Kv Rameshwar Sarma

Effect of integration of supplemental nutrition with public health programmes in pregnancy and early childhood on cardiovascular risk in rural Indian adolescents: long term follow-up of Hyderabad nutrition trial

Objective To determine whether integration of nutritional supplementation with other public health programmes in early life reduces the risk of cardiovascular disease in undernourished populations. Design Approximately 15 years’ follow-up of participants born within an earlier controlled, community trial of nutritional supplementation integrated with other public health programmes. Setting 29 villages (15 intervention, 14 control) near Hyderabad city, south India. Participants 1165 adolescents aged 13-18 years. Intervention Balanced protein-calorie supplementation (2.51 MJ, 20 g protein) offered daily to pregnant women and preschool children aged under 6 years, coupled with integrated delivery of vertical public health programmes. Main outcome measures Height, adiposity, blood pressures, lipids, insulin resistance (homoeostasis model assessment (HOMA) score), and arterial stiffness (augmentation index). Results The participants from the intervention villages were 14 mm (95% confidence interval 4 to 23; P=0.007) taller than controls but had similar body composition. The participants from the intervention villages had more favourable measures of insulin resistance and arterial stiffness: 20% (3% to 39%; P=0.02) lower HOMA score and 3.3% (1% to 5.7%; P=0.008) lower augmentation index. No strong evidence existed for differences in blood pressures and serum lipids. Conclusions In this undernourished population, integrated delivery of supplemental nutrition with other public health programmes in pregnancy and early childhood was associated with a more favourable profile of cardiovascular disease risk factors in adolescence. This pragmatic study provides the most robust evidence to date on this important hypothesis for which classic trials are unlikely. Improved maternal and child nutrition may have a role in reducing the burden of cardiovascular disease in low income and middle income countries.

Relationship between biochemical and clinical indices of B-vitamin deficiency. A study in rural school boys

1. A study amongst schoolboys in villages around Hyderabad, India, showed that almost all the boys had riboflavin deficiency, 61% had pyridoxine deficiency, and 9.4% had thiamin deficiency as judged by enzymic tests. 2. The prevalence of angular stomatitis was 41.3% and that of glossitis was 18.2%. Biochemical deficiency of riboflavin and pyridoxine was marginally higher in children with angular stomatitis with or without associated glossitis, than in children without oral lesions. 3. Treatment with B-complex vitamins (containing 4 mg riboflavin and 10 mg pyridoxine) daily for 1 month produced significant reduction in the prevalence of glossitis but had no effect on angular stomatitis. The latter responded to topical application of gentian violet. 4. Small but significant changes in erythrocyte enzymes occurred over the period of 1 month even without vitamin supplements. 5. Results suggest that while glossitis is a relatively early manifestation of riboflavin or pyridoxine deficiency or both, angular stomatitis has a more complex aetiology perphaps associated with infection.

Cohort Profile: Andhra Pradesh Children and Parents Study (APCAPS)

The Andhra Pradesh Children and Parents Study (APCAPS) was originally established to study the long-term effects of early-life undernutrition on risk of cardiovascular disease. Its aims were subsequently expanded to include trans-generational influences of other environmental and genetic factors on chronic diseases in rural India. It builds on the Hyderabad Nutrition Trial (HNT) conducted in 1987–90 to compare the effects on birthweight of a protein-calorie supplement for pregnant women and children. The index children of HNT and their mothers were retraced and examined in 2003–05, and the children re-examined as young adults aged 18–21 years in 2009–10. The cohort was expanded to include both parents and siblings of the index children in a recently completed follow-up conducted in 2010–12 (N = ∼6225 out of 10 213 participants). Recruitment of the remaining residents of these 29 villages (N = ∼55 000) in Ranga Reddy district of Andhra Pradesh is now under way. Extensive data on socio-demographic, lifestyle, medical, anthropometric, physiological, vascular and body composition measures, DNA, stored plasma, and assays of lipids and inflammatory markers on APCAPS participants are available. Details of how to access these data are available from the corresponding author.

Is relative leg length a biomarker of childhood nutrition? Long-term follow-up of the Hyderabad Nutrition Trial

BACKGROUND Relative leg length is frequently used as a biomarker of childhood nutrition in epidemiological studies, but evidence is lacking. We examined the association between supplemental nutrition in pregnancy and childhood and relative proportions of components of height in adolescence. METHODS In a community trial of nutritional supplementation, villages from adjacent administrative areas were selected to serve as intervention (n = 15) and control (n = 14) arms. In the intervention villages, balanced protein-calorie supplementation (2.51 MJ, 20 g protein) was offered daily to pregnant women and their offspring until the age of 6 years. Children born in the trial were re-examined 15 years later to assess components of height. RESULTS A total of 1165 adolescents (intervention: 654, 49% of trial participants; control: 511, 41% of trial participants) aged 13-18 years were examined. Supplemented children were 10 mm taller [95% confidence interval (CI): 1.4 to 18.7 mm], but almost all of the increase was in trunk length (9 mm, 95% CI: 2.6 to 15.4 mm). The age- and gender-adjusted β-coefficients for the association of nutritional supplementation with relative trunk, leg and lower leg lengths (expressed as standard deviation scores) were 0.26 (95% CI: 0.11 to 0.42), 0.08 (95% CI: -0.03 to 0.19) and 0.03 (95% CI: -0.08 to 0.15) respectively, thereby unsupportive of cephalocaudal gradient in growth. CONCLUSIONS In this nutritional supplementation trial in an undernourished population, we were unable to confirm relative leg length as a biomarker of childhood nutrition. Alternative explanations may underlie the reported associations between childhood conditions and relative leg length.

Evaluation of the Food and Agriculture Organization's global school-based nutrition education initiative, Feeding Minds, Fighting Hunger (FMFH), in schools of Hyderabad, India

OBJECTIVE To assess the efficacy of the Food and Agriculture Organizations global school-based nutrition education initiative, Feeding Minds, Fighting Hunger (FMFH), in improving nutrition-related knowledge levels of schoolchildren. DESIGN Adopting the cluster randomisation technique, five schools each in experimental and control groups were randomly chosen from the member schools of a voluntary organisation. Repeated measures of knowledge levels were carried out at three points in time to assess pre-, post-intervention and retention of knowledge gained during the intervention. Children from experimental schools were given nutrition education by teachers in the classroom setting using FMFH material. SUBJECTS/SETTINGS Schoolchildren (n=358 in the control group and n=312 in the experimental group) of grades VIII and IX from schools in Hyderabad, India. RESULTS The classroom-based intervention resulted in a significant improvement (P<0.01) in nutrition knowledge levels of schoolchildren in the experimental group. Significant improvement in knowledge was also observed in the control group. The effect size indicated that the improvement in knowledge levels of schoolchildren in experimental schools over control schools was medium (d=0.40), indicating the efficacy of the FMFH programme in improving nutrition-related knowledge. No significant decrease (P>0.05) in knowledge levels was observed after 2 months, indicating retention of the knowledge acquired through the intervention. CONCLUSION The FMFH programme provides an opportunity for schoolchildren to learn more about nutrition through their teachers in a classroom setting if the lesson plans are adapted to the local circumstances. Furthermore, it has the potential to make nutrition education interactive, effective and sustainable.

IMPACT OF MASSIVE DOSES OF VITAMIN A ON INCIDENCE OF NUTRITIONAL BLINDNESS

In a longitudinal study designed to assess the impact of a massive-dose vitamin A programme on the incidence of keratomalacia, 50 000 preschool children in 450 slum areas in Hyderabad city (India) were given 200 000 IU of vitamin A once every 6 months. During the study period, the incidence of keratomalacia in areas covered by the programme decreased by about 80%, while in control areas the reduction was of the order of 20%. To test whether large doses of vitamin A supplements prevented keratomalacia, a case-control analysis was done, with patients with severe protein-energy malnutrition being used as controls. The high odds ratio clearly indicated that keratomalacia was more likely to occur in children not receiving supplements.

Impact of long term, low dose B-complex vitamin supplements on vitamin status and psychomotor performance of rural school boys

Abstract Rural school boys having a very high incidence of biochemical vitamin deficiencies, were supplemented with recommended daily requirement of B-complex vitamins or placebo, for 1 year. The objective was to use the data for deriving the interpretive guidelines for biochemical tests of vitamin nutrition status. The supplemented children had significantly superior biochemical status of riboflavin, pyridoxine and folic acid as judged by erythrocyte glutathione reductase and erythrocyte aspartate aminotransferase activation coefficients, and RBC folate levels respectively. However, even in the supplemented group there was a wide scatter in biochemical values, precluding the use of the data for deriving interpretive guidelines. More than 50 percent of the boys in this group continued to have biochemical evidence of deficiency of one or more vitamins using reported criteria. However, selective psychomotor testing revealed beneficial effects of supplements on arm-hand steadiness test. Thus, functional impact of vitamin supplements may be seen even in the absence of clear-cut clinical or biochemical change.

Socio-economic position and cardiovascular risk in rural Indian adolescents: evidence from the Andhra Pradesh children and parents study (APCAPS).

Objectives This study examined association between socio-economic position and cardiovascular risk factors in adolescents to investigate whether childhood socio-economic position is a risk factor for future cardiovascular disease, independently of adult behaviours. Study design and methods Participants (n = 1128, 46% girls, aged 13–18 years) were members of a birth cohort (Andhra Pradesh Children and Parents Study or APCAPS) established to investigate long-term effects of a pregnancy and childhood nutritional supplementation trial conducted in 29 villages near Hyderabad in South India. Cross-sectional associations between socio-economic position and cardiovascular risk factors were examined using linear regression models. Results The mean BMI was 16.7 kg/m2 for boys and 17.8 kg/m2 for girls. Socio-economic position was positively associated with fat mass index (0.15 kg/m2; 95% CI: 0.05–0.25) and inversely associated with central-peripheral skinfold ratio (−0.04; 95% CI: −0.06 to −0.01) and, in boys, fasting triglycerides (−0.05; 95% CI: −0.09 to −0.01). Association of socio-economic position with other risk factors (blood pressure, arterial stiffness, fasting glucose, insulin and cholesterol) was weak and inconsistent, and did not persist after adjustment for potential confounders, including age, sex, pubertal stage, height, adiposity and nutrition supplementation. Conclusions The study thus showed that lower socio-economic position may be associated with greater central adiposity and higher triglyceride levels in these settings. Socio-economic gradient in cardiovascular risk may strengthen in future with later economic and lifestyle changes. Cardiovascular disease prevention strategies should therefore focus on the youth from the low income group.

Impact of Midday Meal Program on Educational and Nutritional Status of School-going Children in Andhra Pradesh, India

The Midday Meal Program(MDM) is in operation in several states of India. This program aims to improve school enrollment and attendance, to reduce dropout rate to better the childrens school performance, and to improve the nutritional status of primary school children. A study was undertaken in the State of Andhra Pradesh to assess the impact of the MDM program on the above parameters. A total of 83 schools from three districts, 45 schools with program and 38 schools without program, were included in the study. Results of the study on the educational component indicated improved attendance, increased retention rate with reduced dropout rates, and a marginal improvement in the scholastic performance. The nutritional component revealed better growth performance among the regular beneficiaries in the program.