Prevalence of Wasting and its Associated Factors among Children Under 5 Years of Age in India: Findings from the Comprehensive National Nutrition Survey.

BACKGROUND: The burden of wasting among under five children in India, has not reduced in the last decade. OBJECTIVES: We used child-level data from the latest nationally representative Comprehensive National Nutritional Survey (CNNS) to estimate the prevalence of wasting at the national and state level in India. METHODS: We explored the association of wasting with maternal, child and household factors using multivariable logistic regression for the age group of 0-5, 6-23 and 24-59 months. RESULTS: The overall prevalence of wasting was 17.3%, ranging from 5.8% to 29.1% across states, 23.3% in children 0-5 months, 19.6 % in children 6-23 months and 15.4 % in children 24-59 months of age. Higher birthweight i.e., every 100g increase (0-5 months aOR = 0.96, 6-23 months aOR = 0.94, 24-59 months aOR = 0.96), higher maternal BMI (0-5 months aOR = 0.51, 6-23 months aOR = 0.62, 24-59 months aOR = 0.67), increasing child age in months (0-5 months aOR = 0.84) and female sex of the child (24-59 months aOR = 0.82) was found to have significantly lower odds of wasting. The odds of wasting were significantly higher for poorest wealth quintile (0-5 months aOR = 1.99, 6-23 months aOR = 2.13), maternal unemployment (0-5 months aOR = 2.25), and lower levels of maternal education (6-23 months aOR = 1.74). CONCLUSIONS: Our analyses showed that burden of wasting continues to remain high in India. Preventive interventions must target reduction of low birthweight. Early identification and management of wasting should be done, especially during the first six months of life who are not part of current therapeutic feeding programme.

Anaemia in Indians aged 10-19 years: Prevalence, burden and associated factors at national and regional levels.

Anaemia control programmes in India are hampered by a lack of representative evidence on anaemia prevalence, burden and associated factors for adolescents. The aim of this study was to: (1) describe the national and subnational prevalence, severity and burden of anaemia among Indian adolescents; (2) examine factors associated with anaemia at national and regional levels. Data (n = 14,673 individuals aged 10-19 years) were from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018). CNNS used a multistage, stratified, probability proportion to size cluster sampling design. Prevalence was estimated using globally comparable age- and sex-specific cutoffs, using survey weights for biomarker sample collection. Burden analysis used prevalence estimates and projected population from 2011 Census data. Multivariable logistic regression models were used to analyse factors (diet, micronutrient deficiencies, haemoglobinopathies, sociodemographic factors, environment) associated with anaemia. Anaemia was present in 40% of girls and 18% of boys, equivalent to 72 million adolescents in 2018, and varied by region (girls 29%-46%; boys 11%-28%) and state (girls 7%-62%; boys 4%-32%). Iron deficiency (ferritin < 15 µg/L) was the strongest predictor of anaemia (odds ratio [OR]: 4.68, 95% confidence interval [CI]: [3.21,6.83]), followed by haemoglobinopathies (HbA2 > 3.5% or any HbS) (OR: 2.81, 95% CI: [1.66,4.74]), vitamin A deficiency (serum retinol <20 ng/ml) (OR: 1.86, 95% CI: [1.23,2.80]) and zinc deficiency (serum zinc < 70 µg/L) (OR: 1.32, 95% CI: [1.02,1.72]). Regional models show heterogeneity in the strength of association between factors and anaemia by region. Adolescent anaemia control programmes in India should continue to address iron deficiency, strengthen strategies to identify haemoglobinopathies and other micronutrient deficiencies, and further explore geographic variation in associated factors.

Prevalence of Iron Deficiency and its Sociodemographic Patterning in Indian Children and Adolescents: Findings from the Comprehensive National Nutrition Survey 2016-18.

BACKGROUND: Anemia control programs in India focus mainly on the measurement of hemoglobin in response to iron-folic acid supplementation. However, representative national estimates of iron deficiency (ID) are not available. OBJECTIVES: The objective of the present study was to evaluate ID prevalence among children and adolescents (1-19 y) using nationally representative data and to examine the sociodemographic patterning of ID. METHODS: Cross-sectional data from the Comprehensive National Nutrition Survey in children (1-4 y: n = 9635; 5-9 y: n = 11,938) and adolescents (10-19 y; n = 11,507) on serum ferritin (SF) and other biomarkers were analyzed to determine inflammation-adjusted ID prevalence [SF (µg/L): <12 in 1-4 y and <15 in 5-19 y] and its relation to sociodemographic indicators. Multiple-regression analyses were conducted to identify the exposure associations of iron status. In addition, the relation between SF and hemoglobin was assessed as an indicator of iron utilization in different wealth quintiles. RESULTS: ID prevalence was higher in 1- to 4-y-old children (31.9%; 95% CI: 31.0%, 32.8%) and adolescent girls (30.4%; 95% CI: 29.3%, 31.5%) but lower in adolescent boys and 5- to 9-y-old children (11%-15%). In all age groups, ID prevalence was higher in urban than in rural participants (1-4 y: 41% compared with 29%) and in those from richer quintiles (1-4 y: 44% in richest compared with 22% in poorest), despite adjustment for relevant confounders. SF significantly interacted with the wealth index, with declining trends in the strength of association between hemoglobin and SF from the richest to the poorest groups suggesting impaired iron utilization for hemoglobin synthesis in poorer wealth quintiles. CONCLUSIONS: ID prevalence was indicative of moderate (in preschool children and adolescent girls) or mild (in 5- to 9-y-old children and adolescent boys) public health problem with significant variation by state and age. Focusing on increasing iron intake alone, without addressing the multiple environmental constraints related to poverty, may not result in intended benefits.

Levels and determinants of malnutrition among India's urban poor women: An analysis of Demographic Health Surveys 2006 and 2016.

A quarter of 400 million urban Indian residents are poor. Urban poor women are as undernourished as or worse than rural women but urban averages mask this disparity. We present the spectrum of malnutrition and their determinants for more than 26,000 urban women who gave birth within 5 years from the last two rounds of Demographic Health Survey 2006 and 2016. Among urban mothers in the lowest quartile by wealth index (urban poor), 12.8% (95% CI [11.3%, 14.5%]) were short or with height < 145 cm; 20.6% (95% CI [19%, 22.3%]) were thin or with body mass index < 18.5 kg/m2 ; 57.4% (95% CI [55.5%, 59.3%]) had any anaemia (haemoglobin < 12 g/dL), whereas 32.4% (95% CI [30.5%, 34.3%]) had moderate to severe anaemia; and 21.1% (95% CI [19.3%, 23%]) were obese (body mass index ≥ 25 kg/m2 ). Decadal gains were significant for thinness reduction (17p.p.) but obesity increased by 12 p.p. Belonging to a tribal household increased odds of thinness by 1.5 (95% CI [1.06, 2.18]) times among urban poor mothers compared with other socially vulnerable groups. Secondary education reduced odds of thinness (0.61; 95% CI [0.48, 0.77]) and higher education of short stature (0.41; 95% CI [0.18, 0.940]). Consuming milk/milk products, pulses/beans/eggs/meats, and dark green leafy vegetables daily reduced the odds of short stature (0.52; 95% CI [0.35, 0.78]) and thinness (0.72; 95% CI [0.54, 0.98]). Urban poor mothers should be screened for nutritional risks due to the high prevalence of all forms of malnutrition and counselled or treated as per risk.

Mid-upper arm circumference cut-offs for screening thinness and severe thinness in Indian adolescent girls aged 10-19 years in field settings.

OBJECTIVE: (i) To assess diagnostic accuracy of mid-upper arm circumference (MUAC) for screening thinness and severe thinness in Indian adolescent girls aged 10-14 and 15-19 years compared with BMI-for-age Z-score (BAZ) <-2 and <-3 as the gold standard and (ii) to identify appropriate MUAC cut-offs for screening thinness and severe thinness in Indian girls aged 10-14 and 15-19 years. DESIGN: Cross-sectional, conducted October 2016-April 2017. SETTING: Four tribal blocks of two eastern India states, Chhattisgarh and Odisha. PARTICIPANTS: Girls (n 4628) aged 10-19 years. Measurements included height, weight and MUAC to calculate BAZ. Standard diagnostic accuracy tests, receiver-operating characteristic curves and Youden index helped arrive at MUAC cut-offs at BAZ < -2 and <-3, as gold standard. RESULTS: Mean MUAC and BMI correlation was positive (0·78, P = 0·001 and r 2 = 0·61). Among 10-14 years, MUAC cut-off corresponding to BAZ < -2 and BAZ < -3 was ≤19·4 and ≤18·9 cm. Among 15-19 years, corresponding values were ≤21·6 and ≤20·7 cm. For both BAZ < -2 and BAZ < -3, specificity was higher in 15-19 v. 10-14 years. State-wise variations existed. MUAC cut-offs ranged from 17·7 cm (10 years) to 22·5 cm (19 years) for BAZ < -2, and from 17·0 cm (10 years) to 21·5 cm (19 years) for BAZ < -3. Single-age area under the curve range was 0·82-0·97. CONCLUSIONS: Study provides a case for use of year-wise and sex-wise context-specific MUAC-cut-offs for screening thinness/severe thinness in adolescents, rather than one MUAC cut-off across 10-19 years, depending on purpose and logistic constraints.

WASH practices and its association with nutritional status of adolescent girls in poverty pockets of eastern India.

BACKGROUND: Water, Sanitation, and Hygiene (WASH) practices may affect the growth and nutritional status among adolescents. Therefore, this paper assesses WASH practices and its association with nutritional status among adolescent girls. METHODS: As a part of an intervention programme, this study is based on baseline cross-sectional data. It was conducted between May 2016-April 2017 in three Indian states (Bihar, Odisha, and Chhattisgarh). From a sample of 6352 adolescent girls, information on WASH practices, accessibility to health services and anthropometric measurements (height, weight and mid upper arm circumference (MUAC)) was collected. Descriptive statistics were used to examine WASH practices, and nutritional status among adolescent girls. Determinants of open defecation and menstrual hygiene were assessed using logistic regression. Association between WASH and nutritional status of adolescent girls was determined using linear regression. RESULTS: Findings showed 82% of the adolescent girls were practicing open defecation and 76% were not using sanitary napkins. Significant predictors of open defecation and non use of sanitary napkin during menstruation were non Hindu households, households with poorer wealth, non availability of water within household premise, non visit to Anganwadi Centre, and non attendance in Kishori group meetings. One-third of adolescent girls were stunted, 17% were thin and 20% had MUAC < 19 cm. Poor WASH practices like water facility outside the household premise, unimproved sanitation facility, non use of soap after defecation had significant association with poor nutritional status of adolescent girls. CONCLUSIONS: Concerted convergent actions focusing on the provision of clean water within the household premise, measures to stop open defecation, promotion of hand washing, accessibility of sanitary napkins, poverty alleviation and behavior change are needed. Health, nutrition and livelihood programmes must be interspersed, and adolescents must be encouraged to take part in these programmes.

Prevalence of overweight and obesity and associated demographic and health factors in India: Findings from Comprehensive National Nutrition Survey (CNNS).

BACKGROUND: Childhood obesity (5-9 years) in India is likely to contribute 11% to the global burden by 2030. METHODS: Data from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018) was used to assess the prevalence and key associated factors of overweight and obesity. Multivariable logistic regression models were applied to identify potential determinants associated with being overweight and obese. RESULTS: Overweight prevalence (including obesity) varied from 1.6% (0-4 years) to 4.8% (10-19 years). The majority of states reported a higher proportion of adolescents overweight and obese, than younger age group 5-9 years. A significantly higher prevalence of children and adolescents with obesity was reported in higher wealth quintiles and residents of urban areas. The prevalence of overweight and obesity and associated demographic and health factors in India included: the presence of NCD risk factor (adolescents: 1.68, 95% CI [1.31-2.14]), micronutrient deficiency (5-9 years children: 1.72, 95% CI [1.30-2.28]), mother's education (5-9 years children: 4.84, 95% CI [2.92-8.03]; adolescents: 2.17, 95% CI [1.42-3.32]), wealth (adolescents: 1.92, 95% CI [1.16-3.19]), place of residence (5-9 years children: 1.68, 95% CI [1.39-2.03]; adolescents: 1.39, 95% CI [1.16-1.66]), child age (5-9 years children: 1.64, 95% CI [1.40-1.93], and screen-time (adolescents: 1.63, 95% CI [1.22-2.19]. CONCLUSION: The findings set out policy and research recommendations to pave the path for curtailing the increasing prevalence of overweight and obesity and achieving the World Health Assembly's Global Nutrition target of 'no increase in childhood overweight (Target 4) by 2025'.

Estimating the potential impact of a health tax on the demand for unhealthy food and beverages and on tax revenue in India.

Foods high in fat, sugar or salt are important contributors to the rising burden of non-communicable diseases globally and in India. Health taxes (HTs) have been used by over 70 countries as an effective tool for reducing consumption of sugar sweetened beverages (SSBs). However, the potential impacts of HTs on consumption and on revenues have not been estimated in India. This paper aims to estimate the potential impact of health taxes on the demand for sugar, SSBs and foods high in fat, sugar or salt (HFSS) in India while exploring its impact on tax revenues. PE of sugar was estimated using Private Final Consumption Expenditure and Consumer Price Index data while price elasticities for SSBs and HFSS were obtained from literature. The reduction in demand was estimated for an additional 10-30% HT added to the current goods and services tax, for varying levels of price elasticities. The results show that for manufacturers of sweets and confectionaries who buy sugar in bulk and assuming a higher price elasticity of -0.70, 20% additional HT (total tax 48%) would result in 13-18% decrease in the demand for sugar used for confectionaries and sweets. For SSBs, HT of 10-30% would result in 7-30% decline in the demand of SSBs. For HFSS food products, 10-30% HT would result in 5-24% decline in the demand for HFSS products. These additional taxes would increase tax revenues for the government by 12-200% across different scenarios. Taxing unhealthy foods is likely to reduce demand, while increasing government revenues for reinvestment back into public health programmes and policies that may reduce obesity and the incidence of non-communicable diseases in India.

Are advertising policies affirmative in restricting the marketing of foods high in fat, salt and sugar (HFSS) in India?: evidence from SWOT Analysis.

The regulatory Indian environment for advertising high fat, salt, and sugar (HFSS) foods and non-alcoholic beverages, on various media was reviewed. Identified national-level policies were categorised as mandatory or self-regulatory based on legal content. For each mandatory regulation, Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was undertaken to determine how existing policies could be strengthened to safeguard children from unhealthy food advertisements. Thirteen policies (nine mandatory; four self-regulatory) relevant to advertising in India were identified. Of the nine mandatory policies, Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements, 2022, is the only policy that restricts HFSS food advertisements to children across all media. There are key shortfalls, including limited scope of 'child-targeted' advertisements and lack of criteria to define HFSS foods. A robust regulatory framework is needed to protect children from HFSS food marketing, not just what is 'directed' at them, with clear evidence-based food classification criteria.

Viewpoints from the National Consultation on Addressing Acute Malnutrition on Mainstreaming Community-Based Program for Management of Acute Malnutrition in India.

High burden of acute malnutrition among children less than 5 years is a major public health problem in India. A "Two-days National Consultation on Addressing Acute Malnutrition" was organized to gather experiences and evidence from 13 states of India on prevention and management of acute malnutrition among children and documenting viewpoints from experts and government counterparts on the same. The consultation centered around five key themes of addressing acute malnutrition; 1) capacity building, 2) strengthening screening, 3) nutritional care of wasting, 4) tracking progress, and 5) scale-up. The paper highlights the experiences and key recommendations around the above key themes. It emerged that there is a need to further accelerate the efforts toward strengthening existing platforms and services to address acute malnutrition among children. Regular trainings of the frontline workers, increased convergence, regular monitoring, and continued service delivery during the pandemic should be undertaken for better outcomes.

Reducing childhood stunting in India: Insights from four subnational success cases.

Global success case analyses have identified factors supporting reductions in stunting across countries; less is known about successes at the subnational levels. We studied four states in India, assessing contributors to reductions in stunting between 2006 and 2016. Using public datasets, literature review, policy analyses and stakeholder interviews, we interpreted changes in the context of policies, programs and enabling environment. Primary contributors to stunting reduction were improvements in coverage of health and nutrition interventions (ranged between 11 to 23% among different states), household conditions (22-47%), and maternal factors (15-30%). Political and bureaucratic leadership engaged civil society and development partners facilitated change. Policy and program actions to address the multidimensional determinants of stunting reduction occur in sectors addressing poverty, food security, education, health services and nutrition programs. Therefore, for stunting reduction, focus should be on implementing multisectoral actions with equity, quality, and intensity with assured convergence on the same geographies and households. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-021-01252-x.

Association between anthropometric criteria and body composition among children aged 6-59 months with severe acute malnutrition: a cross-sectional assessment from India.

A multicentric study is being conducted in which children with severe acute malnutrition (SAM) aged 6-59 months are identified with only weight-for-height z-score (WHZ) < - 3 criteria. The present study aimed to assess associations of anthropometric parameters and body composition parameters, to improve treatment of SAM. We conducted a cross-section assessment using the enrolment data of children who participated in a multi-centric longitudinal controlled study from five Indian states. Fat-free mass (FFM) and fat mass (FM) were determined by bio-electrical impedance analysis (BIA). Six hundred fifty-nine children were enrolled in the study using WHZ < -3 criteria. Available data shows that WHZ, WAZ and BMIZ were significantly associated with FFMI while MUACZ was significantly associated with both FMI and FFMI. Children with both severe wasting and severe stunting had significantly lower FFMI compared to those who were only severely wasted. All forms of anthropometric deficits appear to adversely impact FFM and FM.Trial registrationThe study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 dated 24/09/2020).

Population estimates and determinants of severe maternal thinness in India.

OBJECTIVE: To examine prevalence, risk factors, and consequences of maternal severe thinness in India. METHODS: This mixed methods study analyzed data from the Indian National Family Health Survey (NFHS)-4 (2015-2016) to estimate the prevalence of and risk factors for severe thinness, followed by a desk review of literature from India. RESULTS: Prevalence of severe thinness (defined by World Health Organization as body mass index [BMI] <16 in adult and BMI for age Z score < -2 SD in adolescents) was higher among pregnant adolescents (4.3%) compared with pregnant adult women (1.9%) and among postpartum adolescent women (6.3%) than postpartum adult women (2.4%) 2-6 months after delivery. Identified research studies showed prevalence of 4%-12% in pregnant women. Only 13/640 districts had at least three cases of severely thin pregnant women; others had lower numbers. Three or more postpartum women aged ≥20 years were severely thin in 32 districts. Among pregnant adolescents, earlier parity increased odds (OR 1.96; 95% CI, 1.18-3.27) of severe thinness. Access to household toilet facility reduced odds (OR 0.72; 95% CI, 0.52-0.99]. Among mothers aged ≥20 years, increasing education level was associated with decreasing odds of severe thinness (secondary: OR 0.74; 95% CI, 0.57-0.96 and Higher: OR 0.54; 95% CI, 0.32-0.91, compared with no education); household wealth and caste were also associated with severe thinness. CONCLUSION: This paper reveals the geographic pockets that need priority focus for managing severe thinness among pregnant women and mothers in India to limit the immediate and intergenerational adverse consequences emanating from these deprivations.

Screening and management options for severe thinness during pregnancy in India.

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.

Prevalence of low serum zinc concentrations in Indian children and adolescents: findings from the Comprehensive National Nutrition Survey 2016-18.

BACKGROUND: It is thought that there is a high risk of zinc deficiency in India, but there are no representative national estimates. OBJECTIVES: We aimed to evaluate the national and state-level prevalence of low serum zinc concentrations (SZCs) in Indian children from the nationally representative Comprehensive National Nutrition Survey. METHODS: Prevalence of low SZC, adjusted for C-reactive protein, was estimated among preschool (1-4 y; n = 7874) and school-age children (5-9 y; n = 10,430) and adolescents (10-19 y; n = 10,140), using SZC cutoffs defined by the International Zinc Nutrition Consultative Group. RESULTS: Prevalence of low SZC was high among adolescents (31.1%; 95% CI: 29.8%, 32.4%), compared with school-age (15.8%; 95% CI: 15.3%, 16.3%) or preschool children (17.4%; 95% CI: 16.7%, 18.0%). However, stratification of prevalence by fasting status or using an alternative lower SZC cutoff independent of fasting status led to a reduction in prevalence by 3.7% or 7.8% in children <10 y, respectively. The prevalence of low SZC was higher among rural preschool children, those belonging to households with poor socioeconomic status, and those with severe stunting or underweight. Preschool children with diarrhea (22.6%; 95% CI: 20.8%, 24.4%), productive cough (22.7%; 95% CI: 18.5%, 27.5%), or malaria/dengue (38.5%; 95% CI: 29.4%, 48.2%) in the 2 wk preceding the survey had a higher prevalence of low SZC than those without morbidity (16.5%; 95% CI: 15.9%, 17.2%; 17.6%; 95% CI: 16.9%, 18.2%; and 17.5%; 95% CI: 16.8%, 18.1%, respectively). CONCLUSIONS: The national prevalence of low SZC among preschool (17%) or school-age children (16%) was <20%, which is considered the cutoff indicating a problem of public health significance; but there were variations by state and socioeconomic status. In adolescents, however, the prevalence of low SZC was 31%, which warrants further investigation. The association of low SZC with diarrhea in preschool children necessitates better coverage of Zn administration in the management of diarrhea.

Effectiveness of community-based treatment programs for treatment of uncomplicated severe acute malnourished children aged 6-59 months using locally produced nutrient dense foods: protocol for a multicentric longitudinal quasi-experimental study.

BACKGROUND: Severe acute malnutrition (SAM) is a major underlying cause of mortality among children. Around one third of the world's acutely malnourished children live in India. The WHO recommends community-based management of acute malnutrition (CMAM) for managing children with SAM. In India, different states are implementing community-based SAM treatment programme, hereinafter called CSAM, using varieties of locally produced nutrient dense food items with different nutrient compositions. The study will assess the effectiveness of these state specific CSAM interventions. METHODS: The longitudinal quasi-experimental study will be undertaken in two purposively selected blocks of one district each in the four intervention states and one comparison state. From each state, 200 SAM children identified using weight-for-length/height z-score (WHZ) < - 3 criteria will be enrolled in the study. Their anthropometric data and skinfold thickness will be taken on admission, at sixth week and at discharge by trained field investigators. Other child details, incidence of morbidity and socio-economic details will be collected on admission. To assess food consumption pattern including consumption of locally produced nutrient dense food supplements, dietary assessment, using 24-h dietary recall will be conducted on admission, at sixth week and at discharge. In addition, body composition parameters will be assessed for a sub-set of children using bio-electrical impedance analysis on admission and at discharge to analyse changes in total body water, fat-free mass, and fat mass. Post discharge, all study participants will be followed up monthly until 6 months. Atleast 10% of the sample will be checked for quality assessment. The study's primary outcome is cure rate defined as children attaining WHZ ≥ -2. Secondary outcomes include mean weight gain, mean length of stay, body composition parameters, relapse and mortality rates. Additionally, process evaluation and cost effectiveness analysis will be conducted. DISCUSSION: There is a shortage of robust evidence regarding the effectiveness of locally produced nutrient dense food supplements provided as part of the CSAM intervention in India. This study will contribute to evidence on effective strategies to manage children with uncomplicated SAM in India. The study protocol has all necessary ethical approvals. Written informed consent will be obtained from caregivers of the children. TRIAL REGISTRATION: The study is registered with Clinical Trial Registration of India (Registration No.: CTRI/2020/09/028013 ) Date of registration 24/09/2020.

Outcomes of Hospitalized Infants Aged One to Six Months in Relation to Different Anthropometric Indices - An Observational Cohort Study.

OBJECTIVES: Malnutrition in infants less than six months is increasingly recognized. However, the WHO criteria for identifying malnutrition have not been fully evaluated against the risk of in-patient mortality. The observational study was conducted to evaluate the predictability of in-patient mortality of different anthropometric criteria and combination of criteria in order to understand which diagnostic criteria or combination of criteria most accurately predict in-patient mortality. METHODS: Data from a cohort of infants aged one to six months, admitted to Kalawati Saran Children's Hospital, New Delhi between February and December 2018 was analyzed. The discriminatory ability of different anthropometric indexes [weight-for-age Z score (WAZ), weight-for-length Z score (WLZ) and mid-upper arm circumference (MUAC)] and their combinations to predict in-patient mortality was assessed using Receiver operating characteristic (ROC) curves. RESULTS: A total of 1813 infants aged one to six months were admitted during the 11 mo period, of which 107 (5.9%) died in the hospital. Of all admissions, 39.9%, 26% and 23.4% were severely underweight, severely wasted and severely stunted, respectively. WAZ < -3 was the most sensitive predictor of mortality [sensitivity: 74.8%; specificity: 62.3%; area under the curve (AUC): 0.69, 95% CI: 0.64-0.74]. CONCLUSIONS: WAZ < -3 was the most sensitive predictor out of all individual and combined parameters/indexes in identifying infants less than six months at high risk of mortality which suggests that, it should be used to identify at-risk infants between one to six months on admission to in-patient care. Children identified as falling into this category should be properly evaluated and treated during their in-patient stay.

Evidence base for children affected by HIV and AIDS in low prevalence and concentrated epidemic countries: applicability to programming guidance from high prevalence countries.

As global commitment grows to protect and support children affected by HIV and AIDS, questions remain about how best to meet the needs of these children in low prevalence settings and whether information from high prevalence countries can appropriately guide programming in these settings. A 2007 search for the evidence in low prevalence settings on situational challenges of HIV and AIDS-affected children and interventions to address these challenges identified 413 documents. They were reviewed and judged for quality of documentation and scientific rigor. Information was compiled across eight types of challenges (health and health care, nutrition and food security, education, protection, placement, psychosocial development, socioeconomic status, and stigma/discrimination); and also assessed was strength of evidence for situational and intervention findings. Results were compared to three programming principles drawn from research in high prevalence countries: family-centered preventive efforts, treatment, and care; family-focused support to ensure capacity to care for and protect these children; and sustaining economic livelihood of HIV and AIDS-affected households. Findings show that children affected by HIV and AIDS in low prevalence settings face increased vulnerabilities similar to those in high prevalence settings. These findings support seeking and testing programmatic directions for interventions identified in high prevalence settings. However, low prevalence settings/countries are extremely diverse, and the strength of the evidence base among them was mixed (strong, moderate, and weak in study design and documentation), geographically limited, and had insufficient evidence on interventions to draw conclusions about how best to reduce additional vulnerabilities of affected children. Information on family, economic, sociocultural, and political factors within local contexts will be vital in the development of appropriate strategies to mitigate vulnerabilities.

Nutrition status of nulliparous married Indian women 15-24 years: Decadal trends, predictors and program implications.

In India, 66% of 8 million married adolescents (~5.3 million) are nulliparous and likely to conceive soon. Among married young women aged 20-24 years about 9.1 million are nulliparous. This group remains relatively less reached in maternal nutrition programs. Current estimates of their nutritional status and predictors of body mass index (BMI) are unavailable. Thinness (BMI <18.5 kg/m2), severe thinness (BMI <16 kg/m2), overweight or obesity (BMI ≥ 23kg/m2) prevalence estimates are presented based on a sample of 11,265 married nulliparous adolescents (15-19 years, married, no parity) and 15,358 young women (20-24 years, married, no parity) drawn from the National Family Health Surveys 2005-06 and 2015-16. Trends by age, time and state were analysed. Predictors of BMI were investigated using linear regression. Using BMI for age z score (BAZ) as standard reference, BMI cut-off was calculated for thinness (-2SD) and overweight or obesity (+1SD) among married nulliparous adolescents as recommended for population under 19 years. 35% sampled adolescents and 26% young women were thin; 4%-5% severely thin. Overweight or obesity was higher among married nulliparous young women than married nulliparous adolescents (21% versus 11%). Eight in 1000 were short, thin and young and six in 1000 were short, thin, anemic and young. At 15 years of age, prevalence of thinness based on BMI was 46.5% while based on BAZ, 7.6%. At 24 years of age thinness was 22.5%. Decadal reduction in thinness was half among married nulliparous adolescents (4% points) compared with married nulliparous young women (8% points). Decadal increase in overweight/ obesity ranged from 4% to 5% in both age groups. Western states had high prevalence of thinness; Tamil Nadu had highest prevalence of overweight or obesity. Incremental increase in age and wealth increased BMI among young women more than adolescents. BMI was lower among adolescents and young women wanting a child later than soon [ß -0.28 (CI -0.49- -0.07), ß -0.33(CI -0.56- -0.093), respectively]. BMI cut-off 16.49 kg/m2 and 24.12 kg/m2 had a high sensitivity (100%, 99.7%) and specificity (98.9%, 98.5%) to screen thin and overweight or obese adolescents, respectively. Owing to the high prevalence of both thinness and overweight/obesity among nulliparous married adolescents and women, nutritional anthropometry based screening should be initiated for this target group, along with a treatment package in states with high and persistent malnutrition. Family planning services should be integrated in nutrition programs for this target group to achieve normal nutritional status before conception.

Delivering an Integrated Package of Maternal Nutrition Services in Andhra Pradesh and Telangana (India).

BACKGROUND: Maternal spot feeding programs operational in southern Indian States are providing a package of nutrition services (food, micronutrient supplementation, deworming, gestation weight gain monitoring, and fortnightly nutrition health education) to pregnant women. These remain to be evaluated. OBJECTIVE: We evaluated the maternal spot feeding programs in 2 Southern Indian states. METHODS: Study design was cross-sectional entailing primary data collection (July to November 2016) on 360 pregnant and lactating women (of infants aged 0-6 months) per state and a review of the scheme's management information system (MIS) beneficiaries' records for the time period April 2014 to August 2017. To gain program functioning insights, open-ended interviews (n = 252) with state, district, and block program managers a state-level open space technology workshop was conducted. RESULTS: Average days of meal consumption ranged from 19 to 21 days per month; spot meal enhanced high dietary diversity (≥6 food groups; 57%-59%) and consumption of eggs and milk (74%-96%) among pregnant and lactating women. On-the-spot consumption of iron, folic acid, calcium, and deworming was 18%, 87%, and 56%, respectively; 94% attended at least 1 of the 2 nutrition monthly counseling sessions. Majority (68%) of the beneficiaries were motivated to enroll by self-help groups or family members, suggesting the crucial persuasive role of peers and family members. CONCLUSION: Maternal spot feeding schemes can potentially deliver nutrition interventions outlined in the World Health Organization antenatal care guidelines 2016 for a positive pregnancy outcome. Research on schemes' impact on birth outcomes, maternal depression, social norms, and its cost-effectiveness is needed.