The nutrition transition in India

Reference centile curves for mid-upper arm circumference for assessment of under- and overnutrition in school-aged Indian children and adolescents

OBJECTIVES

Malnutrition is common in developing countries and is not restricted to young children. It has been suggested that measuring mid-upper arm circumference (MUAC) is an easy, accurate, and low-cost method of identifying malnutrition in the early stages. The aims of this study were to construct age- and sex-specific MUAC reference centiles, and to define and validate cutoffs for assessment of under- and overnutrition in Indian children 5 to 17 y of age.

METHODS

This was a cross-sectional, multicentric, observational study conducted in seven schools in seven states from June 2018 to November 2019. The study included 6680 healthy 5- to17-y-old children. MUAC was measured using non-stretch tapes (UNICEF). Sex-specific MUAC percentiles were computed for age and height. Cutoffs for MUAC z-scores for thinness and overnutrition were defined and validated for healthy school children (n = 726) and children with cancer (n = 500).

RESULTS

Reference centiles for MUAC for age (and height) for boys and girls are presented. Cutoffs defined for thinness and for obesity were -0.7 and +1.5 z-score, respectively (corresponding to 25th and 95th percentiles of the MUAC for age/height). For ease of use, rounded cutoffs for thinness were 16 and 18.5 cm from 5 to 9 and 10 to 14 y of age, respectively, in both sexes, and a cutoff of 22 cm in boys and 20 cm in girl from 15 to 17 y of age. For obesity, 20 and 25.5 cm from 5 to 9 and 10 to 14 y of age, respectively, in both girls and boys and a rounded cutoff of 29 cm in boys and 27 cm in girls from 15 to17 y are proposed.

CONCLUSIONS

We presented MUAC percentiles and cutoffs for screening for thinness and overnutrition in Indian children from 5 to 17 y of age. These data may also be used in children with cancer and other chronic disorders with growth failure.

Sexual maturity assessment in Indian children-a study from western India

OBJECTIVES

Pubertal assessment is crucial as puberty is the transition from childhood to adulthood. Pubertal assessment, growth, and secular trend in puberty need to be explored further in India. The objectives were to assess Sexual Maturity Rating (SMR) among children and establish normative data of puberty from western India. We also compared age of attainment of various stages of puberty with BMI and secular trend in menarche.

METHODS

A cross-sectional observational study was undertaken at a tertiary care pediatric center. The study population were healthy girls and boys between 6 and 18 years. Demographic data was noted. Anthropometry and SMR assessment (Tanner staging) were performed. The age of menarche was noted among the girls and their mothers. Data were analyzed using SPSS 21.

RESULTS

In girls, median age of thelarche, pubarche, and menarche was 9.37 (8.5-10.2), 10.18 (9.87-10.49), and 12.55 years (12.41-12.75) respectively. There was an early appearance of thelarche but menarche was delayed in overweight-obese girls (statistically not significant). Age of menarche showed a shift to left in girls as compared to their mothers (p=0.036). In boys, median age of testicular stage 2 and pubarche was 10.7 (9.9-11.8) and 11.6 years (11.1-12.1) respectively. In overweight-obese boys the pubertal milestones were achieved earlier (statistically not significant).

CONCLUSIONS

Normative data on pubertal assessment from western India is presented. Age of menarche shows a shift to left in girls as compared to their mothers. Pubertal milestones were observed at a younger age in overweight obese children which was not significant.

Lessons From the Aftermaths of Green Revolution on Food System and Health

Food production has seen various advancements globally in developing countries, such as India. One such advancement was the green revolution. Notably, the World Bank applauds the introduction of the green revolution as it reduced the rural poverty in India for a certain time. Despite the success of the green revolution, the World Bank reported that health outcomes have not been improved. During the post-green revolution period, several notable negative impacts arose. Exclusive studies were not conducted on the benefits and harms before the introduction of the green revolution. Some of such interventions deviate from the natural laws of balance and functioning and are unsustainable practices. To avoid the adverse effects of some of these developments, a review of these interventions is necessary.

Using Positive Deviance to Understand the Uptake of Optimal Infant and Young Child Feeding Practices by Mothers in an Urban Slum of Mumbai

Objectives Positive deviance research seeks out well-nourished children living in disadvantaged contexts to understand local growth-promoting behaviors. This study explored the factors that influence the uptake of infant and young child feeding behaviors among mothers. Methods Children with a height-for-age z-score (HAZ) > 0 (n = 10) or a HAZ < -2.0 (n = 12) were purposefully selected from households enrolled in a community management of acute malnutrition (CMAM) program in an urban slum of Mumbai, India. Qualitative methods were employed by means of semi-structured key informant interviews with positive and non-positive deviant mothers. Eligibility was restricted to households with limited resources and more than one child. A 24-h dietary recall and anthropometric measurements were taken for the index child. An observation checklist assessed household hygiene. Data analysis was based on the Grounded Theory of qualitative research. Results Positive deviant mothers (those with children with a HAZ > 0) largely exhibited optimal infant and young child feeding practices explained by maternal information seeking behaviors; mothers acknowledging the importance of maternal health; and social support. The relationship between mother and health worker seemed to influence how well they listened to the health workers' recommendations. Across all households, the daily consumption of high-energy, processed foods was apparent. Conclusions Practical considerations include exploring how to tailor CMAM programs to include social support and counseling training for health workers to engage more closely with mothers; exploring the feasibility of a women's social group for mothers to share information on child rearing; and teaching mothers about healthy eating and the link between nutrition and health.

Comparison of food consumption in Indian adults between national and sub-national dietary data sources

Accurate data on dietary intake are important for public health, nutrition and agricultural policy. The National Sample Survey is widely used by policymakers in India to estimate nutritional outcomes in the country, but has not been compared with other dietary data sources. To assess relative differences across available Indian dietary data sources, we compare intake of food groups across six national and sub-national surveys between 2004 and 2012, representing various dietary intake estimation methodologies, including Household Consumption Expenditure Surveys (HCES), FFQ, food balance sheets (FBS), and 24-h recall (24HR) surveys. We matched data for relevant years, regions and economic groups, for ages 16-59. One set of national HCES and the 24HR showed a decline in food intake in India between 2004-2005 and 2011-2012, whereas another HCES and FBS showed an increase. Differences in intake were smallest between the two HCES (1 % relative difference). Relative to these, FFQ and FBS had higher intake (13 and 35 %), and the 24HR lower intake (-9 %). Cereal consumption had high agreement across comparisons (average 5 % difference), whereas fruit and nuts, eggs, meat and fish and sugar had the least (120, 119, 56 and 50 % average differences, respectively). Spearman's coefficients showed high correlation of ranked food group intake across surveys. The underlying methods of the compared data highlight possible sources of under- or over-estimation, and influence their relevance for addressing various research questions and programmatic needs.

Going global: Indian adolescents’ eating patterns

Objective

To describe adolescents’ eating patterns of traditional, global/non-local and mixed foods, and the factors that may influence food consumption, access and preferences, in a globalizing city.

Design

A representative sample of school-going adolescents completed a cross-sectional survey including an FFQ designed to identify traditional and global foods. Student’sttest and ordinal logistic regression were used to examine weekly food intake, including differences between boys and girls and between adolescents attending private and public schools.

Setting

Vijayapura city, Karnataka State, India.

Subjects

Adolescents (n399) aged 13–16 years.

Results

Compared with dietary guidelines, adolescents consumed fruit, green leafy vegetables, non-green leafy vegetables and dairy less frequently than recommended and consumed energy-dense foods more frequently than recommended. Traditional but expensive foods (fruits, dairy, homemade sweets and added fat) were more frequently consumed by private-school students, generally from wealthier, more connected families, than by public-school students; the latter more frequently consumed both traditional (tea, coffee, eggs) and mixed foods (snack and street foods;P≤0·05). Girls reported more frequent consumption of global/non-local packaged and ready-to-eat foods, non-green leafy vegetables and added fat than boys (P≤0·05). Boys reported more frequent consumption of eggs and street foods than girls (P≤0·05).

Conclusions

Adolescents’ eating patterns in a globalizing city reflect a combination of global/non-local and traditional foods, access and preferences. As global foods continue to appear in low- and middle-income countries, understanding dietary patterns and preferences can inform efforts to promote diversity and healthfulness of foods.

Burden of healthcare utilization and out-of-pocket costs among individuals with NCDs in an Indian setting

Non communicable diseases (NCDs) are now the major cause of death and disability worldwide. It increasingly affects people from developing as well as developed countries. Over the coming decades the burden from NCDs is projected to rise particularly fast in the developing world. There is a lack of optimal data collection about the burden of risk factors related to NCDs especially in the developing countries. To assess the burden of healthcare utilization and out-of-pocket costs associated with NCDs in an Indian setting. A cross sectional study was performed to enroll a convenient sample of 166 participants aged 18 years and above from a tertiary hospital in Punjab, a Northern state of India. The data was gathered during the period of Feb 2010-April 2010. A mixed methods approach was used to assess the burden of diabetes, hypertension, high cholesterol, and their associated risk factors. Further we evaluated the burden of healthcare utilization and out-of-pocket costs associated with these conditions using self-reported assessments. Results showed the average age of the participants was 50 years, 63 % (n = 104) were females, 32 % (n = 53) had education less than high school and 20 % (n = 33) had no formal education. About 96 % of the study participants were living with a partner. Majority of the study participants were non-smokers and 17 % (n = 27) of them reported to have history of alcohol consumption. The majority of the participants had access to cell phones (94 %; n = 156) and about 40 % (n = 66) had computers at home. About 33 % (n = 55) of the study participants had some form of previous knowledge of computers. Majority of the study participants went to the private hospital (47.5 %) for seeking healthcare. About 32 % (n = 53) also sought healthcare from some kind of healthcare professional including a primary care doctor or a nurse or even a pharmacist in a village setting. Doctor visits related to diabetes were higher as compared to the individuals either with hypertension or high cholesterol. However; the out-of-pocket costs of the visit to the healthcare professional were much higher for hypertension than for diabetes or high cholesterol. A strengthened surveillance system, effective inter-sectoral action, and improved access to basic healthcare are pivotal to prevent NCDs. A multifaceted NCDs surveillance system could help us measure the burden of risk factors, its associated health care utilization and out of pocket costs, and further facilitate interventions that can guide evidence based decision making.

The acceptability, feasibility and impact of a lay health counsellor delivered health promoting schools programme in India: a case study evaluation

Background

Studies in resource-limited settings have shown that there are constraints to the use of teachers, peers or health professionals to deliver school health promotion interventions. School health programmes delivered by trained lay health counsellors could offer a cost-effective alternative. This paper presents a case study of a multi-component school health promotion intervention in India that was delivered by lay school health counsellors, who possessed neither formal educational nor health provider qualifications.

Methods

The intervention was based on the WHO’s Health Promoting Schools framework, and included health screening camps; an anonymous letter box for student questions and complaints; classroom-based life skills training; and, individual psycho-social and academic counselling for students. The intervention was delivered by a lay school health counsellor who had attained a minimum of a high school education. The counsellor was trained over four weeks and received structured supervision from health professionals working for the implementing NGO. The evaluation design was a mixed methods case study. Quantitative process indicators were collected to assess the extent to which the programme was delivered as planned (feasibility), the uptake of services (acceptability), and the number of students who received corrective health treatment (evidence of impact). Semi-structured interviews were conducted over two years with 108 stakeholders, and were analysed to identify barriers and facilitators for the programme (feasibility), evaluate acceptability, and gather evidence of positive or negative effects of the programme.

Results

Feasibility was established by the high reported coverage of all the targeted activities by the school health counsellor. Acceptability was indicated by a growing number of submissions to the students’ anonymous letter-box; more students self-referring for counselling services over time; and, the perceived need for the programme, as expressed by principals, parents and students. A minority of teachers complained that there was inadequate information sharing about the programme and mentioned reservations about the capacities of the lay health counsellor. Preliminary evidence of the positive effects of the programme included the correction of vision problems detected in health screening camps, and qualitative evidence of changes in health-related knowledge and behaviour of students.

Conclusion

A task-shifting approach of delegating school health promotion activities to lay school health counsellors rather than education or health professionals shows promise of effectiveness as a scalable model for promoting the health and well being of school based adolescents in resource constrained settings.

Cardiovascular autonomic responses to hyperinsulinemia in young adult males of normal and low body mass index

Acute hyperinsulinemia increases sympathetic nervous system activity, it is unclear if individuals of low body mass index (BMI) have different responses from those of normal BMI. Approximately 30% of adults in India have a low BMI and are likely to become hyperinsulinemic as they transition to better nutritional planes. We evaluated whether individuals of low BMI had different autonomic nervous responses to acute hyperinsulinemia as compared with individuals of normal BMI. 51 young men were divided into 2 groups based on their BMI. All subjects underwent anthropometry, physical activity levels and a hyperinsulinemic euglycemic clamp (HEC). Lead II ECG and beat to beat blood pressure were recorded during the HEC. Basal insulin level and steady state plasma insulin values during HEC were significantly higher in the normal BMI. Insulin sensitivity and glucose disposal rates during the HEC were significantly higher in the low BMI group. LF-RR power (nu) increased and HF-RR power (nu) decreased with hyperinsulinemia, resulting in a significant increase in LF/HF ratio but with no between-group differences. There was a significant increase in low frequency systolic blood pressure variability and a significant reduction in baroreflex sensitivity in both the groups with hyperinsulinemia. However, there were no between-group differences in the magnitude of these responses. The present study indicates that insulin mediated activation of the autonomic nervous system was comparable between low and normal BMI groups in spite of differences in insulin sensitivity and body composition and suggests that insulin mediated autonomic nervous activation is affected by other factors.

Do burdens of underweight and overweight coexist among lower socioeconomic groups in India?

BACKGROUND

The coexistence of underweight and overweight in rapidly developing economies is well recognized. However, less is known about the socioeconomic patterning of underweight and overweight as economies move through the epidemiologic transition.

OBJECTIVE

The objective was to assess whether burdens of underweight and overweight coexist among lower socioeconomic groups in India.

DESIGN

Repeated cross-sectional analyses were conducted in nationally representative samples of 76,514 and 80,054 women aged 15-49 y drawn from the 1998-1999 and 2005-2006 Indian National Family Health Survey, respectively. Body mass index (in kg/m(2)) was used to measure weight status. We also calculated a ratio of the number of underweight women (<18.5) divided by the number of overweight women (>24.9). Indicators of socioeconomic status (SES) included wealth and education.

RESULTS

Although the ratio of underweight to overweight women decreased from 3.3 in 1998-1999 to 2.2 in 2005-2006, there were still considerably more underweight women than overweight women. It was only in the top wealth quintile and in groups with higher education that there was a slight excess of overweight women as compared with underweight women. There was a strong positive relation between SES and body mass index at both time points and across urban and rural areas. A positive relation between SES and body mass index was also observed for men in 2005-2006.

CONCLUSIONS

The distribution of underweight and overweight in India remains socially segregated. Despite rapid economic growth, India has yet to experience a situation in which underweight and overweight coexist in the low-SES groups.

Finding a policy solution to India's diabetes epidemic

In India, thirty-five million people have diabetes-a number expected to more than double by 2025, disproportionately affecting working-age people. The economic impact of this increase could be devastating to India's emerging economy. In this paper we discuss drivers of the epidemic, analyze current policies and practices in India, and conclude with recommendations, focusing on multisectoral and international collaboration. We see these recommendations as providing a blueprint for addressing diabetes in India by illuminating opportunities and barriers for policymakers and others.

Food, livestock production, energy, climate change, and health

Food provides energy and nutrients, but its acquisition requires energy expenditure. In post-hunter-gatherer societies, extra-somatic energy has greatly expanded and intensified the catching, gathering, and production of food. Modern relations between energy, food, and health are very complex, raising serious, high-level policy challenges. Together with persistent widespread under-nutrition, over-nutrition (and sedentarism) is causing obesity and associated serious health consequences. Worldwide, agricultural activity, especially livestock production, accounts for about a fifth of total greenhouse-gas emissions, thus contributing to climate change and its adverse health consequences, including the threat to food yields in many regions. Particular policy attention should be paid to the health risks posed by the rapid worldwide growth in meat consumption, both by exacerbating climate change and by directly contributing to certain diseases. To prevent increased greenhouse-gas emissions from this production sector, both the average worldwide consumption level of animal products and the intensity of emissions from livestock production must be reduced. An international contraction and convergence strategy offers a feasible route to such a goal. The current global average meat consumption is 100 g per person per day, with about a ten-fold variation between high-consuming and low-consuming populations. 90 g per day is proposed as a working global target, shared more evenly, with not more than 50 g per day coming from red meat from ruminants (ie, cattle, sheep, goats, and other digastric grazers).