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.

Effect of left ventricular geometric remodeling on restrictive filling pattern and survival in ischemic cardiomyopathy

Background: To evaluate the effects of Left ventricular remodeling patterns in patients with left ventricular restrictive filling pattern (RFP; E/A>2) in ischemic cardiomyopathy (ICM) on prognosis. Methods: Patient data was retrospectively analyzed over a period of 4.5 years to determine the effect of LV geometry by Echocardiographic parameterson survival and re-admission for heart failure. All patients with previous history of transmural myocardial infarction were studied and all were on guideline directed medical therapy. None underwent device therapy or surgery. The stored 2D Echocardiograms were studied. Left ventricular dimensions were noted, including the relative wall thickness (RWT). The patients were grouped based on RWT<0.34 and _x0001_ 0.34 and were compared for clinical outcomes of mortality and re-admissions for heart failure, over a period of 54 months. Results: There were 102 ICM patients who had baseline RFP. We identified two sub-groups based on geometric phenotypes of left ventricular eccentric remodeling and dilated remodeling based on the relative wall thickness (RWT >0.34 or <0.34). The patients with preserved RWT had significantly more dilated ventricles (LVIDd and LVIDs), greater pulmonary artery systolic pressures (PASP), greater diatolic dysfunction (E/A) and less left ventricular ejection fraction (LVEF); p < 0.001. The number of deaths was higher in the reduced RWT patients, as were the number of re-admissions, although the time to survival and time to re-admission was not significant. Conclusions: In this pilot study on ICM patients in advanced heart failure with baseline RFP, the presence of preserved RWT indicative of eccentric remodelling demonstrated a better clinical outcome

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.

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.

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.

Heart rate variability responses to standing are attenuated in drug naive depressed patients.

Depression has been linked to altered cardiac autonomic regulation. Previous studies have been inconsistent in terms of measurement of heart rate variability (HRV), selection of depressed patients with cardiac disorders and not controlling for co-morbid conditions such as substance use and anxiety disorders. The objective of this study is to compare the effect of posture on spectral measures of HRV in drug naive healthy patients with major depression with age and gender matched healthy controls. Spectral measures of HRV in supine position and with active standing were obtained (using Task force recommendations). Repeated measure ANOVA revealed an attenuated response in HRV parameters (HF normalized units & LH/HF ratio) to active standing in depressed subjects compared to healthy controls. We conclude that there is an impaired parasympathetic modulation in response to physiological maneuver (orthostatic challenge) in drug naive subjects with major depression (co-morbid medical or psychiatric conditions) compared to healthy controls.

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.

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.

Prevalence of health related disability among community dwelling urban elderly from middle socioeconomic strata in Bangaluru, India.

Background & objectives: Research has shown that health related conditions and socio-economic factors influence disability in the elderly. We examined the prevalence of health related disability in community dwelling elderly (≥65 yr) residents in a suburb of Bangaluru, Karnataka, India, and assessed the association of disability with various socio-economic variables and current health status. Methods: Using the International Classification of Functioning, Disability and Health (ICF) disability was measured in 356 elderly in the Koramangala suburb of Bangaluru city. Various socio-economic and health related factors associated with disability were documented. Results: A total of 85 per cent of the respondents reported current medical problems. Based on a total disability score computed from the participation section of the ICF, 27 per cent of the respondents had mild disability while 37 per cent had higher level of disability. Disablement was significantly associated with age > 75 yr and impairment in cognitive and sensory functions especially hearing. Interpretation & conclusion: In this urban elderly population while majority had current medical conditions, a significant proportion did not experience any difficulties in activities of daily living. Restriction in participation in activities of daily living was more influenced by increasing age and impairment in cognitive functions and not current health status. A multidimensional measure of disability as captured by the ICF needs to be applied to other populations such as urban poor and rural elderly to get a more comprehensive picture of disability among the elderly in India.

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.

Total body muscle mass estimation from bioelectrical impedance analysis & simple anthropometric measurements in Indian men.

BACKGROUND & OBJECTIVE: Skeletal muscle mass represents about 30-40 per cent of the total body weight, and has important roles in function and metabolism. Although newer methods of measuring muscle mass are accurate and sophisticated, there is a need for methods that can be used in low resource settings. Existing methods of predicting muscle mass are based on mid upper arm circumference (MUAC) measurements, sometimes corrected for triceps skinfold fat. The present study was undertaken to develop predictive equations for estimating muscle mass from simple and non-invasive methods such as bioelectrical impedance (BIA) and anthropometric measurements (circumferences and skinfold thickness) in Indian men. METHODS: BIA measurements and anthropometric measurements were carried out on 67 normal, healthy men between the ages of 18 and 45 yr. True muscle mass was measured from 24 h creatinine excretion. Multiple linear regression with step-wise forward selection was used to predict total muscle mass using measurements like height(2)/impedence, height and weight and using arm muscle area (AMA), thigh muscle area (TMA) and calf muscle area (CMA). RESULTS: The prediction equation for muscle mass (kg) using height(2)/impedance and height was - 12.347+ (0.363 x height(2)/impedance) + (0.122 x height) [R(2) = 0.55; Standard error of estimate (SEE) = 2.58 kg], while the equation using appendicular muscle area was 10.122 + (0.23 x AMA)+ (0.049 x TMA) [R(2) 0.36; SEE 3.07 kg]. INTERPRETATION & CONCLUSION: This study provides prediction equations for estimating muscle mass in healthy Indian males from simple non invasive methods such as BIA and anthropometric measurements such as circumferences and skinfold thickness. Further studies need to be done on a larger sample size and using an external group to validate the equations.