Preterm babies don’t gain growth by early initiation of complementary food


Babies started early on complementary food tend to suffer more due to diarrhoea and lower tract infections.

Babies born preterm (before 37 completed weeks of gestation) have a higher energy requirement than babies born full term and therefore fail to gain weight adequately. Parents of preterm babies and doctors alike are not sure whether breast milk or formula milk alone will meet the energy requirements after the first four months and whether preterm babies should be started on complementary food. While normal babies are given solids and semi-solids only from six months of age, early initiation of complementary food, which has a higher calorie density, in preterm babies appears to be a good idea to meet their energy needs and improve their growth (weight and length).

Till recently there was little evidence of whether earlier introduction of complementary feeding (prior to six months of corrected age) would improve growth of preterm babies.

No gain in growth

A study published a few days ago in The Lancet Global Health has found an answer to this vexatious issue — early initiation of complementary feeding in preterm babies born before 34 weeks of gestation does not improve growth.

Doctors from the All India Institute of Medical Sciences (AIIMS), Safdarjung Hospital and Kasturba Hospital, all in New Delhi, enrolled 403 babies born before 34 weeks of gestation and randomly assigned them to two groups — one in which they were started on complementary feeding at four months of corrected age and the other group of babies where complementary feeding was initiated at six months of corrected age. The corrected age refers to age that is corrected for the period of prematurity — for a baby born at 32 weeks of gestation, which is approximately two months earlier than the normal gestation period, the corrected age is 10 months at the end of one year of birth.

Complementary feeding was standardised in both the groups in terms of frequency, consistency, type of food, preparing food hygienically, and ways of feeding. Complementary foods were given in addition to breastfeeding/other milk feeding.

“Even though one group of babies was started on complementary feeding at an earlier age of four months of corrected age, there was no difference in growth compared with babies who were started on complementary feeding at six months of corrected age,” says Dr. Ramesh Agarwal from the Department of Paediatrics at AIIMS, one of the corresponding authors of the paper.

Some health risks

On the other hand, the study indicates that early initiation of complementary feeding had some negative fallout. “There were more hospitalisations in the group that started on complementary feeding at four months of corrected age,” he says. Though overall hospital admission in both the groups was low, babies in the four-month group were at increased risk of hospital admission due to diarrhoea and lower respiratory tract infections. “There could be several reasons for this increased risk, including potential contamination of complementary foods due to inadequate hygiene or having less breast milk,” he says.

“Our study shows that there is no difference in growth whether complementary feeding is started at four or six months of corrected age. But there are more infections when complementary feeding is started earlier. So it is advisable that complementary feeding is started only at six months of corrected age in preterm babies less than 34 weeks of gestation,” says Dr. Agarwal. However, studying the difference in growth and not infection was the primary objective of the study.

Published in The Hindu on May 7, 2017

IISc develops a handheld device to detect melamine in milk


A handheld device developed by Prof. Sai Siva Gorthi (left), Prateek Katare (middle) and Dr. Kiruba Daniel can detect melamine in milk even at 0.5 ppm concentration.

Detecting melamine in milk has become extremely easy, quick and inexpensive thanks to a handheld melamine detector developed by researchers at the Indian Institute of Science (IISc), Bangalore.

Tiny amount of silver nitrate is dissolved in 50 ml of distilled water and 2 micro litre of this silver nitrate solution is added to milk along with the leaf extract of a commonly seen weed Parthenium for detecting melamine in milk. The results were published in the journal Sensors and Actuators B: Chemial.

“The presence of melamine in milk can be detected at room temperature within a few seconds through a change in colour,” says S.C.G. Kiruba Daniel from the Department of Instrumentation and Applied Physics, IISc and the first author of the paper.

“Our sensor has a very high sensitivity as it can detect melamine even at a low concentration of 0.5 ppm in raw milk.” Melamine content of more than 1 ppm in infant formula and more than 2.5 ppm in other foods should be viewed with suspicion of adulteration, says the Food Safety and Standards Authority of India.

In 2008, at least four babies in China died and around 100,000 became sick after consuming powdered milk baby food laced with melamine. Due to the presence of nitrogen, the addition of melamine to milk makes it look protein-rich.

Prior to melamine detection, the milk is processed to remove fat and proteins as they tend to interfere with detection. While most researchers had used already prepared silver nanoparticles for melamine detection, the IISc team added silver nitrate and the leaf extract in a particular ratio and at a particular pH to the preprocessed milk to synthesise silver nanoparticles.

“If melamine is present then it interferes with the synthesis and there is abrupt formation of nanoparticles leading to colour change,” says Dr. Daniel.

The change in colour depends on the amount of melamine present and, therefore, the extent of its interference with the synthesis of silver nanoparticles. “The colour change can be directly observed by the naked eye and also recorded by spectral change,” he says.

The silver nanoparticles are reddish yellow in the absence of melamine, while it becomes nearly colourless when melamine is present. Light absorption at 414 nm wavelength is a signature of silver nanopartciles. But when melamine is present the absorption of light is reduced as nanoparticle formation decreases.

“Currently, milk samples have to be brought to a central testing facility, so very less testing gets done. But all this can change with our handheld device,” Dr. Daniel says. As little as 1 ml of milk is sufficient for carrying out melamine detection.

The team is in the process of commercialising the product through a start-up that is incubated at the Society for Innovation & Development (SID) in IISc.

Published in The Hindu on September 29, 2016

Repeated use of oil leads to increased trans fat content


High trans fat intake increases the risk of cardiovascular diseases, increases insulin resistance and risk of diabetes.

Beginning next month, manufacturers in India of partially hydrogenated vegetable oils (PHVOs) will be required to reduce the trans fat level from the current 10 per cent limit to 5 per cent, says Dr. R.B.N. Prasad, Chairman of the Scientific Panel on Oils and Fats, Food Safety and Standards Authority of India.  This downward revision is in keeping with FSSAI’s revised trans fat regulation of December 2014. In July 2013, FSSAI brought in regulations to limit the trans fat content to 10 per cent in PHVOs like Vanaspati.

In India, vanaspati, desi ghee, butter and margarine are the main sources of trans fat. Vanaspati is highly favoured by the industry as it prolongs a food product’s shelf life and is cheap. However, it has adverse health effects and is more harmful than saturated fat.  This is because it increases low-density lipoprotein cholesterol (LDL) or bad cholesterol and decreases high-density lipoprotein cholesterol (HDL) or good cholesterol. These changes in the lipoprotein cholesterol content increase the risk of cardiovascular diseases. Saturated fat, on the other hand, increases the level of both bad and good cholesterol and is, therefore, less harmful compared with trans fat.

According to a July 2015 paper (BMC Public Health), a 2 per cent increase in energy intake from trans fat has been associated with a 23 per cent increase in the risk of heart disease. Trans fat intake has also been linked to increased insulin resistance and raised risk of diabetes. It is for these reasons that the World Health Organisation (WHO) has recommended an upper limit of less than 1 per cent of total energy intake through trans fat.
Oil should not be reused more than 2-3 times. If oil is fried continuously for about two hours, then it should not be reused for frying.
A report by the Hyderabad-based National Institute of Nutrition says that if a person consumes 2,000 kcal of food that has 20-30 per cent vanaspati every day, the energy intake from trans fat will be in the range of 0.9-1.35 per cent. So, limiting the trans fat content to 10 per cent will still lead to more than the WHO-recommended level of less than 1 per cent. FSSAI’s downward revision of the upper bound of trans fat to 5 per cent will help meet the WHO limit and go a long way in reducing adverse health effects of trans fat.

A June 2016 paper in Food Chemistry found that repeated heating/frying led to an increase in trans fat content.  This increase was seen even when oil that did not contain any trans fat was heated to 180 degree C. The formation of trans fat during food frying is closely related to the temperature and duration of heating the oil/fat.

In the Indian context, the repeated use of fat/oil for at high temperature in the preparation of certain food items would lead to an increased consumption of trans fat, the authors warn.

“FSSAI clearly states that oil should not be reused more than 2-3 times,” says Dr. Prasad. Polar compounds are formed due to oxidation, hydrolysis and some other chemical reactions of oils during frying.

Some countries have regulations that fried oil should not be used if it contains more than 25 per cent of polar compounds. “If you fry any oil continuously for about two hours then it is better not use this oil for the second time for frying. The oil should instead be used for cooking, like curry preparation, that does not involve frying,” he says.

Yet, there is no way of monitoring reuse of oil or limiting the amount of trans fat in food items prepared in restaurants and roadside vendors. According to the BMC Public Health paper, oil samples collected from street vendors contained high levels of trans fat — 0.1-30 per cent of total fat. As a result, 4 per cent of people in rural areas and 13 per cent in the urban areas were consuming trans fat that is much higher than the WHO recommended level, the paper says.

A February 2016 study (Journal of Nutrition Education and Behavior) also found high levels of trans fat in oil used by street vendors. The oil used by 44 street vendors in two low-income villages in Haryana and an urban slum in Delhi had 25-69 per cent saturated fats and 0.1-30 per cent of trans fatty acids.

Though packaged food products are required to label trans fat content, most local products do not have it on the label. “Even if trans fat content is quoted, these are based on raw ingredients and not the finished product,” writes Swati Bhardwaj, the first author of the Food Chemistry paper from the University of Delhi.

In 2004, Denmark became the first country to limit trans fat to 2 per cent of total fat in all food items. According to a Januray 2016 paper in the American Journal of Preventive Medicine, the number of deaths in Denmark caused by cardiovascular diseases reduced on average by 14.2 per 100,000 population per year due to the regulation. Following Denmark’s example, many other countries (Austria, Switzerland, Iceland, Sweden Canada, Australia, New Zealand, New York City and California) too have limited the trans fat content in food items.

Published in The Hindu on July 17, 2016

Using fat tax to change food consumption behaviour

Using tax as a tool to alter consumer food preferences has been recommended by the World Health Organisation. Mexico provides us with proof that levying additional taxes on non-essential food items that are rich in fat or calories can effectively alter food choices. The country witnessed a 5.1 per cent dip in consumption levels in foodstuff that had more than 275 kcal/100 g energy density following the imposition of an 8 per cent levy in 2014. Sugar-sweetened drinks saw a 12 per cent drop in intake at the end of the very first year the tax was introduced. In this context, Kerala’s decision to slap a 14.5 per cent tax on certain calorie-rich food items such as pizzas, doughnuts and pasta sold in branded restaurants may seem like a step in the right direction. But it bears the stamp of being little more than a political gimmick. For once, such foods sold by branded restaurants, consumed by the higher middle and upper classes, are a very tiny part of the problem of poor food choices for the State’s population. Ignoring a wide variety of high-calorie food items and focussing on a few is no more than tokenism. The revenue that Kerala hopes to mop up from this — Rs.10 crore — is also meagre.

Taxing ‘bad’ foods should be accompanied by cross-subsidies of healthy and wholegrain food items.

If the State is serious about reining in consumption of unhealthy food, then there are several measures it should quickly adopt.The first is to set a threshold limit for fat and/or calorie and tax all foods items that are above this limit. Bringing sugar-sweetened drinks and refined products under the taxable product list should be a priority. There is no reason why packaged food items that have high salt content should not be additionally taxed. Indians are known to consume a few times more than the WHO’s recommended limit of 5 grams a day and most of it comes from packaged food items. Similarly, what excuse can there be for not charging a very high rate of tax on food items that contain trans fats? There are a number of food items sold in India that contain as high as 35-40 per cent of trans fats. Trans fatty acids, made through the process of hydrogenation of oils, which improves the stability or shelf life of the foodstuff that contains them, pose serious coronary risks. Taxing ‘bad’ foods should be accompanied by cross-subsidies of healthy and wholegrain food items. Only a holistic approach such as this will be effective in making a real change in our food consumption behaviour. At the same time, the food industry too should play a significant role in promoting healthy diets.  According to the WHO, the food industry can “reduce the fat, sugar and salt content of processed foods, ensure that healthy and nutritious choices are available and affordable to all consumers, and restrict marketing of foods high in sugars, salt and fats, especially those foods aimed at children and teenagers.”

Published in The Hindu on July 13, 2016

Is Kerala’s fat tax a mere topping than health initiative?



Kerala’s bold step to levy fat tax on certain junk food items appears to mirror the Denmark example.

In a bold step that might have a positive impact on public health, Kerala has become the first State in the country to introduce a 14.5 per cent tax on burgers, pizzas, donuts, sandwiches and pasta sold through branded restaurants. Introducing additional tax on fat-rich food products has been tried out in other countries with varying degrees of success. Where Denmark has failed, will Kerala’s experimentation succeed?

The answer to that question depends on what the objective is. Unfortunately, the rationale behind the move has not been spelt out except that it will bring in additional Rs.10 crore to the government’s coffers.

There is a strong case to bring in several measures to tackle the burgeoning waistline of school children and adults in Kerala. For instance, a June 2012 study (Indian Pediatrics) of 1,634 children between 6-15 years from three urban schools in Kochi, Kerala, found the prevalence of obesity among boys to be 3 per cent and 5.3 per cent for girls and the prevalence of overweight was 10.2 per cent in boys and 12.1 per cent in girls. An April 2014 study of 1,098 school children in the rural areas of Kochi district found 9 per cent of girls and nearly 6 per cent boys were overweight while 2.8 per cent girls and 3.3 per cent boys were obese.

Levying a tax on calorie-rich, unessential food items and beverages has been the preferred route to rein in consumption of unhealthy products and as a means to change consumer behaviour in some developed countries. Hungary taxes food high in fat and sugar, France taxes soft drinks and Mexico levies tax on junk food and sugar-sweetened beverages, while 34 U.S. States and the district of Columbia have food taxes that affect sugar-sweetened  drinks.
The food items have not be chosen based on energy density or fat content threshold. So,  numerous high calorie, fat-rich food products have been left out.

In October 2011, Denmark became the first country in the world to introduce a tax on saturated fat. Tax was levied on all foods that contained more than 2.3 per cent fat, including milk, butter, cheese, oil, and meats, as well as frozen pizzas and other processed foods. However, it was repealed by the end of 2012 even before tax on sugar-sweetened beverages could be introduced. Similarly, in Mexico, where prevalence of overweight and obesity is over 33 per cent in children and about 70 per cent in adults, 8 per cent tax was introduced on all nonessential food items with energy density of more than 275 kcal/100 g and 10 per cent on all sugar sweetened beverages since January 2014.

In contrast, the focus in Kerala has been only a few calorie-rich, nonessential food items for additional taxation and is not based on any cut-off energy density or fat content. As a result, numerous energy-dense, fat-rich food products have been left out. It is also surprising that sugar-sweetened beverages have been excluded from the list of taxed products. In January 2016, the World Health Organisation had urged governments to levy additional taxes on sugar-sweetened beverages to end childhood obesity.

According to a study (Health Policy, June 2015), in Denmark, the fat tax was considered as a “source of funds for the tax reform rather than a public health initiative”.  The taxation rate was “adjusted to yield certain tax revenue rather than a certain health benefit,” the tax did not reflect the actual content of saturated fat in a product and the tax was processed by the Ministry of Taxation and not the Health Committee. Still, consumption of saturated fat items reduced by 10-15 per cent due to the tax (Food Policy, October 2013); an April 2016 study pegs the reduction in intake at 4 per cent. Kerala’s case seems very similar to that of Denmark.

On the other hand, Mexico has shown that a well-thought-out strategy focussing primarily on reducing unhealthy food consumption can yield rich dividends. During the first year of taxation in 2014, a January 2016 paper in the medical journal BMJ says that there was a 12 per cent reduction in sugar-sweetened beverages intake, while a PLOS Medicine study (July 2016) noted a 5.1 per cent drop in the consumption of energy-dense food items.

Results from Mexico also show that while no change in consumption pattern was seen in high socio-economic status households, a 10.2 per cent and 5.8 per cent reduction in the consumption levels was seen in low and medium socio-economic status households respectively. This is not surprising as low-income populations are more sensitive to price changes. However, in the case of Kerala, the prime target is the middle and high socio-economic households. Still, in all probability, the exercise will bring about a change in the consumption pattern as the fat tax is way higher than even Mexico’s.

The outcome of Kerala’s exercise will be keenly watched by other States. The war on obesity and many chronic health diseases caused by fat-rich food intake can be won if Kerala can pull it off by undertaking certain mid-course corrections and not go the Denmark way.

Sin tax reduces intake of energy-dense food in Mexico


After the introduction of sin tax, 25 grams per person per month reduction in intake of energy-dense food was seen in Mexico.

That taxing energy-dense, unhealthy food will result in a drop in consumption levels has come out unequivocally clear in Mexico. In January 2014, Mexico introduced 8 per cent tax on foods items with energy density of over 275 kcal/100 g and one peso per litre of sugar-sweetened beverages.

Data of household consumption of nonessential energy-dense food in Mexico shows a decline in 2014. The nonessential food included salty snacks, chips, pastries and frozen desserts.  The results of a study were published on July 5, 2016 in PLOS Medicine.

While there were no changes in mean volume of purchase of taxed food items among high socioeconomic status households, both low and medium socioeconomic households showed a reduction. The reduction was 10.2 per cent in the case of low socioeconomic households, while the drop was 5.8 per cent in the case of medium socioeconomic households. Compared with households from higher socioeconomic status, the low socioeconomic households bought less taxed food before and after tax but showed the “greatest response” to the tax. An earlier study showed a 6 per cent decline in taxed sugar-sweetened beverages.

The mean volume of purchases of taxed food during 2014 dropped by 25 grams (5.1 per cent) per person per month. The reduction of 25 grams per person per month translates into 70-110 kcal. However, there was no change in the purchase of non-taxable food items during 2014. The greatest change in total purchase of taxed food was seen in salty snacks and cereal-based sweets.

The purchases represent only a “fraction” of all household purchases, so the real absolute change in energy consumption from taxed food products “might be higher”, the authors say.

Besides reducing the amount of energy-dense food consumed by individuals, the introduction of taxes had an unexpected positive impact. Many companies reformulated their products, particularly jam and spreads, to fall under the 275 kcal/100 gram threshold.

The study used data on volume of household food purchases between January 2012 and December 2014 and included 6, 248 households.

Mexico introduced the tax as it has one of the highest prevalence rates for overweight and obesity in the world at over 33 per cent for children in the 2-18 years age group and around 70 per cent for adults. In 2006, the prevalence of diabetes in adults was 14.4 per cent. Mexico is the fourth largest consumer of energy-dense, ultra-refined food and drinks.

Published in The Hindu on July 6, 2016

Nutrition labelling to take the pinch out of salt

Pickle - cropped

A pickle product has no details about salt (sodium) content on the nutrition label. – Photo: R. Prasad

Indian adults consume between 8.5 grams and 15 grams of salt each day as against the World Health Organisation’s (WHO) recommendation of less than 5 grams per day to reduce blood pressure, heart disease and stroke, says a September 2012 paper in PLOS ONE.

And contrary to the WHO’s recommendation of at least 3.5 grams intake of potassium per day, Indians consume far less amount of potassium. Apparently, Indians on average consume 130 grams of fruits and vegetables per day as against the WHO recommendation of 500 grams a day.

Excess water in the blood is filtered out by the kidneys through osmosis. For this to happen, a balance of sodium and potassium is needed. But high intake of sodium alters this sodium balance, causing the kidneys to have reduced function and remove less water resulting in higher blood pressure. This puts strain on the kidneys and can lead to kidney disease.

According to the President of the Public Health Foundation of India (PHFI), Prof. Srinath Reddy, hypertension in the population ranges from 20-39 per cent in urban areas while it is 12-17 per cent in rural areas. An October 2014 paper in the journal BMJ Open says that an estimated 140 million people in India have hypertension, a figure that will touch nearly 214 million by 2030.

If a high proportion of salt consumed by Indians comes from salt added while cooking and at the table, a much higher intake comes from consuming processed food, especially salted snacks, pickle, papad and sauce.

Vast differences revealed

A survey of nearly 5,800 packaged food products reveals huge differences in the salt content of similar foods. For instance, cooking sauces, table sauces and spreads were found to contain on average 5.5 gram per 100g of salt, with some having 10 times that amount.

What makes it difficult for consumers to choose healthy food items is the lack of labelling information about sodium on most packaged food products sold in India. A September 2015 study (Asia Pacific Journal of Clinical Nutrition) carried out in 2010 found that only 31 per cent of Indian food products included information on sodium in the nutrition labelling.

Nothing much seems to have changed since 2010. The survey of 5,800 products carried out from 2013-2014 found that only a third of packaged food products had information on sodium.

It is ironic that despite the high incidence of elevated blood pressure in India and high hypertension-related mortality, the Food Safety and Standards (Packaging and Labelling) Regulations, 2011, has not made it mandatory for manufacturers to provide sodium information. Making sodium data available on packaged products is vital in helping a person wanting to reduce his salt intake.

According to the 2011 regulations, manufacturers are required to provide nutritional information on ‘energy, protein, carbohydrate, sugar and fat’. Declaring the sodium content on the label is not mandatory. However, Codex requires labelling to also include information about saturated fat and sodium.

Label’s markings

But if everything goes to plan, salt (sodium) content may soon be available on the packet labels of food products. According to the former director of the Hyderabad-based National Institute of Nutrition, Dr. B. Sesikeran, and till recently the chairperson of the FSS Scientific Panel on Labels, a revised Food Safety and Standards (Packaging and Labelling) Regulations will be notified soon.

A front-of-pack labelling will include salt (sodium) in addition to total calories, total saturated fat, trans fat, and added sugar. The FSS may also make it mandatory to include markings on whether the five categories on the label are ‘low’ or ‘high’ per serving.

In an email to me, Dr. Shweta Khandelwal, Associate Professor at PHFI says: “Added salt in mg/serving size should be included under the mandatory labelling component. The food industry will always bring up something which will delay or digress from this issue but we need to advocate it in a concerted fashion in light of the already existing and constantly rising epidemic of chronic diseases.”

Inclusion of salt (sodium) on labels will be a welcome step and will be in line with the WHO’s January 2013 guidance to include food and product labelling to reduce sodium and increase potassium consumption. The government should next negotiate with food manufacturers to reduce the amount of salt in processed foods.

Other countries have adopted several proactive measures to cut down on salt consumption. For instance, in South  Africa , a  new  draft  regulation  sets  requirements  for  voluntary  colour coded  front of pack labelling for energy, total sugar, fat, saturated fat and total sodium or salt equivalent per  serving.  The  regulation  was  subject  to  public  consultation  until  the  end  of  August  2014 and the final version is about to be released, says Dr. Khandelwal. While in the case of other countries like Brazil, China and the U.S., salt-reduction strategies have been initiated in select regions.

The ‘salt’ app

Meanwhile, the FoodSwitch app developed by the Sydney-based The George Institute for Global Health will provide consumers with the knowledge and support to choose products that are healthy. The George Institute for Global Health India already has nutrition information on nearly 8,000 food products sold in India across 15 food categories. Another 2,000 products will soon be added to the list.

The free to download app uses the established traffic light labelling system — red (‘high’), amber (‘OK’) and green (‘good’) — to evaluate products in the chosen category.

“The app serves like an advocacy tool for consumers to use the information available on the label,” says the Deputy Director of The George Institute for Global Health India, Delhi, Dr. Pallab Maulik. “If and when India makes it mandatory to have all the details on the label, the app will still be useful in helping consumers choose healthier options.”

Published in The Hindu on July 3, 2016