Medicine

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    The adaptation, implementation, and performance evaluation of intake24, a digital 24-h dietary recall tool for South asian populations: the South asia biobank
    (Elsevier Inc, 2025-01) Bhagtani, D.; Amoutzopoulos, B.; Steer, T.; Collins, D.; Abraham, S.; Holmes, B.A.; Rai, B.K.; Pradeepa, R.; Mahmood, S.; Shamim, A.A.; Mathur, P.; Athauda, L.; De Silva, L.; Khawaja, K.I.; Jha, V.; Kasturiratne, A.; Katulanda, P.; Mridha, M.K.; Anjana, R.M.; Chambers, J.C.; Page, P.; Forouhi, N.G.
    BACKGROUND South Asia's diverse food supply, food preparations, and eating behaviors require dietary instruments that reflect the consumption patterns of South Asians to enable context specific dietary assessment. Such instruments are not readily available for detailed dietary assessment at scale in South Asia.OBJECTIVES We describe the adaptation, implementation, and performance evaluation of Intake24, an open-source digital 24-h dietary recall tool, for dietary assessment in South Asia.METHODS We adapted Intake24 for dietary assessment in the South Asia Biobank (SAB), a large population-based study in Bangladesh, India, Pakistan, and Sri Lanka. Intake24 adaptation encompassed the development of a South Asian food database with commonly consumed foods, linked with corresponding portion sizes, food probes, and nutrient information. Trained interviewers conducted the 24-h recalls. Performance of Intake24 was evaluated in 29,113 South Asian adults.RESULTS The South Asia Intake24 food database included 2283 items and demonstrated good coverage of foods consumed across SAB regions. Median recall completion time was 13 min. Quality control metrics showed 99% of recalls included >8 items and 8% had missing foods. Median energy intake was higher in younger individuals compared to older, and in males compared to females. Underweight participants reported lower energy intake, with no discernible difference across other BMI categories.CONCLUSIONS Intake24 enables comprehensive dietary assessment in regions of South Asia and will facilitate the analysis of dietary patterns, food and nutrient intake, and their relationship with health outcomes among South Asians.
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    Carbohydrate intakes and cardiovascular disease risk factors in South Asians: Results from 56,024 participants in Bangladesh, India, Pakistan and Sri Lanka.
    (American Heart Association, 2024-11) Lahiri, A.; Imamura, F.; Kasturiratne, A.; Jha, V.; Katulanda, P.; Khawaja, K.; Mridha, M.; Anjana, R. M.; Chambers, J.; Forouhi, N.
    BACKGROUND Evidence on effects of carbohydrate intake with cardiovascular disease risk factors is inconsistent and has limited generalizability to diverse populations such as South Asians, whose carbohydrate intakes are typically high. AIMS We examined the association of the quantity and types of carbohydrate intake with two risk factors for major cardiovascular events– hypertension (HT) and hypercholesterolemia (HC). METHODS We analyzed cross-sectional data from participants aged ≥18 years in the South Asia Biobank in Bangladesh, India, Pakistan, and Sri Lanka. Using dietary data assessed with interviewer-led 24h diet recalls, we calculated intakes of total and subtypes of carbohydrates and several indices of carbohydrate quality. Primary outcomes were HT and HC, defined by medication use, doctor diagnosis, blood pressure and blood lipid levels. With mixed effects Poisson regression, HT and HC was regressed on quantiles of carbohydrate intakes by country to estimate prevalence ratios (PR) and 95% confidence intervals (CI), followed by meta-analysis pooling country-specific estimates. We examined interactions by diabetes status and adiposity. RESULTS Of 56,024 adults, 36.6% had HT, 16.1% had HC. In pooled multivariable analyses comparing extreme quantiles, total carbohydrate intake was not associated with HT or HC prevalence. Fructose, free sugar and free sugar-to-fiber ratio were associated with higher prevalence of HT (PRsQ5vsQ1: 1.03-1.15). Higher intakes of cereal fiber (PRQ4vsQ1: 0.96, 95% CI: 0.95-0.98) and legume fiber (PRQ4vsQ1: 0.98, 95% CI: 0.97-0.98) were associated with lower prevalence of HT and higher cereal fiber intake with lower HC prevalence (PRQ5vsQ1: 0.80, 95% CI: 0.75-0.85). Diabetes and adiposity were observed as effect-modifiers (p<0.001). There were null associations in adults with diabetes but in non-diabetic adults, free sugar intake was related positively with HT (PRQ5vsQ1: 1.07, 95% CI: 1.05-1.09) while fiber intake was inversely related (PRQ5vsQ1: 0.98, 0.95-0.97). Starch, sugar and free sugar intake were associated positively with HT prevalence in adults with high body fat (≥20% for men; ≥30% for women) and visceral fat (≥10%) levels (PRsQ5vsQ1: 1.03-1.20); associations were null for low body and visceral fat levels. Associations varied by country (between-country heterogeneity I2>60%).CONCLUSION Associations of dietary carbohydrates with HT and HC depended on the quality and type of intake in South Asians.
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    Policy implementation and recommended actions to create healthy food environments using the healthy food environment policy index (Food-EPI): a comparative analysis in South Asia
    (Elsevier Ltd, 2024) Pineda, E.; Atanasova, P.; Wellappuli, N.T.; Kusuma, D.; Herath, H.; Segal, A.B.; Vandevijvere, S.; Anjana, R.M.; Shamim, A.A.; Afzal, S.; Akter, F.; Aziz, F.; Gupta, A.; Hanif, A.A.; Hasan, M.; Jayatissa, R.; Jha, S.; Jha, V.; Katulanda, P.; Khawaja, K.I.; Kumarendran, B.; Loomba, M.; Mahmood, S.; Mridha, M.K.; Pradeepa, R.; Aarthi, G.R.; Tyagi, A.; Kasturiratne, A.; Sassi, F.; Miraldo, M.
    BACKGROUND The increasing prevalence of diet-related non-communicable diseases (NCDs) in South Asia is concerning, with type 2 diabetes projected to rise to 68%, compared to the global increase of 44%. Encouraging healthy diets requires stronger policies for healthier food environments.METHODS This study reviewed and assessed food environment policies in Bangladesh, India, Pakistan, and Sri Lanka from 2020 to 2022 using the Healthy Food Environment Policy Index (Food-EPI) and compared them with global best practices. Seven policy domains and six infrastructure support domains were considered, employing 47 good practice indicators to prevent NCDs. Stakeholders from government and non-governmental sectors in South Asia (n = 148) were invited to assess policy and infrastructure support implementation using the Delphi method.FINDINGS Implementation of food environment policies and infrastructure support in these countries was predominantly weak. Labelling, monitoring, and leadership policies received a moderate rating, with a focus on food safety, hygiene, and quality rather than obesity prevention. Key policy gaps prioritized for attention included front-of-pack labelling, healthy food subsidies, unhealthy food taxation, restrictions on unhealthy food promotion, and improvements in school nutrition standards to combat NCDs.INTERPRETATION Urgent action is required to expand food policies beyond hygiene and food security measures. Comprehensive strategies targeting NCD prevention are crucial to combat the escalating burden of NCDs in the region.
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    Smokeless and combustible tobacco use among 148,944 South Asian adults: a cross-sectional study of South Asia Biobank
    (Springer, 2023) Xie, W.; Mridha, M.K.; Gupta, A.; Kusuma, D.; Butt, A.M.; Hasan, M.; Brage, S.; Loh, M.; Khawaja, K.I.; Pradeepa, R.; Jha, V.; Kasturiratne, A.; Katulanda, P.; Anjana, R.M.; Chambers, J.C.
    INTRODUCTION Tobacco use, in both smoking and smokeless forms, is highly prevalent among South Asian adults. The aims of the study were twofold: (1) describe patterns of SLT and combustible tobacco product use in four South Asian countries stratified by country and sex, and (2) assess the relationships between SLT and smoking intensity, smoking quit attempts, and smoking cessation among South Asian men. METHODS Data were obtained from South Asia Biobank Study, collected between 2018 and 2022 from 148,944 men and women aged 18 years and above, living in Bangladesh, India, Pakistan, or Sri Lanka. Mixed effects multivariable logistic and linear regression were used to quantify the associations of SLT use with quit attempt, cessation, and intensity. RESULTS Among the four South Asian countries, Bangladesh has the highest rates of current smoking (39.9% for male, 0.4% for female) and current SLT use (24.7% for male and 23.4% for female). Among male adults, ever SLT use was associated with a higher odds of smoking cessation in Bangladesh (OR, 2.88; 95% CI, 2.65, 3.13), India (OR, 2.02; 95% CI, 1.63, 2.50), and Sri Lanka (OR, 1.36; 95% CI, 1.14, 1.62). Ever SLT use and current SLT use was associated with lower smoking intensity in all countries. CONCLUSIONS In this large population-based study of South Asian adults, rates of smoking and SLT use vary widely by country and gender. Men who use SLT products are more likely to abstain from smoking compared with those who do not.
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