The Need for Food Fortification With Zinc in India: Is There Evidence for This?

There has been recent advocacy for food fortification with zinc in India. However, there are three important conditions that should be established before fortifying food with any micronutrient, which requires that there should be i) Established high prevalence of biochemical or sub-clinical deficiency (?20%), ii) Low dietary intakes that increase the risk of deficiency, and iii) Evidence of efficacy of supplementation from clinical trials. For zinc, all three conditions are not satisfied. The prevalence of low serum zinc concentrations in Indian children is well below 20% (~6%), signifying that zinc deficiency is not a public health problem. There is no risk of dietary zinc inadequacy in Indian populations where intake has been measured. Finally, there is no robust evidence that zinc-fortified foods improve functional outcomes, even if the serum zinc concentration is increased. Thus, contemporary evidence does not justify the need for food fortification with zinc in India.

Childhood and Adolescent Anemia Burden in India: The Way Forward

The burden of anemia in Indian children, based on capillary blood sampling, is believed to be profound and worsening (67.1%) according to the successive National Family Health Surveys (NFHS). This might be an overestimate. The recent Comprehensive National Nutrition Survey of Indian children, that used venous blood sampling, found only less than half (30.7%) the NFHS prevalence, of which only one third was due to iron deficiency (ID). Unfortunately, the apparently worsening NFHS anemia burden estimate has been interpreted as an inadequacy of the present iron supplementation policy. This has led to additional iron supply through mandatory rice fortification. However, the lack of efficacy of iron supplementation appears inevitable, if the true prevalence of iron deficiency anemia is only about 10%. Thus, etiology is a critical consideration when devising appropriate and effective prevention policies. Future policies must focus on precision, thoughtfulness, restraint, and community engagement.

Estimated Deficits in Nutrient Intake of ICDS Beneficiaries Who Receive Take Home Ration at Two Districts in Karnataka

Background: The current estimates of energy and protein to bridge nutrient gap in the beneficiaries of the Integrated Child Development Services (ICDS) supplementary nutrition program use sub-optimal methodology for deficit calculation. Objective: To estimate the nutrient deficit and the risk of inadequate nutrient intake in beneficiaries of the ICDS, aged 6-36 months, using individual 24-hour diet recalls, from districts of Chitradurga and Davanagere in Karnataka. Study design: Cross-sectional design. Participants: Children (aged 6 to 36 months) registered as beneficiaries of the ICDS in these districts. Methods: Data were collected on socio-demographic factors, child feeding patterns, perception and usage of take home ration (THR), between August to October, 2019. Three non-consecutive days’ 24-hour diet recall data of children were obtained from mothers, and anthropometric measurements were taken. The proportion of children at risk of inadequate nutrient intakes was estimated using the probability approach. Assuming that 50% of a healthy population will be at risk of nutrient inadequacy such that intake and requirement distributions overlap, the proportion at actual risk of nutrient inadequacy (?50%) was calculated. Results: A combined district analysis showed a median energy deficit of 109 kcal and 161 kcal in children belonging to the age groups of 6-12 month and 13-36 month, respectively. The actual risk of inadequate intake for both age groups ranged between 12- 47% for fat and other micronutrient (iron, calcium, zinc, folate, vitamin B12 and vitamin A), despite breastfeeding, complementary feeding and reported THR use. Conclusion: Children who receive supplementary nutrition as part of the national program fail to meet their nutrient requirements that are essential for growth and development. The study results may help in strengthening the IYCF counselling and in modification of the existing THR, with quality and cost implications.

Association of Vitamin A Status With Under-Five Mortality in India

Objective: To re-estimate the survival benefit from Vitamin A supplementation (VAS) in India using meta-analysis and to correlate mortality and vitamin A deficiency (VAD) in children aged 6 month to 5 year. Methods: Pooled risk ratio (fixed effects model) for mortality reduction with VAS was calculated from available Indian studies. Computed mortality rates in 6 months to 5 years children in Indian states were regressed on VAD prevalence estimates of the states. Results: There was no reduction in risk of all-cause mortality with VAS (RR=0.96; 95% CI: 0.89, 1.03). When regressing mortality on VAD in high or low VAD prevalence states, the regression coefficients were discordant. Conclusion: No survival benefit was observed for VAS in India from the available literature. The targeting of VAS programs should be given serious consideration.

Indian Academy of Pediatrics Revised (2021) Guidelines on Prevention and Treatment of Vitamin D Deficiency and Rickets

Justification: The emerging literature on prevalence of vitamin D deficiency in India, prevention and treatment strategies of rickets, and extra-skeletal benefits of vitamin D suggest the need for revising the existing guidelines for prevention and treatment of vitamin D deficiency in India. Objectives: To review the emerging literature on vitamin D prevalence and need for universal vitamin D supplementation. To suggest optimum vitamin D therapy for treatment of asymptomatic and symptomatic vitamin D deficiency, and rickets. To evaluate the extra-skeletal health benefits of vitamin D in children. Process: A National consultative committee was formed that comprised of clinicians, epidemiologists, endocrinologists, and nutritionists. The Committee conducted deliberations on different aspects of vitamin D deficiency and rickets through ten online meetings between March and September, 2021. A draft guideline was formulated, which was reviewed and approved by all Committee members. Recommendations: The group reiterates the serum 25- hydroxy vitamin D cutoffs proposed for vitamin D deficiency, insufficiency, and sufficiency as <12 ng/mL, 12-20 ng/mL and >20 ng/mL, respectively. Vitamin D toxicity is defined as serum 25OHD >100 ng/mL with hypercalcemia and/or hypercalciuria. Vitamin D supplementation in doses of 400 IU/day is recommended during infancy; however, the estimated average requirement in older children and adolescents (400-600 IU/day) should be met from diet and natural sources like sunlight. Rickets and vitamin D deficiency should be treated with oral cholecalciferol, preferably in a daily dosing schedule (2000 IU below 1 year of age and 3000 IU in older children) for 12 weeks. If compliance to daily dosing cannot be ensured, intermittent regimens may be prescribed for children above 6 months of age. Universal vitamin D supplementation is not recommended in childhood pneumonia, diarrhea, tuberculosis, HIV and non-infectious conditions like asthma, atopic dermatitis, and developmental disorders. Serum 25-hydroxy vitamin D level of >20 ng/mL should be maintained in children with conditions at high-risk for vitamin deficiency, like nephrotic syndrome, chronic liver disease, chronic renal failure, and intake of anticonvulsants or glucocorticoids.

Validity of Maternal Report of Birthweight in a Cohort Study and Its Implication on Low Birthweight Rate Using Simulations

Objective:Maternal recall of birthweight is a convenient and cost-effective way to obtainbirthweight measurements when official records are unavailable. It is important to assess thevalidity of maternal recall of birthweight before using these measurements to drawconclusions about a population. Methods:This is secondary analysis of data from a previouscohort study.We analyzed actual and reported birthweights of 200 mother-and-child pairsfrom Southern India. We validated maternal report of birthweight by generating correlationcoefficients, summary statistics, and Bland-Altman plots. We ran simulations to evaluatehow misclassification as low or normal birthweight changed with the mean birthweight of thecohort. Results:Reported birthweight was strongly correlated with actual birthweight(r=0.80, P<0.001); 55%, 78.5%, and 93% of subjects reported values within 50 g, 250 g, and500 g, respectively of actual birthweight. None of sociodemographic covariates wassignificantly associated with the accuracy of maternal recall of birthweight. 7.5% of childrenwere misclassified as either low or normal birthweight by reported birthweight. Simulationsrevealed that increasing the reported and actual birthweights by 500g reduces themisclassification rate from 7.5% to 1.5%. Conclusion:Maternal recall is a sufficientlyaccurate measure of actual birthweight. However, the distribution of actual birthweight in thepopulation must be taken into consideration when classifying babies as low or normalbirthweight, especially in populations where mean birthweight is close to 2500g

Daily Iron Requirements in Healthy Indian Children and Adolescents

Objective: This study aimed to define the estimated average requirement and therecommended dietary allowance of iron for Indian children and adolescents. Methods: TheEstimated average requirement was derived for children aged 1-17y, from the meanbioavailability-adjusted daily physiological iron requirement, which in turn was estimatedusing a factorial method. This consisted of mean daily iron losses from the body andadditional iron required for tissue growth and storage, while also defining the variance of eachfactor to derive the Recommended dietary allowance. Results: The estimated averagerequirement of iron for children ranged from 5.6 to 11.0 mg/d in children aged 1-9y. Foradolescents aged 10-17y, these ranged from 10.8 to 18.4 mg/d and 15.4 to 18.5 mg/d foradolescent boys and girls, respectively. Conclusion: New estimates of estimated averagerequirement for iron in Indian children are presented, and same may be used to inform ironsupplementation and food fortification policies.

Potential of Probiotics in Hypercholesterolemia: A Meta‑analysis.

Human studies on the effects of probiotics on lowering blood cholesterol levels have not yielded conclusive results. A meta‑analysis of randomized controlled trials evaluating the effect of probiotics on lipid profile was conducted. Articles were reviewed systematically from web search bases; PubMed, Cochrane Clinical Trial Registry. Those studies which were meeting the inclusion criteria‑providing matching placebo, at least single blind for probiotics and placebo, providing mean and standard deviations and not involving the use of probiotics were selected. 14 studies from 12 randomized controlled trials were analyzed providing information of 606 normo/hypercholesterolemic patients using Review Manager 5.3 (The Cochrane Collaboration, Oxford, UK). The pooled mean net change for total cholesterol (TC) is −8.40 mg/dl (−13.63, −3.61), for low‑density lipoprotein (LDL) is −6.63 mg/dl (−10.63, −2.63), for high‑density‑lipoprotein‑cholesterol is 0.59 mg/dl (−0.92, 2.09), and for triglycerides is −1.32 mg/dl (−6.49, 3.85). The findings of the analysis conclude that probiotics supplementation does lower serum TC and LDL‑cholesterol levels significantly and hence a reduction in the risk factor of developing coronary heart disease.

A 4-compartment model based validation of air displacement plethysmography, dual energy X-ray absorptiometry, skinfold technique & bio-electrical impedance for measuring body fat in Indian adults.

Background & objectives: Many methods are available for measuring body fat of an individual, each having its own advantages and limitations. The primary objective of the present study was to validate body fat estimates from individual methods using the 4-compartment (4C) model as reference. The second objective was to obtain estimates of hydration of fat free mass (FFM) using the 4C model. Methods: The body fat of 39 adults (19 men and 20 women) aged 20-40 yr was estimated using air displacement plethysmography (ADP), dual energy X-ray absorptiometry (DEXA), 4-skinfold technique and bio-electrical impedance (BIA). Total body water was estimated using isotope dilution method. Results: All the methods underestimated body fat when compared to 4C model, except for DEXA and the mean difference from the reference was lowest for DEXA and ADP. The precision of the fat mass estimated from 4C model using the propagation of error was 0.25 kg, while the mean hydration factor obtained by the 4C model was found to be 0.74 ± 0.02 in the whole group of men and women. Interpretations & conclusion: The results of the present study suggest that DEXA and ADP methods can provide reasonably accurate estimates of body fat, while skinfold and bio-electrical impedance methods require the use of population specific equations.

Effect of iron status on iron absorption in different habitual meals in young south Indian women.

Background & objectives: Iron deficiency (ID) affects a large number of women in India. An inverse relationship exists between iron (Fe) status and Fe absorption. Dietary inhibitory and enhancing factors exert a profound influence on bioavailability of Fe. Although the current recommended dietary allowance (RDA) for Fe is based on 8 per cent bioavailability, it is not clear if this holds good for the usual highly inhibitory Indian diet matrix. This study was aimed to determine Fe absorption from several habitually consumed south Indian food and to evaluate the interaction of Fe status with absorption. Methods: Four Fe absorption studies were performed on 60 apparently healthy young women, aged 18-35 years. Based on blood biochemistry, 45 of them were ID and 15 were iron replete (IR). The habitual meals assessed were rice, millet and wheat based meals in the ID subjects and rice based meal alone in the IR subjects. Each subject received the test meal labelled with 3 mg of 57Fe and Fe absorption was measured based on erythrocyte incorporation of isotope label 14 days following administration. Results: Mean fractional Fe absorption from the rice, wheat and millet based meals in the ID subjects were 8.3, 11.2 and 4.6 per cent, respectively. Fe absorption from the rice-based meals was 2.5 per cent in IR subjects. Interpretation & conclusions: Fe absorption is dictated by Fe status from low bioavailability meals. Millet based meals have the lowest bioavailability, while the rice and wheat based meals had moderate to good bioavailability. In millet based meals, it is prudent to consider ways to improve Fe absorption.

Potential Factors Related to Waist Circumference in Urban South Indian Children.

Objectives: To identify important factors (linked to lifestyle, eating and sedentary behaviors) relating to waist circumference among urban South Indian children aged 3 to 16 years. Design: Cross sectional. Setting: Urban schools of Bangalore, from August 2008 to January 2010. Participants: 8444 children; 4707 children aged 3-10 years and 3737 children aged 10-16 years. Methods: Data were collected on the frequency of consumption of certain foods, physical activity patterns, sedentary habits at home, sleep duration and behaviors such as habits of snacking, skipping breakfast, eating in front of television and frequency of eating out. Simple linear regression analysis of waist circumference on various food items, physical activity, behavior and parental BMI were performed. A path model was developed to R E S E A R C H P A P E R identify potential causal pathways to increase in waist circumference. Results: Increased consumption of bakery items, non vegetarian foods, increased television viewing, decreased sleep duration, eating while watching television, snacking between meals, family meals, skipping breakfast (in older children), and parental BMI were found to be related to waist circumference. Older children possibly underreported their intake of “unhealthy” foods, but not behaviors. Conclusions: This study identified potential behaviors related to waist circumference in urban school children in India. Longitudinal studies with better measures of morbidity and adiposity are warranted in order to derive casual relationships between various determinants and waist circumference.

Vitamin B12 deficiency & levels of metabolites in an apparently normal urban south Indian elderly population.

Background & objectives: There is no published literature on the extent of vitamin B12 deficiency in elderly Indians as determined by plasma vitamin B12 levels and methylmalonic acid (MMA) levels. Vitamin B12 deficiency is expected to be higher in elderly Indians due to vegetarianism, varied socio-economic strata and high prevalence of Helicobacter pylori infection. We therefore, studied the dietary habits of south Indian urban elderly population and measured vitamin B12, MMA red cell folate and homocysteine (Hcy) levels. Methods: Healthy elderly urban subjects (175, >60 yr) were recruited. Detailed history, physical examination and neurological assessment were carried out. Food Frequency Questionnaire (FFQ) for dietary analysis for daily intake of calories, vitamin B12, folate and detailed psychological assessment for cognitive functions was carried out. Blood samples were analyzed for routine haematology and biochemistry, vitamin B12, red cell folate, MMA and Hcy. Results: The mean age of the study population was 66.3 yr. Median values for daily dietary intake of vitamin B12 and folate were 2.4 and 349.2 μg/day respectively. Sixty two (35%) participants consumed multivitamin supplements. Plasma vitamin B12 level and the dietary intake of vitamin B12 was significantly correlated (P=0.157). Plasma vitamin B12 and Hcy were inversely correlated (P= -0.509). Red cell folate was inversely correlated with Hcy (P= -0.550). Significant negative correlation was observed between plasma vitamin B12 and MMA in the entire study population (P= -0.220). Subjects consuming vitamin supplements (n=62) had significantly higher plasma vitamin B12 levels, lower MMA levels and lower Hcy levels. There was no significant correlation between plasma vitamin B12, MMA, Hcy and red cell folate and any of the 10 cognitive tests including Hindi Mental Status Examination (HMSE). Interpretation & conclusions: Our study is indicative of higher vitamin B12 (2.4 μg/day) intakes in urban south Indian population. Thirty five per cent of the study population consumed multivitamin supplements and therefore, low plasma vitamin B12 levels were seen only in 16 per cent of the study subjects. However, MMA was elevated in 55 per cent and Hcy in 13 per cent of the subjects.

Waist Circumference and Waist for Height Percentiles in Urban South Indian Children Aged 3-16 Years.

Objectives: To develop age and gender specific waist circumference references for urban Indian children aged 3 -16 years. Design: Cross-sectional study. Setting: Urban preschools and schools of Bangalore. Participants: 9060 children (5172 boys and 3888 girls) in the age group of 3-16 years. Methods: Weight, height, and waist circumference were measured using standard anthropometric methodology. Percentiles for waist circumference and Waist/height ratio (W/Ht) for each age and gender were constructed and smoothed using the LMS method. Results: Mean waist circumference increased with age for both girls and boys. The upper end of curve in boys continued to increase, whereas in the girls it tended to plateau at 14 years. The waist circumference of the Indian children from the present study was higher than age and sex matched European children. The proportion of children with W/Ht ratio greater than 0.5 decreased as their age increased. Conclusions: These curves represent the first waist and waist height ratio percentiles for Indian children and could be used as reference values for urban Indian children. We suggest that for a start, the 75th percentile of waist circumference from this study be used as an “action point” for Indian children to identify obesity (as a tautological argument), while retaining the cut-off of 0.5 for the W/Ht ratio; however this underlines the need to derive biologically rational cut-offs that would relate to different levels of risk for adult cardiovascular disease.

Longitudinal trends in physical activity patterns in selected urban south Indian school children.

Background & objectives: There are very few studies describing the pattern of physical activity of children in India. This study was carried out to document patterns of physical activity in south Indian school children aged 8 to 15 yr and examine changes over a one year period. Methods: Physical activity was assessed using interviewer-administered questionnaires at baseline (n=256) and at follow up (n=203) in 2006 and 2007. Frequency and duration of each activity was recorded and metabolic equivalents (MET) assigned. Sedentary activity included activities with MET < 1.5, and moderate-to- vigorous physical activity (MVPA) with >3.0. For each activity, daily duration, intensity (MET), and the product of the two (MET-minutes) were computed. Children were categorized by age group, gender and socio-economic status. Height and weight were measured. Results: At baseline, sedentary activity was higher in children aged >11 yr, while intensity of MVPA was higher in boys than girls. Over one year, physical activity at school significantly decreased (P<0.001). There was also a significant decrease in MVPA MET-min (P<0.001) with interaction effects of age group (P<0.001) and gender (P<0.001). Interpretation & conclusions: There was a significant decline in moderate-to-vigorous physical activity over a single year follow up, largely due to a decrease in physical activity at school. There appears to be a gap between State educational policies that promote physical well-being of school-going children and actual practice.

A pilot study on hyperinsulinaemic euglycaemic clamp based insulin sensitivity in young adult Indian males with low body mass index.

Background & objectives: Indians have decreased insulin sensitivity (IS) and a greater adiposity at a lower body mass index (BMI) when compared with other ethnic groups. Despite this, IS has not been studied in Indians of low BMI. This study thus used the hyperinsulinaemic euglycaemic clamp (HEC) technique to compare IS in young normal weight (NW) and low BMI (LBMI) Indian males. Clamp IS was also compared with convenient indices of insulin sensitivity such as the homeostatic model assessment (HOMA). In the NW group, clamp IS was compared with published data of similarly measured IS in other studies and ethnic groups. Methods: Ten NW [body mass index (BMI): 18.5-25 kg/m2] and ten LBMI (BMI < 18.5 kg/m2) young healthy Indian males aged between 19-32 yr were recruited through advertisements from Bangalore slums. Fasting plasma glucose and insulin, glucose disposal rates (GDR) and IS were the parameters measured during the HEC technique. Results: The NW group had a Clamp IS of 4.5 (3.8, 5.3) (median, lower, upper quartile, mg/(kg. min)/μU/ml) that was close to half that of the LBMI group; 9.9 (7.1, 13.4: P<0.001). Clamp IS in the NW group was significantly lower than that observed in published studies involving other ethnic groups (P<0.05). Clamp IS and per cent body fat (% BF), were significantly and negatively correlated (n=20, ρ = -0.7, P<0.001). Correlations between Clamp IS and other IS indices ranged from ρ = -0.5 for HOMA2-%B to ρ = 0.5 for HOMA2-%S (P<0.05); however, the correlation with HOMA1-IR was not significant (ρ = 0.4). Interpretation & conclusions: The significantly lower Clamp IS of the NW group compared with the LBMI group and other ethnic groups indicated that IS was impaired in Indians at relatively low BMIs. Most of the convenient indices of IS were significantly correlated with Clamp IS, however, the Clamp IS was more sensitive method with greater discriminatory power, since IS differences between LBMI and NW groups were only apparent with Clamp IS.

The requirements of protein & amino acid during acute & chronic infections.

Nutrition and infection interact with each other in a synergistic vicious cycle, leading to an adverse nutritional status and increased susceptibility to infection. Infectious episodes result in hypermetabolism and a negative nitrogen balance which is modulated by hormones, cytokines and other pro-inflammatory mediators, and is compounded by a reduced food intake. The extent of the negative nitrogen balance varies with the type of infection and its duration; however, it is reasonable to suggest that the loss of body protein could be minimized by the provision of dietary nitrogen, although anorexia will limit this. Further, distinctions need to be made about the provision of nutrients or protein during the catabolic and anabolic or recovery phase of the infection, since the capacity of the body to retain protein is enhanced in the anabolic recovery phase. Meeting the increased requirement for protein (and other nutrients) in infection does not imply a complete therapeutic strategy. Infections need to be treated appropriately, with nutrition as an adjunct to the treatment. Prior undernutrition could also impair the body's response to infection, although the weight of the evidence would suggest that this happens more particularly in oedematous undernutrition. In general, the amount of extra protein that would appear to be needed is of the order of 20-25 per cent of the recommended intake, for most infections. In acute infections, this is particularly relevant during the convalescence period. Community trials have suggested that lysine supplementation to the level required for normal daily nutriture, in predominantly wheat eating or potentially lysine deficient communities, improves immune function among other functional nutritional parameters; however, there is as yet insufficient evidence to suggest a specific requirement for amino acids in infections over and above the normal daily requirement as based on recent evidence. Some clinical studies that have showed benefits with specific amino acids through selected clinical outcomes, however, these do not provide enough evidence for a firm recommendation.

Use of rice bran oil in patients with hyperlipidaemia.

BACKGROUND: The quantity and type of dietary fat is known to affect plasma lipid concentration and hence the choice of cooking oil is important to lower the risk of coronary heart disease. Rice bran oil, which was not popular worldwide, is slowly being recognized as a 'healthy' oil in India. We assessed if rice bran oil had hypolipidaemic effects in subjects with elevated lipid levels. METHODS: The study had a cross-over design with subjects (n = 14) randomly assigned to consume either rice bran oil or refined sunflower oil in their homes, for a period of 3 months (period 1). After a washout period of 3 weeks, they were crossed over to the other oil (period 2). The serum lipid values were estimated at the beginning, on day 45 and day 90 of each phase. Additional parameters assessed included anthropometry, dietary and physical activity patterns. RESULTS: The use of rice bran oil significantly reduced plasma total cholesterol and triglyceride levels compared with sunflower oil. The reduction in plasma LDL-cholesterol with rice bran oil was just short of statistical significance (p = 0.06). HDL-cholesterol levels were unchanged. CONCLUSION: The use of rice bran oil as the main cooking oil significantly reduced serum cholesterol and triglyceride levels. The use of rice bran oil together with dietary and lifestyle modifications may have implications for reducing the risk of cardiovascular disease.

Primary prevention: why focus on children & young adolescents?

A focus on children and young adolescents in the primary prevention of health risks and disorders such as cancer, hypertension and other cardiovascular diseases, HIV/AIDS, and obesity has been suggested in many reports published throughout the world. Such a focus is important in India as it has a huge adolescents and children population along with the existing economic, social, and health inequalities among the general population. We propose a systematic elucidation of the rationale for such a focus in primary prevention research. We have reviewed studies describing risk factors, the association between risk factors and disease outcomes in affected patients, exposed populations, adolescent samples, as well as reports from studies conducted in India, and the quantitative and qualitative statistical aspects of research. The literature indicates that a lengthy time interval occurs between exposure to high risk factors and the development of disease, and that many such high risk exposures begin in young adolescence. These findings underline the value of targeting children and adolescents for primary prevention efforts in health care and health education for the attainment of overall healthy population in any country including a country like India.