THE TRIPLE SILENCE OF CARDIOMETABOLIC RISK: AWARENESS, SYMPTOMS AND DIAGNOSIS VERSUS MEASURED CENTRAL OBESITY AND ELEVATED BLOOD PRESSURE IN A NORTH INDIAN COMMUNITY

Background: Detection of metabolic non-communicable disease in the community depends on whether individuals recognise the concept of clustered cardiometabolic risk, perceive that they may be affected, and have been clinically diagnosed. Whether these three subjective channels track objectively measured risk has not been studied in the same individuals. Methods: Community-based cross-sectional survey of 458 consenting adults (aged ≥18 years) attending voluntary cardiometabolic health camps in and around Varanasi district, Uttar Pradesh, India, between 2024 and 2026. Recruitment was a camp-based convenience sample and is not population-representative. We measured waist-hip ratio (WHR; central obesity defined as >0.90 in men and >0.85 in women) and seated blood pressure (BP) in duplicate using a calibrated digital oscillometric device; screen-positive elevated BP was defined as mean systolic ≥140 mmHg or diastolic ≥90 mmHg. Awareness of metabolic syndrome, a 9-item self-perceived symptom checklist, and prior physician-given diagnosis of hypertension, diabetes, obesity, dyslipidaemia, or heart disease were captured by a structured Hindi-language interview. Three pre-specified analyses tested whether each subjective channel tracked the objective markers: (i) multivariable Firth-penalised logistic regression for awareness (with robust-Poisson sensitivity); (ii) receiver-operating-characteristic (ROC) analysis with bootstrap confidence intervals for the symptom score; and (iii) sensitivity, specificity, and Cohen’s κ for self-report against measurement. Results: Central obesity was present in 263/458 (57.4%) of participants and elevated BP in 205/438 (46.8%) of those measured; 361/458 (78.8%) had at least one. Only 60 (13.1%) had heard of metabolic syndrome. Awareness was independent of objective risk (adjusted OR for central obesity 1.03, 95% CI 0.55 to 1.94; for elevated BP 0.95, 0.51 to 1.77) and was driven by higher education (postgraduate vs illiterate OR 55.9, 10.5 to 296.8) and female sex (OR 1.95, 1.05 to 3.64). The 9-item symptom score did not discriminate central obesity (AUC 0.50, 0.45 to 0.55), elevated BP (0.51, 0.46 to 0.57), or either marker. Self-report of prior diagnosis detected almost no measured disease: sensitivity 2.9% for elevated BP and 2.7% for central obesity, leaving 97.1% and 97.3% respectively without prior recognition. Conclusions: In this camp-based community sample, the cardiometabolic risk carried by most adults was conceptually unknown, symptomatically imperceptible, and clinically undiagnosed, a pattern we describe as a triple silence. Awareness, where present, was concentrated in the educated rather than the at-risk. Surfacing this hidden burden will require universal measurement-based screening coupled to point-of-contact communication, rather than reliance on knowledge, symptoms, or self-recognition. These findings are descriptive of the camp-attending population and should be confirmed in probability-sample surveys