The effect of a 1-year multiple micronutrient or n-3 fatty acid fortified food intervention on morbidity in Indian school children.

BACKGROUND/OBJECTIVES: Few studies have shown that supplementation with micronutrients (MNs) or n-3 fatty acids may have health benefits such as reduced morbidity in schoolchildren. The effect of a combination of these nutrients has never been investigated. This study aimed to determine the effect of a combination of two different doses of MN and n-3 fatty acids on morbidity in schoolchildren in Bangalore, India. SUBJECTS/METHODS: In all 598 children (6-10 years) received foods fortified with either high (100% recommended dietary allowance) or low (15% recommended dietary allowance) MN, combined with either high (900 mg α-linolenic acid (ALA) plus 100 mg docosahexaenoic acid) or low (140 mg ALA) n-3 fatty acids for 1 year. Morbidity was measured by weekly self-reports using a structured questionnaire. Poisson regression analyses of episodes/child/year and duration/episode adjusted for age and sex were performed on clusters of symptoms, including upper and lower respiratory tract infections (URTI and LRTI), gastrointestinal complaints (GI) and general symptoms of illness to observe MN and n-3 fatty acid treatment effects. RESULTS: Children consuming high n-3 fatty acids had significantly fewer episodes of URTI/child/year (relative risk (RR)=0.88, 95% confidence interval (CI): 0.79, 0.97) and significantly shorter duration/episode of URTI (RR=0.81, 95% CI: 0.78, 0.85), LRTI (RR=0.91, 95% CI: 0.85, 0.97), GI complaints (RR=0.79, 95% CI: 0.74, 0.85) and general symptoms (RR=0.90, 95% CI: 0.82, 0.98) compared with children who received low n-3 fatty acid intervention. The high MN intervention reduced the duration of general symptoms (RR=0.89, 95% CI: 0.82, 0.98). CONCLUSION: Although n-3 fatty acids may be beneficial for reducing illness in Indian schoolchildren, more research is needed to confirm presence of combined effect with MN.

Helicobacter pylori infection does not influence the efficacy of iron and vitamin B(12) fortification in marginally nourished Indian children.

BACKGROUND/OBJECTIVES: Helicobacter pylori infection and iron and vitamin B(12) deficiencies are widespread in economically disadvantaged populations. There is emerging evidence that H. pylori infection has a negative effect on the absorption of these micronutrients. The aim of this study was to evaluate the effect of H. pylori infection on the efficacy of micronutrient (including iron and vitamin B(12))-fortified foods supplied for 1 year in marginally nourished children. SUBJECTS/METHODS: In all, 543 Indian children, aged 6-10 years, participated in a double-blind, randomized controlled intervention trial, receiving foods fortified with either high (100% Recommended Dietary Allowances (RDA)) or low (15% RDA) amounts of iron, vitamin B(12) and other micronutrients. The presence of H. pylori infection was diagnosed by the (13)C-labeled urea breath test at 11 months after the start of the intervention. Blood hemoglobin, serum ferritin (SF), total body iron and plasma vitamin B(12) were estimated at baseline and 12 months, and differences between these time points were assessed using an independent t-test. RESULTS: Overall, the prevalence of H. pylori infection in this group of children was 79%. Baseline hemoglobin, SF, body iron and vitamin B(12) concentrations were not associated with H. pylori infection. The response to the intervention (either high or low amounts of iron and vitamin B(12) fortification) in terms of change in iron markers and vitamin B(12) status did not differ between children with and without H. pylori infection. CONCLUSIONS: This study shows that the presence of H. pylori infection did not affect the efficacy of long-term iron and vitamin B(12) fortification in these marginally nourished children.

Childhood cognitive ability: relationship to gestational diabetes mellitus in India.

AIMS/HYPOTHESIS: Our aim was to test the hypothesis that gestational diabetes mellitus (GDM) in mothers is associated with poorer cognitive ability in their offspring in India. METHODS: During 1997 to 1998 maternal GDM status was assessed by OGTT at 30 +/- 2 weeks of gestation. Between 2007 and 2008, at a mean age of 9.7 years, 515 children (32 offspring of GDM mothers [ODM]; 483 offspring of non-GDM mothers [controls]) from the Mysore Parthenon birth cohort underwent cognitive function assessment using tests from the Kaufman Assessment Battery for Children--Second Edition and additional tests measuring learning, long-term storage/retrieval, short-term memory, reasoning, attention and concentration, and visuo-spatial and verbal abilities. RESULTS: Compared with controls, ODM scored higher in tests for learning, long-term retrieval/storage (p = 0.008), reasoning (p = 0.02), verbal ability (p = 0.01), and attention and concentration (p = 0.003). In multiple regression, adjusted for the child's age, sex, gestation, neonatal weight and head circumference, maternal age, parity and BMI, and the parent's socioeconomic status, education and rural/urban residence, this difference remained significant only for learning, long-term retrieval/storage (beta = 0.4 SD (95% CI 0.01-0.75); p = 0.04) and verbal ability (beta = 0.5 SD (95% CI 0.09-0.83); p = 0.02), and not with other test scores. CONCLUSIONS/INTERPRETATION: In this population of healthy Indian children, there was no evidence of lower cognitive ability in ODM. In fact some cognitive scores were higher in ODM.

Glucose kinetics and pregnancy outcome in Indian women with low and normal body mass indices.

BACKGROUND/OBJECTIVES: Fetal energy demands are met from the oxidation of maternally supplied glucose and amino acids. During the fasted state, the glucose supply is thought to be met by gluconeogenesis. Underweight women with low body mass index (BMI) might be unable to adequately supply amino acids to satisfy the demands of gluconeogenesis. SUBJECTS/METHODS: Glucose kinetics were measured during the first and second trimesters of pregnancy in 10 low-BMI and 10 normal-BMI pregnant women at the 12th hour of an overnight fast using a primed 6 h U-(13)C glucose infusion and was correlated to maternal dietary and anthropometric variables and birth weight. RESULTS: Low-BMI mothers consumed more energy, carbohydrates and protein, had faster glucose production (R (a)) and oxidation rates in the first trimester. In the same trimester, dietary energy and carbohydrate correlated with glucose production, glycogenolysis and glucose oxidation in all women. Both groups had similar rates of gluconeogenesis in the first and second trimesters. Glucose R (a) in the second trimester was weakly correlated with the birth weight (r=0.4, P=0.07). CONCLUSIONS: Maternal energy and carbohydrate intakes, not BMI, appear to influence glucose R (a) and oxidation in early and mid pregnancy.

In vivo arginine production and nitric oxide synthesis in pregnant Indian women with normal and low body mass indices.

BACKGROUND/OBJECTIVES: Nitric oxide (NO) has been proposed as a mediator of vascular expansion during pregnancy. Inability to increase NO synthesis and/or production of its precursor, arginine, may be a contributor to pregnancy-induced hypertension or preeclampsia. Because maternal weight is associated with blood pressure and risk of preeclampsia during pregnancy, it may also influence arginine and/or NO production. The purpose of this study was to determine the in vivo arginine production and NO synthesis rate in pregnant women with normal (n=10) and low (n=10) body mass indices (BMIs). SUBJECTS/METHODS: Arginine flux and NO synthesis rate were measured in the postabsorptive state with constant infusions of 15N2-arginine and 13C,2H4-citrulline. Plasma concentrations of arginine and NO metabolites were also measured. Kinetic parameters were correlated to maternal variables, gestational age, birth weight and blood pressure. RESULTS: Endogenous arginine flux was significantly faster in the low-BMI compared with normal-BMI women in the first trimester (63.1+/-3.4 vs 50.2+/-2.0 micromol/kg per h, P<0.01), but not in the second. Plasma NO concentration was higher (44.7+/-5.3 vs 30.4+/-1.9 micromol/l, P=0.03) and its rate of synthesis trended faster in the low-BMI compared with normal-BMI group in the second trimester. Maternal weight and BMI were negatively correlated with arginine flux in both trimesters and NO synthesis in the second trimester. CONCLUSIONS: These findings suggest, but do not prove, that maternal BMI may be a factor in the ability to produce NO during pregnancy and may be one way by which BMI influences blood pressure during pregnancy.

The effect of fish and omega-3 LCPUFA intake on low birth weight in Indian pregnant women.

BACKGROUND: Inadequate consumption of fish could be a risk factor for low birth weight (LBW). This study assessed fish intake and omega-3 LCPUFA intake and status for their association with LBW in a cohort of urban, south Indian pregnant women. SUBJECTS/METHODS: In a prospective cohort study, data on maternal fish intake and omega-3 LCPUFA intake and status of 676 women were obtained at baseline (first trimester), the second and third trimesters of pregnancy. Infant birth weight was measured immediately following hospital delivery. The dropout rate was 7.6%. RESULTS: Fifty-six percent of the study women consumed fish with low daily median intakes (3.4, 4.1 and 3.8 g day(-1) at the three trimesters, respectively). Consequently, the median intakes of EPA and DHA during pregnancy were also low at 2.1 and 10.1 mg day(-1), respectively. EPA and DHA intakes were associated with their status in erythrocyte membrane phospholipids during pregnancy (r=0.40 and 0.36, r=0.34 and 0.32 and r=0.37 and 0.41, at the three trimesters, respectively, all P<0.001). Women who did not eat fish during the third trimester had a significantly higher risk of LBW (OR: 2.49, P=0.019). Similarly, low EPA intake during the third trimester had an association with a higher risk of LBW (OR: 2.75, P=0.011). CONCLUSIONS: Among low fish-eating pregnant women, fish intake in the third trimester was closely associated with birth weight. Supplementation with omega-3 LCPUFA during pregnancy may have important implications for fetal development in India.

Adiposity in women and children from transition countries predicts decreased iron absorption, iron deficiency and a reduced response to iron fortification.

BACKGROUND: Overweight is increasing in transition countries, while iron deficiency remains common. In industrialized countries, greater adiposity increases risk of iron deficiency. Higher hepcidin levels in obesity may reduce dietary iron absorption. Therefore, we investigated the association between body mass index (BMI) and iron absorption, iron status and the response to iron fortification in populations from three transition countries (Thailand, Morocco and India). METHODS: In Thai women (n=92), we examined the relationship between BMI and iron absorption from a reference meal containing approximately 4 mg of isotopically labeled fortification iron. We analyzed data from baseline (n=1688) and intervention (n=727) studies in children in Morocco and India to look for associations between BMI Z-scores and baseline hemoglobin, serum ferritin and transferrin receptor, whole blood zinc protoporphyrin and body iron stores, and changes in these measures after provision of iron. RESULTS: In the Thai women, 20% were iron deficient and 22% were overweight. Independent of iron status, a higher BMI Z-score was associated with decreased iron absorption (P=0.030). In the Indian and Moroccan children, 42% were iron deficient and 6.3% were overweight. A higher BMI Z-score predicted poorer iron status at baseline (P<0.001) and less improvement in iron status during the interventions (P<0.001). CONCLUSIONS: Adiposity in young women predicts lower iron absorption, and pediatric adiposity predicts iron deficiency and a reduced response to iron fortification. These data suggest the current surge in overweight in transition countries may impair efforts to control iron deficiency in these target groups. Interactions of the 'double burden' of malnutrition during the nutrition transition may have adverse consequences.

Nutritional status of affluent Indian school children: what and how much do we know?

OBJECTIVE: This paper reviews available literature on nutritional status of Indian school children 6-18 years from middle and high socio economic status (MHSES). METHODS: Literature search was conducted using Medline literature database search, followed by review of full length journal papers and unpublished materials such as research reports. RESULTS: Studies showed that anemia prevalence (hemoglobin concentration <120 g/L) ranged from 19 to 88% across five different cities in India. Other micronutrient deficiencies including, folate, riboflavin, niacin, vitamin C, vitamin A, and vitamin B12 were also present based on biochemical parameters in one study and clinical signs of deficiency in three other studies. Overweight and obesity were prevalent among 8.5-29.0% and 1.5-7.4% respectively among school children, as indicated by 11 studies. Predominant components in children's diet were cereals and pulses, followed by milk and milk products; the fruits and vegetables component was comparatively lower. CONCLUSION: Nutritional status of MHSES children in India needs attention especially with respect to the high prevalence of anemia, overweight and obesity. There are indications that micronutrient deficiencies exist, but sufficient data are lacking, in particular biochemical data. A current estimate, using well designed methodologies, of prevalence of micronutrient deficiencies and information on the etiology of anemia among children of MHSES groups would be valuable to help understand the nutritional status and extent of micronutrient malnutrition.

Low anemia prevalence in school-aged children in Bangalore, South India: possible effect of school health initiatives.

OBJECTIVE: Anemia is a serious public health problem in Indian school children. Since 2003, simple health intervention programs such as antihelminthic treatment and vitamin A supplementation have been implemented in primary schools in the Bangalore region, Karnataka, India. This study examines the prevalence of anemia in school children who are beneficiaries of this program. DESIGN: Cross-sectional survey. SETTING: Bangalore district, South India. SUBJECTS: A total of 2,030 boys and girls, aged 5-15 years, attending schools in the Bangalore district. INTERVENTIONS: School-based, twice yearly intervention: deworming (albendazole 400 mg, single oral dose) and vitamin A supplementation (200,000 IU, single oral dose). MAIN OUTCOME MEASURES: Anemia prevalence based on measure of blood hemoglobin (Hb). RESULTS: Mean age and blood Hb concentration of all children were 9.5+/-2.6 years and 12.6+/-1.1 g/dl (range 5.6-16.7), respectively. The overall anemia prevalence in this group was 13.6%. Anemia prevalence was lower in boys than girls (12.0%; n=1037 vs 15.3%; n=993 respectively, P<0.05). There was no significant difference in anemia prevalence between children in urban and rural locations (14.6 and 12.3%, respectively). CONCLUSIONS: The current low anemia prevalence in Bangalore could be due to the impact of school-based intervention programs that have been in place since 2003. The beneficial interactions of deworming and vitamin A supplementation could have widespread implications for current preventive public health initiatives. There is now need for the development of clear policy guidelines based on these simple and integrated interventions.

The relationship of neonatal serum vitamin B12 status with birth weight.

Earlier studies have shown a relationship between maternal vitamin B12 status and birth weight. This study extends those findings directly in terms of neonatal vitamin B12 status and birth weight. One hundred and twelve women were followed from the first trimester of pregnancy and maternal blood was obtained in all three trimesters along with cord blood at birth of their neonates. The maternal and cord serum vitamin B12 concentrations were examined in relation to birth weight. There was a significant correlation between vitamin B12 concentration in maternal antenatal serum during each of the trimesters of pregnancy and cord serum (all P< 0.01). Neonates that were born with lower birth weights (categories of <2500 g and 2500-2999g) had significantly lower mean cord serum vitamin B12 concentrations when compared to those who were > or = 3000g (P = 0.02 and P = 0.05 respectively). A similar, however, non significant trend was observed for antenatal vitamin B12 concentrations at first and third trimesters. Cord serum vitamin B12 concentrations were significantly correlated with birth weight, up to 40 weeks of pregnancy (r=0.28, P=0.01) but not beyond that (> or =40 weeks gestation). Vitamin B12 status in the mother was related to neonatal vitamin B12 status as measured by cord serum vitamin B12 concentration. In addition, low neonatal vitamin B12 concentrations were adversely associated with low birth weights.

Anthropometry and body composition of south Indian babies at birth.

OBJECTIVES: To assess the consequences on body composition of increasing birth weight in Indian babies in relation to reported values in Western babies, and to assess the relationship between maternal and neonatal anthropometry and body composition. DESIGN: Prospective observational study. SETTING: Bangalore City, India. SUBJECTS: A total of 712 women were recruited at 12.5+/-3.1 weeks of gestation (mean+/-standard deviation, SD) and followed up until delivery; 14.5% were lost to follow-up. Maternal body weight, height, mid upper-arm circumference and skinfold thicknesses were measured at recruitment. Weight and body composition of the baby (skinfold thicknesses, mid upper-arm circumference, derived arm fat index and arm muscle index; AFI and AMI, respectively) were measured at birth in hospital. RESULTS: The mean+/-SD birth weight of all newborns was 2.80+/-0.44 kg. Birth weight was significantly related to the triceps and subscapular skinfold thickness of the baby. In a small number of babies with large birth weight for gestational age, there was a relatively higher normalised AFI relative to AMI than for babies with lower or appropriate birth weight for gestational age. Maternal height and fat-free mass were significantly associated with the baby's length at birth. CONCLUSIONS: Skinfold thicknesses in Indian babies were similar to those reported in a Western population with comparable birth weights, and the relationship of AFI to birth weight appeared to be steeper in Indian babies. Thus, measures to increase birth weight in Indian babies should take into account possible adverse consequences on body composition. There were no significant relationships between maternal anthropometry and body composition at birth on multivariate analysis, except for sum of the baby's skinfold thicknesses and maternal fat-free mass (P<0.02).

Low maternal vitamin B12 status is associated with intrauterine growth retardation in urban South Indians.

OBJECTIVE: To assess the maternal sociodemographic, anthropometric, dietary and micronutrient status in apparently healthy pregnant women in order to determine their associations with intrauterine growth retardation (IUGR). DESIGN: Prospective observational study. SETTING: Bangalore City, India. SUBJECTS: A total of 478 women were recruited at 12.9+/-3.3 weeks of gestation and followed up at the first, second and third trimesters of pregnancy and at delivery. The dropout rate was 8.5%. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Birth weight was measured at hospital delivery. RESULTS: The mean birth weight was 2.85+/-0.45 kg. In all, 28.6% of newborns were IUGR. There was a strong inverse relationship between maternal educational level and risk of IUGR. A low body weight at baseline was also associated with a high risk of IUGR. Compared with women in the highest quartile for second trimester weight gain, those in the lowest quartile had a significantly higher adjusted odds ratio (AOR: 3.98; 95% CI: 1.83, 8.65) for IUGR. Women in the lowest tertile for serum vitamin B(12) concentration during each of the three trimesters of pregnancy had significantly higher risk of IUGR (AOR: 5.98, 9.28 and 2.81 for trimesters 1-3, respectively). CONCLUSIONS: The present study demonstrates associations between educational status, maternal weight and gestational weight gain with IUGR. Importantly, in a subsample, there were strong associations of vitamin B(12) status with IUGR, suggesting that better socioeconomic conditions, improved nutritional status and early detection of vitamin B(12) deficiency in pregnancy combined with appropriate interventions are likely to play an important role in reducing IUGR.

Biological variation of plasma ferritin in healthy adult males in south Indian population-A sample study.

A sample study of biological variation of plasma ferritin in healthy adult males 19-25 years of age (n=6) in the Indian population was determined. Venous blood was collected on 3 non-consecutive days during a 3 week period. Plasma ferritin was measured using enzyme linked immunoassay in an automated immunoassay system. Analytical and Biological variation was calculated. We found a mean biological variation of 21.64%. Thus, our results indicate that biological variation contributed most to the intraindividual variation.

Consequences of inadequate food energy and negative energy balance in humans.

Energy deficiency is probably best measured in adults by the body mass index (BMI). Acute energy deficiency (AED) is associated with body weight loss, along with changes in body composition, as well as a reduced BMR and physical activity. Chronic energy deficiency (CED) is an inadequacy in food to which individuals adapt, at some cost. Individuals with this have never 'lost' weight: they have simply grown less. They adapt to the decreased food energy by reductions in their total energy expenditure (TEE), linked mainly to a lower body size, and to their physical activity. It seems unlikely that enhanced metabolic efficiency contributes substantially to energy saving in CED. Supplementation of energy deficient individuals is accompanied by significant fat deposition; this may have deleterious consequences. Women in many developing countries achieve a successful outcome to pregnancy in spite of being chronically undernourished. Reductions in basal metabolism and behavioural changes in the form of diminished physical activity could meet most of the extra energy needed for pregnancy. Milk energy output is maintained within the expected range in undernourished lactating mothers. Energy deficiency in children is best measured by height-for-age for stunting, and weight-for-height for wasting. Deficits in behavioural and functional parameters in children exist with undernutrition, and can be reduced by early nutritional supplementation along with the appropriate environment.

Body fat topography in Indian and Tibetan males of low and normal body mass index.

Body fat topography was determined using anthropometric techniques in young, healthy, Indian and Tibetan adults. Indian subjects had significantly higher fat contents with greater abdominal obesity when compared with Tibetans matched for body mass index (BMI). This differential fat distribution may contribute, in part, to the greater cardiovascular risk of Indians. Using a cross sectional model, the data was also analysed to assess the probable changes in body fat topography with weight gain. This model suggests a preferential gain in abdominal subcutaneous fat as compared to other sites. This data may have implications while evaluating disease risks with weight gain.