471

Acta Cardiol 2011; 66(4): 471-481 doi: 10.2143/AC.66.4.2126596

Address for correspondence:
Dr. R.B. Singh, MD, Formerly Professor of Medicine,
Subharti Medical College, Halberg Hospital and Research Institute,
Civil Lines, Moradabad-10(UP) 244001, India.
E-mail: rbs@tsimtsoum.net, icn2005@sancharnet.in
Received 11 February 2011; accepted for publication
17 February 2011.
Singh

s verbal autopsy questionnaire for the assessment of

causes of death, social autopsy, tobacco autopsy and
dietary autopsy, based on medical records and interview
Ram B. SINGH
1
, MD; Jan FEDACKO
2
, MD; Viola VARGOVA
2
, MD; Adarsh KUMAR
3
, MD;
Varun MOHAN
3
, MD; Daniel PELLA
2
, MD; Fabien DE MEESTER
4
, PhD; Douglas WILSON
5
, DSc
1
Halberg Hospital and Research Institute, Moradabad, India;
2
P.J. Safaric University, Kosice, Slovakia;
3
Government Medical College, Amritsar,
India;
4
Tsim Tsoum Institute, Krakow, Poland;
5
School of Medicine and Health, Durham University, Durham, UK.
Introduction The exact causes of death in India are not known because autopsy studies are di cult to conduct due to religious considerations.
There are rapid changes in diet and lifestyle amongst social classes causing changes in the pattern of risk factors and mortality. In the present study, we
attempt to develop a verbal autopsy questionnaire based on medical records and interview of a family member, for the assessment of causes of death,
social class, tobacco consumption and dietary intakes among urban decedents in north India.
Methods For the period 1999-2001, we studied the randomly selected records of death of 2222 (1385 men and 837 women) decedents, aged 25-64
years, out of 3034 death records overall from the records at the Municipal Corporation, Moradabad. Families of these decedents were contacted individu-
ally to nd out the causes of death, by scientist- administered, informed-consented, verbal autopsy questionnaire, completed with the help of the spouse
and local treating doctor practicing in the appropriate health care region. Clinical data and causes of death were assessed by a questionnaire based on
available hospital records and a modied WHO verbal autopsy questionnaire. Dietary intakes of the dead individuals were estimated by nding out the
food intake of the spouse from 3-day dietary diaries and by asking probing questions about dierences in food intake by the decedents. Tobacco consump-
tion of the victim was studied by a questionnaire administered to family members. Social classes were assessed by a questionnaire based on attributes of
per capita income, occupation, education, housing and ownership of consumer luxury items in the household. The diagnoses of overweight and obesity
were based on the new WHO and International College of Nutrition criteria.
Results Cardiac diseases (23.4%, n = 520) including coronary artery disease (10%), valvular heart disease (7.2%, n = 160), diabetic heart disease
(2.2%, n = 49), sudden cardiac death and inammatory cardiac disease, each (2.0%, n = 44) were the most common causes of deaths as reported using the
modied verbal autopsy questionnaire. Brain diseases including stroke (7.8%, n = 175) and inammatory brain disease were reported amongst 1.9% (n = 42)
victims. Thus, NCDs (37.0%, n = 651); circulatory diseases (31.2%, n = 695) including stroke and cardiac diseases, and malignant neoplasms (5.8%, n = 131)
emerged as the most common causes of death. Injury and accidents (14.0%, n = 313) including re, falls and poisonings were also common. Miscellaneous
causes of death were observed amongst 8.5% (n = 189) of victims. Pregnancy and perinatal causes (0.72%, n = 15) were not commonly recorded in our
study. Renal diseases (11.2%, n = 250), pulmonary diseases (22.3%, n = 495) and liver diseases (4.8%, n =107) were also commonly recorded causes of
death. It is clear that causes of death related to various body systems can be more accurately assessed by the modied verbal autopsy questionnaire.
Circulatory diseases as the cause of mortality were signicantly more common among higher social classes (1-3) than in lower social classes (4 and 5) who
died more often, due to infections. Death due to coronary disease, stroke, hypertension, diabetes and obesity were signicantly more common among
higher social classes 1-3 and among victims with higher body mass index (BMI) compared to social class 4 and 5 who had lower BMI.
Conclusions This study indicates that causes of death, social
class, tobacco and dietary intakes, can be accurately assessed by a modi-
ed verbal autopsy questionnaire based on medical records and by inter-
view of family members. Circulatory diseases, injury-accidents and malig-
nant diseases have become the major causes of death in India, apart from
infections.
Keywords Mortality nutrition tobacco stroke infections
cancer.
94733_ActaCardio_66-4_11_11-4733.indd 471 4/08/11 15:37
R .B . Si n g h e t al . 472
In the present study, we report the estimates for the
causes of mortality, based on a modified verbal autopsy
questionnaire which is completed with the help of the
spouse and available medical records of the victim, in
an urban population of north India.
MATERIAL AND METHODS
Moradabad is a city situated in north India. The popu-
lation of the city is 0.641 million residing in 306 streets or
60 wards based on the 2001 census. All the deaths that
occurred in the city of Moradabad may be verified in the
birth and death record section of the municipal board
office. Religious considerations do not allow us to conduct
an autopsy to find out the exact causes of death among
victims due to various causes in the hospital and elsewhere.
Therefore, records available at the Municipal Board, based
on the death certificate are the only sources, and may not
be absolutely correct. These records are based on certifi-
cates issued by the doctors based on clinical diagnosis and
laboratory examinations and are open to bias.
We studied the records of 2842 randomly selected,
adult victims, aged 25-64 years, of whom 2222 had rela-
tives who could respond to take part in this study, during
the last two years, July1999 to July 2001
9,10
. Of these 2222
victims, 1385 were males and 837 were females. All the
families of these 2222 victims were contacted individually
to find out the causes of death by verbal autopsy ques-
tionnaire
9,10
. In developing countries due to religious
considerations, WHO has suggested that the causes of
death be investigated by detailed questionnaires admin-
istered to the spouse and the doctors involved
14
. The head
of every family was personally called after communica-
tion with the help of the local accessible doctor in the
street. At least three calls, via letter, telephone and per-
sonal contact via street doctors were made before any
subject or family was declared a non-contact or non-
responder; one in the morning, one in the evening,
around 17.00 hrs, and the last one during the weekend.
Our team included a scientist, a health worker and
a doctor, who were trained and briefed regarding the
details of the questionnaire before starting the survey.
The verbal autopsy questionnaire was pre-tested by the
evaluation committee in roughly 30 to 60 families for
various aspects concerned with causes of death. It was
found that 10% of the families who came within reach
of the survey were declared non-contact or non-respon-
der as observed in another survey
11
. Detailed interviews
were possible among 90% of the families approached.
Clinical data on age, sex, height, weight, marital status,
occupation, education, past and family history, history
of hypertension, diabetes, stroke, heart attack, kidney
disease, liver disease, alcohol intake, drug intake, tobacco
INTRODUCTION
Causes of death are less commonly known in devel-
oping countries, although hospital records indicate a
rapid increase in mortality and morbidity due to non-
communicable diseases (NCDs); cardiovascular disease
(CVD), diabetes mellitus, cancer and a decrease in mor-
tality due to infections
1-8
. According to WHO estimates,
17.5 million people died from CVDs in 2005, represent-
ing 30% of all global deaths
2
and coronary artery disease
(CAD) was the leading cause of death, i.e. 7.6 million
and 5.7 million deaths were due to stroke
2
. CVD on
average was already becoming a significant cause of
death in developing countries, between 1970 and 1975,
whereas the corresponding period in developed coun-
tries was 50 years earlier in the 1920s
6,7
. The majority of
these deaths (80%) occurred in low- and middle-income
countries. Due to religious considerations, autopsy is
not possible in many countries, therefore WHO experts
and the International College of Nutrition, International
College of Cardiology and the Tsim Tsoum Institute
have developed a verbal autopsy questionnaire to find
out the causes of death in these countries
9,10
. Risk factors
for NCDs are significantly more common in the urban
population of India
11-13
and among higher social classes
(1-3), compared to lower social classes (4-5). Infections
and undernutrition are more common among lower
social classes, which may be the commonest cause of
death in developing countries
14-19
. However, the urban
population has a double burden of diseases, related to
over- and undernutrition
11-13
. In developed countries,
lower social classes have greater cardiovascular and
cancer mortality, as well as all-cause mortality
6,7
than
higher social classes.
In view of the scarcity of public health and medical
care resources, accurate information on overall and
cause-specific mortality is important to prioritize vari-
ous activities related to prevention and treatment of
diseases. Certification by an attending physician based
on clinical manifestations and investigations is the stand-
ard method to find out the cause(s) of mortality. How-
ever, this approach may not be applicable in many low-
and middle-income countries, because many deaths
occur at home without investigations and without auto-
psy. Therefore, data on causes of death are limited and
may be potentially biased when based on hospital rec-
ords
1-6,8
. Verbal autopsy is a simple and low-cost alterna-
tive for determining the causes of death which is available
in most of the developing countries
14-19
. The reliability
of verbal autopsy questionnaires may be enhanced by
examining the available medical records of the victims
9,10
.
It is also an excellent alternative in other countries where
autopsy is difficult due to various considerations and it
could be better than routine death certificates
16,19
.
94733_ActaCardio_66-4_11_11-4733.indd 472 4/08/11 15:37
Si n g h

s ve rb al au to p sy q u e sti o n n ai re fo r th e asse ssm e n t o f cau se s o f d e ath 473

which data on height and weight were not available, we
collected these data from these matching subjects. Sub-
jects were classified according to BMI into underweight
(BMI > 18.5), normal weight (18.5-22.9 kg/m
2
), over-
weight (23-24.9 kg/m
2
) and obesity ( 25 kg/m
2
). The
diagnosis of risk factors was based on available records
and information from the spouse and doctors involved.
Statistical analysis
Contingency table analysis using the chi-square sta-
tistic was used for the comparison of frequencies of appro-
priate variables for men and women in the two groups.
Similarly, for continuous variables, the data were adjudged
to be normally distributed and the two-tailed Students
t-test was applied. P < 0.05 was the probability level con-
sidered to be statistically significant.
RESULTS
The results for age, sex and associated clinical data, based
on the records and by verbal autopsy questionnaire, among
the 2222 victims, aged 25-64 years, who died due to various
causes, are given in table 1. The mean age, body mass index
and body weight were significantly higher among male
compared with female victims. There was a high prevalence
of obesity and tobacco intake among men compared with
women (table 1). Social classes 3-5 were com parable in the
two sexes. The prevalence of underweight victims was
14.2% (n = 315), overweight 29.4% (n = 654) and obese
20.8% (n = 461) and the majority of the overweight and
obese victims were from social classes 1-3. Table 2 indicates
the causes of death according to the modified verbal autopsy
questionnaire
14-16
.This modified questionnaire was able to
diagnose 23.4% of deaths due to heart disease and 9.8% due
to brain disease, including stroke (7.8%) and inflammatory
brain diseases (1.9%) and 5.8% of deaths due to malignant
causes. Thus, circulatory diseases were the cause of death
among 31.2% (n = 695) of the victims. Accidental deaths
according to the modified questionnaires were much higher
(14.0%). Renal diseases, including acute renal failure and
chronic renal failure, were the cause of death among 11.2%
of the victims, pulmonary disease in 22.3% and liver disease
in 4.8% of the victims. Miscellaneous or other causes of
deaths were reported among 8.5% of victims. Results on
social classes, tobacco and food intake have been reported
in other publications (
9,10,21,22
).
DISCUSSION
This study showed that using the modified verbal
autopsy questionnaire allowed us to diagnose 23.4% of
intake, lung tuberculosis, bronchitis, asthma, cancer,
mental diseases, diarrhoea and dysentery, and brain,
CVD, infectious diseases, malaria, dengue and accidents,
etc., were recorded. Leading questions were asked to
know the system involved as given in appendix I. The
questionnaire was completed based on the medical record
of the victim, the death certificate issued by the doctor,
interview of the doctor and the family doctor, interview
of the spouse and other family members, with the help
of a pre-tested verbal autopsy questionnaire, to accurately
assess the cause of death of each victim (appendix I).
Verbal autopsy questionnaire allowed the interviewer to
ascertain the clinical presentation of the victim during
illness and up to death based on the above documents.
This information on the probable cause of death related
to each body system was reviewed by the internist physi-
cian to assess the final cause of death for all victims.
Social autopsy
The socio-economic status (SES) of the family was
classified based on attributes of housing condition, edu-
cation, occupation, per capita income and ownership
of consumer durables like a television, etc., in the house-
hold
9,10
. Per capita income was calculated by dividing
the total income of the family, by the number of family
members. Social classes were graded according to SES
1-5 depending on scores as given in appendix II.
Tobacco autopsy
The tobacco consumption of the victims was studied
by completing a questionnaire by asking probing ques-
tions to the spouse. The smoking of cigarettes, beedies,
hukka and pipe as well the chewing of tobacco in the
form of flavoured tobacco, khaini and gutka, were asses-
sed as given in appendix III.
Dietary autopsy
Dietary intakes of the victim were obtained by trained
interviewers by finding out the food intake of the spouse
(using 3-day dietary diaries) and filling out of question-
naires from answers to probing questions about differ-
ences in food intake by the decedents as given in appen-
dix IV. Food models, food measures and food portions
were used by the dietitian to estimate the exact food
intake of the victims. Salt intake was assessed by finding
out the amount of salt mixed in the food divided by the
number of family members and then adding salt con-
sumed by each member during eating.
The family doctor or the spouse of the victim was
asked to suggest a person with identical age, sex, height
and weight as the victim. In those medical records, in
94733_ActaCardio_66-4_11_11-4733.indd 473 4/08/11 15:37
R .B . Si n g h e t al . 474
reviewed to assess the final cause of death among all the
victims by the internist physician (RBS). Verbal autopsy
appears to be a valid and reliable supplemental method
to assess causes of death in a population where records
of death are maintained in a municipal corporation in
any country of the world. One important reason for the
success of our verbal autopsy may be the appropriate
modifications made to adapt it to the local setting, in
the adult questionnaire suggested by WHO.
In low-resource countries like India, verbal autopsy
methodology was developed for national mortality sur-
veillance systems
20
as well as for body weight autopsy
9
,
social autopsy
10
, tobacco consumption autopsy
21
and
dietary autopsy
22
. In many developing countries, verbal
autopsy has been found to provide more valid causes of
death compared to routine death certificates issued by
the doctors
9,10,14-21
. All known studies using verbal auto-
psy to find out the causes of death among adults, did not
find similar results. In the Chinese, Yang et al. indicated
that verbal autopsy is not a very precise tool for assess-
ing the leading causes of death among adults and provide
only marginal support for this method
15
. It seems that
verbal autopsy is a developing method which may be
the cause of inconsistency in results from some of the
studies
15
. Verbal autopsy methodology and question-
naires appear to have many variations depending upon
the investigators
9,10,14-22
. In some of them, ICD coding
deaths due to heart diseases and 9.8% due to brain dis-
eases, including stroke and inflammatory brain diseases.
However, according to another verbal autopsy question-
naire based on WHO guidelines
16
, CVDs including CAD
could be diagnosed only in 10% and cerebrovascular
disease in 7.8% and the remaining causes of CV deaths
were classified as other causes of death. Only transport
accidents were included in the other questionnaires
16
,
although accidental deaths according to modified ques-
tionnaires were much higher (14% vs 2.3%). Renal dis-
eases including acute renal failure and chronic renal
failure were the cause of death among 11.2% of victims,
which are difficult to diagnose using the other question-
naire
16
. Among other causes of death according to the
modified questionnaire, compared with WHO
16
, there
were figures of 37.3 vs 8.5%, respectively, which means
that among one third of victims, causes of death could
not be classified according to body systems. It seems
that using the modified questionnaires, most of the
victims could be classified systematically, relatively more
accurately, into various causes of death according to
body systems (table 2). Verbal autopsy questionnaires
allowed the interviewer to ascertain the clinical presen-
tation of the victim during illness and up to death, avail-
able in the medical records and from the family members
and doctors of the decedents. This information on prob-
able cause of death related to each body system was
Table 1 Clinical data based on medical records and assessment by verbal autopsy questionnaire
Clinical Data
Male (n = 1385) Female (n = 837)
Mean (SD)
Age, years 42.12 (13.02) 40.05 (11.60)
Body weight, kg 60.12* (6.24) 53.10 (6.95)
Body mass index (kg/m
2
) 23.18 (2.18) 23.65 (2.46)
Prevalence of risk factors for deaths No. (%) No. (%)
Coronary artery disease 131 9.5* 42 5.0
Hypertension (> 140/90 mmHg) 457 33 251 30
Diabetes mellitus 110 08 58 7.0
Smoking 277 20* 50 6.0
Tobacco chewing 415 30* 83 10
Smoking + tobacco chewing 623 45* 125 15
Obesity (> 25 kg/m
2
) 277 20 184 22
Overweight (> 23kg/m
2
) 747 54* 368 44
Underweight(< 18.5kg/m
2
) 207 15 108 13
Fruit, vegetable and legume intake (< 215g/day) 712 51.4 422 50.4
Western type food intake
(> 255 g/day) 875 63.2 502 59.9
Social classes 3-5 774 55.9 453 54.1
* = P < 0.02, P value was obtained by chi square test by comparison of group data for men and women or by two-tailed Student t-test.
(Records of data were available only in 70% to 80% of subjects, the rest were assessed by asking leading questions to spouse and the lane doctors).
94733_ActaCardio_66-4_11_11-4733.indd 474 4/08/11 15:37
Si n g h

s ve rb al au to p sy q u e sti o n n ai re fo r th e asse ssm e n t o f cau se s o f d e ath 475

based diagnosis of the primary cause of death was avail-
able. Therefore, this verbal autopsy method appears to
be a promising approach and of potential gold standard
value in identifying most precisely the exact cause of
death which may be as good as postmortem examina-
tion. Our verbal autopsy questionnaire also provides
system for the causes of death may not have been used
and hence WHO has recently published instructions
to improve the quality and standards for this method
18
.
The advantage of medical records and death certificates
during the completion of a verbal autopsy questionnaire
is that in the majority of these victims, a prior hospital-
Table 2 Causes of deaths based on available records and verbal autopsy (modied from WHO).
Cause of death Men (n = 1385) Women (n = 837) Total (n = 2222)
1 Cardiac diseases (n = 520, 23.4%)
Coronary artery disease 137(9.9) 85(10.1) 222(10.0)
Sudden cardiac death 25(1.7) 20(2.4) 45(2.0)
Valvular heart disease 105(7.5) 55(6.5) 160(7.2)
Inammatory cardiac disease 24(1.7) 20(2.4) 44(2.0)
Diabetic vascular disease 23(1.6) 26(3.1) 49(2.2)
2 Nervous system diseases (217, 9.8%)
Cerebrovascular disease (CVD) 115(8.3) 60(7.1) 175(7.8)
Meningitis, encephalitis 25(1.8) 17(2.0) 42(1.9)
3 Malignant neoplasm (n = 131, 5.8%)
Lung cancer 24(1.7) 12(1.4) 36(1.6)
Oral cancer 23(1.6) 11(1.3) 34(1.5)
Liver cancer 16(1.1) 10(1.1) 26(1.1)
Stomach, colon cancer 14(1.0) 8(0.9) 22(0.9)
Breast cancer 7(0.8) 7(0.31)
Uterus, cervix, ovary cancer 6(0.6) 6(0.27)
4 Injury- accidents (n = 313, 14.0%)
Unintentional 30(2.1) 16(1.9) 46(2.0)
Road tra c accidents 45(3.2) 28(3.3) 73(2.3)
Poisonings 37(2.6) 21(2.5) 58(2.6)
Fires 33(2.3) 20(2.4) 53(2.3)
Falls 27(1.9) 15(1.7) 42(1.9)
Drowning 27(1.9) 14(1.6) 41(1.8)
5 Renal diseases (n = 250, 11.2%) 163(11.7) 87(10.3) 250(11.3)
6 Pulmonary diseases (n = 495, 22.3%)
Chronic bronchitis, asthma 97(7.0) 65(7.7) 162(7.3)
Tuberculosis 85(6.1) 34(4.0) 119(5.3)
Acute pulmonary infection 149 (10.7) 65 (7.6) 214(9.6)
7 Liver diseases (n=107, 4.8%)
Hepatitis 60(4.2) 20(2.4) 80 (7.0)
Cirrhosis 15(1.0) 12(1.4) 27(1.3)
8 Miscellaneous (n = 189, 8.5%)
Pregnancy and perinatal 15(1.7) 15(0.72)
Suicide 16(1.1) 25(2.9)* 41(1.8)
Congenital anomalies 17(1.2) 20(2.4) 37(1.0)
Burns 13(0.9) 20(2.4) 33(1.3)
Diarrhoea/dysentery 40(2.8) 23(2.7) 63(2.9)
Total 1385(62.33)* 837(37.66) 2222(100)
*= P < 0.05, by comparison of death rate in men and women by chi square test.
94733_ActaCardio_66-4_11_11-4733.indd 475 4/08/11 15:37
R .B . Si n g h e t al . 476
may be the risk factor for death due to rheumatic infec-
tions whereas cardiac cachexia appears to be the under-
lying mechanism in heart failure. The remainder of the
male and female decedents were from higher social
classes and presented with a BMI of 23 kg/m
2
and above
and causes of death were mainly CAD, SCD and stroke,
as reported earlier
9,10
. These findings and other studies
indicate that BMI may be an important determinant of
death due to various causes; underweight causing more
deaths due to infections and overweight and obesity due
to diseases of affluence
23,24
. Recent studies also confirm
the role of diet and lifestyle factors in the pathogenesis
of death due to various diseases
22-27
.
In brief, our results indicate that verbal autopsy for
the assessment of causes of death, social class, tobacco
consumption and dietary intakes of the victims, appears
to be reliable and valid. These methods of verbal autopsy,
social autopsy, tobacco autopsy and dietary autopsy can
be used in large-scale cohort studies in any country of
the world.
ACKNOWLEDGEMENTS
Acknowledgements are due to the International Col-
lege of Nutrition, the International College of Cardiology
and The Tsim Tsoum Institute, Krakow, Poland for logis-
tic support in preparing this article.
CONFLICT OF INTEREST: none declared.
information about social class, tobacco and food con-
sumption of the decendents, which may be of further
help in the planning of prevention programmes.
One important weakness in our study is that we could
not compare our results with causes of death obtained
by death certificate alone versus verbal autopsy com-
bined with medical records by using kappa statistics.
Other weaknesses are that only one internist physician
reviewed the records of all the victims and only when
diagnosis of the cause was doubtful, a second opinion
was asked from another internist physician. It seems that
at least 3 internist physicians are necessary to review the
records to finalize the cause of death, if adequate
resources are available. It is possible that many people
die at home due to lack of resources for hospitalization,
although government hospitals provide a free service to
the poor in most of the towns in India. Our results may
also underestimate the potential sensitivity and specific-
ity of the verbal autopsy methods because questionnaires
were completed by only one interviewer
1
. In the future,
use of MP3 players to compare audiodata (observed on
computer) with paper records on a 5% population to
determine the degree of concordance of the autopsy
questionnaire can further improve the verbal autopsy,
as advised by other experts
16
.
We also found a higher prevalence of overweight and
obesity among victims dying due to circulatory diseases
among both men and women
9
. Among deaths due to
circulatory causes, 25.7% (n = 110) male and 27.1%
(n = 69) female deaths were associated with BMI < 23 kg/
m
2
, and the causes of death were rheumatic heart disease
and heart failure. Among these deaths, undernutrition
1. Singh V. Chemical analysis of inorganic metal
ions in the diets of victims in relation to cause
of death. PhD thesis accepted by MJP
Rohilkhand University, 2002.
2. World Health Organization. The World Health
Report 2002, Reducing risks, promoting
healthy life. WHO, Geneva 2002.
3. Gerber Y, Jacobsen J, Frye RL,
Weston SA, Killian JM, Roger VL.
Secular trends in deaths from cardiovascular
diseases. A 25-year community study.
Circulation 2006, 113: 2285-92.
4. Yusuf S, Reddy S, Ounpuu S, Anand S.
Global burden of cardiovascular diseases:
part II: variations in cardiovascular disease
by specific ethnic groups and geographic
regions and prevention strategies.
Circulation 2001, 104: 2855-864.
5. Yusuf S, Reddy S, Ounpuu S, Anand S. Global
burden of cardiovascular disease: part 1:
general considerations and epidemiologic
transition, risk factors and impact of
urbanization. Circulation 2001, 104: 2746-53.
6. Kesteloot H. Social class, all-cause and
cardiovascular mortality.
Acta Cardiol 2004, 59: 117.
7. Kesteloot H. Social class, all-cause,
cardiovascular and cancer mortality:
the importance of cigarette smoking.
Acta Cardiol 2003; 58: 285-7.
8. Goyal A, Yusuf F. The burden of cardiovascular
disease in the Indian subcontinent.
Ind J Med Res 2006; 124: 235-244.
9. Singh RB, Singh S, Singh V, Kulshrestha SK,
Mechirova V, Pella D. Association of increased
mortality with underweight, overweight and
obesity among urban descendants in
North India dying due to various causes.
World Heart J 2008; 1: 341-7, Novascience, NY,
USA (www.novapublishers.com)
10. Singh RB, Singh V, Kulshrestha SK, Singh S,
Gupta P, Kumar R, Krishna A, Srivastav SSL,
Gupta SB, Pella D, Cornelissen G.
Social class and all-cause mortality in
an urban population of North India.
Acta Cardiol 2005; 60: 611-7.
11. Singh RB, Beegom R, Mehta AS, Niaz MA,
De AK, Mitra RK, Haque M, Verma SP,
Dube GP, Siddiqui HM, Wander GS, Janus ED,
Postiglion A, Haque MS. Social class, coronary
risk factors and undernutrition, a double
burden of diseases, in women during
transition, in five Indian cities.
Int J Cardiol 1999; 69: 139-47.
12. Singh RB, Sharma JP, Rasogi V, Niaz MA,
Ghosh S, Beegom R, Janus ED. Social class
and coronary disease in a rural population of
north India. The Indian Social Class and Heart
Survey. Eur Heart J 1997; 18: 588-95.
13. Singh RB, Ghosh S, Niaz MA, Rastogi V.
Validation of physical activity and
socioeconomic questionnaire in relation to
food intakes for the five city study and a
proposed classification for Indians.
J Assoc Physicians India 1997, 45: 603-7.
14. Soleman N, Chandramohan D,
Shibuya K. Verbal autopsy:
current practices and challenges.
Bull World Health Organ 2006; 84: 239-45.
REFERENCES
94733_ActaCardio_66-4_11_11-4733.indd 476 4/08/11 15:37
Si n g h

s ve rb al au to p sy q u e sti o n n ai re fo r th e asse ssm e n t o f cau se s o f d e ath 477

15. Yang G, Rao C, Ma J, Wang L,
Wan X, Dubrovsky G, Lopez AD.
Validation of verbal autopsy procedures
for adult deaths in China.
Int J Epidemiol 2006; 35: 741-8.
16. Khademi H, Etemadi A, Kamangar F,
Nouraie M, Shakeri R, Abaie B, Pourshams A,
Bagheri M, Hooshyar A, Islami F, Abnet CC,
Pharoah P, Brennan P, Boffetta P, Dawsey SM,
Malekzadeh R. Verbal autopsy: reliability and
validity estimates for causes of death in the
Golestan cohort study in Iran.
PLoS ONE 2010; 5(6): e11183.
17. Jha P, Gajalakshami V, Gupta PC, Kumar R,
Mony P, Dhingra N, Peto R, RGI-CGHR Study
collaborators. Prospective study of
one million deaths in India:
rationale, design and validation results.
PLoS Medicine 2006; 3(2): e18.
18. Baiden F, Bawah A, Biai S, Binka F, Boerma T,
Byass P, Chandramohan D, Chatterji S,
Engmann C, Greet D, Jakob R, Kahn K,
Kunii O, Lopez AD, Murray CJ, Nahlen B, Rao C,
Sankoh O, Setel PW, Shibuya K, Soleman N,
Wright L, Yang G. Setting international
standards for verbal autopsy.
Bull World Health Organ 2007; 85: 570-1.
19. Gajalakshmi V, Peto R. Verbal autopsy of
80,000 adult deaths in Tamilnadu, South India.
BMC Public Health 2004; 4: 47.
20. Setal PW, Sankoh O, Rao G, Velkoff VA,
Mathers C, Gonghuan Y, Hemed Y, Jha P,
Lopez AD. Sample registration of
vital events with verbal autopsy:
a renewed commitment to measuring
and monitoring vital statistics.
Bull World Health Org 2005; 83: 611-7.
21. Singh RB, Singh S, Chattopadhyay P, Singh K,
Singh V, Kulshrestra SK, Tomar RS, Kumar R,
Singh G, Mechorova V, Pella D.
Tobacco consumption and causes of death
in an urban population of north India.
Int J Chron Obstruct Pulmon Dis 2007;
2(2): 177-85.
22. Fedacko J, Vargova V, Singh RB, Singh S,
Singh V, Kulshrestha SK, Pella D, De Meester F.
Dietary autopsy questionnaire to assess the
association of dietary patterns with causes of
death among urban decendents in north
India. J Med Science 2011; (in press).
23. Adams KF, Schatzkin A, Harris TB, Kipnis V,
Mouw T, Ballard-Barbash R, Hollenbeck A,
Leitzmann MF. Overweight, obesity, and
mortality in a large prospective cohort of
persons 50 to 71 years old.
N Engl J Med 2006; 355: 763-78.
24. Flegal KM, Graubard BI, Williamson DF,
Gail MH. Excess deaths associated with
underweight, overweight and obesity.
JAMA 2005; 293: 1861-7.
25. Bantle, JP. Dietary fructose and metabolic
syndrome and diabetes.
J Nutr 2009; 139: 1263S-1268S.
26. Lim JS, Mietus-Snyder M, Valente A,
Schwarz JM, Lustig RH. The role of fructose
in the pathogenesis of NAFLD and the
metabolic syndrome. Nat Rev Gastroenterol
Hepatol 2010; 7: 251-64.
27. Singh RB, De Meester F, Wilkzynska A.
The Tsim Tsoum approaches for prevention
of cardiovascular disease. Cardiology Research
and Practice; volume 2010, article ID 824938,
18 pages. doi:10.4061/2010/824938.
http://downloads.sage-hindawi.com/
journals/crp/2010/824938.pdf
APPENDIX I
HALBERG HOSPITAL & RESEARCH INSTITUTE/ICN/ICC/TTI
VERBAL AUTOPSY QUESTIONNAIRE BASED ON DEATH CERTIFICATE,
MEDICAL RECORDS AND INTERVIEW
Name and post of expert lling the questionnaire Tel.: .
History given by: spouse/father/mother/sister/son/daughter/in-laws (tick)
Education of person Date
Place and time of interview
Unique ID
G EN ER A L D A TA
Name of victim Surname Sex Age
Address
Tel.:
1. Religion: (a) Hindu (b) Moslem (c) Christian (d) Sikh
2. Final education of victim Occupation of victim Family type
3. Date place . and time of death .
4. Physically matching subject with victim/Name, address
C LI N I C A L D A TA O F V I C TI M (b y m e d i cal re co rd s)
5. Family history of diabetes, hypertension, cholesterol, heart attack, stroke, cancer, bron chitis, asthma,
obesity, suicide, HIV, depression, psychosis, alcohol intake, tobacco.
6. Any past history of above, illnesses (name)
7. Height cm, weight kg, BMI (kg/m
2
)
8. Waist circumference cm, maximum hip circumference , WHR
9. Blood pressure mmHg, grey hair/cataract/wrinkles (tick)
10. History of surgery
11. Chest pain
94733_ActaCardio_66-4_11_11-4733.indd 477 4/08/11 15:37
R .B . Si n g h e t al . 478
Table Causes of death reported based on available records and verbal autopsy (modied from WHO)
(Ask leading questions to know the system involved).
Cause of death Death certificate Spouse Doctor Final
1 Circulatory diseases
coronary artery disease, sudden cardiac death, diabetes, vascular disease, valvular heart disease,
inammatory cardiac disease.
2 Nervous system diseases cerebrovascular disease, meningitis, encephalitis.
3 Malignant neoplasm lung, oral, liver, stomach, breast, uterus, cervix, ovary.
4 Injury-accidents unintentional, road accidents, poisonings, res, falls, drowning.
5 Renal diseases acute renal failure, chronic renal failure.
6 Pulmonary diseases chronic bronchitis, asthma, tuberculosis, acute pulmonary infection.
7 Liver diseases hepatitis, cirrhosis.
8 Miscellaneous pregnancy and perinatal problems, suicide, congenital anomalies, burns, diarrhoea/dysentery.
APPENDIX II
SOCIAL AUTOPSY QUESTIONNAIRE
SOCIOECONOMIC STATUS: (scores constructed on each of these attributes)
a) Educational status
4 If all members of family had education beyond X.
3 If the subject had education beyond X and all other members up to X.
2 If at least any one member had high school education but no one above X.
1 If no member had education beyond 5
th
year of primary education.
0 If all members were illiterate.
b) Occupational status
4 If all members of family were professionals (doctor, engineer, professor, etc.) and
executives.
3 If the subject was a professional or executive and all other members of household below
this level.
2 If at least one member professional or business executive and all other members below
this level.
1 If no member was beyond clerk.
0 If all labourers or unskilled workers.
c) Housing status
4 If housing was a bungalow or at in a good locality.
3 If housing was in a medium class locality but built with excellent oors, walls and roof.
2 If house was in a slum but good oors, walls, roof.
1 If 1-2 room, accommodation in slum.
0 If one room in slum, public toilet, no electricity or fan.
Scores for rented house were same.
d) Ownership of consumer durables
4 If the subject or family had a motor car.
3 If family had scooter/video/colour television.
2 If family had bicycle, sewing machine, radio etc.
1 If family had bicycle, no other consumer durable
0 If no consumer durable of any kind.
e) Per capita monthly income
4 If very rich (> Rs. 1000)
3 If > Rs. 600
2 If Rs. 300-600
1 If < Rs. 300
0 If irregular earning, too poor to buy enough food
So ci o e co n o m i c statu s
SES groups Total score
SES-1 17-20
SES-2 13-16
SES-3 9-12
SES-4 5-8
SES-5 < 5
Total score
94733_ActaCardio_66-4_11_11-4733.indd 478 4/08/11 15:37
Si n g h

s ve rb al au to p sy q u e sti o n n ai re fo r th e asse ssm e n t o f cau se s o f d e ath 479

APPENDIX III
TOBACCO AUTOPSY QUESTIONNAIRE
1. Type of tobacco consumption:
(a) Cigarettes (b) Beeri
(c) Hukka (d) Chillum
2. How many cigarettes, beedies or how many times you smoke,
Hukka pipe or any other per day
3. If you do not smoke, have you ever smoked before? (Yes/No)
If yes then, when, for how much time
4. Do you have tobacco chewing habit? Y/N
5. If yes, which form of tobacco chewing?
6. Pan with zarda/Pan without zarda/Pan parag/Khaini/any other
7. How much tobacco or how many times you chew per day times mg
APPENDIX IV
DIETARY AUTOPSY QUESTIONNAIRE
The following questions are about the foods that spouse usually eats (Dierence from victim

s food
intake to be noted)
Please give the number of days per week on which you usually eat various foods.
Ring the appropriate answer like this:
If you eat a food 7 days a week, then ring the 7, thus: (7) 6 5 4 3 2 1 M R
If you eat a food 3 days a week, then ring the 3, thus: 7 6 5 4 (3) 2 1 M R
If you eat a food less than one day a week but more
than once a month, then ring M, thus: 7 6 5 4 3 2 1 (M) R
If you eat a food less than once a month or never,
then ring R, thus: 7 6 5 4 3 2 1 M (R)
CEREALS: Please answer every question
(g/week) O ce use (g/day)
BREAD Number/day Thickness
12. White 7654321 MR THICK MEDIUM THIN
CHAPATI: Number/Day
13. Paratha 7654321 MR THICK MEDIUM THIN
14. Puree 7654321 MR THICK MEDIUM THIN
15. Chapati 7654321 MR THICK MEDIUM THIN
16. Dalia 7654321 MR
ROOT TUBERS:
17. Potatoes boiled, baked, mashed 7 6 5 4 3 2 1 M R
18. Potatoes: chips or fried from shop 7 6 5 4 3 2 1 M R
19. Potatoes: chips or fried curry from home 7 6 5 4 3 2 1 M R
20. Sweet potato 7 6 5 4 3 2 1 M R
LEGUMES:
21. Pulse-red gram, green gram, Bengal gram 7 6 5 4 3 2 1 M R
22. Baked beans, lentils or butter beans 7 6 5 4 3 2 1 M R
23. Peas, kidney beans 7 6 5 4 3 2 1 M R
94733_ActaCardio_66-4_11_11-4733.indd 479 4/08/11 15:37
R .B . Si n g h e t al . 480
VEGETABLES/SPICES:
24. Radish 7 6 5 4 3 2 1 M R
25. Cabbage 7 6 5 4 3 2 1 M R
26. Cauliower 7 6 5 4 3 2 1 M R
27. Green leafy vegetables (grilled/fried/salad) 7 6 5 4 3 2 1 M R
28. Onion 7 6 5 4 3 2 1 M R
29. Garlic 7 6 5 4 3 2 1 M R
30. Chilli 7 6 5 4 3 2 1 M R
31. Black pepper 7 6 5 4 3 2 1 M R
32. Spices (total, g/day) 7 6 5 4 3 2 1 M R
33. Brinjal 7 6 5 4 3 2 1 M R
34. Carrots 7 6 5 4 3 2 1 M R
(g/week) O ce use (g/day)
35. Bitter gourd 7 6 5 4 3 2 1 M R
36. Jack fruit 7 6 5 4 3 2 1 M R
FRUITS: (g/week) Number
37. How many bananas eaten per week?
38. How many guavas eaten per week?
39. How many apples eaten per week?
40. How many oranges eaten per week?
41. How many grape fruit eaten per week?
42. How many musk melons eaten per week?
43. How many slices of melons eaten per week?
44. How many tomatoes eaten per week?
45. How many mangoes eaten per week?
46. How many other fruits eaten per week? (name)
47. How many slices of papaya eaten per week? (name)
MILK:
48. Do you take milk Y/N
49. If yes, what type of milk do you usually have (St-No-go)
50. How much milk (not skimmed or dried) do you drink a day in tea or coee in milky drinks and in
cereals
(a) Less than 100 ml
(b) 100-200 ml
(c) 200-500 ml
(d) More than 500 ml
CURD: How much curd do you take g /week
FOOD HABIT- Vegetarian/non-veg./eggitarian
EGGS and FISH
51. How many eggs do you eat per week?
52. Fish (Singhara/oily, sh ngers) 7 6 5 4 3 2 1 M R
53. Which sh do you take (river sh/sea sh/both)?
MEATS:
54. Lamb, curry, fried 7 6 5 4 3 2 1 M R
55. Chicken or other poultry, curry fried 7 6 5 4 3 2 1 M R
56. Beef (including minced beef ) curry, fried 7 6 5 4 3 2 1 M R
57. Pork curry fried 7 6 5 4 3 2 1 M R
FATS: visible fat, (g/week)
58. How much of the following foods do the whole family and person concerned use on average per
week? (g)
(Whole family)/week (Person concerned/week)
Claried butter (ghee) g
Butter g
Lard and vegetable ghee/trans fat
94733_ActaCardio_66-4_11_11-4733.indd 480 4/08/11 15:37
Si n g h

s ve rb al au to p sy q u e sti o n n ai re fo r th e asse ssm e n t o f cau se s o f d e ath 481

Fat (specify) g
Liquid vegetable oils g
Mustard oil g
Ground nut/soybean/corn/sunower oil g
Cream g
Sugar g
Salt g
CONFECTIONARY:
59. Ice cream, sweet yoghurt or chocolate 7 6 5 4 3 2 1 M R
60. Digestive biscuits or plain biscuits 7 6 5 4 3 2 1 M R
61. Milk sweet (Rasgula, Bar) 7 6 5 4 3 2 1 M R
62. Non-milk sweets (Jalebi, Laddu) 7 6 5 4 3 2 1 M R
69. How many persons normally eat in your household?
Number of adults (including yourself )
Number of children 1-4 years old
70. Are you on a special diet? No, If yes, then
(a) Slimming diet suggested by your doctor
(b) Diabetic diet
(c) Vegetarian diet
(d) Fruit and vegetable enriched diet
71. What type of milk do you usually have?
(a) Whole cows, bualo, goats, mixes (packet)
(b) Skimmed
(c) Other (specify please)
72. How many times per week do you eat and drink outside
73. Do you eat heavy breakfast (> 1000 Cal)
dinner (> 1500 Cal) (Yes/No)
94733_ActaCardio_66-4_11_11-4733.indd 481 4/08/11 15:37