Anura V. Kurpad

The International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE): design and methods

BackgroundThe primary aim of the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE) was to determine the relationships between lifestyle behaviours and obesity in a multi-national study of children, and to investigate the influence of higher-order characteristics such as behavioural settings, and the physical, social and policy environments, on the observed relationships within and between countries.Methods/designThe targeted sample included 6000 10-year old children from 12 countries in five major geographic regions of the world (Europe, Africa, the Americas, South-East Asia, and the Western Pacific). The protocol included procedures to collect data at the individual level (lifestyle, diet and physical activity questionnaires, accelerometry), family and neighborhood level (parental questionnaires), and the school environment (school administrator questionnaire and school audit tool). A standard study protocol was developed for implementation in all regions of the world. A rigorous system of training and certification of study personnel was developed and implemented, including web-based training modules and regional in-person training meetings.DiscussionThe results of this study will provide a robust examination of the correlates of adiposity and obesity in children, focusing on both sides of the energy balance equation. The results will also provide important new information that will inform the development of lifestyle, environmental, and policy interventions to address and prevent childhood obesity that may be culturally adapted for implementation around the world. ISCOLE represents a multi-national collaboration among all world regions, and represents a global effort to increase research understanding, capacity and infrastructure in childhood obesity.

Low maternal vitamin B12 status is associated with intrauterine growth retardation in urban South Indians.

Objective:To assess the maternal sociodemographic, anthropometric, dietary and micronutrient status in apparently healthy pregnant women in order to determine their associations with intrauterine growth retardation (IUGR).Design:Prospective observational study.Setting:Bangalore City, India.Subjects:A total of 478 women were recruited at 12.9±3.3 weeks of gestation and followed up at the first, second and third trimesters of pregnancy and at delivery. The dropout rate was 8.5%.Interventions:None.Main outcome measures:Birth weight was measured at hospital delivery.Results:The mean birth weight was 2.85±0.45 kg. In all, 28.6% of newborns were IUGR. There was a strong inverse relationship between maternal educational level and risk of IUGR. A low body weight at baseline was also associated with a high risk of IUGR. Compared with women in the highest quartile for second trimester weight gain, those in the lowest quartile had a significantly higher adjusted odds ratio (AOR: 3.98; 95% CI: 1.83, 8.65) for IUGR. Women in the lowest tertile for serum vitamin B12 concentration during each of the three trimesters of pregnancy had significantly higher risk of IUGR (AOR: 5.98, 9.28 and 2.81 for trimesters 1–3, respectively).Conclusions:The present study demonstrates associations between educational status, maternal weight and gestational weight gain with IUGR. Importantly, in a subsample, there were strong associations of vitamin B12 status with IUGR, suggesting that better socioeconomic conditions, improved nutritional status and early detection of vitamin B12 deficiency in pregnancy combined with appropriate interventions are likely to play an important role in reducing IUGR.Sponsorship:This research was partly supported by the GlaxoSmithKline Consumer Healthcare Ltd, India.

Sociodemographic patterning of non-communicable disease risk factors in rural India: a cross sectional study.

Objectives To investigate the sociodemographic patterning of non-communicable disease risk factors in rural India. Design Cross sectional study. Setting About 1600 villages from 18 states in India. Most were from four large states due to a convenience sampling strategy. Participants 1983 (31% women) people aged 20–69 years (49% response rate). Main outcome measures Prevalence of tobacco use, alcohol use, low fruit and vegetable intake, low physical activity, obesity, central adiposity, hypertension, dyslipidaemia, diabetes, and underweight. Results Prevalence of most risk factors increased with age. Tobacco and alcohol use, low intake of fruit and vegetables, and underweight were more common in lower socioeconomic positions; whereas obesity, dyslipidaemia, and diabetes (men only) and hypertension (women only) were more prevalent in higher socioeconomic positions. For example, 37% (95% CI 30% to 44%) of men smoked tobacco in the lowest socioeconomic group compared with 15% (12% to 17%) in the highest, while 35% (30% to 40%) of women in the highest socioeconomic group were obese compared with 13% (7% to 19%) in the lowest. The age standardised prevalence of some risk factors was: tobacco use (40% (37% to 42%) men, 4% (3% to 6%) women); low fruit and vegetable intake (69% (66% to 71%) men, 75% (71% to 78%) women); obesity (19% (17% to 21%) men, 28% (24% to 31%) women); dyslipidaemia (33% (31% to 36%) men, 35% (31% to 38%) women); hypertension (20% (18% to 22%) men, 22% (19% to 25%) women); diabetes (6% (5% to 7%) men, 5% (4% to 7%) women); and underweight (21% (19% to 23%) men, 18% (15% to 21%) women). Risk factors were generally more prevalent in south Indians compared with north Indians. For example, the prevalence of dyslipidaemia was 21% (17% to 33%) in north Indian men compared with 33% (29% to 38%) in south Indian men, while the prevalence of obesity was 13% (9% to 17%) in north Indian women compared with 24% (19% to 30%) in south Indian women. Conclusions The prevalence of most risk factors was generally high across a range of sociodemographic groups in this sample of rural villagers in India; in particular, the prevalence of tobacco use in men and obesity in women was striking. However, given the limitations of the study (convenience sampling design and low response rate), cautious interpretation of the results is warranted. These data highlight the need for careful monitoring and control of non-communicable disease risk factors in rural areas of India.

Mechanistic roles for calcium and vitamin D in the regulation of body weight

Low intakes of calcium and inadequate vitamin D status often cluster with higher prevalence rates of obesity. Consequently, there has been much interest in the mechanisms by which calcium and vitamin D could regulate body weight and adiposity. This review has focused on randomized controlled trials (RCTs) that have manipulated these nutrients and studied pathways of energy balance. Overall, there is consistent evidence that calcium and vitamin D increase whole body fat oxidation after single and multiple meals, and that calcium promotes a modest energy loss through increased faecal fat excretion. The evidence is equivocal for a greater diet‐induced thermogenesis, increased lipolysis, suppression of key lipogenic enzymes, decreased hunger ratings or reduced energy/macronutrient intake. Emerging evidence suggests a potential improvement in insulin sensitivity following vitamin D that would impinge on food intake and substrate oxidation. However, the very few RCTs on supplemental vitamin D and energy balance have not explored postprandial avenues of the hormones actions. Future efforts in this area need to define the threshold intake of these nutrients that would maximize metabolic and gastrointestinal outcomes. Such studies would provide a platform for endorsing the non‐skeletal role of calcium and vitamin D in human pathophysiology.

Vitamin B-12 Supplementation during Pregnancy and Early Lactation Increases Maternal, Breast Milk, and Infant Measures of Vitamin B-12 Status

Pregnant women in resource-poor areas are at risk of multiple micronutrient deficiencies, and indicators of low vitamin B-12 status have been associated with adverse pregnancy outcomes, including anemia, low birth weight, and intrauterine growth retardation. To evaluate whether daily oral vitamin B-12 supplementation during pregnancy increases maternal and infant measures of vitamin B-12 status, we performed a randomized, placebo-controlled clinical trial. Pregnant women <14 wk of gestation in Bangalore, India, were randomly assigned to receive daily oral supplementation with vitamin B-12 (50 μg) or placebo through 6 wk postpartum. All women were administered iron and folic acid supplements throughout pregnancy. One hundred eighty-three women were randomly assigned to receive vitamin B-12 and 183 to receive placebo. Compared with placebo recipients, vitamin B-12-supplemented women had significantly higher plasma vitamin B-12 concentrations at both the second (median vitamin B-12 concentration: 216 vs. 111 pmol/L, P < 0.001) and third (median: 184 vs. 105 pmol/L, P < 0.001) trimesters. At 6 wk postpartum, median breast milk vitamin B-12 concentration was 136 pmol/L in vitamin B-12-supplemented women vs. 87 pmol/L in the placebo group (P < 0.0005). Among vitamin B-12-supplemented women, the incidence of delivering an infant with intrauterine growth retardation was 33 of 131 (25%) vs. 43 of 125 (34%) in those administered placebo (P = 0.11). In a subset of infants tested at 6 wk of age, median plasma vitamin B-12 concentration was 199 pmol/L in those born to supplemented women vs. 139 pmol/L in the placebo group (P = 0.01). Infant plasma methylmalonic acid and homocysteine concentrations were significantly lower in the vitamin B-12 group as well. Oral supplementation of urban Indian women with vitamin B-12 throughout pregnancy and early lactation significantly increases vitamin B-12 status of mothers and infants. It is important to determine whether there are correlations between these findings and neurologic and metabolic functions. This trial was registered at clinicaltrials.gov as NCT00641862.

Television viewing and sleep are associated with overweight among urban and semi-urban South Indian children

BackgroundChildhood obesity is an emerging problem in urban Indian children and increases in childhood overweight and obesity may be major contributors to the adult obesity epidemic. Thus, identifying potential risk factors for childhood obesity and formulating early interventions is crucial in the management of the obesity epidemic. The present study was aimed at evaluating dietary and physical activity patterns as determinants of overweight in a sample of children.MethodsFive hundred and ninety eight children aged 6–16 years, visiting St. Johns Medical College Hospital, Bangalore City, India for minor complaints or routine checkups were recruited into the study. These children were studied for their physical activity patterns, sleep duration, sedentary habits and eating behaviours as potential determinants of overweight.ResultsDecreased duration of sleep and increased television viewing were significantly associated with overweight. Among the eating behaviours, increased consumption of fried foods was significantly associated with overweight.ConclusionOur data suggests that duration of sleep, television viewing and consumption of fried foods may be significant factors that contribute to overweight. Further longitudinal studies are needed to confirm these findings.

Effect of fortification with multiple micronutrients and n−3 fatty acids on growth and cognitive performance in Indian schoolchildren: the CHAMPION (Children's Health and Mental Performance Influenced by Optimal Nutrition) Study

BACKGROUND Fortification with multiple micronutrients has been shown to improve growth and cognitive performance among children in developing countries, but it is unknown whether higher concentrations are more effective than lower concentrations. OBJECTIVE We compared the effect of 2 different concentrations of a combination of micronutrients and n-3 (omega-3) fatty acids on indicators of growth and cognitive performance in low-income, marginally nourished schoolchildren in Bangalore, India. DESIGN In a 2-by-2 factorial, double-blind, randomized controlled trial, 598 children aged 6-10 y were individually allocated to 1 of 4 intervention groups to receive foods fortified with either 100% or 15% of the Recommended Dietary Allowance of micronutrients in combination with either 900 mg alpha-linolenic acid plus 100 mg docosahexaenoic acid or 140 mg alpha-linolenic acid for 12 mo. Anthropometric and biochemical assessments were performed at baseline and 12 mo. Cognitive performance was measured at baseline and at 6 and 12 mo. RESULTS The high micronutrient treatment significantly improved linear growth at 12 mo (0.19 cm; 0.01, 0.36) and short-term memory at 6 mo (0.11 SD; 0.01, 0.20) and was less beneficial on fluid reasoning at 6 (-0.10 SD; -0.17, -0.03) and 12 (-0.12 SD; -0.20, -0.04) mo than was the low micronutrient treatment, whereas no differences were observed on weight, retrieval ability, cognitive speediness, and overall cognitive performance. No significant differences were found between the n-3 treatments. CONCLUSIONS The high micronutrient treatment was more beneficial for linear growth than was the low micronutrient treatment. However, with some small differential effects, higher micronutrient concentrations were as effective as lower concentrations on cognitive performance. This trial was registered at clinicaltrials.gov as NCT00467909.

Effect of Caralluma Fimbriata extract on appetite, food intake and anthropometry in adult indian men and women

Caralluma fimbriata is an edible cactus, used by tribal Indians to suppress hunger and enhance endurance. The effect of Caralluma extract was assessed in overweight individuals by a placebo controlled randomized trial. Fifty adult men and women (25-60 years) with a body mass index (BMI) greater than 25 kg/m2 were randomly assigned into a placebo or experimental group; the latter received 1 g of Caralluma extract per day for 60 days. All subjects were given standard advice regarding a weight reducing diet and physical activity. At the end of 30 and 60 days of intervention, blood glucose and lipids, anthropometric measurements, dietary intake and assessment of appetite was performed. Waist circumference and hunger levels over the observation period showed a significant decline in the experimental group when compared to the placebo group. While there was a trend towards a greater decrease in body weight, body mass index, hip circumference, body fat and energy intake between assessment time points in the experimental group, these were not significantly different between experimental and placebo groups. Caralluma extract appears to suppress appetite, and reduce waist circumference when compared to placebo over a 2 month period.

Iron fortification reduces blood lead levels in children in Bangalore, India.

OBJECTIVE. Chronic lead poisoning and iron deficiency are concentrated in urban children from lower socioeconomic strata, and both impair neurocognitive development. Our study objective was to determine if iron fortification reduces blood lead levels in urban, lead-exposed, iron-deficient children in Bangalore, India. DESIGN, SETTING, AND PARTICIPANTS. A randomized, double-blind, controlled school-based feeding trial was done in 5- to 13-year-old iron-deficient children (n = 186). At baseline, a high prevalence of lead poisoning was found in the younger children. Subsequently, all 5- to 9-year-old children participating in the trial (n = 134) were followed to determine if iron fortification would affect their blood lead levels. INTERVENTION. Children were dewormed and fed 6 days/week for 16 weeks either an iron-fortified rice meal (∼15 mg of iron per day as ferric pyrophosphate) or an identical control meal without added iron. Feeding was directly supervised and compliance monitored. OUTCOME MEASURES. Hemoglobin, serum ferritin, C-reactive protein, transferrin receptor, zinc protoporphyrin, and blood lead concentrations were measured. RESULTS. The prevalence of iron deficiency was significantly reduced in the iron group (from 70% to 28%) compared with the control group (76% to 55%). There was a significant decrease in median blood lead concentration in the iron group compared with the control group. The prevalence of blood lead levels ≥10 μg/dL was significantly reduced in the iron group (from 65% to 29%) compared with the control group (68% to 55%). CONCLUSIONS. Our findings suggest providing iron in a fortified food to lead-exposed children may reduce chronic lead intoxication. Iron fortification may be an effective and sustainable strategy to accompany environmental lead abatement.

Physical Activity, Sedentary Time, and Obesity in an International Sample of Children

PURPOSE To determine the relationships between moderate-to-vigorous physical activity (MVPA), vigorous physical activity (VPA), sedentary time, and obesity in children from 12 countries representing a wide range of human development. METHODS The sample included 6539 children age 9-11 yr. Times in MVPA, VPA, and sedentary behaviors were assessed by accelerometry. The body mass index (BMI; kg·m) was used to classify children as obese based on z-scores (> +2 SD) from World Health Organization reference data. RESULTS The mean (SD) times spent in MVPA, VPA, and sedentary behavior were 60 (25) min·d, 18 (11) min·d, and 513 (69) min·d, respectively. The overall proportion of the sample that was obese ranged from 5.2% to 24.6% across sites. The odds ratios for obesity were significant for MVPA (0.49; 95% CI, 0.44-0.55), VPA (0.41; 0.37-0.46), and sedentary time (1.19; 1.08-1.30) in the overall sample. The associations of MVPA and VPA with obesity were significant in all 12 sites, whereas the association between sedentary time and obesity was significant in five of the 12 sites. There was a significant difference in BMI z-scores across tertiles of MVPA (P < 0.001) but not across tertiles of sedentary time in a mutually adjusted model. The results of receiver operating characteristic curve analyses for obesity indicated that the optimal thresholds for MVPA (area under the curve [AUC], 0.64), VPA (AUC, 0.67) and sedentary behavior (AUC, 0.57) were 55 (95% CI, 50-64) min·d, 14 (11-16) min·d, and 482 (455-535) min·d, respectively. CONCLUSIONS Greater MVPA and VPA were both associated with lower odds of obesity independent of sedentary behavior. Sedentary time was positively associated with obesity, but not independent of MVPA. Attaining at least 55 min·d of MVPA is associated with lower obesity in this multinational sample of children, which supports current guidelines.