Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

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On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Saraswati Dental College
On Sep 2018

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On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : BC07 - BC11 Full Version

Estimation of Proinflammatory Cytokines and Mediator CD40 Ligand Levels in Young Tribal Subjects of Tripura- An Observational Study

Published: March 1, 2022 | DOI:
Debaprasad Chakrabarti, Partha Sarathi Pal

1. Professor, Department of Medicine, Tripura Medical College and Dr. BRAM Teaching Hospital, Agartala, Tripura, India. 2. Assistant Professor, Department of Biochemistry, Agartala Government Medical College, Agartala, Tripura, India.

Correspondence Address :
Partha Sarathi Pal,
Malanchaniwas Qtr, Type-IV/18, Block-8, Near A.G Office, P.O. Kunjavan,
Agartala, Tripura, India.


Introduction: Obesity is the established risk factor for the development of cardiovascular diseases like hypertension, diabetes mellitus, chronic heart diseases and atrial fibrillation. Cytokines such as Interleukin-6 and Interleukin-12 (IL-6, IL-12) play a significant role in the development of obesity related disorders. Cluster of differentiation 40 (CD40) ligand, a trimetric protein structurally related to Tumour Necrosis Factor alpha (TNF-α) family contributes to atherothrombosis by being a link between platelets, inflammation, thrombosis and atherogenesis. The present study was undertaken to explore the interplay between inflammatory cytokines and CD40 Ligand (CD40L) in young obese tribal subjects.

Aim: To estimate the level of proinflammatory cytokines like IL-6, IL-12 and CD40 ligand in obese subjects and compare with non obese tribal subjects of Tripura, India.

Materials and Methods: In this observational study, 60 non obese and 60 young obese tribal subjects within age group of 18-36 years were enrolled, over a period of two years from March 2014 to March 2016 at Tripura Medical College (TMC) and Dr. BRAM Teaching Hospital, Tripura, India. Serum levels of IL-6, IL-12 and C-reactive Protein (CRP) were estimated by Enzyme-Linked Immunoassay (ELISA). Plasma level of fibrinogen activity was measured by coagulation assay. The Homeostasis Model Assessment (HOMA) of insulin resistance was calculated as insulin (micro unit per milliliter) x glucose (milimoles/Ltr)/22.5. Soluble Cluster of differentiation 40 Ligand (sCD40L) in serum was determined by ELISA. Statistical analysis was performed using Mann-Whitney test, Chi-square test and regression analysis.

Results: Cohort consisted of 19 (31.1%) males and 41 (68.3%) females whereas the control non obese group comprised of 16 (26.6%) males and 44 (73.3%) females. In the present study, the authors had observed that the biochemical parameters like fasting blood glucose, cholesterol, triglycerides and High-Density Lipoprotein (HDL) cholesterol were significantly higher in obese subjects compared to non obese subjects. Further, the authors observed that CRP, IL-6, IL-12 and fibrinogen level were statistically higher in obese subjects. A statistical significant difference was found in fasting insulin level and Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) between obese and the non obese group. Finally, there was positive relationship between CD40 ligand and cytokines with obesity.

Conclusion: The present study has demonstrated that the circulating levels of IL-6 and IL-12 have a strong relationship with obesity and other parameters of metabolic risk. It was also observed that there is a clear positive relationship between CD-40L and cytokine families.


Adipose tissue, Interleukins, Metabolic risk, Obesity

Obesity is a complex disorder and a major health risk factor linked to diabetes, hypertension, stroke, Cardiovascular Disease (CVD), cancer as well as early death (1). Central obesity is closely associated with insulin resistance, lipid disorders, oxidative stress and low grade chronic inflammation resulting in accelerated atherothrombotic process. The levels of several acute phase response proteins and proinflammatory cytokines are significantly increased in both atherosclerosis and obesity (2),(3).

Cytokines such as IL-6 originating from adipose tissue have a fundamental role in the pathogenesis of CVD. IL-6 acts synergistically with other interleukins and growth factor and enhances circulating platelet count (4). Similarly IL-12, another proinflammatory cytokine has received increasing attention in the development of obesity related disorders (5).

Insulin resistance is the central pathophysiologic cause of metabolic syndrome. Insulin resistance which is assessed by HOMA-IR is related with several cardiovascular risk factors like hyperglycaemia, dyslipidaemia, obesity and inflammation (6). HOMA-IR has been proved to be a robust method for the surrogate assessment of insulin resistance (7).

Fibrinogen has a strong impact on blood coagulation and platelet aggregation. It has also been shown to have direct influence on the vascular wall as well as play the role of acute phase reactant. These features provide the pathophysiological mechanistic link between fibrinogen and CVDs. Furthermore, an increased level of fibrinogen is positively correlated with higher risk of developing CVD (8),(9).

The CD40L system has been implicated in the pathogenesis of atherothrombotic complications in CVDs and as well as in inflammation and thrombosis (10).

The CD40 ligand and its soluble counterpart sCD40L is a trimetric protein structurally related to TNF alfa super-family. It binds to CD40, on cells such as endothelial cells, monocytes and dendritic cells (11),(12). Normally absent from the surface of unstimulated platelets, CD40L is rapidly presented to the surface after platelet activation (13). Platelet associated CD40L on exposure to CD40 expressing cells induces the expression of adhesion molecules, the release of inflammatory cytokines and procoagulant tissue factor (14).

The data on the extent of proinflammatory and prothrombotic cytokines is mainly derived from western population and remains largely unknown in obese indigenous tribes of India. Whereas an accepted convention of wisdom exists for Indian tribes that they are suffering from under nutrition and away from lifestyle related diseases. However, studies have shown, Indian tribal population are experiencing phenomenal changes on socio-cultural and economic front because of the rapid urbanisation, lifestyle changes and dietary habits leading to increasing prevalence of obesity (15),(16).

A study has shown that not only there is a trend of increasing prevalence of obesity in tribal population of India; they are at higher risk than the general Indian population (17). With this background, the present study has been designed to explore the correlation between inflammatory cytokines and CD40L among young obese and non obese subjects which is not well studied in North Eastern part of India previously.

Material and Methods

This was an observational study, conducted at Tripura Medical College and Dr. BRAM Teaching Hospital, Tripura, India, after due approval by the Institutional Ethical Committee {approval no.F.3 (PO-75) Ethical/SFTMC/2010-11/4015, Date 08-10-2013}. The study period was two years from March 2014 to March 2016. All the subjects were enrolled after obtaining written informed consent.

Inclusion criteria: During the study period, total of 60 subjects belonging to ethnic population with central obesity attending Medicine Outpatient Department of TMC and Dr. BRAM Teaching Hospital served as cases in the study. For comparison, equal numbers of non obese healthy tribal subjects (attendant of the patients) were included randomly which served as controls in the study. The study population was between 18-36 years.

Exclusion criteria: Subjects suffering from atherosclerotic diseases and having impaired renal or liver function and connective tissue disorders, cancers and those taking steroid treatment were excluded from the study. Neither the obese subjects nor the non obese had any active infectious or inflammatory disease.

Sample size calculation: Going through the hospital census annually on an average 30-40 young adult patients of tribal ethnicity attended at Medicine OPD of TMC and Dr. BRAM Teaching Hospital over the three years preceding the study period. As only a limited number of patients within the prespecified age group were seen in outpatient setting, all the 60 tribal subjects who attended Medicine OPD between March 2014 to March 2016 were included in this study.

Samples for obese tribal subjects were collected using census sampling technique and for non obese tribal subjects were taken according to convenient sampling technique.

Study Procedure

All the participants underwent complete medical examination, Blood Pressure (BP) and anthropometric measurements. The anthropometric variables like weight, height, Body Mass Index (BMI) and waist circumference were verified in duplicate considering the mean value of two measurements. According to the National Health, Lung and Blood Institute (NHLBI), BMI is calculated as weight in kilograms divided by the square of height in meters (kg/m2) (18). According to the WHO recommendation, BMI cut-off points are <16 kg/m2 (severe underweight), 16.0-16.9 kg/m2 (moderate underweight), 17-18.4 kg/m2 (mild underweight), 18.5-24.9 kg/m2 (normal range), ≥25 kg/m2 (overweight), 25-29.9 kg/m2 (preobese), ≥30 kg/m2 (obesity) (19). Waist circumference was measured using a stretch resistant tape that provides a constant 100 gm tension placing it at the midpoint between the lower margin of least palpable rib and the top of iliac crest. The WHO recommended cut-off for Waist Hip ratio (WHR) ≥0.90 for men and ≥0.85 for women considered as central obesity (20).

Resting BP was measured in sitting position after 15 minutes of rest using a mercury manometer and a cuff appropriately sized for arm size of the subject. Blood samples were taken after overnight fasting and collected into pyrogen free tubes at room temperature. Collection tubes were then centrifuged at 3000 rpm for 20 minutes and serum samples were stored at -20°C in numerous aliquots until use. Fasting Blood glucose (GOD-POD method), Serum Cholesterol (CHOD-PAP method), Triglyceride (GPO-Triender method) and HDL (Direct) were measured in automated equipment (Erbachem 5 plus V2, Erba Mannheim) following manufacturer’s (Erba) instructions.

Serum CRP, IL-6 and IL-12 were assayed with commercial enzyme linked immunosorbent assay in Lisaquant-TS (Tulip Diagnostic) ELISA reader. Each assay was performed according to the manufacturer’s protocol. All biochemical measurements were performed at the same time in order to avoid procedural variations. The cut-off value of CRP (Abnova), IL-6 (Diaclone SAS) and IL-12 (Diaclone SAS) were taken upto 10 mg/L, <2 pg/mL and 2.2 mg/mL respectively by ELISA in Lisaquant-TS ELISA reader (21),(22),(23).

Fasting blood insulin and fibrinogen were measured by ELISA in Lisaquant-TS ELISA reader and coagulometric methods in Sysmex coagulation analyser respectively. The cut-off value of Insulin (Diagnostic automation) was taken between 2-25 μIU/mL and for fibrinogen (Diagone Ltd.,), it was from 2-4g/L (24),(25). The estimate of insulin resistance was determined by means of HOMA- IR as follows: fasting blood insulin concentration (mU/L) X fasting glucose concentration (mmol/L) divided by 22.5. The cut-off value of HOMA-IR was taken 2.5 (26).

Soluble CD40L was estimated by ELISA in Lisaquant-TS ELISA reader immediately or after one to three freeze thaw cycles and at different centrifugation speeds as described by Schoenbeck U et al., (27). The cut-off value of sCD40L (Biovision Incorporated) is <6 pg/mL.

Statistical Analysis

The statistical analysis was performed with Statistical Package for Social Science (SPSS) (version and 13.0, Chicago IL). Normality of the data was checked by Shapiro-Wilk test. The unpaired Mann-Whitney U test was used to assess statistical difference between two independent groups. In correlation analysis, normally, distributed data was analysed with Pearson’s correlation whereas Spearman’s correlation was used for non normal data. Multivariate linear regression analysis was performed to assess the independent relationships between sCD40L levels and other variables after adjusting for confounding factors. Results were presented as Mean+SEM. The p-value <0.05 was considered significant.


The study included 60 obese subjects and 60 non obese control subjects with mean age of 30.47±3.75 years and 27.20±6.89 years, respectively. Male and female ratio of study subjects and controls were 1:2.1 and 1:2.7 respectively. Anthropometric, clinical and laboratory characteristics of the obese and non obese population are described in (Table/Fig 1).

In this study, the authors observed that parameters like fasting blood glucose, serum cholesterol, serum triglyceride and HDL cholesterol were significantly higher in obese cases compared to non obese subjects.

Similarly the plasma levels of CRP, an inflammatory marker, IL-6 and IL-12 the proinflammatory cytokines, fibrinogen a prothrombotic factor and CD40L (index of platelet activation) were significantly higher in obese subjects compared to non obese. Statistically significant differences were also found in fasting insulin level and HOMA-IR between obese and the non obese group (Table/Fig 1).

The present study showed that a clear correlation exists between elevated IL-6 with rising level of blood glucose, IL-12, fibrinogen, and sCD40L in obese group compared to the non obese population (Table/Fig 2).

Statistically significant association was also observed between IL-12 and levels of triglyceride, CRP, IL-6, fibrinogen, and sCD40L in obese subjects only (Table/Fig 3).

Study also demonstrated that an elevated concentration of sCD40 L was associated with rising levels of CRP, IL-6, IL-12, fibrinogen, insulin and HOMA-IR in the obese group, and it was statistically significant (Table/Fig 4).

After applying the multivariate logistic regression analysis, it was observed that only the value of IL-6 remained significant and independent predictor high sCD40L level (p=0.001) (Table/Fig 5), (Table/Fig 6).


It was observed that proinflammatory cytokines like IL-6, IL-12 and CD40 Ligand are significantly elevated in young obese tribal population compared to non obese cohorts. As such rising trend of obesity is seen in the young Indian tribes, it is a matter of great concern for their future cardiovascular health and other obesity related diseases (17). While burden of this cardiometabolic risk factor should be viewed in a regional and ethnic context; data regarding obesity in indigenous population is sparse.

In the present study, most individuals in the obese cohort had multiple cardiometabolic risk factors. It was observed that high levels of CRP, an inflammatory marker was present in more than one quarter of study population.

It was observed that IL-6, present substantially in adipose tissue, was significantly higher in obese subjects compared to non obese subjects. This pleotrophic cytokine exhibited a significant increase in parallel with obesity and showed positive correlation with fasting blood sugar, fibrinogen and sCD40 Ligand. Similar observation was made by Roytblat L et al., in their study on obese adolescent population (28). Likewise El-Mikkawy DME et al., in their study concluded that high circulating level of IL-6 signals the intensity of chronic and systemic inflammation that results with high grades of obesity and this might contribute to the development of atherosclerotic vascular diseases both directly and indirectly through alteration of HDL cholesterol (29). Similar observation was also made by Baikpour M et al., who showed that a significant positive correlation exist between serum level of IL-6 and obesity with BMI ≥25 kg/m2 (30).

It is well recognised that IL-6 cytokine has multiple effects ranging from inflammation to host defense, tissue injury and modulating insulin resistance. It has been seen that high levels of IL-6 are predictive of type 2 diabetes and myocardial infarction in adults and ablation of this proinflammatory molecule improves insulin signaling in tissues (31).

The present study demonstrates that circulating levels of IL-12 has a strong relationship with obesity and other parameters of metabolic risk like hypertriglyceridaemia, hyperfibrinogenaemia and sCD40L. Study by Suarez-Alvarez K et al., has also shown that IL-12 has a strong positive relationship with systemic low grade inflammation and obesity related markers (5). Comparable findings were also reported by Mohamed AA et al., where it was observed that there is increased secretion of proinflammatory cytokines like IL-12 in obese subjects in comparison to normal weight control group (32).

Although, a pathophysiological role cannot be deduced with the study design, the association of circulating cytokines and several anthropometric and metabolic markers linked to insulin resistance points to the participation of these cytokines in the genesis of insulin resistance. The present data suggests that plasma IL-6 and IL-12 values could be used as a metabolic marker in the identification of glucose intolerance and lipid alteration in young obese subjects.

In the present study, the authors observed that fibrinogen was significantly higher in obese individuals, and this marker showed a positive relation with CRP, reflecting the role of underlying subclinical inflammation in obesity. Observation of this study was consistent with study described by Hafez M et al., (33).

It was also observed in the present study that sCD40 L were significantly elevated in obese subjects compared to non obese subjects. Similar to the present study, Unek IT et al., demonstrated that level of CRP and sCD40 L were significantly higher in obese subjects in comparison with normal weight subject (34). In terms of sCD40 L and cytokines, findings of the present study reveal that, there is a clear positive relationship between these two families. These findings are in tune with a previous study done by EI-Shahhat N et al., (35). As a key player in immunity, CD40 L signaling regulates ‘T’ cell activation and cytokine production. Besides this, CD40/CD40 L axis is intricately involved in thrombosis and coagulation process (36).

Thus, the present study reveals that a clear positive correlation exists between molecular markers like IL-6, IL-12, sCD40 L with obesity, insulin resistance and prothrombotic factors. This association is a result of close relationship with metabolic pathways and inflammation. Macrophages and adipocytes are directly involved in production of cytokines like IL-6 and IL-12 (37). Adipocyte hypoxia secondary to adipose tissue expansion leads to development of obesity related inflammation by increasing cytokines production and promotion of expression of proinflammatory genes (38).

As India is presently facing a double threat due to the obesity and diabetes epidemics, urgent measures are necessary to tackle them both. National policies are needed to be formulated to overcome the dual epidemics of diabetes and obesity before they grow out of hand. At present only a few strategies exist to treat obesity. Identifying the emerging role of proinflammatory cytokines in obesity and their relationship with CD40 can throw a light on therapeutic intervention in obesity and mitigate the cardiovascular adverse events.

Evidence suggests that reducing CD40 L by the use of conventional drugs such as statin and antiplatelet agents may lead to improved clinical outcome. Thus, CD40 could be a promising therapeutic target in high risk obese individuals given its close association with atherothrombosis and proinflammatory cytokines (39).


The authors acknowledge the following limitations in the present study. First, the sample size was small in the study, hence not empowered to draw a definite conclusion. Second, the authors could not include all the tribes of Tripura, nor could the authors make any subgroup analysis of the different tribes included in the present study. Therefore, results of the present study cannot be extrapolated to other groups. Third, the dietary, occupational and economic parameters of the study population were not categorised in the present study pre specified design. Hence, their social and cultural aspect cannot be commented upon. Finally, as the authors could not follow-up the cases prospectively, incidence of future cardiovascular events remains unknown.


In the present study IL-6 and IL-12 had a positive relationship with obesity. Likewise, CD40L is also closely interlinked with the measured cytokines. However, larger clinical studies are required to elucidate all these issues and develop therapeutic strategy of prevention. In absence of a definite therapy to modify the underlying inflammatory and hypercoagulable state, early and more aggressive cardiometabolic risk factor intervention is suggested to mitigate the obesity, one of the greatest public health challenges.


At first the authors thank Indian Council of Medical Research, Government of India for giving us permission for this project. The authors are also thankful to the Principal, TMC and DR. BRAM Teaching Hospital for providing all the institutional support. Authors express gratitude to Dr Arjun Das, MD (PSM) and Dr Bitan Sengupta MD (PSM) for helping the statistical analysis.


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DOI and Others

DOI: 10.7860/JCDR/2022/51602.16119

Date of Submission: Aug 09, 2021
Date of Peer Review: Sep 09, 2021
Date of Acceptance: Feb 10, 2022
Date of Publishing: Mar 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Aug 11, 2021
• Manual Googling: Jan 18, 2022
• iThenticate Software: Feb 16, 2022 (25%)

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