31 March 2008 Society wellness: new parameters

Pulse Of A Nation

Health may get redefined for the Indian
Pulse Of A Nation
Pulse Of A Nation
The Desi Health Card
There could be big surprises in store for Indians. The ICMR is testing health parameters to see whether the 'normal range' for the West is applicable in the case of Indians. Some parameters:
  • Blood pressure
  • Body mass index
  • Blood sugar level
  • Cholesterol
  • Low-density lipoproteins
  • High-density lipoproteins
  • Triglycerides
  • Haemoglobin
  • Kidney and liver function tests
  • Vitamin content
  • Prostate-specific antigens
    (In all, there are 272 parameters)


Health in India is set to go desi. In an ambitious move with far-reaching implications, the Indian Council of Medical Research (ICMR) plans to reassess markers of good health. It will soon launch a nation-wide programme to review normal values for as many as 272 medical parameters used in everyday clinical tests. This because the present reference standards against which Indians are tested have been adapted from western countries and are often not applicable to Indians, given the climatic, geographical and genetic differences involved.

ICMR hopes that at the end of the exercise, called the Indian National Clinical Laboratory Parameters (INCLAP), it will have a more relevant set of values to accurately determine the physical well-being of Indians. That INCLAP could redefine good health is evident from the parameters it will be reviewing—blood pressure, glucose content, cholesterol and fat, vitamin, enzyme and hormone levels, body mass index and much more. INCLAP, simply put, will determine their ideal values in the Indian context.

The project has its genesis in meetings held under the aegis of the Medically Aware and Responsible Citizens of Hyderabad (MARCH). "At our meetings, medical professionals often argued on sound biological proof that reference standards of clinical laboratory parameters for good health in use cannot be applied to Indians since they have been adapted from the west," points out P.M. Bhargava, chairman of MARCH. This, proponents of INCLAP argue, is mainly because the Indian population is characterised by immense ethnic/genetic differences, unlike the more homogeneous populations of western countries. This means any markers of good health for Indians will have to define stability accounting for a much wider range in the relevant variables, brought on by the interplay of genetics and environment—for instance, climatic specificities and dietary cultures attuned to these.

Science bowing to cultural relativism? No, the ICMR— which accepted the essential premise of the idea mooted by MARCH in initiating the present exercise—says it's a valid and overdue inquiry. "We feel the reference standards may be different for Indians, given the fact that we are generally smaller in size and have different structures and metabolisms," says Vasantha Muthuswamy, ICMR's senior deputy director general. "This will be the first such exercise in the world," she claims.

Bhargava, who chairs the INCLAP taskforce, points to the scale of it all. "The consequences are immense as India has a large number of perfectly normal people who are being declared sick. All the same, many who should be warned in time for poor health aren't being alerted," he states. "Imagine the distress one has to go through if one is declared anaemic as per western standards but may not be so according to Indian ones. It also means wasting resources on unnecessary iron-boosting drugs."

Some of the pieces in this medical science puzzle will begin to fall into place when a pilot project gets rolling in the second half of this year. It aims to cover a sample size of 3,000 people in six states across the country, recording values on 52 parameters. "Well-known private laboratories such as Vimta Labs, Dr Lal Pathlabs and srl Ranbaxy have been identified as partners. We will have mobile labs travelling to the selected regions to collect samples," says Muthuswamy.

The pilot project is expected to identify and deal with possible bottlenecks in what will be a colossal, complex exercise. Notes Partha Majumder, member of the INCLAP taskforce and a population geneticist at Calcutta's Indian Statistical Institute: "We would like to push ourselves to the extreme in collecting samples from remote corners, transporting them on time to the laboratory and estimating the clinical laboratory parameters." The pilot project will also gauge the preparedness for the larger study, expected to cost around Rs 500 crore and last anywhere between 5 and 10 years. The final sample size is likely to run into several hundred thousand individuals.

While INCLAP will be the first definite and comprehensive reassessment, there have been isolated studies to show how western values for certain parameters do not apply to Indians. One such study was conducted by T. Malati of the Hyderabad-based Nizam's Institute of Medical Sciences, where she heads the biochemistry department. After studying a sample size of 580 Indian men, she found the cutoff mark for prostate-specific antigens (PSA), which determine the likelihood of prostate cancer, was half (2 nanogram/ml of blood) of the western one (4 nanogram/ml). PSA is one of the screening tests for possible onset of prostate cancer. "This implies a lot of Indians being tested for PSA are not being alerted on time to enable them to go for early check-ups," she says.

Similarly, an ongoing study by Malati hints that the level of cholesterol required to precipitate strokes and cardiac arrests in Indians is much lower than in the west. "Today, Indian labs consider anything between 150 to 200 mg/dL as acceptable but my study indicates those between 175 and 200 mg/dL have a borderline risk of heart or stroke-related ailments." It has also been found that CD4 and CD8 counts, which determine how advanced an hiv infection may be, is "much lower" in Indians than in western populations. Average haemoglobin content in Indians is also two notches lower than western recommended levels for males (15 g/dL) and females (12 g/dL).

To give one an idea of the project's likely impact, INCLAP will even decide whether or not a person is diabetic. At present, individuals with glucose content higher than 126 mg/dL in their blood are normally labelled diabetic. "But diabetes goes beyond just the level of blood glucose," argues Majumder. "It has a host of other concomitant problems like fatigue, frequent urination, weight loss and delay in wound healing. If a person with blood glucose higher than 126 mg/dL can continue with his or her daily chores without any of these problems, it may be crucial to reassess whether to declare the person a diabetic," he says. INCLAP, thus, may arrive at a fresh threshold for blood sugar in various Indian populations.

Given the enormous stakes involved, K. Srinath Reddy, president of Public Health Foundation of India, argues the final values should be determined after taking samples from people over a period of time and not just once. "What's normal pathologically may not be normal physiologically," he warns. But Bhargava feels that is "virtually impossible" going by the complexity and magnitude of the project. Nonetheless, he says, INCLAP'S effort will be to arrive at as many credible figures as possible.


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