H. P. S. Sachdev

Plant breeding to control zinc deficiency in India : How cost-effective is biofortification?

OBJECTIVE To estimate the potential impact of zinc biofortification of rice and wheat on public health in India and to evaluate its cost-effectiveness compared with alternative interventions and international standards. DESIGN The burden of zinc deficiency (ZnD) in India was expressed in disability-adjusted life years (DALYs) lost. Current zinc intakes were derived from a nationally representative household food consumption survey (30-day recall) and attributed to household members based on adult equivalent weights. Using a dose-response function, projected increased zinc intakes from biofortified rice and wheat were translated into potential health improvements for pessimistic and optimistic scenarios. After estimating the costs of developing and disseminating the new varieties, the cost-effectiveness of zinc biofortification was calculated for both scenarios and compared with alternative micronutrient interventions and international reference standards. SETTING India. SUBJECTS Representative household survey (n = 119 554). RESULTS The calculated annual burden of ZnD in India is 2.8 million DALYs lost. Zinc biofortification of rice and wheat may reduce this burden by 20-51% and save 0.6-1.4 million DALYs each year, depending on the scenario. The cost for saving one DALY amounts to

Water supplementation in exclusively breastfed infants during summer in the tropics.

US 0.73-7.31, which is very cost-effective by standards of the World Bank and the World Health Organization, and is lower than that of most other micronutrient interventions. CONCLUSIONS Not only may zinc biofortification save lives and prevent morbidity among millions of people, it may also help accommodate the need to economise and to allocate resources more efficiently. Further research is needed to corroborate these findings.

Potential impact and cost-effectiveness of Golden Rice.

This study was designed to determine the need for water supplementation to maintain water homoeostasis in exclusively breastfed infants during summer in a tropical country. A prestudy questionnaire revealed that 97% of 34 nurses and 63% of 70 doctors advocated such supplementation. 45 healthy, male, exclusively breastfed babies, aged 1-4 months, were recruited from a well-baby clinic. 9 who had never received supplemental water plus a random selection of 14 others were allocated to group I (breastmilk only); the remaining 22 infants were allocated to group II (breastmilk plus supplemental fluid according to the mothers usual practice). The babies were studied at the hospital for 8 h; breastmilk intake was measured by weighing the infant before and after each feed, water intake by calibrated bottles, and urine output by accurate collection and measurement. The maximum room temperatures were 34-41 degrees C and relative humidities 9-60% (below 50% in all but 3 infants). In group II the mean water intake was 11% (95% confidence interval 7-16%) of the total fluid intake. Both breastmilk intake (274 vs 210 ml) and total fluid intake (274 vs 233 ml) were higher in group I than in group II (p = 0.003, p = 0.073, respectively), after adjustment for age, weight, length, room temperature, and humidity. However, there were no significant differences between the groups in urine output, urine or serum osmolality, weight change, or rectal temperature whether or not the factors adjusted for included total fluid intake. Thus, exclusively breastfed infants do not need supplemental water to maintain water homoeostasis; a reduced breastmilk intake is a potential disadvantage of this practice.

Potential impacts of iron biofortification in India

Genetic engineering (GE) in agriculture is a controversial topic in science and society at large. While some oppose genetically modified crops as proxy of an agricultural system they consider unsustainable and inequitable, the question remains whether GE can benefit the poor within the existing system and what needs to be done to deliver these benefits? Golden Rice has been genetically engineered to produce provitamin A. The technology is still in the testing phase, but, once released, it is expected to address one consequence of poverty – vitamin A deficiency (VAD) – and its health implications. Current interventions to combat VAD rely mainly on pharmaceutical supplementation, which is costly in the long run and only partially successful. We develop a methodology for ex-ante evaluation, taking into account the whole sequence of effects between the cultivation of the crop and its ultimate health impacts. In doing so we build on a comprehensive, nationally representative data set of household food consumption in India. Using a refined disability-adjusted life year (DALY) framework and detailed health data, this study shows for India that under optimistic assumptions this country’s annual burden of VAD of 2.3 million DALYs lost can be reduced by 59.4% hence 1.4 million healthy life years could be saved each year if Golden Rice would be consumed widely. In a low impact scenario, where Golden Rice is consumed less frequently and produces less provitamin A, the burden of VAD could be reduced by 8.8%. However, in both scenarios the cost per DALY saved through Golden Rice (US

Effect of administration of intestinal anthelmintic drugs on haemoglobin: systematic review of randomised controlled trials

3.06-19.40) is lower than the cost of current supplementation efforts, and it outperforms international cost-effectiveness thresholds. Golden Rice should therefore be considered seriously as a complementary intervention to fight VAD in rice-eating populations in the medium term. JEL classifications: I0, I3, Q16, Q18.

RISK FACTORS FOR FATAL DIARRHEA IN HOSPITALIZED CHILDREN IN INDIA

Iron deficiency is a widespread nutrition and health problem in developing countries, causing impairments in physical activity and cognitive development, as well as maternal mortality. Although food fortification and supplementation programmes have been effective in some countries, their overall success remains limited. Biofortification, that is, breeding food crops for higher micronutrient content, is a relatively new approach, which has been gaining international attention recently. We propose a methodology for ex ante impact assessment of iron biofortification, building on a disability-adjusted life years (DALYs) framework. This methodology is applied in an Indian context. Using a large and representative data set of household food consumption, the likely effects of iron-rich rice and wheat varieties are simulated for different target groups and regions. These varieties, which are being developed by an international public research consortium, based on conventional breeding techniques, might be ready for local distribution within the next couple of years. The results indicate sizeable potential health benefits. Depending on the underlying assumptions, the disease burden associated with iron deficiency could be reduced by 19-58%. Due to the relatively low institutional cost to reach the target population, the expected cost-effectiveness of iron biofortification compares favourably with other micronutrient interventions. Nonetheless, biofortification should not be seen as a substitute for other interventions. Each approach has its particular strengths, so they complement one another.

Predicting adult metabolic syndrome from childhood body mass index: follow-up of the New Delhi birth cohort

Objective To evaluate the effect of routine administration of intestinal anthelmintic drugs on haemoglobin. Design Systematic review of randomised controlled trials. Data sources Electronic databases and hand search of reviews, bibliographies of books, and abstracts and proceedings of international conferences. Study selection Included studies were randomised or quasi-randomised controlled trials using an intestinal anthelmintic agent in the intervention group, in which haemoglobin was evaluated as an outcome measure. Trials in which treatment for schistosoma (praziquantel) was given exclusively to the intervention group were excluded. Results The search identified 14 eligible randomised controlled trials. Data were available for 7829 subjects, of whom 4107 received an anthelmintic drug and 3722 received placebo. The pooled weighted mean difference (random effect model) of the change in haemoglobin was 1.71 (95% confidence interval 0.70 to 2.73) g/l (P<0.001; test for heterogeneity: Cochran Q=51.17, P<0.001; I2=61% (37% to 76%)). With the World Health Organizations recommended haemoglobin cut-offs of 120 g/l in adults and 110 g/l in children, the average estimated reduction in prevalence of anaemia ranged from 1.1% to 12.4% in adults and from 4.4% to 21.0% in children. The estimated reductions in the prevalence of anaemia increased with lower haemoglobin cut-offs used to define anaemia. Conclusions Routine administration of intestinal anthelmintic agents results in a marginal increase in haemoglobin (1.71 g/l), which could translate on a public health scale into a small (5% to 10%) reduction in the prevalence of anaemia in populations with a relatively high prevalence of intestinal helminthiasis.

Oral rehydration of neonates and young infants with dehydrating diarrhea: comparison of low and standard sodium content in oral rehydration solutions.

There is scant information on the risk factors for diarrheal deaths in developing countries. A prospective evaluation was therefore conducted on 382 consecutive children (<5 years of age), who were hospitalized with diarrhea. A complete profile, including outcome, was available for 357 patients, 37 of whom died (10.4%). In the univariate analysis, four factors were significantly associated (p < 0.02) with death: associated major infection {pneumonia, septicemia, or meningitis), severe wasting (±50% weight for age), severe stunting (±85% height for age), and protraction of illness (>14 days). In the multivariate analysis, all four factors retained their significance. The adjusted odds ratios (95% confidence interval) were 4.7 (3.9, 5.6), 3.3 (2.7, 4.0), 1.9 (1.6, 2.3), and 1.5 (1.3, 1.8), respectively. In addition, in children <19 months of age (n = 241; 29 deaths) breast-feeding had a significant (p < 0.001) protective effect (adjusted OR—2.3, 95% CI—1.9–2.8). It is concluded that even in a setting with high diarrheal fatality rates, high-risk children can be identified and targeted for intensive intervention.

Controlled trial of rice powder and glucose rehydration solutions as oral therapy for acute dehydrating diarrhea in infants.

Objectives: To assess whether serial measurements of childhood body mass index (BMI) give clinically useful predictions of the risk of developing adult metabolic syndrome and impaired glucose tolerance or type 2 diabetes. Design/setting: Follow-up of a community-based birth cohort in Delhi, India. Participants: 1492 men and women aged 26–32 years whose BMI was recorded 6-monthly throughout childhood. Main outcome measures: The predictive value of childhood BMI for adult metabolic syndrome and impaired glucose tolerance (IGT) and diabetes mellitus. Results: 25% of subjects had metabolic syndrome and 15% had IGT/diabetes mellitus. Both outcomes were associated with greater childhood BMI gain (metabolic syndrome: OR 1.63 (95% CI 1.44 to 1.85); IGT/diabetes mellitus: 1.39 (1.20 to 1.60) per unit increase in within-cohort BMI SD score between 5 and 14 years). The best predictions of adult disease were obtained using a combined test comprising (i) any increase in BMI SD score between 5 and 14 years and (ii) a BMI SD score >0 at 14 years (metabolic syndrome: sensitivity 45%, specificity 78%; IGT/diabetes mellitus: 37%, 73%). Likelihood ratios were low (metabolic syndrome: 1.4–2.0; IGT/diabetes mellitus: 1.2–1.4). A single high BMI measurement at 14 years (overweight or obese, according to International Obesity Task Force criteria) was highly specific but insensitive (metabolic syndrome: sensitivity 7%, specificity 97%; IGT/diabetes mellitus: 8%, 97%). Charts for plotting BMI SD scores through childhood were produced. Conclusions: Serial measurements of childhood BMI give useful predictions of adult risk and could guide advice to children and parents on preventing later disease.

Maternal micronutrients and fetal outcome

Oral rehydration among infants aged 0–3 months has not been adequately investigated. A controlled, randomized study was thus conducted in 65 young infants hospitalized with acute noncholera dehydrating diarrhea. The study was designed to compare the efficacy and safety of the standard WHO oral glucose-electrolyte solution containing 90 mmol of sodium per liter (Group A: 22 infants) with that of an oral glucose-electrolyte solution containing 60 mmol of sodium per liter (Group B: 22 infants) and with standard intravenous therapy (Group C: 21 infants). Among the 44 infants in Groups A and B, none required intravenous therapy. Dehydration, acidosis, and initial hyponatremia or hypokalemia were corrected with equal efficacy in all the three groups. In the critical first 8 h, the mean sodium absorption was significantly higher (p < 0.01) in Group A. This resulted in hypernatremia (50%), periorbital edema (50%), mild pedal edema (27%), excessive irritability, and convulsions (4.5%). The mean serum sodium levels at 8, 24, and even 48 h were significantly higher (p < 0.05) than those in Groups B and C. It is concluded that glucose-electrolyte oral solution containing 60 mmol of sodium per liter is as safe and effective as intravenous rehydration for the treatment of noncholera neonatal and early infantile diarrhea, while the standard WHO solution carries a significant risk of hypernatremia under similar conditions.