A Randomized Trial of Iron-Biofortified Pearl Millet-Based Complementary Feeding in Children Aged 12 to 18 Months Living in Urban Slums in India

Objectives

To determine the efficacy of iron-biofortified pearl millet (FePM, Dhanashakti, ICTP-8203Fe)-based complementary feeding on iron status and growth, in children living in urban slums of Mumbai, India.

Methods

This randomized controlled feeding trial of FePM was conducted among 223 children aged 12 to 18 months who were not severely anemic (hemoglobin (Hb) ≥9.0 g/dL) (Clinicaltrials.gov ID: NCT02233764). Children were randomized to receive either complementary foods prepared from FePM or conventional non-biofortified pearl millet (CPM) daily for 9 months. Iron status (Hb, serum ferritin (SF)), and anthropometric indicators (i.e., length, weight, head, mid-upper arm circumferences, triceps and subscapular skinfolds) were evaluated at enrollment and throughout the trial. World Health Organization (WHO) anthropometric Z-scores were calculated using WHO growth standards. Primary outcomes were Hb and SF concentrations, and growth, defined as WHO Z-scores. An intent to treat approach was used for analyses. We used the Hodges–Lehmann–Sen test to assess the change in primary outcomes between baseline and the last visit and report corresponding 95% confidence intervals.

Results

At baseline, 67.7% of children were anemic (Hb < 11.0 g/dL) and 59.6% were iron-deficient (SF < 12.0 µg/L). FePM did not significantly increase iron biomarkers or improve growth, compared to CPM. In subgroup analyses, FePM improved hemoglobin concentrations in male children, and in children with iron deficiency or iron depletion (SF < 25.0 µg/L) at baseline, compared to CPM.

Conclusions

Daily consumption of FePM-based complementary foods did not significantly improve iron status or growth in children living in this population. However, the intervention significantly improved hemoglobin concentrations among male children and individuals who were iron-deficient or iron-depleted at baseline.

Funding Sources

HarvestPlus.

Sustainability of integrated anaemia prevention activities implemented through non-government organizations and schools, and its effect on haemoglobin status of adolescent girls in urban slums of Pune, in Maharashtra, India

BACKGROUND

Programmes for the prevention of iron deficiency anaemia among adolescent girls need sustainable inputs for maximum benefits.

AIM

To assess the interventions sustained for anaemia prevention implemented through NGOs and schools.

METHODS

An intervention study followed longitudinally in three phases. Phase I comprised (a) needs assessment of the community and (b) capacity assessment of service providers through a cross-sectional survey in nine slums, through six NGOs and three schools. Based on needs assessment, an integrated intervention for anaemia prevention was provided for adolescent girls (n = 384) in the community. To ensure sustainability the capacity of stakeholders (n = 67) was built by providing training in the components of the integrated intervention and establishing linkages with the public health system. Refresher training was conducted during phase II (n = 69) for reinforcing and strengthening of activities introduced in phase I. In phase II and III continuations of activities by the NGOs and schools that were initiated in phase I were monitored. Sustainability of activities was measured using an index that comprised technical, programmatic, social, and financial indicators. The impact of sustained interventions was assessed by comparing the mean rank haemoglobin concentrations of centres with varying levels of coverage.

RESULTS

Scores of sustainability indicators decreased from phase II to phase III. Organizations that showed > 50% coverage showed significantly higher mean rank haemoglobin (p = < 0.05) during phases II and III.

CONCLUSION

There is a need to identify and address barriers that prevent sustainable interventions for anaemia control.

Nutrient-Dense Meal Delivery in Partnership with Small-Scale Producers in Mumbai Urban Slums: Implementation Considerations Within a Randomized Controlled Feeding Trial

Objectives

Despite the multitude of evaluations of nutrition intervention trials in low-income settings, documented practice to operate such trials is scarce. We aimed to fill this gap by outlining key steps and resources required to run a small-scale intensive feeding trial such as establishing collaborations, developing an operational infrastructure, and daily orchestration of logistics for food preparation, delivery, and administration.

Methods

A randomized controlled feeding trial among 223 children in urban slums of Mumbai, India was completed in 2018. We established partnerships to facilitate the acquisition and proper storage of the study intervention, biofortified and conventional pearl millet. Feeding centers (FC) were identified based on a census. Two staff per FC managed daily operations: weighing and dispensing individual portions to participants based on their group allocation, recording of leftovers and adverse events.

The study team developed and standardized recipes for all menu items. Development considered staple crop and nutrient density per serving, cost and availability of ingredients, and scalability. Highly accepted recipes were included in a cyclic menu. Hot meals were prepared in partnership with the university canteen, where a kitchen coordinator was responsible for daily quality control, aliquoting, and dispensation to contracted auto-drivers for FC delivery. A certified bakery produced customized shelf stable items in bulk. Items were vacuum packed individually, labeled, and delivered to FC directly. Shelf-life was tested periodically.

Results

Over 26 tons of crops were procured at a cost of 25,000 USD. The cost of preparing and delivering about 30,000 fresh meals was about 15,000 USD, while the cost of approximately 60,000 shelf stable meals was about 10,000 USD. Over 15 months, we served 91,815 meals at a cost of 0.59 USD/meal in the context of a randomized controlled feeding trial.

Conclusions

We highlight opportunities and challenges of developing a sustainable food supply system for an intervention trial. We also outline a sustainable model for delivery of nutrient-dense meals in partnership with small-scale producers instead of establishing a centralized kitchen to facilitate advocacy and scale up.

Funding Sources

HarvestPlus.

Anemia and Micronutrient Deficiencies in Young Children in Urban Slums of Mumbai, India

Objectives

To examine the burden of anemia and micronutrient deficiencies among young children living in urban slums of Mumbai, India.

Methods

Participants were children 10–18 months of age (n = 278) residing in urban slums in Mumbai who were screened as part of a randomized feeding trial of biofortified pearl millet. Venous blood was collected by a pediatric phlebotomist and hemoglobin (Hb) concentrations were assessed via Coulter counter. Samples were processed and stored &lt;−80°C until laboratory analyses. Serum ferritin (SF), vitamin B12, and erythrocyte (RBC) folate concentrations were analyzed via chemiluminescence. C-reactive protein (CRP) was analyzed by nephelometry, α-1 acid glycoprotein (AGP) was analyzed by spectrophotometry, and serum retinol was evaluated via HP-LC. Serum ferritin and serum retinol levels were adjusted for inflammation using methods proposed by Thurman. Anemia and severe anemia were defined as Hb &lt; 11.0 g/dL and Hb &lt; 7.0 g/dL. Iron deficiency (ID) was defined as SF &lt; 12.0 µg/L, iron insufficiency was defined as SF &lt; 20.0 µg/L, and inflammation was defined as CRP &gt; 5.0 mg/L. Iron deficiency anemia was defined as Hb &lt; 11.0 g/dL and SF &lt; 12.0 µg/L. Vitamin A deficiency was defined as serum retinol &lt;20.0 µg/L. Vitamin B12 deficiency and vitamin B12 insufficiency were defined as &lt;148.0 pmol/L and &lt;221.0 pmol/L; folate deficiency was defined as RBC folate &lt;340 nmol/L. Linear and binomial regression models were used to examine associations of micronutrient biomarkers with Hb levels and risk of anemia.

Results

A total of 75.5% of children were anemic and 2.9% had severe anemia. The prevalence of iron deficiency was 61.4% (69.5% after Thurman adjustment), 57.4% of children had IDA, and 9.7% had CRP &gt; 5.0 mg/L. The prevalence of vitamin B12 deficiency was 17.0%, 41.8% of children had vitamin B12 insufficiency, and 19.9% had folate deficiency. Among anemic children, 84.5% had ≥1 micronutrient deficiency and 22.7% had ≥ 2 micronutrient deficiencies. Iron deficiency (RR: 2.15; 95% CI: 1.55, 2.99; P &lt; 0.001), and vitamin B12 deficiency (RR: 1.32; 95% CI: 1.09, 1.60; P &lt; 0.01) were associated with significantly increased risk of anemia.

Conclusions

Findings indicate that the burden of anemia, iron deficiency, and vitamin B12 insufficiency were high in young children in Mumbai, India.

Funding Sources

Harvest Plus; AF was supported by the National Institutes of Health.

Prevalence and Correlates of Undernutrition in Young Children Living in Urban Slums of Mumbai, India: A Cross Sectional Study

Background: Young children living in urban slums are vulnerable to malnutrition and subsequently poor health outcomes, but data on the correlates of stunting, underweight, wasting, and anemia specifically among 10-18 month-old children in India remain limited. Objective: In this analysis, we sought to describe the prevalence of and examine correlates for different markers of undernutrition, including stunting, underweight, and anemia among 10-18 month-old children living in urban slums, an understudied vulnerable group. Methods: Children and their mothers (n = 323) were screened for anthropometry, demographics, and complete blood counts for hemoglobin concentration between March and November 2017 (Clinicaltrials.gov ID: NCT02233764). Correlates included child and mother's age, sex, birth order, birth weight, illness episodes, hemoglobin concentration, family income, maternal height, and maternal education level. Risk ratios (RR, 95% CI) for binary outcomes (stunting, underweight, wasting and anemia) and mean differences (β, 95% CI) for continuous outcomes (anthropometric Z-scores, hemoglobin concentration) were calculated using multivariate binomial and linear regression (SAS 9.4). Results: The prevalence of stunting was 31.2%, underweight 25.1%, wasting (9.0%), and anemia (76%) among all children. Male children had a higher prevalence of poor growth indices and lower anthropometric Z-scores than females. Male sex, low birthweight, shorter maternal height, report of ≥1 episodes of illness within the past month, older maternal age, and birth order ≥2 were also associated with poor growth and anemia in multivariate models. Correlates of undernutrition were different among females and males. Female children had a 40% (20, 60%) higher risk of anemia associated with diarrhea, and male children who were firstborn had a 20% (0, 70%) lower risk of anemia. Conclusions: These results show that poor growth and anemia among young children is prevalent in urban slums of Mumbai, and that sex of the child may play an important role in informing interventions to address undernutrition.

Corrigendum: Acceptability of Iron- and Zinc-Biofortified Pearl Millet (ICTP-8203)-Based Complementary Foods among Children in an Urban Slum of Mumbai, India

[This corrects the article DOI: 10.3389/fnut.2017.00039.].

Effect of iron and zinc-biofortified pearl millet consumption on growth and immune competence in children aged 12-18 months in India: study protocol for a randomised controlled trial

INTRODUCTION

Biofortified crops represent a sustainable agricultural solution for the widespread micronutrient malnutrition in India and other resource-limited settings. This study aims to investigate the effect of the consumption of foods prepared with iron- and zinc-biofortified pearl millet (FeZn-PM) by children on biomarkers of iron and zinc status, growth, and immune function.

METHODS AND ANALYSIS

We will conduct a randomised controlled feeding trial in identified slums of Mumbai, India among 200 children aged between 12 and 18 months. Children will be randomised to receive foods prepared with the biofortified PM (FeZn-PM, ICTP8203-Fe) or non-biofortified PM. Anthropometric and morbidity data will be gathered every month for 9 months. Biological samples will be collected at baseline, midline and endline to assess iron and zinc status, including haemoglobin, serum ferritin, serum transferrin receptor, serum zinc, C-reactive protein and alpha-1 acid glycoprotein. Biological samples will be archived for future analyses. The midline measurement will be a random serial sample between baseline and endline. Immune function will be assessed at each time point by the measurement of T cell counts and vaccine responses in a subset, respectively.

ETHICS AND DISSEMINATION

This study has obtained clearance from the Health Ministry Screening Committee of the Indian Council of Medical Research. Ethical clearance has been obtained from Cornell University's Institutional Review Board, the Inter System Biomedica Ethics Committee and St John's Research Institute's Institutional Ethics Review Board. The results of this study will be disseminated at several research conferences and as published articles in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Clinical trial registration number NCT02233764. CTRI registration number REF/2014/10/007731.

Acceptability of Iron- and Zinc-Biofortified Pearl Millet (Dhanashakti)-Based [corrected] Complementary Foods among Children in an Urban Slum of Mumbai, India

Biofortification, a method for increasing micronutrient content of staple crops, is a promising strategy for combating major global health problems, such as iron and zinc deficiency. We examined the acceptability of recipes prepared using iron- and zinc-biofortified pearl millet (FeZnPM) (~80 ppm Fe, ~34 ppm Zn, varietal ICTP-8203), compared to conventional pearl millet (CPM) (~20 ppm Fe, ~19 ppm Zn) in preparation for an efficacy trial. Our objective was to examine the acceptability of FeZnPM compared to CPM among young children and mothers living in the urban slums of Mumbai. Standardized traditional feeding program recipes (n = 18) were prepared with either FeZnPM or CPM flour. The weight (g) of each food product was measured before and after consumption by children (n = 125) and the average grams consumed over a 3-day period were recorded. Mothers (n = 60) rated recipes using a 9-point hedonic scale. Mean intakes and hedonic scores of each food product were compared using t-tests across the two types of pearl millet. There were no statistically significant differences in consumption by children (FeZnPM: 25.27 ± 13.0 g; CPM: 21.72 ± 6.90 g) across the food products (P = 0.28). Overall mean hedonic scores for all recipes were between 7 to 9 points. CPM products were rated higher overall (8.22 ± 0.28) compared to FeZnPM products (7.95 ± 0.35) (P = 0.01). FeZnPM and CPM were similarly consumed and had high hedonic scores, demonstrating high acceptability in this population. These results support using these varieties of pearl millet in a proposed trial [http://Clinicaltrials.gov ID: NCT02233764; Clinical Trials Registry of India (CTRI), reference number REF/2014/10/007731, CTRI number CTRI/2015/11/006376] testing the efficacy of FeZnPM for improving iron status and growth.

Is lack of breakfast contributing to nutrient deficits and poor nutritional indicators among adolescent girls?

BACKGROUND

Breakfast is considered the first and most important meal of the day. Missing the first meal may result in significant nutritional deficits, if not compensated in subsequent meals.

AIM

To describe the nutrient intake through breakfast and to study its association with nutritional indicators among adolescent girls.

METHODS

A cross-sectional study among adolescent girls ( n = 565) 16-18 years was carried out in urban slums of Pune, Maharashtra, India. Haemoglobin was assessed by cyanmethemoglobin method. Nutritional status was assessed through anthropometry and three 24-hours diet recall. Z scores, independent sample test, and linear logistic regression were used to assess undernutrition, to compare means of nutrient intake and to associate nutrient intake with nutritional status, respectively.

RESULTS

Almost 50% did not consume solid food for breakfast and 99% of the participants consumed inadequate breakfast (<610 kcal). Two types of breakfast emerged: I (bakery products + beverage) and II (traditional breakfast + beverage). Although the mean energy intake of type II breakfast (235±100.55 kcal) and the mean micronutrient intake was significantly higher than type I (micronutrients: vitamin C and folate ( p = 0.001), iron ( p = 0.01)) it did not meet the adequacy norms for breakfast. Among nutritional indicators breakfast intake was not directly associated with body mass index. However, mean intake of nutrients such as energy, protein and iron through the day were significantly lesser ( p = 0.001, p = 0.01 and p = 0.01 respectively) among anaemic adolescents. Linear regression showed significant association between energy, fat intake and BAZ scores.

CONCLUSIONS

Compensating dietary deficits that arise in the first meal would directly address the day's nutrient deficit. The results highlight the need for a food-based approach to address undernutrition among adolescent girls in resource-poor settings.

Folate Status and Intake of Tribal Indian Adolescents Aged 10 to 17 Years

Background

Adequate folate intake and levels are advisable throughout life but are of particular importance during adolescence, a period of rapid growth. However, folate insufficiency in economically deprived Indian adolescents is understudied.

Objective

This cross-sectional study examined the prevalence of folate deficiency and adequacy of folate intake of 224 tribal Indian adolescents (10 to 17 years of age). The secondary aim was to study the association between anemia status and folate status.

Methods

Radioimmunoassay, multiple-pass 24-hour dietary recall, and HemoCue were used to measure red blood cell (RBC) folate, folate intake, and anemia status, respectively.

Results

The geometric mean (95% CI) RBC folate concentration (nmol/L) was 360.2 (329.7 to 393.6), and the mean ± SD folate intake (μg/day) and hemoglobin level (g/L) were 159.9 ± 44.7 and 125.4 ± 13.0, respectively. Almost half of boys and girls aged 10 to 12 and 13 to 15 years and 66.7% of girls aged 16 to 17 years were deficient in RBC folate (< 340 nmol/L). The mean ± SD folate intake (μg/day) of girls (139.4 ± 34.5) was lower than that of boys (173.8 ± 45.5) ( p < .001). With respect to adequacy of folate intake, a greater proportion of girls in the age group of 13–15 years (78.5% vs 38.6%, p < 0.001) and 16–17 years (100.0% vs 76.9%, p = 0.04) had intakes below their Recommended Dietary Allowance (RDA). No association was observed between folate intake and RBC folate deficiency or between anemia status and RBC folate deficiency.

Conclusions

Folate insufficiency was widespread in tribal Indian adolescents. There is an urgent need to develop culturally sensitive strategies for improvement.

Mid-Upper-Arm Circumference (MUAC) as a Simple Measure to Assess the Nutritional Status of Adolescent Girls as Compared With BMI

Background. The use of mid-upper-arm circumference (MUAC) as a screening measure for assessing undernutrition has the following advantages: makes use of simple equipment, is easy to carry to field sites, and requires minimal training. MUAC cutoffs for undernutrition are available for children and adults but not for adolescents. Objective. To compare MUAC with BMI in assessing undernutrition among adolescent girls and to evaluate the sensitivity and specificity of MUAC as a tool in assessing their nutritional status. Methodology. A total of 565 unmarried adolescent girls of both school-going and non-school-going age (16-18 years old) from the urban slums of Pune city Maharashtra, India, were recruited for the cross-sectional study. Anthropometric measurements, including height, weight, and MUAC were recorded. Results. The percentage of adolescents who were malnourished was 4.8% according to BMI and 5.0% for MUAC. BMI highly correlated with MUAC (r = 0.593), and MUAC as a screening tool showed 28.57% sensitivity and 96.46% specificity. Further studies among different age groups need to be carried out to arrive at standard cutoffs for MUAC.

Serum Retinol, α-tocopherol, and Lipid Peroxide Concentrations in Low-income Indian Pregnant Mothers

Serum α-tocopherol, retinol, and malondialdehyde concentrations were measured at 7th month of pregnancy in 122 women from low socio-economic background. Maternal anthropometric measurements, 24-hour nutrient intakes, and pregnancy outcome were recorded. One-third (34.3 %) of mothers had low birth weight babies and 10 % delivered preterm. Maternal diets were inadequate in all the nutrients, the most limiting being vitamin A. Three-fourths of mothers had intakes less than 25 % of the Indian recommended daily intake (RDI) of 600 µg retinol equivalents/day. Serum α-tocopherol concentrations of 98 % were indicative of deficiency and almost half the mothers had low serum retinol concentrations (≤10 µg/dL). Mean malondialdehyde level was 7.0 ± 1.4 nmoles/mL. These values are higher than reports in the literature and were attributable to poor intake of most dietary antioxidants. Malondialdehyde concentrations were negatively correlated with serum α-tocopherol. Birth weight was positively correlated with maternal weight and biceps skinfold thickness, macronutrient intakes, serum retinol, and α-tocopherol concentrations. Preterm delivery was associated with low anthropometric measurements and low nutrient intakes especially vitamin A. Mothers who delivered preterm had significantly lower malondialdehyde concentrations than those who delivered at term. The role of antioxidant nutrients, especially vitamin A and oxidative stress in relation to fetal growth and pregnancy outcome among mothers from low socioeconomic settings requires attention.

Nutrition in pregnancy and lactation

Nutrition at optimal levels is fundamental in the maintenance of positive health. Matemal nutrition is very important for the course and outcome of pregnancy. Lactation represents a stage wherein health and nutritional status of the infant are dependent on the mother. Successful pregnancy and lactation require adjustments in maternal body composition, metabolism and function of various physioogical systems. A diet that meets matemal nutritional needs is required for these adjustments, so that maternal well-being is safeguarded with birth of an healthy infant. Adequate nutrition supports the growth of both matemal and foetal tissues. Chronic undernutrition throughout pregnancy affects birth weights of newborns. Poor nutrition causes intra-uterine growth retardation. Specific nutrients like zinc, iodine and folate are also required for development of the foetus. Foetal iron deficiency exists in maternal iron deficiency anaemia. Maternal nutritional status, breast milk composition and volume are elaborated in the article. Proteins, fats, minerals and vitamins and their requirements are narrated in detail. Additional nutritional requirements during lactation have been tabulated in this article. Thus improving the nutrition and health of girls and younger women and of mothers during pregnancy and lactation will derive benefits in terms of improved health of their children throughout their lives.