Summary

APCAPS research falls into the below categories:

1. Research conducted with the prospective APCAPS cohort (APCAPS follow-ups 1-4).
2. Research conducted with the wider community residing in the 29 APCAPS villages in Ranga Reddy district, Telangana.
3. Profiling of the environment of the APCAPS villages for examining environmental risk-factors of chronic disease.
4. Intervention development and evaluation in the APCAPS villages.
5. Qualitative studies to inform APCAPS research and guide intervention development.
6. Methodological studies to improve research quality.
7. Related studies.

Studies with the APCAPS cohort

While the primary aim of each APCAPS cohort follow-up differed, chronic disease risk factor and outcome data is largely comparable across follow-ups and can be used to answer research questions outside of the original primary aims. Participant eligibility (index children, mothers, fathers, siblings) varied across the follow-ups. Learn more about data availability in the APCAPS cohort.

APCAPS Follow-up 1 (2003-05) 

Background

Undernutrition in early life may contribute to the cardiovascular disease epidemic in India and other low- and middle-income countries. The primary aim of APCAPS follow-up 1 was to examine the prevalence of risk factors for cardiovascular disease in adolescents born during the Hyderabad Nutrition Trial (1987-90) (aged 13-17 in 2003-05) which evaluated the impact of food supplements for pregnant women on birthweight of their kin.

Learn more about the Hyderabad Nutrition Trial on the 'About' page (click the 'background to the cohort' panel to read more).

Methods

Mothers who participated in the Hyderabad Nutrition Trial (both intervention and control villages) were retraced. All individuals born during the Hyderabad Nutrition Trial period (1987-90) were eligible to participate (“APCAPS index children”). However, due to resource constraints of the study, only a sub-sample of individuals were invited to participate. An interviewer-administered questionnaire and clinical examination of the index children was carried out at clinics in the study villages, and a brief questionnaire and clinical examination was undertaken on their mothers.

Learn more about data available from APCAPS follow-up 1.

Key findings

Results of the primary analysis suggested a lower risk of cardiovascular disease (as evidenced by arterial stiffness and insulin resistance) in adolescents from the intervention villages in comparison to controls.

Results of further analyses indicated that (1) lower socio-economic position was associated greater central adiposity and higher triglyceride levels, but not other cardiovascular risk factors, (2) relative leg length was not associated with nutritional supplementation, challenging the use of leg length as a biomarker for early childhood nutrition which has been based mainly on observational data, and (3) school enrolment, and potentially schooling grades, were higher in adolescents from intervention villages, though test scores were not associated.

Funding

The Eden Fellowship in Paediatrics, Royal College of Physicians, UK to Dr Sanjay Kinra

APCAPS Follow-up 2 (2009-10) (also known as the Hyderabad DXA study) 

Background

APCAPS follow-up 2 primarily aimed to examine the effect of early life undernutrition on amount and distribution of body fat, diabetes and cardiovascular disease risk, as well as the association between body fat and diabetes and cardiovascular disease risk, in the index children of the APCAPS cohort (aged ~18-21 years in 2009-10).

Methods

All children born during the Hyderabad Nutrition Trial period (1987-90) (“APCAPS  index children”) were eligible and invited to participate in the study, irrespective of (non-) participation in APCAPS follow-up 1. An interviewer-administered questionnaire and clinical examination (including Dual-energy X-ray absorptiometry (DXA), anthropometrics, vascular measures) of the index children in young adulthood was carried out in clinics in the National Institute of Nutrition, Hyderabad. In addition, around 918 people from a related study, the Indian Migration Study, who mostly lived in Hyderabad or different areas of the district, were surveyed at the same time with the same protocols and data collection instruments (for more details see this paper or enquire with the study team).

Learn more about data available from APCAPS follow-up 2.

Key findings

Results indicated lack of a long-term association between early life undernutrition and adult lean body mass or muscle strength. Further results indicated (1) current lean mass and weight-bearing physical activity were more important determinants of bone mass than early-life undernutrition, (2) the postulated link between Vitamin D and cardiovascular risk may be attributable to confounding by lifestyle factors such as obesity and physical inactivity in studies conducted in high-income settings, and (3) no strong evidence that DXA or waist-to-hip ratio (a measure of abdominal adiposity) were better at predicting cardiometabolic risk in comparison to BMI.

Funding

The Wellcome Trust, UK

APCAPS Follow-up 3 (2010-12) 

Background

APCAPS follow-up 3 primarily aimed to explore the trans-generational effects of environmental and genetic risk factors on cardiovascular and other chronic diseases and to continue examining the effect of early life undernutrition on cardiometabolic risk in the APCAPS index children.

Methods

Parents and siblings of the APCAPS index children were invited to participate, as were the APCAPS index children, resulting in close timing of APCAPS follow-up 2 and 3. An interviewer-administered questionnaire and clinical examination of the index children, their siblings and parents was carried out in clinics in the National Institute of Nutrition, Hyderabad.

Learn more about data available from APCAPS follow-up 3.

Key findings

Results indicated lack of association between early life undernutrition and cardiovascular risk in the APCAPS index children in early adulthood. Further results indicated (1) lack of evidence of an inverse association between parental childhood socioeconomic conditions or stature and offspring’s risk of cardiovascular disease, (2) women were four times as likely to be anaemic as men and were particularly vulnerable to co-occurring anaemia and cardiometabolic risk, and (3) exposure to supplementary nutrition in utero and during the first three years of life was associated higher ages at menarche, first cohabitation with partners and first pregnancies among the women.

Funding 

The Wellcome Trust, UK

APCAPS Follow-up 4 (2021-23)

Background

Evidence on the burden, risk-factors, outcomes, and care of multimorbidity (co-occurrence of two-plus chronic conditions in an individual) in rural and urbanising India is limited, in part due to a lack of longitudinal and objectively measured data on chronic conditions. APCAPS follow-up 4 primarily aimed to develop APCAPS into a data resource for examining the epidemiology, and improving the prevention and care, of multimorbidity in rural/urbanising India.

Methods

All APCAPS members aged ≥40 years old were invited to participate. An interviewer-administered questionnaire and clinical examination was conducted to screen locally prevalent non-communicable and infectious diseases, mental health conditions, cognitive impairments, and functional deficits and frailty, using a combination of self-reported clinical diagnoses, symptom-based questionnaires, physical examinations, and biochemical assays. 

Read the study protocol for APCAPS follow-up 4.

Learn more about data available from APCAPS follow-up 4.

Key findings

Study ongoing.

Funding

Medical Research Council, UK

Studies within the APCAPS study villages

Village-wide Household Survey (2011-14) 

Summary

In 2011-14, all households in the 29 APCAPS villages were surveyed and geotagged. Health and development data were collected for each coresident child under 6 years of age, comprising information on infant feeding (colostrum intake, total duration of breastfeeding and age of onset of weaning), immunisation and anthropometric measurements. Data were collected from 23,314 households which contained ~91,000 individuals, including ~9,000 children under 6 years.

Learn more about data available from APCAPS household survey.

Key findings

Study results indicated that early stage village urbanicity was associated with shorter duration of breastfeeding.

Funding

The Wellcome Trust, UK

Explaining the Differential Severity of COVID-19 between Indians in India and the UK (DiSeCT) (2020-2024) 

Summary

Limited data suggest a greater severity of COVID-19 (COVID hospitalisation/mortality and Long COVID) in Indians living in the UK than in Indians living in India. The DiSECT study aims to determine whether differences in A) the rate of COVID-19 mortality and B) prevalence of long-term symptoms of COVID-19, between Indian populations in India compared to the UK, are explained by differences in demographic composition (age, sex) and non-communicable diseases (diabetes, hypertension, obesity).

Key findings

Study ongoing.

Funding

Department of Biotechnology, India (India data collection/analyses), Medical Research Council, UK, (UK analyses).

Profiling the environment of the APCAPS study villages

Urbanicity Index (2010-12) 

Summary

There is extensive evidence that level of urbanisation (“urbanicity”) is a key determinant of health status. A measure of urbanicity utilising remote sensing night-time light intensity (NTLI) data, acquired through the USA's Defence Meteorological Satellite Programme's Operational Linescan System, was developed.

Key findings

Since the first survey wave in 2003–2005, the 28 APCAPS villages had changed from rural agricultural communities with similar NTLI levels to represent a continuum of NTLI levels with growing differentiation at higher levels. The variation in night-time intensity has also increased over the past twenty years, suggesting the presence of uneven rates of urbanization. Studies using the NTLI estimates indicate that early stage village urbanicity was associated with shorter duration of breastfeeding and that moderate increases in urbanisation levels were associated with cardiovascular risk-factors.

Funding

The Wellcome Trust Strategic Award, UK

Built Environment Survey (2016) 

Summary

All non-residential places in the 29 APCAPS villages were surveyed and geotagged, including food shops and outlets, health facilities, educational facilities, and local parks/open spaces used for physical activity. Households of the prospective APCAPS cohort were also geotagged, allowing exploration of how environmental risks impact chronic disease risk in a rapidly urbanising setting.

Learn more about data available from APCAPS built environment survey.

Key findings

Study results have indicated that higher density of fruit and vegetable vendors is associated with lower blood pressure while higher density of highly processed and take-away food vendors was associated with higher blood pressure and BMI/waist circumference. See the findings of this study.

Study results have also indicated that living a greater distance from the nearest alcohol outlet is associated with lower daily alcohol intake, waist circumference and blood pressure. There is also an association between the number of alcohol outlets within a 400m area and waist circumference and blood pressure. See the findings of this study.

Funding

The Wellcome Trust, UK

Cardiovascular Health Effects of Air pollution in Telangana, India (CHAI) Study (2015-18) 

See “Related Studies” for details.

Intervention development and evaluation

A financial incentive scheme to increase fruit and vegetable purchasing from unorganised retailers in rural India (2019-2021) 

Summary

Intake of fruits and vegetables in India is amongst the lowest in the world, with intake in rural areas even lower. Attempts to increase the intake of fruits and vegetables through nutrition education programs have had limited success globally. The aim of the study was to determine the effectiveness of a financial incentive scheme offering a ~20% cashback on the purchase of fruits & vegetables from unorganized retailers in rural India. The intervention was informed by behavioural economics and developed through consultation with the local stakeholders and community. The study used a cluster-randomized controlled trial design and ran for three months in three of the six trial villages.

Key findings

After the scheme was over, the weekly household purchase of fruits and vegetables was ∼28% higher for intervention villages compared to control villages (corresponding to ∼1.5 portions of fruit and vegetables per person per day). The findings confirm the feasibility of using such interventions in unorganised food retail environments and suggest that such interventions may be effective in influencing food purchasing (findings here).

Funding

The Drivers of Food Choice (DFC) Competitive Grants Program

Qualitative studies

APCAPS qualitative studies

Summary

Qualitative studies have been conducted within the APCAPS villages to explore a range of topics including: community members’ and key stakeholders’ (e.g., healthcare providers, local administrators) perceptions of chronic disease and its influences, changes occurring to the local environment, needs of local populations, and views and suggested priorities of the APCAPS study.

Key findings

Results of a study conducted with community members in 2013 indicated that participants believed their communities were currently less healthy, more polluted, less physically active, had poorer access to nutritious food and shorter life expectancies than previously. Another study used a novel qualitative geographical information systems approach to identify prices, vendor and product properties, and social capital as drivers of food acquisition practices in adults in the APCAPS villages.

Methodological studies

Cardio-metabolic effects of meat intake in Indians (2021-23) 

Summary

The double burden of undernutrition and cardio-metabolic diseases have impacted India for several decades following expanded urbanisation. Meat provides a dense source of essential amino acids and contains many micronutrients to potentially combat undernutrition. However, its uptake in diet is limited due to concerns about increased risk of cardio-metabolic disease. The study aims to identify risks of cardio-metabolic disease associated with meat consumption. Metabolite data has been collected from a sub-sample of the prospective APCAPS cohort. Urinary and blood metabolite samples will be processed and analysed to identify both short-term and long-term markers of meat intake and metabolism. This study further aims to more improve nutritional metabolomics and integrative epidemiology capacity in India.

Key findings

Study ongoing.

Funding

Medical Research Council, UK

Digital Biomarker Development (2021-2023) 

Summary

Recent developments in machine learning, particularly in deep learning, could be used to identify novel health-related phenotypes using digital data (e.g., images, audio). This has the potential to reduce participant burden and risk of exposure to infectious disease (e.g., COVID-19) in comparison to traditional methods of epidemiological studies (e.g., lengthy questionnaires). With participant approval, image (e.g., body shape (clothed)), video (e.g., participants walking a 6-meter course), and audio data (e.g., recordings of participants breathing) was collected on a subset of participants during APCAPS follow-up 4. We will use machine learning methods to identify biomarkers with the aim of developing novel screening methods.

Results

Study ongoing.

Other methodological studies 

Other methodological studies have: developed and evaluated a questionnaire tool for accurately measuring diet and physical activity in India, compared the validity of two reference methods for estimating body composition (dual-energy X-ray absorptiometry and isotope dilution technique), and developed and evaluated anthropometric prediction equations for estimating lean body mass and appendicular lean soft tissue in the Indian population (using standard anthropometric indices).

Related studies

Indian Migration Study (2005-07) 

Summary

The Indian Migration Study (IMS) aimed to investigate the effects of rural-urban migration on chronic disease risk in India. It used a sibling pair design, comparing chronic disease risk factors in migrant urban factory workers and their spouses with that of their siblings who still lived in rural areas (non-migrants). Urban participants were recruited from factories in Lucknow, Nagpur, Hyderabad and Bangalore. Their rural-dwelling siblings came from 18 of the 28 states in India. A sample of workers who had always lived in urban areas and their urban-dwelling siblings were also recruited. All participants (6,510 in total) answered questions about their diet and physical activity, had anthropometric measurements taken and gave blood samples. Protocols and data collection instruments of APCAPS and the IMS are largely aligned, allowing joint analysis.

Key findings

A study combined APCAPS and IMS data to examine the association between childhood socioeconomic circumstances and cardiovascular risk; results indicated an inverse association between standard of living in childhood and blood pressure in adulthood, independent of socioeconomic circumstances in adulthood. Results of other IMS studies have suggested that body fat increases rapidly when individuals first move to an urban environment, whereas other cardiometabolic risk factors evolve gradually.

Read the study protocol for the Indian Migration Study.

Data access

The data are available to researchers to access following an approval process – see ‘collaborate’ for further information.

Funding

The Wellcome Trust, UK

Cardiovascular Health Effects of Air pollution in Telangana, India (CHAI) Study (2015-18)

Summary

While there is convincing evidence that fine particulate matter (PM_2.5) causes cardiovascular mortality and morbidity, very little of this evidence is based on populations of low- and middle-income countries. There are large knowledge gaps regarding the health effects of such exposures in India. The Cardiovascular Health effects of Air pollution in Telangana, India aimed to 1) characterize the exposure of particulate air pollution from household and outdoor sources, 2) to integrate information from GPS, wearable cameras, and continuous measurements of personal exposure to particles to understand where and through which activities people are most exposed and 3) quantify the association between particles and markers of atherosclerosis. CHAI participants were randomly sampled, stratified by village from participants in APCAPS third follow up, who were still resident of APCAPS villages and 18 years or older. Three stationary monitoring stations within the study area were established to characterize ambient concentrations of PM_2.5 and their temporal variability. We measured 24-h integrated gravimetric PM_2.5 for 21 days over two seasons at 23 sites which were located within 16 of the area villages. Please see CHAI website for further information.

Results

The CHAI study developed land-use regression models for predicting exposure to PM2.5 and black carbon and examining the relationship between air pollution and chronic disease. CHAI study findings indicate a positive association between ambient PM_2.5 and household air pollution with carotid intima-media thickness in the APCAPS cohort, a positive association between PM_2.5 and blood pressure for women, and lack of an association between PM_2.5 and blood pressure for men or black carbon for either gender, and lack of an association between PM_2.5 or black carbon with blood glucose or diabetes status.

Data access

Data on predicted PM2.5 and black carbon exposure (personal and ambient) is available for APCAPS follow-up 3 and can be accessed with the usual approval process – see ‘collaborate’ for further information. Land-use regression models for predicting exposure to PM2.5 and black carbon are published (please see above) and can be used to predict PM2.5 and black carbon exposure for other APCAPS follow-ups.

Funding

The European Research Council

Nagasaki Islands Study 

Summary

The Nagasaki Islands Study has been conducted under a population-based open cohort design in Goto city, located in the remote islands of Nagasaki prefecture, Japan. This study aims to assess environmental and genetic factors associated with non-communicable diseases in the community, as well as to prevent, diagnose, and treat such diseases effectively.

Similar protocols and data collection instruments have been used in APCAPS and the Nagasaki Islands Study, allowing cross-contextual analyses.

Key findings

A study combined APCAPS and Nagasaki Islands Study data to examine the association between atherosclerosis and handgrip strength in non-hypertensive populations.

Data access

An anonymous dataset supporting the findings of Nagasaki Islands Study is available upon reasonable request. Please see the Nagasaki Island Study website for the application form and letter of pledge and send it to the Nagasaki Islands Study team.