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.

Background Sri Lanka has made progress in communicable diseases and poverty reduction, however malnutrition in all forms remains a public health challenge. Previous research has focused primarily on short-term interventions towards primary school aged children, in high-income countries, often targeting narrow outcomes, such as fruit and vegetable consumption. This study aims to address some of these limitations by assessing the long-term effectiveness of a school-based behavioural intervention among adolescents through holistic dietary changes to help prevent obesity, type 2 diabetes, and cardiovascular disease. Methods This study will involve 11–14 year old adolescents attending public schools within Colombo and Gampaha districts of Western Province, Sri Lanka. It is a three-arm cluster randomised controlled trial, with one class per school being selected to participate. Based on sample size/power calculations, the trial will involve 244 schools/classes. Schools will be randomly allocated in a 1:1:1 ratio to two intervention arms (Arms A and B) and one control arm (Arm C). Arm A consists of a non-financial reward; Arm B consists of non-financial reward & pre-commitment device and Arm C will be the control. A difference-in-differences approach will estimate the average treatment effect, adjusting for clustering, fixed effects, and relevant baseline covariates including but not limited to age, gender, and waist circumference. Subgroup analyses will also be conducted. Discussion This study aims to assess the feasibility and effectiveness of a holistic dietary behavioural interventions for adolescents aged 11–14. As the trial is school-based, participants and intervention staff cannot be blinded, but it will adhere to established procedures to maintain separation between staff that deliver the intervention and staff that take outcome measurements. As a minor percentage of children in this age group either study in private schools or drop out of school, we will not be missing a large percentage of children from our sampling framework. Registration Registered at ISRCTN (registration number: ISRCTN11340383) on 29 August 2025.

INTRODUCTION: In South Asia, hypertension is a leading modifiable risk factor for premature death. Ambulatory blood pressure monitoring (ABPM) is an internationally recommended method for hypertension diagnosis, but remains underutilized in South Asia, with little evidence on users’ perspectives. This study aims to identify barriers and proposed strategies related to the acceptability and adoption of ABPM for hypertension management from the perspectives of patients with hypertension and healthcare professionals in Bangladesh, Pakistan, and Sri Lanka. METHODS: Across government and private facilities in Bangladesh, Pakistan, and Sri Lanka, we performed semi-structured interviews with 35 patients with hypertension who had previous experience of using ABPM. We also interviewed 29 healthcare professionals involved in hypertension management who had knowledge on ABPM use, including 11 technicians, 15 specialist physicians, 2 primary care physicians, and 1 administrative head. Guided by a combined framework of the Theoretical Framework of Acceptability and the Consolidated Framework of Implementation Research, we used framework analysis to identify barriers and proposed strategies. RESULTS: While patients with hypertension and healthcare professionals generally supported expanding ABPM use across all three countries, social stigma around ABPM emerged as a common cultural barrier for patients in South Asia. Other key barriers included low public awareness, limited public availability and insurance coverage, lack of organizational alignment and readiness, and patient burden and inconvenience. Participants proposed strategies to address these barriers, including public awareness campaigns to promote and normalize ABPM use, expanding public access through government and donor support, improving ABPM integration by standardizing clinical pathways and strengthening the workforce, and developing more user-friendly ABPM device. CONCLUSION: In resource-constrained South Asian settings, our findings highlight the need for public education and stronger government support to improve ABPM adoption and acceptability. We provide actionable and context-sensitive insights to inform interventions aimed at reducing social stigma and expanding equitable ABPM access, and to support local guidelines and policies for improving hypertension management through acceptable approaches.

Background Non-communicable diseases (NCDs) account for over 80% of deaths in Sri Lanka. Addressing these diseases is challenging due to their complex social, behavioural, and environmental causes. Community-based health promotion programmes focused solely on single risk factors and education provision show limited effectiveness. This study describes Happy Village Plus (HVP), a grassroots, community-based intervention designed to select and implement health promotion interventions aligned with communities’ health-related needs in Western Province, Sri Lanka. Methods HVP was conducted in six communities from November 2022 to June 2024. We recorded Capacity Building and Engagement Activities by type of activity and stakeholders engaged, and Community Interventions by approach and health determinant. Communities' health-related risk factor needs were obtained from individual-level data from 1712 individuals. Regression analyses were conducted to assess whether the community interventions chosen matched communities’ health-related needs. Findings A total of 1217 Capacity Building and Engagement activities were recorded. Community interventions (n = 975) most often addressed diet-related determinants, followed by physical activity and BMI, and to a lesser extent, tobacco and alcohol. For most communities, insufficient fruit and vegetable consumption was the most prevalent health-related need, followed by insufficient physical activity, alcohol use, and smoking. Our results show the selected interventions align with identified needs. Interpretation This paper demonstrates the feasibility of implementing grassroots, holistic, multi-faceted, community interventions covering a wide range of health determinants and NCD risk factors in a developing country context. We highlight that, when empowered, communities can select interventions that align with their health needs, with higher disease prevalence increasing the likelihood of choosing relevant interventions.

There is scant research examining income-based inequalities in risk factors of non-communicable diseases (NCDs) and inequities of preventive care services across the South Asian population. We conducted a cross-sectional study of 202,682 adults aged 18 or above in four South Asian countries: Bangladesh, India, Pakistan, and Sri Lanka. We combined South Asia Biobank (SAB) surveillance data with environmental mapping exposure and 24-h dietary recall to estimate income-based inequalities using concentration curves and concentration indices (CI) that measure the magnitude and directional inequality effects. We also computed the horizontal inequity index (HII) for need-standardised healthcare utilisation and advice by measuring the extent to which the distribution of health promotion advice matches the distribution of diet-related risk factor variables across the income distribution. We reported concentration index coefficients and standard errors. Inequalities in exposure and diet-related risk factors of NCDs were observed. Underweight was concentrated amongst the poor (CI = − 0.16, SE = 0.005, p < 0.001), while overweight and obesity were concentrated amongst the rich (CI = 0.11, SE = 0.003, p < 0.001). Non-recommended intake of fats (CI = 0.04, SE = 0.003, p < 0.001) and carbohydrates were concentrated amongst the rich (CI = 0.05, SE = 0.003, p < 0.001), while non-recommended intake of free sugars (CI = − 0.05, SE = 0.004, p < 0.001) and fruits and vegetables amongst the poor (CI = − 0.07, SE = 0.005, p < 0.001). Exposure to unhealthy outlets was concentrated amongst the rich (CI = 0.02, SE = 0.002, p < 0.001). There were persistent and pro-rich inequities in healthcare utilisation (HII = 0.02, SE = 0.002, p < 0.001) and advice for salt reduction (HII = 0.02, SE = 0.004, p < 0.001), fat reduction (HII = 0.02, SE = 0.004, p < 0.001), healthy weight (HII = 0.03, SE = 0.006, p < 0.001), and fruits and vegetables consumption (HII = 0.04, SE = 0.004, p < 0.001). These findings indicate the need to address and mitigate income-based inequalities in diet-related risk factors of NCDs and underscore the need of policies directed at mitigating NCDs risk exposure and achieving improved and equitable access to healthcare.

Alcohol taxation is a key policy to reduce consumption and alcohol harm but evidence on tax design and indicators to assess taxation policy are lacking. Tax design and two indicators: tax as a share of lowest retail price and affordability, were investigated in eight high-income and nine middle-income jurisdictions. Collaborators populated the International Alcohol Control (IAC) study online Alcohol Policy Tool, providing measures of tax design, tax rates; and typical lowest prices available for retail take-away alcohol. These data were used to calculate tax/share of retail price. Affordability of alcohol was assessed against gross national income (GNI) per capita. High-income jurisdictions had higher tax/share and higher affordability on average compared with middle-income jurisdictions. Over the sample as a whole there was no association between these two indicators of tax policy. The tax designs used also varied with high-income jurisdictions more likely to use specific excise tax reflecting potency and middle-income jurisdictions more likely to utilise ad valorem and specific volume based taxes and to use more than one method across a beverage. Increased alcohol taxation to reduce alcohol consumption and harm is established as a high impact policy and is believed to work by affecting affordability. However, less is known about the best taxation methods to reduce affordability or the best measures to monitor and compare alcohol taxation between countries and over time. In this sample of high- and middle-income jurisdictions tax/price share was not found to predict affordability, suggesting the need to further research indicators of alcohol affordability.

Background:Sales of ultra-processed foods (UPFs) are rising in South Asia, yet UPF consumption and its sociodemographic determinants remain largely unknown. We aimed to quantify UPF consumption and investigate its sociodemographic correlates in four countries of South Asia. Methods:Between January 2020 and September 2022, the South Asia Biobank recruited 63,914 participants aged 18 years or older who were resident in Bangladesh, Pakistan, Sri Lanka, and North and South India, and self-reported as being of South Asian ethnicity. We analysed data from 60,714 eligible adults. Dietary consumption was assessed using interviewer-led 24-h recalls. Foods were classified by their degree of processing using the NOVA classification. Two-part multivariable-adjusted regression models examined associations of sociodemographic factors with the likelihood and quantity of UPF consumption. Findings:In Bangladesh, Sri Lanka, and North India, ∼75% of participants reported consuming UPFs during the previous day, versus 41% in South India and Pakistan. Among consumers, UPFs contributed 13-17% of total energy intake, with biscuits being a common source across regions. Other UPFs included sweetened beverages in Pakistan, packaged salty snacks in South India, and breakfast cereals in Bangladesh. Younger age was associated with UPF consumption in Pakistan and Sri Lanka whereas in Bangladesh and North India, older age was. Women were more likely to consume UPFs in all regions except Bangladesh. In Bangladesh, Pakistan, and North India, any level of education above none (i.e., primary, secondary, or higher) was associated with UPF consumption. Among consumers, UPF consumption was lower in married or cohabiting than single people, in all regions. UPF consumption was higher in rural versus urban residents in Bangladesh and Sri Lanka but lower in Pakistan. Interpretation:UPF consumption varied across South Asia by sociodemographic factors including age, gender, and education. Understanding this heterogeneity is crucial when designing interventions aimed at reducing UPF consumption. Our findings of regional variations in the types of UPFs consumed provide valuable insights for targeted interventions. Funding:The South Asia Biobank is funded by the National Institute for Health Research.

The built environment around schools that are regularly accessed by young people is determined by governments, national and regional policies in each country or region. Zoning regulations for tobacco and alcohol sales are expected to restrict availability and access by young people. This study aimed to examine (non) compliance with tobacco and alcohol zoning regulations around schools in Bangladesh, India, Pakistan and Sri Lanka. In a representative sample of geographic locations in Bangladesh, India North (Delhi) and India South (Chennai), Pakistan and Sri Lanka, the built environment was mapped by systematically walking all streets within the site boundary to collect data on different types of tobacco and alcohol retailers and schools. Data was collected on KoboToolBox, and the maps indicating zoning compliance were created using ArcGIS. Descriptive analysis of outlet compliance to the zoning laws was conducted at the national and school levels, with heterogeneity analyses done by school type, income level and outlet type for tobacco and alcohol. The zoning regulations for tobacco and alcohol differed among the settings ranging from 50 to 100 m for tobacco and absolute bans to 500 m for on-premise alcohol. Among the five different settings within the four countries, 441 areas were studied, including 3615 schools. Non-compliance with the zoning laws is evident in all jurisdictions for both tobacco and alcohol. Within restricted zones around schools (location non-compliant with zoning laws), 12–38

Background: South Asia’s diverse food supply, food preparations, and eating behaviors require dietary instruments that reflect the consumption patterns of South Asians to enable context specific dietary assessment. Such instruments are not readily available for detailed dietary assessment at scale in South Asia. Objectives: We describe the adaptation, implementation, and performance evaluation of Intake24, an open-source digital 24-h dietary recall tool, for dietary assessment in South Asia. Methods: We adapted Intake24 for dietary assessment in the South Asia Biobank (SAB), a large population-based study in Bangladesh, India, Pakistan, and Sri Lanka. Intake24 adaptation encompassed the development of a South Asian food database with commonly consumed foods, linked with corresponding portion sizes, food probes, and nutrient information. Trained interviewers conducted the 24-h recalls. Performance of Intake24 was evaluated in 29,113 South Asian adults. Results: The South Asia Intake24 food database included 2283 items and demonstrated good coverage of foods consumed across SAB regions. Median recall completion time was 13 min. Quality control metrics showed 99% of recalls included >8 items and 8% had missing foods. Median energy intake was higher in younger individuals compared to older, and in males compared to females. Underweight participants reported lower energy intake, with no discernible difference across other BMI categories. Conclusions: Intake24 enables comprehensive dietary assessment in regions of South Asia and will facilitate the analysis of dietary patterns, food and nutrient intake, and their relationship with health outcomes among South Asians.

BackgroundThe alcohol industry uses many of the tobacco industry’s strategies to influence policy-making, yet unlike the Framework Convention on Tobacco Control, there is no intergovernmental guidance on protecting policies from alcohol industry influence. Systematic assessment of alcohol industry penetration and government safeguards is also lacking. Here, we aimed to identify the nature and extent of industry penetration in a cross-section of jurisdictions. Using these data, we suggested ways to protect alcohol policies and policy-makers from undue industry influence.MethodsAs part of the International Alcohol Control Study, researchers from 24 jurisdictions documented whether 22 indicators of alcohol industry penetration and government safeguards were present or absent in their location. Several sources of publicly available information were used, such as government or alcohol industry reports, websites, media releases, news articles and research articles. We summarised the responses quantitatively by indicator and jurisdiction. We also extracted examples provided of industry penetration and government safeguards.ResultsThere were high levels of alcohol industry penetration overall. Notably, all jurisdictions reported the presence of transnational alcohol corporations, and most (63%) reported government officials or politicians having held industry roles. There were multiple examples of government partnerships or agreements with the alcohol industry as corporate social responsibility activities, and government incentives for the industry in the early COVID-19 pandemic. In contrast, government safeguards against alcohol industry influence were limited, with only the Philippines reporting a policy to restrict government interactions with the alcohol industry. It was challenging to obtain publicly available information on multiple indicators of alcohol industry penetration.ConclusionGovernments need to put in place stronger measures to protect policies from alcohol industry influence, including restricting interactions and partnerships with the alcohol industry, limiting political contributions and enhancing transparency. Data collection can be improved by measuring these government safeguards in future studies.

Adolescents continue to be exposed to alcohol marketing, despite the existence of alcohol control policies in Sri Lanka. National-level policies restrict all forms of alcohol advertising, promotions, and sponsorship and sale to minors. The act calls for the need to protect children and adolescents from exposure to the harm of alcohol. This article investigates stakeholders' perceptions of the alcohol marketing policy environment in Sri Lanka, with a specific focus on policies designed to prevent or curtail adolescent drinking. Between May and July 2019, in-depth interviews were conducted with policy stakeholders in Colombo, Sri Lanka. Thematic analysis was conducted on the audio-recorded interviews that were transcribed and translated and imported to NVivo12. Fifteen policy stakeholders from government and nongovernment organizations participated in this study. The overarching theme identified a lukewarm alcohol marketing policy environment. This situation was facilitated by the alcohol industry acting as the vector, an amber light approach towards public health programs, and other factors contributing to the perceived ineffectiveness of the alcohol marketing policy environment. A unified public health approach supported by policy and political commitment may pave the way for better alcohol control in Sri Lanka.

Introduction South Asians are at high risk of type 2 diabetes (T2D). We assessed whether intensive family-based lifestyle intervention leads to significant weight loss, improved glycaemia and blood pressure in adults at elevated risk for T2D. Methods This cluster randomised controlled trial (iHealth-T2D) was conducted at 120 locations across India, Pakistan, Sri Lanka and the UK. We included 3684 South Asian men and women, aged 40-70 years, without T2D but with raised haemoglobin A1c (HbA1c) and/or waist circumference. Participants were randomly allocated either to the family-based lifestyle intervention or control group by location clusters. Participants in the intervention received 9 visits and 13 telephone contacts by community health workers over 1-year period, and the control group received usual care. Reductions in weight (aim >7% reduction), waist circumference (aim >= 5 cm reduction), blood pressure and HbA1C at 12 months of follow-up were assessed. Our linear mixed-effects regression analysis was based on intention-to-treat principle and adjusted for age, sex and baseline values. Results There were 1846 participants in the control and 1838 in the intervention group. Between baseline and 12 months, mean weight of participants in the intervention group reduced by 1.8 kg compared with 0.4 kg in the control group (adjusted mean difference -1.10 kg (95% CI -1.70 to -1.06), p<0.001). The adjusted mean difference for waist circumference was -1.9 cm (95% CI -2.5; to 1.3), p<0.001). No overall difference was observed for blood pressure or HbA1c. People who attended multiple intervention sessions had a dose-dependent effect on waist circumference, blood pressure and HbA1c, but not on weight. Conclusion An intensive family-based lifestyle intervention adopting low-resource strategies led to effective reduction in weight and waist circumference at 12 months, which has potential long-term benefits for preventing T2D. A higher number of attended sessions increased the effect on waist circumference, blood pressure and HbA1c.

AbstractBackgroundPeople from South Asia are at increased risk of type 2 diabetes (T2D). There is an urgent need to develop approaches for prevention of T2D in South Asians, that are cost-effective, generalisable and scalable across settings.HypothesisCompared to usual care, risk of T2D can be reduced amongst South Asians with central obesity or raised HbA1c, through a 12 month lifestyle modification programme delivered by community health workers.DesignCluster randomised clinical trial (1:1 allocation to Intervention or Usual care), carried out in India, Pakistan, Sri Lanka, and UK, with 30 sites per country (120 sites total). Target recruitment 3,600 (30 participants per site) with annual follow-up for three years.Entry criteriaSouth Asian, men or women, age 40-70 years with i. Central obesity (waist circumference ≥100cm in India and Pakistan; ≥90cm in Sri Lanka) and / or ii. Prediabetes (HbA1c 6.0-6.4% inclusive). Exclusion criteria: known type 1 or 2 diabetes, normal or underweight (body mass index<22kg/m2); pregnant or planning pregnancy; unstable residence or planning to leave the area; serious illness.EndpointsThe primary end point is new onset T2D at 3 years, defined as: i. HbA1c≥6.5% or ii. Physician diagnosis and on treatment for T2D. Secondary endpoints at 1 and 3 years are: i. Physical measures: waist circumference, weight and blood pressure; ii. Lifestyle measures: smoking status, alcohol intake, physical activity, dietary intake; iii. Biochemical measures: Fasting glucose, insulin and lipids (total and HDL cholesterol, triglycerides); and iv. Treatment compliance.InterventionLifestyle intervention (60 sites) or Usual care (60 sites). Lifestyle intervention was delivered by a trained community health worker over 12 months (5 one-one session, 4 group sessions, 13 telephone sessions) with the goal of the participants achieving e a 7% reduction in body mass index and a 10 cm reduction in waist circumference through i. improved diet and ii. increased physical activity. Usual care comprised a single 30 minute session of lifestyle modification advice from the community health worker.ResultsWe screened 33,212 people for inclusion into the study. We identified 10,930 people who met study entry criteria, amongst whom, 3,682 agreed to take part in the intervention. Study participants are 49.2% female and aged 52.8 (SD 8.2) years. Clinical characteristics are well balanced between Intervention and Usual care sites. More than 90% of follow-up visits are scheduled to be complete December 2020. Based on follow-up to end 2019, the observed incidence of T2D in the study population is in line with expectations (6.1% per annum).ConclusionThe iHealth-T2D study will advance understanding of strategies for prevention of diabetes amongst South Asians, use approaches for screening and intervention that are adapted for low-resource settings. Our study will thus inform the implementation of strategies for improving the health and well-being of this major global ethnic group.IRB approval16/WM/0171Trial registrationEudraCT 2016-001350-18. Registered 14 April 2016 https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/ihealth-t2d/ ; ClinicalTrials.gov NCT02949739. Registered 31 October 2016, https://clinicaltrials.gov/ct2/show/NCT02949739, First posted 31/10/2016.FunderEuropean Commission (award 643774) and National Institute for Health Research (award 16/136/68)

Objective: Alcohol is the leading cause of disabilityadjusted life years among 15- to 19-year-olds globally; yet, social and structural determinants of alcohol use among adolescents in low- and middle-income countries are largely unknown. Given that a quarter of the global adolescent population lives in South Asia, this systematic review aims to identify factors influencing alcohol use among 10- to 19-year-olds living in South Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka). Method: We systematically searched eight databases (SCOPUS, MEDLINE, EMBASE, CINAHL Plus, Cochrane Library, PsycINFO, AMED, EBSCO Host), gray literature, and relevant websites for studies reporting influences at psycho-individual, family, school, peer, neighborhood, or country levels. QATSDD (Quality Assessment Tool for Studies with Diverse Designs) was used for quality assessment. The study protocol was registered with PROSPERO (CRD42017084773). Results: Twenty-three studies were eligible for inclusion. Male gender, age greater than 14 years, depression, religious belief, parental/family members'drinking, reduced parental attention, peer-drinking/pressure/approval, and urban neighborhood were associated with increased risks of adolescent drinking. No information was available from Afghanistan, Bhutan, Bangladesh, Pakistan, and Maldives. There is little evidence available on the determinants at a national (legislature, industry, and media), school, and personality level. Conclusions: The distal determinants of alcohol use among adolescents living in South Asia are largely unknown. As adolescent drinking behaviors change in response to social media and industry influence, more evidence is needed to reflect the South Asia context.

Ceylon Medical Journal (CMJ) is a peer-reviewed, open access journal published quarterly by the Sri Lanka Medical Association in the last week of March, June, September and December each year. The mission of the CMJ is to promote the science and art of medicine and betterment of public health. The Journal publishes original papers and commentaries which have relevance to medicine and allied sciences. The CMJ is committed to maintaining and conforming to the editorial and ethical standards recommended by the International Committee of Medical Journal Editors.

BackgroundMedical education research in general, and those focusing on clinical settings in particular, have been a low priority in South Asia. This explorative study from 3 medical schools in Sri Lanka, a South Asian country, describes undergraduate medical students’ experiences during their final year clinical training with the aim of understanding the teaching-learning experiences.MethodsUsing qualitative methods we conducted an exploratory study. Twenty eight graduates from 3 medical schools participated in individual interviews. Interview recordings were transcribed verbatim and analyzed using qualitative content analysis method.ResultsEmergent themes revealed 2 types of teaching-learning experiences, role modeling, and purposive teaching. In role modelling, students were expected to observe teachers while they conduct their clinical work, however, this method failed to create positive learning experiences. The clinical teachers who predominantly used this method appeared to be ‘figurative’ role models and were not perceived as modelling professional behaviors. In contrast, purposeful teaching allowed dedicated time for teacher-student interactions and teachers who created these learning experiences were more likely to be seen as ‘true’ role models. Students’ responses and reciprocations to these interactions were influenced by their perception of teachers’ behaviors, attitudes, and the type of teaching-learning situations created for them.ConclusionsMaking a distinction between role modeling and purposeful teaching is important for students in clinical training settings. Clinical teachers’ awareness of their own manifest professional characterizes, attitudes, and behaviors, could help create better teaching-learning experiences. Moreover, broader systemic reforms are needed to address the prevailing culture of teaching by humiliation and subordination.

An ecological correlation study was conducted to determine the association between consumption of coconut products and cardiovascular disease (CVD) deaths in Sri Lanka. Data on coconut consumption patterns from 1961 to 2006 were abstracted from the FAO database, and mortality data from reports of the Department of Census and Statistics, and UN databases. Correlational and regression analyses were carried out. There was no increase in the per capita consumption of coconut products from 1961 to 2006 (range 54.1-76.2kg/capita/year). The CVD death rates and the proportionate mortality rate due to CVD increased from 1961 to 2006. CVD death rates were significantly associated with per capita GDP, percentage of urban population, and elderly dependency ratio but not consumption of coconut products after adjusting for the other variables (R-2=0.94). The results do not provide evidence at the population level that consumption of coconut products increases mortality due to cardiovascular diseases.