Knowledge Integration and Economic Analysis

Knowledge integration uses one or more of the following methods: review of available evidence, program evaluation reports, implementation research outputs, secondary analysis of data from large nationally representative surveys, intervention trials or cohorts, and reports of consultative groups.

Economic evaluation is the comparative analysis of alternative courses of action in terms of both their costs and consequences. It involves two main areas, first, the costs and consequences of programmes or interventions and, second, choices which have to be made in allocation of resources. The purpose is to identify the best course of action, based on the evidence available.

Knowledge Integration and Translational Platform – Nutrition Domain Center

The Knowledge Integration and Translational Platform (KnIT) was launched in 2016 with support from Biotechnology Industry Research Assistance Council, Dept. of Biotechnology and the Bill and Melinda Gates Foundation. It was conceptualized for providing evidence and experience-based guidance on how to accelerate progress, equity, impact in maternal and child health and nutrition. The platform aims to collate and analyzing available evidence within India, to inform policymakers and health authorities and aid in the development of evidence-based policy.

The overall interest is in the domain of maternal and child nutrition with specific interest in thriving of children for attainment of their full potential for growth and development. The priority areas have been chosen with the first 1000 days of life in mind, starting with antenatal period and till 2 years of age. The current priority areas include antenatal care, growth and nutrition in early life, low birth weight, anemia.

Work done under Priority Areas of KnIT Nutrition

ANTENATAL CARE

Utilisation of Full Antenatal Care and Associated Factors in India: Analysis from National Family and Health Survey 4

Analysis of NFHS-4 data showed that full ANC utilisation defined as defined as 4 or more antenatal visits, at least one tetanus toxoid (TT) injection and consumption of iron folic acid (IFA) for a minimum of 100 days in India was inadequate and inequitable. Although half of the women did not receive the minimum recommended ANC visits, the utilisation of TT immunisation was almost universal. The positive association of full ANC with ICDS utilisation and child’s father involvement may be leveraged for increasing the uptake of full ANC. Strategies to address the socio-demographic factors associated with low and inequitable utilisation of full ANC are imperative for strengthening India’s maternal health program.

Ki Rally on Gestational Weight Gain and its Association with Birth Outcomes

KnIT Nutrition team at SAS participated in a rally with subject matter and data science experts to explore the relationship between pregnancy weight gain at different time points and adverse birth outcomes. Data from 8 studies and about ~42000 patients with at least 2 measures of Gestational weight gain were analyzed to answer the questions of interest. Relationship between GWG and birthweight was found to best predicted by the overall gestational weight gain (last vs first measurement) of mother ~60g/ kg of GWG (R2 = 0.28, univariable model). This was also found to vary with maternal pre-pregnancy BMI with obese mothers showing the weakest correlation of birthweight to GWG.

Gestational Weight Gain in Pregnancy and its Association with Birth Outcomes: Analysis from an Intervention Cohort in Delhi, India

Analysis of data from the intervention group of the ongoing randomised controlled trial:Women and Infants Integrated Interventions for Growth Study (WINGS) showed that 2nd and 3rd trimester GWG is a strong predictor of anthropometric, pregnancy outcomes and duration of gestation. There was no significant association with preterm birth, both overall and spontaneous. The association of GWG with LAZ scores at birth was modified by early pregnancy BMI.

GROWTH AND NUTRITION IN EARLY LIFE

Burden of Severe Acute Malnutrition in the first 6 months of life and its associated risk factors: analysis from National Family and Health Survey 4

We used data from India’s National Family Health Survey 4 to estimate the prevalence of severe wasting (weight for length < ‐3 SD) among 18,898 infants under 6 months of age. We also examined the association of severe wasting with household, maternal, and child‐related factors using multivariable logistic regression analysis. This analysis reveals a high burden of severe wasting in infants less than 6 months in India. Preventive interventions must be targeted at reducing low birth weight due to fatal growth restriction and prematurity. Appropriate care practices at facilities and postdischarge with extra attention to those born small and sick can prevent further deterioration in nutritional status.

Scientific Consultation on Nutrition in Early Life

The scientific consultation on “Nutritional status of Indian children in early life” emphasized high burden of growth faltering in early life. The evidence on most robust anthropometric parameters for identification of growth faltering in young infants, is inconclusive and current guidelines for management of growth faltering among infants less than 6 months of age are based on low or very low-quality evidence. Overall, the aim of the research agenda ahead, should be to identify scalable effective actions to prevent and recuperate from growth faltering that also help in improving survival, health, and neurodevelopment, without contributing to adverse long-term metabolic risks. The proceedings from this meeting have been published in BMC Proceedings. (https://doi.org/10.1186/s12919-020-00195-z)

Predictive Ability of Different Anthropometric Indicators for Mortality in the First Six Months of Life: Secondary Data Analysis

The burden of undernutrition in the first six months of life is high. Diagnostic criteria for undernutrition in this age group have been identified as a priority area of research by WHO. We compared WLZ with WAZ and LAZ measured at six weeks of age for predicting deaths between 6 weeks and 6 months of age, using data from an individually randomized trial conducted in the urban slums of Delhi, India. The specificity ranged between 85.9 to 95.9% for all three anthropometric indicators. However, the sensitivity was highest for WAZ < -3 (64.6 %) vs LAZ<-3 (39.1%), and WLZ<-3 (25.0%). WAZ <-3 had highest AUC of 0.75, adjusted relative risk (aRR 10.6) and the population attributable fraction (57.9%) out of the three indicators. Our findings suggest that WAZ<-3 at 6 weeks of age was a better predictor of death between 6 weeks to 6 months of life and that it should be considered to diagnose SAM in this age group. Status: The manuscript has been published in BMC Pediatrics journal.

Impact of Change in Nutritional Status i.e. Stunting and Wasting on Diarrhoea-associated Mortality in India

Interventions to improve the nutritional status of under five children have direct as well as indirect benefits. We used the Lives Saved Tool (LiST) to assess the attribution of different factors and intervention packages such as direct diarrhoea case management interventions, nutritional factors and WASH interventions which contributed to diarrhoea specific under five mortality reduction (DSMR) during 1980 to 2015.

The major factors associated with DSMR reduction in under-fives during 1980 to 2015, were increase in ORS use, reduction in stunting prevalence, improved sanitation, changes in age-appropriate breastfeeding practices, increase in the vitamin-A supplementation and persistent diarrhoea treatment. While it is crucial to improve the coverage and equity in ORS use, an integrated approach to promote nutrition, WASH and direct diarrhoea interventions is likely to yield the highest impact on reducing the remaining diarrheal deaths in under-five children.

LOW BIRTH WEIGHT

Secondary Analysis to Examine Linear Growth of Low Birth Weight Children Born to Short Stature Mothers in India

Low birth weight (LBW) infants are at an increased risk of stunting and poor linear growth. The risk might be additionally higher in these infants when born to short mothers. We did an analysis to determine the risk of linear growth faltering and difference in linear growth velocity in LBW infants born to short mothers (<150 cm) compared to those born to mothers with height ≥150 cm during the first year of life.

We found that infants born to short mothers had around two-fold higher odds of stunting and lower attained length‐for‐age Z scores compared to infants of mothers with height ≥150 cm, at all ages of assessment. Linear growth velocity was significantly lower in infants of short mothers particularly in the first 6 months of life. We conclude that LBW infants born to short mothers are at a higher risk of stunting and have slower postnatal growth velocity resulting in lower attained length‐for‐age Z scores in infancy

Systematic Review and Meta-analysis to Estimate the Cognitive and Motor Deficits Among Low Birth Weight Children in South Asia

South Asia contributes substantially to global low birth weight population (i.e. those with birth weight < 2500 g). Synthesized evidence is lacking on magnitude of cognitive and motor deficits in low birth weight (LBW) children compared to those with normal birth weight (NBW) (i.e. birth weight ≥ 2500 g). The meta-analysis aimed to generate this essential evidence.

We found that in south Asia, children born LBW, especially with < 2000 g birth weight, have substantial cognitive and motor impairment compared to children with NBW. Early child development interventions should lay emphasis to children born LBW

Prebiotic and Probiotic Supplementation for Improving Growth and Neurodevelopment in Preterm Very Low Birth Weight Infants

Preterm very low birth weight (VLBW) infants are at risk of gut dysbiosis and neurodevelopmental deficits. Prebiotics and probiotics may modulate gut microbiota and influence brain functions. This review synthesized literature on effect of prebiotic and/or probiotic supplementation in preterm VLBW on their neurodevelopmental outcomes.

Interventions did not decrease or increase the risk of cognitive and motor impairment, cerebral palsy, visual, and hearing impairment. Quality of evidence was “low” to “very low.” Limited evidence from RCTs does not demonstrate a difference in neurodevelopmental outcomes between prebiotic/probiotic treated and untreated control groups.

ANAEMIA

Technical Consultation of the National Expert Group on Prevention and Treatment of Iron Deficiency Anaemia

A “National Expert Group Technical Consultation on Prevention and Treatment of Iron Deficiency Anemia” held from 23rd to 24th April 2018 at All India Institute of Medical Sciences, New Delhi. The Consultation was conducted under the aegis of Ministry of Health and Family Welfare, Government of India. Knowledge Integration and Translational Platform – Nutrition domain center was also a partner in this meeting. The Consultation followed a participative and transparent approach, comprising presentation of relevant evidence, remarks by a lead discussant, discussion among all participants, followed by the development of a consensus. Consensus was reached on the following specific aspects: prophylaxis iron dose for pregnant women and other age groups; use of Enteric coated tablets, and use of Hemoglobin estimation techniques and the benefits and risks of fortification.

Exploratory Analysis of Dietary Factors Using Data Triangulation, Modelling and Machine Learning Techniques to Inform Program Strategies to Combat Anaemia

Anemia prevalence in India remains high despite preventive iron supplementation programs. Consequently, concurrent national policies of iron fortification of staple foods have been initiated. This study evaluated the relation between dietary iron intake and anemia (hemoglobin <12 g/dL) in women of reproductive age (WRA; 15–49 y) with respect to iron fortification in India.

The relation between iron intake and the odds of anemia was weak (OR: 0.992; 95% CI: 0.991, 0.994); increasing iron intake by 10 mg/d reduced the odds of anemia by 8%. Providing fortified iron alone may not result in substantial anemia reduction among WRA in India and could have variable benefits and risks across states. Geographically nuanced dietary strategies that include limited fortification and the intake of other beneficial nutrients should be carefully considered.

Risk Factors of Non-communicable Diseases Among Children and Adolescents In India: Analysis from Comprehensive National Nutrition Survey

Despite high levels of undernutrition, emerging evidence suggests increasing burden of non-communicable diseases among children and adolescents. Analysis using the CNNS factsheet data shows that in the age group of 5 to 9 years, 12 % were diabetic or pre-diabetic, 26% had low HDL, 34% high serum triglycerides and 7% had high serum creatinine. In the age group of 10 to 19 years, 11 % were diabetic or pre-diabetic, 28% had low HDL, 16% high serum triglycerides and 7% had high serum creatinine. BMI > +1sd was low (<5%) in both groups. Children and adolescents from the lower wealth quintiles and rural areas had higher prevalence of these risk factors, in general. Low HDL was positively correlated with stunting, population below poverty line and negatively correlated with female literacy. Overweight and obesity was positively correlated with urbanization and female literacy. The current programmes do not include specific interventions for NCDs and its risk factors among children and adolescents. Status: Manuscript submitted to BMC Public Health journal and is under peer review.

Knowledge Integration and Translational Platform – State Support

The mandate of the State Interaction Unit (SIU) is to work in close collaboration with the states of Haryana, Himachal Pradesh and Rajasthan. KnIT-SIU has provided technical and analytical support for helping in evidence-based formulation of policies in the domain of maternal and child health and nutrition. Several meetings leading to impact on the state policies have been organized through this platform. These inputs are based on the needs to the respective state governments.

Haryana

KnIT participated in a consultation for finalization of the strategy for a new nutrition mission for the state. The meeting in Chandigarh was a national level consultation workshop to discuss and finalize the same. The meeting was attended by Honorable Chief Minister of the State, secretaries of department of Health and WCD, the partners, member health of NITI Aayog, Govt. of India and eminent academicians of the state and program leaders. Modifications in the current program which were proposed and accepted.

KnIT also supported the state through a consultative process to arrive at a consensus strategy for scale up of KMC in all districts of Haryana. The consultation would review pilot district-based projects on KMC by WHO and other institutions in Sonipat, Haryana, Raebareli, Uttar Pradesh and Koppel, Karnataka. The lessons drawn would relate to need for change in national and state strategy, and more specifically suggest a model for rapid scale up of KMC in districts other than Sonipat. The consultation was organized by KnIT together with WHO, SAS, Community Empowerment Lab, Karnataka Trust and state and central government representatives.

Himachal Pradesh

A two-day consultation meeting to accelerate the reduction in the prevalence of stunting among under five children and anaemia in women of reproductive age group and under five children in Himachal Pradesh was organised on 11th and 12th April 2018 at Shimla, Himachal Pradesh. KnIT Nutrition was the technical partner for this meeting, organised by the Ministry of Health and Family Welfare, Govt. of Himachal Pradesh. Several departments of the Himachal Pradesh government i.e. Woman and Child Development, Food and Civil Supplies, Ayurveda and Health participated in the meeting.

Himachal Pradesh has experienced in a decline in infant mortality at a study rate but acceleration will require faster reduction in neonatal mortality particularly in those districts which are difficult to access on account of hilly terrain, road access, extreme weather and challenges for human resource for health care on a sustainable basis. The data sources for this analysis are both secondary and primary. The secondary data sources include HMIS, district based NFHS-4 data and baseline survey in one block of district Sirmaur. In addition, reports of assessments available in knowledge and skills of ASHA workers, ANMs, nurses and physician were reviewed. The quality of neonatal care in sub-centres, PHCs, CHCs and district hospitals were assessed.

Rajasthan

The state government of Rajasthan requested assistance in analysis and interpretation of the performance, strength and weakness of project ‘POSHAN’ design and delivery. The project POSHAN relates to identification and home treatment of children with SAM in state of Rajasthan, an effort to scale up home treatment of SAM in 10 districts of Rajasthan. KnIT-SIU analyzed data provided by the state and answered questions regarding recovery rate, time to recovery and proportion of children improved but not fully recovered.

An Indepth Analysis to Understand the Burden of Wasting and Severe Wasting and the Associated Factors Among Under-five Children in India: A Collaboration between UNICEF and CHRD-SAS

India-specific data on the patterns of growth for high-risk groups like low birth weight, preterm and small for gestational age are of poor quality and/or scarce. The 2006 WHO Growth standards used in national programs for growth monitoring does not include all these high-risk groups and there is ambiguity regarding the most appropriate indicator for identifying infants under 6 months of age who are at risk of growth faltering and adverse outcomes like mortality, morbidity, and continued malnutrition. High quality evidence on the efficacy of exclusive breastfeeding and lactational support for prevention of undernutrition in the first 6 months of life is needed.

CHRD-SAS has a rich repository of data from previous and ongoing studies and we are also a partner in the Knowledge Integration (Ki) initiative which is a repository of health research data from across the globe. We will use data from intervention trials (Women and Infant Integrated Growth Study, WINGS), cohort studies on acute malnutrition (Ki) and cross-sectional studies (Ki and Comprehensive National Nutrition Survey, CNNS) and surveys to estimate the prevalence of wasting and severe wasting in the first 6 months and the first year of life. Estimates will be generated overall and by high risk groups.

We believe that the results from this analysis will be helpful in identifying indicators for growth faltering and in assessing growth that is possible and can be targeted and monitored through program interventions for high risk groups. Understanding the risk periods for growth faltering, its duration and associated factors may provide a window for targeted early intervention and preventing undernutrition. Status: The report based on the analysis is completed and the manuscript titled “Prevalence of wasting and its associated factors among children under five years of age in India: findings from the Comprehensive National Nutrition Survey” will be submitted for peer review soon.

Technical review for “Effectiveness of Community-based Treatment Programs to Treat Children aged 6-59 Months with Uncomplicated Severe Acute Malnutrition using Alternative Energy Dense Foods: A Multicentric Prospective Longitudinal Follow Up Study”

The overall goal is to work collaboratively with the Centre of excellence Kalawati Saran’s team to provide an independent technical review of the design, implementation, analysis and interpretation of the initiative to assess the impact of the mainstreaming CMAM study in India.

This study is a partnership between Children’s Investment Fund Foundation (CIFF), UNICEF and Kalawati Saran’s Children’s Hospital.

The aim of the study is to estimate the cure rates for CMAM programs using locally available options for energy dense food through a quasi-experimental design in 5 states.4 states (Telengana, MP, Chattisgarh and Odisha) have already started using CMAM protocols or are planning to pilot the use of energy dense foods in their CMAM programs. Jharkhand will be the control state with a basic protocol.

Results from the study will be shared to help other states adopt the guidelines and energy dense foods which were effective. Status: Ongoing

Equity and Poverty Impact of Community-initiated Kangaroo Mother Care

The following analyses are being conducted to assess the impact of ciKMC on household poverty and expenditure.

The equity impact of ciKMC on survival during the first 28 and first 180 days of life across axes of disadvantage like gender, caste, socioeconomic status etc.

The impact on ciKMC on catastrophic out-of-pocket expenditure and impoverishment due to cost of care seeking

Better estimates on the efficacy of ciKMC on household out-of-pocket expenses will allow for a higher precision when estimating the economic return to investment in this intervention – which is particularly important in resource poor settings.

Data Science in Maternal and Child Health

The availability of the HBGDKi datasets comprising of more than 180 studies from across the world including 30 datasets from India provides and excellent opportunity to apply advanced analytical and machine learning techniques for exploring these datasets and answering questions in the domain of maternal and child health and nutrition.

We utilized the opportunity available through Grand Challenges Exploration India, to collaborate with the Indian Institute of Technology, Delhi and St. John’s Research Institute, Banglore to apply for this competitive call with the aim of answering questions in the priority areas for KnIT.

The Indian Institute of Technology Delhi and KnIT-Nu project aims at exploring risk factors of adverse maternal and child health outcomes using machine learning and other advanced data analytical approaches. The St. John’s Research Institute and KnIT-Nu project aims to use a data science approach to develop growth cut-offs for graded care of malnutrition.