Ranjit Mohan Anjana

Background: Menopause marks a key reproductive milestone with significant implications for women’s long-term cardiometabolic health. However, the influence of cardiometabolic health during the reproductive years on the timing of menopause remains poorly understood. We prospectively examined the association between cardiometabolic health profiles and menopause onset in South Asian women, a population at high risk of early cardiometabolic dysfunction. Methods: We analyzed longitudinal data from menstruating women aged 30–50 years in the CARRS cohort from 2010 to 2024. Baseline cardiometabolic measures included overweight/obesity (body mass index ≥25 kg/m2), hypertension (systolic blood pressure ≥140 or diastolic blood pressure ≥90 mmHg, prior history, or medication use), diabetes (hemoglobin A1c ≥6.5%, physician diagnosis, or use of glucose-lowering medication), and non-high-density lipoprotein cholesterol (non-HDL-C ≥ 130 mg/dl). Using Cox proportional hazards models, we examined associations between baseline cardiometabolic status and time to natural menopause, adjusting for sociodemographic and reproductive factors. Results: Among 2225 women (median age 37 years; IQR: 33, 40), 44% reached natural menopause at a median age of 46 (IQR: 43, 49) years. Women with hypertension reached natural menopause approximately 1 year earlier than those without hypertension. In adjusted models, women with hypertension experienced relatively earlier natural menopause over follow-up (HR 1.34, 95% CI: 1.19–1.52). In contrast, the timing of natural menopause did not differ by baseline diabetes, weight, or non-HDL-C status. Conclusion: Hypertension was associated with earlier timing of menopause in South Asian women. Further research is needed to explore underlying mechanisms and long-term health implications.

Diabetes affects 589 million adults globally, 80% of whom live in low- and middle-income countries (LMICs). Although modern diabetes therapies such as sodium–glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1 RA) improve cardiovascular and renal outcomes and analog insulins help reduce risk of hypoglycemia, affordability remains a barrier to equitable access to these agents. This article analyzes how India has reduced the costs of modern diabetes therapies and improved affordability, pricing trends, regulatory frameworks, pharmaceutical manufacturing policies, and public distribution initiatives in India. India has achieved approximately 60%–90% price reductions for SGLT2i and GLP-1 RA following patent expiry, driven by strong generic competition, structured price regulation, and governmental support, leading to much greater access to these agents. Costs of insulin biosimilars of glargine are also much lower in India, making them more affordable. Cross-national price comparisons show 15- to 65-fold differences between Indian generic prices and U.S. list prices for selected agents. On the policy front, government initiatives like the Ayushman Bharat have considerably helped to increase accessibility for the poor and vulnerable sections of the society. Despite these advances, challenges remain, particularly in rural areas where modern therapies may still be unaffordable or unavailable. Moreover, due to multiple manufacturers providing generics, there could be differences in quality and pharmacokinetics, even between the branded generics. However, India’s experience demonstrates that affordable access to modern diabetes medicines is achievable through coordinated pharmaceutical policy, regulatory efficiency, and enhanced manufacturing capacity, offering lessons for LMICs and high-income countries facing high drug costs.

Oral glucose tolerance test (OGTT) is universally recommended for screening and diagnosis of gestational diabetes (GDM). This pure glucocentric approach is inadequate as other risk factors contribute to adverse perinatal outcomes. Our study tested the performance of a population-specific composite risk score-based risk stratification on perinatal outcomes. This was carried out in three prospective early pregnancy cohorts in the UK, India and Kenya and was externally validated in two real-world datasets. Our analysis illustrated clear differences in risk factors and rates of perinatal outcomes across the populations, highlighting the need for a population-specific approach. Our data also showed that rates of perinatal outcomes increased with increasing risk categories. Incorporation of key maternal risk factors that contribute to adverse perinatal outcomes with HbA1c offers a move away from an OGTT-based approach to GDM screening and a pragmatic solution for settings with limited health infrastructure where OGTT is difficult to perform.

Gestational diabetes mellitus (GDM) and preeclampsia (PE) are among the most common medical complications in pregnancy, with prevalence rates of 10-25% and 3-9.4%, respectively. Both conditions are important causes of maternal and neonatal morbidity and pose considerable risks to maternal and fetal health. GDM and PE are traditionally viewed as distinct clinical entities. However, they share several common risk factors, including advanced maternal age, obesity, family history of metabolic disease, dyslipidemia and genetic predisposition. The two conditions also have overlapping pathophysiological pathways, particularly involving metabolic and vascular dysfunctions such as insulin resistance, chronic inflammation and endothelial dysfunction. This article reviews the prevalence of GDM and PE, the risk factors common to the two conditions and biomarkers that may aid in early identification of these disorders. The report also discusses clinical implications of the overlap between the two disorders, with a plea for integrated management strategies. Finally, the article also highlights potential preventive measures and underscores the importance of multidisciplinary approaches to improve pregnancy outcomes in those with GDM and PE.

Background Low appendicular skeletal muscle (ASM) predicts adverse health outcomes in European, North American and East Asian populations. Few studies have examined ASM amongst South Asians, a major global population group recognized to have high rates of abdominal obesity and increased cardiometabolic risk. Methods We investigated 197,066 participants of South Asia Biobank (SAB), a population-based study of men and women aged 18-80 years, living in Bangladesh, India, Pakistan, and Sri Lanka. ASM was measured by bio-impedance. Normative ranges for height-adjusted (ASM/Ht2) and BMI-adjusted (ASM/BMI) muscle mass were developed amongst 129,801 initially healthy participants. Associations between ASM indices and all-cause mortality were assessed in a longitudinal sub-cohort of 24,874 participants followed longitudinally (median 4·5 years). Findings Our derived thresholds for low ASM were similar to published criteria in men, but substantially lower than those reported in women. Among participants aged 41 to 80 years, low ASM was present in 9·3% of men and 2·5% of women based on ASM/Ht2, and 7·1% and 2·3% in men and women respectively based on ASM/BMI. Older age and male sex were associated with increased risk of low ASM. The associations of low ASM with overweight and obesity were directionally opposite for ASM/BMI compared to ASM/Ht2, indicating these measures capture divergent muscle mass phenotypes. There were 1,447 deaths among the 24,874 participants followed longitudinally. Low ASM was a risk factor for all-cause mortality based on our ASM/Ht2 threshold (1·37 [1·15-1·64], P<0·001) but not based on published criteria. Interpretation We provide a robust framework for assessment of skeletal muscle mass in South Asians, and the basis for future studies investigating the etiology and clinical significance of low muscle mass in South Asia.

Aims/hypothesis Beyond longer diabetes duration, uncertainty remains regarding the factors that contribute to a higher risk of developing complications in younger vs older people with type 2 diabetes. We investigated whether younger age was associated with a more adverse risk-factor profile compared with older age among people with type 2 diabetes. Methods We conducted cross-sectional analyses of demographic and clinical data from individuals with type 2 diabetes participating in national health surveys from four countries: the Australian Diabetes, Obesity and Lifestyle Study (AusDiab), the US National Health and Nutrition Examination Survey (NHANES), the Mauritius Non-Communicable Diseases Survey (Mauritius Survey), and the Indian Council of Medical Research-India Diabetes (ICMR-INDIAB) study. Type 2 diabetes was defined according to each study’s criteria, including previously diagnosed and newly diagnosed (screen-detected) diabetes (NDM). Individuals with normal glucose tolerance (NGT) were included for comparison. Regression analyses with natural splines assessed association between age at survey and cardiometabolic risk factors in each cohort. Results There were 903 participants with type 2 diabetes from AusDiab, 7086 from NHANES, 2682 from the Mauritius Survey and 10,151 from ICMR-INDIAB. In three of the four studies (excluding ICMR-INDIAB), BMI decreased with increasing age. Younger individuals had higher low-density lipoprotein cholesterol (in NHANES and AusDiab) and lower high-density lipoprotein cholesterol (in all studies except ICMR-INDIAB) compared with older individuals. In AusDiab, NHANES and the Mauritius Survey, triglycerides were highest in younger adults, declining with age. In AusDiab, the Mauritius Survey and ICMR-INDIAB, fasting plasma glucose (FPG) increased with age until 45–55 years, after which it declined. In NHANES, younger individuals with diabetes had higher FPG than older individuals. In all four studies, haemoglobin A_1c (HbA_1c) increased with age, peaking around 50–60 years, before declining. In NDM, 2 h plasma glucose did not vary across age. Systolic blood pressure (SBP) and urinary albumin/creatinine ratio (UACR) were higher in older individuals. Comparing diabetes with NGT, differences in FPG, HbA_1c, triglycerides and diastolic blood pressure (DBP) were greater at younger than older ages in most cohorts. The same was observed for BMI and SBP, but only in two studies (AusDiab and NHANES). Conclusions/interpretation Younger individuals with type 2 diabetes have higher BMI and triglycerides (observed in three out of four studies) but lower SBP and UACR than older individuals with type 2 diabetes. FPG and HbA_1c peak in middle age. Differences relative to individuals without diabetes were more pronounced at younger than older ages for FPG, HbA_1c, triglycerides and DBP, and were possibly greater for BMI and SBP. These age-related patterns likely influence the overall risk of diabetes-related complications. Graphical Abstract The alternative text for this image may have been generated using AI.