The role of dairy consumption in the relationship between wealth and early life physical growth in India: evidence from multiple national surveys.

INTRODUCTION: Prevalence of undernutrition continues to be high in India and low household wealth is consistently associated with undernutrition. This association could be modified through improved dietary intake, including dairy consumption in young children. The beneficial effect of dairy on child growth has not been explored at a national level in India. The present analyses aimed to evaluate the direct and indirect (modifying association of household level per adult female equivalent milk and milk product consumption) associations between household wealth index on height for age (HAZ) and weight for age (WAZ) in 6-59 months old Indian children using data from of nationally representative surveys. METHODS: Two triangulated datasets of two rounds of National Family Health Survey, (NFHS-3 and 4) and food expenditure (National Sample Survey, NSS61 and 68) surveys, were produced by statistical matching of households using Non-Iterative Bayesian Approach to Statistical Matching technique. A Directed Acyclic Graph was constructed to map the pathways in the relationship of household wealth with HAZ and WAZ based on literature. The direct association of wealth index and its indirect association through per adult female equivalent dairy consumption on HAZ and WAZ were estimated using separate path models for each round of the surveys. RESULTS: Wealth index was directly associated with HAZ and WAZ in both the rounds, but the association decreased from NFHS-3 (ßHAZ: 0.145; 95% CI: 0.129, 0.16) to NFHS-4 (ßHAZ: 0.102; 95%CI: 0.093, 0.11). Adult female equivalent milk intake (increase of 10gm/day) was associated with higher HAZ (ß_NFHS-3=0.001;95% CI: 0, 0.002; ß_NFHS-4=0.002;95% CI: 0.002, 0.003) but had no association with WAZ. The indirect association of wealth with HAZ through dairy consumption was 2-fold higher in NFHS-4 compared to NFHS-3. CONCLUSIONS: The analysis of triangulated survey data shows that household level per- adult female equivalent dairy consumption positively modified the association between wealth index and HAZ, suggesting that regular inclusion of milk and milk products in the diets of children from households across all wealth quintiles could improve linear growth in this population.

Estimation of Hydration and Density of Fat-Free Mass in Indian Children Using a 4-Compartment Model: Implications for the Estimation of Body Composition Using 2-Compartment Models.

BACKGROUND: Accurate methods are needed to measure body fat mass (FM), particularly in South Asian children who are thought to have greater adiposity for a given body size. The accuracy of simple 2-compartment (2C) models of measuring FM depends on the primary measurement of the fat free mass (FFM) and the validity of assumed constants for FFM hydration and density. These have not been measured in this particular ethnic group. OBJECTIVES: To measure FFM hydration and density in South Indian children using a 4-compartment (4C) model and to compare FM estimates from this 4C-model with 2C-model-based estimates from hydrometry and densitometry, using literature-reported FFM hydration and density in children. METHODS: This study included 299 children (45% boys), aged 6-16 y from Bengaluru, India. Total body water (TBW), bone mineral content (BMC), and body volume were measured using deuterium dilution, dual-energy X-ray absorptiometry, and air displacement plethysmography, respectively, to calculate the FFM hydration and density, and the FM using 4C and 2C models. The agreement between FM estimates from 2C and 4C models was also evaluated. RESULTS: Mean FFM hydration and density were 74.2% ± 2.1% and 71.4% ± 2.0% and 1.095 ± 0.008 kg/L and 1.105 ± 0.008 kg/L in boys and girls respectively, which were significantly different from published values. Using the presently estimated constants, the mean hydrometry-based FM (as % body weight) estimates decreased by 3.5% but increased by 5.2% for densitometry-based 2C methods. When 2C-FM (using previously reported FFM hydration and density) were compared with 4C-FM estimates, the mean difference was -1.1 ± 0.9 kg for hydrometry and 1.6 ± 1.1 kg for densitometry. CONCLUSIONS: Previously published constants of hydration and density of FFM may induce errors of -12% to +17% in FM (kg) when using different 2C models in comparison to the 4C models in Indian children. J Nutr 20xx;x:xx.

Central obesity in low BMI as a risk factor for COVID-19 severity in South Indians.

BACKGROUND AND OBJECTIVES: South Asians are known to have excess adiposity at a lower body mass index, with truncal fat accumulation. Whether this confers higher risk to develop severe COVID-19 is not known. This study evaluated body mass index, body fat mass and waist circumference as risk factors for COVID-19 severity and its progression, in South Asian adults. METHODS AND STUDY DESIGN: Details of COVID-19 patients (19-90 years) were obtained prospectively, along with weight, height, waist circumference and body fat mass assessed by bioelectrical impedance analysis. Binomial logistic and Poisson regression were performed to test associations between waist circumference, body fat mass and body mass index to evaluate the adjusted OR or relative risk for disease severity at admission and length of stay. RESULTS: After adjusting for age, sex, height and co-morbidities, body mass index >23 kg/m2 (adjusted OR 2.758, 95% CI 1.025, 7.427), waist circumference (adjusted OR 1.047, 95% CI 1.002, 1.093) and body fat mass (adjusted OR 1.111, 95% CI 1.013, 1.219) were associated with a significant risk for disease severity at admission, while only waist circumference (adjusted relative risk 1.004, 95% CI 1.001, 1.008), and body fat mass (adjusted relative risk 1.011, 95% CI 1.003, 1.018), were associated with a significantly longer length of stay. CONCLUSIONS: Body mass index, at a lower cut-off of >23 kg/m2, is a significant risk factor for COVID-19 disease severity in the group of patients studied. The waist circumference and body fat mass are also good indicators for both severity at admission and length of stay.

Metabolic Availability of Lysine in Milk and a Vegetarian Cereal-Legume Meal Determined by the Indicator Amino Acid Oxidation Method in Indian Men.

BACKGROUND: Lysine rich foods such as milk and legumes serve as important food additions to the lysine deficient cereal-based diets of vegetarian populations in low- and middle-income countries (LMICs) to alleviate the risk of quality corrected dietary protein inadequacy. Dietary protein quality can be determined by estimating the metabolic availability (MA) of lysine. OBJECTIVES: The study aimed to estimate the MA of lysine in spray-dried cow milk powder (SMP), heat-treated spray-dried cow milk powder (HSMP), and a habitually consumed cereal-legume based vegetarian meal (VM), using the indicator amino acid oxidation (IAAO) slope-ratio method. METHODS: The MA of lysine in SMP, HSMP, and VM was estimated in 7 healthy young men aged 19-24 y with BMI of 21.5 ± 0.5 kg/m2 in a repeated measures design. The IAAO response slopes with 2 graded lysine intakes (10.5 and 15.0 mg·kg-1·d-1) from the SMP and VM were compared with the response slope generated with 3 graded crystalline lysine intakes (6.0, 10.5, and 15.0 mg·kg-1·d-1) at the subrequirement level. To produce HSMP, pasteurized cow milk was heat treated and spray dried. The MA of lysine in HSMP was tested at a single level of lysine intake (15 mg·kg-1·d-1). A total of 8 IAAO experiments were conducted on each participant in randomized order. The IAAO slopes were estimated using a linear mixed-effect regression model. RESULTS: The MA of lysine in SMP, HSMP, and VM was 91.9%, 69.9%, and 86.6% respectively. CONCLUSIONS: Heat treatment reduced the MA of lysine by 22% in HSMP compared with SMP in healthy Indian adults. The lysine MA estimates can be used to optimize lysine limited cereal-based diets, with the addition of appropriately processed legumes and milk powder, to meet the protein requirement. This trial was registered at Clinical Trials Registry of India (http://ctri.nic.in) as CTRI/2019/08/020568.

An uncertainty estimate of the prevalence of stunting in national surveys: the need for better precision.

BACKGROUND: Stunting is determined by using the World Health Organization (WHO) child growth standard which was developed using precise measurements. However, it is unlikely that large scale surveys maintain the same level of rigour and precision when measuring the height of children. The population measure of stunting in children is sensitive to over-dispersion, and the high prevalence of stunting observed in surveys in low and middle-income countries (LMIC) could partly be due to lower measurement precison. OBJECTIVES: To quantify the incongruence in the dispersion of height-for-age in national surveys of < 5 y children, in relation to the standard WHO Multicenter Growth Reference Study (MGRS), and propose a measure of uncertainty in population measures of stunting. METHODS: An uncertainty factor was proposed and measured from the observed incongruence in dispersion of the height-for-age of < 5 y children in the MGRS against carefully matched populations from the Demographic Health Survey of 17 countries ('test datasets', based on the availability of data). This also allowed for the determination of uncertainty-corrected prevalence of stunting (height-for-age Z score < - 2) in < 5 y children. RESULTS: The uncertainty factor was estimated for 17 LMICs. This ranged from 0.9 to 2.1 for Peru and Egypt respectively (reference value 1). As an explicit country example, the dispersion of height-for-age in the Indian National Family Health Survey-4 test dataset was 39% higher than the MGRS study, with an uncertainty factor of 1.39. From this, the uncertainty-adjusted Indian national stunting prevalence estimate reduced to 18.7% from the unadjusted estimate of 36.2%. CONCLUSIONS: This study proposes a robust statistical method to estimate uncertainty in stunting prevalence estimates due to incongruent dispersions of height measured in national surveys for children < 5 years in relation to the WHO height-for-age standard. The uncertainty is partly due to population heterogeneity, but also due to measurement precision, and calls for better quality in these measurements.

Protein intakes of pregnant women and children in India-protein quality implications.

The recent National Family Health Survey (NFHS-4, 2016) reports a national average of 18% for low birthweight (LBW) and 38% for stunting in children <5 years. Nutrition and environmental influences (chronic enteric pathogenic exposure through poor water, sanitation, and hygiene) are two critical factors that impact the health outcomes of the populxation. This is particularly relevant for vulnerable age groups such as pregnant women and children <5 years, who bear long-lasting and intergenerational consequences of impoverished nutrition and suboptimal living conditions. The present review provides, for the first time, an analysis of indispensable amino acid (IAA) requirements for pregnant women, separately for the second and third trimesters, using protein accretion data from a recent Indian study. Furthermore, using these estimates for pregnancy, and the current IAA requirements for young children, the quality of protein was assessed in Indian diets consumed by pregnant women and children (1-3 and 4-6 years) from national representative rural National Nutrition Monitoring Bureau survey. The assessment was considered in the context of an adverse environment and in relation to outcomes such as LBW, stunting, and underweight. Finally, an assessment was made of the proportion of the surveyed population at risk of dietary quality protein inadequacy and implications for planning nutrition intervention programmes. Specifically, state-wise estimates of the risk of quality protein inadequacy are provided, in addition to evaluations of additional dietary supplementation, which could inform the policy of supplementary nutrition programmes to improve health outcomes.

Local Sources of Protein in Low- and Middle-Income Countries: How to Improve the Protein Quality?

Protein inadequacy is a major contributor to nutritional deficiencies and adverse health outcomes of populations in low- and middle-income countries (LMICs). People in LMICs often consume a diet predominantly based on staple crops, such as cereals or starches, and derive most of their daily protein intakes from these sources. However, plant-based sources of protein often contain low levels of indispensable amino acids (IAAs). Inadequate intake of IAA in comparison with daily requirements is a limiting factor that results in protein deficiency, consequently in the long-term stunting and wasting. In addition, plant-based sources contain factors such as antinutrients that can diminish protein digestion and absorption. This review describes factors that affect protein quality, reviews dietary patterns of populations in LMICs and discusses traditional and novel small- and large-scale techniques that can improve the quality of plant protein sources for enhanced protein bioavailability and digestibility as an approach to tackle malnutrition in LMICs. The more accessible small-scale food-processing techniques that can be implemented at home in LMICs include soaking, cooking, and germination, whereas many large-scale techniques must be implemented on an industrial level such as autoclaving and extrusion. Limitations and considerations to implement those techniques locally in LMICs are discussed. For instance, at-home processing techniques can cause loss of nutrients and contamination, whereas limitations with larger scale techniques include high energy requirements, costs, and safety considerations. This review suggests that combining these small- and large-scale approaches could improve the quality of local sources of proteins, and thereby address adverse health outcomes, particularly in vulnerable population groups such as children, adolescents, elderly, and pregnant and lactating women.

Evaluation of Protein Quality in Humans and Insights on Stable Isotope Approaches to Measure Digestibility - A Review.

The recent Food and Agricultural Organization/World Health Organization/United Nations University expert consultations on protein requirements and quality have emphasized the need for the new Digestible Indispensable Amino Acid Score (DIAAS), as a measure of protein quality. This requires human measurements of the true ileal digestibility of individual indispensable amino acids (IAAs) until the end of the small intestine. Digestibility is measured using standard oro-ileal balance methods, which can only be achieved by an invasive naso-ileal intubation in healthy participants or fistulation at the terminal ileum. Significant efforts have been made over the last 2 decades to develop noninvasive or minimally invasive methods to measure IAA digestibility in humans. The application of intrinsically labeled (with stable isotopes like 13C, 15N, and 2H) dietary proteins has helped in circumventing the invasive oro-ileal balance techniques and allowed the differentiation between endogenous and exogenous protein. The noninvasive indicator amino acid oxidation (IAAO) technique, which is routinely employed to measure IAA requirements, has been modified to estimate metabolic availability (a sum of digestibility and utilization) of IAA in foods, but provides an estimate for a single IAA at a time and is burdensome for participants. The recently developed minimally invasive dual isotope tracer method measures small intestinal digestibility of multiple amino acids at once and is suitable for use in vulnerable groups and disease conditions. However, it remains to be validated against standard oro-ileal balance techniques. This review critically evaluates and compares the currently available stable isotope-based protein quality evaluation methods with a focus on the digestibility and metabolic availability measurements in humans. In view of building a reliable DIAAS database of various protein sources and subsequently supporting protein content claims in food labeling, a re-evaluation and harmonization of the available methods are necessary.

Perspective: When the cure might become the malady: the layering of multiple interventions with mandatory micronutrient fortification of foods in India.

When public health programs with single nutrients are perceived to have a poor impact on the target health outcome, the policy response can be to supply more, by layering additional mandatory programs upon the extant programs. However, we argue for extreme caution, because nutrients (like medicines) are beneficial in the right dose, but potentially harmful when ingested in excess. Unnecessary motivations for the reactionary layering of multiple intervention programs emerge from incorrect measurements of the risk of nutrient inadequacy in the population, or incorrect biomarker cutoffs to evaluate the extent of nutrient deficiencies. The financial and social costs of additional layered programs are not trivial when traded off with other vital programs in a resource-poor economy, and when public health ethical dilemmas of autonomy, equity, and stigma are not addressed. An example of this conundrum in India is the perception of stagnancy in the response of the prevalence of anemia to the ongoing pharmacological iron supplementation program. The reaction has been a policy proposal to further increase iron intake through mandatory iron fortification of the rice provided in supplementary feeding programs like the Integrated Child Development Services and the School Mid-Day Meal. This is in addition to the ongoing pharmacological iron supplementation as well as other voluntary iron fortifications, such as those of salt and manufactured food products. However, before supplying more, it is vital to consider why the existing program is apparently not working, along with consideration of the potential for excess intake and related harms. This is relevant globally, particularly for countries contemplating multiple interventions to address micronutrient deficiencies. Supplying more by layering multiple nutrient interventions, instead of doing it right, without thoughtful considerations of social, biological, and ethics frameworks could be counterproductive. The cure, then, might well become the malady.

Sodium Intake Pattern in West Indian Population.

BACKGROUND: High sodium intake is a major public health concern. Sodium consumption pattern of West Indian population has never been reported before. OBJECTIVES: The cross-sectional study assessed sodium intake pattern by considering all possible dietary sources and spot urine sodium estimation among sedentary healthy adults of productive age group (35-55 years). MATERIALS AND METHODS: Twenty-four-h dietary recall (3 alternative days in a week), food frequency assessment, weighing of table, and cooking salt (n = 218) were performed. Spot urine samples were collected for subset (n = 33) to quantify sodium excretion. Flame photometer "CL 361" was used for food sodium quantification. RESULTS: Men had higher sodium intake than women (3.9 ± 0.4 vs. 3.8 ± 0.4 g/day). Significantly higher sodium intake among men was from processed ready to eat foods (0.8 ± 0.3 vs. 0.6 ± 0.1, P < 0.05) and among women was from cooking and table salt (2.6 ± 0.3 vs. 2.8 ± 0.3, P < 0.001). Lowest quartile (<25th percentile) intake of oral sodium consumption (2.4 ± 0.5 g/day) was higher than WHO safe recommendation level of <2 g/day. Late afternoon spot urine sodium content was used to predict 24-h sodium excretion (6.1 ± 0.5 g/day), in turn population level sodium intake estimation. Analyzed sodium content of most frequently consumed all ready to eat foods was found to be higher than the reported values. CONCLUSION: There is a strong need of evidence-based guidelines and policy formulation for national salt reduction program in India.

Effect of a cereal and milk meal with or without fruits and nuts on the postprandial glycemic response in Indian men.

BACKGROUND AND OBJECTIVES: Some cereals, consumed at breakfast, have shown lower glycemic responses. Limited data exist in the Indian context, where the effect could be modified due to genetic or racial differences. This study aimed to investigate the effect of cereal and milk, with or without fruits/nuts, on the glycemic response in healthy Indian men. METHODS AND STUDY DESIGN: A randomized cross-over study was carried out on 16 men (18 - 45 years), with 3 interventions providing equal amounts of glycemic carbohydrate: a glucose drink (Reference), cereal and milk (CM), and cereal, milk, fruits and nuts (CMO), on separate days. Plasma glucose, serum insulin, C-peptide, ghrelin, energy expenditure (EE), substrate oxidation and appetite/satiety were measured repeatedly over 3 hours post meal. RESULTS: A significant time effect and time x meal interaction between the meals, higher for the Reference meal, was observed for plasma glucose (p<0.001), insulin (p<0.001), C-peptide (p<0.001), and carbohydrate oxidation (p<0.001); while lower for satiety (p<0.001). The plasma glucose concentrations of CM and CMO meals returned to baseline 60 min postprandially, then remained there, unlike the Reference meal, where the plasma glucose values returned to baseline at 120 min and dipped significantly below baseline at 150 and 180 min. A significant effect of time (p<0.001) was observed for EE between meals. Ghrelin levels did not differ significantly between the test meals. CONCLUSIONS: Cereal with milk, along with fruits and nuts at breakfast, has a lower and stable glycemic response, along with increased satiety among healthy male subjects.