Implementation, delivery, and utilization of iron fortified rice supplied through public distribution system across different states in India: An exploratory mixed-method study.

Food fortification with micronutrients is one of the cost-effective and sustainable methods to prevent micronutrient deficiencies at community level. The rice fortified with iron, folic acid, and vitamin B12 is being supplied through various social welfare schemes in India in a phased manner and planned to cover the entire country by March 2024. We have conducted a situational analysis to assess the rollout of fortified rice supplied through the Public Distribution System (PDS) and to evaluate the accessibility, availability, acceptability, and utilization of fortified rice by the beneficiaries of the PDS. This was a mixed-method, sequential exploratory study conducted in six districts from six different states of India that had begun distribution of fortified rice through PDS in pilot mode during 2020-2021. In each district, the district supply officer of the PDS, Food Corporation of India (FCI) or State Food Corporation (SFC) warehouse supervisor, and four Fair Price Shop (FPS) dealers were interviewed. Under each FPS, a minimum of seven beneficiary households were randomly selected and interviewed using a structured questionnaire. The in-depth interviews were conducted with different stakeholders using theme guides. All the interviewed stakeholders were aware about their roles and responsibilities and purpose to distribute fortified rice. There was a continuous supply of fortified rice (across all visited districts) to beneficiaries through a well-established system. Acceptability and compliance to intake of fortified rice was good with no reported gastrointestinal adverse outcomes following fortified rice intake. There was an efficient roll-out of fortified rice though PDS with a good compliance to intake of fortified rice. It is feasible to design and conduct a study to assess the impact of fortified rice on anemia and iron storage at the community level.

Impact of COVID-19 during pregnancy on placental pathology, maternal and neonatal outcome - A cross-sectional study on anemic term pregnant women from a tertiary care hospital in southern India.

Background: SARS-CoV-2 infection during pregnancy may cause adverse maternal, neonatal and placental outcomes. While tissue hypoxia is often reported in COVID-19 patients, pregnant women with anemia are suspected to be more prone to placental hypoxia-related injuries. Methods: This hospital-based cross-sectional study was conducted between August-November 2021, during COVID-19 second wave in India. Term pregnant women (N=212) admitted to hospital for delivery were enrolled consecutively. Since hospital admission mandated negative RT-PCR test for SARS-CoV-2 virus, none had active infection. Data on socio-demography, COVID-19 history, maternal, obstetric, and neonatal outcomes were recorded. Pre-delivery maternal and post-delivery cord blood samples were tested for hematological parameters and SARS-CoV-2 IgG. Placentae were studied for histology. Results: Of 212 women, 122 (58%) were seropositive for SARS-CoV-2 IgG, but none reported COVID-19 history; 134 (63.2%) were anemic. In seropositive women, hemoglobin (p=0.04), total WBC (p=0.009), lymphocytes (p=0.005) and neutrophils (p=0.02) were significantly higher, while ferritin was high, but not significant and neutrophils to lymphocytes (p=0.12) and platelets to lymphocytes ratios (p=0.03) were lower. Neonatal outcomes were similar. All RBC parameters and serum ferritin were significantly lower in anemic mothers but not in cord blood, except RDW that was significantly higher in both, maternal (p=0.007) and cord (p=0.008) blood from seropositive anemic group compared to other groups. Placental histology showed significant increase in villous hypervascularity (p=0.000), dilated villous capillaries (p=0.000), and syncytiotrophoblasts (p=0.02) in seropositive group, typically suggesting placental hypoxia. Maternal anemia was not associated with any histological parameters. Univariate and multivariate logistic regression analyses of placental histopathological adverse outcomes showed strong association with SARS-CoV-2 seropositivity but not with maternal anemia. When adjusted for several covariates, including anemia, SARS-CoV-2 seropositivity emerged as independent risk factor for severe chorangiosis (AOR 8.74, 95% CI 3.51-21.76, p<0.000), dilated blood vessels (AOR 12.74, 95% CI 5.46-29.75, p<0.000), syncytiotrophoblasts (AOR 2.86, 95% CI 1.36-5.99, p=0.005) and villus agglutination (AOR 9.27, 95% CI 3.68-23.32, p<0.000). Conclusion: Asymptomatic COVID-19 during pregnancy seemed to be associated with various abnormal placental histopathologic changes related to placental hypoxia independent of maternal anemia status. Our data supports an independent role of SARS-CoV-2 in causing placental hypoxia in pregnant women.

Challenges in Accessing and Delivering Maternal and Child Health Services during the COVID-19 Pandemic: A Cross-Sectional Rapid Survey from Six States of India.

BACKGROUND/OBJECTIVES: Globally, the COVID-19 pandemic and its prevention and control policies have impacted maternal and child health (MCH) services. This study documents the challenges faced by patients in accessing MCH services, and the experiences of health care providers in delivering those services during the COVID-19 outbreak, explicitly focusing on the lockdown period in India. METHODS: A cross-sectional study (rapid survey) was conducted in 18 districts from 6 states of India during March to June, 2020. The sample size included 540 MCH patients, 18 gynaecologists, 18 paediatricians, 18 district immunisation officers and 108 frontline health workers. Bivariate analysis and multivariable analysis were used to assess the association between sociodemographic characteristics, and challenges faced by the patients. RESULTS: More than one-third of patients (n = 212; 39%) reported that accessing MCH services was a challenge during the lockdown period, with major challenges being transportation-related difficulties (n = 99; 46%) unavailability of hospital-based services (n = 54; 23%) and interrupted outreach health services (n = 39; 18.4%). The supply-side challenges mainly included lack of infrastructural preparedness for outbreak situations, and a shortage of human resources. CONCLUSIONS/RECOMMENDATIONS: A holistic approach is required that focuses on both preparedness and response to the outbreak, as well reassignment and reinforcement of health care professionals to continue catering to and maintaining essential MCH services during the pandemic.

Developing and demonstrating an atomistic and holistic model of anthropometric failure among children under five years of age using the National Family Health Survey (NFHS)-5 data from India.

Introduction: Composite Index of Anthropometric Failure (CIAF) and its further modifications have not incorporated all the combinations of malnutrition. We propose a new model incorporating all the forms of malnutrition among children under five years of age. However, the current models might misclassify a growing child as malnourished. Our objective is to develop a comprehensive scoring system using the three anthropometric Z-scores [height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) Z-scores] and demonstrate the proposed CIAF model using the National Family Health Survey-5 (NFHS-5) data from India. Methods: A new scoring system was developed using the WAZ, HAZ, and WHZ scores to determine the child's nutritional status. We also proposed a new CIAF model by including all possible categories of malnutrition and practically demonstrated it using the NFHS-5 dataset after applying the new scoring system. Under-five children with heights, weights, and ages available were included in the analysis. The groups of malnutrition are presented as weighted proportions before and after applying the new score to the proposed model. Results: Our final analysis included individual-level data of 198,802 children under five years of age (weighted N = 195,197). After applying the new scoring system to the proposed model, the prevalence of stunting has reduced to 11.8% (95% CI 11.66-11.94) from 13.2% (95% CI 13.09-13.39) and wasting prevalence has reduced to 4.9% (95% CI 4.85-5.04) from 6.4% (95% CI 6.29-6.51). The most common forms of anthropometric failures among Indian children by using the newly developed CIAF model are: "Stunting and underweight" (30,127; 15.4%), Stunting only (23,035; 11.8%), and "wasting and underweight" (14,698; 7.5%). We found a new category called "Stunting, underweight, and overweight" (stunting = HAZ < -2SD, underweight = WAZ < -2SD, overweight = WHZ > +2SD). It constituted 0.1% (220 children) of the total sample. Conclusion: When the new scoring system is applied to the proposed CIAF model, it captures all forms and combinations of malnutrition among under-five children without overlap and prevents misclassifying a growing child as malnourished. The newly identified category shows that stunting (HAZ < -2SD), overweight (WHZ > +2SD) and underweight (WAZ < -2SD) can co-exist in the same child.

Maternal Nutrition, Body Composition and Gestational Weight Gain on Low Birth Weight and Small for Gestational Age-A Cohort Study in an Indian Urban Slum.

Maternal nutritional status and care during pregnancy are essential for adequate birth weight. In this prospective cohort study (N = 1061) in an urban slum, we investigated the association of maternal anthropometry, body composition, gestational weight gain and dietary intakes with low birthweight (LBW, <2.5 kg). About one-third of the women were short (<150 cm), 35% were underweight (<45 kg), 23% suffered from chronic energy deficiency (CED, BMI < 18.5 kg/m2) and another 30% were overweight/obese. The mean age and BMI were 23 years and 21.7 kg/m2, respectively, and haemoglobin was 10.73 g/dL. The mean birthweight (N = 605) was 2.81 ± 0.5 kg, and the average gestational age was 38 ± 2 weeks. About 15% of infants had LBW, and 48% were small for gestational age (SGA). Maternal body composition was assessed by skinfold thickness (SFT) in all trimesters. In the first trimester (N = 762), we found that mean fat-free mass (FFM), fat mass (FM) and body fat percentage (% BF) were 38.86 kg, 11.43 kg and 21.55%, respectively. Low birthweight was significantly associated with preterm deliveries (p < 0.001) and less fat free mass (p = 0.02) in the third trimester. Among other factors were age (p = 0.017), maternal anthropometry (height: p = 0.031; weight: p = 0.059) and fewer antenatal check-ups (p = 0.037). Small size (SGA) was consistently associated with maternal bodyweight at all trimesters (term I, p = 0.013, term II, p = 0.003 and term III, p < 0.001), fat mass in the third trimester (p < 0.001) and maternal height (p = 0.003).

Burden and Predictors of Malnutrition Among Indian Adolescents (10-19 Years): Insights From Comprehensive National Nutrition Survey Data.

Introduction: Malnutrition among adolescents is a persistent problem with a profound impact on different dimensions of health. The objective of this analysis is to assess the burden of malnutrition (Stunting, Thinness, Overweight, and Obesity) and their associated socio-demographic factors among Indian adolescents (10-19 years) from the Comprehensive National Nutritional Survey (CNNS 2016-18) data. Methods: We used Individual-level data of 35,831 adolescents from the CNNS conducted in 2016-18 for this analysis. CNNS collected data on the nutritional status of adolescents along with socio-demographic variables from all states of India. Burden of stunting (Height for age Z score, HAZ < -2 SD), thinness (BMI for age Z score, BAZ < -2 SD), overweight (BAZ > 1 SD) and obesity (BAZ > 2 SD) were estimated for the entire country and individual states. A multivariable logistic regression analysis was used to assess the socio-demographic factors associated with stunting, thinness, and overweight. Results: CNNS collected data from 35,831 adolescents, of which 31,941 with BAZ scores, and 32,045 with HAZ scores were included in the final analysis. The burden of stunting and thinness among Indian adolescents was 27.4% (95% CI 26.4, 28.4%) and 24.4% (23.5, 25.4%), respectively. The burden of overweight and obesity was 4.8% (4.5, 5.1%) and 1.1% (0.9, 1.3%), respectively. Adolescents in the age group of 15-19 years (AOR 1.23, 95% CI 1.11, 1.36) compared to 10-14 years, females (AOR 1.20; 1.08, 1.33) compared to males, were at increased odds of getting stunted. Adolescents from lowest wealth index families (AOR 1.66; 1.33, 2.07) were at increased odds of thinness compared to peers of higher wealth index families. Adolescents of 10-14 years (AOR 1.26, 95% CI 1.06, 1.49) compared to 15-19 years, urban residents (AOR 1.43, 95% CI 1.19, 1.71) compared to rural residents, were at increased odds of overweight. Conclusion: Indian adolescents face the double burden of malnutrition that is undernutrition (stunting and thinness) alongside overnutrition (overweight and obesity) that are linked with socio-demographic factors. The National Nutritional Programs (POSHAN Abhiyan) should prioritize high-risk groups specifically older age group (15-19 years), females, and low wealth Index quintile families identified in this analysis.

Investigation of an acute neurological outbreak in Eluru, India, 2020.

On 4th December 2020, a sudden outbreak, with neurological symptoms like seizures, loss of consciousness etc., was reported in a town from south India. By 3rd day about 400 people were involved. A multi disciplinary team from our institute visited the site to investigate the outbreak. Based on the case history and clinical examination of the patients, the team suspected a probable diagnosis of an acute pesticide, heavy metal and/or mycotoxin exposure for which, biological samples (blood, urine) were collected from those who reported the symptoms as well as from a few who did not report symptoms (controls). To identify the source, water and food samples were collected. The samples were subjected to ICP-MS for heavy metal analysis, LC-MS/MS for pesticide analysis, microbiological analysis and ELISA-Kit method for aflatoxins if any. Clinical and dietary details were collected from a total of 112 participants, of which, 103 cases (77 active cases at Hospital and 26 recovered cases from community) and 9 were controls. A total of 109 biological samples, 36 water samples and food samples were collected. The mean age of the study participants was 29.2 years. Among cases, Seizures were seen in 84%, loss of consciousness in 66%, mental confusion in 35%, pinpoint pupil in 11%. Triazophos (organophosphate) pesticide was present in 74% of Blood samples and its metabolites were present in 98% of the urine samples collected from the cases. All the ten heavy metals investigated including lead, mercury and nickel were found to be within permissible limits except for a few samples. No presence of mycotoxins was observed in Food samples. Water samples which included Head pump and reservoir were free from pesticides; however, all water samples from households of cases had triazophos pesticide with a mean concentration of 1.00 ug/L. Thus, it was concluded that, the probable cause of outbreak was Triazophos (Organophosphate) pesticide contamination in water at the Household level. Regular surveillance for the presence of residual pesticides in soil, water and food with heightened vigour is recommended to prevent future outbreaks.

Omega-3 polyunsaturated fatty acid intake and plasma fatty acids of school going Indian children - a cross-sectional study.

Long-chain omega-3 polyunsaturated fatty acids (PUFA) such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) play an essential role in cognitive and behavioural changes among school going children. This study delineates the dietary omega-3 PUFA [alpha-Linolenic acid (ALA), DHA, and EPA] intake and plasma fatty acids levels among school-going children. This is a cross-sectional study purely observational in nature, wherein 625 apparently healthy boys and girls aged between 7 and 13 years were selected from five different schools of Hyderabad. Dietary information on omega-3 PUFA (ALA, DHA, and EPA) intake was collected using a food frequency questionnaire. Plasma fatty acid concentrations were measured in 34% of sub-sample using standard gas chromatography. The study revealed that the average dietary intakes of omega-3 PUFA, ALA, DHA, and EPA were 55.46, 15.82, 35.59, 4.06 mg/day, respectively. There was a significant difference in mean DHA intake among gender and age group [girls (38.64±1.45 mg/day), boys (31.80±1.38 mg/day) p < 0.001] and [7-10 years (31.75±1.38 mg/day), 11-13 years (38.07±1.40 mg/day) p < 0.01]. The mean plasma DHA and DPA levels of overall subjects were 0.98 nmol% and 0.18nmol% respectively which was comparable among different gender, age and BMI-for age groups. There was a positive correlation between dietary DHA intake and plasma DHA level [ρ=0.376 (p < 0.001)]. The current study demonstrated that the omega-3 PUFA intake in school going children was less and reinforces the importance of increasing the omega-3 PUFA intake through diet and supplements.

Effect of Yoganidra on Blood Pressure, Hs-CRP, and Lipid Profile of Hypertensive Subjects: A Pilot Study.

BACKGROUND: Yoganidra is a systematic method of promoting a state of complete physical, mental, and emotional relaxation. It is a safe, inexpensive, and very effective method of management of hypertension when used along with standard pharmacological therapy. This study aims to assess the effect of yoganidra on blood pressure (both systolic blood pressure (SBP) and diastolic blood pressure (DBP)), Hs-CRP, and lipid profile of hypertensive subjects at the time of enrollment (subjects that are hypertensive at the time of enrollment). METHODS: Both treated and untreated subjects (n = 74) with hypertension (blood pressure ≥140/90 mmHg) and age between 35 and 70 years were included in this study after obtaining ICMR-NIN-IEC approval and written informed consent from all subjects. Subjects with critical illness and/or psychological disturbances were excluded from this study. The subjects in the experimental group (n = 31) practiced yoganidra for 45 minutes daily for 12 weeks under strict supervision. There was no intervention in the control group (n = 43). Weekly blood pressure was recorded in the experimental group, whereas it was performed at baseline and at endpoint for control groups. Hs-CRP and lipid profile were estimated at baseline and endpoint for both the groups. RESULTS: A significant reduction in mean SBP from 142.9 mm Hg (SD ± 16.46) to 118.68 mm Hg (SD ± 9.21; p value 0.0001) and DBP from 89.84 mm Hg (SD ± 10.42) to 77.03 mm Hg (SD ± 6.47: p value 0.0001) was observed among the experimental group after 12 weeks of yoganidra practice when compared with the control group. A significant reduction in mean Hs-CRP (2.21 ± 1.49 to 1.06 ± 0.82 mg/L, p < 0.001 ∗∗∗ ) was observed among the experimental group. There were no significant differences between triglycerides and total cholesterol levels, whereas LDL-C and HDL-C showed a trend of improvement in the experimental group after intervention. CONCLUSIONS: In this pilot study, we observed a significant reduction in blood pressure and Hs-CRP in the yoganidra group compared with the control group. There were no significant side effects observed in the intervention group during the study period.

Effectiveness of zinc supplementation to full term normal infants: a community based double blind, randomized, controlled, clinical trial.

UNLABELLED: The study was aimed to test whether zinc supplementation, if initiated early, can prevent stunting and promote optimum body composition in full term infants. For this, full term pregnant women from low income urban community were enrolled and were followed-up for 24 months postpartum. Body mass index (BMI) was calculated from maternal weight and height that were collected one month after delivery. Infants' weight, and length, head, chest and mid upper arm circumferences and skin fold thicknesses at triceps, biceps and subscapular area were collected at baseline (before randomization) and once in three months up till 24 months. Three hundred and twenty four infants were randomized and allocated to zinc (163) or placebo (161) groups respectively. Supplementation of zinc was initiated from 4 months of age and continued till children attained 18 months. The control (placebo) group of children received riboflavin 0.5 mg/day, whereas the intervention (zinc) group received 5 mg zinc plus riboflavin 0.5 mg/day. When infants were 18 months old, dietary intakes (in 78 children) were calculated by 24 hour diet recall method and hemoglobin, zinc, copper and vitamin A were quantified in blood samples collected from 70 children. The results showed prevalence of undernutrition (body mass index <18.5) in 37% of the mothers. Mean±SD calorie consumption and zinc intakes from diets in infants were 590±282.8 Kcal/day and 0.97±0.608 mg/day respectively. Multiple linear regression models demonstrated maternal weight as a strong predictor of infants' weight and length at 18 months of age. As expected, diarrhea duration impacted infants' linear growth and weight gain adversely. Zinc supplementation for a mean period of 190 days, starting from 4 months up to 18 months of age, in full term normal infants, consuming an average energy of 590 Kcal/day, had significant effect on the skin fold thicknesses, but not on their linear growth. TRIAL REGISTRATION: Clinical Trail Registration India (CTRI) CTRI/2012/08/002884.