International Journal of Obesity (2001) 25, 1722–1729

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PAPER
High prevalence of diabetes, obesity and
dyslipidaemia in urban slum population in northern
India
A Misra1*, RM Pandey2, J Rama Devi1, R Sharma3, NK Vikram1 and Nidhi Khanna3

1
Department of Medicine, All India Institute of Medical Sciences, New Delhi, India; 2Department of Biostatistics, All India Institute
of Medical Sciences, New Delhi, India; and 3Department of Dietetics, All India Institute of Medical Sciences, New Delhi, India

BACKGROUND AND AIMS: In this study, a prevalence survey of various atherosclerosis risk factors was carried out on hitherto
poorly studied rural – urban migrants settled in urban slums in a large metropolitan city in northern India, with the aim of
studying anthropometric and metabolic characteristics of this population in socio-economic transition.
DESIGN: A cross-sectional epidemiological descriptive study.
SUBJECTS: A total of 532 subjects (170 males and 362 females) were included in the study (response rate approximately 40%).
METHODS AND RESULTS: In this study, diabetes mellitus was recorded in 11.2% (95% CI 6.8 – 16.9) of males and 9.9% (95%
CI 7.0 – 13.5) of females, the overall prevalence being 10.3% (95% CI 7.8 – 13.2). Based on body mass index (BMI), obesity was
more prevalent in females (15.6%; 95% CI 10.7 – 22.3) than in males (13.3%; 95% CI 8.5 – 19.5). On the other hand, classifying
obesity based on percentage body fat (%BF), 10.6% (95% CI 6.4 – 16.2) of males and 40.2% (95% CI 34.9 – 45.3) of females
were obese. High waist – hip ratio (WHR) was observed in 9.4% (95% CI 5.4 – 14.8) of males and 51.1% (95% CI 45.8 – 56.3) of
the females. All individual skinfolds and sum of skinfolds were significantly higher in females (P < 0.001). In both males and
females above 30 y of age, there was a steep increase in the prevalence of high WHR, and in females, %BF was very high
(particularly in %BF quartile > 30%). Furthermore, total cholesterol and low-density lipoprotein cholesterol were high in both
males and females. Stepwise multiple linear regression analysis showed that for both males and females BMI, WHR and %BF
were positive predictors of biochemical parameters, except for HDL-c, for which these parameters were negatively associated.
CONCLUSIONS: Appreciable prevalence of obesity, dyslipidaemia, diabetes mellitus, substantial increase in body fat, general-
ised and regional obesity in middle age, particularly in females, need immediate attention in terms of prevention and health
education in such economically deprived populations.
International Journal of Obesity (2001) 25, 1722 – 1729

Keywords: Asian Indian people; diabetes mellitus; body fat; hypercholesterolaemia; waist – hip ratio

Introduction prevalence of diabetes in urban areas.3,4 Contribution of

Type 2 diabetes, obesity and hyperlipidaemia have been
traditionally considered as diseases of affluence. A wealth
of data indicates that Asian Indian people abdominal obesity
and insulin resistance, and develop glucose intolerance more
often.1 The prevalence of diabetes is higher in migrant Asian
Indian people as compared to other ethnic groups.2 Some of
the studies done on native Indian people also show high
*Correspondence: A Misra, Department of Medicine, All India Institute of
Medical Sciences, New Delhi 110 029, India.
E-mail: anoopmisra@hotmail.com
Received 27 October 2000; revised 21 March 2001;
accepted 3 April 2001
dietary practices and lifestyle factors are crucial, making
incidence and prevalence of obesity and diabetes mellitus
significantly more in the urban population. Recently, con-
siderable concern has been caused by the increasing preva-
lence of diabetes in India,5 particularly in the urban
population.6
High prevalence of malnutrition in people belonging to
low socio-economic strata in developing countries led to the
assumption that obesity and diabetes will not be a crucial
problem in them. Whereas a rural population usually has
low risk of development of diabetes and obesity in India,7
their migration to metropolitan cities exposes them to sev-
eral adverse lifestyle and environmental influences. In cities

they usually settle down in urban slums, and take to daily
wage jobs. Several lifestyle alterations result from this transi-
tion: changes from their traditional penurious eating habits;
exposure to severe stress; decreased physical activity; and
increase in smoking, tobacco chewing and alcohol intake.
Unfortunately, this population has not been researched in
detail. A few studies from the developed countries indicate
that the prevalence of established risk factors including
obesity and diabetes mellitus are higher among men and
women with low level of education as a measure of socio-
economic status.8 A recent study from the UK records that
type 2 diabetes is inversely related to socio-economic strata.9
In this study, the prevalence of diabetes in the least deprived
quintile was 13.4 per thousand persons (95% CI 11.44 –
15.36), compared to 17.22 (95% CI 13.84 – 17.11) in the
most deprived.
However, in developing countries, poverty and scarcity of
food is greater, awareness of diseases non-existent, and it
appears that these diseases may be equally prevalent in poor
people.10 – 12 In one of the largest studies to date, Sawaya et al
report obesity in 6.4% of the boys and 8.7% of the girls, in
2411 subjects from 535 families living in the shanty towns of
São Paulo, Brazil.13 In this population, there was 30% pre-
valence of malnutrition, and 78 – 90% prevalence of stunted
growth in children. Even in this population, high prevalence
of overweight (16.7%) and obesity (14.1%) was noted in
adults.13 Moreover, in 9% of the families, malnutrition in
children and obesity in adults co-existed.
To study the lifestyle, anthropometric and metabolic
attributes of such a population of low socio-economic
strata, we attempted a cross-sectional prevalence survey of
obesity, diabetes mellitus, hyperlipidaemia and related life-
style factors in an urban slum in New Delhi (Delhi Urban
Slum Survey), the largest metropolitan city in northern
India.
Material and methods
The urban slum colony of Gautam Nagar situated in South
Delhi was selected for the study. An approximately 16 square
kilometre area includes 4000 dwellings. The total population
of the area is approximately 30 000 people. The area was
arbitrarily divided into four equal sectors using an electoral
list available from the Slum Development Wing, Govern-
ment of India. The list provided the name, age and address of
those eligible for voting ( > 18 y). Pregnant females, disabled
subjects, drug abusers and acutely ill subjects were excluded
from the study. The fieldwork was completed within a period
of 20 months, starting in January 1998. The first 2 months
were taken for training the physicians for various field
techniques (eg blood pressure measurement and anthropo-
metric measures), selection of the volunteers and reconnais-
sance of the slum area. Several visits were made initially to
establish contact with the Pradhan (chief of the community)
and other prominent people of the community. To establish
rapport with the community several medical camps were
Diabetes, obesity and dyslipidaemia in urban slums
A Misra et al
1723
held in the area, offering free check-ups and medical advice.
A pilot survey of knowledge, attitude and practice (KAP
survey) carried out at this time revealed that 80 – 90% of
the subjects were unaware of the diseases, their con-
sequences and healthy dietary and lifestyle practices.
Two medical teams each consisting of one physician, two
technicians and three to four male and female volunteers
(recruited from the slum area under study) were assigned two
sectors each. The teams visited the every third dwelling, and
informed and motivated the eligible household members for
the field exercise. Subjects agreeing to participate in the
study were instructed to come to a defined clinical area
between 7:00 and 9:30 am after 12 h of overnight fasting.
In particular, the relevance of the overnight fast was
explained to them. Of those approached, only 40%
responded. Furthermore, the response of females was better
than males in the area, since males go to work quite early in
the morning, while females remain behind to do household
chores and part-time jobs. All the subjects were fully
informed about the purpose of the study. Those detected as
having any disease were provided with complete medical
investigation and management in the referral hospital free of
cost.
A detailed questionnaire incorporating demographic pro-
file, socio-economic data, migration pattern, relevant symp-
toms, tobacco and alcohol consumption, physical activity
pattern, and food frequency questionnaire was administered
to the recruited subjects. A complete physical examination
was performed on all the subjects. Blood pressure was
recorded in sitting position after 5 min rest with a mercury
sphygmomanometer according to the standard guidelines. If
one abnormal reading was observed, a second reading was
recorded after 10 min of rest.
Anthropometric measurements
Weight was measured to the nearest 0.1 kg and height to the
nearest 0.1 cm. The body mass index (BMI) was calculated as
weight (kg)=height2 (m). Waist circumference was measured
midway between iliac crest and lowermost margin of the
ribs, and the hip girth was measured at the maximum
circumference of buttocks with the subject wearing mini-
mum clothes. The mean of three readings of each was taken
for the calculation of waist – hip ratio (WHR). Biceps, triceps,
subscapular and suprailiac skinfolds were measured using
Lange skinfold callipers. For biceps skinfold, with right arm
pendant, the fat pad was measured at the level of the nipple
line, and triceps fat pad was measured midway between
acromion process of scapula and olecranon process. Fat
pads at the inferior angle of scapula, and superiorly on iliac
crest directly in the mid-axillary line were measured for sub-
scapular and supra-iliac skinfolds. All skinfolds were mea-
sured to the nearest 1 mm. A mean of three readings was
recorded at each site. Sum of all skinfolds (S4SF) and ratios of
subscapular and triceps skinfold (SS=TR ratio) and central
(sum of subscapular skinfold and suprailiac skinfold) and
International Journal of Obesity
 Diabetes, obesity and dyslipidaemia in urban slums
A Misra et al
1724
peripheral (sum of biceps skinfold and triceps skinfold) analysis. P-value < 0.05 was considered as statistically
skinfolds were calculated. Percentage body fat (%BF) was significant.
calculated using the standard equation of Durnin and
Womersely.14 The equation has been validated for the mea-
surement of %BF in Asian Indians.15 Observations
Out of 650 subjects screened, 532 subjects (170 males, 362
females) had complete records of clinical profile. Biochem-
Biochemical samples and analysis ical tests, although performed in all individuals, remained
A fasting venous blood sample was obtained after anthro- incomplete in a few subjects. Overall, there was a preponder-
pometry and physical examination for blood glucose and ance of Hindu population (91%), followed by Muslims (7%)
lipid profile. Estimation of total cholesterol (TC), serum and Christians (2%). Most of them had migrated from the
triglycerides (TG), and high-density lipoprotein cholesterol nearby states, Uttar Pradesh (60%), neighbouring townships
(HDL-c), was performed on the sample drawn after 12 h of Delhi (13%), Rajasthan (6%) and others. The reason for
overnight fast. TC was estimated with the ferric chloride migration was the search for better economic prospects.
method.16 The method described by Rosenberg and The demographic profile of the study population is shown
Gottfried17 was used for the determination of TG. After in Table 1. Approximately sixteen percent of the males were
precipitation of very low-density lipoprotein cholesterol unemployed and the majority of the rest belonged to the
and low-density lipoprotein cholesterol (LDL-c) from the labourer class (Table 1). The majority of the females were
serum by phosphotungstic acid and magnesium chloride, housewives followed by household workers (Table 1). Seven-
the supernatant was taken and HDL-c estimation performed teen percent of the males and 63.5% of the females were not
by the method described for TC. The value of LDL-c was earning. The monthly income of majority of males was
calculated using Friedwald’s equation. below 3000 rupees (  US$70), and in females it was below
2000 rupees (  US$45; Table 1). Prominently, approximately
70% of the males were smokers or chewed tobacco regularly.
Definitions
Obesity was defined as BMI >25 kg=m2.18 %BF was defined as
indicative of obesity if it was >25% in males and > 30% in Table 1 Demographic characteristics and prevalence of hypertension,
glucose intolerance and dyslipidaemia
females.19,20 WHR of >0.95 for males and >0.80 for females
was considered to indicate abdominal obesity.21 High S4SF Variables Males (n ¼ 170) Females (n ¼ 362)
was arbitrarily defined as >50 mm.22 Persistent elevation of
Age (y) (mean  s.d.) 37.8  13.5 34.3  12.1
blood pressure >140=90 mmHg was defined as hypertension. Occupation, % (n):
Dyslipidemias were defined by the criteria laid down by unemployed 15.9 (27) Nil
National Cholesterol Education Program, Adult Treatment household worker 4.1 (7) 14.6 (53)
Panel II.23 Type 2 diabetes mellitus and impaired fasting labourer 33.5 (57) 6.9 (25)
government service 5.9 (10) 0.8 (3)
glucose were diagnosed according to the diagnostic criteria roadside vendor 7.6 (13) 4.2 (15)
of the American Diabetic Association.24 housewife N.A. 67.7 (245)
miscellaneous 32.9 (56) 5.8 (21)
Earnings per month (in rupees (US$))
No earnings 17.0 (29) 63.5 (230)
Statistical methods < 1000 (  US$25) 11.2 (19) 15.7 (57)
Data were entered into an Excel spreadsheet. All the entries 1000 – 2000 (  US$25 – 45) 37.6 (64) 12.4 (45)
were double-checked for any possible keyboard error. For 2001 – 3000 (  US$45 – 70) 22.9 (39) 6.9 (25)
> 4000 (  US$90) 11.2 (19) 1.5 (5)
both anthropometric and biochemical parameters, the dis-
Smoking 50.3 (86) 10.3 (37)
tribution was confirmed for approximate normality. Mean Tobacco chewing 21.8 (37) 9.2 (33)
and standard deviation then summarised the variables. The Alcohol consumption 16.4 (28) 6.0 (22)
a
Z-test was applied to compare the difference in various Impaired fasting glucose 14.1 (24) 15.7 (57)
b
Diabetes mellitus 11.2 (19) 9.9 (36)
anthropometric parameters amongst males and females.
Hypertensionc 11.8 (20) 11.6 (42)
Correlation between various anthropometric and biochem- Hypercholesterolemia d
26.8 (44) (n ¼ 164) 27.5 (95) (n ¼ 345)
ical parameters was evaluated using Pearson’s correlation Hypertriglyceridemia e
16.8 (27) (n ¼ 161) 12.3 (42) (n ¼ 342)
f
coefficient. For comparing the mean difference in various Low HDL-c 15.8 (25) (n ¼ 158) 16.7 (55) (n ¼ 330)
g
High LDL-c 26 (39) (n ¼ 150) 25.4 (80) (n ¼ 315)
anthropometric parameters across three groups as stratified
by various biochemical parameters, one-way analysis of a
Fasting plasma glucose 110 – 126 mg%.
b
variance (ANOVA), followed by a multiple range test was Fasting plasma glucose >126 mg%.
c
used. Stepwise multiple linear regression analysis was used to Blood pressure 140=90 mmHg.
d
Total cholesterol >200 mg%.
determine the anthropometric predictors for biochemical e
Serum triglycerides >200 mg%.
parameters. STATA 6.0, intercooled version (STATA Corpora- f
HDL-c: high-density lipoprotein cholesterol <35 mg%.
g
tion, Houston, Texas, USA) was used for the statistical LDL-c: low-density lipoprotein cholesterol >130 mg%.

International Journal of Obesity


Most people were staying in one or two room temporary
hutments, with extremely poor sanitary and hygienic con-
ditions. There were no proper medical facilities in the area;
however, there were a few practitioners of alternative med-
icine (Ayurveda and homeopathy). People with medical pro-
blems approached these practitioners first, as they dispense
medicines at cheap rates.
Impaired fasting glucose (IFG) was observed more in
females as compared to males, although the difference was
not statistically significant (Table 1). Type 2 diabetes was
observed in 11.2% (95% CI 6.8 – 16.9) and 9.9% (95% CI
7.0 – 13.5) of males and females, respectively; the overall
prevalence being 10.3% (95% CI 7.8 – 13.2). Prevalence of
hypertension was similar in both males and females (Table
1). Hypercholesterolaemia was observed in a high number of
males (26.8%; 95% CI 20.2 – 34.3) and females (27.5%; 95%
CI 22.9 – 32.5), and similarly equally high number of subjects
had high LDL-c levels (Table 1). However, hypertriglyceri-
daemia was observed more often in males, although the
difference was statistically not significant. Further, 15.8%
Diabetes, obesity and dyslipidaemia in urban slums
A Misra et al
1725
(95% CI 10.5 – 22.4) males and 16.7% (95% CI 12.8 – 21.1)
female subjects showed low levels of HDL-c (Table 1).
The anthropometric and body fat profile of the study
population has been shown in Tables 2 and 3. By the
measurement of BMI alone, obesity was more prevalent in
females (15.6%; 95% CI 12.0 – 19.8) than males (13.3%; 95%
CI 8.5 – 19.5; Table 3). The overall prevalence of obesity was
13.9% (95% CI 11.1 – 17.2). Taking %BF as the measurement
of obesity, 10.6% (95% CI 6.4 – 16.3) males and 40.2% (95%
CI 35.0 – 45.4) females were classified as obese. The overall
prevalence of obesity, determined by %BF, was 30.7% (95%
CI 26.8 – 34.8; Table 3). The mean BMI of males and females
were comparable. WHR was higher in females, although the
difference was statistically insignificant. High WHR was
observed in 51.1% (95% CI 45.8 – 56.3) of the females and
9.4% (95% CI 5.5 – 14.8) of the males (Table 3). There was a
significant difference in the values of the biceps, triceps,
subscapular and supra-iliac skinfolds, all values being
higher in females. S4SF was also higher in females as com-
pared to males (P < 0.001). Moreover, high S4SF was

Table 2 Profile of various measures of obesity

Males Females

Measures of obesity n Mean  s.d. n Mean  s.d.

Body mass index 165 20.0  4.1 359 20.7  4.5 (NS)
Skinfolds (mm) and ratios
Waist – hip ratio 170 0.86  0.11 362 1.02  3.95 (NS)
Biceps 170 5.5  3.8 362 8.3  5.4*
Triceps 170 9.7  6.6 362 14.8  7.8*
Subscapular 170 13.1  7.3 362 17.1  9.5*
Suprailiac 169 14.3  7.5 361 19.9  11.3*
S4SF (sum of four skinfolds) 169 42.3  21.2 361 60.0  30.9*
Central skinfolds (sum of 169 27.2  13.0 361 36.9  19.8*
subscapular and suprailiac skinfolds)
Peripheral skinfolds (sum of triceps and biceps skinfolds) 170 15.2  9.6 362 23.1  12.6*
Central – peripheral skinfold ratio 169 2.01  0.69 361 1.67  0.59*
SS=TR (Subscapular – triceps skinfold ratio) 170 1.54  0.64 362 1.23  0.7*
Body fat (%) 169 17.5  6.2 361 28.4  7.6*

NS statistically not significant; *P < 0.001.

Table 3 Percentage prevalence of diabetes mellitus and various measures of obesity stratified in quartiles according to age groups
2
% Body fat quartiles, % (n) BMI (kg=m ) quartiles, % (n)
High
Age group (y) Sex DM Up to 18 > 18 – 25 > 25 – 30 > 30 Total Up to 18 > 18 – 23 > 23 – 24.9  25 Total WHR

18 – 30 M 6.6 (4) 63.9 (389) 24.6 (15) 6.6 (4) 4.9 (3) 100 (61) 39.0 (23) 47.5 (28) 8.5 (5) 5.0 (3) 100 (59) 0.0 (0)
F 7.1 (13) 17.4 (32) 32.6 (60) 20.1 (37) 29.9 (55) 100 (184) 33.0 (60) 52.0 (91) 5.5 (10) 11.5 (21) 100 (182) 41.8 (77)
Total 6.9 (17) 29.0 (71) 30.6 (75) 16.7 (41) 23.7 (58) 100 (245) 34.4 (83) 49.4 (119) 6.2 (15) 10.0 (24) 100 (241) 31.4 (77)
31 – 50 M 10.7 (9) 61.9 (52) 27.4 (23) 8.3 (7) 2.4 (2) 100 (84) 28.0 (23) 41.5 (34) 14.6 (12) 15.9 (13) 100 (82) 15.5 (13)
F 10.0 (15) 7.3 (11) 22.7 (34) 19.3 (29) 50.7 (76) 100 (150) 25.5 (38) 40.9 (61) 14.1 (21) 19.5 (29) 100 (149) 60.0 (90)
Total 10.3 (24) 26.9 (63) 24.4 (57) 15.4 (36) 33.3 (78) 100 (234) 26.4 (61) 41.1 (95) 14.3 (33) 18.2 (42) 100 (231) 44.0 (103)
51 and above M 24.0 (6) 71.0 (17) 21.0 (5) 8.0 (2) 0.0 (0) 100 (24) 41.7 (10) 37.5 (9) 16.7 (4) 4.1.0 (1) 100 (24) 12.0 (3)
F 29.6 (8) 18.5 (5) 22.2 (6) 7.4 (2) 51.9 (14) 100 (27) 35.7 (10) 32.1 (9) 10.7 (3) 21.5 (6) 100 (28) 66.7 (18)
Total 26.9 (14) 44.2 (23) 21.2 (11) 7.7 (4) 26.9 (14) 100 (52) 39.3 (20) 33.3 (17) 13.7 (7) 13.7 (7) 100 (51) 40.4 (21)
Total M 11.2 (19) 64.0 (108) 25.4 (43) 7.6 (13) 3.0 (5) 100 (169) 34.0 (56) 43.0 (71) 12.7 (21) 13.3 (17) 100 (165) 9.4 (16)
F 9.9 (36) 13.3 (48) 27.7 (100) 18.8 (68) 40.2 (145) 100 (361) 30.2 (108) 44.7 (160) 9.5 (34) 15.6 (56) 100 (359) 51.1 (185)
Total 10.3 (55) 29.4 (156) 27.0 (143) 15.3 (81) 28.3 (150) 100 (530) 31.3 (164) 44.2 (231) 10.5 (55) 13.9 (73) 100 (523) 37.8 (201)

DM: diabetes mellitus; high WHR (waist – hip ratio), males > 0.95, females > 0.80.

International Journal of Obesity

 Diabetes, obesity and dyslipidaemia in urban slums
A Misra et al
1726
observed in 30.8% (95% CI 23.9 – 38.3) of males as compared
to 54.6% (95% CI 49.2 – 59.7) of females. SS-TR was higher in
males as compared to females (P < 0.001; Table 2).
Prevalence of diabetes increased with advancing age
(Table 3). The subjects were stratified according to the age
groups: 18 – 30 y, 31 – 50 y and 51 y and above. BMI and %BF
were further categorised into four approximate quartiles
(BMI — < 18, 18 – 23, 23.1 – 24.9 and  25 kg=m2, %BF —
<18, 18 – 25, 25.1 – 30 and >30%; Table 3). In females,
there was a significantly increasing trend in the prevalence
of obesity as defined by BMI, with advancing age (chi-square
for trends ¼ 4.5, P < 0.05); the highest being in the 51 y and
above age group (22.2%). In males, the prevalence of obesity
was highest in the age group of 31 – 50 y. There was a steeper
rise in the WHR after 30 y of age, particularly in females. Of
note, 15.5% males and 60% females had high WHR in the
31 – 50 y age group, increasing by 18% as compared to
females aged 18 – 30 y. In females aged 51 y and above it
increased further to 66.7%. Similar to BMI-defined obesity,
%BF-defined obesity also showed a significant increasing
trend with advancing age (chi-square for trends ¼ 14.1,
P < 0.001). In females it was noticed to be high even in the
younger age group (29.9%), and increased remarkably to
approximately 50% in the middle aged and elderly. The
magnitude of increase was mostly observed in highest quar-
tile of %BF. In contrast, the percentage of males with high
%BF remained stable in the range of 8 – 11.5% across the age
groups (Table 3).
On comparing the various anthropometric measures
across the BMI quartiles, a progressive increase in the mean
values with increase in BMI in both males and females was
observed (Table 4). Of particular interest is the increase in
mean value of %BF across the BMI quartiles in both males
and females (Table 4). No similar trend of increase in pre-
valence of glucose intolerance and lipid abnormalities was
observed with increase in BMI in either sex. The metabolic
abnormalities were observed more often in subjects belong-
ing to the BMI quartile of >18 – 23 kg=m2; however, numbers
of subjects in the upper two quartiles of BMI were smaller
(Table 4).
Multivariate regression analysis was applied to determine
the anthropometric predictors of biochemical parameters.
Age was considered as a confounding variable and it was
forced into the stepwise regression model. BMI was observed
to be a significant positive predictor of fasting blood glucose
for both males and females in this model. Further, it was a
significant positive predictor of TC in females. For serum TG,
both BMI and %BF were significant positive predictors in
females. WHR and %BF were negatively associated with
HDL-c in both males and females (Table 5).
Discussion
The remarkably high prevalence of obesity in the study
population is of particular note despite their poor socio-
economic strata. Although the mean BMIs are in the range

Table 4 Anthropometric measurements (mean  s.d.), glucose intolerance and dyslipidaemia (% (n)), according to BMI quartiles

Body mass index quartiles (kg=m2)

Variables Sex Total I: Up to 18 II: > 18 – 23 III: > 23.1 – 24.9 IV: > 25 P value
c e
Waist – hip ratio M 170 0.83  0.05 (55) 0.86  0.07 (70) 0.87  0.07 (21) 0.97  0.26 , (17) P < 0.001
a b c e
F 362 0.79  0.07 (108) 0.81  0.06 (161) 0.84  0.06 (34) 0.84  0.07 , (56) P < 0.001
Percentage body fat M 169 13.9  4.5 (56) 18.4  6.1a (71) 19.4  5.7b (21) 23.6  6.2c,e (17) P < 0.001
F 361 23.7  6.5 (108) 28.3  6.5a (161) 30.1  6.6b (34) 36.7  6.1c,e,f (56) P < 0.001
Biceps skinfold M 170 4.6  3.8 (56) 4.9  2.7 (71) 7.9  4.6b,d (21) 9.2  3.8c,e (17) P < 0.001
a b c e f
F 362 5.7  3.3 (108) 7.7  4.1 (161) 9.1  4.8 (34) 14.3  7.4 , , (56) P < 0.001
b c e
Triceps skinfold M 170 6.9  4.9 (56) 10.0  7.1 (71) 11.9  4.8 (21) 15.9  7.1 , (17) P < 0.001
a b c e f
F 362 10.6  5.3 (108) 14.4  6.3 (161) 16.0  5.4 (34) 23.9  9.2 , , (56) P < 0.001
a b c e f
Subscapular skinfold M 170 9.3  4.4 (56) 13.5  6.0 (71) 15.4  8.6 (21) 22.1  9.1 , , (17) P < 0.001
F 362 11.5  6.4 (108) 16.4  7.7a (161) 19.8  7.3b (34) 28.2  10.3c,e,f (56) P < 0.001
Suprailiac skinfold M 169 10.3  5.0 (56) 14.9  6.7a (71) 16.6  6.2b (21) 24.4  8.7c,e,f (16) P < 0.001
F 361 13.9  8.0 (108) 19.3  9.6a (161) 22.2  8.6b (34) 32.7  12.7c,e,f (55) P < 0.001
Impaired fasting glucose M 23 30.4 (7) 43.5 (10) 8.7 (2) 17.4 (4) NS
F 56 25.0 (14) 39.3 (22) 10.7 (6) 25.0 (14) P ¼ 0.004
Diabetes mellitus M 19 21.1 (4) 47.4 (9) 21.1 (4) 10.4 (2) NS
F 35 28.6 (10) 25.7 (9) 11.4 (4) 34.3 (12) P ¼ 0.004
Hypercholesterolaemia M 42 21.4 (9) 45.3 (19) 23.8 (10) 9.5 (4) P ¼ 0.05
F 92 25.0 (23) 39.1 (36) 15.2 (14) 20.7 (19) P ¼ 0.03
Hypertriglyceridaemia M 26 19.2 (5) 61.5 (16) 7.7 (2) 11.6 (3) NS
F 42 11.9 (5) 42.9 (18) 16.7 (7) 28.5 (12) P ¼ 0.003
Low high-density lipoprotein-cholesterol M 24 25.0 (6) 54.2 (13) 4.1 (1) 16.7 (4) NS
F 55 29.1 (16) 49.1 (27) 10.9 (6) 10.9 (6) P ¼ 0.70
High low-density lipoprotein-cholesterol M 38 23.7 (9) 42.1 (16) 23.7 (9) 10.5 (4) NS
F 77 31.2 (24) 37.7 (29) 10.4 (8) 20.7 (16) P ¼ 0.26
a
I vs II; bI vs III; cI vs IV; dII vs III; eII vs IV; fIII vs IV at P < 0.05; NS statistically not significant.

International Journal of Obesity


Table 5 Multiple linear regression analysis to determine anthropometric predictors of biochemical parameters
Biochemical parameters Males
b a
Fasting blood glucose 55.0 þ 0.35(Age ) þ 0.95(BMI )
a b
Total cholesterol 158.7 þ 0.65(Age ) þ 1.1(BMI) þ 37.4(WHR)
a a
Serum triglycerides 92.6 þ 0.01(Age) þ 2.18(%BF )
High-density lipoprotein-cholesterol 43.6 þ 0.01(Age) 7 3.7(WHR) 7 0.06(%BF)
Low-density lipoprotein-cholesterol 121.8 þ 0.65(Agea) þ 0.52(%BF)
a b c
P < 0.05; P < 0.01; P < 0.001.
BMI, body mass index, WHR, waist – hip ratio, %BF, percentage body fat.
of 20 – 21, the prevalence of obesity, as defined by BMI, is
high. Moreover, high WHR is noteworthy, both in males
and, particularly, females.
The prevalence of obesity recorded in the current study is
lower compared to that recorded (27.8%) in an urban sample
of adults in New Delhi.25 Unfortunately, few comparable
studies performed in the urban slums are available in the
literature. Studies from developed countries indicate higher
prevalence of atherosclerosis risk factors among men and
women with lower socio-economic status.8 In developing
countries, the problem of poverty and scarcity of food is
particularly acute in the slum areas. In the Klong Toey slums
of Bangkok, 25.5% of the subjects were overweight and 10%
were obese.10,11 A study involving women in a low-income
area in Karachi showed 42 and 8% of women to be over-
weight and have abdominal obesity respectively,12 an obser-
vation similar to the current study. Sawaya et al reported
high prevalence of obesity and malnutrition coexisting in
the same population.13
Estimations of individual skinfolds in the current study
show comparatively lower values when compared to those
recorded in South Asian men and women in the UK, having
mean BMI in the range of 25 – 26,1 indicating more subcu-
taneous fat in the immigrant Asian Indian people in the UK.
Although desirable and much needed, data on skinfolds of
rural and urban native Indian population are not available.
In the current study, the ratio of central vs peripheral skin-
folds is greater in males due to excess truncal fat, and this is
also reflected by higher SS=TR ratios. However, WHR was
higher in females, indicating excess abdominal fat even in
females. Mean WHR is lower in males, and higher in females
as compared to Asian Indian people in the UK.1 Of further
interest is the remarkable increase in the prevalence of high
WHR in middle-aged females, with no appreciable increase
in their BMI. In males, WHR increased with increase in age
from 30 to 50 y (Table 3). More than a third of the population
over 30 y of age having abdominal obesity is of considerable
concern because of associated metabolic and cardiovascular
consequences.
The detailed observations on anthropometric measure-
ments and %BF have rarely been explored in the studies
done on Asian Indian people living in India. The most
striking observation in the current study is high %BF in
females. In males, only 10.6% had excess %BF, a figure
generally approximating the percentage prevalence of high
Diabetes, obesity and dyslipidaemia in urban slums
A Misra et al
1727
Females
40.6 þ 0.43(Age ) þ 0.97(BMIa) þ 6.3(WHR)
c
a
85.1 þ 0.69(Age ) þ 1.63(BMI ) þ 47.5(WHR)
b a
7 64.2 þ 0.68(Age ) þ 3.1(BMI ) þ 81.5(WHR) þ 1.2(%BF )
50.9 þ 0.04(Age) 7 0.05(BMI) 7 13.5(WHR)
61.8 þ 0.46(Age) þ 56.2(WHR)
BMI in this group. There is, however, a marked discordance
between the two measures of obesity in females; 40.2% show
%BF more than 30%, while only 15.6% show BMI higher
than 25. The most striking observation is the increase in
body fat with advancing age (about 50% had high body fat
above the age of 30 y). The conspicuous feature in women,
therefore, is under-representation of obesity when defined by
BMI alone. These observations are of considerable practical
relevance, questioning BMI as a valid epidemiological tool in
Asian Indian population, particularly in females. Further, all
the metabolic complications of excess fat are likely to be
present in these women with high body fat, even when their
BMI is in a normal range. Such women, when postmeno-
pausal and without the benefit of hormonal protection, are
more likely to develop occlusive consequences of athero-
sclerosis.
Variable prevalence (3 – 11.2%) of diabetes has been
reported from urban areas of India depending upon on the
region, caste and type of survey, diagnostic tool and diag-
nostic terminology.6,7 In the urban population of Delhi, the
prevalence of diabetes mellitus ranged from 1.6 to 9%, being
more common in obese subjects.25 In the rural Indian
population, it is reported to be in the range of 1 – 5%.7,26,27
In one of the well-designed studies in rural areas of North
Arcot District in south India, the prevalence of impaired
glucose tolerance (IGT) and diabetes mellitus was 6.6 and
4.9%, respectively, as investigated by 2 h post-75 g oral glu-
cose load values.27 Similarly, in a rural community in the
state of Punjab, only 4.6% were diabetic.28 It is also note-
worthy that the prevalence of IFG is greater in females as
compared to males in the current study, although it was
statistically insignificant. In a recent study from Kashmir
valley, authors record higher prevalence of IGT and diabetes
mellitus in females as well.29 The observed prevalence of IFG
and diabetes mellitus in the present study is higher than that
reported from the rural population, and equal to or more
than that observed in the urban population. However, it is
difficult to compare most studies done in India, since diag-
nostic criteria of diabetes, methodology of tests, and sam-
pling modes were different. Nonetheless, the prevalence of
IFG and type 2 diabetes mellitus in this sample of urban slum
population is impressive.
Similarly, in the present study, the high prevalence of
dyslipidaemia is striking. Studies from various parts of India
again reveal differences in the prevalence. For example,
International Journal of Obesity
 Diabetes, obesity and dyslipidaemia in urban slums
A Misra et al
1728
7.1% of the subjects had hypercholesterolaemia in a rural
community in northern state of Punjab.28 Of specific con-
cern are approximately 27% of the subjects with high levels
of total cholesterol in the current study. While BMI, and %BF
correlated to serum lipid levels more in females, correlation
was better observed with %BF in males. Since most of the
subjects are not likely to be tested for blood lipids due to
either unawareness of the diseases and=or economic con-
straints, undetected hypercholesterolaemia, coupled with
low levels of HDL-c, generalised and abdominal obesity, and
hypertension are harbingers of accelerated atherosclerosis.
What is the cause of high prevalence of obesity and other
risk factors in this poor population? Certainly, there is a
considerable shift in their dietary and lifestyle profile. The
dietary profile is changed to a mixture of rural and urban
diets, with higher consumption of saturated fat and low
intake of fibre. Further, most of these people used to be
hard working farmers in the fields in their villages, and have
changed to sitting around on the roadside as vendors, thus
radically changing their activity profile. Barker’s hypothesis
may also be invoked to explain these observations.30,31
Although originally reported from the developed countries,
these observations have now been recorded from the Indian
subcontinent as well.32 – 33 The metabolic effects of adverse
in-utero environment and low birth weight appear in child-
hood and adolescence, and may be further exacerbated in
the face of deteriorating lifestyle factors. Such a situation is
likely to occur in economically deprived people who move
from the villages to large cities. Further, activation of
hypothalamus – pituitary – adrenocortical axis is known to
occur due to adverse socio-economic circumstances, which
is often combined with psychosocial stress and ‘physiologi-
cal defeat reaction’.34,35 Increased WHR and generalised
obesity may thus result.36
Economic deprivation and poor living conditions in vil-
lages lure people to the cities, and such migration has been
increasing rapidly in India. As estimated in 1995, 30 – 50% of
the population of many cities in India reside in the urban
slums. Approximately 23 such cities have populations
exceeding the million mark, and the current estimate of
their total population would be close to 100 million.37 One
can thus judge the burden of the slum population, and
magnitude of their health problems. Chronic afflictions
such as diabetes and coronary heart disease (CHD) are
difficult diseases to handle by poor people on a long-term
basis. Availability of cheap but standard care (eg government
hospitals) is often difficult to access because of long travel
distance, patient crowding, understaffing and non-availabil-
ity of drugs and equipment. As a result they often seek the
help of ‘quacks’ and other unqualified practitioners of med-
icine. Further, absence from work deprives them of their
wages, and treatment of the diseases and its complications
poses extreme hardship from which the individual and
his=her family never recovers.
The non-communicable diseases, particularly the upsurge
of diabetes mellitus, hypertension and CHD pose a grim
International Journal of Obesity
challenge to India in this century. Findings of the present
study are particularly ominous, and dispel the notion that
the policy makers need to be concerned only about commu-
nicable diseases in the people of low socio-economic strata in
urban slums. There is, therefore, an urgent need for con-
certed governmental and non-governmental efforts and firm
political will to tackle this important problem. Moreover,
further studies are needed to delineate the problem in detail
and specify the adverse factors, particularly the changes in
the nutrition and activity profile.
Acknowledgements
The study was fully supported by financial grant from
Science and Society Division, Department of Science and
Technology, Ministry of Science and Technology, Govern-
ment of India. The authors express their appreciation to the
staff of SRB Centre of Clinical Pharmacology, Department of
Medicine, All India Institute of Medical Sciences, New Delhi
including Mr Ramesh Giri, Mr Inder Taneja, Mr Gian Chand
and Mrs Alice Jacob for performing various investigations,
Mr RL Taneja for performing quality control of various
biochemical tests, Mrs Jyoti for typing and Miss Kajal for
editing the manuscript. Help and voluntary services pro-
vided from the volunteers, in particular the late Mr Jaipal,
and the population of the slum community is appreciated.
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