Research
Research remains the core activity of HAP. At present HAP is involved in various research projects both independent and in association with world-renowned academic institutions.
PROLIFE: ‘Population Registry of Lifestyle Diseases’.
Kerala has proportionately the largest burden of lifestyle diseases, like diabetes, heart disease, hypertension and obesity in India. HAP has initiated and completed many studies on all these diseases; however, the influence of dominant risk factors both environmental and individual can only be understood through prospective studies recruiting a large cohort. PROLIFE- ‘Population Registry on Lifestyle Diseases’ is an attempt by HAP to recruit a large cohort aged 20 years or more for long term follow up. At present our cohort of over 78,000 adults have been followed up for 5 years and has provided exciting information on the cause of death, extent of morbidity and state of health of the study population
This study was initially undertaken (and completed) as a project sponsored by Kerala Research Programme on Local Level Development of the Centre for Development Studies. For this purpose, HAP adopted a large rural community with over 162,000 people, for monitoring their health status and appropriate interventions. The population belonged to a geographical jurisdiction of a Community Development Block at Varkala comprising of 7 Panchayats. The registry gathered detailed information, not only lifestyle diseases, but on a wide range of information on births, deaths, major diseases, hospitalization and other significant health related events. Details of birth, like age of mother, parity, nature of delivery, gender, weight of baby on birth and complications, if any, are collected. Death information consists of age, sex, cause of death, place and date of death. The cause of death has been verified through administering a validated verbal autopsy instrument. The information so collected was transferred to a computer on a regular basis. Birth and death reports carrying all information are conveyed telephonically on a daily basis. More importantly we have gathered extensive socio-economic and demographic data on every household as on 1 March 2001. Comprehensive lifestyle characteristic questionnaires were administered to over one lakh subjects who were 20 year or more on the cut off day. Few papers were published in international journals, as a forerunner to future publications.
In view of the importance of the information collected already, HAP was keen on doing the follow up of the study. However, due to paucity of funds it could not be taken up then. However, during the year under review, the Population Health Research Institute, McMaster University, Canada was keenly interested on the prospects of the follow up study and hence PHRI had come forward and shown interest in the study and provide the necessary financial support. The follow up of the study would commence as soon as financial support would be forthcoming.
The causes of death in relation to lifestyle attributes and socio-economic variable are currently being explored. We have also gathered conclusive evidence on profile of death in the community. The information corroborates our knowledge on the magnitude of lifestyle diseases in Kerala. Cardiovascular deaths contribute to over 45% of all deaths, followed by suicides and accidents. Cancers comes next. Of all infectious diseases contribute only about 5 % to the mortality. The picture that emerges is one of nearly complete epidemiological transition.
To our knowledge, a prospective study of this magnitude and depth has not been so far attempted in India. Our data was gathered by 105 grass root level health workers who serve the anganwadies of the community. Monthly meetings and interaction with our research officer contributed to sharpening up of their skills and commitment. HAP believes at this path breaking study would soon capture global attention as a pioneering effort in understanding the dynamics of health in a population under transition. Few papers have been published in international journals as a forerunner to future publications and preparing few more papers for publication.
PURE: Prospective Urban Rural Epidemiology
For most populations, the last century has witnessed dramatic improvements in health. Life expectancy has increased from a global average of 46 years in 1950 to 66 years in 1998. During the 1st half of the twentieth century, developed countries experienced rapid declines in deaths from infections, childhood diseases, and increases in chronic diseases. These changes are attributed to economic development and societal and lifestyle changes associated with urbanization. Low and middle-income countries (LIC and MIC) are undergoing several transitions (economic, nutrition, urbanization), which collectively affect health, giving rise to marked increases in obesity, diabetes, and CVD. It is expected that by 2020, >85% of global CVD will be in developing countries. Therefore there is an urgent need to understand how societal changes in LIC, MIC, and HIC increase chronic diseases such as CVD, in order to develop strategies that mitigate these processes. To do so a global research program that includes investigation of macro-environmental changes (urbanization and other societal factors) and individual level factors (lifestyle, metabolic and genetic) is required. Urban and rural cohorts are established to track changing environments, societal influences on lifestyle, risk factors and CVD, utilizing periodic standardized data collection in multiple communities from 18 countries (Argentina, Brazil, Canada, Chile, China, Colombia, India, Iran, Poland, S. Africa, Sweden, Tanzania, Thailand, UAE, Zimbabwe etc.) representing every major region of the world involving a total of about 120,000 individuals. The lead investigator in this multi-country effort is Prof Salim Yusuf, world renowned cardiologist and researcher. HAP is one of the study partners in India and has already recruited over 5650 subjects, against the target of 5500.
PURE is a multinational, multicentred study guided and coordinated by Population Health Research Institute, a joined institute of McMaster University, and Hamilton Health Sciences, Canada. The PURE study, which is unique in nature, covers all aspects of health of the population in selected study areas. It is an international study and has four other Indian collaborators, namely, St. John’s Research Institute, Bangalore, Post Graduate Institute of Medical Education & Research, Chandigarh, Dr. Mohan’s Diabetes Speciality Centre, Chennai and Jaipur Medical College. At the international level, eighteen countries around the globe are participating in the study.
The study was launched in 2003 and 5650 subjects in the age group 35-70 years were recruited for the base-line assessment of physical, biochemical, mental and risk factor status. We have done the ground work for two important related community studies, namely, prospective studies to prevent progression of IGT to Diabetes Mellitus II and to determine the risk factors of TOD among Diabetic and hypertensive patients. It is proposed to conduct follow up study for at least 15 years, once in every 5 years, to elucidate the factors most responsible for coronary, cerebra-vascular and other degenerative diseases. The findings from the study would help formulate appropriative preventive strategies including lifestyle modification. The baseline study was conducted in 15 locations in Trivandrum district, 8 urban and 7 rural. The urban locations are Peyad, Aakulam, Karimam, Kundamanbhagom, Malayinkeezhu, Karipur, Thachottukavu and Pirayil in Trivandrum District and the rural locations are Thockad, Panayara, Palachira, Chemmaruthy, Cherunniyoor, Ottoor and Mathiracode of Varkala Block.
INDADE: Indo-Danish Collaboration on Diabetes Epidemiology
This is a collaborative study undertaken by HAP, the other collaborators being Novo Nordisk, Denmark and University of Southern Denmark.
Studies by HAP have established that Kerala has among the highest reported prevalence of type 2 diabetes. However, little is known about the sequel of diabetes or its economic impact on the population. It is against this backdrop that HAP has fostered a partnership with the University of Southern Denmark and Novo Nordisk to undertake pioneering studies on epidemiology of diabetes, with special emphasis on evolution, progression, complication and socio economic costs of diabetes mellitus.
The main aim of the project is to establish a scientific cooperation between the partners in India and Denmark. The background for this is the concern of the enormous increase in diabetes worldwide, in particular in the third world. There is also a specific interest in developing model for sustainable health care in the third world. Decision makers are unprepared to meet the challenges of diabetes and other chronic diseases when it comes, and it is necessary to generate information needed for planning purposes and for evolving focused strategies both for intervention and public health education, awareness and understanding among patients and general public of the potential scope of the diabetes problem. This project builds on an existing programme, namely, PROLIFE initiated by HAP about 10 years back.The study focuses on:
- The ‘dynamics’ of diabetes (incidence, mortality and prevalence) in rural areas in Kerala
- The epidemiology of complications of diabetes and its associations with other Non-Communicable Diseases
- Health economics appraisals and modeling in various scenarios concerning diabetes in rural India
- Intervention research focused on lifestyle modifications aimed at delaying the progression of Impaired Glucose Tolerance to overt diabetes
For this study a Panchayat (Ottoor), under the Varkala block, was selected from the PROLIFE community which covers a population of 15,917 people of which 10,846 are adults above 19 years. As part of annual screening rounds 73 % (Round 1) and 79 % (Round2) of the adults were screened for diabetes, hypertension and overweight. The screening process would be continued on an yearly basis. The third round of screening is about to complete. After the screening rounds, 1368 (Round 1 screening) and 2058 diabetics (Round 2 screening) were identified and it is proposed to study the social, economic, psychological and clinical implications in this cohort. The screening process would be continued on an yearly basis. After the first round of screening, 1450 diabetics were identified and it was proposed to study the social, economic, psychological and clinical implications in this cohort. They would be followed up in the coming years. Several publications based on this study are planning to be published soon.
Phase I of the study, which was completed during the period under review, screened over 6,800 adults for diabetes. Phase II has been finalized and work on Phase II was started in January 2010. The INDADE study is envisaged to be a four year programme.
A couple of international collaborative research programmes, including clinical trials are in the process of evolution, which is planning to be executed in the upcoming year.