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The article discusses the findings in National Nutrition Monitoring Bureau (NNMB) surveys in India on estimates of vitamin A deficiency (VAD) prevalence. It mentions the low validity of serum retinol estimates through dry blood spot (DBS) technique because the serum C-reactive protein (CRP) level test was not done on the children. It also notes that the surveys could have overestimated VAD prevalence and explains the vitamin A supplementation policy in India.

A response by R. K. Marwaha to a letter to the editor about their article "Iodine Nutrition in Upper Socioeconomic School Children in Delhi, India" in the April 2010 issue is presented.

A letter to the editor is presented about a study on the prevalence of type 2 diabetes mellitus (T2DM) and impaired glucose tolerance (IGT) in obese children in Delhi, India.

The author reflects on the management of severe acute malnutrition in India through ready to use therapeutic food (RUTF). He mentions the association between home-based management with RUTF and better outcome compared with standard therapy administered in the hospital. He cites reduced exposure to hospital-acquired infections as one of the benefits of home-based management. He emphasizes the importance of evaluating imported RUTF through multicentric efficacy and effectiveness trials that are carefully planned.

A letter to the editor is presented about a cross-sectional study on the prevalence of overweight and obesity in school children in Delhi, India.

Characterisation of anaemia amongst school going adolescent girls in rural Haryana, India - CORRIGENDUM In the published article, the authors overlooked mentioning that 0.5g/dl was added to the original hemoglobin values to correct for the difference using direct and indirect cyanmethaemoglobin method. Characterisation of anaemia amongst school going adolescent girls in rural Haryana, India. [Extracted from the article]

Looks at a study done in the National Capital Territory of Delhi, India in which it was determined that iodization of salt was the most successful means of preventing iodine deficiency disorders. Details of the study; Statistical information concerning the study.

A letter to the editor is presented in response to the articles "Management of children with severe acute malnutrition: Experience of nutrition rehabilitation centres in Uttar Pradesh, India" and "Comorbidities in hospitalized children with severe acute malnutrition" are presented.

A letter to the editor is presented in response to the article "Iron Sucrose Versus Oral Iron Therapy in Pregnancy Anemia" by S. Neeru and colleagues in the 2012 issue.

The article discusses the overestimated vitamin A deficiency (VAD) prevalence among children at a rural preschool in West Bengal, India due to survey methodology. It questions the reliability of tests including night blindness assessment, conjunctival xerosis (X1A) and estimates of serum retinol for determining VAD prevalence. It also notes that overestimates are not extrapolated to the data of the whole state.

Aim : In India out of 282 districts surveyed 242 have been found to be endemic to iodine Deficiency. The country adopted policy of Universal Salt Iodization (USI) in 1984. The production of iodized salt increased from 0.3 million in 1984 to 4.9 million in 1999. The study was conducted to assess the current status of salt iodization in India. Methods: Salt samples were collected from beneficiaries in 93 districts and from traders in 69 districts in different regions of the country. A total of 65,288 and 809 salt samples were collected from beneficiaries and traders, respectively utilizing multistage sampling procedure. The salt samples were analyzed for the iodine concentration using iodometric titration method. Results: At the beneficiary and traders level, 59% and 60% salt samples had more than 15 ppm of iodine respectively. Only, 2.8% and 1.4% of salt samples had nil iodine at the beneficiary and trader level, respectively. Conclusion: The findings of the present study indicates the successful implementation of USI programme in India and suggest further strengthening the quality of salt at beneficiary and traders level to achieve elimination of Iodine Deficiency Disorders. [ABSTRACT FROM AUTHOR]

Purpose: There are no representative estimates of vitamin A deficiency (VAD) and risk of vitamin A (VA) dietary inadequacy in Indian children and adolescents. To evaluate, from national surveys, the prevalence of VAD measured by serum retinol concentrations (< 0.7 µmol/L or < 20 µg/dL), and the risk of VA dietary inadequacy and excess intake beyond the tolerable upper limit (TUL). Methods: National and state-level VAD prevalence adjusted for inflammation was estimated in school-age children (5–9 years: 10,298) and adolescents (10–19 years: 9824) from the Comprehensive National Nutrition Survey (CNNS 2016-18). The risk of dietary inadequacy against age-specific average VA requirements, and excess intake against the TUL, was assessed from the National Sample Survey Office (NSSO 2014) data. Results: Serum retinol concentrations increased with age (5–19 years) in both genders and were significantly lower in school-age children (1.02 µmol/L, CI: 1.01–1.03) compared to adolescents (1.13 µmol/L, CI 1.12–1.15). The inflammation-adjusted prevalence of VAD in school-age children and adolescents was 19.3% (CI 18.8–19.9) and 14.4% (CI 13.9–14.9) respectively, and this was > 20% in seven and four states for children and adolescents, respectively. The prevalence of VAD was significantly higher among children with lower socio-economic status. The risk of dietary VA inadequacy, from the NSSO survey, was 69 and 78% in children and adolescents, respectively. This risk reduced to 6 and 17% with VA fortified oil and milk intake, while the proportion of intakes exceeding the TUL became 6 and 0.5% in children and adolescents, respectively. Conclusions: The national prevalence of VAD in school-age children and adolescents in India was just less than 20%. The risk of dietary VA deficiency is likely to decline substantially with VA fortified food intake, but a risk of excessive intake also begins to appear; therefore, a careful assessment of the risk of hypervitaminosis A is required at these ages. [ABSTRACT FROM AUTHOR]

Non-Alcoholic fatty liver disease (NAFLD) is a broad term covering a spectrum of conditions ranging from hepatic steatosis, steatohepatitis and cirrhosis. NAFLD is highly prevalent across all regions of the world with its global prevalence of 25.2%(95%CI:22.1-28.7). It is commonly referred as the 'hepatic manifestation' of metabolic syndrome (MetS). Moreover, it is strongly associated with the individual components as well as MetS as a whole. NAFLD has been independently associated with other non-communicable diseases (NCDs) like chronic kidney disease (CKD), Polycystic ovary Syndrome (PCOS), Stroke and Cancers. This strong association of NCDs with NAFLD not only affects the prevalence but also the progression and management of the disease. Thus, this review aims at highlighting the association of NAFLD with other NCDs. A literature search was undertaken in the MEDLINE database using the necessary MeSH terms. The review concludes NAFLD is a systemic disease, not just confined to liver-specific morbidity and mortality, but also associated with numerous extra-hepatic manifestations, such as metabolic syndrome, cardiovascular diseases, chronic renal diseases, and malignancy. With co- existence of NAFLD with various NCDs it is expected to become the most overwhelming liver disease in the world in coming years. Hence, to reduce medical and economic impact associated with these comorbidities, it is recommended that all countries should estimate and predict the burden on comorbidities associated with NAFLD and galvanize its health resources in providing integrated therapeutic approaches for management of NAFLD and related comorbidities at an early stage. [ABSTRACT FROM AUTHOR]

Background: Anemia control programs in India focus mainly on the measurement of hemoglobin in response to iron-folic acid supplementation. However, representative national estimates of iron deficiency (ID) are not available.Objectives: The objective of the present study was to evaluate ID prevalence among children and adolescents (1-19 y) using nationally representative data and to examine the sociodemographic patterning of ID.Methods: Cross-sectional data from the Comprehensive National Nutrition Survey in children (1-4 y: n = 9635; 5-9 y: n = 11,938) and adolescents (10-19 y; n = 11,507) on serum ferritin (SF) and other biomarkers were analyzed to determine inflammation-adjusted ID prevalence [SF (μg/L): <12 in 1-4 y and <15 in 5-19 y] and its relation to sociodemographic indicators. Multiple-regression analyses were conducted to identify the exposure associations of iron status. In addition, the relation between SF and hemoglobin was assessed as an indicator of iron utilization in different wealth quintiles.Results: ID prevalence was higher in 1- to 4-y-old children (31.9%; 95% CI: 31.0%, 32.8%) and adolescent girls (30.4%; 95% CI: 29.3%, 31.5%) but lower in adolescent boys and 5- to 9-y-old children (11%-15%). In all age groups, ID prevalence was higher in urban than in rural participants (1-4 y: 41% compared with 29%) and in those from richer quintiles (1-4 y: 44% in richest compared with 22% in poorest), despite adjustment for relevant confounders. SF significantly interacted with the wealth index, with declining trends in the strength of association between hemoglobin and SF from the richest to the poorest groups suggesting impaired iron utilization for hemoglobin synthesis in poorer wealth quintiles.Conclusions: ID prevalence was indicative of moderate (in preschool children and adolescent girls) or mild (in 5- to 9-y-old children and adolescent boys) public health problem with significant variation by state and age. Focusing on increasing iron intake alone, without addressing the multiple environmental constraints related to poverty, may not result in intended benefits. [ABSTRACT FROM AUTHOR]

Background  The stability of biological samples is vital for reliable measurements of biomarkers in large-scale survey settings, which may be affected by freeze-thaw procedures. We examined the effect of a single freeze-thaw cycle on 13 nutritional, noncommunicable diseases (NCD), and inflammatory bioanalytes in serum samples. Method  Blood samples were collected from 70 subjects centrifuged after 30 minutes and aliquoted immediately. After a baseline analysis of the analytes, the samples were stored at − 70°C for 1 month and reanalyzed for all the parameters. Mean percentage differences between baseline (fresh blood) and freeze-thaw concentrations were calculated using paired sample t -tests and evaluated according to total allowable error (TEa) limits (desirable bias). Results  Freeze-thaw concentrations differed significantly (p < 0.05) from baseline concentrations for soluble transferrin receptor (sTfR) (− 5.49%), vitamin D (− 12.51%), vitamin B12 (− 3.74%), plasma glucose (1.93%), C-reactive protein (CRP) (3.45%), high-density lipoprotein (HDL) (7.98%), and cholesterol (9.76%), but they were within respective TEa limits. Low-density lipoprotein (LDL) (− 0.67%), creatinine (0.94%), albumin (0.87%), total protein (1.00%), ferritin (− 0.58%), and triglycerides (TAG) (2.82%) concentrations remained stable following the freeze-thaw cycle. In conclusion, single freeze-thaw cycle of the biomarkers in serum/plasma samples after storage at − 70°C for 1 month had minimal effect on stability of the studied analytes, and the changes in concentration were within acceptable limit for all analytes. [ABSTRACT FROM AUTHOR]

The article focuses on comparison of hemoglobin concentrations has measured by HemoCue and a hematology analyzer in Indian children and adolescents 1-19 years of age. Topics include anemia being a severe public health problem among children and adolescents globally, the potentially being serious consequences for the health and development of children and physical and mental capacity of adolescents, and the conventional has automated hematology analyzer, based on the cyanmethemoglobin method.

Obesity has emerged as an epidemic worldwide. The present study was conducted to assess the prevalence of overweight and obesity amongst children in the age group of 5-18 years belonging to low, middle and high income group in National Capital Territory NCT of Delhi. A total of 16,595 children (LIG 5087, MIG 5134 and HIG 6368) were covered in the present study. Overweight and obesity were assessed using Body Mass Index (BMI) and Triceps Skin Fold Thickness (TSFT) utilizing age and sex specific cut off points. Considering the BMI cut off points, the prevalence of obesity and overweight in Low Income Group (LIG) school children was 0.1 and 2.7 percent respectively, amongst Middle Income Group (MIG) school children it was 0.6 and 6.5 percent and in High Income Group (HIG) school children was 6.8 and 15.3 percent respectively (p<0001). With regard to the TSFT criteria, the prevalence of obesity and overweight in LIG school children was 1.2 and 2.4 percent, amongst MIG school children it was 2.5 and 4.9 percent and in children belonging to HIG schools was 9.3 and 13.1 percent respectively (p<0.001). The present study documented that the prevalence of overweight and obesity was higher in the HIG children as compared to the MIG and the LIG for all age groups, highlighting the possible role of change in the dietary pattern and physical activities with increase in income levels. [ABSTRACT FROM AUTHOR]

AIM: Hemoglobin (Hb) measurement is the primary method for assessment of anemia in a community. The Cyanmethomoglobin (CM) method is most widely used. The HemoCue (HQ) method is extensively used for estimating the Hb. This study was undertaken to compare the estimation of Hb results obtained between standard CM and HQ methods. Methods: A hospital based study was conducted amongst adult patients attending a hospital in New Delhi. Four hundred and eighty six patients requiring hematological investigations were included. The study was conducted in two phases, Phase I and Please II. The patients in the two Phases were independent of each other. In Phase I, Hb investigations were performed amongst 1.51 patients by the standard CM and the HQ methods in blood samples from the fingerpick method. In Phase II, Hb investigations were performed by the standard CM and HQ method amongst 335 patients in blood samples collected by venous puncture. Results: For the different levels of Hb i.e. 10g/dl and more, 7-<10g/dl and severe <7g/dl, HQ method overestimated Fib levels as compared to the standard CM method. On comparison of results obtained from the standard CM and HQ methods by utilizing the Standard statistical procedures, it was found that HQ method overestimated the Hb levels by 1.5g/d1 in capillary blood samples and by 1.2 g/dl in venous blood. Conclusion: The findings of the present study suggest that to have scientifically valid estimation of Hb, a correction factor of minus 1.5 and minus 1.2 should be applied to the Hb values obtained from HQ method in case of capillary and venous blood samples, respectively. [ABSTRACT FROM AUTHOR]

A cluster randomized control trial study was conducted in Ballabgarh block of Faridabad District, Haryana, India. Baseline data of a total of 198 non-anemic and 202 anemic adolescent girls (12-19 years) was analyzed for hemoglobin and serum level of hepcidin, ferritin, folate acid, soluble transferrin receptor, vitamin B 12 and CRP. Deficiency of iron ( p  < 0.001), folate ( p  < 0.01) and their mixed deficiency ( p  < 0.001) significantly increased with increasing severity of anaemia and contributed to 48.7% mild anaemia and 66.9% moderate anaemia. Anaemia of inflammation contributed to 16.2% of mild anaemia and 11.7% of moderate anaemia. More than one third of mild anaemia is caused by other causes. Current iron and folic acid program can alleviate around more than 2/3rd moderate anaemia and around half of mild anaemia among adolescent girls. Unknown causes of anaemia need further investigation., Competing Interests: Conflict of interestThe authors have no relevant financial or non-financial interests to disclose., (© The Author(s), under exclusive licence to Indian Society of Hematology and Blood Transfusion 2023. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Objectives: To develop and validate weight estimation tools using mid upper arm circumference (MUAC) and body length, and determine accuracy and precision of Broselow tape in children 6 mo to 15 y of age., Methods: Data of 18,456 children aged 6 mo to 5 y and 1420 children aged 5 to 15 y were used to develop linear regression equations using length and MUAC to estimate weight. These were validated on prospectively enrolled populations of 276 and 312 children, respectively. Accuracy was measured by Bland-Altman bias, median percentage errors, and percentage of predicted weight within 10% of true weight. Broselow tape was tested on the validation population., Results: Gender specific equations were developed which estimated weight within 10% of true weight in 69.9% (64.1-75.2%) and 65.7% (60.1-70.9%) of children aged 6 mo to 5 y, and 5 to 15 y, respectively. Broselow tape predicted weight within 10% of the true weight in 40.5% (34.7-46.6%) and 32.5% (26.7-38.7%) of children aged 6 mo to 5 y and 5 to 15 y, respectively., Conclusions: The model developed from MUAC and length accurately estimated weight in children aged 6 mo to 15 y, and is potentially useful during emergencies. The Broselow tape frequently overestimated weight in authors' setting., (© 2023. The Author(s), under exclusive licence to Dr. K C Chaudhuri Foundation.)

Background: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide. India and other developing countries are witnessing an unprecedented rise in the prevalence of NAFLD. As part of population-level strategy, at primary healthcare, an efficient risk stratification is crucial to ensure appropriate and timely referral of individuals who require care at secondary and tertiary levels. The present study was conducted to assess the diagnostic performance of two non-invasive risk scores, fibrosis-4 (FIB-4), and NAFLD fibrosis score (NFS), in Indian patients of biopsy-proven NAFLD., Methods: We conducted a retrospective analysis of biopsy-proven NAFLD patients that reported to our center between 2009 and 2015. Clinical and laboratory data were collected and two non-invasive fibrosis scores, NFS and FIB-4 score, were calculated using the original formulas. Liver biopsy was utilized as gold standard for diagnosis of NAFLD, diagnostic performance was determined by plotting receiver operator characteristic (ROC) curves and area under the ROC curve (AUROC) was calculated for each score., Results: The mean age of 272 patients included was 40 (11.85) years and 187 (79.24%) were men. We found that the AUROCs for FIB-4 score (0.634) was higher for any degree of fibrosis as compared to NFS (0.566). The AUROC for FIB-4 for advanced liver fibrosis was 0.640 (.550-.730). The performance of the scores for advanced liver fibrosis was comparable with overlapping confidence intervals for both scores., Conclusion: The present study found an average performance of FIB-4 and NFS risk scores for detecting advanced liver fibrosis in Indian population. This study highlights the need for devising novel context-specific risk scores for efficient risk stratification of NAFLD patients in India., (© 2023. Indian Society of Gastroenterology.)

Background/objectives: Population zinc (Zn) status assessment is based on serum zinc concentration (SZC) cut-offs defined by the International Zinc Nutrition Consultative Group (IZiNCG). The objective of this study is to derive reference SZC cut-offs in apparently healthy 1-19 year Indian children and adolescents using comprehensive national nutrition survey (CNNS) data, and to measure the prevalence of Zn deficiency., Subjects/methods: Apparently healthy children (n = 12,473) were selected from the CNNS, by including the highest 2 wealth quintiles, and excluding stunted, thin and obese children, and those with CRP > 5 mg/L, anaemia, hypo-albuminemia, diabetes, recent diarrhoea and history of smoking. The 2.5th centile of age-based distributions defined the SZC cut-offs, used to measure the prevalence of Zn deficiency in India, as against the IZiNCG cut-offs., Results: The present study SZC cut-offs were significantly lower, by 10-18 µg/dL, than the IZiNCG cut-offs; more in adolescents. Prevalence of Zn deficiency in the entire CNNS, with these cut-offs, was 2.7 (<10 years) to 5.5 (10-19 years) times lower than with the IZiNCG cut-offs. No geographical state, nor any age group, had Zn deficiency as a serious public health problem (≥20%). In contrast, with IZiNCG cut-offs, 9-27 states (depending on age group) had a public health problem., Conclusions: The present study reference SZC cut-offs for Zn deficiency are lower than the IZiNCG cut-offs, and their rigorous selection from a national sample makes them more appropriate for use in India. A re-examination of the global applicability of IZiNCG recommended cut-offs in other LMICs appears appropriate., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To re-estimate the survival benefit from Vitamin A supplementation (VAS) in India using meta-analysis and to correlate mortality and vitamin A deficiency (VAD) in children aged 6 month to 5 year., Methods: Pooled risk ratio (fixed effects model) for mortality reduction with VAS was calculated from available Indian studies. Computed mortality rates in 6 months to 5 years children in Indian states were regressed on VAD prevalence estimates of the states., Results: There was no reduction in risk of all-cause mortality with VAS (RR=0.96; 95% CI: 0.89, 1.03). When regressing mortality on VAD in high or low VAD prevalence states, the regression coefficients were discordant., Conclusion: No survival benefit was observed for VAS in India from the available literature. The targeting of VAS programs should be given serious consideration.

Objective: The prevalence of anemia has remained high among Indian adolescent girls over the past decade, despite the ongoing iron and folic acid (IFA) supplementation program. This study was conducted to assess the impact of daily supplementation of a package of IFA with vitamin B 12 on hemoglobin levels among adolescent girls., Methods: A community-based cluster-randomized trial was conducted in the rural block of Faridabad District, Haryana, India in the year 2017. A total of 760 adolescent girls in the age group of 12-19 years with mild and moderate anemia were selected from government schools. Daily-supervised administration of iron and folic acid was conducted for 90 days: experimental group-IFA (iron (60 mg), folic acid (500) mcg), and cyanocobalamin (1000 mcg), control group-IFA and placebo. Hemoglobin, serum ferritin, and vitamin B 12 levels were assessed at baseline and endline., Results: Two-hundred adolescent girls completed 90 doses of daily supplementation. The mean hemoglobin (experimental group: 1.3 ± 1.0 g/dL, control group: 1.6 ± 1.2 g/dL, P = 0.004) and ferritin levels (experimental group: 18.6 ± 31.5 ng/mL, control group: 18.8 ± 35.0 ng/mL, P = 0.188) increased in both the control and experiment groups. Serum vitamin B 12 deficiency significantly reduced to 2.5% in the experimental group and ferritin deficiency alleviated in more than 96% of the girls post intervention., Conclusions: Daily supplementation of IFA with/without vitamin B 12 for 90 days eliminated iron, vitamin B 12 deficiency and reduced the overall proportion of anemia by 53.5%. However, addition of vitamin B 12 to IFA supplementation had no impact on improving the hemoglobin levels among adolescent girls. The present study does not recommend provision of vitamin B 12 for prevention and treatment of anemia in this population group., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

When public health programs with single nutrients are perceived to have a poor impact on the target health outcome, the policy response can be to supply more, by layering additional mandatory programs upon the extant programs. However, we argue for extreme caution, because nutrients (like medicines) are beneficial in the right dose, but potentially harmful when ingested in excess. Unnecessary motivations for the reactionary layering of multiple intervention programs emerge from incorrect measurements of the risk of nutrient inadequacy in the population, or incorrect biomarker cutoffs to evaluate the extent of nutrient deficiencies. The financial and social costs of additional layered programs are not trivial when traded off with other vital programs in a resource-poor economy, and when public health ethical dilemmas of autonomy, equity, and stigma are not addressed. An example of this conundrum in India is the perception of stagnancy in the response of the prevalence of anemia to the ongoing pharmacological iron supplementation program. The reaction has been a policy proposal to further increase iron intake through mandatory iron fortification of the rice provided in supplementary feeding programs like the Integrated Child Development Services and the School Mid-Day Meal. This is in addition to the ongoing pharmacological iron supplementation as well as other voluntary iron fortifications, such as those of salt and manufactured food products. However, before supplying more, it is vital to consider why the existing program is apparently not working, along with consideration of the potential for excess intake and related harms. This is relevant globally, particularly for countries contemplating multiple interventions to address micronutrient deficiencies. Supplying more by layering multiple nutrient interventions, instead of doing it right, without thoughtful considerations of social, biological, and ethics frameworks could be counterproductive. The cure, then, might well become the malady., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Competing Interests: We declare no competing interests.

Background: Anemia control programs in India focus mainly on the measurement of hemoglobin in response to iron-folic acid supplementation. However, representative national estimates of iron deficiency (ID) are not available., Objectives: The objective of the present study was to evaluate ID prevalence among children and adolescents (1-19 y) using nationally representative data and to examine the sociodemographic patterning of ID., Methods: Cross-sectional data from the Comprehensive National Nutrition Survey in children (1-4 y: n = 9635; 5-9 y: n = 11,938) and adolescents (10-19 y; n = 11,507) on serum ferritin (SF) and other biomarkers were analyzed to determine inflammation-adjusted ID prevalence [SF (μg/L): <12 in 1-4 y and <15 in 5-19 y] and its relation to sociodemographic indicators. Multiple-regression analyses were conducted to identify the exposure associations of iron status. In addition, the relation between SF and hemoglobin was assessed as an indicator of iron utilization in different wealth quintiles., Results: ID prevalence was higher in 1- to 4-y-old children (31.9%; 95% CI: 31.0%, 32.8%) and adolescent girls (30.4%; 95% CI: 29.3%, 31.5%) but lower in adolescent boys and 5- to 9-y-old children (11%-15%). In all age groups, ID prevalence was higher in urban than in rural participants (1-4 y: 41% compared with 29%) and in those from richer quintiles (1-4 y: 44% in richest compared with 22% in poorest), despite adjustment for relevant confounders. SF significantly interacted with the wealth index, with declining trends in the strength of association between hemoglobin and SF from the richest to the poorest groups suggesting impaired iron utilization for hemoglobin synthesis in poorer wealth quintiles., Conclusions: ID prevalence was indicative of moderate (in preschool children and adolescent girls) or mild (in 5- to 9-y-old children and adolescent boys) public health problem with significant variation by state and age. Focusing on increasing iron intake alone, without addressing the multiple environmental constraints related to poverty, may not result in intended benefits., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: It is thought that there is a high risk of zinc deficiency in India, but there are no representative national estimates., Objectives: We aimed to evaluate the national and state-level prevalence of low serum zinc concentrations (SZCs) in Indian children from the nationally representative Comprehensive National Nutrition Survey., Methods: Prevalence of low SZC, adjusted for C-reactive protein, was estimated among preschool (1-4 y; n = 7874) and school-age children (5-9 y; n = 10,430) and adolescents (10-19 y; n = 10,140), using SZC cutoffs defined by the International Zinc Nutrition Consultative Group., Results: Prevalence of low SZC was high among adolescents (31.1%; 95% CI: 29.8%, 32.4%), compared with school-age (15.8%; 95% CI: 15.3%, 16.3%) or preschool children (17.4%; 95% CI: 16.7%, 18.0%). However, stratification of prevalence by fasting status or using an alternative lower SZC cutoff independent of fasting status led to a reduction in prevalence by 3.7% or 7.8% in children <10 y, respectively. The prevalence of low SZC was higher among rural preschool children, those belonging to households with poor socioeconomic status, and those with severe stunting or underweight. Preschool children with diarrhea (22.6%; 95% CI: 20.8%, 24.4%), productive cough (22.7%; 95% CI: 18.5%, 27.5%), or malaria/dengue (38.5%; 95% CI: 29.4%, 48.2%) in the 2 wk preceding the survey had a higher prevalence of low SZC than those without morbidity (16.5%; 95% CI: 15.9%, 17.2%; 17.6%; 95% CI: 16.9%, 18.2%; and 17.5%; 95% CI: 16.8%, 18.1%, respectively)., Conclusions: The national prevalence of low SZC among preschool (17%) or school-age children (16%) was <20%, which is considered the cutoff indicating a problem of public health significance; but there were variations by state and socioeconomic status. In adolescents, however, the prevalence of low SZC was 31%, which warrants further investigation. The association of low SZC with diarrhea in preschool children necessitates better coverage of Zn administration in the management of diarrhea., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background: Intra-individual coexistence of anthropometrically defined undernutrition and 'metabolic obesity', characterised by presence of at least one abnormal cardiometabolic risk factor, is rarely investigated in young children and adolescents, particularly in Low-and-Middle-Income-Countries undergoing rapid nutrition transition., Methods: Prevalence of biomarkers of metabolic obesity was related to anthropometric and socio-demographic characteristics in 5-19 years old participants from the population-based Comprehensive National Nutrition Survey in India (2016-2018). The biomarkers, serum lipid-profile (total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides), fasting glucose, and glycosylated hemoglobin (HbA1C), and all jointly were analysed in 22567, 23192, 25962 and 19143 participants, respectively., Results: Overall (entire dataset), the prevalence of abnormalities was low (4.3-4.5%) for LDL and TC, intermediate for dysglycemia (10.9-16.1%), and high for HDL and triglycerides (21.7-25.8%). Proportions with ≥1 abnormal metabolic obesity biomarker(s) were 56.2% overall, 54.2% in thin (BMI-for-age < -2 SD) and 59.3% in stunted (height-for-age < -2 SD) participants. Comparable prevalence was evident in mild undernutrition (-1 to -2 SD). Clustering of two borderline abnormalities occurred in one-third, warranting active life-style interventions. Metabolic obesity prevalence increased with BMI-for-age. Among those with metabolic obesity, only 9% were overweight/obese (>1 SD BMI-for-age). Among poor participants, triglyceride, glucose and HDL abnormalities were higher., Conclusions: A paradoxical, counter-intuitive prevalence of metabolic obesity biomarker(s) exists in over half of anthropometrically undernourished and normal-weight Indian children and adolescents. There is a crucial need for commensurate investments to address overnutrition along with undernutrition. Nutritional status should be characterized through additional reliable biomarkers, instead of anthropometry alone., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: WHO's haemoglobin cutoffs to define anemia were based on five studies of predominantly White adult populations, done over 50 years ago. Therefore, a general re-examination of the existing haemoglobin cutoffs is warranted for global application, in representative healthy populations of children and adults. Such data are scarce in low-income and middle-income countries; however, a 2019, large-scale, nationally representative survey of children and adolescents aged 0-19 years in India (Comprehensive National Nutrition Survey [CNNS]) offered an opportunity for this re-examination. Using this survey, we aimed to assess the age-specific and sex-specific percentiles of haemoglobin and cutoffs to define anaemia in the CNNS population., Methods: For this population-based study, we constructed age-specific and sex-specific haemoglobin percentiles from values reported for a defined healthy population in the CNNS, which used rigorous quality control measures during sample collection and in the laboratory analyses. To obtain a healthy population, we excluded participants with iron, folate, vitamin B12, and retinol deficiencies; inflammation; variant haemoglobins (haemoglobin A 2 and haemoglobin S); and history of smoking. We considered age-specific and sex-specific 5th percentiles of haemoglobin derived for this healthy population as the study cutoff to define anaemia. We compared these with existing WHO cutoffs to assess significant differences between them at each year of age and sex for quantifying the prevalence of anaemia in the entire CNNS sample., Findings: Between Feb 24, 2016, and Oct 26, 2018, the CNNS survey collected blood samples from 49 486 individuals. 41 210 participants had a haemoglobin value, 8087 of whom were included in our study and comprised the primary analytical sample. Compared with existing WHO cutoffs, the study cutoffs for haemoglobin were lower at all ages, usually by 1-2 g/dL, but more so in children of both sexes aged 1-2 years and in girls aged 10 years or older. Aanemia prevalence with the study cutoffs was 19·2 percentage points lower than with WHO cutoffs in the entire CNNS sample with valid haemoglobin values across all ages and sexes (10·8% with study cutoffs vs 30·0% with WHO cutoffs)., Interpretation: These findings support the re-examination of WHO haemoglobin cutoffs to define anaemia. Our haemoglobin reference percentiles, derived from healthy participants in a large representative Indian survey, are suitable for national use in India. Substantial variations in the 5th percentile of haemoglobin values across the 1-19 years age range and between sexes argue against constructing common cutoffs in stratified age groups for convenience., Funding: None., Translations: For the Hindi, Punjabi, Tamil and Kannada translations of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests HSS designed the draft protocol of the CNNS with consultancy support from UNICEF, India. HSS, AS, UK, and AVK were members of the Technical Advisory Committee of the CNNS, constituted by the Ministry of Health and Family Welfare of the Government of India, to oversee its conduct and analysis. HSS is a member of the WHO Nutrition Guidance Expert Advisory Subgroup on Diet and Health and Guideline Development Group on the use and interpretation of haemoglobin concentrations for assessing anaemia status in individuals and populations, member of the National Technical Board on Nutrition of NITI Aayog, and member of expert groups of the Ministry of Health and Family Welfare on Nutrition and Child Health. AVK was a nutrition advisor to the Tata Trusts, during the conduct of the study. AS, RA, SR, NK, and AP were involved in the CNNS study implementation and main analyses. SA declares no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Biochemical vitamin A deficiency (VAD) is believed to be a serious public health problem (low serum retinol prevalence >20%) in Indian children, justifying universal high-dose vitamin A supplementation (VAS)., Objective: To evaluate in Indian children younger than 5 y the risk of biochemical VAD from the Comprehensive National Nutrition Survey, as well as dietary vitamin A inadequacy and excess over the tolerable upper limit of intake (TUL) from national and subnational surveys, factoring in fortification and VAS., Methods: Child serum retinol data, corrected for inflammation, were examined to evaluate national- and state-level prevalence of VAD. Simultaneously, dietary intakes from the National Sample Survey Office and the National Nutrition Monitoring Bureau were examined for risk of dietary vitamin A deficiency against its average requirement (AR) derived for Indian children. Theoretical estimates of risk reduction with oil and milk vitamin A fortification were evaluated along with the risk of exceeding the TUL, as well as when combined with intake from VAS., Results: The national prevalence of biochemical VAD measured in 9563 children was 15.7% (95% CI: 15.2%, 16.3%), and only 3 states had prevalence significantly >20%. The AR of vitamin A was 198 and 191 µg/d for boys and girls; the risk of dietary inadequacy was ∼70%, which reduced to 25% with oil and milk fortification. Then, the risk of exceeding the TUL was 2% and 1% in 1- to 3-y-old and 4- to 5-y-old children, respectively, but when the VAS dose was added to this intake in a cumulative 6-mo framework, the risk of exceeding the TUL rose to 30% and 8%, respectively., Conclusion: The national prevalence of VAD risk is below 20% in Indian children. Because there is risk of excess intake with food fortification and VAS, serious consideration should be given to a targeted approach in place of the universal VAS program in India., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Background  The stability of biological samples is vital for reliable measurements of biomarkers in large-scale survey settings, which may be affected by freeze-thaw procedures. We examined the effect of a single freeze-thaw cycle on 13 nutritional, noncommunicable diseases (NCD), and inflammatory bioanalytes in serum samples. Method  Blood samples were collected from 70 subjects centrifuged after 30 minutes and aliquoted immediately. After a baseline analysis of the analytes, the samples were stored at - 70°C for 1 month and reanalyzed for all the parameters. Mean percentage differences between baseline (fresh blood) and freeze-thaw concentrations were calculated using paired sample t -tests and evaluated according to total allowable error (TEa) limits (desirable bias). Results  Freeze-thaw concentrations differed significantly ( p < 0.05) from baseline concentrations for soluble transferrin receptor (sTfR) (- 5.49%), vitamin D (- 12.51%), vitamin B12 (- 3.74%), plasma glucose (1.93%), C-reactive protein (CRP) (3.45%), high-density lipoprotein (HDL) (7.98%), and cholesterol (9.76%), but they were within respective TEa limits. Low-density lipoprotein (LDL) (- 0.67%), creatinine (0.94%), albumin (0.87%), total protein (1.00%), ferritin (- 0.58%), and triglycerides (TAG) (2.82%) concentrations remained stable following the freeze-thaw cycle. In conclusion, single freeze-thaw cycle of the biomarkers in serum/plasma samples after storage at - 70°C for 1 month had minimal effect on stability of the studied analytes, and the changes in concentration were within acceptable limit for all analytes., Competing Interests: Authors ContributionConflicts of Interest All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Ransi Ann Abraham, Garima Rana and the Population Council team. The first draft of the manuscript was written by Ransi Ann Abraham, and all authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript. The authors declare that they have no conflicts of interest. The views expressed are those of the authors and do not necessarily reflect those of their organization., (The Indian Association of Laboratory Physicians. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Introduction: The present study was conducted to assess the association of tobacco and alcohol consumption with cardiovascular risk factors among elderly population living at high altitude regions of India., Materials and Methods: A cross-sectional study was conducted among 1003 elderly people living in district Nainital, Uttarakhand state, India. Thirty subjects were identified from 30 villages using population proportionate to size sampling methodology. The data on the consumption of tobacco and alcohol, mini nutritional assessment, Barthel activities of daily living scale, height, weight, blood pressure, fasting blood sugar, triglycerides, and total cholesterol was collected., Results: We found that smoking tobacco was associated with high cholesterol, lower body mass index, and low nutritional status (all, P < 0.05). Elderly subjects who consumed alcohol had 1.56 times higher risk of having high fasting blood glucose., Conclusions: Consumption of tobacco and alcohol increased the risk of cardiovascular diseases among elderly subjects. There is a need to improve these modifiable health behaviors through targeted educational and rehabilitation programs., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Family Medicine and Primary Care.)

Background: In India, iodine deficiency (ID) still remains a serious concern even after five decades of enormous efforts. ID during the preconception period of adolescent girls may negatively affect future neonates, resulting in neonatal hypothyroidism. Hence, the present study was conducted to assess the prevalence of goiter and associated factors among adolescent girls in a poor socioeconomic district of Rajasthan., Methodology: A cross-sectional study was conducted during January-March 2015 in Tonk district of Rajasthan. A total of 1912 adolescent girls were selected from thirty schools using population proportionate to size sampling. Adolescent girls were clinically examined for thyroid using palpation method. Casual urine ( n = 344) and salt samples ( n = 370) were collected from a subgroup of girls for the estimation of urinary iodine concentration (UIC) and iodine content in salt, respectively., Results: The overall goiter prevalence was 15.3% (95% confidence interval 13.6%-16.9%) and the median UIC was 266 μg/l (interquartile range: 150-300 μg/l) among 1912 adolescent girls (age, 15.7 ± 1.4 years). Around 16.8% of the families of adolescent girls were consuming salt with inadequate iodine (<15 ppm). Goiter prevalence was statistically significantly different with respect to age groups ( P = 0.03). There was no statistically significant difference in goiter prevalence with respect to iodine content of salt ( P = 0.98) and UIC ( P = 0.41). The median UIC increased with an increase in consumption of iodine content of salt from inadequacy to adequacy ( P = 0.15)., Conclusion: Adolescent girls, residing in an underdeveloped district, are in the transition phase from mild ID (goiter prevalence 15.3%) to iodine sufficiency (median UIC 266 μg/l)., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Indian Journal of Community Medicine.)

Introduction: Anemia is a major public health problem amongst elderly population in India. Anemia in old age further worsens the age-related decline in functional ability, mobility, fatigue, bone density, and skeletal muscle mass. There is lack of evidence on the prevalence and risk factors of anemia among elderly population. Hence, this study was undertaken., Methodology: A community-based cross-sectional study was conducted during the year 2015-2016 in District Nainital, Uttarakhand state, India. A total of 958 subjects were selected from 30 clusters (villages) identified using population proportional to size methodology. Information on sociodemographic profile, nutritional status, body mass index, and dietary intake was obtained. Blood sample was collected from each subject on the filter paper for estimation of hemoglobin (Hb) level using cyanmethemoglobin method., Results: We found that 92.1% of the elderly subjects were anemic. Moderate and severe anemia was found to be significantly higher among female subjects, unemployed, illiterates, subjects using smoke-producing fuel, subjects belonging to lower socioeconomic status, malnourished and underweight subjects, subjects with self-reported hyperacidity, and subjects who had not utilized health facility and had lower iron and vitamin C intake when compared with subjects with mild anemia and normal hemoglobin levels., Conclusion: High prevalence of anemia exists amongst elderly subjects living at high-altitude region of rural Uttarakhand State, India. There is a need to educate the elderly population about the importance of adequate intake of foods rich in iron and vitamin C to reduce the prevalence of anemia among them., (Copyright: © Journal of Family Medicine and Primary Care.)

Anaemia is a severe public health problem amongst all vulnerable age groups in India. The National Nutritional Anaemia Prophylaxis Programme initiated in 1970, was revised and expanded to include beneficiaries from all age groups namely children aged 6-59 months, 5-10 yr, adolescents aged 10-19 yr, pregnant and lactating women and women in reproductive age group under the National Iron Plus Initiative (NIPI) programme in 2011. The dose of iron, frequency and duration of iron supplementation and roles and responsibilities of the functionaries were described. At present, the coverage of beneficiaries with iron and folic acid has been poor at the national level. The prevalence of anaemia has continued to remain high during the last 60 years, and there has been no significant change in the scenario due to various reasons. The constraints in implementation and measures to improve the NIPI programme are discussed in the current article., Competing Interests: None

Background: Limited data are available on the epidemiology of breast cancer (BC) in India., Objective: To study the epidemiological characteristics of BC patients attending a tertiary care hospital in National Capital Territory of India., Materials and Methods: A cross-sectional study was conducted and information from 320 women with confirmed BC was collected on a questionnaire for demographic profile, socioeconomic status (SES), reproductive risk factors, and family history of BC. Information on clinical presentation and staging of BC was recorded. Anthropometric assessment for body mass index (BMI) was done. Data were analyzed and presented as mean ± standard deviation and frequency tables., Results: The mean age at diagnosis of BC was 47 ± 10 years. Fifty-three percent of patients were illiterate or only primary school education. About 74% of patients were from urban areas. Only 11% of patients were from upper SES and 26% from lower SES. Forty-seven percent of patients had stage II followed by 36% with stage III BC. About 15% patients had experienced early menarche (<13 years of age) and 15% of women had attained late menopause (>51 years of age). About 42% of patients had <3 children and 15% patients had a family history of BC. About 38% patients were overweight and 21% were obese., Conclusion: Other than the established risk factors, other factors such as lack of education, SES, and higher BMI were present in our study. A higher percentage of women were diagnosed with BC at later stages. There is a need for educating women about BC, self-examination of breast, and screening programs for early detection of BC., Competing Interests: None

Introduction: Preanalytical conditions are critical for blood sample integrity and poses challenge in surveys involving biochemical measurements. A cross sectional study was conducted to assess the stability of select biomarkers at conditions that mimic field situations in surveys., Material and Methods: Blood from 420 volunteers was exposed to 2 - 8 °C, room temperature (RT), 22 - 30 °C and > 30 °C for 30 min, 6 hours, 12 hours and 24 hours prior to centrifugation. After different exposures, whole blood (N = 35) was used to assess stability of haemoglobin, HbA1c and erythrocyte folate; serum (N = 35) for assessing stability of ferritin, C-reactive protein (CRP), vitamins B12, A and D, zinc, soluble transferrin receptor (sTfR), total cholesterol, high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), tryglicerides, albumin, total protein and creatinine; and plasma (N = 35) was used for glucose. The mean % deviation of the analytes was compared with the total change limit (TCL), computed from analytical and intra-individual imprecision. Values that were within the TCL were deemed to be stable., Result: Creatinine (mean % deviation 14.6, TCL 5.9), haemoglobin (16.4%, TCL 4.4) and folate (33.6%, TCL 22.6) were unstable after 12 hours at 22-30°C, a temperature at which other analytes were stable. Creatinine was unstable even at RT for 12 hours (mean % deviation: 10.4). Albumin, CRP, glucose, cholesterol, LDL, triglycerides, vitamins B12 and A, sTfR and HbA1c were stable at all studied conditions., Conclusion: All analytes other than creatinine, folate and haemoglobin can be reliably estimated in blood samples exposed to 22-30°C for 12 hours in community-based studies., Competing Interests: Potential conflict of interest: None declared.

Anemia is a major public health problem in India with prevalence of more than 50% amongst children and adolescents. The decline in the burden of anemia has been insignificant over the past 5 decades. The present review assesses the National Guidelines for Prevention and Control of Anemia in India, the current status of the program implementation and possible reasons for the continued high prevalence of anemia in the country.