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Background & objectives Reducing maternal anaemia and enhancing feto-maternal health to achieve desired birth outcomes is a major health concern in India. Micronutrient deficiencies during pregnancy may impact fetal growth and neonatal outcomes. There is increasing interest in using multiple micronutrient supplement (MMS) during pregnancy. However, the World Health Organization (WHO) recommends use of MMS containing Iron and Folic Acid (IFA) in the context of "rigorous research". Against this backdrop, an Indian Council of Medical Research (ICMR)-led MMS design expert group met over six months to review the evidence and decide on the formulation of an India-specific MMS supplement for pregnant mothers for potential use in a research setting. Methods The India-MMS design expert group conducted a series of meetings to assess the available evidence regarding the prevalence of micronutrient deficiencies in pregnant women in India, the health benefits of supplementing with different micronutrients during pregnancy, as well as nutrient interactions within the MMS formulation. Based on these considerations, the expert group reached a consensus on the composition of the MMS tailored for pregnant women in India. Results The India-specific MMS formulation includes five minerals and 10 vitamins, similar to the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) composition. However, the quantities of all vitamins and minerals except Zinc, Vitamin E, and Vitamin B6 differ. Interpretation & conclusions This report provides an overview of the process adopted, the evidence evaluated, and the conclusions from the expert working group meetings to finalize an MMS supplement in pregnancy for the Indian context to be used in a research setting.

Multiple micronutrient deficiencies (MNDs) co-exist, often because of poor intakes and adversely impact health. Habitual diets were assessed in 300 school children (6-17 years old) recruited from two government schools by simple random sampling. Probability of adequacy (PA) for 11 micronutrients and mean probability of adequacy (MPA) was calculated. Haemoglobin, plasma ferritin, folic acid, vitamin B 12 and C-reactive protein were estimated. Descriptive statistics and regression analysis were used to estimate magnitude and factors associated with MNDs. The contribution of fortified foods and/or supplements in addressing inadequacies and excessive intakes was modelled. The PA ranged from 0.04 for folate to 0.70 for zinc, and the MPA was 0.27. Prevalence of anaemia (53%), iron deficiency (57%; ID), iron deficiency anaemia (38%; IDA), folate deficiency (24%) and B 12 deficiency (43%) was high. Dietary inadequacy of iron, zinc and a low MPA was associated with anaemia and IDA. Inclusion of double fortified salt (DFS), fortified rice (FR) or iron folic acid (IFA) supplements individually in habitual diet reduced probability of iron inadequacy significantly from 82% to ≤13%. Inclusion of DFS and FR simultaneously led to disappearance of iron inadequacy, but risk of excessive intake increased to 16%. Inclusion of DFS, FR and IFA together increased risk of excess iron intake to 40%. Nevertheless, intakes of folate and B 12 remained inadequate even with FR and/or IFA. These results indicate a high risk of dietary MNDs in children and suggest need for more systematic intake measurements in representative sample and adjustment of iron dosages to avoid excessive intakes., (© 2020 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Background: Undernutrition during intrauterine life and early childhood is hypothesised to increase the risk of cardiovascular disease (Developmental Origins of Health and Disease Hypothesis), but experimental evidence from humans is limited. This hypothesis has major implications for control of the cardiovascular disease epidemic in South Asia (home to a quarter of world's population), where a quarter of newborns have low birth weight. We investigated whether, in an area with prevalent undernutrition, supplemental nutrition offered to pregnant women and their offspring below the age of 6 years was associated with a lower risk of cardiovascular disease in the offspring when they were young adults., Methods and Findings: The Hyderabad Nutrition Trial was a community-based nonrandomised controlled intervention trial conducted in 29 villages near Hyderabad, India (1987-1990). Protein-calorie food supplement was offered daily to pregnant and lactating women (2.09 MJ energy and 20-25 g protein) and their offspring (1.25 MJ energy and 8-10 g protein) until the age of six years in the 15 intervention villages, but not in the 14 control villages. A total of 1,826 participants (949 from the intervention villages and 877 from the control villages, representing 70% of the cohort) at a mean age of 21.6 years (62% males) were examined between 2009 and 2012. The mean body mass index (BMI) of the participants was 20 kg/m2 and the mean systolic blood pressure was 115 mm Hg. The age, sex, socioeconomic position, and urbanisation-adjusted effects of intervention (beta coefficients and 95% confidence intervals) on outcomes were as follows: carotid intima-media thickness, 0.01 mm (-0.01 to 0.03), p = 0.36; arterial stiffness (augmentation index), -1.1% (-2.5 to 0.3), p = 0.097; systolic blood pressure, 0.5 mm Hg (-0.6 to 1.6), p = 0.36; BMI, -0.13 kg/m2 (-0.75 to 0.09), p = 0.093; low-density lipoprotein (LDL) cholesterol, 0.06 mmol/L (-0.07 to 0.2), p = 0.37; and fasting insulin (log), -0.06 mU/L (-0.19 to 0.07), p = 0.43. The limitations of this study include nonrandomised allocation of intervention and lack of data on compliance, and potential for selection bias due to incomplete follow-up., Conclusions: Our results showed that in an area with prevalent undernutrition, protein-calorie food supplements offered to pregnant women and their offspring below the age of 6 years were not associated with lower levels of cardiovascular risk factors among offspring when they were young adults. Our findings, coupled with evidence from other intervention studies to date, suggest that policy makers should attach limited value to cardiovascular health benefits of maternal and child protein-calorie food supplementation programmes., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: GDS is a member of the Editorial Board of PLOS Medicine.

Objective: To assess the benefits of nutrition supplementation in children living with HIV (CLHIV)., Methods: A prospective observational study was carried out at antiretroviral therapy (ART)/pediatric centre of excellence (PCOE), Niloufer hospital for a period of one year in CLHIV (N = 164) aged 1 to 18 y referred to ART/PCOE. Nutrition supplementation was given in the form of Ready to Use Food (About 350 kcal and 12 g of protein per day) supplementation to assess improvement in Height for age Z (HAZ), Weight for Age Z (WAZ), Weight for Height Z (WHZ) and Body Mass Index for age Z (BMIZ) scores over a period of one year., Results: At baseline, 65.5 % and 57.5 % of children below and above 5 y respectively were stunted. 24.1 % and 45.3 % children below and above 5 y respectively were wasted/thin (as assessed by BMI for age). Mean BMIZ score significantly improved in both the age groups (0.96 Z score, P < 0.001) in below and above 5 (0.37 Z score, P < 0.001) respectively at the end of 12 mo. Mean HAZ score also significantly improved in children above 5 y (0.09 Z score, P < 0.05) with non-significant improvement below 5 y (0.14 Z score, P < 0.57) by the end of 12 mo., Conclusions: Nutrition supplementation over one year resulted in moderate improvement in the nutritional status of CLHIV. However, it is unclear, whether the improvement in nutritional status was due to regular visits to ART centre that may have resulted in better adherence to treatment or an additional benefit of nutrition intervention. This warrants a well-designed randomized controlled trial to examine the benefits of nutrition supplementation in CLHIV attending ART centre.

In the present study, we examined the associations of early nutrition with adult lean body mass (LBM) and muscle strength in a birth cohort that was established to assess the long-term impact of a nutrition program. Participants (n = 1,446, 32% female) were born near Hyderabad, India, in 29 villages from 1987 to 1990, during which time only intervention villages (n = 15) had a government program that offered balanced protein-calorie supplementation to pregnant women and children. Participants' LBM and appendicular skeletal muscle mass were measured using dual energy x-ray absorptiometry; grip strength and information on lifestyle indicators, including diet and physical activity level, were also obtained. Ages (mean = 20.3 years) and body mass indexes (weight (kg)/height (m)(2); mean = 19.5) of participants in 2 groups were similar. Current dietary energy intake was higher in the intervention group. Unadjusted LBM and grip strength were similar in 2 groups. After adjustment for potential confounders, the intervention group had lower LBM (β = -0.75; P = 0.03), appendicular skeletal muscle mass, and grip strength than did controls, but these differences were small in magnitude (<0.1 standard deviation). Multivariable regression analyses showed that current socioeconomic position, energy intake, and physical activity level had a positive association with adult LBM and muscle strength. This study could not detect a "programming" effect of early nutrition supplementation on adult LBM and muscle strength.

High prevalence of anaemia is a severe public health problem in India. In 2018, India launched the Anemia Mukt Bharat (AMB) strategy that focuses on six beneficiary groups for coverage, six institutional mechanisms for health system strengthening and six programmatic interventions to accelerate reductions in anaemia prevalence. This paper uses the Health Management Information System data (2017-18 to 2019-20) to examine gains in IFA coverage across Indian states. A coverage-based AMB index is computed to review performance across states. After the launch of AMB strategy, the Iron and Folic Acid (IFA) supplementation coverage between 2017-18 and 2019-20 has increased for all beneficiary groups [pregnant women from 78% to 90%; lactating mothers from 34% to 49%; school going adolescent girls (boys) from 23% to 40% (21% to 42%); out-of-school adolescent girls from 6% to 23%; children 5-9 years from 8% to 3% and children 6-59 months from 7% to 15%]. Coverage was relatively low for target groups being served through a multi-departmental convergence mechanism (health and other departments such as education department for schools or women and child development department for Anganwadi centres) than compared to those served by health department alone. However, no major gender disparities are noted in the coverage of IFA supplementation among school-going girls and boys. Bulk of the variations in coverage is attributable to state-specific differences. Training and sensitization workshops for state and district officials are found to be associated with increased coverage across beneficiary groups. The paper argues that despite following international best practices in the field, it is important to harness synergy in programme implementation across line departments to eliminate coverage inefficiencies. [ABSTRACT FROM AUTHOR]

Recent National Family Health Survey-4 data shows that anaemia continues to be a major public health problem in India. In India much of the anaemia is due to iron deficiency, and women and children are at the greatest risk of anaemia. TheMinistry of Health and Family Welfare took a policy decision, in 2013, to develop the National Iron+ Initiative (NIPI) to address the prevailing iron deficiency anaemia. This initiative covered pregnant and lactating women, children and adolescents. However, the guidelines do not match the current World Health Organization (WHO) guidelines for prevention of iron deficiency anaemia in these population groups. The background evidence for the WHO and NIPI is thus reviewed to come to a common consensus on the optimum recommendation of iron supplementation for the population, while taking into consideration the feasibility of the program, without burdening the groups with iron over-dose. However, from the present review, there is a need for increased number of trials in India that could qualify for a high grade of evidence to support the guidelines of NIPI. Document Overview: This document was prepared to review the guidelines for the National Iron Prophylaxis Initiative (NIPI) program, in the context of the current WHO guidelines, as well as evidence that may have emerged subsequently. The review was prepared for 4 population groups in 3 sections: 1. Infants and children 2. Adolescents and non-pregnant women in the reproductive age group 3. Pregnant women The section on adolescents and non-pregnant women were combined as the guidelines are common for these categories. Lactating mothers were not included in this review. The review also includes a section on treatment of iron deficiency anaemia. The structure within each section is as the follows * A background section that included the physiological basis for supplementation; * A summary of evidence leading to the current WHO guidelines; * The current Indian recommendations for iron prophylaxis in that specific group; * Evidence published after the WHO recommendation; * Conclusion. This is not a systematic review. The focus was on reviewing evidence for a comparison of efficacy of doses, daily vs intermittent regimes, and the duration of intervention. The grade of evidence was not considered for the studies i PICOT (Population, Intervention, Control group, Outcome, Time) guidelines were followed to conduct the review. Appendixes are given at the end of the document. These highlight the methods used in the Cochrane reviews that were summarized here. [ABSTRACT FROM AUTHOR]

Background: Undernutrition and physical inactivity are both associated with lower bone mass. Objective: This study aimed to investigate the combined effects of early-life undernutrition and urbanized lifestyles in later life on bone mass accrual in young adults from a rural community in India that is undergoing rapid socioeconomic development. Design: This was a prospective cohort study of participants of the Hyderabad Nutrition Trial (1987-1990), which offered balanced protein-calorie supplementation to pregnant women and preschool children younger than 6 y in the intervention villages. The 2009-2010 follow-up study collected data on current anthropometric measures, bone mineral density (BMD) measured by dual-energy X-ray absorptiometry, blood samples, diet, physical activity, and living standards of the trial participants (n = 1446, aged 18-23 y). Results: Participants were generally lean and had low BMD [mean hip BMD: 0.83 (women), 0.95 (men) g/cm²; lumbar spine: 0.86 (women), 0.93 (men) g/cm²]. In models adjusted for current risk factors, no strong evidence of a positive association was found between BMD and early-life supplementation. On the other hand, current lean mass and weight-bearing physical activity were positively associated with BMD. No strong evidence of an association was found between BMD and current serum 25-hydroxyvitamin D or dietary intake of calcium, protein, or calories. Conclusions: Current lean mass and weight-bearing physical activity were more important determinants of bone mass than was early-life undernutrition in this population. In transitional rural communities from low-income countries, promotion of physical activity may help to mitigate any potential adverse effects of early nutritional disadvantage. [ABSTRACT FROM AUTHOR]

The double burden of childhood undernutrition and adult-onset adiposity in transitioning societies poses a significant public health challenge. The development of suboptimal lean body mass ( LBM) could partly explain the link between these two forms of malnutrition. This review examines the evidence on both the role of nutrition in 'developmental programming' of LBM and the nutritional influences that affect LBM throughout the life course. Studies from developing countries assessing the relationship of early nutrition with later LBM provide important insights. Overall, the evidence is consistent in suggesting a positive association of early nutritional status (indicated by birth weight and growth during first 2 years) with LBM in later life. Evidence on the impact of maternal nutritional supplementation during pregnancy on later LBM is inconsistent. In addition, the role of nutrients (protein, zinc, calcium, vitamin D) that can affect LBM throughout the life course is described. Promoting optimal intakes of these important nutrients throughout the life course is important for reducing childhood undernutrition as well as for improving the LBM of adults. [ABSTRACT FROM AUTHOR]

Objective: To examine the catch up growth in severely wasted children using energy dense local foods at a hospital based nutrition rehabilitation unit. Design: Retrospective cohort. Setting: In-patient ward at a tertiary care government pediatric hospital in Hyderabad. Patients: Children with severe malnutrition (n=309) admitted to nutrition ward from January 2001 to December 2005. Intervention: A diet based on energy dense local foods along with multivitamin-multimineral supplements. Main outcome measures: Catch up growth (g/kg/day) during each week of hospital stay. Results: Mean age of the children was 25 months (range 2-60). Their baseline weight for height (WHZ) Z score was -4.1. Mean weight gain was moderate (5g/kg/day) and baseline WHZ score had a significant negative relationship to the weight gain. The prevalence of morbidities was high and the commonest morbidity was fever. Weight gain was higher by almost 40% in the absence of morbidities in any week. Conclusions: The diet based on local energy dense foods was found to be suitable for the nutrition rehabilitation of severely malnourished children though the rate of weight gain was moderate. [ABSTRACT FROM AUTHOR]