Significant sex difference in the association between C-reactive protein concentration and anthropometry among 13- to 19-year olds, but not 6- to 12-year olds in Nepal.

Life history theory predicts a trade-off between immunostimulation and growth. Using a cross-sectional study design, this study aims to test the hypothesis that C-reactive protein (CRP) is negatively associated with height-for-age z-scores (HAZ scores) and BMI-for-age z-scores (BAZ scores) among 6- to 19-year olds (N = 426) residing in five Nepalese communities. Dried blood spot (DBS) samples were collected and assayed for CRP using an in-house enzyme immunoassay (EIA). Sex- and age-group-specific CRP quartiles were used to examine its association with growth in linear mixed-effects (LME) models. A significant difference was found in the proportion of elevated CRP (>2 mg/L, equivalent to ∼3.2 mg/L serum CRP) between 13- and 19-year-old boys (12%) and girls (4%). Concentrations of CRP were positively associated with HAZ score among adolescent (13-19 years) boys, which may indicate that individuals with greater energy resources have better growth and a better response to infections, thus eliminating the expected trade-off between body maintenance (immunostimulation) and growth. Adolescent boys with low BAZ and HAZ scores had low CRP values, suggesting that those who do not have enough energy for growth cannot increase their CRP level even when infected with pathogens. Among adolescent girls a positive association was observed between CRP and BAZ scores suggesting the possible effects of chronic low-grade inflammation due to body fat rather than infection. The association between CRP and growth was less evident among children (6-12 years) compared with adolescents, indicating that the elevated energy requirement needed for the adolescent growth spurt and puberty may play some role.

Factors associated with arsenicosis and arsenic exposure status in Nepal: implications from community based study.

A significant public health problem due to exposure to arsenic via groundwater in communities of lowland Terai region of Nepal has issued forth need to assess the exposure status and factors associated with arsenicosis. We observed arsenical dermal manifestations and collected and assessed total arsenic content in tubewell water, urine, and hair samples of study subjects at arsenic affected communities in Nawalparasi district of Nepal. The explanatory variables associated with arsenicosis were elevated arsenic in tubewell, male gender and increased age (P < 0.05). 67% (73/109) and 66% (77/117) of subjects exceeded the normal urinary and hair arsenic levels respectively. Among them 52% (57/109) and 47% (55/117) exceeded normal urinary and hair arsenic levels having no arsenical dermal manifestations. Males and symptomatic cases had significantly higher hair arsenic levels (P < 0.05). We also observed significant positive correlation of both urine and hair arsenic levels to tubewell arsenic levels (r = 0.27, 0.37, P < 0.01) and negative correlation of urine arsenic levels with the age of the subjects (r = -0.18, P = 0.06). We conclude that elucidating factors associated with arsenicosis could be of prime importance in intervention and preventive measures. In arsenic affected communities of Nepal exposure to arsenic is still a major problem despite mitigation efforts and the potential for sub-clinical effects in exposed population is high.

Gender differences in "luxury food intake" owing to temporal distribution of eating occasions among adults of Hindu communities in lowland Nepal.

Our previous studies in developing countries have indicated that gender differences in intake of luxury foods incur risk of micronutrient deficiencies among women. As the next step, we examined the causes of gender differences in food intake by comparing eating patterns, including meal frequency (skipping) and temporal distribution of food consumption throughout the day among adults of Hindu communities in lowland Nepal. A total of 321 adults (126 men and 195 women) aged 20 years and above were randomly selected from 94 households in three rural communities. A face-to-face questionnaire-based 24-hour dietary recall interview was conducted whereby foods eaten throughout the six eating occasions (morning snack, breakfast, lunch, daytime snack, dinner, and evening snack) were recorded and analyzed. Results shows that men frequently skipped lunch (p <0.001), they also frequently consume daytime snack (p <0.001), and consumed purchased luxury foods such as tea with sugar and milk (p = 0.008) and samosa (p = 0.049) as daytime snack. The six-eating occasion analysis revealed that gender differences in food intake of rural Nepalese adults occurred during lunch and daytime snack, attributing to gender differences in daily activity patterns.

Pathways leading to early growth faltering: an investigation into the importance of mucosal damage and immunostimulation in different socio-economic groups in Nepal.

Early childhood growth retardation persists in developing countries despite decades of nutritional interventions. Adequate food is necessary, but not sufficient, to ensure normal growth where there is ubiquitous exposure to infection. Pathways associated with infection, small intestinal mucosal damage and chronic immunostimulation remain largely undemonstrated in countries other than The Gambia. We conducted a longitudinal study of one squatter and one middle-class group (n 86, 3-18 month olds) to assess these relationships in Nepal. Growth, mucosal damage index (MDI; urinary lactose:creatinine ratio adjusted for body weight), morbidity reports, and blood concentrations of albumin, alpha-1-acid glycoprotein, IgG and Hb, were recorded monthly. Growth status worsened dramatically from 6 to 18 months, with squatters more stunted (height-for-age Z-score (HAZ), P<0.001) and underweight (weight-for-age Z-score (WAZ), P=0.009) than middle class. IgG increased with age, was elevated in squatter children, and negatively related to WAZ (P=0.034). MDI showed significant negative associations with growth performance, explaining 9 and 19% of height and weight deficits (DeltaHAZ, P=0.004; DeltaWAZ, P<0.001). Unexpectedly, these associations were weaker in squatter children, namely in the group which showed poorer growth, elevated morbidity, greater pathogen exposure (IgG) and higher MDI (P<0.001). In Nepal, as in The Gambia, children exhibit poor growth, mucosal damage and immunostimulation. The relative impact of pathways associated with infection and undernutrition may, however, differ across socio-economic groups: in poorer children, the impact of mucosal damage and immunostimulation could be masked by nutritional constraints. This has important implications for public health interventions.

Design for sustainable development--household drinking water filter for arsenic and pathogen treatment in Nepal.

In the last 20 years, the widespread adoption of shallow tubewells in Nepal Terai region enabled substantial improvement in access to water, but recent national water quality testing showed that 3% of these sources contain arsenic above the Nepali interim guideline of 50 microg/L, and up to 60% contain unsafe microbial contamination. To combat this crisis, MIT, ENPHO and CAWST together researched, developed and implemented a household water treatment technology by applying an iterative, learning development framework. A pilot study comparing 3 technologies against technical, social, and economic criteria showed that the Kanchan Arsenic Filter (KAF) is the most promising technology for Nepal. A two-year technical and social evaluation of over 1000 KAFs deployed in rural villages of Nepal determined that the KAF typically removes 85-90% arsenic, 90-95% iron, 80-95% turbidity, and 85-99% total coliforms. Then 83% of the households continued to use the filter after 1 year, mainly motivated by the clean appearance, improved taste, and reduced odour of the filtered water, as compared to the original water source. Although over 5,000 filters have been implemented in Nepal by January 2007, further research rooted in sustainable development is necessary to understand the technology diffusion and scale-up process, in order to expand access to safe water in the country and beyond.

Mutual interaction between nutritional status and chronic arsenic toxicity due to groundwater contamination in an area of Terai, lowland Nepal.

OBJECTIVE: To reveal the inter-relationship between nutritional status and arsenic toxicity. DESIGN: Cross-sectional study. SETTING: A survey in an area of lowland Nepal, where a high prevalence of both skin manifestation and malnutrition was observed. Daily arsenic intake was estimated by measuring the arsenic concentration and daily consumption of the drinking water. PARTICIPANTS: Adult villagers (248 men and 291 women). About half were classified as "underweight" (body mass index <18.5), indicating poor nutritional status. MAIN RESULTS: Arsenic intake was negatively correlated with body mass index and substantially increased the prevalence of underweight individuals, among whom the prevalence of skin manifestations was 1.65-fold higher than normal weight individuals. When exposure level was considered, the prevalence of skin symptoms was consistently higher in the underweight than in the normal group. Although enhanced susceptibility in men was apparent by the increased prevalence of cutaneous symptoms, no sex difference was observed in the prevalence of underweight individuals related with exposure to arsenic. CONCLUSIONS: The present data suggested that exposure to arsenic is associated with an increased prevalence of underweight, a serious health problem in developing countries, which in turn is associated with increased skin manifestation of arsenic poisoning.

Prevalence of arsenicosis in terai, Nepal.

This paper summarizes the findings of surveys on arsenicosis cases conducted during 2001-2004 in terai, Nepal, by governmental and non-governmental organizations in their respective project areas and by some national and international institutes. Studies were conducted in six arsenic-contaminated districts of terai, namely Nawalparasi, Bara, Parsa, Rautahat, Rupandehi, and Kapilvastu. In these districts, arsenic contamination in tubewells varied from 2.1% to 25.7%. The prevalence of arsenicosis was, on average, 2.2% and varied from 0.7% in Kapilavastu district to 3.6% in Nawalparasi district. In the community-based study, the highest prevalence (18.6%) of arsenicosis was found in Patkhouli village of Nawalparasi, where 95.8% of tubewells were contaminated with arsenic. The prevalence of arsenicosis was higher in older age-groups (>50 years) of both the sexes. Males suffered more from arsenicosis than females (odds ratio: 2.50, 95% confidence interval 1.80-3.47). Skin manifestations, such as melanosis and keratosis, were the common symptoms of arsenicosis. Most patients were identified in the early or mild stage of the disease. They are expected to recover if further exposure to arsenic could be avoided by providing arsenic-safe drinking-water through intervention measures.

Arsenic contamination in drinking water and skin manifestations in lowland Nepal: the first community-based survey.

A community-based, dose-response study on arsenic contamination was conducted in three communities in Terai in lowland Nepal. The arsenic concentration of all the tube wells in use (n = 146) and the prevalence of arsenic-induced skin manifestation among 1,343 (approximately 80% of the inhabitants) subjects indicated the existence of a highly contaminated area in Terai. It was found that overall prevalence of arsenicosis among the subjects > or = 15 years old was 6.9%, which was comparable to those found by the same examiner in arsenic-contaminated areas in Bangladesh, and that males had prevalence a twice as high as females, which could not be explained by the difference in the exposure level.

Arsenicosis in two villages in Terai, lowland Nepal.

Although arsenic contamination of groundwater has been detected recently in the Terai region of Nepal, scarce data have been available regarding the possible health effects of the contamination. A study was carried out in two rural villages of Nawalparasi district, where the existence of arsenic contamination has been reported. Almost all tubewells in one of the two villages (Goini, G) exceeded (ranging from 0.104 mg/L to 1.702 mg/L) the maximum permissible limit for arsenic in drinking water in Nepal (0.05 mg/L), and only a few tubewells (19.5%) in the other village (Kunuwar Big, KB) were below this level (0.004 mg/L to 0.972 mg/L). Prevalence rates of arsenicosis diagnosed on the basis of the presence of dermatological manifestations were 11.3% (56 out of 495 examined) and 6.5% (34/525) in G and KB, respectively, with an overall prevalence rate of 8.9%. In terms of gender, the prevalence rate was higher in males (11.5%; 61/531) than in females (5.9%; 29/489), supporting previous observations including our own. Most (71.1%) of the identified patients were 20-49 years old, and the prevalence rate appeared to be higher among those in their 30s or 40s in the both sexes. The youngest patient was 10 years of age. All the patients were either in the mild or moderate stage of the disease and most (78.9%) were in the mild stage. Melanosis with some other manifestations was observed in 95.6% of the patients, while keratosis was found in 57.8%. Leucomelanosis without any other manifestations, which has not been reported either in Bangladesh or India, was observed in 3.3% of the identified patients. Only one patient had Bowen's disease. To our knowledge, the current study provides for the first time quantitative information regarding the arsenicosis patients in Nepal.

Groundwater arsenic contamination, its health impact and mitigation program in Nepal.

About 47% of Nepal's total population is living in Terai region and 90% of them are relying on groundwater as their major source of drinking water. About 200,000 shallow tubewells have been installed by different agencies in 20 Terai districts, serving 11 million people. Recently, arsenic contamination of groundwater has been recognized as a public health problem in Nepal. This has sensitized government, national and international nongovernment organizations working on water quality sector to carry out water quality assessment for arsenic in the affected communities. So far, 15,000 tubewells has been tested where 23% samples exceeded World Health Organization guideline value of 10 microg/L and 5% exceeded "Nepal Interim Arsenic Guideline" of 50 microg/L. It is estimated that around 0.5 million people in Terai are living at risk of arsenic poisoning (>50 microg/L). Some recent studies have reported the prevalence of dermatosis related to arsenicosis from 1.3 to 5.1% and the accumulation of arsenic in biological samples like hair and nail much higher than the acceptable level. Though some steps are being taken by government and private organizations to combat the problem, it has not been able to cover all the affected communities. Nepal still needs more research work on arsenic occurrence and effects and mitigation programs simultaneously.