Health Status of Indian Population - Current Scenario

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1 Original Article Health Status of Indian Population - Current Scenario Tester F Ashavaid, Seema P Todur, Alpa J Dherai Abstract Objective : We aimed at establishing reference intervals for the various biochemical and hematological analytes in healthy population. We also tried to find the percentage of people with coronary artery disease (CAD) and the associated risk factors in 39,940 subjects who had attended the health check up program at our hospital from the years 1996 to Methods : The medical record folders of all the subjects were screened manually. Reference values were established using SPSS-8.0 package and the percentiles calculated and with it the corresponding 90% confidence interval (CI). Results : The prevalence of hypertension, diabetes mellitus, and coronary artery disease was found to be 22.5%, 14.2%, and 3.9% respectively. In addition only 41.1% of the population was found to be normolipemic. Most of the analytes showed reference intervals which were in agreement with our reporting values. There was no influence of diet on the reference intervals. Also, there were some analytes like lipids where it was felt that changing the reference values would assign the subjects at greater risk for CAD. Conclusion : Implementation of reference intervals in case of lipids poses a dilemma. Lifestyle and diet modifications would have to be implemented to reduce the burden of CAD in this population. INTRODUCTION Various biochemical and hematological analytes in the human body are subject to variation caused by physiological processes, genetic differences, diseases and environmental factors. An observed value of an analyte provides meaningful information only when compared to relevant reference values obtained from the same person or from comparable reference individuals. As per the IFCC (International Federation of Clinical Chemistry) guidelines it is necessary for every laboratory to have their own set of reference values. 1 In India, laboratories across the country follow reference values, which have been established in the Western population. However, the lifestyle, diet, and the genetic pool in the western population differ from our population. Also to the best of our knowledge there is no documented data available on Indian biochemical and hematological reference intervals - even an internet search did not yield any result. It was therefore felt necessary to establish the reference values for the various routine biochemical and hematological analytes in our population. Research Laboratories and Department of Biochemsitry, P. D. Hinduja National Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai dr_tashavaid@hindujahospital.com Received : ; Revised : ; Acepted : MATERIALS AND METHODS The study population consisted of subjects who had attended the health check up program at our hospital from the years 1996 to 2001 totaling to about 39,940 subjects. In the health check up department, patient's physical and medical history was taken and a copy of the reports maintained in the medical records department. The medical record folders of all these subjects were screened manually. All the subjects had fasted overnight for minimum 12 hrs and the blood samples collected in plain, fluoride and EDTA tubes. The serum samples were analyzed for BUN, creatinine, uric acid, total bilirubin, SGPT, alkaline phosphatase, GGT, total protein, albumin, calcium, cholesterol, triglycerides, and HDL cholesterol. Plasma from fluoride tubes was analyzed for fasting and postprandial blood glucose levels. Whole blood from EDTA was used for hemoglobin estimation, WBC and platelet counts. The samples were analyzed on the same automated analyzer i.e. Beckman Systems Synchron Cx7 using standard IFCC methods. Hemoglobin, WBC count, and platelet count from EDTA anticoagulated blood was carried out on Beckman Coulter cell-counter. Prior to analysis, the analyzer was calibrated with calibrators provided by the manufacturer, and controls were run on the analyzers using IFCC protocols. The controls were run at both normal and pathological concentrations for each analyte. During the course of the study JAPI VOL. 52 MAY

2 there was no change in the equipment, reagents, calibration standards, and controls. Exclusion Criteria The IFCC has laid down guidelines which have to be followed while establishing reference intervals in a healthy population. 2 Accordingly, the individuals suffering from the following conditions had to be excluded: a) Pathophysiological states - renal failure, congestive heart disease, chronic respiratory diseases, liver diseases, malabsorbtion syndromes, and nutritional anemias. b) Systemic diseases - hypertension, diabetes c) Intake of pharmacologically active agents - alcohol, and tobacco, oral contraceptives, replacement or supplementation therapy eg. insulin d) Modified physiological states - pregnancy, psychological and mental disorders such as severe stress and depression, exercise or physical training, food intake prior to blood collection e) Other factors - obesity (BMI >30 kg/m 2 ). 3 Statistics The healthy subjects (n=4466) obtained after applying the exclusion criteria, were used for establishing the reference values. They were categorized according to age (<25yrs, 25-34yrs, 35-44yrs, 45-54yrs, 55-64yrs, and >65yrs) sex, and diet (vegetarian and non-vegetarian). Reference intervals were established using the commercially available SPSS- 8.0 package. Distribution pattern for each of the variable was studied and subjected to test for normality. As many parameters displayed non-gaussian distributions, nonparametric methods were used. Thus percentiles are quoted rather than limits based on calculations involving the mean and standard deviation. For the non-parametric estimates, the observations of the reference samples were arranged in ascending order and assigned rank numbers such that the lowest value is ranked-1 and the largest ranked-n. The limits that enclose 95% of the reference population are estimated by identifying the rank number corresponding to the 2.5 percentile (r1) and the 97.5 percentile (r2) as follows: r1 = (n + 1) r2 = (n + 1) The value corresponding to rank r1 is the lower reference limit and the value corresponding to rank r2 is the upper reference limit respectively. 90% confidence interval (CI) for these limits depend on the sample size and are determined. As it is common to define reference interval as the central 95% interval bounded by the 2.5 percentile and 97.5 percentiles, the estimates of percentiles presented in the following sections is based on the conventional central 95% interval. 4 RESULTS The screening revealed that of the 39,940 subjects about 8986 subjects (22.5%) of the population were suffering from hypertension (HTN) [140/90], 5599 (14.2%) from diabetes, and 1542 (3.9%) from CAD. A detailed distribution of the clinical diseases is depicted in Fig. 1. Apart from the diseases, 2412 (6%) subjects were stress positive, 0.7% (n=258) were stress test inconclusive, 32.2% (n=12861) were found to be suffering from various ailments like asthma, anemia, urinary tract infection, etc. or they were smokers, or consuming alcohol, or were on antibiotics, or undergoing either homeopathic or ayurvedic treatment. Only 4466 subjects (11.2%) did not show the presence of any of the above-mentioned factors and these were in accordance with the IFCC guidelines and could be termed as healthy. 2 The data for healthy subjects was stratified according to age and sex for establishing reference values. The analysis revealed that the entire data could be categorized into two groups. Accordingly the first group consisted of analytes where the reference intervals showed minor variations as compared to our laboratory reporting values, whereas the second group consisted of lipid parameters, which showed wide variations. Otherwise, most of the analytes showed reference intervals, which were in agreement with our reporting values as shown in Table 2. The laboratory reference intervals or laboratory reporting intervals are on the basis of values provided in the inserts provided in the kits and have been established using the IFCC guidelines. Also there was no influence of diet on the reference intervals. DISCUSSION The screening revealed that of the 39,940 subjects about 8986 subjects (22.5%) of the population were suffering from hypertension (HTN) [140/90] (Fig. 1). These subjects were already on treatment when they came to our hospital or were diagnosed to be hypertensive at the time of checkup. An additional 1712 (4.2%) subjects were found to be having slightly elevated blood pressure, but not diagnosed as hypertensive. In a study conducted in Mumbai in 1980 on 5723 subjects, the prevalence of HTN was found to be Table 1 Prevalence of HTN, DM, and CAD in various populations Author Year Subjects Place Prevalence (%) HTN Dalal P Mumbai 15.5* Gupta R Jaipur 31.5** Shanthirani Chennai 21.1** Singh RB Moradabad 20.8** * BP - >160/95, ** BP - >140/90 DM Ramachandran { Chennai 13.5 Ramachandran Bangalore 12.4 Ramachandran ,216 New Delhi 11.6 Ramachandran Mumbai 9.3 Singh RB Moradabad 6 Singh RB Moradabad 2.8** CAD Mohan V Chennai 11 Gupta R Jaipur 6 Singh RB Moradabad 9 Singh RB Moradabad 3.3** ** - Rural population JAPI VOL. 52 MAY 2004

3 Table 2 : Comparison of the reference values in the two groups Reported Interval Consolidated Interval LL (90%CI) - UL (90%CI) (LL-lower limit UL-upper limit) Total Protein (g/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) Albumin (g/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) BUN (mg/dl) Males (n = 2172) ( ) - 17 ( ) Females (n = 2294) ( ) - 16 ( ) Calcium (mg/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) WBC (cells X10 3 /µl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) Platelet (cellsx10 5 /µl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) Fasting plasma glucose (mg/dl) Males (n = 2172) ( ) -116( ) Females (n = 2294) ( ) - 115( ) Post prandial plasma glucose (mg/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) Creatinine (mg/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) Uric acid (mg/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) Hemoglobin (g/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) Bilirubin (mg/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) SGPT (U/L) Males (n = 2172) ( ) - 72 ( ) Females (n = 2294) ( ) - 50 ( ) Alkaline phosphatase (U/L) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) GGT (U/L) Males (n = 2172) ( ) - 49 ( ) Females (n = 2294) ( ) - 35 ( ) Total cholesterol (mg/dl) Males (n = 2172) ( ) - 267( ) Females (n = 2294) ( ) - 263( ) LDL cholesterol (mg/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) Triglycerides (mg/dl) Males (n = 2172) ( ) ( ) Females (n = 2294) ( ) ( ) HDL cholesterol (mg/dl) Males (n = 2172) ( ) - 62 ( ) Females (n = 2294) ( ) - 69 ( ) JAPI VOL. 52 MAY

4 Fig. 1 : Health scenario in the population reviewed (n=39,940) % (Table 1). 5 A study conducted by Gupta et al, in Jaipur in an urban population consisting of 2122 subjects, showed the prevalence of hypertension to be 31.5%. 6 In an epidemiological study involving two residential areas in Chennai, more famously referred to as the Chennai Urban Population Study (CUPS), Shanthirani et al found the overall prevalence of HTN in the population to be 21.1%. 7 This is in keeping with our findings. The prevalence of HTN was 20.8% in a rural population (n = 1935) comprising of two randomly selected villages in the Moradabad district in North India. 8 These subjects were categorized into social classes 1-4 depending on the socio-economic status based on occupation, housing conditions, land holding, total per capita income, ownership of consumer durables, and education. It was observed that the prevalence of HTN was significantly higher among social class 1 and 2. This indicates that increasing hypertension may also be a manifestation of urbanization or westernization of traditional societies. Hypertension in our population was followed by diabetes. Diabetes is the most common metabolic disorder which still in the year 2003 remains incurable. 9 It has been estimated that the number of adults with diabetes in the world will rise from 135 million in 1995 to 300 million in the year The major part of this increase will occur in developing countries. The countries with the largest number of diabetics are India, China, and the US, and would continue remaining so even in the year In the first authentic data from a multicentre study conducted by the Indian Council of Medical Research (ICMR) in the early 1970s, it was reported that the prevalence of diabetes was 2.3% in the urban and 1.5% in the rural areas. 11 In our study population about 5599 subjects (14.2%) were found to be suffering from diabetes (Fig. 1). Also 2104 subjects (5.3%) of the population showed the presence of glucose in urine. In the recent National Urban Diabetes Survey (NUDS), Ramachandran et al assessed the prevalence of DM in 11,216 subjects in six major cities, covering all the regions of the country. The prevalence of diabetes was found to be 13.5% among Chennai residents, in Bangalore %, Hyderabad %, Kolkata %, New Delhi %, and in Mumbai - 9.3%. 12 In yet another study conducted in the rural (n = 1769) and urban (n = 1806) populations of north India (Moradabad), the prevalence of diabetes were 2.8% and 6.0% respectively. 13 The study suggests that the prevalence Fig. 2 : Retrospective data of Indian population (n=4466). of diabetes is on the rise in rural areas but is more prevalent in urban areas. As diabetes can affect nearly every organ system in the body, populations across the country bear the burden of diabetes complications: blindness, end-stage renal disease, lower extremity amputations, and the increased risk for stroke, ischaemic heart disease, peripheral vascular disease, and neuropathy. 14 On further screening it was observed that of these 39,940 subjects at least 1542 subjects (3.9%) had proven coronary artery disease (CAD) (Fig. 1). These subjects either had angiographically verified CHD, or had undergone angioplasty, or CABG. In India, the prevalence of CHD not only shows a North-South divide, but also an urban-rural divide. While a study in Chennai (South India) on 1,399 subjects shows the overall prevalence of CAD to be 11.0% 15 another study by Gupta R on 1415 urban men of Jaipur (North India) shows the prevalence of CAD to be 6.0%. 16 When the same study was extended to 1982 rural men by Gupta R the prevalence of CAD was found to be significantly more in urban men (urban 6% vs rural 3.4%, p< 0.001). 16 Singh et al also conducted a study to determine the prevalence of CAD in rural and urban populations of north India. 17 The study consisted of 1769 subjects who were from the rural countryside and 1806 urban subjects. The prevalence of CAD was more in urban population (9.0%) as compared to the rural population (3.3%). 17 A cross-sectional survey revealed coronary artery disease (CAD) prevalence rates of 10% in urban Delhi and 5% in rural Haryana. 18 The prevalence of CAD in urban India (10%) is about double that of rural India (5%) and about fourfold higher than in the US (2.5%). 18 After abiding by the exclusion criteria laid down by the IFCC only 4466 subjects were found to be healthy. The entire data was categorized into two groups on the basis of the differences in the laboratory reference intervals and consolidated reference intervals. Accordingly the first group consisted of analytes whose reference intervals showed minor variations as compared to our reporting values (Table 2). The analytes coming under the first group are fasting and postprandial blood glucose levels, BUN, calcium, total protein, albumin, WBC, platelet, alkaline phosphatase, GGT, JAPI VOL. 52 MAY 2004

5 creatinine, uric acid, hemoglobin, bilirubin, and SGPT. Though the reference intervals varied slightly, the 95 interpercentile levels across the various age groups, in both males and females, irrespective of diet, showed differences as compared to our reporting values. While the interpercentile levels for fasting glucose did not vary much, in case of postprandial glucose the levels were found to rise along with increasing age and was particularly high in the 55-64yrs non-vegetarian females (64-175mg/dl) and in the >65yrs vegetarian males (80-172mg/dl), as compared to our reporting values (70-140mg/dl). The median levels of creatinine remained fairly stable across the various age groups, in both males and females, irrespective of diet. The presence of elevated creatinine levels in males as compared to females could be attributed to the fact that creatinine is stored as a waste product in muscle mass and muscle mass is high in males. 19 The creatinine levels in both sexes showed variations as compared to our reporting values, and the levels were found to increase with age. This could be because with increasing age there is decrease in muscle mass leading to decreased production of creatinine and its decreased excretion from the body. This suggests that there is a need to present the reference values after stratifying them according to age, and sex. Uric acid levels in our study remained unaffected by both vegetarian and non-vegetarian diet and the levels were more in males as compared to females. The 97.5 percentile levels were much higher in all the groups as compared to our reporting upper limit. Hemoglobin levels at the 2.5th percentile (lower limit) in both males and females were much lower than our reporting values. However while in males, the levels at 97.5th percentile (upper limit) were higher, in females these levels were within our upper reporting limits. In case of parameters of liver function test, the median levels of total bilirubin, SGPT, and GGT in both males and females were within our reporting values. However, levels at 97.5th percentile of both total bilirubin and SGPT in males, were elevated than our reporting values. GGT levels were well within our reporting values. The levels were however observed to be much higher than our reporting values in yrs non-vegetarian males and 55-64yrs vegetarian females. The exact cause for the presence of elevated liver enzymes in these subjects cannot be explained as none of these subjects had any history of liver disease. The second group consisted of lipids like total cholesterol, triglycerides, and LDL cholesterol. The upper limit of these analytes varied widely as compared to our reporting values (Table 2). As abnormal levels of lipids and lipoproteins can pose a risk for the development of CAD, we further checked these 4466 clinically healthy subjects for hyperlipidemia using the current reporting levels in our laboratory. Hypercholesterolemia (total cholesterol > 220mg/dl) was present in 18.4% of the subjects (Fig. 2). Elevated LDL cholesterol (LDL-C, [>140mg/dl]) was also included in this group and was calculated using the Friedwald formula. 20 Similarly elevated total cholesterol: HDL cholesterol (HDL- C) levels 4.5) arising due to elevated total cholesterol levels were included. As the levels of these analytes were influenced by total cholesterol levels, they were therefore included in the hypercholesterolemic group. In our study the median levels of total cholesterol (50th percentile) showed an upward rise with increasing age (25yrs - 65yrs) irrespective of diet, in both males (182mg/dl-204mg/dl) and females (163mg/dl - 211mg/dl), the only exception being a slight decrease in median levels (187mg/dl) in 55yrs -65yrs old vegetarian males. That the subjects are prone to developing premature CAD can be highlighted by the fact that even in the subjects belonging to the lower age groups like 25-34yrs the upper limit (97.5th percentile) was nearly 240mg/dl and >240mg/dl in females and males respectively. 21 Similarly even in the case of LDL cholesterol the upper limit in the lower age groups was more than 140mg/dl. The high prevalence of cholesterol has been observed in a study from Kerala on 206 residents of an urban housing settlement in Thiruvananthapuram. 22 The prevalence of hypercholesterolemia (>240mg/dl) was observed to be almost double than in the adults of US (32% versus 18%). 22 In our population low HDL-C levels (males < 35mg/dL and females <45mg/dL) were present in 22.68% of the population (Fig. 2). This group also contained combinations of (a) low HDL-C and increased ratio, (b) low HDL-C, elevated LDL- C, with and without elevated ratio. In our study it was also observed that the median levels of HDL cholesterol in both the genders were on the lower side of our reporting values. Also in all the subjects irrespective of diet and age, the levels at 2.5th percentile were much lower than the lower limit of our reporting values. This again stresses the vulnerability of our population to CAD. According to the Coronary Artery Disease among Indians Study, optimal HDL-C levels was present only in 14% of the Asian Indian men and 5% of Asian Indian women. 23 Hypertriglyceridemia (>200mg/dL) [Fig. 2] in our study was present in 1.52% of the subjects. Hypertriglyceridemia in combination with low HDL-C levels was present in 1.46% of the subjects. This group also consisted of subjects who in addition to both the analytes mentioned above also showed the presence of increased LDL-C and ratio. Finally there were subjects with combined hyperlipidemia. This group of 2.35% consisted of subjects with elevated levels of both total cholesterol and triglycerides with or without increased ratio, increased LDL-C, and low HDL-C. An interesting observation in case of lipids was that there was not much difference in the levels of lipids between vegetarians and the non-vegetarians. This could be because of smaller servings and sometimes infrequent consumption of meat by the non-vegetarians. Also the high levels of lipids in all age groups in both the sexes could be attributed to the fact that diet in India is rich in saturated fats. A diet high in saturated fats includes not only meat but also whole milk as well as high fat dairy products and certain vegetable oils (coconut, palm, and palm kernel oil). Trans fatty acids formed during hydrogenation of vegetable oils can raise cholesterol levels as well. 24 JAPI VOL. 52 MAY

6 Only 42.18% of the population from 4466 subjects was found to be normolipemic (Fig 2). This does indicate that a large portion of our healthy subjects has lipid and lipoprotein levels that are not within the normal limits. These subjects would be at greater risk for developing heart disease. According to the National Cholesterol Education Program (NCEP) III guidelines, in individuals free of CHD, total cholesterol levels of < 200mg/dl, LDL cholesterol levels <130 mg/dl, are classified as desirable. 21 HDL levels 60mg/dl are considered as negative risk factor for CHD. 21 Thus it appears that there are some analytes whose values need not be revised and some whose values may have to be revised and presented according to age and gender. With regards to lipids, it is felt that revising the reference values as per our findings would result in a larger percent of normolipidemics (Fig. 2) but this would be inappropriate, as it would encourage the patients to continue a lifestyle with a false sense of security. CONCLUSION Though contemporary mortality data from India are unavailable, our retrospective analysis of nearly 40,000 subjects suggests that an epidemic of CAD is already underway. Prevalence of CAD and its risk factors like DM, HTN, and dyslipidemia are on the rise in both urban and rural areas. Within the Indian subcontinent, a dramatic increase in the prevalence of CAD has been predicted in the next 20yrs due to rapid changes in demography and lifestyle consequent to economic development. 25 While in the US the cholesterol levels have decreased by 25mg/dl ( mg/dl) in the last 25 yrs, 26 in India there has been an increase in the total cholesterol levels by about 25mg/dl. 27 In our study too we found the lipid levels to be much higher than the levels recommended by NCEP III guidelines even in the younger age groups. In the US the lowering of cholesterol levels was brought about by creating cholesterol awareness programs, bringing about dietary change, and identifying individuals at high risk who need intensive intervention efforts. Revising the reference values for lipids would be unwise; a wiser option would be implementing the NCEP Adult Treatment Panel (ATP) III guidelines for classification. The need of the hour is to increase awareness among the people. Those at low risk could be asked to modify their lifestyle, bring about change in their diet, and increase in physical activity. Also just as in the USA and in other western countries, the people at high risk (i.e. showing family history, abnormal levels of lipids) once identified could be put on medication. All this would form part of the preventive strategy to reduce risk factors and thus, the ever increasing burden of CAD in our population. Acknowledgements We acknowledge the support of the National Health Education Society of the P. D. Hinduja National Hospital and Medical Research Centre, Mumbai, India. In addition we also acknowledge the entire health check up staff, including the consulting clinicians, the MRD staff of the hospital, the statistics department of University of Mumbai, Mr. Bowlekar, the statistician. We also thank our research fellows and students who helped us with timely inputs. REFERENCES 1. Solberg H. 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7 prevalence in Indian men. J Assoc Physicians India 1996;44: Singh RB, Sharma JP, Rastogi V, Raghuvanshi RS, Moshiri M, Verma SP, Janus ED. Prevalence of coronary artery disease and coronary risk factors in rural and urban populations of north India. Eur Heart J 1997;18: Reddy KS. Rising burden of cardiovascular diseases in India. In: Sethi KK, editor. Coronary Artery Disease in Indians - A Global Perspective. Mumbai: Cardiological Society of India, 1988: Whelton A, Watson AJ, Rock RL. Nitrogen metabolites and renal function In: Burtis CA, Ashwood ER (eds). Tietz Textbook of Clinical Chemistry, 2nd edn, WB Saunders Co (Publ) 1994; Friedwald WT, Levy RI, Fredrickson DS. Estimation of the concentration of LDL cholesterol in plasma, without the use of the preparative ultracentrifuge. Clin Chem 1972;18: Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults: Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA 2001;285: Joseph A, Kutty VR, Soman CR. High risk for coronary heart disease in Thiruvananthapuram city: a study of serum lipids and other risk factors. Indian Heart J 2000;52: Enas EA, Davidson MA, Garg A, Nair VM, Yusuf S. Prevalence of coronary heart disease and its risk factors in Asian Indian migrants to the United States Proc Int Symp Atherosclerosis, Rosemont, IL, Oct.6-11, Enas EA. Cooking oil, cholesterol and coronary artery disease. Indian Heart J 1996;48: Dhawan J. Coronary heart disease risks in Asian Indians. Curr Opin Lipidol 1996;7: Johnson CL, Rifkind BM, Sempos CT, Carroll MD, Bachorik PS, Briefel PR, et al. Declining serum total cholesterol levels among US adults: The National Health and Nutrition Examination Surveys. JAMA 1993; 269: Gupta R, Singhal S. Epidemiological evolution, fat intake, cholesterol levels and increasing coronary heart disease in India: paper presented at National Symposium on Hyperlipidaemia, March 21, 1997, New Delhi: NHS, Announcement ICP ORATION Suggestions are invited from members for the following assignments so as to reach Dr. Sandhya Kamath, Hon. General Secretary not later than 31st July, Rabindranath Tagore Oration and 2006 There are no prescribed nomination/application forms for the above orations but, persons are selected from the recommendations received from members of the Association. The recommendations for the above assignments must be accompanied with reasons for recommending a particular person showing the value of his/her research and eight copies each of three of his/her best publications. All relevant papers in connection with the suggestions, such as the bio-data, list of publications etc., should be submitted in 8 sets by the proposer. The recipient of the above award should deliver a lecture pertaining to his/her work at the Annual Conference in January, A person who has received oration in the past is not eligible for the above oration. Oration is open to eminent persons from the discipline of Medicine and allied subjects such as Pharmacology, Biochemistry, Pathology and Physiology. The orator in the discipline of Medicine should preferably be a fellow of ICP. The members of the Governing Body of API and the Members of the Faculty Council of ICP are not eligible to receive any award. Turf Estate, No. 006 & 007, Dr. E. Moses Road, Opp. Shakti Mill Compound, Mahalaxmi (West), Mumbai Tel. : (022) Tel./Fax : (022) Dr. Sandhya Kamath Hon. General Secretary JAPI VOL. 52 MAY