In an interview with ETHealthworld, Dr T S Sridhar, Head, Division of Molecular Medicine, St John's Research Institute, Bengaluru, talks about his understanding and approach towards breast cancer management. Edited excerpts:
Please share your understanding of breast cancer in India and how it differs from that of the West?
My interest in breast cancer has been over the last 10 years and it arose from a common refrain I heard when I returned to India after having finished my training in the US, which was that breast cancer in Indian women is different from breast cancer in Caucasians western women.
While at the face of it this seemed to be true, we wanted to understand this at three different levels as to what the differences were due to the cultural differences between India and the west. Next was the demographic difference. India is a very young country versus the western populations and third and most importantly from the point of view of treatment whether there were real biological differences between the breast cancer in India women versus the western so that is what got us started about 100 years ago.
How is your approach to breast cancer different from others?
We started off by establishing breast cancer support group called the Adhara which was manned by young trained medical counsellors who were able to first meet with the patient and their family, establish a rapport and get to know the social economic background in which these women were embedded, and then get to know their actual challenges in going through the treatment.
We then work very closely with the pathologists and then the medical doctors. The most important thing is that we stayed in touch with these patients. Our approach was socio cultural, demographic as well as the biologic differences in breast cancer in Indian women compared to what we already knew about breast cancer in western women.
It was known that breast cancer in India happens on an average of about 10 years earlier than breast cancer in western women. It is about 60 years the median means half of all women with breast cancer in the west have it after the age of 60 and in India it is a decade earlier which is 50. So, half of all women in India are under the age of fifty.
We confirmed the finding and in India it is actually happening earlier. But, if you look at the demographics of US - the nation where I worked and for which I know the statistics, the median age of women in the US is a little after 35 and if you look at the median age of Indian women it is now about 28 years, so the population itself is left shifted, meaning we are a younger population.
We have far more younger women compared to the west and so the demographics is part of it. Socio-cultural norm that doesn’t not allow a women to speak about a lump in her breast have actually been persistent despite being exposed to higher education. It is truly a cultural problem and the way to deal with this obviously as a consequence is to attack it at its roots
Is Indian breast cancer more aggressive in nature?
Whether the tumour was ER negative or ER positive, its behaviour was independent of ethnicity. An ER positive tumour in western woman, Asian woman, Japanese woman or an Indian woman behaves the same way. So because we have more ER negative tumours they think Indian breast cancer is more aggressive which is not correct. Breast cancer aggression is related to its biology, if it is ER negative it is more aggressive and if it is ER positive it is more manageable. So that was a very important thing that we established.
Third thing that we found was most of the patients were treated with standard surgery radiation and chemotherapy. In the general ward all of this adds up to about 2-3 lakh rupees in Bangalore today in a private setup. The outcome of all treated patients if they come to the doctor early, meaning before stage one and stage two, they are now doing just as well as people treated anywhere else in the world.
Impact of your research?
Our research has not directly impacted patient care in the short run however what we have done because we did the molecular genetic analysis of these tumours, we have developed certain tests which now permit us to put these women into categories, subcategorize them, people who might respond to one therapy better than the other and who might have a propensity for the disease to spread. These tests are actually in development and it is likely that they will be available for patients.
Last month, doctors at Sri Jayadeva Institute of Cardiovascular Sciences were taken aback when a 23-year-old daily wager, who presented himself with complaints of chest pain, sweating and giddiness, was diagnosed with a heart attack.
What surprised the doctors was the fact that he did not have any conventional risk factors or a family history of heart attack. A few weeks ago, the doctors had seen a 19-year-old student, who had just started smoking, landing up with a similar problem.
These are not one-off cases. An analysis of 700 patients, including women aged below 40, who were treated at the hospital in the last nine months, revealed that over 40% of the cases did not have any conventional risk factors or family history. The analysis clearly indicated that the incidence of heart disease is increasing among the young, even among those who do not have any risk factors.
Prompted by this and wanting to study why even those without any risk factors are landing up with cardiovascular diseases, the hospital has now tied up with St. John’s Research Institute (SJRI) and the Centre for Human Genetics (CHG). The study titled ‘Premature coronary artery disease - heart attack in the young’ has been undertaken by a team of four assistant professors of cardiology - Rahul Patil, Lakshmi Shetty, Satvik Manjunath, and Vijay Kumar - led by institute Director C.N. Manjunath.
The memorandum of understanding for the study was signed by Dr. Manjunath, CHG Director Sharath Chandra, and SJRI dean Tony D.S. Raj in the presence of Medical Education Minister Sharanprakash R. Patil at a programme on Tuesday. This is in the run-up to World Heart Day that is observed on September 29.
Explaining the cause of heart attacks in the young, Dr. Manjunath said some people have an excessive tendency for clot formation in their bodies.
“This is called hypercoagulable state. In our hospital, we are seeing at least five to six people aged below 25 in a year with problems related to hypercoagulable state and we are concerned about this trend,” he said.
The study will focus on finding out whether there are any new risk factors emerging in youngsters (who do not have any conventional risk factors). A genetic analysis will be done to study whether there are any genetic mutations that are increasing the risk for heart attacks, the doctor explained.
An emerging risk
Apart from conventional risk factors such as diabetes, smoking, sedentary lifestyle, stress and family history, increasing air pollution is turning out to be a new risk factor for cardiovascular diseases.
“Inhaling polluted air is nothing but urban smoking, and is as bad as smoking. The incidence of heart attacks is three to five times more in smokers than in non-smokers,” Dr. Manjunath said.
Pointing out that an increasing number of auto-rickshaw drivers and traffic policemen were now being treated at the hospital, the doctor said, “Polluted air contains hydrogen suphide, nitrogen dioxide, carbon monoxide, and ozone. Besides, rampant garbage burning that includes plastic and rubber material is only adding to the air pollution. While other countries have already woken up to tackle air pollution, there needs to be a concerted effort by authorities to check this problem here.”
Iron status indicators of children fed with iron fortified wheat flour showed significant improvements by the end of the study conducted at St John’s Medical College and Research Institute, Bangalore.
Iron deficiency (ID) and iron deficiency anaemia (IDA) are widespread globally. Forty percent of the world’s children in their school going years are reported to be anaemic and cereal flour fortification with iron (Fe) is the most cost effective and sustainable way in reducing the prevalence of ID and IDA. Wheat is currently the primary staple food for nearly one-third of the world’s population and forms the major cereal food consumed by the people living in Northern India.
Wheat flour fortification with elemental iron is technically challenging, primarily due to poor absorption from elemental iron and the presence of phytic acid. Sodium iron ethylenediaminetetraacetic acid (NaFeEDTA) is a unique fortificant, since it protects Fe from the phytic acid present in foods by binding more strongly to ferric Fe at the pH of the gastric juice in the stomach and then exchanging the ferric (Fe) for other metals in the duodenum as the pH rises. It is two-to-four fold more bio-available than ferrous sulphate, particularly in meals with high phytate content, thereby making it ideal for use in wheat flour.
A randomised controlled study (RCT) was carried out by St. Johns’s Medical College, Bangalore to test if NaFeEDTA-fortified whole wheat flour could reduce ID and improve body iron stores (BIS), and iron parameters. Iron deficient (ID) school children (6-12 year old, n=401) were randomly assigned to either a daily wheat-based lunch meal fortified with 6 mg of iron as NaFeEDTA (as chappatis or dosa), or an otherwise identical unfortified control meal. Haemoglobin (Hb) and iron status were measured at baseline, 3.5, and 7 months.
Sensory assessments showed wheat flour fortified with NaFeEDTA was not different in appearance, taste, colour or texture from non-fortified wheat flour, and children consumed all the meals provided over the study period. Over 7 months, the prevalence of ID and IDA in the treatment group significantly decreased from 62% to 21% and 18 % to 9%, respectively. Iron status indicators such as Hb, serum ferritin, transferrin receptor, zinc protoporphyrin and BIS showed significant improvements by the end of the study (all P less than 0.0001). Testing of urinary zinc over the trial period showed that NaFeEDTA did not affect urinary zinc excretion. As per FSSAI standards, NaFeEDTA, due to its better bioavailability, can be fortified to a lower level than other iron salts in atta, maida or rice to a level of 14-21.25 mg/Kg.
History tells us the first women healers, oppressed and short of power over their own destinies, transitioned from the zenana to university halls with obstinacy and personal brilliance.
Sex ratios in medical schools have now decidedly tipped to the female side. And a fair amount of work by institutions and individuals has gone into reaching this point of overturning. Until the 1900s women were not allowed to see male doctors when sick, leave alone study medicine. “In the public mind, very little is known about the so-called native women who were trained in western medicine and then graduated to work in what was a man's world, and still is, at least, in some branches of medicine,“ says Dr Mario Vaz, Professor, Department of Physiology, and head in-charge of History of Medicine at St John's Medical College in Bengaluru. He is delivering a talk about the personal histories of early pioneering physicians at the Bangalore International Centre at 6.30pm on April 7.
There was Anandibai Joshi, born in 1865, who fought to be educated. As an eight-year old she told her parents that if she had no education, she'd no reason to live. “It's remarkable,“ says Dr Vaz, “she follows her tutor from a village in Maharashtra to Thana and ultimately marries him. She wished to study medicine at the first women's medical college for women in Philadelphia but leaving home for the West had its taboos. Her grandmother offered to accompany her. She eventually did go to America and completed medicine. She returned to India but within a year, she was dead of tuberculosis. She couldn't achieve what she set out to do.“
There was Kadambini Ganguly born in 1861, the first female trained in western medicine in South Asia (at Women's College, Calcutta), and possibly the whole of the British Empire. She graduated the same year as Joshi did in America. But she took a licentiate which was a lower qualification than a degree, “she works for many years and soon there are many like her. These women have the real need to prove they were not there just because they were women of means, of unique circumstances. But they were smart. They may be the only woman in the class but they'd top. Their presence shocked people. They were able to deal with anything. They were inspired in that sense.“
There was Rukhmabai who is still talked about in contemporary legal circles. Married at 12 years-old, her husband came to fetch her when she reached menarche but she refused to go and fought for divorce. She became instrumental in the enactment of the Age of Consent, 1891. She studied medicine in England and practiced as a physician for many years in Surat. Muthulakshmi Reddi was the first to enter a men's college to study medicine.
He believes these stories need to be reclaimed, and the history of medicine made less event and politics-driven. In fact these women were so driven because of episodes in their lives. For instance, the death of a sibling, or a child. It was a time when many women died in childbirth along with their newborns. “Only women were seen as fit to deal with `women's problems' or childbearing. It was as though they didn't have problems that men did,“ says Dr Vaz. Only daiis, or midwives, many very ably, handled women's illnesses.
Until recently at St John's, there was a conscious split down the centre when each class took 30 boy and 30 girl candidates. But now with open admissions there are more women getting through. “The initial division was to ensure that enough women were getting an education. Now the division is gone. We have increased our strength to 150 students of whom 90 are women,“ says Dr Vaz, smiling. To fully understand what problems women have faced historically, it is important to understand how western medicine developed: The old European universities always had medical schools attached to them, “the physician there was really a liability. He would have read the classics, Greek, Latin. He'd know astronomy. He'd know everything but medicine. And this is the gender construct of how Western medicine developed. The courts, the monarchy always had a physician. But it was probably the women who did the healing. They were herbalists and midwives who learned empirically through the generations but their main methods were bleeding or cauterising. Still, they did better than medieval physicians who lectured their patients with discourses that had no bearing on their health. They dismissed women healers as engaging in witchcraft, sorcery and quackery. At the height of the inquisitions these women were even punished.“
Women, for instance, considered childbirth a natural process, “a midwife would watch and wait and let the woman deliver her baby of her own accord. Physicians would intervene, they would monitor her progress at labour and in the process, because the germ theory had not emerged and handwashing wasn't a habit we lived in the time of humours they were transferring infections from one person to another between examinations. As a result what was called child-bed fever was extremely high in wards managed by men and extremely low when managed by women. Men would over-intellectualise or intellectualise in quotes because they had very little real understanding, anyway. Women would come in perfectly healthy, have a child and three days later die because of what we know today as sepsis or infection which spreads into the bloodstream. As part of doctors' duties they had to do postmortems, too, and straight after doing those they would return to wards.“
In India, as in the rest of the world, the first lot of women wanting to study western medicine lived in the Victorian era and were frequently upper class and could not soil their hands by touching poor people. Or they were considered too delicate to be doctors. The same society didn't mind poor women working in mines, for instance, or do everything menial that men could.
Women were educated but hardly ever in the sciences, maybe arithmetic because that enabled them to look after their home accounts or inheritance matters, as long as it did not necessitate their leaving the house. “There was the concept of the zenana,“ he says, “this private space the westerner could not fully understand. It was demonised as a place of intrigue. These were the circumstances for women's medical care provision in the 19th century.“
The hours spent cooped up in classrooms and in front of electronic gadgets was bound to have an effect: A cross-sectional screening of nearly one lakh children across schools in Bengaluru has shown that almost 20.7% were either overweight or obese, and 13.3% at risk of developing lifestyle diseases in adulthood.
The results of the screening, conducted by healthcare startup, AddressHealth, between January and December 2016, tie in with a 2015 study conducted by researchers from St. John’s Research Institute (SJRI).
According to the study led by Rebecca Kuriyan, associate professor in clinical nutrition and lifestyle management, SJRI, which sampled 1,913 schoolchildren in Bengaluru, high obesity indicators were associated with an increased risk of high blood pressure.
“More than obesity, the levels of overweight children had increased in the last few years in both research and clinical practice,” said Dr. Kuriyan, who has been studying childhood obesity for several years. “A waist-to-height ratio greater than 0.5 puts them at risk of hypertension and other lifestyle diseases in adulthood. Measuring this ratio is an inexpensive initial screening tool that everyone can use,” Dr. Kuriyan said. She added that armed with this information, parents could make positive lifestyle changes like increasing physical activity and inculcating healthy eating habits, which would protect children in the future.
The AddressHealth survey included a equal number of children from private schools ranging from affordable (where fees are less than ?15,000 a year) to expensive schools (where fees was more than ?45,000 a year). “The aim is to bring preventive healthcare to parents, so that they understand the need to instil healthy habits in their children,” said Anand Lakshman, founder of AddressHealth. “If we can identify health problems at a young age and take corrective measures early on, we will be making an investment in their future well-being,” he added.
The screening threw up other startling results too. Nearly 30% of the children needed some kind of dental intervention, and 13.6% had vision problems.
The International Atomic Energy Agency of the United Nations has renewed and re-designated St. John’s Research Institute as their First and Only Nutrition Collaborating Centre in the World. The Institute was first recognised in the year 2010 which has since been renewed from 2015 to 2019.
Dr. Anura Kurpad, who heads the Division of Nutrition, was responsible for this recognition for St. John’s.
More Information is available at: http://www-naweb.iaea.org/na/news-na/na-st-johns-research-institute.html
Tomorrow, INTACH will hold a walk-through of city’s long history of medicine and its practitioners
“We invite you for a special INTACH Parichay event on the history of medicine,” said a curiously worded event invite from the Indian National Trust for Art and Cultural Heritage (INTACH).
It was an invitation to a walk-through (or ‘parichay’) planned by INTACH at the Maj. Gen. S.L. Bhatia Museum at the St. John’s Medical College (SJMC) campus on Saturday.
“Many a time, heritage and history go beyond structures and buildings,” says Meera Iyer, co-convener, INTACH, Bengaluru. “The items on display at the museum give an insight into world medical history.”
So what makes this museum so special? “The manuscripts, records and collectibles housed there, which include an original print of A History of Medicine by Parke Davis, received in 1968, original archives of Maj. Gen. Bhatia from 1920s to 1960s, correspondence with Nobel laureate A.V. Hill, and original physicians’ costumes, are priceless,” says Radhika Hegde, curator of the museum and lecturer at St. John’s.
Maj. Gen. Bhatia, who served as Director-General of Health Services, retired in Bengaluru and wanted to create a museum to preserve his immense collection of medical memorabilia.
The records at the museum trace the history of medicine through the ancient time of unwritten practices in Europe and the raw surgical methods of the Greek physician Galen, who tested them on animals first. Compared to the dark medieval ages of Europe, many discoveries in medical treatment were made in Asian countries with plant derivatives, including Ayurveda in India, adds Ms. Hegde.
“The museum also contains century-old medical instruments, including a midwife kit, about 2,000 books assiduously collected by Maj. Gen. Bhatia, a multitude of photographs ... it is not just a medical student’s haven, but also a heritage lover’s paradise,” Ms. Hegde says.
“The parichay will not just take people around on an acclimatisation tour, but will also showcase the Bengaluru angle to fascinating medical discoveries,” says Mario Vaz, director of the museum.
The museum also chronicles the struggles faced by Maj. Gen Bhatia in setting it up. His vision did not end after a see-saw struggle with the State government fizzled out. In 1964, Maj. Gen Bhatia was appointed Professor Emeritus of History of Medicine at St. John’s Medical College. Along with the first dean of the medical college, L. Monteiro, and Y.P. Rudrappa (the then dean of Bangalore Medical College), he started an association of history of medicine in 1971. The museum was inaugurated on June 12, 1974.
The Major General SL Bhatia Museum for the History of Medicine in Bengaluru brings alive important stages in the journey of medicine through its exhibits that include models, instruments, photographs and costumes, writes Meera Iyer
The Black Death, the dreaded plague that swept through Europe in the 1300s, felled thousands, nay millions. Through the throngs of the dead and the dying, swept a figure, black-robed, hooded and masked. Where there should have been a nose, he had a prominent beak. His eyes were hidden behind large circles of glass and in one hand, he wielded a long cane.
This figure, who seemed verily a Shadow of Death, was in fact a plague doctor. His bizarre get-up was meant to protect him from the plague. The good doctor used the cane to prod his patients. His ‘beak’ was stuffed with sweet-smelling herbs like mint and rosemary. This was supposed to protect him from the ‘bad and putrid air’ that in the medieval period was thought to cause plague. Whether the robes and herbs protected the doctor, we cannot say for sure, but I heartily agreed with Dr Mario Vaz, professor of physiology and the history of medicine, when he said, “He probably cut a terrifying figure.” Even in the bright environs of a museum, the all-too-realistic model of a plague doctor, cane held aloft, beak and glass eyes in place, made me want to edge away.
Dr Mario is the director of the Major General SL Bhatia Museum for the History of Medicine, located in the verdant environs of the St John’s Medical College, Bengaluru. The museum is the centre around which the Department of the History of Medicine at St John’s Medical College works.
The museum is named after Major General S L Bhatia, the first Indian Dean of Grant Medical College in Mumbai (India’s third oldest medical college), a director general of health service for India, the only physician recipient of the Military Cross for services during World War I, and a recipient of the Order of the Empire. In the early 1960s, he bequeathed his archives and collections to St John’s Medical College, and in 1974, he helped establish the Museum of the History of Medicine, the first of its kind in India. With its collections growing over the years, it is still one of the largest and most comprehensive of such museums in the country.
The museum has a number of exhibits that are sure to keep both young and old minds engaged. There are photographs, costumes, interesting instruments and models. Apart from these are a number of prints – all original second edition prints of paintings by Robert Thom, and produced by Parke-Davis and Company – depicting major episodes and personalities in the journey of medicine from the earliest times to today. Behind each exhibit lies a gripping tale.
Dr Mario is an ideal raconteur, bringing alive the emotions and drama behind the milestones in medicine. Using the picture of a surgery being performed, Dr Mario told the story of the advent of anaesthesia. The excruciating pain of surgery performed without anaesthesia meant that patients rarely, if ever, resorted to surgeons. Surgeons, meanwhile, had the unenviable task of operating on patients who screamed in agony. In the 1840s, a dentist conducted a demonstration of what was to be a pain-free surgery using nitrous oxide — laughing gas — as an anaesthetic. But the experiment failed. Midway through the operation, the patient cried out in pain, prompting observers to jeer, “Humbug!”
Two years later, another dentist named William Morton persuaded the chief surgeon at the Massachusetts General Hospital to try ether instead. This time, the patient remained unconscious throughout. At the end of the surgery, the tearful surgeon told his hushed audience the words that every anaesthetist now knows: “Gentlemen, this is no humbug.”
Naturally enough for a museum on medicine, there are some exhibits which might churn the stomachs of the lily-livered amongst us. One such exhibit that caught my attention was of a traditional Western midwife’s kit, comprising a series of lethal-looking needles, each about the length of my finger and running the gamut from curved to straight, and thick to thin. Also included in the kit was a glass catheter, an item apparently not used any longer because, as Dr Mario remarked drily, “they used to keep breaking.” Next to the kit was a clipping of an article from an old medical journal talking about the removal of a broken glass catheter from the bladder of a patient.
The museum highlights Indian advances in medicine too. Amongst these are panels about Dr Yellaparagada Subba, an Indian biochemist with several achievements to his name, including understanding the role of adenosine triphosphate (ATP) in cells, and from the medical point of view, discoverer of antibiotics like the tetracycline drugs, in use even today. Dr Mario also enlightened us about the methods used by ancient Indian plastic surgeons, some of which are remarkably similar to modern procedures.
Even more fascinating were the traditional methods of inoculations against diseases like small-pox that Dr Mario and the museum’s curator, Radhika Hegde, informed us were in use even until the 1800s.
Though the museum was established in the 1970s, it has been open to the general public only from this month. According to Radhika, their primary goal is to reach out to schools, especially elementary and secondary school children, in the hope of enriching their learning. The Museum is not-for-profit and does not charge entry fee at present.
Visitors who would like to visit the museum may email Radhika Hegde at email@example.com, or call 9632172577.
India has one of the highest neonatal mortality rates and in the absence of adequate facilities in most rural hospitals, neonates may not receive timely care, which may lead to further health complications. To address this major problem, researchers from Robert Bosch Center for Cyber Physical Systems at the Indian Institute of Science (IISc), and St John's Research Institute (SJRI), both based in Bengaluru, have developed a wearable sensor, which picks up temperature abnormalities in newborn babies and transmits it remotely to the phone of a health worker or raises audible alarms for the family member to be alerted immediately, or if no corrective action is taken.
The first-of-its-kind sensor device and the back-end analytics system are undergoing a feasibility study and clinical trial currently among a few dozen mother-baby pairs from urban hospital settings in Bengaluru. The system is being tested for data capture-validation and alert response to the mother/village health worker/hospital. In the next phase, this device is proposed to be tested in rural settings of the country.
"The nenonatal monitoring device, which is strapped on to the baby's abdomen, is currently being tested by St John's Research Institute," said IISc Prof Bharadwaj Amrutur, who is working with Prof Prem Mony of SJRI, along with other researchers from both institutes.
"We are currently in the second phase of the tests, where we are testing the device in a controlled group of 100 mothers and babies at hospitals in Bengaluru. The aim is to ascertain how safe and comfortable it is for the baby. One-third of the target has been achieved. In the next phase, we will test the device in rural hospitals in Karnataka," Dr Mony, Prof of Epidemiology & Population Health, told Bangalore Mirror.
INSPIRED BY 'KANGAROO MOTHER CARE'
This technology is also useful for testing compliance with a simple method of care for preterm or low-birth-weight (LBW) infants called Kangaroo Mother Care (KMC), recommended by the World Health Organisation (WHO). According to WHO, Kangaroo mother care is care of preterm or LBW infants, carried skin-to-skin with the mother. It is a powerful, easy-to-use method to promote the health and well-being of infants born preterm as well as full-term. It is also a cost-effective method as compared to incubators or warmers used routinely.
"Some 20 million low-birth-weight (LBW) babies are born each year, because of either preterm birth or impaired prenatal growth, mostly in less developed countries. They contribute substantially to a high rate of neonatal mortality whose frequency and distribution correspond to those of poverty. LBW and preterm birth are thus associated with high neonatal and infant mortality and morbidity. Of the estimated 4 million neonatal deaths, preterm and LBW babies represent nearly a third, directly or indirectly. Therefore, the care of such infants becomes a burden for health and social systems everywhere. For many small preterm infants, receiving prolonged medical care is important. However, Kangaroo Mother Care is an effective way to meet baby's needs for warmth, breastfeeding, protection from infection, stimulation, safety and love," says a WHO study on KMC.
The device being tested by researchers in Bengaluru takes inspiration from KMC guidelines and measures the body temperatures of the baby and mother, as also the position of baby, that is the resting angle of baby.
According to 2014 estimates of the Ministry of Health & Family Welfare, about 27 per cent of all babies were born with low birth weight (LBW) in India. Experts said despite the fact that among the primary interventions available for care of low birth weight or prematurity in newborns, Kangaroo Mother Care is recognised as a high-impact and cost-effective intervention, it continues to be under-utilised in India. Accordingly researchers, including those from SJRI are looking at ways to close this implementation gap.
According to SJRI's website, two key project areas include "development of KMC sensor for position and temperature" and "accelerating scale-up of Kangaroo mother care."
Malnutrition among children is not only a rural phenomenon, it exists in Hyderabad too. A study conducted by four researchers from Tata Institute of Social Sciences-Mumbai, St. John’s Research Institute-Bengaluru and University of Hyderabad on malnutrition among adolescent students from government schools in Hyderabad has revealed this.
The study sample was small for the research – 197 participants comprising 84 males and 113 females aged between 12 and 17 years from 13 government schools in Hyderabad. It threw up shocking results.
The researchers found that 76.1 per cent of the students were malnourished, having Body Mass Indexes (BMI) of less than 18.5. The lowest recorded BMI was a dangerous 12.5.
As per the World Health Organisation, BMI below 18.5 is considered underweight and less than 16 is in the “severe thinness” category.
Only 22.8 per cent of the participants had normal BMI of between 18.5 and 24.99. Being overweight or obese, a rising concern associated with children in urban areas, was not a problem for most children from the government schools with only 1 per cent of the study sample having BMI above 25.
The researchers also tried to understand the socio-economic perspective to malnourishment. During research, the school children were defined the concept of pucca houses indicating higher economic strata and kaccha (temporary) houses, indicating lower economic strata. It was found that malnourishment was higher by 6 per cent among children who lived in kaccha houses.
Also known as the afterbirth, the placenta is a unique organ that adapts to intrauterine environmental stressors such as maternal undernutrition to ensure optimal foetal growth. Nevertheless, we lack mechanistic understanding of the tipping point when the placental adaptation becomes pathophysiological [a condition typically observed during a disease state] leading to foetal growth restriction and low birth weight. This has immediate and delayed consequences since the foetal origins hypothesis proposes that the risk of developing non-communicable diseases in adulthood has a foundation in suboptimal foetal growth and small size at birth.
Considering that two-fifth of the low-birth weight babies in developing countries are born in India, it becomes crucial to understand the molecular pathways that mediate foetal adaptation to suboptimal intrauterine conditions in the Indian population comprising of multiple ancestries, cultures and associated food and lifestyle factors.
To be able to capture the range of variability of placental and birth correlates in a heterogenous population, the need of the hour is at-scale and systematic examination of the placentae. We have developed methods and are using them to collect and preserve placentae. Utilising the 400 placentae collected from our birth cohort, we are beginning to address questions related to the transcriptional and epigenetic control of genes in critical regulatory pathways in the placenta to understand the cause of foetal growth restriction.
Recent findings from our group’s work published in the journal Placenta indicate that the placental transcript abundance of an imprinted gene, growth receptor binding protein 10 (GRB10), is associated with human foetoplacental [pertaining to the foetus and placenta] growth in a gender-specific manner.
The long-term vision of our group is to systematically engage with the mechanistic basis of adaptation to nutritional and environmental exposures in the seemingly intractable problem of low-birth weight in India, with the eventual goal of informing sensible preventive strategies.
Mukhopadhyay is assistant professor, division of nutrition, St John's Research Institute, St John's National Academy of Health Sciences in Bengaluru.
A staggeringly large number of Indians in 15 states are either overweight or underweight, and suffer from anaemia, according to the latest release of National Family and Health Survey (NFHS 4). These states make up about 44% of the country's population. The survey was done in 2015.
Abnormal weight was measured by working out the body mass index (BMI), which is a measure of how much a person weighs relative to his/her height. A BMI less than 18.5 kg per square metre makes you underweight, while over 25 means you are overweight. Both conditions are caused by bad nutrition and result in bad health parameters.
An abnormal BMI is strikingly common among women across the 15 surveyed states, and it ranges from 24% in Meghalaya to a shocking 51% in Andhra Pradesh and Telangana. Even in Tamil Nadu, which otherwise shows better health parameters, 46% women report abnormal BMI. Among men, the same pattern is visible in these states but the proportions are slightly lower.
In poorer states like Bihar, the share of underweight population — 30% women and 25% men — is far higher than overweight people — 12% to 13%.
Conversely, in better off states like Haryana, 16% women and 11% men have low BMI, but 20% are overweight. There is a sharp urban-rural divide too, with higher numbers of overweight people living in urban areas.
Despite slight dips compared to the last survey in 2005-06, the proportion of adults in the 15-49 years age group suffering from anaemia is still very high among women, ranging around 45% in Karnataka to as high as 63% in high-income Haryana, among the big states.
Among men, it ranges from 15% in Telangana to 30% in West Bengal.
Why is such a large share of Indian population suffering from both abnormal weight and anaemia?
According to Anura Kurpad, professor of nutrition at St John's Research Institute, Bengaluru, the two problems are interlinked.
"A low BMI usually reflects energy deficiency. If all food intake is low, it is reasonable that the intake of micronutrients, like iron, will be low. This is compounded by the fact that Indian diets are already poor in diversity and consequently low in micronutrients anyway, and further, even inhibitory to their absorption. Eating lower amounts of this poor diet magnifies the risk of anaemia," he says.
"On the other side, a high BMI usually implies high body fat. Fat can release inflammatory signals that increase the level of hepcidin, which in turn inhibits iron absorption. In effect, anyone with a chronic inflammatory condition is at risk of low iron stores and fat mimics this," he adds.
Two types of issues — structural and income related — are causing this nutritional double whammy, according to Hemal Shroff, a public health specialist at the Tata Institute of Social Sciences (TISS), Mumbai.
"Some of these structural issues are — excessive focus on wheat and rice production, increased availability of processed foods and sugary drinks, reduction in physical activities in urban areas, lack of government intervention in improving access to healthy foods, etc." she says. Poor incomes lead to people not having access to healthy foods, although many would argue that poor people make non-nutritive food choices, Shroff points out. She is also critical of the government for only "planning" interventions and not implementing them.
Broadening girths are expanding India’s battle against malnutrition, a new Indian study has revealed, setting off a host of so-called lifestyle ailments.
This is happening as India fights a losing battle with the bulge, hosting as it does the third-most number of obese people in the world, 61 million and growing.
Malnutrition is commonly associated with emaciated, undernourished people, not with being obese or overweight—or over-nourished, as it is called in dietary parlance.
Actually, the ‘over’ in over-nourished relates only to calories, or energy intake. Getting those excessive calories from fat- and sugar-rich, nutrient-poor foods can lead to significant micronutrient deficiencies in obese people, said Carlyne Remedios, senior nutritionist, Centre for Obesity and Digestive Surgery, Mumbai and co-author of the study published in August 2015 in the journal Obesity Surgery.
Of 2,740 people with a Body Mass Index (BMI) more than 30 kg/m2, the cut off for obesity, forming the study group, 43% suffered from iron deficiency, 56.7% from vitamin B12 deficiency, 11% from calcium deficiency, 35% from vitamin D3 deficiency and 10% from protein deficiency.
Micronutrient Deficiencies In Obese People In India
Micronutrient Deficiency in obese people (%) Deficiency in general population (%)
Iron 43 60-80
Vitamin B12 57 35-75
Calcium 11 8-40.6
Vitamin D3 35 44-90
A new US study has arrived at a similar conclusion as Remedios. One in five obese patients of that study had insufficient levels of three or more of these micronutrients: vitamin A, vitamin B12, vitamin D, vitamin E, iron, folate (vitamin B9) and thiamine (vitamin B1).
Clearly, abundance of food and nutrition are not synonymous.
Overweight Indians: Growing Almost As Fast As Malnourishment Is Contained
India’s new face of malnourishment is likely to belong to the urban and affluent, those who can afford to choose their diet.
Three times more obese and overweight people live in urban areas than in rural areas, as per the National Family Health Survey III. Their numbers are growing almost as fast as the number of undernourished Indians is being contained.
Diets Gone Awry Are Broadening India’s Girth
A 28-year-old man, 5 feet 4 inches tall, weighed 100 kg. His diet was overloaded with bad carbohydrates and bad fats, and low in protein. Severely obese, he complained of persistent body ache and pain in the thighs and around the knees. His vitamin B12 levels were low.
Investigations showed that the patient was suffering from vitamin D deficiency and high uric acid, findings that are “typical of overweight people”, said the consulting doctor Anil Arora, head of unit and lead consultant, Department of Orthopaedics, Max Super Speciality Hospital, Patparganj, Delhi.
A 13 year-old girl, 5 feet 4 inches tall, weighed 114 kg. She consulted a dietician for a weight-loss programme.
“Dietary assessment revealed she ate no vegetables, just high-fat and high-carbohydrate foods and a lot of meat, mostly chicken. Overall, her intake of calcium, iron and other micronutrients was low,” said Sherin Verghese, manager, dietetics, Malabar Institute of Medical Sciences, Kozhikode.
Blood tests showed the young teen to be borderline diabetic, despite her young age.
Research and the experience of dieticians across the country trace a clear correlation between faulty diets and excess weight.
A 2010 study in Gujarat compared the daily diet of overweight people and normal weight people. Overweight people were consuming almost 10% more grams of oil per day and 20% fewer grams of vegetables.
In a 2013 survey focussed on women conducted in Delhi, obese women identified fried food as the leading cause for their condition, while overweight women attributed excess weight to overeating.
“Most overweight and obese people consume a surfeit of energy-dense foods rich in saturated fats and simple sugars“, said Karishma Chawla, Mumbai-based nutritionist and founder, Eat Rite 24×7, a nutrition consultancy, “We call them empty calories for being nutrient poor.”
To add to this, metabolic changes associated with obesity can compromise the absorption of micronutrients from food.
Technically, obesity is a kind of inflammation, which research has shown impairs iron absorption or iron utilisation.
A recent Indian study at St. John’s Research Institute in Bengaluru showed that obese women face an increased risk of iron deficiency, and they also absorb less dietary iron.
“Research is yet to fully confirm but we believe that adipose (fat) impedes the utilisation of micronutrients—iron and potentially other micronutrients—by the tissues,” said Remedios.
From Fatness To Disease—Via Micronutrient Deficiencies
Raised BMI is a major risk factor for non-communicable diseases such as heart disease and stroke, the leading cause of death in 2012, diabetes, musculoskeletal disorders and some cancers—endometrial, breast, and colon, according to the World Health Organisation.
Less commonly reported is the association between obesity, nutritional deficiencies and disease.
A US study has traced a link between obesity, diabetes and deficiencies of vitamin D, chromium, vitamin B7 (biotin), vitamin B1 (thiamine) and vitamin C.
A 2012 study of 1,765 North Indians diabetics, pegged the overall vitamin D deficiency rate at 76%. It identified progressively worse deficiency in those with higher BMI: 65% in those with BMI less than 23kg/m, 75% in those with BMI 23-27.5 kg/m and 81% in those with BMI greater than 27.5 kg/m.
This is highly plausible.
“Overweight people are at higher risk of developing vitamin D deficiency because the vitamin is fat-soluble, which means it gets stored or ‘locked up’, so to speak, in fat cells, with less available to the body for use,” said Seema Gulati, head of the Nutrition Research Group, Center for Nutrition & Metabolic Research (C-NET).
Conversely, when fat people lose weight, their serum vitamin D level may increase, said Gulati.
Lower vitamin B12 and folic acid levels are characteristic of hypertensive overweight and obese people as compared to hypertensive people of normal weight, according to a 2009 study in Mumbai. Even among people with normal blood pressure, those who were overweight or obese had lower vitamin B12 and folic acid levels than those of normal weight.
Why Watching Your Weight Is The Only Way Out—And Why It Is So Hard
Obesity can shave off up to eight and a half years of an adult male’s lifespan and six years of an adult female’s lifespan. Obese people also lose two to four times more healthy life years than a person of normal weight.
While that is reason enough to lose weight, shedding kilograms isn’t so easy.
In the last 33 years, no country has significantly reduced obesity, according to the Global Burden of Disease Study 2013.
With the prevalence of overweight people in India estimated to increase to 27.8% by 2030, and with the most population growth expected to occur in urban India where obesity is expanding the fastest, experts said public policy should focus on malnutrition at the other end of the spectrum—that presents its own challenges because in India, over- and under-nutrition are not simply a problem of the rich or the poor.
“Often, over- and under-nutrition overlap and coexist in the same household even in rural and periurban areas as a result of ‘urbanicity’,” said Sutapa Agrawal, epidemiologist, Public Health Foundation of India.
Dual burden households make public health interventions tricky.
Strategies to address under-nutrition—such as increasing household food supplies—could contradict obesity curtailment programmes while interventions to address obesity—like recommendations of a low fat diet—may adversely effect any underweight members, said Agrawal.
So what is the best way forward?
Catch them young before the fat creeps on: create awareness in children through school education programmes that simultaneously address both types of malnutrition, she said.
This article was originally published on IndiaSpend.com, a data-driven and public-interest journalism non-profit.
London's top college — the revered King's College, for the first time comes out in support of re-introducing post study work visa for students. The removal of the visa has resulted in a major dip in Indian students enrolling in British Universities. In an exclusive interview to TOI's London correspondent Kounteya Sinha, King's College president and principal Professor Edward Byrne who is embarking on his maiden visit to India says that bright, motivated Indian students are an indispensable part the British community and their presence in King's — in the heart of London significantly benefits British society, culture and economy. Indian students together are the third largest international student (undergraduate and postgraduate) body at King's with alumni like Sarojini Naidu and Khushwant Singh.
What is the main purpose of your visit?
This is my first trip to India as President and Principal of King's College London, a role I was appointed to in September 2014. This will be a fantastic opportunity for us to meet our partners from leading Indian institutions such as Delhi University, Lady Shri Ram College, Jawaharlal Nehru University (JNU) and the Tata Memorial Cancer Centre, amongst many others, and to explore new opportunities for collaborations in education and research.
How important is India for King's and why?
India is a major part of our internationalisation programme, which aims to build long-term mutually beneficial relationships of educational exchange and collaboration. As such, India is a vital global partner and we are involved in a wide range of activities that aim to benefit society, here in India and worldwide.
We want to demonstrate that we are dedicated to attracting the best international minds from India, and build relationships with world-class institutions across the country.
Bright, motivated international students are an indispensable part the King's community and their presence in the heart of London significantly benefits our society, culture and economy. Our India Institute is a central part of King's international engagement and we are incredibly fortunate to have a great leader in Avantha Professor Sunil Khilnani.
Scotland and Scottish universities have called on Westminster to reintroduce the post study work visa so that Indian students can return to UK. So has several British universities. Would you want that too?
We are fully supportive of this and remain committed to welcoming Indian students to the UK and King's.
How important is an Indian student for the British coffer?
Bright, motivated Indian students are an indispensable part the King's community and their presence in the heart of London significantly benefits our society, culture and economy.
Have you had any distinguished Indian alumni at King's historically? Are you planning to may be have a India day in King's like university of Edinburgh has done?
India features continually in our college life. And we're very proud of our Indian alumni, not least among whom are Sarojini Naidu, the 'Nightingale of India', and Khushwant Singh. Singh, who sadly passed away recently, studied at King's 1934. He was awarded a Fellowship of King's College London in recognition of his exceptional achievements in the fields of literature and journalism.
Sarojini Naidu, the Indian independence activist, poet and former president of the Indian National Congress, had the chance to study at King's back in 1895 thanks to a scholarship she received — it's a good reminder of the immeasurable value to society a scholarship can deliver.
We have a thriving alumni branch in India of over 1300 people, many of whom are working in law, medicine, management, social sciences and education. I'm meeting some of our alumni on this visit and it's something I always relish. Our alumni are exceptional in whatever field they pursue their career and it's a real pleasure to meet them.
What major breakthroughs do you intend to achieve through this (like what tie ups do you want to finalise)?
We are very excited about collaborations in areas of health and medical research and we're keen to explore areas where we can work with Indian partners. King's is the largest centre for the education and training of healthcare professionals in Europe with pioneering research into the fields of cancer, neuroscience and mental health.
We are in dialogue with the Ministry of Health & Family Welfare, Government of India, with whom we hope to develop certificate courses in Health, at NEIGRIHMS (Shillong) and RIMS (Imphal), Institutes of national importance in India's North East.
During the visit, a member of the delegation from King's will also visit the India Institute of Science in Bangalore where we have some exciting research projects and meet the Dean of St John's Research Institute, our partner institution for the inaugural King's-Bangalore Summer School, where the certificate course in Infection & Immunity was launched in July 2015.
We have partnerships with Delhi University (DU) that includes an outstanding new disability programme, where, working with the Equal Opportunity Cell and the Disability Unit at King's, a group of disabled students from DU visit King's for an annual programme and vice versa.
Furthermore we have an exciting research partnership with the Tata Memorial Centre (TMC) in Mumbai which is addressing the challenge of delivering affordable cancer care for an ageing global population. In May 2015 we successfully launched a certificate course in Fundamentals of Oncology for both undergraduate and post graduate students, delivered by leading academics from King's and Tata Memorial Centre. 42 meritorious students were handpicked from Greater Mumbai's leading institutions to participate in this course at zero tuition fee. We are working to secure funding for this programme to enable it to continue for the next 3 years.
Have you been seeing a rise in Indian students enrolling in King's?
Indian students together are the third largest international student (undergraduate and postgraduate) body at King's. Numbers have increased, especially since we established our in-country presence. We have our offices with the UKIBC centres in in Mumbai and Delhi. With the expansion of our departments in Business and Engineering, we expect that number to rise further.
Since 2012, over 2000 students from 25 Indian cities have benefited from 2 week course programmes at our Summer Schools, which are partnered with some of India's leading institutions: Lady Shri Ram College (Delhi); HR College (Mumbai); Tata Memorial Centre (Mumbai); St John's Research Institution (Bangalore).
Around 63 Indian students have been provided with scholarships to attend the London Summer School at King's since 2012. Every year we welcome faculty and research staff from many institutions in India, including higher education, research and government, who come to meet their counterparts in King's, study there or enhance their professional skills.
Avantha Professor Sunil Khilnani directs our King's India Institute, a leading centre for the study of contemporary India that has become a destination for young researchers, with 30+ PhD students working across disciplines.
Many vice chancellors including those from Cambridge, Oxford, Edinburgh to name a few have spoken out against the present visa regime in UK which has seen a massive fall in Indian students going up UK. What is your opinion on it?
We are very much open to receiving students from India, and absolutely value the positive ethos they bring. We are working with the Government to improve visa conditions.
Students from India interested in applying to King's shouldn't be put off by the visa application process. We have a dedicated in-house team to help with visas and deal with any issues arising from UKBA.
Most pregnant women complain about the bad taste of iron tablets and the side effects that they cause. The adherence level of consuming these tablets is very low most times, resulting in many not taking the right dosage. This causes a high rate of maternal and neonatal deaths.
To beat this challenge, nutritionists at St John's Hospital are in the process of developing a biscuit that will replace these tablets. They are concentrating on making a food-based product that tastes good, has a nice flavour and increases absorption.
Pratibha Dwarkanath, nutrition lecturer at St John's Research Institute is heading the $2,70,000 project that is funded with Development Innovation Fund by Grand Challenges Canada through the Canadian government. About 14 contestants had applied for this challenge last year.
Dr Dwarkanath said, "We have set up a cohort of pregnant women at St John's Hospital and have decided to bake these biscuits that will have iron content as there is in pills. This was decided in the backdrop of increasing cases of anaemia in pregnant women, which affects the health of their children. This also leads to several complications in the child such as impaired psychomotor development and certain cognitive disabilities." The research project is carried out under the aegis of Dr AV Kurpad, Head, Department of Nutritionists, and NewYork based Violet Health Sciences. Right now the biscuits are being tested for bioavailability after which they will be tested on two groups of women.
"After the results of the bioavailability tests are out, we will test them on pregnant women. One group will be given placebo biscuits and the other these iron biscuits. After a specific interval of time, their haemoglobin levels will be tested to check the efficacy level of these biscuits," Dr Dwarkanath explained.
The institute had applied to Grand Challenges last year, which had the theme of Saving Brains that encourages bold ideas to improve global health. The grant was approved after the institute proposed this idea and decided to take up the project.
"Tackling anaemia is a big challenge in the Indian scenario where about 17 million people are given iron pills, yet 11 million do not take them and the adherence level is as low as 35 per cent. The pill is big and tastes metallic. They are generally given as supplements during pregnancy.
Aggressive marketing of the biscuit is likely to lead to its being used by previously non-adherent pregnant women resulting in increased iron store in newborns," Dr Dwarkanath added.
It is linked to low birth weight, premature deliveries & intrauterine growth restriction.
She may be anaemic or not, but the good news about pregnancy anyway comes with large doses of iron supplement pills being prescribed - often as much as 100 mg per day. Although well-meaning, considering the huge national burden of anaemia among women - especially in rural areas - this practice may not actually be a good idea for healthy pregnant women after all!
A recent study by a group of doctors and students at St John's Medical College in Bengaluru revealed that excessive iron dosage among healthy, non-anaemic women could have an adverse effect not just on the pregnancy but also on the baby, born or unborn.
They say problems like low birth weight, premature birth and poor growth of the baby while in the womb (also called intrauterine growth restriction) may occur due to excess intake of iron. Dosage of iron, regardless of the haemoglobin level, was increased since 2013 by the Ministry of Health and Family Welfare as part of the National Plus initiative because large number of women were diagnosed with anaemia especially in rural areas, leading to several maternal and child deaths.
The study was conducted on a sample size of 1,196 non-anaemic, healthy women. It was a part of the Obama-Singh Fellowship programme at St John's Hospital and has been published in the European Journal of Clinical Nutrition which is part of the Nature Group.
A cohort of non-anaemic pregnant women, who came to St John's Hospital, was studied. The women were aged between 17 and 40 and were free from any chronic illnesses like diabetes, hypertension, heart and thyroid diseases.
The principal investigators for the study were two final-year MBBS students, Pooja Mishra and Lisha Shastri from St John's Medical College who were among the first batch of students who were part of the research programme. They were guided by Dr Pratibha Dwarkanath, lecturer, division of nutrition, Dr A V Kurpad, professor and head, department of nutrition, St John's Research Institute.
The students were also invited to Harvard's School of Public Health as part of the exchange programme where they further analysed the study for three months.
The other investigators for the study included T Thomas, C Duggan, C M McDonald and A V Thomas.
Explaining the motive behind the study, Mishra said, "In India, there's a large burden of anaemia, which is why as per the national guidelines it was decided on a high dosage and all the doctors have to go by that rule. But the WHO (World Health Organisation) recommends a dosage of 60 mg and the same is followed in European countries and the level of iron is very good for women in these countries. The supplements are usually started in the second trimester (between third and sixth month) of pregnancy." The dosage was measured by interviewing the women on the amount they consumed and the study had some interesting revelations.
Based on the outcome it was seen that women who took their iron tablets dedicatedly without missing them were twice at risk of having babies with low birth weight as compared to people who took a lower dosage.
Shastri said, "There have been studies done across the world and in All India Institute of Medical Sciences (AIIMS), Delhi, where the results are similar. That suggests that there is a need to decrease the dosage of iron among non-anaemic women. Iron in high daily doses could be responsible for cellular damage through oxidative stress. This needs to be balanced with sufficient anti-oxidants which can be obtained from fruits rich in Vitamin C. The dosage of iron varies from one individual to another which is why there cannot be a standardised dosage that can be fixed for everyone."
Ann Sarah Koshy is happiest pulling out sticky, wailing babies into the world. For her, delivering the bundles of poor women and sharing their joys matters most. Now, the young intern with a rural hospital off Sarjapur Road is off to Harvard University to research how Vitamin B12 helps in neonatal growth.
Ann, 22, who completed MBBS at St John's Hospital, Bangalore, is the recipient of the Obama-Singh 21st-Century Knowledge Initiative. This fellowship was planned as a part of US aid in Indian education when President Barack Obama came to India in 2010. Ann was one among 10 students selected for the research mentorship.
"It hasn't sunk in yet. I can't believe they would approve my research and allow me to do a course in global nutrition," she told TOI.
Ann, though, never wanted to be a doctor. She recalls, "When I was selected to give a farewell day speech in school, I saw my mother walk out to attend a surgery while other parents listened to me in rapt attention. I told myself I'd never become a doctor. I haven't got enough of my parents because both are doctors. But I don't know why I gave up maths and studied MBBS, though I scored 99 in mathematics and 95 in biology. I wanted to be an astronaut but they broke my heart when they said I was short."
It was in 2008 that St John's Research Institute was chosen under this initiative, and tied up with National Institute of Health, USA.
Ann's mother Dr Annamma Thomas is professor of obstetrics and gynaecology, and father Dr Reji Koshy Thomas is professor of ophthalmology at St John's Hospital. She owes her leadership skills and go-getter attitude to her father. "I was the first woman general secretary of the students' association in St John's College. I knew I had to break the glass ceiling. I like my job in hospital as I'm the resident doctor and have to take my own decisions," she added.
At Harvard, Ann will research how vitamin B12 can boost neurological development in a foetus. As a prelude, she's begun research on 300 pregnant women in Bangalore, across economic strata, and treated 150 of them with vitamin B12 supplements. She plans to compile the research at Harvard in the next six weeks. She also applied for a course in clinical epidemiology and audit course on global nutrition which the US varsity has accepted.
Missed by nurses, patients
Karunapalyam, the rural hospital off Sarjapur Road where Ann Sarah Koshy works, is going to miss their only resident doctor. "Nurses say they're sad as they won't have a doctor for the next six weeks. But I've promised to come back and complete my internship. My patients also look on me to bring them better service," says Ann.
If you think Indians have a balanced diet, you may be wrong. But the blame cannot be pinned on junk food alone. The problem lies with policies of the government which don’t encourage the growth of pulses, an expert working group of the United Nation’s Food and Agriculture Organization (FAO) observed.
The team was at the St John’s Research Institute from March 2-5 to evaluate the quality of protein in the diet of Indians.
“The best approach for optimal health and well-being is to prioritize protein quality so that we eat neither more nor less than what we really need, and spend wisely on protein-rich food,” said the FAO team. The team is evaluating staple diets of people from various countries and coming up with a report on how to make them protein sufficient. The report focuses on measuring protein quality in foods from animal and plant sources.
Speaking to TOI, Dr Anura V Kurpad, head of nutrition, St John’s Research Institute, and president, Nutrition Society of India, said some dietary surveys have shown that Indians mainly get proteins from serials, pulses and milk. “Consumption of rice and wheat, a major component of the Indian diet, has limited the quality of amino acids. Pulses, milk and meat are rich in quality proteins. But over the decades, the production of pulses has decreased. The Food Security Bill has ignored the importance of pulses and thereby this rich source of protein is missing from the platter. Agricultural policies have to look into these concerns,” said Anura, who worked with the FAO team. According to him, there is need to define the protein quality in food sources.
J Albert, nutrition officer, FAO, who is stationed in Rome, said, “The Italian diet is one of the healthiest. “Vegetables, fruits, fish and olive oil, sources of quality proteins, are major components of staple Italian food. Being an American and having lived in Italy for the past 20 years, I find that Italians follow a nutritious diet. Wealthy countries consume excess of meat proteins, which is not a good sign. A case in point is the increasing incidence of obesity in the US,” she said.
It was in its meeting in 2011 that FAO decided to conduct a research on protein quality in human diet. “We are currently in the process of collecting data from various countries. Just as rice is widely grown and consumed in India, corn is given way too much importance in African countries. Good quality proteins are also missing from the African diet,” said Dr Warren Lee, FAO representative.
An analysis of a unique handwashing campaign shows for the first time that using emotional motivators, such as feelings of disgust and nurture, rather than health messages, can result in significant, long-lasting improvements in people's handwashing behaviour, and could in turn help to reduce the risk of infectious diseases.
An evaluation of the SuperAmma ('SuperMum') behaviour-change intervention, published in the 'Lancet Global Health' journal, shows that six months after the campaign was rolled out in 14 villages in rural India, rates of handwashing with soap increased by 31 per cent, compared to communities without the programme, and were sustained for 12 months.
"Every year, diarrhoea kills around 800,000 children under five years old. Handwashing with soap could prevent perhaps a third of these deaths," explains study author Dr Val Curtis, from the London School of Hygiene and Tropical Medicine (LSHTM). "Handwashing campaigns usually try to educate people with health messages about germs and diseases, but so far efforts to change handwashing behaviour on a large scale have had little success. Understanding the motivating factors for routine handwashing is essential to any initiative likely to achieve lasting behaviour change."
In this cluster-randomised community trial, researchers from the LSHTM and St John's Research Institute, with communications consultants Centre of Gravity in Bangalore, India, tested whether a scalable village intervention designed to increase handwashing with soap in southern Andhra Pradesh, India, was successful in bringing about behavioural change.
The intervention adapted an open access global toolkit developed by the same team, and targeted emotional drivers found to be the most effective levers for behaviour change: disgust (the desire to avoid and remove contamination), nurture (the desire for a happy, thriving child), status (the desire to have greater access to resources than others), and affiliation (the desire to fit in).
From 57 eligible villages – with populations of 700–2000 people, a state-run primary school and a preschool – 14 villages were selected and randomly assigned to receive the intervention or no intervention. As part of the SuperAmma intervention, promoters put on community and school-based events involving animated films, comic skits, and public pledging ceremonies during which women promised to wash their hands at key occasions and to help ensure their children did the same.
Observed rates of handwashing with soap at key moments (after toilet use, before food handling, or after cleaning a child) were measured in a random sample of 25 households in each village at the start of the study and at three subsequent visits (six weeks, six months, and one year after the intervention).
At the start of the study, handwashing with soap was rare in both the intervention and control groups (1 per cent and 2 per cent respectively). After six weeks, handwashing was more common in the intervention group (19 per cent vs 4 per cent), and after six months, handwashing in the intervention group had increased to 37 per cent compared with 6 per cent in the control group. One year after the campaign, and after the control villages had received a shortened version of the intervention, rates of handwashing with soap were the same in both groups (29 per cent).
According to study co-author Katie Greenland, from the LSHTM, "The SuperAmma campaign appears to be successful because it engages people at a strong emotional level, not just an intellectual level, and that's why the behavioural change was long-lasting. Whether the observed increase in handwashing with soap is sufficient to reduce infection remains unclear, but in view of our promising results, public health practitioners should consider behaviour change campaigns designed along the lines of our approach."
In a linked comment piece, Elli Leontsini and Peter J Winch from Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, caution: "The level of handwashing uptake achieved for key occasions post-intervention was comparable to that of other studies… and might not be high enough to have an effect on public health. Creation of a more enabling environment by means of multiple conveniently placed and replenished handwashing stations in and around the home might be needed to achieve a higher, more effective, increase in handwashing with soap at key occasions."
This study was funded by the Wellcome Trust and UK aid from the Department of International Development (DFID) as part of the SHARE research programme.
Low birth weight and consequent high infant mortality rate (IMR) have been hounding Indian mothers for a long time. One reason behind the high number of children born with low weight in India could be deficiency of vitamin B-12 during pregnancy, a group of researchers from Bangalore and USA have concluded in a decade-long study.
The study, ‘High folate and low vitamin B-12 intakes during pregnancy are associated with small-for-gestational age infants in South Indian women,’ was published in the December 2013 issue of the American Journal of Clinical Nutrition.
The study conducted during a span of about 10 years at the St. John’s Research Institute by an international research team headed by nutritionist Pratibha Dwarkanath suggests that “consumption of high-folate supplements coupled with low vitamin B-12 intake during pregnancy may be a problem at least in India (where vitamin B-12 intake is generally quite low due to vegetarianism)”.
Vitamin B-12 plays a key role in the normal functioning of the brain and nervous system, and in the formation of blood. Only bacteria and archaea have the enzymes required for its synthesis.
A team of researchers from Bangalore and the US studied the diet of over 2,000 pregnant women between 17 and 40 years of age in their first trimester of pregnancy for 10 years. The team studied the food composition of these women, along with their intake of folate (folic acid) and vitamin B-12. Use of nutritional supplements was also recorded. These data were then related to measures of infant health such as duration of pregnancy and birth weight.
Dr. Anura V Kurpad, Professor and HOD, Nutrition, St. John’s Research Institute, said: “Babies born with low birth weight are a major problem in India, which needs to be taken care of. The research was undertaken to figure out the root cause of this problem, as it can lead to high risk of IMR and chronic diseases when the child grows up.”
Being vegetarians, most Indians are already low on vitamin B-12, said Dr. Kurpad. “It is, therefore, important for a gynecologist to prescribe not only folate, but also vitamin B-12 to pregnant women. Non-vegetarians can consume the required dose of vitamin B-12 from their diet, but for vegetarians, the only source of this vitamin is milk and its products.” He suggested that a vegetarian woman should consume at least 500mL of milk or milk products everyday during pregnancy to fulfil the minimum requirement of vitamin B-12.
Senior gynecologist and former Health Director of Karnataka, Dr. B Dhanya Kumar, said: “Vitamin B-12 is important to control low birth weight and premature birth. Pregnant women with high deficiency of B-12 are also prescribed injections.”
Vitamin B-12 plays a key role in the normal functioning of the brain.
A new mobile application will identify clinical signs of domestic violence in victims. The app will be launched by the Soukhya project which is working to tackle the problem for the past three years.
Soukhya which was jointly implemented by Bruhat Bangalore Mahanagara Palike’s Health department in collaboration with St John’s Research Institute, Research Triangle Institute and Dimagi Inc., is already working on the initial implementation of the application.
The application called ‘Commcare’ has been developed by a company named Dimagi based in Boston and is active so far in the east, west and south zones of Bangalore. This application allows a nurse or a doctor to register a woman who shows symptoms of domestic violence, screen her for causes and once screened, make the adequate referrals. Once a case is identified, a message is sent.
Even as tuberculosis (TB) cuts a swathe through the country, efforts are being made to curtail the spread of the disease and offer succour to sufferers.
As part of the overall campaign, the St John’s Research Institute in the City has announced its decision to work with world-renowned scientist-immunologist, Prof Stefan H E Kaufmann, Director of the Department of Immunology at the Max Planck Institute for Infection Biology in Berlin, in fine-tuning a BCG vaccine that Kaufmann has developed against the disease. Dr . John Kenneth will head the clinical research work from Bangalore.
Speaking to Deccan Herald, Kaufmann said St John’s Institute will be active in the clinical part of vaccine development, while the Max Planck Institute will concentrate on basic research. “The institute in Bangalore will screen patients and obtain data of their health status and interact with us on the basis of that data. Together, we will combine their practice with our theoretical research to strengthen the vaccine that has been developed.” Kenneth told this newspaper that St John’s would be doing translational research — where doctors contribute to basic research by working with patients. “We are the only translational research institute in the country and we would be proud to contribute to the vaccine against TB.”
The St John’s Institute will also assist the Max Planck Institute by identifying biomarkers in the blood of patients to discover whether a patient is diseased or not. Identifying bio-markers is part of clinical activity. Once the markers are identified, the data is passed on to basic researchers who may re-examine their theories.
The 45th National Conference of the Nutrition Society of India (NSI) was held between 21st and 22nd November, 2013, at the National Institute of Nutrition (NIN), Hyderabad. The conference was inaugurated by Dr. Anura V Kurpad, President, NSI . The dignitaries included Dr. Anura V Kurpad, President, NSI, Dr. V. M. Katoch, Director General, ICMR, Prof Barrie M Margetts, President, World Public Health Nutrition and Dr. B. Sesikeran, Former Director, NIN.
There were 15 presentations from the Division of Nutrition, St. John’s Research Institute at the NSI Conference - 3 Oral presentations and 12 Poster presentations.
Oral presentations were by -
Poster presentations were by -
Of the presentations, “Four” won prizes:
Grand Challenges Canada, funded by the Government of Canada, extended a total of $10.1 million to 14 bold, creative projects aimed at improving the early brain development of kids in low-resource countries.
All 14 projects will be implemented in developing countries: five in Africa, six in Asia and three in Latin America and the Caribbean.
In India, St. John's Research Institute, Unit of CBCI Society for Medical Education, Bangalore, has been awarded a Seed grant of CDN $270,000 for the project Iron-fortified biscuits to reduce maternal and child anemia.
Anemia -- a low level of red blood cells causing a body's reduced capacity to carry oxygen -- results from micronutrient deficiencies, most often iron.
India has one of the highest rates of anemia globally: over 79% of children aged 6 to 8 months and 58% of the 26 million pregnant women each year. Some 17 million of these women have access to iron pills yet 11 million do not take them for the recommend time (adherence rate: 35%). Why? The pill is big and tastes metallic.
Yet iron deficiency anemia dramatically affects the health of a pregnant woman and her unborn baby, increasing risks of death and sickness during childbirth, including hemorrhage and low-birth weight. Long-term, iron deficiency anemia delays psychomotor development and impairs cognitive development in infants, preschool and school-aged children around the world.
Moreover, researchers say, the effects of anemia are, "not likely to be corrected by subsequent iron therapy... anemic children will have impaired performance in tests of language skills, motor skills, and coordination, reportedly equivalent to a 5 to 10 point deficit in IQ."
Part of the answer may be an iron-fortified biscuit for use by pregnant women, indistinguishable in taste from popular Indian biscuits.
Coupled with marketing, project leaders say their new biscuit is more likely to be used by previously non-adherent pregnant women, and increase iron stores in newborns, "which translates to more sustainable and protected early brain development."
"After extensive consumer research, the nutrition team led by Dr A.V. Kurpad and the project collaborators, Violet Health Inc have developed several prototypes specifically designed with the tastes and preferences of pregnant women in India," says project leader Dr. Pratibha Dwarkanath of St John's Research Institute, unit of CBCI Society for Medical Education.
"We estimate our solution to be more cost-effective than the iron pill, while reaching more anemic women and their children"
"After proof of concept, we anticipate a scaled trial in Karnataka within three years and reducing anemia in women and infants."
Project collaborators include Violet Health, Inc., NY, and the Indian Institute of Management, India Bangalore.
For more details on the award and projects, please click on the link given below:
We are happy to inform you that The Division of Nutrition, St. John's Research Institute (SJRI), has been selected for the prestigious Obama-Singh 21st Century Knowledge Initiative award. The award is a part of the ongoing educational partnership between India and the United States.
The Division of Nutrition will partner with Harvard School of Public Health (HSPH) for the Harvard India Nutrition Initiative. This initiative will aim to substantially contribute to the establishment of sustainable public health research and education capacity in India through mutually beneficial exchanges of faculty and students between Bangalore and Boston, the expansion of an existing and very successful short course in nutrition research methods (the Bangalore-Boston Nutrition Collaborative) co-taught by SJRI, HSPH and Tufts faculty, the development of new nutrition epidemiology courses by SJRI and HSPH faculty and the expansion of access to a website for distance learning via the newly launched edX initiative. The three-year Initiative will be led at SJRI by Dr. Rebecca Kuriyan Raj and Dr. Anura Kurpad.
India and the United States have announced eight new partnerships in fields including health, technology, energy and sustainable development, and training of human resources – amounting to around US$2 million – as part of the second round of the Obama-Singh 21st Century Knowledge Initiative.
The announcement was made at the India-US Education Dialogue in New Delhi last week, chaired jointly by Human Resource Development Minister MM Pallam Raju and US Secretary of State John Kerry.
Each project will receive an award of approximately US$250,000, which can be used over a three-year period, with the objectives of cultivating educational reform including online education, fostering economic growth, generating shared knowledge to address global challenges, and developing junior faculty at Indian and American institutions of higher learning.
The partnerships include a Harvard-India Nutrition Initiative between the Harvard School of Public Health and the St John’s Research Institute in Bangalore; and agreements between Aligarh Muslim University and Ohio State University, and between Assam Agricultural University and Washington State University.
Prime Minister Manmohan Singh and US President Barack Obama announced the Obama-Singh Initiative in November 2009. Each government pledged US$5 million for the endeavour, for a total of US$10 million.
Four memoranda of understanding were also signed, including one between the Indian Institute of Technology, Bombay, and edX – a massive open online course (MOOC) platform founded by the Massachusetts Institute of Technology (MIT) and Harvard University to offer free online university-level courses in a wide range of disciplines.
Thousands of Indians are flocking to MOOC platforms offering free online courses from the world’s top universities including Stanford, MIT, Harvard and Yale.
On EdX, Indians form the second-largest group. On Coursera, 8.8% of those enrolled are Indians compared to 27.7% from the US.
It is not just the lure of completing a course taught by a reputed international university that is pulling thousands of Indian students to MOOCs. Students see it as an opportunity to study with world-renowned professors, add to existing qualifications and increase job prospects.
With the transformation that MOOCs were bringing in the educational sphere, the Indian government planned on focusing closely on them, said Raju.
A second memorandum of understanding was signed between the All India Council for Technical Education (AICTE) and the American Association of Community Colleges (AACC) to set up community colleges in India.
India has announced it will set up 200 community colleges over the next few years.
“We will share the best practices and hand-hold Indian institutes in establishing community colleges across India. These will be sector-specific, needs-based courses catering to the markets of specific regions,” said Alice Blayne-Allard, associate vice-president of the AACC.
Construction, hospitality, hotel management, healthcare and automobiles are key areas where the AACC will help Indian efforts, she said. According to Raju, the ministry was working with the AACC to develop a framework for community colleges in the country.
The Institute of International Education also released a white paper titled The US Community College Model: Potential for applications in India.
According to the government’s concept note, the community colleges will provide three-year undergraduate programmes with flexible course structures. The colleges can also provide short-term management courses similar to business schools to produce a job-ready workforce and entrepreneurs.
Such colleges will have boards with representation from industry to ensure desired standards – a model followed by Indian institutes of technology and Indian institutes of management.
“We’re going to look at the importance of community colleges to meeting the demand for higher education on the horizon. Five hundred million students in India in the next nine years may need opportunities for community college education,” said Kerry while addressing the meeting.
“Yet India, obviously, today has a huge shortage of classrooms, teachers and vocational programmes.”
The US stressed jointly working towards increasing the skills of students to face future challenges, and said this could be done through exchange programmes and partnerships between India and the US.
Under the Fulbright-Nehru programme, more than 18,000 scholars have participated in exchanges between India and America. More than 100,000 Indian students are enrolled in US higher education institutions.
The US also announced the launch of a new “Passport to India” initiative, to bring American students to India for a hands-on experience in the private sector.
With India’s foreign higher education providers bill still pending in parliament, most of the collaborations that have been announced are in areas outside the scope of the bill.
Ashok Thakur, secretary of higher education in the Ministry of Human Resources, said at the meeting: “Unfortunately, the foreign education providers bill is still with parliament, which is refusing to oblige us. But we have been working outside it, thinking laterally.”
He said that last year the idea of a twinning arrangement had been suggested. There had been some glitches, but restrictions had been removed. What was now needed was greater awareness about opportunities, and workshops between the US and India.
Raju told the Indian media last week the bill would be tabled in the upcoming session of parliament.
In early 20th century writings, Indian novelist Sarat Chandra Chattopadhyay sought to expose the social inequities of rural Bengali society. So it's perhaps fitting that Prof. Amit Mandal is a big Chattopadhyay fan, because Prof. Mandal has devoted much of his professional life to researching disorders and diseases that disproportionately affect disadvantaged populations.
Today, as Professor of Molecular Medicine and Clinical Proteomics at St. John's Research Institute in Bangalore, India, Amit Mandal is one of the world's foremost scientists using mass spectrometry to pursue proteomics research on everything from hemoglobinopathies, iron deficient anemia and mental disorders, to prostate cancer and multiple sclerosis.
Mandal's scientific interests began at a young age. “In my childhood, in school and at college, I was deeply involved in the Science Club,” he said. “We used to participate in different scientific programs and show common people, for example, how to detect adulteration in food using chemicals found in the home.”
He went on to earn his Bachelor of Science degree in chemistry at the University of Calcutta. Mandal became drawn to a career in science because, as he put it, “I get frustrated doing the same thing every day. Scientific research is the only field where every day you do something new.”
That led to a Master's degree in pure chemistry, followed by a Ph.D in biophysics from the Bose Institute in Calcutta.
“I was inspired in science, basically, by my teachers at the master’s level at university and definitely during my research period in PhD, postdoc,” said Mandal. “I've been fortunate to have good mentors at all levels, in particular, Dr. Padmanabhan Balaram, the director of the Indian Institute of Science, during my second postdoc. He taught me how to speak truth in science – how to criticize my data, to criticize my analysis. Because if I don’t criticize myself, then I cannot convince others of my scientific explanation.”
While at the Bose Institute, Mandal worked on protein-nucleic acid interaction and protein folding using spectroscopic techniques, such as fluorescence, circular dichroism, and nuclear magnetic resonance. When he joined Balaram's laboratory, he hoped to learn more about the use of nuclear magnetic resonance to study biological proteins, but that quickly changed.
“On my first day Dr. Balaram asked me, 'What do you know about mass spec?' So I said, 'I don’t know anything.' I hadn’t seen a mass spectra of any molecule so far. So then he told, 'Then go and learn mass spec',” he recalled, laughing. “That was my entry into mass spec.”
Mandal described his first use of mass spectrometry in 2005 as “a fascinating experience for me.” His mass spectrometry experience grew as he started working on clinical proteomics, mostly with hemoglobin. In 2007, he joined St. John's, a research facility under St. John’s National Academy of Health Sciences, India, where he began building the structural proteomics laboratory laboratory.
In 2008, Mandal received funding from India's Department of Science and Technology to launch a proteomics project. His relationship with Waters began at that time when he first began using a Waters SYNAPT HDMS Mass Spectrometer equipped with an electrospray ionization source and a MALDI source. The instrumentation is giving Mandal and his research colleagues new insights into the structural changes associated with post-translational modifications of hemoglobin and its variants.
Much of Prof. Mandal's work at St. John's has been focused on understanding the structural biology of hemoglobin as it relates to disorders, such as hemoglobinopathy and iron-deficient anemia.
“We have published two papers that talk about structural perturbation and structure function correlation in hemoglobin variants using isotope exchange based mass spectrometry,” he explained. “I’m also conducting a proteomics project where we are trying to find out any biological signature molecule in patients who attempted suicide and were rescued and brought into St. John’s Medical College emergency department.”
When you add in the work that Mandal and his staff of nine are doing on prostate cancer and multiple sclerosis, it's a very busy laboratory. Away from work, Prof. Mandal enjoys music, sports, politics, and reading.
“I read basically anything,” he said. “I love to read anything that covers politics, that covers literature. Chattopadhyay is my favorite writer, because he addresses social issues around family and religion.”
As the first member of his family to become a scientist and a Ph.D, Amit Mandal is keenly aware of how his work may uncover the mechanisms that underlie blood disorders that afflict millions of people around the world. His favorite author would likely approve.
Looking ahead, Mandal's driving force remains the same. “It’s the joy of solving scientific problems,” he said with a smile. “That is what is most satisfying to me.”