Monal R. Shroff

Cluster‐randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers

Inadequate feeding and care may contribute to high rates of stunting and underweight among children in rural families in India. This cluster-randomized trial tested the hypothesis that teaching caregivers appropriate complementary feeding and strategies for how to feed and play responsively through home-visits would increase childrens dietary intake, growth and development compared with home-visit-complementary feeding education alone or routine care. Sixty villages in Andhra Pradesh were randomized into three groups of 20 villages with 200 mother-infant dyads in each group. The control group (CG) received routine Integrated Child Development Services (ICDS); the complementary feeding group (CFG) received the ICDS plus the World Health Organization recommendations on breastfeeding and complementary foods; and the responsive complementary feeding and play group (RCF&PG) received the same intervention as the CFG plus skills for responsive feeding and psychosocial stimulation. Both intervention groups received bi-weekly visits by trained village women. The groups did not differ at 3 months on socioeconomic status, maternal and child nutritional indices, and maternal depression. After controlling for potential confounding factors using the mixed models approach, the 12-month intervention to the CFG and RCF&PG significantly (P < 0.05) increased median intakes of energy, protein, Vitamin A, calcium (CFG), iron and zinc, reduced stunting [0.19, confidence interval (CI): 0.0-0.4] in the CFG (but not RCF&PG) and increased (P < 0.01) Bayley Mental Development scores (mean = 3.1, CI: 0.8-5.3) in the RCF&PG (but not CFG) compared with CG. Community-based educational interventions can improve dietary intake, length (CFG) and mental development (RCF&PG) for children under 2 years in food-secure rural Indian families.

Maternal autonomy is inversely related to child stunting in Andhra Pradesh India.

Child stunting, an outcome of chronic undernutrition, contributes to poor quality of life, morbidity and mortality. In South Asia, the low status of women is thought to be one of the primary determinants of undernutrition across the lifespan. Low female status can result in compromised health outcomes for women, which in turn are related to lower infant birthweight and may affect the quality of infant care and nutrition. Maternal autonomy (defined as a womans personal power in the household and her ability to influence and change her environment) is likely an important factor influencing child care and ultimately infant and child health outcomes. To examine the relationship between maternal autonomy and child stunting in Andhra Pradesh, India, we analysed data from National Family Health Survey (NFHS)-2. We used cross-sectional demographic, health and anthropometric information for mothers and their oldest child <36 months (n = 821) from NFHS-2. The main explanatory variables of autonomy are presented by four dimensions - decision making, permission to travel, attitude towards domestic violence and financial autonomy - constructed using seven binary variables. Logistic regression models were used to test associations between indicators of female autonomy and the risk of having a stunted child. Women with higher autonomy {indicated by access to money [odds ratio (OR) = 0.731; 95% confidence interval (CI) 0.546, 0.981] and freedom to choose to go to the market [OR = 0.593; 95% CI 0.376, 0.933]} were significantly less likely to have a stunted child, after controlling for household socio-economic status and mothers education. In this south Indian state, two dimensions of female autonomy have an independent effect on child growth, suggesting the need for interventions that increase womens financial and physical autonomy.

Serum Antioxidant Status Is Associated with Metabolic Syndrome among U.S. Adults in Recent National Surveys

Potential antiinflammatory and antioxidant effects were recently ascribed to naturally occurring micronutrients. The extent and magnitudes of their differential effects on the metabolic syndrome (MetS) are still unknown. We examined the association between serum antioxidant status and MetS. NHANES 2001-2006 cross-sectional data among adults aged 20-85 y were analyzed (n = 3008-9099). MetS was defined with the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) and also by elevated homeostatic model assessment insulin resistance (HOMA-IR), C-reactive protein (CRP) and hyperuricemia. Serum antioxidants included retinol, retinyl esters, carotenoids [α-carotene, β-carotene (cis+trans), β-cryptoxanthin, lutein+zeaxanthin, total lycopene], vitamin E, and vitamin C. MetS (NCEP ATP III) prevalence in U.S. adults was 32.0% among men and 29.5% among women. Adults with MetS had consistently lower serum carotenoid concentrations compared with those without MetS, even after controlling for total cholesterol and TG among other potential confounders. Vitamin E had no significant relationship with MetS in the full multiple logistic regression model, whereas retinol+retinyl esters were inversely related to MetS among men only. The latter were also inversely related to elevated CRP and positively associated with hyperuricemia. Vitamin C exhibited a similar pattern to serum carotenoids with an inverse linear association with MetS (binary), HOMA-IR, and hyperuricemia. Future intervention studies of dietary and lifestyle change must be conducted to assess the utility of modifying serum antioxidant concentrations, especially carotenoids, given their suboptimal levels among U.S. adults with MetS, for the prevention of type 2 diabetes and various cardiovascular endpoints.

Does maternal autonomy influence feeding practices and infant growth in rural India

The high prevalence of child under-nutrition remains a profound challenge in the developing world. Maternal autonomy was examined as a determinant of breast feeding and infant growth in children 3-5 months of age. Cross-sectional baseline data on 600 mother-infant pairs were collected in 60 villages in rural Andhra Pradesh, India. The mothers were enrolled in a longitudinal randomized behavioral intervention trial. In addition to anthropometric and demographic measures, an autonomy questionnaire was administered to measure different dimensions of autonomy (e.g. decision-making, freedom of movement, financial autonomy, and acceptance of domestic violence). We conducted confirmatory factor analysis on maternal autonomy items and regression analyses on infant breast feeding and growth after adjusting for socioeconomic and demographic variables, and accounting for infant birth weight, infant morbidity, and maternal nutritional status. Results indicated that mothers with higher financial autonomy were more likely to breastfeed 3-5 month old infants. Mothers with higher participation in decision-making in households had infants that were less underweight and less wasted. These results suggest that improving maternal financial and decision-making autonomy could have a positive impact on infant feeding and growth outcomes.

Serum Folate, Vitamin B-12, and Homocysteine and Their Association With Depressive Symptoms Among U.S. Adults

Objective: To examine, in a nationally representative sample of U.S. adults, the associations of serum folate, vitamin B-12, and total homocysteine (tHcy) levels with depressive symptoms. Several nutritional and physiological factors have been linked to depression in adults, including low folate and vitamin B-12 and elevated tHcy levels. Methods: Data on U.S. adults (age, 20–85 years; n = 2524) from the National Health and Nutrition Examination Survey during the period 2005 to 2006 were used. Depressive symptoms were measured with the Patient Health Questionnaire (PHQ), and elevated symptoms were defined as a PHQ total score of ≥10. Serum folate, vitamin B-12, and tHcy were mainly expressed as tertiles. Multiple ordinary least square (OLS), logistic, and zero-inflated Poisson regression models were conducted in the main analysis. Results: Overall, mean PHQ score was significantly higher among women compared with men. Elevated depressive symptoms (PHQ score of ≥10) were inversely associated with folate status, particularly among women (fully adjusted odds ratio [tertiles T3 versus T1] = 0.37; 95% confidence interval, 0.17–0.86), but not significantly related to tHcy or vitamin B-12. No interaction was noted between the three exposures in affecting depressive symptoms. In older adults (≥50 years) and both sexes combined, tHcy was positively associated with elevated depressive symptoms (fully adjusted odds ratio [tertiles T2 versus T1] = 3.01; 95% confidence interval, 1.01–9.03), although no significant dose-response relationship was found. Conclusions: Future interventions to improve mental health outcomes among U.S. adults should take into account dietary and other factors that would increase levels of serum folate. BH4 = tetrahydro biopterins; CNS = central nervous system; DSM = Diagnostic and Statistical Manual; MEC = Mobile Examination Center; MR = methylation reactions; NHANES = National Health and Nutrition Examination Surveys; OLS = ordinary least square; PHQ = Patient Health Questionnaire; PIR = Poverty Income Ratio; tHcy = total homocysteine; T = tertile.

Serum Antioxidant Concentrations and Metabolic Syndrome Are Associated among U.S. Adolescents in Recent National Surveys

Specific micronutrients, including retinol, retinyl esters, carotenoids [α-carotene, β-carotene (cis+trans), β-cryptoxanthin, lutein+zeaxanthin, and total lycopene], vitamin E, and vitamin C have antiinflammatory and antioxidant effects, properties shown to reduce oxidative stress, a process that accompanies the pathogenesis of many chronic diseases. It is still largely unknown whether they are associated with the occurrence of metabolic syndrome (MetS) in the adolescent U.S. population. MetS was defined by the International Diabetes Federation (IDF) criteria. Other non-MetS outcomes relying on blood measurements were elevated HOMA-IR, C-reactive protein (CRP), and hyperuricemia. We tested associations between serum antioxidants and MetS outcomes among adolescents aged 12-19 y using cross-sectional data from NHANES 2001-2006 (n = 782-4285). IDF MetS prevalence was estimated at 7% among boys and 3% among girls. In adjusted models, adolescents with MetS had consistently lower carotenoid concentrations compared with their counterparts without MetS. Total carotenoids were also inversely related to HOMA-IR and CRP. Vitamin C was inversely related to uric acid level and MetS binary outcome. Retinol+retinyl esters exhibited an inverse relationship with CRP and a positive relationship with uric acid and HOMA-IR as well as MetS binary outcome. Vitamin E had no association with MetS, particularly after controlling for serum cholesterol and TG. In conclusion, among U.S. adolescents, serum carotenoid concentrations were inversely associated with MetS status, HOMA-IR, and CRP, whereas serum vitamin C was inversely related to MetS status and serum uric acid. Vitamin E had no consistent association with MetS, whereas retinol+retinyl esters had a positive relationship with HOMA-IR, uric acid, and MetS, while being inversely related to CRP. These associations need further study.

Adherence to a snacking dietary pattern and soda intake are related to the development of adiposity: a prospective study in school-age children.

OBJECTIVE Snacking has been related to increased prevalence of overweight among school-age children in cross-sectional studies. It is uncertain, however, whether snacking influences the development of adiposity over time. DESIGN We examined whether adherence to a snacking dietary pattern was associated with greater increases in childrens BMI, subscapular:triceps skinfold thickness ratio and waist circumference over a median 2·5-year follow-up. Dietary patterns were identified through principal component analysis of an FFQ administered at recruitment in 2006. Anthropometric follow-up was conducted annually. Linear mixed-effects models were used to estimate rates of change in each indicator according to quartiles of adherence to the snacking pattern. We also examined change in BMI, subscapular:triceps skinfold thickness ratio and waist circumference in relation to intake of the food items in the snacking pattern. SUBJECTS Children (n 961) 5-12 years of age. SETTING Public schools in Bogotá, Colombia. RESULTS After adjustment for age, sex, total energy intake and socio-economic status, children in the highest quartile of adherence to the snacking pattern had a 0·09 kg/m2 per year higher BMI gain than children in the lowest quartile (P trend = 0·05). A similar association was observed for mean change in subscapular:triceps skinfold thickness ratio (highest v. lowest quartile difference = 0·012/year; P = 0·03). Of the food items in the snacking pattern, soda intake was positively and significantly associated with change in BMI (P trend = 0·01) and waist circumference (P trend = 0·04) in multivariable analysis. CONCLUSIONS Our results indicate that snacking and soda intake are associated with development of adiposity in school-age children.

Formative research methods for designing culturally appropriate, integrated child nutrition and development interventions: an overview

Nutritional and developmental insults in the first few years of life have profound public health implications, including substantial contributions to neonatal, infant, and early childhood morbidity and mortality, as well as longer term effects on cognitive development, school achievement, and worker productivity. Optimal development that can lead to the attainment of an individuals fullest potential, therefore, requires a combination of genetic capacity, adequate nutrition, psychosocial stimulation, and safe, clean physical environments. Researchers and policymakers have called for integrated child nutrition and development interventions for more than 20 years, yet there are only a handful of efficacy trials and even fewer examples of integrated interventions that have been taken to scale. While a critical component in the design of such interventions is formative research, there is a dearth of information in both the literature and policy arenas to guide this phase of the process. To move the field forward, this paper first provides an overview of formative research methods with a focus on qualitative inquiry, a description of the critical domains to be assessed (infant and young child feeding, responsive feeding, and child development), and currently available resources. Application of these methods is provided through a real‐world case study—the design of an integrated nutrition and child development efficacy trial in Andhra Pradesh, India. Recommendations for next steps are discussed, the most important of which is the need for a comprehensive set of formative guidelines for designing locally tailored, culturally appropriate, integrated interventions.

Helicobacter pylori Seropositivity and Cognitive Performance Among Us Adults: Evidence From a Large National Survey

Background Helicobacter pylori seropositivity is a potential risk for poor cognition among US adults. Methods Cross-sectional data from the National Health and Nutrition Examination Survey III, Phase 1 (1988–1991), were used. Measures included age group-specific neuropsychological test batteries and two measures of H. pylori seropositivity (immunoglobulin G [IgG] and IgG CagA) (20–59 years old: n = 2090–2,248; 60–90 years old: n = 2123–2388). We explored sex- and race-specific associations. Results Using multiple ordinary least square and zero-inflated Poisson regression models, we detected a poorer performance among those 60–90 years old with H. pylori IgG+ versus IgG− on a verbal memory test (story recall, correct items), overall (&bgr; = −0.04 [0.01], p = .010). Non-Hispanic (NH) blacks and women (20–59 years old) performed worse on the serial digits learning total errors (SDL-TE) when H. pylori IgG+ (versus IgG−), another verbal memory test (&bgr; = +0.94 [0.40; p = .029] and &bgr; = +1.19 [0.44; p = .012], respectively; p<.10 for interaction by sex and race). More trials to completion on this test (SDL-TTC) were also required among H. pylori IgG+ overall (20–59 years old; &bgr; = +0.30 [0.13], p = .033). Other race-specific associations without significant interaction by race were detected in the same direction of worse performance with seropositivity in all three major race groups and for both age categories, covering several domains of cognition. Conclusions H. pylori seropositivity markers were associated with poor cognition among US adults. Longitudinal research is needed to extrapolote those findings to cognitive decline, incident dementia, and Alzheimers disease.

Serum leptin, thyroxine and thyroid-stimulating hormone levels interact to affect cognitive function among US adults: evidence from a large representative survey.

Neuroanatomical connections point to possible interactions between areas influencing energy homeostasis and those influencing cognition. We assessed whether serum leptin, thyroxine, and thyroid stimulating hormone (TSH) levels are associated with and interact to influence cognitive performance among US adults. Data from the National Health and Nutrition Examination Survey III (1988-1994) were used. Measures included a battery of neuropsychological tests and serum leptin, thyroxine, and TSH levels (20-59-year-old: n = 1114-2665; 60-90-year-old: n = 1365-5519). Among those 20-59-year-old, the middle tertile of leptin (vs. first tertile) was inversely related to the number of errors on the symbol digits substitution test. Increased thyroxine level was associated with a poorer performance on the serial digits test in the 20-59-year-old, but a better performance on the math test in 60-90-year-old group. TSH was associated with poor performance on various tests in the 20-59-year-old, but better performance in the 60-90-year-old group. Significant antagonistic interactions were found in both age groups between thyroxine, TSH, and leptin for a number of tests, including between leptin and thyroxine in the 60-90-year-old group in their association with word recall-correct score. We found significant associations of our main exposures with cognitive function among US adults, going in opposite directions between age groups in the cases of thyroid hormonal levels, as well as some interactive effects between exposures. It is important to conduct prospective cohort studies to provide further insight into potential interventions that would assess interactive effects of various hormonal replacement regimens.