7/31/2019 vit d3 f

1/48

1

Dr B. Sesikeran. MD, FAMSDirector

National Institute of NutritionHyderabad 500 007

(Indian Council of Medical Research)

Department of Health ResearchMinistry of Health and Family welfare

Government of India

Pediatric Nutrition and Research in India

7/31/2019 vit d3 f

2/48

2

56.9

81

30.233.3

12.4

33.3

87

45

35

15.5

37.5

60

0

20

40

60

80

100

Energy protein calcium iron vit A Vit C

1-3 yrs 4-6 yrs

Dietary Intakes in Preschool Children

Consumption as percentage of RDA

NNMB, 2006

7/31/2019 vit d3 f

3/48

3

P+ C--

P+ C+

P-- C --

P+ C--

P+ C--

P+ C+

P C--

P C--

1-3 yrs

4-6 yrs

Protein and Calorie adequacy by age groups

47.3%

30.1%

22.5%

64.8%23.8%

11.4%

NNMB, 2006

n = 1948

n = 2040

Calorie inadequacy >69%

Calorie inadequacy >75%

7/31/2019 vit d3 f

4/48

4

Actual Intakes,kcal/day

RDA, kcal/day

Urban slum, 18 mths 590 1100

Hospital study, 3yrs 900 1400

NNMB reports,

1-6years

897 1200-1600

There is gross deficit of more than 500 kcal /day at any age inpreschool children,

Dietary Intakes of Preschool Children

7/31/2019 vit d3 f

5/48

5

15

33

24

75

33

20

32

25

54

76

0

10

20

30

4050

60

70

80

cereals pulses MMP fats GLV

1-3 yrs 4-6 yrs

Dietary Intakes in Preschool Children

Consumption as percentage of RDA

NNMB, 2006

7/31/2019 vit d3 f

6/48

6

Dietary intakes 1 3 yrs 4 - 6 yrsIn gms / day, n = 1948, n = 2040

Cereals 135 126 (75%) 209 173(76%)

Pulses 13 16 (33%) 19 20 (54%)

Milk & milkproducts

86 140 (24%) 62 99 (24.8%)

Fats & oils 5 6 (33%) 8 8 (32%)

GLV 6 20 (15%) 10 29 (20%)

Other veg 16 28 (85%) 26 38 (86%)

Sugar

& jaggery

9 14 (35%) 10 13 (25%)

Consumption in gms / day, mean SD ,

RDA % in parenthesis

NNMB, 2006

7/31/2019 vit d3 f

7/48

7

1

58.7

39.2

33.6

21.5

0

10

20

30

40

50

60

70

80

90

Micro Nutr.

Prot. & Energy

Proportion of Individuals Consuming

7/31/2019 vit d3 f

8/488

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11

1990 2000

Distribution (%) of Solely Breast fed infants and nutritional

Status by age and period of survey, n =1700 in 2000

Age (Months)

Percentage

NNMB

2

3

4

5

6

7

8

9

10

1 2 3 4 5 6 7 8 9 10 11

NCHS 1990 2000

7/31/2019 vit d3 f

9/489

0

10

2030

40

50

60

0

7/31/2019 vit d3 f

10/4810

0

10

20

30

40

50

60

0

7/31/2019 vit d3 f

11/4811

Weights by Age (0-24 months) Urbanslum study, n=470

2

4

6

8

10

12

0 3 6 9 12 18 21 24

WHO, 2006

Normal >2.5kg

Age (Months)

Weight(Kg)

LBW

7/31/2019 vit d3 f

12/4812

Trends of Proportion of Normally Nourished ChildrenAcross 8 States in the First Two Years of Life

0

10

20

30

40

50

60

70

80

90

100

1stM

on

2ndM

on

3rdMon

4thM

on

5thM

on

6thM

on

9mth

s

12mth

s

15mth

s

18mth

s

21mth

s

24mth

s

AP CG JH MP OR RA UP WB

Care study, 8 states

7/31/2019 vit d3 f

13/4813

Child Weights from birth to 2 years by tertiles of maternalweight- Confirms the significant role of maternal weight in

birth weight and later growth and development

2

4

6

8

10

12

0 3 12 18 24

< 41 kg

> 47.5 kg

Age (Months), NIN, Urban slum study

Weight(Kg)

41-47.5 kg

7/31/2019 vit d3 f

14/4814

Distribution (%) of Pre-school children (1-5 Yrs)

According to Gomez Classification

6

10 9

13

32

38

41

4448 44

44

38

15

96

5

0

10

20

30

40

50

60

Normal Mild Moderate Severe

1975-79

1988-90

1996-97

2005-06

Percent

7/31/2019 vit d3 f

15/4815

Distribution (%) of Children by Undernutrition andPeriod of Survey

6460

55

67

4952

21 23

15

0

20

40

60

80

Underweight Stunting Wasting

1990-91

2000-01

2005-06

Percent

UNDERNUTRITION (< Median - 2SD)

7/31/2019 vit d3 f

16/4816

NFHS 3

Total Urban Rural

Under nutritionWt for age - 45.9 36.4 49

StuntingHt for age 38.4 31.1 40.7

Wastingwt for height 19.1 16.9 19.8

7/31/2019 vit d3 f

17/4817

Prevalence (%) of Nutritional deficiency signsamong Preschool Children

0.1

0.1

0.6

1.3

0.6

0.7

0.7

1.8

0.8

2.1

5.7

5.7

0 1 2 3 4 5 6 7

Marasmus

Bitot Spots

Ang.Stomat.

1975-79

1988-90

1996-97

2005-06

Percent

7/31/2019 vit d3 f

18/4818

7479

4649

4 5

0

1020

30

40

5060

70

80

90

Any anemia Moderate anemia severe anemia

NFHS-2 NFHS-3

Anemia among Children Age 6-35 Mo

Percent

1998-99 2005-06

7/31/2019 vit d3 f

19/4819

Details % RDA of energy IronMean SD (n)

Children

1-6 yrs

< 70 5.9 4.57 (2898)

(CI- 5.7 6.1)

70 100 9.7 6.46 (856)

(CI- 9.3 10.2)

100 14.0 9.19 (234)

(CI- 12.9 15.2)

Pooled 7.2 5.87 (3988)

Mean Intake of Iron (Mg) by Energy Intakes,( Percentage of RDA ) in Children

Source NNMB

7/31/2019 vit d3 f

20/4820

Pooled: 0.8

< 0.5 %

0.5 %

Kerala0

Tamil Nadu0.5

Karnataka0.7

Andhra Pradesh1.2

Maharashtra1.3

Madhya Pradesh1.4

Orissa0.3

West Bengal0.6

7/31/2019 vit d3 f

21/4821

Indo-US responsive feeding study

RESPONSIVE COMPLEMENTARY FEEDING

INTERVENTION: IMPACT ON FOOD INTAKE,

GROWTH & DEVELOPMENT

7/31/2019 vit d3 f

22/4822

Recruit - 3rd trimester of pregnancy

Randomize

Repeat Evaluations at 6, 9, 12, 15 m

Baseline Evaluationat 3m of Infants age

Group 2Comp Feed

Group 3CF, RF, Dev

Group 1Control

Intervention 3-15 months

STUDY DESIGN

7/31/2019 vit d3 f

23/4823

Intervention

Group 1

Group 2

Group 3

MaternalBehavior

Child

Growth

Hb

Development

DietFeedingBehavior

PlayBehavior

Morbidity

Intake

BMI

SESEducation

MentalHealth

Birth WtGender

FR

7/31/2019 vit d3 f

24/4824

90

100

110

120

Mental Motor

group 1

group 2

group 3

DQvaried significantly by Group

1

7/31/2019 vit d3 f

25/4825

Make feeding a pleasurable experience for you and your child

7/31/2019 vit d3 f

26/4826

Micronutrient Beverage Study

7/31/2019 vit d3 f

27/48

27

Changes in levels of some hematopoieticmicronutrients (final initial)

117.6

118.6

117.4

114.9

111

114

117

120

Initial Final

Supplement

Placebo

39.5

19.2

37.5

14.3

0

20

40

60

Initial Final

Supplement

Placebo

264.4

571

256.8316.5

0

200

400

600

Initial Final

Supplement

Placebo

273.3

510.2

239.6

357.1

0

200

400

600

Initial Final

Supplement

Placebo

Hemoglobin (g/dl) Plasma Ferritin (g/L)

RBC Folate (n mol/L Plasma Vitamin B12

***

***

7/31/2019 vit d3 f

28/48

28

Changes in levels of Vitamins D & C(final initial)

0.7

1.3

0.88

1.07

0

0.4

0.8

1.2

1.6

Initial Final

Supplement

Placebo

31.5

62.4

30.9

54.1

0

20

40

60

80

Initial Final

Supplement

Placebo

Vitamin D (mol/L) Vitamin C (mol/L)

***

***

7/31/2019 vit d3 f

29/48

29

SUMMARY OF BIOCHEMICAL CHANGESat end of study

Supplementation of a micronutrient-enriched beverage for

14 mo significantly improved the status of many of the

nutrients.

Significant with respect to vitamins A, B2, and B12, folic

acid, vitamin D, parathyroid hormone, and thyroid-

stimulating hormone in children who received the

supplement compared with those who received only

placebo.

Hemoglobin status improved only in children who had

anemia in the supplemented group.

7/31/2019 vit d3 f

30/48

30

GROWTH

Baseline Z scores of height and weight for age,weight for height were similar in both Groups of

children across age.

The duration of supplementation was also not

different between Groups.

After 14 months of supplementation, there were

significant differences in growth between Groups

7/31/2019 vit d3 f

31/48

31

INCREMENTS IN WHOLE-BODY BONEMINERAL CONTENT (G) BY GRADE &

GROUPS

105.3

133.9

168.8

150.2

176.9

200.1

154.5

128.3

152

207.2

94.3

132.5

211.2

165.8

126.7121.8

85.185.1

0

50

100

150

200

250

2 3 4 5 6 7 8 9 Pooled

School Grades

Supplement

Placebo

*

Supplemented Group significantly higher (p

7/31/2019 vit d3 f

32/48

32

SUMMARY OF FINDINGS

Mean height & weight velocities & BMI increments

were significantly higher in the supplemented

Group

Plasma Ferritin, RBC Folate, Vitamin A, VitaminB2, PTH & Vitamin D, was significantly higher in

the supplemented compared to control Group

Whole bone mineral content & whole body bone

area were significantly higher among the

supplemented Group compared to controls.

7/31/2019 vit d3 f

33/48

33

0

0.2

0.4

0.60.8

1

1.2

1.4

1.6

Tertile I Tertile II Tertile III

Fat gain FFM gain Total Wt. gain

WeightGaininkgs

8.9 g/kg/d 5.6 g/kg/d 4g/kg/ d

NIN study, Asia Pac J Clin Nutr

Nutritional rehabilitation of SAM children, Children who had higher wt. gainin 1 month gained more of FFM and Fat gain was relatively similar in allchildren contrary to the belief that rapid weight gain may be associatedwith higher body fat

SAM Study

7/31/2019 vit d3 f

34/48

34

Current study with London school of Hygiene

The Hyderabad nutrition trial ( 1987-1990),

2580 infants born in

15 villages Supplementary food was offered tomothers and young infants under ICDS programand 14 control villages where ICDS was notimplemented.

Birth weights slightly & significantly higher in theintervention (2,655 g, s.d. 424) than control group(2,594, s.d 430) (p

7/31/2019 vit d3 f

35/48

35

The Hyderabad nutrition trial ( 1987-1990), Follow upstudy (2003-05)

These children were re-examined during adolescence(age 13-18 years, n=1165 ).

The supplemented group were significantly taller, andhad significantly lower insulin resistance 20% lowerHOMA score- (95% CI 3, 39; p=0.02)

and arterial stiffness: augmentation index 3.3% less(95% CI 1, 5.7; p=0.008)

Sanjay Kinra et al, BMJ, 2008

7/31/2019 vit d3 f

36/48

36

These subjects are currently followed up after a gapof 5 years with additional parameters like,

DEXA, for total BMC, total & regional adiposity

Carotid intimal thicknessLipid profile

Physical activity

Dietary intakes etc along with

HOMA index, augmentation index, Anthropometry,

7/31/2019 vit d3 f

37/48

37

Zinc studies

7/31/2019 vit d3 f

38/48

38

Zinc Intakes in Children 15-18 Months inAddition to Breast Milk NIN Studies

Age months Zinc intake mg/d

Radha krishna et al

Urban slum

18 mths

n=1050.98 0.59

Shahnaz et al

Rural

15 mths

n=525

0.95 0.55

EAR= 2mg/d and RDA 4-5 mg/d

7/31/2019 vit d3 f

39/48

39

Prevalence of Zinc Deficiency inChildren , Under 5 Years

Age Cut offlevel

% Zincdeficient

Nita bhandari,

BMJ,2002

15.4 (7.4)

months

7/31/2019 vit d3 f

40/48

40

Vitamin D Deficiency

7/31/2019 vit d3 f

41/48

41

81.5

62

76.572.2

0

10

20

30

40

50

60

70

80

90

urban Rural

child (M)

Child (F)

Prevalence of VDD in children -Tirupati, South India

Harinarayan et al, IJMR,2008

7/31/2019 vit d3 f

42/48

42

Cut off point Prevalence %

Delhi, Goswami,2001,Adoloscent

< 20 ng/ml >90%

Javaid, Pregnancy.Lancet,2006

< 20 ng/ml 84%

Pregnancy , NIN study, 2008 < 20 ng/ml 87.8%

Cord blood, NIN, 2008 < 20 ng/ml 91%

Alok sachan et al pregnancy,Lucknow, 2005

< 15 ng/ml 66.7%

Seema Puri et al

Adolescent girls< 20 ng/ml 90.8%

Harinarayan et al Tirupati,children

< 20 ng/ml 75%

Prevalence of vitamin D Deficiency in India

7/31/2019 vit d3 f

43/48

43

Author Year Agegroups

(yr)

Numberof

subjects

Prevalence (%)

Overweight Obesity

Mohan B 2004 11- 17 2467 11.6 2.6

Khadilkar Y 2004 10 15 1228 19.9 5.7

Chatwal J 2004 9 15 2008 14.2 11.1

Subramaniam V 2003 10 15 707 10.0 6.0

Laxmaiah A et al 2004 12 - 17 1208 04.6 1.6

Chatterji P 2002 4 18 5000 29.0 6.0

Kapil U 2002 10 16 870 24.7 7.4

Ramchandran A 2002 13 18 4700 16.8 3.1

Pandey S & Vaidya R 2001 3 - 17 2439 15.1 15.3

PREVALENCE (%) OVERWEIGHT AND OBESITY AMONGCHILDREN: VARIOUS STUDIES in India

7/31/2019 vit d3 f

44/48

44

3.3

2.0

7.7

14.9

0

2

4

6

8

10

12

14

16

Low SES Middle SES Upper Middle

SES

High SES

Prevalence of (%) Overweight/Obesityby SES Andhra Pradesh

NIN/WHO study 2006-07

Prevalence of overweight/Obesity and Physical Activity

7/31/2019 vit d3 f

45/48

45

Category NOverweight/

ObeseP value

TV viewing(hrs/day)

None 143 5.6 a b

P < 0.05< 3 hrs/day 730 4.9 a b

3hrs/day 335 9.3 b

Participation in

outdoor games(hrs/week)

None 526 8.4 a

P < 0.004< 6 hrs 228 6.6 a

6hrs 416 5.1 b

Participation inHH activities(hours/day)

None 221 18.6 a

P < 0.001< 3 hrs 233 4.7 b

3hrs 716 3.9 b

Prevalence of overweight/Obesity and Physical Activity

(NIN Study 2005-067)

Research Priorities

7/31/2019 vit d3 f

46/48

46

1. Identifying Bio markers for Zinc deficiency, estimating theprevalence zinc deficiency and its functional

consequences

2. Vitamin D Deficiency, Extent, functional consequencesof VDD with special reference to immune status andinfections

3. Functional consequences of iron deficiency in pregnancyand early infancy on child growth, behaviou and CNSdevelopment

4. Role of Folic acid and B 12 in chronic diseases

5. Strategies for tackling Multiple MND

6. Early life nutrition and later adult chronic diseases

7. Preventive strategies for controlling the double burden of

malnutrition

Research Priorities

R h P i iti

7/31/2019 vit d3 f

47/48

47

8. Role of Essential fatty acids in pre and post natal

development

i. Pregnancy, IU growth and Development

ii. Infant growth and cognitive development

iii. Immune functions and infections in infancyand childhood

9. Role of macro and micro nutrients with specialreference to Vitamin D, Folic acid, B 12, Zinc inepigenetics

Research Priorities

7/31/2019 vit d3 f

48/48

Thank you for your attention