Education and screening for obesity, hypertension, and diabetes (including gestational diabetes) "at the doorstep" of women from nine underprivileged urban areas in Delhi National Capital Region.

BACKGROUND AND AIMS: Women in underprivileged urban areas have poor access to health and education, making them vulnerable to non-communicable diseases (NCDs), specifically diabetes. The current project has sought to focus on this group, to educate and screen this population to prevent and manage obesity and diabetes. METHODS: The project was conducted in 9 underprivileged areas of Delhi NCR using a mobile van unit. Women from these areas were invited for health education (this included talks, lectures and distribution of Information, Education & Communication material), screening {anthropometric, blood glucose and blood pressure (BP) measurements} diet counselling sessions and referral of subjects with uncontrolled blood glucose. RESULTS: Baseline survey on knowledge of diabetes and nutrition showed low awareness. Health education sessions (n, 46) included face-to-face discussion and problem solving and distribution of simple pictorial leaflets (n, 3000). The health education sessions were well accepted. In total, 4% women (n,3175/91000- total population, 3056 non-pregnant, 119 pregnant) participated in the research trial. Among non-pregnant women, an average weight gain of 11.8 kg between the ages of 20-40 years was observed. The average BMI and waist circumference (WC) was 26.8 ± 5.3 kg/m2 and 91.1 ± 13.2 cm, respectively in non-pregnant women. Further, 75.3.0% (2207/2928) and 96.7% (2875/2971) of the non-pregnant women had overweight/obesity and abdominal obesity, respectively. In the non-pregnant women, 21.7% had known diabetes. Further, 7.4% non-pregnant women and 2.5% pregnant women were identified as having hyperglycaemic state. Hypertension was observed in 11.9% pregnant women and 49.9% of non-pregnant women. CONCLUSION: Extremely high prevalence of obesity, along with diabetes and hypertension in underprivileged urban women requires intensive individualised and group health education, screening, and counselling "at the doorsteps", as has been shown in our model.

COVID-19 pandemic and challenges for socio-economic issues, healthcare and National Health Programs in India.

BACKGROUND AND AIMS: The nationwide lockdown was imposed in India following novel coronavirus pandemic. In this paper, we discuss socio-economic, health and National healthcare challenges following lockdown, with focus on population belonging to low socio-economic stratum (SES). METHODS: A literature search was conducted using PubMed and Google Scholar. In addition, existing guidelines including those by Ministry of Health and Family Welfare, Government of India, and articles from several non-academic sources (e.g. news websites etc.) were accessed. RESULTS: While the nationwide lockdown has resulted in financial losses and has affected all segments of society, the domino effect on health, healthcare and nutrition could possibly pose major setbacks to previously gained successes of National health programs. CONCLUSION: Apart from firm economic measures, all National Health Programs should be re-strengthened to avert possible surge of communicable (apart from COVID19) and non-communicable diseases. These efforts should be focussed on population belonging to low SES.

"Diabetes care at doorsteps": A customised mobile van for the prevention, screening, detection and management of diabetes in the urban underprivileged populations of Delhi.

Diabetes is on the rise in India and recently shown to be increasing in the urban underprivileged. Lack of awareness of the disease, its complications, combined with lack of financial resources among the underprivileged, often results in late detection and more complications in them. To combat this, healthcare delivered at the doorstep through the use of a customised mobile medical van is a potentially attractive option. We used a customized mobile van (included trained personnel, glucose meters, fundus evaluation camera, apparatus for detection of neuropathy and foot circulation and net enabled Skype calling for remote consultation) for educating general population regarding healthy lifestyle and screening, management and intervention in patients with diabetes. The project covered 10 underprivileged areas (n, 2,31,000 people) in Delhi. Total of 24,072 individuals (10.9% of total population) attended 352 awareness sessions. A total 3,12,347 visits (included repeat visits) were carried out for screening, education and management for obesity and diabetes. During screening (n, 16,834), 2933 subjects (18.7%) had high random blood glucose levels (>200 mg/dL) and had a blood pressure averaging 127.1 ± 23.6/81.3 ± 16.6 mm of mercury (n, 16,339). A pre-post intensive lifestyle counselling for 6 months in a subset of 352 diabetic patients (of which 77.8% i.e. n, 274 were overweight/obese) showed a significant lowering in weight (p < 0.001). In addition, 292 frontline workers and 256 paramedical workers were given training regarding lifestyle and diabetes, over 20 sessions. Based on achievements of this project of spreading awareness, screening, and management of diabetes and obesity in the large number of individuals in urban underprivileged colony, we believe this project could be extended to other cities and rural areas of India, and to other developing countries as well.

Setting priorities in child health research in India for 2016-2025: a CHNRI exercise undertaken by the Indian Council for Medical Research and INCLEN Trust.

BACKGROUND: Millennium Development Goal 4 (MDGs) mobilised countries to reduce child mortality by two thirds the 1990 rate in 2015. While India did not reach MDG 4, it considerably reduced child mortality in the MDG-era. Efficient and targeted interventions and adequate monitoring are necessary to further progress in improvements to child health. Looking forward to the Sustainable Development Goal (SDG)-era, the Indian Council of Medical Research and The INCLEN Trust International conducted a national research priority setting exercise for maternal, child, newborn health, and maternal and child nutrition. Here, results are reported for child health. METHODS: The Child Health and Nutrition Research Initiative (CHNRI) method for research priority setting was employed. Research ideas were crowd-sourced from a network of child health experts from across India; these were refined and consolidated into research options (ROs) which were scored against five weighted criteria to arrive weighted Research Priority Scores (wRPS). National and regional priority lists were prepared. RESULTS: 90 experts contributed 596 ideas that were consolidated into 101 research options (ROs). These were scored by 233 experts nationwide. National wRPS for ROs ranged between 0.92 and 0.51. The majority of the top research priorities related to development of cost-effective interventions and their implementation, and impact evaluations, improving data quality; and monitoring of existing programs, or improving the management of morbidities. The research priorities varied between regions, the Economic Action Group and North-Eastern states prioritised questions relating to delivering interventions at community- or household-level, whereas the North-Eastern states and Union Territories prioritised research questions involving managing and measuring malaria, and the Southern and Western states prioritised research questions involving pharmacovigilance of vaccines, impact of newly introduced vaccines, and delivery of vaccines to hard-to-reach populations. CONCLUSIONS: Research priorities varied geographically, according the stage of development of the area and mostly pertained to implementation sciences, which was expected given diversity in epidemiological profiles. Priority setting should help guide investment decisions by national and international agencies, therefore encouraging researchers to focus on priority areas. The ICMR has launched a grants programme for implementation research on maternal and child health to pursue research priorities identified by this exercise.

Research priorities in Maternal, Newborn, & Child Health & Nutrition for India: An Indian Council of Medical Research-INCLEN Initiative.

In India, research prioritization in Maternal, Newborn, and Child Health and Nutrition (MNCHN) themes has traditionally involved only a handful of experts mostly from major cities. The Indian Council of Medical Research (ICMR)-INCLEN collaboration undertook a nationwide exercise engaging faculty from 256 institutions to identify top research priorities in the MNCHN themes for 2016-2025. The Child Health and Nutrition Research Initiative method of priority setting was adapted. The context of the exercise was defined by a National Steering Group (NSG) and guided by four Thematic Research Subcommittees. Research ideas were pooled from 498 experts located in different parts of India, iteratively consolidated into research options, scored by 893 experts against five pre-defined criteria (answerability, relevance, equity, investment and innovation) and weighed by a larger reference group. Ranked lists of priorities were generated for each of the four themes at national and three subnational (regional) levels [Empowered Action Group & North-Eastern States, Southern and Western States, & Northern States (including West Bengal)]. Research priorities differed between regions and from overall national priorities. Delivery domain of research which included implementation research constituted about 70 per cent of the top ten research options under all four themes. The results were endorsed in the NSG meeting. There was unanimity that the research priorities should be considered by different governmental and non-governmental agencies for investment with prioritization on implementation research and issues cutting across themes.

Setting research priorities for maternal, newborn, child health and nutrition in India by engaging experts from 256 indigenous institutions contributing over 4000 research ideas: a CHNRI exercise by ICMR and INCLEN.

BACKGROUND: Health research in low- and middle- income countries (LMICs) is often driven by donor priorities rather than by the needs of the countries where the research takes place. This lack of alignment of donor's priorities with local research need may be one of the reasons why countries fail to achieve set goals for population health and nutrition. India has a high burden of morbidity and mortality in women, children and infants. In order to look forward toward the Sustainable Development Goals, the Indian Council of Medical Research (ICMR) and the INCLEN Trust International (INCLEN) employed the Child Health and Nutrition Research Initiative's (CHNRI) research priority setting method for maternal, neonatal, child health and nutrition with the timeline of 2016-2025. The exercise was the largest to-date use of the CHNRI methodology, both in terms of participants and ideas generated and also expanded on the methodology. METHODS: CHNRI is a crowdsourcing-based exercise that involves using the collective intelligence of a group of stakeholders, usually researchers, to generate and score research options against a set of criteria. This paper reports on a large umbrella CHNRI that was divided into four theme-specific CHNRIs (maternal, newborn, child health and nutrition). A National Steering Group oversaw the exercise and four theme-specific Research Sub-Committees technically supported finalizing the scoring criteria and refinement of research ideas for the respective thematic areas. The exercise engaged participants from 256 institutions across India - 4003 research ideas were generated from 498 experts which were consolidated into 373 research options (maternal health: 122; newborn health: 56; child health: 101; nutrition: 94); 893 experts scored these against five criteria (answerability, relevance, equity, innovation and out-of-box thinking, investment on research). Relative weights to the criteria were assigned by 79 members from the Larger Reference Group. Given India's diversity, priorities were identified at national and three regional levels: (i) the Empowered Action Group (EAG) and North-Eastern States; (ii) States and Union territories in Northern India (including West Bengal); and (iii) States and Union territories in Southern and Western parts of India. CONCLUSIONS: The exercise leveraged the inherent flexibility of the CHNRI method in multiple ways. It expanded on the CHNRI methodology enabling analyses for identification of research priorities at national and regional levels. However, prioritization of research options are only valuable if they are put to use, and we hope that donors will take advantage of this prioritized list of research options.

Assessment of nutritional status in Indian preschool children using WHO 2006 Growth Standards.

BACKGROUND & OBJECTIVES: This study attempts to compare the pattern of growth of Indian children as assessed by weight for age, height for age and BMI for age with the WHO standards for growth (2006) and to explore the implications of differences in undernutrition rates in the 0-59 months of age group as assessed by these three indices. METHODS: From the National Family Health Survey-3 database, growth curves for height, weight and BMI for age in Indian preschool children were computed using LMS software and compared with the WHO (2006) standards. Using the WHO (2006) standards, trends in prevalence of undernutrition as assessed by height, weight and BMI for age in the 0-59 month age group were computed. RESULTS: During the first three months there was no increase in underweight and stunting rates. There was progressive increase in underweight and stunting rates between 3-23 months of age. Low BMI for age and wasting rates were highest at birth. INTERPRETATION & CONCLUSIONS: Poor growth is an adaptation to chronic low energy intake and stunting is a measure of cumulative impact of chronic energy deficiency on linear growth. It is important to prevent stunting because it is not readily reversible. Low BMI is an indictor of current energy deficit. Early detection of energy deficit using BMI for age and expeditious interventions to correct the deficit might be effective in prevention of stunting.

Undernutrition & risk of infections in preschool children.

BACKGROUND & OBJECTIVE: It is well documented that in preschool children undernutrition is associated with immune depression and increased risk of infections; infections aggravate undernutrition. Underweight is the most widely used indicator for assessment of undernutrition for investigating undernutrition and infection interactions. In India, nearly half the children are stunted and underweight; but majority of children have appropriate weight for their height and less than a fifth are wasted. The present study was undertaken to explore which of the five anthropometric indices for assessment of undernutrition (weight for age, height for age, wasting, BMI for age, and wasting and stunting with low BMI) is associated with more consistent and higher risk of morbidity due to infection in preschool children. METHODS: The National Family Health Survey-3 (NFHS-3) database provided the following information in 56,438 preschool children: age, sex, weight, height, infant and young child feeding practices and morbidity due to infections in the last fortnight. Relative risk (RR) of morbidity due to infections was computed in infants and children with stunting, underweight, low BMI for age, wasting and stunting with low BMI (< mean-2SD of WHO 2006 standards). RESULTS: Comparison of the RR for infections in undernourished children showed that the relative risk of morbidity due to infections was higher and more consistently seen in children with low BMI and wasting as compared to stunting or underweight. The small group of children who had stunting with wasting had the highest relative risk of morbidity due to infection. INTERPRETATION & CONCLUSION: In Indian preschool children, RR for infection was more consistently associated with BMI for age and wasting as compared to weight for age and height for age. Low BMI for age and wasting indicate current energy deficit; early detection and correction of the current energy deficit might reduce the risk of infection and also enable the child to continue in his/her growth trajectory for weight and height.