic conditions. We will develop and evaluate an innovative mobile health (mHealth) software application -mWellcare which provides a patient health profile, decision support for clinical care, monitoring and feedback for use in Indian Community Health Centers (CHCs). We will conduct this research following the steps proposed by the MRC for evaluation of complex interventions. Technical development of mWellcare will be conducted, user acceptability appraised and potential barriers overcome. mWellcare will be evaluated in 40 CHCs of two states, Harayana and Karnataka to determine its effectiveness on the management of patients with hypertension and/or diabetes based on their clinical outcomes (systolic blood pressure and HbA1c) compared to an enhanced care arm using a cluster randomized study design over a period of twelve months. In parallel a business plan will be established to enable the scaling up and sustainability of mWellcare.

Management of Acute Coronary Events (MACE) Registry

Name Funding Body Duration Status Team
Management of Acute Coronary Events (MACE) Registry ICMR Ongoing

 

About

An up to date registry data on acute coronary syndrome (ACS) is required in India to incorporate evidence-based medicine in treatment and to gather information on long term outcomes of patients. This will lead to an efficient coordination of ACS prevention, treatment and rehabilitation. The MACE registry study is funded by ICMR and coordinated by CCDC and St. John’s Medical College, Bangalore. This feasibility study aims to provide a framework for data collection which may provide cost effective strategies to reduce the burden of ACS, as well as provide country specific optimal management strategies to reduce mortality due to ACS. It is expected that initiation of MACE Registry at multiple sites in the country will contribute towards improving the understanding of ACS patient characteristics and establishing country specific guidelines for management of ACS. CCDC trained the participating centres and also helped develop the web module.

Enhanced integration of primary and secondary health systems and patient empowerment through improved continuity of patient care and clinical handover – Development Phase I

Name Funding Body Duration Status Team
Enhanced integration of primary and secondary health systems and patient empowerment through improved continuity of patient care and clinical handover – Development Phase I Wellcome Trust December 2014-November 2015 Completed Principal Investigators:
Prof. D Prabhakaran (PHFI)

Project partner: Dr. Jeemon Panniyammakal– Lead project investigator in Delhi

 

About

Effective integration of care between community (primary) and hospital care (secondary) health services is essential for a patient whose needs extend beyond the initial episode, and more care is required by the next level of health provider. This may include referral to a hospital if a primary care doctor cannot manage the condition or the continuation of medication and check-ups in the primary care after a hospital admission. The crucial stage is communication of patient-specific information from one caregiver to another or to the patient and family, to ensure patient care continuity and safety. This is known as clinical handover. Clinical handover, or the patient information exchange, occurs within an institution (e.g. hospital) or between different institutions (e.g. Hospital and primary care)

Studies in the high-income countries have shown ineffective handover can lead to incorrect treatment, delays in medical diagnosis, life-threatening adverse events, patient complaints, increased health care expenditure, increased length of stay, increased re-admissions, and other impacts on health systems. We think this is also the case in low and middle incomes countries like India, and so considerable scope exists to improve practice in a way that is cost-effective and potentially even cost releasing. The aim of this project is to look at medical information exchange about patients between healthcare providers in primary and secondary centres in India. This means we want to describe how and what happens between healthcare providers (e.g. nurses, doctors, community health workers) when the patient is discharged from the hospital (secondary to primary care) or referred from primary care healthcare providers to hospitals. We also want to see what information is given to the patients by the healthcare providers at these times.

Objectives

1.To describe the existing situation of exchanging patient information in terms of:

  • Policies (laws and guidelines for healthcare providers to follow),
  • Training for healthcare providers,
  • Activities (what happens at patient discharge and referral), and
  • Culture (what do patients/healthcare providers think about medical information exchange and its importance) for clinical handover between primary and secondary care during referrals and discharge

2. To identify things that may be stopping good medical information exchange be-tween healthcare providers in primary and secondary care, and identify motivators and things that will help improve information exchange

3. To develop ideas and interventions that could improve the situation of medical in-formation exchange between primary and secondary care (clinical handover) in India.

Website : http://www.birmingham.ac.uk/research/activity/mds/projects/HaPS/PCCS/handover-india/index.aspx

SOLAN SURVEILLANCE STUDY (SSS)

Name Funding Body Duration Status Team
Solan Surveillance Study (SSS) Medtronic Foundation, NHLBI & ICMR 2 years Completed PIs: Dr. D. Prabhakaran & Dr. Nikhil Tandon;Co-I: Dr. Ajay V.S., Dr. Devraj Jindal; Project Coordinator: Dr. Abha Pawar

 

About

SSS is a Health system intervention project to reduce CVD in Solan District of Himachal Pradesh. Overall aim of Solan Surveillance study (SSS) was to develop a model surveillance system for cardio-metabolic diseases (CMDs) and its risk factors in rural India. SSS is uniquely positioned to generate reliable data on the burden of the CMD and their risk factors in the rural Indian population and address the vital gaps in research data in order to help formulate evidence based health policies for the protection and promotion of cardio-metabolic health in the Indian Population.

The SSS was implemented by Centre for Chronic Disease Control (CCDC) and All India Institute of Medical Sciences (AIIMS) in collaboration with government of Himachal Pradesh. The study, has established a database of 40,000 individuals above the age of 20 years residing in well-defined rural communities (38 sub-centre areas) of Solan. The sub-centers chosen are adjoining the Community Health Centers (CHCs: Dharampur, Kunihar, Dharlagarh, and Syri) and the regional hospital in Solan.

Twenty eight Community Health Workers (CHWs) were selected and trained, who visited all the households in these sub-center areas. They, through a tablet computer based software, gathered health data information encompassing broad categories such as: demographic and socio-economic characteristics of the population; presence of CMDs and its risk factors; previous or existing target organ damage, female reproductive history, quality of life, disability, health care utilization; quality, and cost(s) of care. People identified with hypertension or diabetes were linked to their respective CHCs and were given necessary medical care.

Blood Sample Collection: With the help of 15 phlebotomists, blood sample collection was carried out in study areas to collect the blood samples of 8000 randomly selected participants. The phlebotomists made the appointment with the participant by informing them before visiting their houses. Report of blood investigations (lipid profile, fasting blood sugars, Hba1c, Serum urea & Creatinine) were delivered within 10 days of the blood collection to the participants.

Dry Blood Spot Study

Name Funding Body Duration Status Team
Dry Blood Spot Study 2010-2012 Completed

 

About

The aim of this collaboration is to extend the National Institute of Nutrition’s (NIN) Monitoring Survey (2009-11) by collection of dried blood spots for subsequent DNA extraction and creation of a DNA bio-repository for genetic epidemiological studies.

Participating Institutes: National institute of Nutrition (NIN); South Asia Network for Chronic Disease (SANCD)

Impact

We collected ~35,000 dry blood spot samples from rural areas of 10 states of Indian to create bio-bank for conducting nutrition based genetic epidemiological studies. We extended this project by collecting ~15,000 DBS samples of urban areas as well in 10 Indian states. Funds from European Union funded GIFTS grant helped in standardizing high yield DNA extraction from DBS and measuring biochemical assays like C-reactive protein, triglycerides, etc.

Genomic & Epigenomic Complex Disease Epidemiology (GEoCoDE)

Name Funding Body Duration Status Team
Genomic & Epigenomic Complex Disease Epidemiology European Union 4 years (2010 – 2014) Completed PI: Prof. George Davey Smith

 

About

The EU FP7 project Genomic & Epigenomic Complex Disease Epidemiology (GEoCoDE) collaboration, of which SANCD is a partner, has provided opportunities for staff exchanges between SANCD and University of Bristorl, UK, focusing on increasing epigenetic knowledge and practical laboratory skills.

Partners

  • University of Bristol, MRC CAiTE
  • University of Newcastle
  • University of Southampton
  • University of Exeter
  • International Agency for Research on Cancer, Lyon, France
  • University of Turin, Italy
  • Erasmus University Medical Centre, Rotterdam, The Netherlands
  • Centre de Recerca en Epidemiologia Ambiental, Spain
  • University of Western Australia
  • University of Queensland, Australia
  • Federal University of Pelotas, Brazil
  • University of Sao Paolo, Brazil
  • National Institute of Cancer, Rio de Janeiro, Brazil
  • University of Alberta, Canada
  • Nanjing Medical University, China
  • South Asia Centre for Chronic Diseases, Public Health Foundation of India, New Delhi, India
  • Centre for Cellular and Molecular Biology, Hyderabad, India
  • King Edward Memorial Hospital, Pune, India
  • Tata Memorial Hospital, Mumbai, India
  • Massey University, Wellington, New Zealand
  • University of the Witwatersrand, Johannesburg, South Africa
  • University of Cape Town, South Africa
  • North Western University, Department of Medicine, Feinberg School of Medicine, Chicago
  • Children's Hospital of Philadelphia, USA

Impact

Dr. Gagandeep Kaur Walia Academic Visit to
  • Newcastle University (May-June 2010) for epigenetic laboratory and statistical techniques involved in DNA methylation data
  • University of Bristol (September-October 2013) to perform data cleaning and analyze cardio-metabochip and 450k DNA methylation data
Dr. Vipin Gupta Academic Visit during March-June, 2011 for training in
  • Epigenetic Epidemiology: Newcastle University
  • Genomic Epidemiology:   University of Bristol and LSHTM
Publications
  1. Taylor AESandeep MNJanipalli CSGiambartolomei CEvans DMKranthi Kumar MVVinay DGSmitha PGupta VAruna MKinra SSullivan RMBowen L,Timpson NJDavey Smith GDudbridge FPrabhakaran DBen-Shlomo YReddy KSEbrahim SChandak GR. Associations of FTO and MC4R variants with obesity traits in Indians and the role of rural/urban environment as a possible effect modifier. J Obesity, 2011. 2011:307542.
  2. Gupta VVinay DGRafiq SKranthikumar MVJanipalli CSGiambartolomei CEvans DMMani KRSandeep MNTaylor AEKinra SSullivan RMBowen L,Timpson NJSmith GDDudbridge FPrabhakaran DBen-Shlomo YReddy KSEbrahim SChandak GRIndian Migration Study Group. Association analysis of 31 common polymorphisms with type 2 diabetes and its related traits in Indian sib pairs. Diabetologia, 2012. 55:349-357.
  3. Gupta VVinay DGSovio URafiq SKranthi Kumar MVJanipalli CSEvans DMani KRSandeep MNTaylor AKinra SSullivan RBowen LTimpson N,Smith GDDudbridge FPrabhakaran DBen-Shlomo YReddy KSEbrahim SChandak GRIndian Migration Study Group. Association analysis of 25 type 2 diabetes related loci with measures of obesity in Indian sib pairs. PLoS ONE. 2013. 8:e53944.
  4. Rafiq SVenkata KKGupta VVinay DGSpurgeon CJParameshwaran SMadana SNKinra SBowen LTimpson NJSmith GDDudbridge FPrabhakaran DBen-Shlomo YReddy KSEbrahim SChandak GRIndian Migration Study Group. Evaluation of seven common lipid associated loci in a large Indian sib pair study. Lipids Health Dis. 2012. 11:155.
  5. Elliott HR, Walia GK, Groom A, Duggirala A, Reddy U, Chandak GR, Gupta V, et al. Migration and DNA methylation: An Indo-European comparison of methylation patterns in type 2 diabetes susceptibility genes. J Diab Res Clin Metab, 2013, doi: 10.7243/2050-0866-2-6.
  6. Gupta V and Ebrahim S. Comment on: Chauhan et al. Impact of common variants of PPARG, KCNJ11, TCF7L2, SLC30A8, HHEX, CDKN2A, IGF2BP2 and CDKAL1 on the risk of type 2 diabetes in 5164 Indians. Diabetes. 2010. 59:2068-2074.
  7. Walia GK, Gupta V, Aggarwal A, Asghar M, Dudbridge F, Timpson N, Singh NS, Kumar RM, Kinra S, prabhakaran D, Reddy KS, CHandan GR, Smith GD, Ebrahim S. Association of common genetic variants with lipid traits in Indian population. PLoS ONE 9(7): e101688

Website: http://www.bristol.ac.uk/caite/geocode/

Environmental and Genetic Determinants of Obesity and Diabetes in India

Name Funding Body Duration Status Team
Environmental and Genetic Determinants of Obesity and Diabetes in India Wellcome Trust, UK 2010-2014 Completed PI: Prof. Shah Ebrahim
Co-I: Prof. George Davey Smith, Dr D Prabhakaran, Dr K Srinath Reddy, Dr Vipin Gupta, SANCD, PHFI

 

About

The overall aim of this study is to examine roles of candidate genetic variants and migration on risk of obesity and diabetes in population samples of Indian adults in north, central and southern India. Our specific objectives are: a) conduct SNP genotyping for these genes for which there is strong evidence in European populations of association with obesity, diabetes and cardiovascular risk factors to determine their prevalence in Indians drawn from geographically and culturally diverse populations, b) to compare the frequency of these SNP markers in Indian rural-urban migrants and non-migrants, c) to examine whether these SNP markers are associated with obesity phenotypes (BMI, waist circumference, % body fat) and diabetes phenotypes (diagnosed, fasting blood glucose, insulin resistance) in migrants and non-migrants. The role of mediating variables (e.g. BMI for gene-diabetes associations; physical activity for gene-obesity associations) will also be examined. This work has been extended through a Wellcome Trust enhancement award with the objectives of collecting more detailed genetic markers using the Metabochip (around 200,000 SNPs) relevant to obesity, diabetes and cardiovascular disease and to conduct new epigenetic studies which aim to examine how environmental factors, particularly over and under-nutrition affect gene expression.

Impact

With the original grant we genotyped 70 SNPs (GWAS loci related to cardiometabolic disease traits in western populations) on all 7000 participants. In addition, we have genotypic data on population informative markers: lactase persistence and skin pigmentation, for the evaluation of population structure. With the help of this data we could validate GWAS loci related to glycemic, obesity and lipid traits in Indian population. We validated variants of FTO and MC4R with obesity and body mass index (Taylor et al. 2011). We also found association of four GWAS loci (TCF7L2, ADAM30, CDKN2A/B and CDKAL1) with type 2 diabetes and its related intermediate traits (Gupta et al. 2010). We also robustly validated nine GWAS variants related to lipids (APOA5, GCKR, LPL, LDLR, APOB, APOA1, CETP, TRIB1 and CELSR2-PSRC1-SORT1) in Indian population (Raffiq et al. 2012; Walia et al. Communicated article). The strength of a large sample size (~3500 sib pairs) and sib-pair design provided resistance from population stratification and increased the reliability of these finding in India.

We also generated DNA methylation data on type 2 diabetes susceptibility loci (FTO, ADCY5 and KCNJ11) on 92 sib-pairs each from North and South India that highlighted geographical and ethnic differences in methylation patterns that may be attributed to genetic and/or region-specific environmental factors (Elliott et al. 2013).

With the help of enhancement grant, a total of 5076 samples (2538 sib-pairs) were run for cardio-metabochips. This coustomized chip is a collection of 200,000 genetic variants reported to be associated with different cardiometabolic traits. This will help us in validating GWAS loci for cardiometabolic traits in Indian population and conducting some mendelian randomization experiments for establishing causal inferences. We also generated 450k methylation data on 90 Hyderabad sib pairs (180 subjects). In this epigenetic component we aim to explore the urban/rural methylation differences among same sex sib pairs in India and comparing those differences with European populations. In addition, we aim to identify genotype-epigenotype correlations of regions related to obesity and diabetes in IMS participants and finally for strengthening causal inference regarding the role of epigenetic variation in disease in an Indian context.

  • Dr. Hannah Elliott presented “Migration and DNA methylation: a comparison of methylation patterns in type 2 diabetes susceptibility genes between Indians and Europeans” in 62nd Annual Meeting of American Society of Human Genetics (ASHG) held in San Francisco, California from 6-10 November 2012 Dr. Gagandeep Kaur Walia presented “Association of Lipid traits with common genetic variants in Indian population” in PHFI Research Symposium held in New Delhi from 7-8 January, 2013
  • A 2-day hands-on training course was organised at CCMB, Hyderabad, in 2010, in collaboration with Dr Frank Dudbridge from LSHTM. The course had 25 participants including researchers at CCMB, SANCD and from University of Newcastle. There was intense discussion on various methodologies and approaches for undertaking association analysis of various SNPs with intermediate traits in the Indian Migration Study. Different groups have been assigned responsibility to analysis various traits.
  • Dr. Hannah Elliott and Dr. Alix Groom from Newcastle University presented the preliminary findings of DNA methylation data generated to type 2 diabetes susceptibility genes to the group to invite suggestions for statistical methods to be used for family based design in the workshop mentioned above.
  • The preliminary findings of the data generated on 70SNPs were presented to academic audience in University of Bristol and Newcastle University by Dr. Vipin Gupta and Dr. Gagandeep Kaur Walia respectively in 2010 and 2011 to invite suggestions and comments for meaningful interpretations.

Publications

  1. Kulanthinal et al. Estimation of additive genetic and environmental sources of quantitative trait variation using data on married couples and their siblings. Genet Res 2008; 90:269
  2. Ebrahim S, Kinra S, Bowen L et al. The effect of rural-to-urban migration on obesity and diabetes in India: a cross-sectional study. PLoS Med 2010; 7(4):e1000268
  3. Kinra S, Bowen L, Lyngdoh T, Prabhakaran D, Reddy KS, Ramakrishnan L, et al. Sociodemographic patterning of non-communicable disease risk factors in rural India: a cross sectional study. BMJ 2010;341:c4974. doi:10.1136/bmj.c4974
  4. Kinra S, Andersen E, Ben-Shlomo Y et al. Association Between Urban Life-Years and Cardiometabolic Risk: The Indian Migration Study. Am J Epidemiol.2011 DOI: 10.1093/aje/kwr053
  5. Taylor AESandeep MNJanipalli CSGiambartolomei CEvans DMKranthi Kumar MVVinay DGSmitha PGupta VAruna MKinra SSullivan RMBowen L,Timpson NJDavey Smith GDudbridge FPrabhakaran DBen-Shlomo YReddy KSEbrahim SChandak GR. Associations of FTO and MC4R variants with obesity traits in Indians and the role of rural/urban environment as a possible effect modifier. J Obesity, 2011. 2011:307542.
  6. Gupta VVinay DGRafiq SKranthikumar MVJanipalli CSGiambartolomei CEvans DMMani KRSandeep MNTaylor AEKinra SSullivan RMBowen L,Timpson NJSmith GDDudbridge FPrabhakaran DBen-Shlomo YReddy KSEbrahim SChandak GRIndian Migration Study Group. Association analysis of 31 common polymorphisms with type 2 diabetes and its related traits in Indian sib pairs. Diabetologia, 2012. 55:349-357.
  7. Gupta VVinay DGSovio URafiq SKranthi Kumar MVJanipalli CSEvans DMani KRSandeep MNTaylor AKinra SSullivan RBowen LTimpson N,Smith GDDudbridge FPrabhakaran DBen-Shlomo YReddy KSEbrahim SChandak GRIndian Migration Study Group. Association analysis of 25 type 2 diabetes related loci with measures of obesity in Indian sib pairs. PLoS ONE. 2013. 8:e53944.
  8. Rafiq SVenkata KKGupta VVinay DGSpurgeon CJParameshwaran SMadana SNKinra SBowen LTimpson NJSmith GDDudbridge FPrabhakaran DBen-Shlomo YReddy KSEbrahim SChandak GRIndian Migration Study Group. Evaluation of seven common lipid associated loci in a large Indian sib pair study. Lipids Health Dis. 2012. 11:155.
  9. Elliott HR, Walia GK, Groom A, Duggirala A, Reddy U, Chandak GR, Gupta V, et al. Migration and DNA methylation: An Indo-European comparison of methylation patterns in type 2 diabetes susceptibility genes. J Diab Res Clin Metab, 2013, doi: 10.7243/2050-0866-2-6.
  10. Gupta V and Ebrahim S. Comment on: Chauhan et al. Impact of common variants of PPARG, KCNJ11, TCF7L2, SLC30A8, HHEX, CDKN2A, IGF2BP2 and CDKAL1 on the risk of type 2 diabetes in 5164 Indians. Diabetes. 2010. 59:2068-2074.
  11. Walia GK, Gupta V, Aggarwal A, Asghar M, Dudbridge F, Timpson N, Singh NS, Kumar RM, Kinra S, prabhakaran D, Reddy KS, CHandan GR, Smith GD, Ebrahim S. Association of common genetic variants with lipid traits in Indian population. PLoS ONE 9(7): e101688

Study on food acquisition and intra-household food consumption patterns

Name Funding Body Duration Status Team
Study on food acquisition and intra-household food consumption patterns Wellcome Trust, UK 2010-11 Completed Fiona Taylor, Swati Khurana, Vikal Tripathy, Ambika Satija, Neha Khandpur, Sutapa Agrawal, Manas Ranjan Pradhan

 

About

SANCD has completed study evaluating availability, cost and affordability of a healthy food basket, nutritional labeling as per current government directives, as well as food acquisition and intra-household food consumption patterns. The study aimed to explore food acquisition and intra-household consumption patterns in low and middle income (LMI) households in Delhi.

Impact

With the original grant we genotyped 70 SNPs (GWAS loci related to cardiometabolic disease traits in western populations) on all 7000 participants. In addition, we have genotypic data on population informative markers: lactase persistence and skin pigmentation, for the evaluation of population structure. With the help of this data we could validate GWAS loci related to glycemic, obesity and lipid traits in Indian population. We validated variants of FTO and MC4R with obesity and body mass index (Taylor et al. 2011). We also found association of four GWAS loci (TCF7L2, ADAM30, CDKN2A/B and CDKAL1) with type 2 diabetes and its related intermediate traits (Gupta et al. 2010). We also robustly validated nine GWAS variants related to lipids (APOA5, GCKR, LPL, LDLR, APOB, APOA1, CETP, TRIB1 and CELSR2-PSRC1-SORT1) in Indian population (Raffiq et al. 2012; Walia et al. Communicated article). The strength of a large sample size (~3500 sib pairs) and sib-pair design provided resistance from population stratification and increased the reliability of these finding in India.

Publications

Pradhan M, Taylor F, Agrawal S, Prabhakaran D, Ebrahim S. FOOD ACQUISITION AND INTRA-HOUSEHOLD CONSUMPTION PATTERNS: A STUDY OF LOW AND MIDDLE INCOME URBAN HOUSEHOLDS IN DELHI, INDIA. Indian J Community Health. 2013 Dec;25(4):391-402. PMCID: PMC4248079

Genetic Association study of Polymorphisms related to Chronic Obstructive Pulmonary Disease and its Measures, in North Indian Population: COPD Genetics Consortium

Name Funding Body Duration Status Team
Genetic Association study of Polymorphisms related to Chronic Obstructive Pulmonary Disease and its Measures, in North Indian Population: COPD Genetics Consortium Department of Biotechnology, India. Sept 2011-Sept 2014 (one year no cost till Sept 2015) Completed PI: Dr D Prabhakaran Co-PIs: Dr. Randeep Gularia, Prof. Raj Kumar, Prof. Dhurva Chaudhry, Prof. Rajiv Paliwal, Dr. D Gupta, Dr. Vipin Gupta

 

About

SANCD, now part of CCCI initiated the Chronic Obstructive Pulmonary Disease consortium in India along with various clinicians, geneticists, anthropologists to enroll the cases and controls for COPD and also collect high altitude population based lung functions data. The purpose of this study is to evaluate the genetic and environmental determinants of chronic obstructive pulmonary disease (and their interactions) in North Indian populations through a multi-centre study. All India Institute of Medical Sciences(AIIMS), New Delhi; Vallabhbhai Patel Chest Institute (VPCI), University of Delhi; Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh ; Post Graduate Institute of Medical Sciences, Rohtak, Haryana; Pramukhswami Medical College(PSMC), Gujarat are the collaborating partner institutes for this project.

Impact

Not much effort has gone into understanding risk factors of respiratory disorders in Indian despite their huge epidemiological burden. COPD genetics consortium will help in validating GWAS loci in North Indian population that were identified in Europeans. Since the participants are intensively phenotyped for all the associated risk factors, it will also help in examining the environmental and lifestyle factors of COPD in India.

We have recruited a total of 3192 participants in the study. Out of these, there are 1087 COPD cases and 1709 controls recruited from six hospitals in North India and 396 participants were recruited from the population based settings. We have standardized 34 GWAS loci related to COPD and lung function and have genotyped 1152 samples and the data quality was found to be satisfactory after assessing quality control checks.

Publications

Walia GK, Vellakkal R, Gupta V. Chronic Obstructive Pulmonary Disease and its Non-Smoking Risk Factors in India. COPD: Journal of Chronic Obstructive Pulmonary Disease 2015 Oct 9:1-11

Gupta V, Ebrahim S . Genomics of Chronic Obstructive Pulmonary Disease . In: Jindal SK , Vijayan VK (Eds.). World Clinics Pulmonary and Critical Care Medicine. Chronic Obstructive Pulmonary Disease . New Delhi : Jaypee Brothers Medical Publishers (P) Ltd . 2013 ; 2 : 55 – 71

Diet, inflammation and cardio-metabolic outcomes in a longitudinal birth cohort

Name Funding Body Duration Status Team
Diet, inflammation and cardio-metabolic outcomes in a longitudinal birth cohort Department of Biotechnology, India. 2013-2014 Completed PI: Preet Dhillon; Co-Is: Ruby Gupta, D.Prabhakaran, Shweta Khandelwal

 

About

This one year project funded by Department of Biotechnology, Govt. of India got approval in 2013. In this project the association between diet and inflammatory markers, biochemical cardio-metabolic outcomes (e.g., glucose, triglycerides), measures of adiposity and blood pressure in a sample of n=1000 men and women aged 40+ years from APCAPS will be investigated. More specifically, the study will evaluate associations of food groups, macro- and micro-nutrients, fats and fatty acids and specific food items with five inflammatory biomarkers in this rural population. This study will also evaluate how changes in the diet, cardio-metabolic outcomes and adiposity are associated with changes in inflammatory biomarkers (e.g., CRP) where repeat measurements are available (n~500).

Impact

CCCI Seminar by Krithiga Shridhar “Cardiovascular risk factors linked to saturated fats are not mediated through inflammatory bio-markers: Evidence from Andhra Pradesh Children and Parents Study (APCAPS).”

International trial CORONARY (CABG off or on pump revascularization study)

Name Funding Body Duration Status Team
International trial CORONARY (CABG off or on pump revascularization study) Canadian Institute for Health Research and centrally coordinated by the Population Health Research Institute based at the McMaster University, Canada. 7 Years; 2009-2015 Completed PI-Dr. Dorairaj Prabhakaran Project Coordinator- Kavita Singh, Raji Devarajan

 

About

The CABG off or On Pump Revascularization Study (CORONARY) is the largest, randomized-controlled surgical trial to date that was designed to evaluate the safety and long-term outcomes of CABG patient who underwent either off-pump or on-pump surgery. The primary objective of the study is to determine whether off-pump CABG surgery compared to on-pump CABG surgery reduces major clinical vascular events in the short term (30 days) and whether the benefits are maintained at long term (5 years) in patients undergoing isolated CABG surgery. The trial has recruited 4700 patients worldwide and 1307 participants were recruited from India. The study has a planned follow-up of at least 5 years. At 1-year, no significant difference was observed between either methods of CABG surgery in the primary composite outcome. Also, the CORONARY trial demonstrated that off-pump CABG was clinically as safe and effective as on-pump with no difference in costs. Thus the decision as to which method to choose is free from costs restraints and should be based on patient preference and surgeon expertise. The final visits for study participants were completed in December 2015.

Publications

  1. Lamy A, Devereaux PJ, Prabhakaran D, Hu S, Piegas LS, Straka Z, Paolasso E, Taggart D, Lanas F, Akar AR, Jain A, Noiseux N, Ou Y, Chrolavicius S, Ng J, Yusuf S. Rationale and design of the coronary artery bypass grafting surgery off or on pump revascularization study: a large international randomized trial in cardiac surgery. Am Heart J. 2012 Jan;163(1):1-6.
  2. Garg AX, Devereaux PJ, Yusuf S, Cuerden MS, Parikh CR, Coca SG, Walsh M, Cook RJ, Whitlock RP, Noiseux N, Novick RJ, Ou Y, Lamy A; CORONARY Investigators. Coronary Artery Bypass Grafting Surgery Off- or On-pump Revascularisation Study (CORONARY): kidney substudy analytic protocol of an international randomised controlled trial. BMJ Open. 2012 Apr 18;2(2):e001080.
  3. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, Straka Z, Piegas LS, Akar AR, Jain AR, Noiseux N, Padmanabhan C, Bahamondes JC, Novick RJ, Vaijyanath P, Reddy S, Tao L, Olavegogeascoechea PA, Airan B, Sulling TA, Whitlock RP, Ou Y, Ng J, Chrolavicius S, Yusuf S; CORONARY Investigators. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012 Apr 19;366(16):1489-97.
  4. Lamy A, Tong W, Devereaux PJ, Gao P, Gafni A, Singh K, Taggart D, Straka Z, Akar AR, Piegas L, Ou Y, Yusuf S. The cost implications of off-pump versus on-pump coronary artery bypass graft surgery at one year. Ann Thorac Surg. 2014 Nov;98(5):1620-5.

Website: https://rome.phri.ca/coronary/Default.aspx

m-Power Heart Project

Name Funding Body Duration Status Team
m-Power Heart Project Medtronic Foundation 2 years Completed PI: Dr. D. Prabhakaran Co-PI: Dr. Nikhil Tandon Co-I: Dr. Ajay V.S. Project Coordinator: Dr. Devraj Jindal & Mr. Rakshit Sharma

 

About

The Centre for Chronic Disease Control (CCDC), now part of CCCI and All India Institute of Medical Sciences (AIIMS) collaborated with the Government of Himachal Pradesh to develop and pilot a model project “m-Power Heart” for the prevention and control of hypertension and diabetes in Solan District which could be replicated in entire India. “m-Power Heart” project was carried out at the 5 Community Health Centers (CHCs) and the regional hospital of Solan District.

The primary objective of this project was:

To design a feasible and sustainable evidence-based, decision support-enabled, health care delivery model for the management of hypertension and diabetes in the primary health care facilities of Himachal Pradesh.

The specific components of the project were:

  • Setting up of Non-Communicable Diseases (NCD) clinic at all the CHCs of Solan District
  • Quality improvement strategies for care delivery at CHCs through a structured training program for the health care team and use of clinical management guidelines
  • Deployment of smart-phone based Decision Support System (DSS) at NCD clinics to facilitate evidence based care
  • Setting-up of a referral clinic at Regional Hospital, Solan

Surgical Intervention for Ischaemic Heart Failure Extension Study (STICHES)

Name Funding Body Duration Status Team
Surgical Intervention for Ischaemic Heart Failure Extension Study (STICHES) National Heart, Lung and Blood Institute Study was started in 2004 and 10 year follow-up completed by November 2015 Completed Prof. Eric Velazquez, Kerry L Lee,Daniel B Mark, Christopher M. O’Connor, Robert M. Califf, Robert H. Jones; Country PI- Prof. D Prabhakaran, Project Manager- Dr. J Panniyammakal, Clinical Research Associate- Dr. Suganthi Jaganathan

 

About

The STICH Trial completed enrolment of 1,212 subjects, which included 168 subjects randomized in India, in whom the responsible physicians were at equipoise regarding the benefits of myocardial revascularization in May 2007. Patients were randomized 1:1 to continuing optimal medical therapy (MED) with or without Coronary Artery Bypass Graft (CABG) to test whether CABG leads to the hypothesized mortality reduction of 25% over MED at an average of 5 years. Duke Clinical Research Institute is the coordinating centre for this study. The STITCHES Trial is an extension of the STITCH Trial, taking advantage of the opportunities that the surviving STICH patients will be followed for an additional 5 years in a minimal risk, registry type study with the following specific aims:

  • To determine whether CABG with medical therapy (MED) improves 10-year survival compared to MED alone and how treatment-related outcome differences seen at 5 years vary over time.
  • To determine whether CABG with MED leads to differences in health outcomes including functional status and symptoms compared to MED alone at 10 years among important subgroups defined by baseline clinical status, symptoms, coronary anatomy, functional status, non-invasive measures of myocardial ischemia and viability and/or genotype.
  • To quantify the relative, incremental predictive value of baseline non-invasive cardiac imaging on long-term treatment-dependent results (relative to the short and intermediate-term).
  • To determine whether CABG with MED leads to changes in cardiac morphology, function and hemodynamics over time (4 and 24 months) compared to MED alone and to define how these changes relate to 10 year health outcomes.
  • To determine whether CABG with medical therapy (MED) improves 10-year survival compared to MED alone and how treatment-related outcome differences seen at 5 years vary over time.
  • To determine whether CABG with MED leads to differences in health outcomes including functional status and symptoms compared to MED alone at 10 years among important subgroups defined by baseline clinical status, symptoms, coronary anatomy, functional status, non-invasive measures of myocardial ischemia and viability and/or genotype.
  • To quantify the relative, incremental predictive value of baseline non-invasive cardiac imaging on long-term treatment-dependent results (relative to the short and intermediate-term).
  • To determine whether CABG with MED leads to changes in cardiac morphology, function and hemodynamics over time (4 and 24 months) compared to MED alone and to define how these changes relate to 10 year health outcomes.

Publications

http://www.stichtrial.org/category/publications

Website: http://www.stichtrial.org/

Use of a Multidrug Pill in reducing cardiovascular Events (UMPIRE) Trial

Name Funding Body Duration Status Team
Use of a Multidrug Pill in reducing cardiovascular Events (UMPIRE) Trial European Commission 2 Years; June 2010-July 2012 Completed PI: Dr. Dorairaj Prabhakaran Co-I: Dr. Nikhil Tandon Project Coordinator: Kavita Singh

 

About

UMPIRE Trial is a phase 3 – randomised, controlled clinical trial of fixed-dose combination medication, Red Heart Pill, in patients (1000 in Europe and 1000 in India) at high risk of cardiovascular disease. The Red Heart Pill contains low dose aspirin, statin and two blood pressure lowering medicines and will be compared to usual cardiovascular medications to test its effect on adherence and change in blood pressure and LDL cholesterol at 12 months. The trial has completed recruiting 1000 patients each in India and Europe by July 2011; end of study visits have begun and are expected to be complete by July 2012. The Imperial College London is the International Coordinating Center while in India the study is coordinated by George Institute India, Hyderabad and CCDC, New Delhi.

Publications

  1. Thom S, Field J, Poulter N, Patel A, Prabhakaran D, Stanton A, Grobbee DE, Bots ML, Reddy KS, Cidambi R, Rodgers A. Use of a Multidrug Pill In Reducing cardiovascular Events (UMPIRE): rationale and design of a randomised controlled trial of a cardiovascular preventive polypill-based strategy in India and Europe. Eur J Prev Cardiol. 2014 Feb;21(2):252-61.
  2. Salam A, Stewart F, Singh K, Thom S, Williams HJ, Patel A, Jan S, Laba T, Prabhakaran D, Maulik P, Day S, Ward H. INterpreting the Processes of the UMPIRE Trial (INPUT): protocol for a qualitative process evaluation study of a fixed-dose combination (FDC) strategy to improve adherence to cardiovascular medications. BMJ Open. 2013 May 28;3(5).
  3. Thom S, Poulter N, Field J, Patel A, Prabhakaran D, Stanton A, Grobbee DE, Bots ML, Reddy KS, Cidambi R, Bompoint S, Billot L, Rodgers A; UMPIRE Collaborative Group. Effects of a fixed-dose combination strategy on adherence and risk factors in patients with or at high risk of CVD: the UMPIRE randomized clinical trial. JAMA. 2013 Sep 4;310(9):918-29.

Umpire Trial Website: http://www.spacecollaboration.org/

Indian Migrants Study

Name Funding Body Duration Status Team
Indian Migrants Study Wellcome Trust 2005-2007 Completed PIs: Shah Ebrahim, K. Srinath Reddy Co-PIs: George Davey Smith(University of Bristol), Dorairaj Prabhakaran(CCDC), Yoav Ben-Shlomo (University of Bristol)

 

About

It is a sib comparison, within country migration study to understand the impact of migration on cardiovascular disease risk factors in India. CCDC is responsible for coordination of research activities, monitoring of data collection process, source data verification, and data management of the study. This is being conducted in collaboration with Bristol University, UK. The scientific aim of the study is to elucidate the effects of within-country migration on obesity and diabetes mellitus in India. The main hypothesis to be considered is that risks of developing obesity and diabetes among migrants from rural to urban areas are due to differential migration conditions and subsequent social and economic changes that mediate changes in dietary intake and physical activity patterns. Since 2004, CCDC has received a grant of nearly USD 0.80 million towards the cost of this project.

Using the framework of a cardiovascular risk factor screening the Indian Migration Study examined migrants and their families for rural-urban differences in lifestyle patterns, socioeconomic status, anthropometrics and physiological measures with respect to the prevalence of cardio-metabolic outcomes. The study was designed to evaluate the health effects of migration from rural to urban places on chronic diseases such as obesity and diabetes, on risk factors such as tobacco use, physical activity, diet and on physiological measures, biomarkers, genetic and epigenetic variation. The study was conducted in factories of north, central and south India where investigators recruited migrant urban factory workers, their spouses and non-migrant rural siblings still living in their place of origin. Migration histories were classified into stages of recent, long-term, and intergenerational migration, and comparisons of rates were made between rural and urban participants of varying migration types.

Media Coverage

Simplified Cardiovascular Management (SIMCARD) study

Name Funding Body Duration Status Team
Simplified Cardiovascular Management (SIMCARD) study National Heart, Lung and Blood Institute Completed

 

About

The SIMCARD Study is a cluster-randomised trial to evaluate the effects of a simplified cardiovascular management programme in China and India. The proposal was developed jointly by CARRSCOE and George institute for Global Health, China. Both are Centers of excellence (COE) under the National Heart Lung and Blood institute (NHLBI). The overall goal of this study is to develop, pilot test, and evaluate a highly simplified but guideline-based program for cardiovascular management in resource-scarce settings. The specific aim is to evaluate the effects of implementing a simple lowcost cardiovascular management program for high-risk individuals, delivered by primary care providers (PCPs) or community health workers (CHWs), on the proportion of patients appropriately treated with diuretics as well as a number of secondary outcomes. This project aims to address the highly prevalent problem of CVD in poor areas. The study in India will be carried out in 12 villages recruiting 1200 subjects aged 40 years and above, equally divided between the intervention and control arm over a period of 24 months.

Assessment of dietary salt intake levels among adults in Delhi and Haryana

Name Funding Body Duration Status Team
Assessment of dietary salt intake levels among adults in Delhi and Haryana PHFI and Wellcome Trust-UK Universities Consortium Completed

 

About

Multiple epidemiological studies conducted worldwide have found excess dietary salt or sodium intake to be associated with increased risk of high blood pressure or hypertension. Also nearly half of blood pressure related CVD events occur among those without clinical hypertension, so population wide salt reduction is clearly one of the most cost-effective strategies to prevent CVD. This sub-study of CARRS Surveillance Study and the ICMR Urban-Rural Study seeks to provide contemporary data on salt consumption levels and sources of dietary salt in Delhi and Haryana, which will reflect recent dietary changes that are occurring in India. The three main objectives are 1) to determine the mean daily salt consumption through the collection of 24- hour urinary sodium excretion samples, 2) to determine the main sources of salt in the diets using 24-hour dietary recall method and 3) to assess knowledge, attitudes and behaviours with regard to salt consumption and its impact on health by a questionnaire. The total duration of the proposed project is two years and survey will include 1400 participants with roughly half each residing in urban Delhi and rural Haryana.

Prevalence of Polycystic ovarian syndrome (PCOS) and its association with cardiometabolic risk factors in reproductive age women in Delhi and Chennai, India

Name Funding Body Duration Status Team
Assessment of dietary salt intake levels among adults in Delhi and Haryana Fogarty International Centre Completed

 

About

This cross sectional study employs a cluster randomized sampling technique to calculate the prevalence of self-reported irregular menstruation and clinical hyperandrogenism among Indian women and compare metabolic syndrome components in women with and without PCOS like symptoms. The primary objective of this study is to assess the prevalence of women reporting PCOS like symptoms in a large representative sample of Indian women living in Delhi and Chennai. The secondary objective is to assess Prevalence of CHD and its risk factors in urban and rural areas of NCR a repeat Survey the prevalence of cardio metabolic risk factors (hyperlipidaemia, diabetes, hypertension and body composition) within this sample and measure how they vary with different elements of PCOS, specifically irregular menstruation and hyperandrogenism.

Stress, distress and diabetes in Delhi- a qualitative study of chronic diseases in urban India

Name Funding Body Duration Status Team
Stress, distress and diabetes in Delhi- a qualitative study of chronic diseases in urban India Fogarty International Centre Completed

 

About

This study is collaboration between Emory University Atlanta, and CCDC. It is an ethnographic project which used in-depth interviews, embedded as a sub-study in the on-going CARRS surveillance study to examine the subjective experience of depression, stressors and coping with diabetes in Delhi.

Comparison of fiscal and regulatory policies to prevent non-communicable diseases in India

Name Funding Body Duration Status Team
Comparison of fiscal and regulatory policies to prevent non-communicable diseases in India International Development Research Centre (IDRC) Completed

 

About

This project aims to generate the evidence-base for the effectiveness of alternative fiscal, legal, and regulatory strategies on controlling the NCDs related to tobacco, salt, sugar and palm oil. The major objectives of this study are to: i) Review previous overviews of fiscal and regulatory policies on the consumption of the ‘unhealthy’ commodities; ii) Model the effects of taxation of unhealthy’ commodities on NCDs in India.

 
Last Modified : April 16, 2016, 4:32 pm