Field Testing of IAP2015 Charts

Local anthropometric parameters for assessing double burden of malnutrition in South Asian and Southeast Asian countries: a review and retrospective analysis

The double burden of malnutrition (DBM) is a significant public health issue in South and Southeast Asia (SA and SEA). This study aimed to assess the impact of using local and regional ethnicity-specific anthropometric references versus international references on the prevalence of DBM in these regions.A narrative review of DBM prevalence using local versus international standards was conducted. Additionally, deidentified datasets from India and Indonesia were analyzed to evaluate the effectiveness of different growth standards in identifying DBM. Anthropometric Z-scores were compared, and sensitivity, specificity, and positive predictive value (PPV) were calculated.WHO standards had the lowest specificity for identifying short stature in India and Indonesia. BMI-for-age charts using WHO Growth Reference (2007) had lower sensitivity and higher specificity for metabolic risk. Local references showed lower stunting and higher overweight or obesity prevalence. International standards overestimated stunting and underestimated obesity, leading to misclassification and missed cases of metabolic risk.

Funding

None.

Comparison of the Predictive Value of IAP 2015 and WHO Body Mass Index Criteria for Hypertension in Indian Children and Adolescents

OBJECTIVE

To compare the predictive value of the IAP and WHO criteria in identifying obesity complications in Indian children and adolescents.

METHODS

Blood pressure and body mass index was measured in 4434 children and adolescents [2539 boys; mean age 11.9 (3.0), 5.1-18 y] from affluent schools. The predictive accuracy of IAP 2015 and WHO BMI criteria in identifying hypertension was assessed.

RESULTS

IAP 2015 BMI criteria labelled 203 more children obese than the WHO reference (649 as against 446). Hypertension was present in 75 (37%) of these. The difference in the prevalence of hypertension in subjects obese as per IAP 2015 criteria and their nonobese counterparts (50.2% as against 10.8%, p < 0.0001) was greater than that between subjects obese only by IAP 2015 or by both the criteria (36.9% as against 56.3%, p < 0.0001). The difference in the proportion of subjects with hypertension between two consecutive IAP 2015 BMI SDS category was highest for + 1.5 in boys (32.3% as against 49.8%, p < 0.0001) and + 2 in girls (25.9% as against 59.3%, p < 0.00012).

CONCLUSION

IAP BMI criteria better predict hypertension in Indian children than WHO cutoffs and should be used in clinical practice to predict obesity complications.

Field Testing of Synthetic Growth Charts in 1-60-Month-Old Indian Children

BACKGROUND

Malnutrition among under-five children (U5C) in India is a major public health problem due to double burden caused by nutritional transition. WHO cut-offs are adopted as global growth standards which define how children should grow in condition of optimal nutrition and health. Growth references which are representative of population-specific existing growth patterns need to be updated regularly which is cumbersome; hence, the author's group published 'synthetic growth references' for Indian children of age 0-18 years.

OBJECTIVES

The objective of this study is to field test the new synthetic growth references in U5C for height-for-age, weight-for-age and body mass index (BMI)-for-age against WHO charts in urban and rural Indian children to estimate prevalence of various indices of malnutrition.

METHODS

A cross-sectional anthropometric assessment of apparently healthy rural and urban Indian U5C attending vaccination centre was performed using standard protocols. They were converted to Z-scores using WHO and Indian synthetic growth references. The equality of proportion of parameters of malnutrition was tested by McNemar's test and P value <0.05 was considered significant.

RESULTS

WHO charts significantly overestimated stunting and malnutrition as compared to synthetic references with difference in sensitivity of 7.2% and 8.5%, respectively, and converse for over-nutrition by 2.1%. The most commonly affected parameter of malnutrition was underweight. Stunting was significantly higher in rural population using both cut-offs (P < 0.05).

CONCLUSION

The synthetic references limit the spread of weight and BMI and do not overestimate stunting and wasting. They may be more useful for identification of malnutrition and may thus be recommended for routine screening in Indian U5C.

Evaluation of Children and Adolescents with Obesity

Childhood overweight and obesity in Indian children and adolescents is a relatively new but widespread epidemic. Hence, it is necessary to evaluate and identify these children to prevent long-term complications. The most important evaluation to identify and assess obesity-related risks in these children involves anthropometric assessment and using appropriate growth charts. Overweight and obesity are defined using weight-for-length or -height parameters (World Health Organization 2006 charts) in Indian children less than 5 y and body mass index (Indian Academy of Pediatric 2015 charts) in Indian children aged 5-18 y. Waist circumference is another important predictor of pediatric obesity-related comorbidities and is also a component to define metabolic syndrome. Tall and obese children usually have primary obesity, and short and obese children require further evaluation for endocrine disease or syndromic causes. The presence of developmental delay, hearing or vision impairment, genital and digit abnormalities or dysmorphism should warrant a genetic evaluation. It is important to document social and dietary history as well as time spent in physical activity and usage of electronic screen. Finally, comorbidities associated with childhood obesity are common, which can result in long-term complications; hence, these comorbidities should be screened and managed to prevent long-term cardiometabolic risks.

A Study on New IAP 2015 Growth References in Rural South Indian Children

OBJECTIVES

To ascertain the utility of the new pan Indian 2015 IAP references in rural South Indian children and the ability of new IAP charts to recognise children with abnormal cardiometabolic risk factors in 10 to 16 y age group.

METHODS

Among school health camps conducted at two centres of Tamil Nadu- rural Vellore and rural Erode- height, weight, waist circumference, blood pressure, triceps skin-fold thickness and body fat percentage were measured by trained pediatricians and Z-scores calculated. The anthropometric measures were studied as per IAP 2015 references and compared to other national and international references. Their utility in identification of malnutrition and cardiometabolic risk ascertained.

RESULTS

A total of 420 children (210 from Erode and 210 from Vellore) in the age group of 10 to 16 y were included in the study. New IAP references recognized more short stature (4.2 vs. 3%), wasting (11 vs. 1.5%) and overweight (14.2 vs. 13.2%) children compared to old IAP charts. The Z-scores of anthropometric measures as per New IAP 2015 references had significant correlation with old IAP and other international data (p < 0.05). It was noted that new IAP charts could detect 83.3%, old IAP chart 50% and WHO 83.3% of subjects with malnutrition. New IAP charts could detect 70.3% cardiometabolic risk associated with over nutrition compared to old IAP (57.4%) and WHO (51.8%).

CONCLUSIONS

There is a significant prevalence of both under nutrition and overweight in rural setting. IAP 2015 reference is useful to diagnose children with under nutrition and overweight including abnormal cardiometabolic risk.

Extended growth charts for Indian children

OBJECTIVES

While growth charts depicting 7 percentile lines for height and weight are useful for healthcare workers and pediatricians, endocrinologists need indication-specific z score cutoffs to plan investigations and treatment. The current Indian charts do not offer lower percentile/z scores (-2.25, -2.5, and -3 z score) lines. Also, increasing prevalence of childhood overweight and obesity necessitates a quick screening of nutritional status without calculations while using the same growth chart. Our objectives were to produce extended and user-friendly growth charts for 0-18-year-old Indian children that depict -2.25, -2.5, and -3 z score height lines in addition to the standard 7 lines and to add a quick BMI assessment tool as an inset.

METHODS

LMS values from IAP 2015 growth charts (5-18 years) and WHO 2006 MGRS charts (<5 years) were used to generate -2.25, -2.5, and -3 z score height lines (1.2, 0.6, and 0.1 percentiles, respectively) from 0-18 year for boys and girls. These newly generated lines were added to standard 7 (3, 10, 25, 50, 75, 90, 97) percentile lines for height charts. In addition, modified BMI quick screening tool was incorporated as an inset.

RESULTS

The extended height charts (with 10 lines), standard (7 lines) weight charts, and quick BMI assessment tool are presented in a single unified chart for use by endocrinologists.

CONCLUSIONS

These charts will help in defining specific height z score cutoffs as well as screen for overweight and obesity without any calculations in Asian Indian children.

Medical nutrition therapy of pediatric type 1 diabetes mellitus in India: Unique aspects and challenges

Medical nutrition therapy (MNT) is a vital aspect of management of type 1 diabetes mellitus (T1DM) and should be tailored to ethnic and family traditions and the socioeconomic and educational status of the patient. In this article, we discuss the unique aspects of MNT in children and adolescents with T1DM in the Indian setting, with focus on the challenges faced by patients, dieticians and physicians and how these can be overcome. The authors reviewed the available literature on MNT in T1DM from India and prepared the document based on their vast collective clinical experience in treating patients with T1DM from different regions in India. Indian diets are predominantly carbohydrate-based with high glycemic index (GI) and low protein content. Various methods are available to increase the protein and fiber content and reduce the GI of food in order to limit glycemic excursions. Insulin regimens need to be tailored to the child's school timings, meal schedule, and the availability of a responsible adult to supervise/administer insulin. All patients, irrespective of economic and education background, should be taught the broad principles of healthy eating, balanced diet and carbohydrate counting. There are various barriers to dietary compliance, including joint family system, changing lifestyles, and other factors which need to be addressed. There is a need to customize dietary management according to patient characteristics and needs and develop standardized patient educational material on principles of healthy eating in various regional languages.

Comparison of Nutrition Status as Assessed by Revised IAP 2015 Growth Charts and CDC 2000 Growth Charts in Lower Socioeconomic Class School Children

This retrospective study was done to compare the nutrition status as assessed by the Revised IAP 2015 and CDC 2000 growth charts in 4011 school children from the lower socioeconomic class, 5 to 16 y of age in Chennai, Tamil Nadu. The anthropometric measurements taken as per standard guidelines were retrieved from the school health records. The data were converted to Z scores and agreement between the two charts was assessed by kappa coefficient using SPSS version 16. The prevalence of overweight/obesity, thinness and stunting was 12.2%, 9.8% and 9% respectively with IAP 2015 charts. The corresponding values are 7.3%, 41.7% and 23% respectively with CDC 2000 charts. Minimal agreement was found for body mass index (BMI) for age (kappa 0.314) and weak agreement for height for age (kappa 0.497). Revised IAP 2015 growth charts diagnose more Indian children with overweight and obesity than CDC 2000 growth charts. The CDC growth chart diagnoses more stunting and thinness.