Prevalence of nonalcoholic fatty liver disease in an adult population in a rural community of Haryana, India.

Background: Though nonalcoholic fatty liver disease (NAFLD) is increasingly becoming prevalent in the Indian population, knowledge regarding the burden and risk factors of NAFLD is limited, more so from rural areas. This study was thus conducted to estimate the prevalence of NAFLD among adults in a rural community of Haryana, India and to measure the association of diet, physical activity, and other selected risk factors with NAFLD. Materials and Methods: The present study was conducted in a rural community of Haryana, India among resident adults ≥35 years of age. Eight out of 28 villages were selected by probability proportion to size sampling. The number of eligible and consenting participants randomly selected from each village was 27. Out of 216 participants thus recruited, 184 participants reported for undergoing ultrasonography (USG) of the liver, anthropometry, blood pressure recording, and blood sample collection. Finally, 176 participants were analyzed. Results: Prevalence of NAFLD was 30.7%. There was no significant difference in the calorie intake and average total physical activity between participants with and without NAFLD. On multivariate analysis, hypertension [adjusted odds ratio (OR): 2.3, 95% confidence interval (CI): 1.1-5.0, P 0.03] and an increased waist circumference (adjusted OR: 4.9, 95% CI: 1.5-7.0, P < 0.001) were independently associated with NAFLD. A normal high-density lipoprotein (HDL) level was protective against NAFLD (adjusted OR: 0.4, 95% CI: 0.2-0.8, P 0.001). Conclusions: The high prevalence of NAFLD is already a public health problem, even in the rural parts of India. Urgent public health interventions are required to prevent its development by controlling the cardiometabolic risk factors associated with it.

Prevalence of iodine deficiency among adult population residing in Rural Ballabgarh, district Faridabad, Haryana.

Community-based surveys are essential to monitor iodine deficiency disorders (IDD) program at both the state and national levels. There is paucity of information on population iodine nutrition status in Haryana state using standard methods. A cross-sectional study was conducted in villages of Comprehensive Rural Health Services Project (CRHSP), Ballabgarh, Haryana, India. A total of 465 randomly selected individuals were assessed for urinary iodine concentration (UIC) by microplate method and household salt iodine content using iodometric titration. Of the interviewed households, 73% were using adequately iodized salt (≥15 ppm). Iodine nutrition was deficient in 17% respondents (UIC <100 μg/L); 20.2% among males and 13.9% among females. Iodine intake of the study population as measured by UIC was adequate but nearly one-fourth of households in the study population were consuming inadequately iodized salt. The availability and access to adequately iodized salt in the study population should be improved by strengthening regulatory monitoring.

A reliable and accurate portable device for rapid quantitative estimation of iodine content in different types of edible salt.

Background: Continuous monitoring of salt iodization to ensure the success of the Universal Salt Iodization (USI) program can be significantly strengthened by the use of a simple, safe, and rapid method of salt iodine estimation. This study assessed the validity of a new portable device, iCheck Iodine developed by the BioAnalyt GmbH to estimate the iodine content in salt. Materials and Methods: Validation of the device was conducted in the laboratory of the South Asia regional office of the International Council for Control of Iodine Deficiency Disorders (ICCIDD). The validity of the device was assessed using device specific indicators, comparison of iCheck Iodine device with the iodometric titration, and comparison between iodine estimation using 1 g and 10 g salt by iCheck Iodine using 116 salt samples procured from various small-, medium-, and large-scale salt processors across India. Results: The intra- and interassay imprecision for 10 parts per million (ppm), 30 ppm, and 50 ppm concentrations of iodized salt were 2.8%, 6.1%, and 3.1%, and 2.4%, 2.2%, and 2.1%, respectively. Interoperator imprecision was 6.2%, 6.3%, and 4.6% for the salt with iodine concentrations of 10 ppm, 30 ppm, and 50 ppm respectively. The correlation coefficient between measurements by the two methods was 0.934 and the correlation coefficient between measurements using 1 g of iodized salt and 10 g of iodized salt by the iCheck Iodine device was 0.983. Conclusions: The iCheck Iodine device is reliable and provides a valid method for the quantitative estimation of the iodine content of iodized salt fortified with potassium iodate in the field setting and in different types of salt.

Challenges in scaling up successful public health interventions: Lessons learnt from resistance to a nationwide roll-out of the weekly iron–folic acid supplementation programme for adolescents in India.

Anaemia, a major public health problem globally, affects an estimated 1.6 billion people.1 It has effects on the physical and mental health, as well as the productivity of people, particularly those in the vulnerable groups.2,3 The National Family Health Survey (NFHS)-3, 2005–06 estimated that 56% of women and 30% of men in India in the age group of 15–19 years were anaemic.4 Anaemia among people in the age group of 15–24 years was reported to be more common in the rural than urban areas, and among families belonging to the lower socioeconomic strata (Table I). Iron deficiency anaemia is one of the most prevalent micronutrient deficiencies globally and in India.5 About 60% of adolescents in the age group of 10–17 years have been reported to consume less than 50% of the recommended dietary allowance of iron, according to the 2012 National Nutrition Monitoring Bureau (NNMB) multistate survey.6 The low iron content of a typical Indian diet, along with the high prevalence of worm infestation, is the cause of the high prevalence of anaemia in India.7 The various strategies for the

Iodized Salt Coverage Study 2010: Household Consumption and Consumer Behavior about Iodized Salt in Rural Areas of Select States of India.

Objectives: This study assessed the household coverage with iodized salt and consumer behavior with regards to edible salt in rural areas of eight selected states of India. Methods: The study was conducted by ICCIDD in association with MI and the Salt Commissioner’s Office in 2010. Iodine content of household edible salt was measured and consumer behavior in terms of knowledge and perceptions regarding iodized salt and edible salt buying behavior was assessed in 9600 rural household in selected states. Results: 47.2% of the households were consuming adequately iodized salt; 47%, 35%, 45%, 59%, 50%, 42%, 35%, and 64% respectively in states of Andhra Pradesh, Karnataka, Madhya Pradesh, Orissa, Rajasthan, Tamil Nadu, Uttar Pradesh and Uttarakhand. 58% of the respondents were aware about the iodized salt but only 13% of the respondents perceived ‘iodized salt’ to be an attribute of good quality salt. 54% of the households were using packaged crushed salt. Households with higher wealth index, awareness about iodized salt, using packaged crushed salt, and purchasing edible salt from general stores or Public Distribution System (PDS) were more likely to use adequately iodized salt. Conclusions: Despite an improvement of twenty percentage points from a previous survey in 2005-06, the coverage with adequately iodized salt in these states remains below the national average for rural areas. Increasing awareness and demand generation at the household level and introduction of good quality iodized salt in the Public Distribution System at affordable cost will help in improving the household coverage with adequately iodized salt in these states.

Academic Institutions Role in Ensuring Sustainability of IDD Control Program: A Case Study from India.

Objectives: This paper discusses the role of academic institutions in ensuring sustainability of Iodine Deficiency Disorders (IDD) control Programme. Methods: A case study of six decade long (1956-2013) contribution of All India Institute of Medical Sciences (AIIMS), New Delhi in IDD Control Programme in India is presented. Results: AIIMS, New Delhi, in association with other partners, launched seminal Kangra Valley Study in 1956 to assess the impact of iodized salt on IDD. Success of the study led to initiation of National Goitre Control Programme in 1962. Researchers from AIIMS provided evidence for extra- Himalayan existence of IDD, and impact of iodine on cognition leading to introduction of universal salt iodization in 1986 and subsequent renaming of programme as National Iodine Deficiency Disorders Control Programme (NIDDCP). In the year 2000,when ban on sale of non-iodized salt was lifted research and policy advocacy was carried out to to achieve re-imposition of ban on non-iodized salt. AIIMS took lead in bringing all agencies working on IDD on the same platform through formation of National Coalition in 2006, the Secretariat of which is located at AIIMS. AIIMS continues to influence policy through representation in expert committees and other government forum. Currently tenth generation of IDD researchers is active in research and policy advocacy on IDD in the country. Conclusions: The reason for success of academic institution in ensuring sustainability is continuity in efforts, presence of champion, a multi-disciplinary team, , mentorship, credibility, evidence based policy and programme research and a facilitating role in coalition building to achieve coordination.

Making a postgraduate journal club an effective learning opportunity: Experience from the Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi

A journal club (JC) is defined as a group of individuals who meet regularly to critically discuss the applicability of current peerreviewed articles published in medical journals.1 The memoirs of Sir James Paget, a surgeon at St Bartholomew’s Hospital, London, UK (1835–54), contain the earliest mention of a JC. Sir Paget described ‘a kind of club in a small room over a baker’s shop near the hospital gate where we could sit and read journals and play cards’.2 There is evidence of the existence of the first formal JC in 1875, when William Osler of McGill University, Montréal, Canada found a way of making expensive periodicals affordable by purchasing expensive journals with fellow students at a group rate.

Prevalence of Household-level Food Insecurity and Its Determinants in an Urban Resettlement Colony in North India.

An adequate food intake, in terms of quantity and quality, is a key to healthy life. Malnutrition is the most serious consequence of food insecurity and has a multitude of health and economic implications. India has the world’s largest population living in slums, and these have largely been underserved areas. The State of Food Insecurity in the World (2012) estimates that India is home to more than 217 million undernourished people. Various studies have been conducted to assess food insecurity at the global level; however, the literature is limited as far as India is concerned. The present study was conducted with the objective of documenting the prevalence of food insecurity at the household level and the factors determining its existence in an urban slum population of northern India. This cross-sectional study was conducted in an urban resettlement colony of South Delhi, India. A pre-designed, pre-tested, semi-structured questionnaire was used for collecting socioeconomic details and information regarding dietary practices. Food insecurity was assessed using Household Food Insecurity Access Scale (HFIAS). Logistic regression analysis was performed to determine the factors associated with food insecurity. A total of 250 women were interviewed through house-to-house survey. Majority of the households were having a nuclear family (61.6%), with mean familysize being 5.5 (SD±2.5) and the mean monthly household income being INR 9,784 (SD±631). Nearly half (53.3%) of the mean monthly household income was spent on food. The study found that a total of 77.2% households were food-insecure, with 49.2% households being mildly food-insecure, 18.8% of the households being moderately food-insecure, and 9.2% of the households being severely food-insecure. Higher education of the women handling food (OR 0.37, 95% CI 0.15-0.92; p≤0.03) and number of earning members in the household (OR 0.68, 95% CI 0.48-0.98; p≤0.04) were associated with lesser chance/odds of being food-insecure. The study demonstrated a high prevalence of food insecurity in the marginalized section of the urban society. The Government of India needs to adopt urgent measures to combat this problem.

Cost of Ambulatory Care by Mobile Health Clinic Run by a Medical College in India for the Year 2008-09.

Background: The feasibility of using mobile health clinics (MHCs) to deliver health services in urban poor areas has to be explored as the health needs of the residents are not sufficiently addressed by the existing primary health care delivery system in India. Objective: To estimate the cost of providing primary health care services and the out of pocket expenditure (OOPE) incurred, while utilizing these services provided through the MHC based Urban Health Program of a Medical College in North India for the year 2008-2009. Materials and Methods: A cross-sectional study to estimate OOPE was conducted among 330 subjects selected from patients attending the mobile health care facility. For estimation of provider cost, 5 steps process involving identification of cost centres, measurement of inputs, valuing of inputs, assigning of inputs to cost centers, and estimation of unit cost were carried out. Results: Total annual cost of providing services under Urban Health Program in the year 2008-2009 was Rs. 7,691,943 Unit cost of providing outpatient curative care, antenatal care, and immunization were Rs. 107.74/visit, Rs. 388/visit and Rs. 66.14 per immunization, respectively. The mean OOPE incurred was Rs. 29.50/visit, while utilizing outpatient curative services and Rs. 88.70/visit for antenatal services. Conclusion: The MHC can be considered as a viable option to provide services to urban poor.

Sex-specific Trends in Under-five Mortality in Rural Ballabgarh.

Objectives: To assess sex-specific differentials in child survival from 1992-2011. Methods: We analyzed data from the electronic database of Health and Demographic Surveillance System (HDSS) site in Ballabgarh in North India. Results: Sex ratio at birth was adverse for girls throughout the study period (821 to 866 girls per 1,000 boys) and was lowest in the period 2004-2006 at 821 girls per 1,000 boys. Overall, under-five mortality rates during the period 1992-2011 remained stagnant due to increasing neonatal mortality rate (9.2 to 27.7 P< 0.001). Mortality rates among girls were consistently and significantly higher than boys during the post-neonatal period (160% to 200% higher) as well as in childhood (160% to 230% higher). Conclusions: Strategies to address the neonatal mortality and gender differences are required for further reductions in child mortality in India.

Iodine deficiency disorders (IDD) control in India.

Iodine deficiency disorders (IDD) constitute the single largest cause of preventable brain damage worldwide. Majority of consequences of IDD are invisible and irreversible but at the same time these are preventable. In India, the entire population is prone to IDD due to deficiency of iodine in the soil of the subcontinent and consequently the food derived from it. To combat the risk of IDD, salt is fortified with iodine. However, an estimated 350 million people do not consume adequately iodized salt and, therefore, are at risk for IDD. Of the 325 districts surveyed in India so far, 263 are IDD-endemic. The current household level iodized salt coverage in India is 91 per cent with 71 per cent households consuming adequately iodized salt. The IDD control goal in India was to reduce the prevalence of IDD below 10 per cent in the entire country by 2012. What is required is a “mission approach” with greater coordination amongst all stakeholders of IDD control efforts in India. Mainstreaming of IDD control in policy making, devising State specific action plans to control IDD, strict implementation of Food Safety and Standards (FSS) Act, 2006, addressing inequities in iodized salt coverage (rural-urban, socio-economic), providing iodized salt in Public Distribution System, strengthening monitoring and evaluation of IDD programme and ensuring sustainability of IDD control activities are essential to achieve sustainable elimination of IDD in India.

Evolution of Iodine Deficiency Disorders Control Program in India: A Journey of 5,000 Years.

Iodine defi ciency disorders (IDD) has been documented since around 5,000 years. However, geological factors like frequent glaciations, fl ooding, and changing of course of rivers has led to iodine defi ciency in soil. As a result everyone remains at risk of IDD, if optimum intake of iodine is not sustained. Evolution of the IDD control program in India has been a dynamic process. The model of IDD control program in India provides important lessons for successful implementation of a national health program. In formulating National Health Programs; policy environment, scientifi c inputs, political will, and institutional structure for decision making are necessary but not suffi cient. Continuous and dynamic generation of reliable and representative state and national level data, proactive recognition of values of key stakeholders and addressing them through sustained advocacy, development of partnerships among stakeholders, institutional continuity, and mentorship are critical for achieving sustainability of results.

Economic evaluation of iodine deficiency disorder control program in Sikkim: A cost-benefit analysis.

Background: Iodine deficiency disorders (IDDs) are the most common cause of preventable brain damage globally. The strategy of prevention and control of iodine deficiency is based on iodine supplementation. Edible salt iodization and iodized oil injections are the two most commonly used vehicles for iodine supplementation. The objective of the study was to conduct a cost-benefit analysis of the two programs of iodine supplementation, i.e., iodized salt program (ISP) and iodized oil program (IOP) against no preventive program (NPP) option. Materials and Methods: The study was conducted in 1990 in the state of Sikkim in India. The costs were calculated on the assumption of universal coverage of ISP and coverage of IOP among all children aged 0-14 years and women in the age group of 15-44 years. Direct and indirect cost of ISP and direct cost of IOP was computed based on the costs of year 1991. The discount rate taken was 10% and all the costs were converted to the year 2010 using wholesale price index (WPI) data. Consequences in terms of health effects, Social/emotional effects, and resource use were included. Results: The discounted cost of ISP and IOP was Rs. 59,225,964 and Rs. 46,145,491, respectively. In ISP, 64.1% of the total cost was required for salt iodization, 17.6% for monitoring, and 18.3% for communication. In IOP, 50.9% of the costs were required for iodized oil; rest was for syringes and needles, manpower expenses, travel, and communication. Total resource saving was Rs. 95,566,220 for ISP and Rs. 92,177,548 for IOP. Incremental benefit for ISP was Rs. 36,340,256 and Rs. 46,032,057 for IOP. The cost-benefit ratio for ISP was 1.61 and 2.00 for IOP. Conclusion: IOP has a higher cost-benefit ratio for prevention of IDDs than ISP in the state of Sikkim, India.

Economic evaluation of iodine deficiency disorder control program in Sikkim: A cost effectiveness study.

Background: Edible salt iodization and iodized oil injections are the two most commonly used vehicles for iodine supplementation. In year 1989, the state government of Sikkim was planning to implement Iodine Deficiency Disorder control program in state and had following two options to choose from, based on existing knowledge; a) a salt iodization program, b) an iodized oil injection program. No information was available at that point of time on comparative advantages of the above stated two approaches. Objectives: To identify the most cost-effective alternative for IDD elimination in Sikkim, amongst the following 3 alternatives: a) Iodized salt program (ISP), b) Iodized oil injection program (IOP) to high risk group, c) no preventive program. Materials and Methods: Study population was the general population of state of Sikkim, India in year 1990. Cost- effective analysis was undertaken comparing 3 alternative programs, targeted towards IDD elimination in state of Sikkim. Identification, measurement and valuation of the costs of ISP and IOP and identification and measurement of the consequences of IDD were done to carry out the cost-effective analysis. Visible goiter person years (VGPY), endemic cretinism, IDD attributable death were used to assess the health consequences/disease burden of IDD. Results: The cost per VGPY, endemic cretinism and IDD attributable death were Rs 76.67, Rs 24,469 and Rs 9,720, respectively for ISP. The cost per VGPY, endemic cretinism and IDD attributable death were Rs 75.82, Rs 19,106 and Rs 7,709, respectively for IOP. Conclusion: The results of the analysis showed that iodized oil program is more cost-effective for prevention of irreversible IDDs than the iodated salt program in state of Sikkim, India.

The allure of the private practitioner: Is this the only alternative for the urban poor in India.

The main objective of the study has been to identify trajectories of health seeking behaviour of the urban poor, particularly their use of the private health sector, with the aim to identify strategies to improve quality of health care for this burgeoning population. This article presents findings from a slum settlement in Delhi where ethnographic sub-studies were carried out over two years among private health providers and selected households alongside a survey of household expenditure patterns. The primary research tools were in-depth interviews with practitioners and key informants as well as observations of clinical interactions. Illness narratives and case studies were documented over two years. The software package q.s.r. Nvivo was used for coding and content analysis. It was found that almost 90% of the respondents exclusively depend on local unlicensed and unregistered practitioners for basic primary health care. Long distances, time-consuming procedures, rude behaviour and, in many cases, bribes that had to be paid to staff in the hospitals were cited as major deterrents to utilising government facilities. Despite the public health consequences of inappropriate treatment protocols and misuse of drugs by these untrained private providers, in the absence of a structured urban primary health care system in the country, they seem to be the only alternative for the burgeoning urban poor in vast metros such as Delhi.

A review of tracking progress towards elimination of Iodine deficiency disorders in Tamil Nadu, India.

Background : Iodine deficiency disorders (IDD) are significant health problem in India. But there is dearth of regional/state level information for the same. Objective: This study was designed to study the current status of IDD in Tamil Nadu. Materials and Methods: A cross-sectional community-based survey was conducted in the state of Tamil Nadu. The study population was children in the age group of 6-12 years and the probability proportional to size 30 cluster methodology was used for sample selection. The parameters studied were prevalence of goiter, urinary iodine excretion, and iodine content in salt at the household level. Results: A total of 1230 children aged between 6 and 12 years were studied. The total goiter rate was 13.5% (95% CI: 11.1-14.9). The median urinary iodine excretion was found to be 89.5 μg/L (range, 10.2-378 μg/L). The 56% of the urinary iodine excretion values were <100 μg/L. The proportion of households consuming adequately iodized salt (iodine content ≥ 15 parts per million) was 18.2% (95% CI: 16.1-20.5). Conclusion: The total goiter rate of 13.5% and median urinary iodine excretion of 89.5 μg/L is indicative of iodine deficiency in Tamil Nadu.