India is home to over 15 million blind people. Diabetes is a global epidemic but India is one of the top 3 countries most affected with 69 million people diagnosed with diabetes. Diabetic retinopathy is the most common complication of diabetes, whereby blood vessels in the retina leak or die and, if left untreated, this leads to visual loss. Sight threatening diabetic retinopathy (STDR) is the leading cause of blindness in the working age group causing loss of productivity, affecting individual households and the national economy. Despite a fast growing economy, a billion people in India live below the poverty line. Diabetes may result in poverty and poverty is associated with diabetes. Therefore, unless the complications of diabetes are identified early and treated, the impact of blindness on the quality of life and productivity of the Indian population will continue to have a negative impact on the nation's economy. Annual screening of all people with diabetes with retinal photography and prompt treatment of STDR has been shown to decrease the rate of blindness in the UK. However, the technology involved is costly, requires trained manpower and is impractical as a method for screening 69 million people in India annually, when the major proportion of health expenses have to borne by the patients. By increasing research capacity and capability through this programme, we aim to initiate systematic diabetic retinopathy screening in India through research and evaluate innovative technologies that can accurately identify patients at risk of blindness due to STDR close to home. These technologies can be applied in all DAC listed countries with prospects of reverse innovation in the UK. The range of research capability activities (SDG Goal 4) and capacity building in India is aimed at better patient outcomes (SDG Goal 3), developing a workforce with quality education (SDG 4), enhancing sustainable livelihoods (SDG Goal 8) and contributing to India's and the UK's work towards an efficient value based healthcare. Firstly, we will introduce population based diabetic retinopathy screening in India and evaluate whether a hand-held camera with smartphone technology and automated grading is feasible in both India and the UK instead of the standard costly cameras and trained manpower employed in the UK currently. We expect more population coverage of retinal screening with this technology and more patients to be referred for treatment. The research capability at the referral hospitals will also improve from this programme with new quality standards being set for treatment. Secondly, we will develop and validate a blood test of a panel of established markers that can detect STDR and other complications of diabetes with the aim to translate into clinical practice. This will allow patients to monitor their own blood tests for STDR. This has the potential to revolutionise the way people with diabetes are monitored for STDR and other complications globally, empower patients and health care workers with new knowledge, improve research capability in India and the UK, improve research capacity in India and improve the global economy in terms of sustained health, industry and innovation and decreasing inequality in terms of access to healthcare. The programme has the potential to change the landscape of diagnosing and triaging STDR globally. In addition, development of a diabetic retinopathy research network of researchers in India will ensure scalability and sustainability of world-class research in India. These research projects will have secondary benefits to the UK in terms of increasing research capability and reverse innovation. Moreover, the programme will also provide comparative cost-effectiveness data of current standard of care versus these newer technologies to inform national guidelines committees and policy makers globally.

Results of studies from India and the UK show that South Asian people are at high risk for risk COVID-19, or to being infected with the SARS-CoV2 virus which causes this illness. The reasons for this increased risk in South Asians are not known. To address this important knowledge gap, we will take advantage of our established 'population cohorts' comprising South Asian men and women in India and the UK who have been under surveillance for up to 20 years. All participants were recruited before the onset of the COVID-19 pandemic, and have measures of key risk factors relevant to COVID-19, including weight, blood pressure, diabetes, heart disease and socio-economic factors. In addition, we have comprehensive assessment of metabolism, genetic variation, and of gene regulation for many of the participants, generated in previous research projects. These already available cohorts, with rich data and samples, provide a powerful and efficient opportunity to define the primary risk factors for COVID-19 in South Asians. In this new study, we will invite 30,000 of these South Asian people (10,000 in India, 20,000 in the UK) to be tested for evidence of infection with the SARS-CoV2 virus (antibody test). We will also ask them to complete a questionnaire about COVID-19 symptoms, relevant behaviours disease, attitudes to vaccination, and impact of the COVID-19 pandemic (and control measures) on mental, physical and financial wellbeing. We will link to medical records and mortality data where possible to identify people with severe COVID-19. We will use the data collected to determine what are the major risk factors in South Asians in India and the UK, for infection with SARS-CoV2, or experiencing severe or prolonged COVID-19. We will focus initially on recognised risk factors such as adiposity, raised blood pressure and diabetes, cardiovascular disease, health behaviours (alcohol, smoking, physical inactivity), socio-economic indicators, and measures of metabolic health. We will compare our results in South Asians with equivalent measures for Europeans, and determine whether known risk factors explain the high risk of COVID-19 in Asians. We will use the results to develop simple tools for predicting risk of COVID-19 in South Asians, that can be used to prioritise people for vaccination or behavioural interventions, and to protect them from COVID-19. We will also report on vaccine hesitancy in South Asians (delayed or low acceptance of vaccination) as well as the main reasons for this. This will help identify potential obstacles to successful immunisation programmes and the need for public health education to build understanding, trust and confidence. Finally, we will use 'all-of-the-data' including the available health and genetic data to investigate for previously unidentified risk factors or biological processes that might contribute to COVID-19 in South Asians. The findings will provide much needed knowledge into the reasons underlying the high burden of COVID-19 in South Asians, and will inform health policy and practice for prevention and control of the disease in India, the UK and globally. We will deliver significant initial outputs within the first 3 months, thus bringing early impact from the work. The research is led by teams from India and the UK who have been at the forefront of responses to COVID-19 at national level. The team also have established expertise, and track record in research to understand the health of South Asian populations. Our research thus addresses a major public health challenge, is timely, efficient and has a high probability of delivering results that will reduce morbidity and mortality from COVID-19 amongst South Asians, who represent 25% of the world's population.

A Novel High Intensity Short Interval Dance Intervention for Non Communicable Disease (NCD) Prevention in Asian Indian Adolescent Girls - THANDAV - a pilot study. This proposed developmental grant protocol will take place in India with a duration of 18 months. We will test a personalized exercise and education intervention, aided by digital technology to deliver this novel 'THANDAV' (Taking HIIT And Dance to Adolescents for Victory over NCDs) intervention. The principal research question will be - Can a culturally appropriate high intensity short duration (10 min) dance intervention become sustainable exercise in Asian Indian girls aged 10- 17 years to improve their physical fitness and prevent NCDs? The burden due to NCDs has reached explosive proportions with the largest increases happening in low and middle-income countries like India. Exercises levels are abysmally low in India with women being less active than men. The benefits of physical activity in adolescents and youth are well established, with most global guidelines recommending at least 60 minutes of moderate to vigorous physical activity per day. Evidence suggests that adolescence is the time of steepest decline in physical activity, thus making our chosen cohort high-risk age group for diabetes and other non-communicable diseases. The age of onset of type 2 diabetes in India is in the age group of 25- 34 years. Hence, efforts to promote physical activity among adolescents and youth are essential. The barriers to exercising in females include time constraints and exercise not being 'culturally acceptable'. Dance is a socially and culturally accepted form of activity in India. We hypothesize that the short duration and fun element of the THANDAV intervention, coupled with the cultural and social acceptability of dance, will aid the long-term sustainability of such an intervention, which is vital for NCD prevention. We aim to investigate the development, feasibility, acceptability of the intervention and resulting improvements in physical activity and fitness levels in adolescents. The primary outcome will thus be increases in physical activity as measured by step count leading to improvement in fitness levels as measured by heart rate of adolescent girls. After assessing the methodology and impact of the intervention through this pilot study, we plan to apply for the full trial grant wherein we will evaluate the sustainable impact of the THANDAV intervention with an improvised digital design on tangible metabolic health outcomes in a randomized controlled trial mode. The outcomes in the full trial grant will be metabolic parameters including weight, body fat, blood pressure, glucose, lipids, insulin along with important outcome measures including sustainability and scalability. MDRF has been collaborating with multi-disciplinary investigators from the University of Dundee (UoD), Scotland (UK) since 2017 as part of a 4-year NIHR Global Heath Research Unit on Global Diabetes Outcomes Research. The India-Scotland Partnership for Precision Medicine in Diabetes (INSPIRED) project aims to improve the understanding of genetic, lifestyle and environmental factors underlying the high burden of diabetes and its complications. The THANDAV proposal is an extension of this existing collaboration with Dr. Colin Palmer being the Co-Investigator from University of Dundee (UoD), Scotland (UK).