This study aimed to document urban-rural differences in diet, physical activity, and obesity in Punjab, India using a cross-sectional survey of over 5,000 individuals. The results showed minimal differences in dietary habits and physical activity levels between urban and rural areas. Urban females had a higher proportion of obesity compared to rural females. Nearly 90% of individuals in both urban and rural areas reported no physical activity during leisure time. The study highlights declining physical activity levels in India in recent times. A multi-pronged strategic approach is recommended to promote healthy diets and restrict unhealthy diets.

1. Urban rural differences in diet, physical activity and
obesity in India: are we witnessing the great Indian
equalisation? Results from a cross-sectional STEPS
survey
Jaya Prasad Tripathy, J.S. Thakur, Gursimer Jeet, Sohan
Chawla, Sanjay Jain and Rajendra Prasad
Tripathy et al. BMC Public Health (2016) 16:816
DOI 10.1186/s12889-016-3489-8

2. INTRODUCTION
1. Non-communicable diseases (Burden) :
• Increasing prevalence of NCD deaths
• 52 million deaths by 2030
2. Unhealthy dietary practices, sedentary lifestyle and obesity
3. Nations’ economic, demographic and nutrition transition
4. Studies from western countries on diet and levels of physical
activity in population
5. Limited information available

3. OBJECTIVE
• Study planned to document urban rural differences in dietary
practices, levels of physical activity and obesity in a North
Indian state of Punjab.

4. STROBE check list
Recommendation Report
Title and
abstract
a)Study’s design in the title or the
abstract
b)Informative and balanced
summary in the abstract
Yes
Introduction Background/rationale
Objectives with hypothesis
Yes
4

5. MATERIALS AND METHODS
Study design: Cross sectional
Study setting: Punjab – Urban and rural areas
Study period:
Study tool:
Sampling method:
2014-2015
WHO STEP Surveillance (STEPS) questionnaire
Multistage stratified cluster sampling
Sample size: 5400 (Prevalence of physical activity as 50%,
95% confidence interval, 0.05 margin of error
and 85% response rate)
Study subjects: Individuals in the age group 18-69 years
residing in the selected households

6. Punjab
RuralUrban
Multistage stratified geographically
clustered sampling
*PPS: Probability Proportional to Size
CEB: Census Enumeration Block
Selection of
villages
Selection of
wards
*CEB
Selection of
households
Selection of
households
PPS sampling PPS sampling
Random sampling
Systematic random sampling
Systematic random sampling

7. STROBE check list
Methodology
Study design Study design No
Setting Study Setting , locations, and
relevant dates, including periods &
data collection
Yes
Participants Eligibility criteria
Sources and methods of selection
Yes
Variables Outcomes, exposures, predictors,
potential confounders & diagnostic
criteria
Yes
Data sources/
measurement
Sources of data and details
Comparability of assessment
methods
Yes
7

8. Recommendation Report
Bias Potential sources of bias No
Study size Sample size calculation Yes
Quantitative
variables
How quantitative variables were
handled in the analyses
Yes
Statistical
methods
1. Describe all statistical methods,
including those used to control for
confounding
2. Describe any methods used to
examine subgroups and interactions
3. Explain how missing data were
addressed
Yes
STROBE check list…

9. PARAMETERS STUDIED
1. Socio-demographic profile and
Behavioural information (Tobacco and alcohol use, diet, physical
activity, H/O chronic diseases, family H/O chronic conditions, health
screening and health care costs)
2. Physical measurements
a) Weight: SECA electronic weighing scale to nearest 100g
b) Height: SECA adult portable stadiometer to the nearest 0.1cm
c) Waist circumference: SECA constant tension tape to the nearest
0.1cm
Midway between the lowest rib margin and the iliac crest
d) BMI: Categorised as normal, overweight and obese

10. PARAMETERS STUDIED..
3. Dietary practices
• 1 serving of vegetable – 1 cup of raw green leafy vegetables / ½
cup of other vegetables (cooked/chopped raw)
• 1 serving of fruit – 1 medium size piece of apple, banana or
orange, ½ cup of chopped, canned fruit / ½ cup of fruit juice

11. PARAMETERS STUDIED..
4. Levels of physical activity
• GPAQ (Global Physical Activity Questionnaire) developed by WHO
• 3 domains – work, transport & during leisure time in a normal
active week
• Activities – vigorous, moderate & light
• Minimum duration of physical activity/week recommended by
WHO → 150 min of moderate intensity physical activity / 75
min of vigorous intensity physical activity
(OR)
Equivalent combination of moderate + vigorous
intensity physical activity at least 600 MET with each activity
performed in bouts of at least 10 min duration

12. PARAMETERS STUDIED..
4. Obesity
• Asian cut off
< 18.5 → Underweight
18.5 – 23 → Normal weight
23 – 27.5 → Pre-obese
> 27.5 → Obese
• WHO cut off
< 18.5 → Underweight
18.5 – 24.9 → Normal weight
25 – 29.9 → Pre-obese / Overweight
30 – 34.9 → Class 1 obesity
35 – 39.9 → Class 2 obesity
> 40 → Class 3 obesity

13. RESULTS
Total 5400 eligible individuals
- (5127 studied)
RESULTS

14. Table 1: Socio-demographic profile of study participants in STEPS Survey,
Punjab, India

15. Table 2: Urban rural differences in dietary practices, STEPS Survey, Punjab,
India 2014-2015

16. Table 3: Urban rural differences in levels of physical activity, STEPS
Survey, Punjab, India 2014-2015

17. Table 3: Urban rural differences in body mass index and abdominal
obesity, STEPS Survey, Punjab, India 2014-2015

18. Table 4: Socio-demographic characteristics associated with obesity and
lack of physical activity, STEPS Survey, Punjab, India 2014-2015

19. Recommendation Report
Results
Participants 1. Report numbers of individuals at each
stage of study
2. Give reasons for non-participation at
each stage
3. Consider use of a flow diagram
Yes
Descriptive
data
1. Characteristics of study participants,
number of participants with missing data
(Give information separately if
applicable, for exposed and unexposed
groups in cohort studies)
2. Indicate number of participants with
missing data for each variable of interest
3. Summarise follow-up time (eg, average
and total amount)
Yes
Outcome data Numbers of outcome events or summary
measures over time
Yes
STROBE check list…

20. Recommendation Report
Results 1. Unadjusted estimates and, if applicable,
confounder-adjusted estimates and their
precision (eg, 95% confidence interval)
2. Report category boundaries when
continuous variables were categorized
3. If relevant, consider translating estimates of
relative risk into absolute risk for a
meaningful time period
Yes
Other results Report other analyses done—eg analyses of
subgroups and interactions, and sensitivity
analyses
STROBE check list…

21. DISCUSSION
Diet and physical activity:
• Present study - Minimal urban rural differences in dietary habits
and levels of physical activity
• Other studies- Higher physical inactivity in urban areas and poor
intake of fruits and vegetables in the rural areas
• Similar survey conducted in 2005 in India reported 6.8% of overall
inactivity levels
• Recent studies reports 38 to 70% of higher levels of physical
inactivity in India – indicating declining physical activity levels in
recent times

22. DISCUSSION...
Obesity:
• Present study – Urban females had higher proportion of
obesity compared to rural counterparts
• Previous study have highlighted significant urban rural
differences in prevalence of overweight and obesity with
urban dwellers being more overweight and obese

23. DISCUSSION...
Recreational physical activity:
• Current study – 90% of individuals in both urban and rural
areas reports no physical activity during leisure time
• Other studies in India and Vietnam – inactivity in the
recreational domain to be as high as 90%

24. RECOMMENDATIONS
Multi-pronged strategic approach :
• For promoting healthy diet
• Restricting the use of unhealthy diet
Regulations to control the content of salt, sugar, saturated fats
and trans fats in dietary products

25. STRENGHTS
• Multi-stage stratified sampling approach
• Involved whole state of Punjab
• Followed standard methodology of STEPS survey

26. LIMITATIONS
• Self-reported survey
• Inherent bias
• Validity- GPAQ

27. STROBE check list…
Recommendation Report
Discussion
Key results Key results with reference to study
objectives
Yes
Limitations Limitations of the study
Sources of potential bias
Yes
Yes
Interpretation Overall interpretation of results
considering objectives, limitations
Results from similar studies
Yes
Generalizability External validity of the study results No
Other
information
Source of funding and the role of the
funders for the present study
Yes