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1.  “Nothing Special, Everything Is Maamuli”: Socio-Cultural and Family Practices Influencing the Perinatal Period in Urban India 
PLoS ONE  2014;9(11):e111900.
Globally, India contributes the largest share in sheer numbers to the burden of maternal and infant under-nutrition, morbidity and mortality. A major gap in our knowledge is how socio-cultural practices and beliefs influence the perinatal period and thus perinatal outcomes, particularly in the rapidly growing urban setting.
Methods and Findings
Using data from a qualitative study in urban south India, including in-depth interviews with 36 women who had recently been through childbirth as well as observations of family life and clinic encounters, we explored the territory of familial, cultural and traditional practices and beliefs influencing women and their families through pregnancy, childbirth and infancy. We found that while there were some similarities in cultural practices to those described before in studies from low resource village settings, there are changing practices and ideas. Fertility concerns dominate women’s experience of married life; notions of gender preference and ideal family size are changing rapidly in response to the urban context; however inter-generational family pressures are still considerable. While a rich repertoire of cultural practices persists throughout the perinatal continuum, their existence is normalised and even underplayed. In terms of diet and nutrition, traditional messages including notions of ‘hot’ and ‘cold’ foods, are stronger than health messages; however breastfeeding is the cultural norm and the practice of delayed breastfeeding appears to be disappearing in this urban setting. Marriage, pregnancy and childbirth are so much part of the norm for women, that there is little expectation of individual choice in any of these major life events.
A greater understanding is needed of the dynamic factors shaping the perinatal period in urban India, including an acknowledgment of the health promoting as well as potentially harmful cultural practices and the critical role of the family. This will help plan culturally appropriate integrated perinatal health care.
PMCID: PMC4219795  PMID: 25369447
2.  Relationship between adiposity and cognitive performance in 9-10 year old children in south India 
Archives of disease in childhood  2013;99(2):126-134.
Studies in high-income countries have shown inverse associations between adiposity and cognitive performance in children. We aimed to examine the relationship between adiposity and cognitive function in Indian children.
At a mean age of 9.7 years, height, weight, triceps and subscapular skinfold thicknesses and waist circumference were recorded for 540 children born in Mysore, India. Body fat percentage was estimated using bio-impedance. Cognitive function was assessed using 3 core tests from the Kaufman Assessment Battery for children-II edition and additional tests measuring learning, short-term memory, reasoning, verbal and visuo-spatial abilities, attention and concentration. Data on the parents’ socio-economic status, education, occupation and income were collected.
According to WHO definitions, 3.5% of the children were overweight/obese (BMI>+1SD) and 27% underweight (BMI<−2SD). Compared to normal children, overweight/obese children scored higher in tests of learning/long-term retrieval, reasoning and verbal ability (unadjusted p<0.05 for all). All the cognitive test scores increased with increase in BMI and skinfold thickness, (unadjusted β=0.10 to 0.20 SD; p<0.05 for all). The effects, though attenuated, remained mainly significant after adjustment for age, sex and socio-economic factors. Similar associations were found for waist circumference and percentage body fat.
In this Indian population, in which obesity was uncommon, greater adiposity predicted higher cognitive ability. These associations were only partly explained by socio-economic factors. Our findings suggest that better nutrition is associated with better cognitive function, and that inverse associations between adiposity and cognitive function in high-income countries reflect confounding by socio-economic factors.
PMCID: PMC3982043  PMID: 24146284
Adiposity; Children; Cognitive function; India; Birth cohort
3.  Enhanced care by community health workers in improving treatment adherence to antidepressant medication in rural women with major depression 
Background & objectives:
Depression remains largely undiagnosed in women residing in rural India and consequently many do not seek help. Moreover, among those who are diagnosed, many do not complete treatment due to high rates of attrition. This study was aimed to compare the effectiveness of enhanced care with usual care in improving treatment seeking and adherence to antidepressant medication in women with depression living in rural India.
Six villages from rural Bangalore were randomized to either community health worker supported enhanced care or usual care. A total of 260 adult depressed women formed the final participants for the analysis. The outcome measures were number of women who sought and completed treatment, number of clinic visits, duration of treatment with antidepressant, changes in severity of depression (HDRS) and changes in quality of life [WHO-QOL (Brev) scale].
A significantly greater number of women from the treatment intervention (TI) group completed the treatment and were on treatment for a longer duration compared to the treatment as usual (TAU) group. However, there were no significant differences in the severity of depression or quality of life between the TI and the TAU groups or between treatment completers and treatment dropouts at six months.
Interpretation & conclusions:
Enhanced care provided by the trained community health workers to rural women with major depression living in the community resulted in greater number of women seeking help and adhering to treatment with antidepressants. However, despite enhanced care a significant number of rural women diagnosed with depression either did not seek help or discontinued treatment prematurely. These findings have significant public health implications, as untreated depression is associated with considerable disability.
PMCID: PMC4001335  PMID: 24718398
Antidepressant adherence; community health workers; depression; primary healthcare; rural women
4.  Thyroid dysfunction in major psychiatric disorders in a hospital based sample 
Background & objectives:
Abnormalities in thyroid hormonal status is common in major psychiatric disorders. Although the relevance of thyroid dysfunction to bipolar disorder is well-recognized, yet the association between thyroid dysfunction and schizophrenia-spectrum disorders is under-emphasized. The aim of this study was to examine and compare the rates of abnormal thyroid hormonal status in patients with schizophrenia-spectrum disorders and mood disorders in an inpatient tertiary care general hospital psychiatry unit.
This was a retrospective hospital-based study on 468 inpatient samples. Data on serum thyroid stimulating hormone (TSH), T3 (triiodothyroxine), T4 (L-thyroxine), free unbound fractions of T3 and T4 (FT3 and FT4) were obtained from records of 343 patients, 18 patients were anti-TPO (anti thyroid peroxidase antibody) positive. The rates of abnormal thyroid hormonal status were compared using the chi square test.
Abnormal thyroid hormonal status in general, and presence of hypothyroidism and hyperthyroidism, in particular were seen in 29.3, 25.17 and 4.08 per cent patients with schizophrenia spectrum disorders, respectively. These were comparable to the rates in patients with mood disorders (23.24, 21.62 and 1.62%, respectively). Eleven of the 18 patients with antiTPO positivity had a schizophrenia-spectrum disorder. There were no gender differences.
Interpretation & conclusions:
Thyroid dysfunction was present in patients with schizophrenia-spectrum disorder as well as mood disorders. Autoimmune thyroid disease was more commonly seen in patients with schizophrenia-spectrum disorders compared to mood disorders. The findings reiterate the relevance of screening patients with schizophrenia-spectrum disorders for abnormal thyroid hormonal status.
PMCID: PMC3978977  PMID: 24521631
Autoimmune thyroiditis; hyperthyroidism; hypothyroidism; mood disorder; schizophrenia
5.  Correlates of anaemia in pregnant urban South Indian women: a possible role of dietary intake of nutrients that inhibit iron absorption 
Public health nutrition  2012;16(2):316-324.
To identify correlates of anaemia during the first trimester of pregnancy among 366 urban South Indian pregnant women.
Cross-sectional study evaluating demographic, socio-economic, anthropometric and dietary intake data on haematological outcomes.
A government maternity health-care centre catering predominantly to the needs of pregnant women from the lower socio-economic strata of urban Bangalore.
Pregnant women (n 366) aged ≥18 and ≤40 years, who registered for antenatal screening at ≤14 weeks of gestation.
Mean age was 22.6 (SD 3.4) years, mean BMI was 20.4 (SD 3.3) kg/m2 and 236 (64.5%) of the pregnant women were primiparous. The prevalence of anaemia (Hb <11.0g/dl) was 30.3% and of microcytic anaemia (anaemia with mean corpuscular volume <80fl) 20.2%. Mean dietary intakes of energy, Ca, Fe and folate were well below the Indian RDA. In multivariable log-binomial regression analysis, anaemia was independently associated with high dietary intakes of Ca (relative risk; 95% CI: 1.79; 1.16, 2.76) and P (1.96; 1.31, 2.96) and high intake of meat, fish and poultry (1.94; 1.29, 2.91).
Low dietary intake of multiple micronutrients, but higher intakes of nutrients that inhibit Fe absorption such as Ca and P, may help explain high rates of maternal anaemia in India.
PMCID: PMC3713478  PMID: 22575487
Anaemia; Pregnancy; Correlates; South India
6.  Higher maternal plasma folate but not vitamin B-12 concentrations during pregnancy are associated with better cognitive function scores in 9-10 year old children in South-India1-3 
The Journal of nutrition  2010;140(5):1014-1022.
Folate and vitamin B-12 (B-12) are essential for normal brain development. Few studies have examined the relationship of maternal folate and B-12 status during pregnancy to offspring cognitive function. To test the hypothesis that lower maternal plasma folate and B-12 concentrations and higher plasma homocysteine concentrations during pregnancy, are associated with poorer neurodevelopment, cognitive function was assessed during 2007-2008 among 536 children (aged 9-10 y) from the Mysore Parthenon birth cohort. Maternal folate, B-12 and homocysteine concentrations were measured in stored plasma samples taken at 30±2 wk gestation. The children’s cognitive function was measured using 3 core tests from the Kaufman Assessment Battery and additional tests measuring learning ability, long-term storage/retrieval, attention and concentration, visuo-spatial and verbal abilities. During pregnancy 4% of mothers had low folate concentrations (<7 nmol/L), 42.5% had low B-12 concentrations (<150 pmol/L) and 3% had hyperhomocysteinemia (>10 μmol/L). There was a 0.1-0.2 SD increase in the children’s cognitive scores per SD increase in maternal folate concentration (p<0.001 for all tests). The associations with learning ability and long-term storage/retrieval, visuo-spatial ability, attention and concentration were independent of maternal age, BMI, parity, the parents’ education, socio-economic status, rural/urban residence, religion, the child’s gestational age, birth size, sex and the children’s size, educational level and folate and B-12 concentrations at 9.5 y. There were no consistent associations of maternal B-12 and homocysteine concentrations with childhood cognitive performance.
In this Indian population higher maternal folate, but not vitamin B-12 concentrations during pregnancy, predicted better childhood cognitive ability.
PMCID: PMC3672847  PMID: 20335637
7.  Rationale and design of South Asian Birth Cohort (START): a Canada-India collaborative study 
BMC Public Health  2013;13:79.
People who originate from the Indian subcontinent (South Asians) suffer among the highest rates of type 2 diabetes in the world. Prior evidence suggests that metabolic risk factors develop early in life and are influenced by maternal and paternal behaviors, the intrauterine environment, and genetic factors. The South Asian Birth Cohort Study (START) will investigate the environmental and genetic basis of adiposity among 750 South Asian offspring recruited from highly divergent environments, namely, rural and urban India and urban Canada.
Detailed information on health behaviors including diet and physical activity, and blood samples for metabolic parameters and DNA are collected from pregnant women of South Asian ancestry who are free of significant chronic disease. They also undergo a provocative test to diagnose impaired glucose tolerance and gestational diabetes. At delivery, cord blood and newborn anthropometric indices (i.e. birth weight, length, head circumference and skin fold thickness) are collected. The mother and growing offspring are followed prospectively and information on the growth trajectory, adiposity and health behaviors will be collected annually up to age 3 years. Our aim is to recruit a minimum of 750 mother-infant pairs equally divided between three divergent environments: rural India, urban India, and Canada.
The START cohort will increase our understanding of the environmental and genetic determinants of adiposity and related metabolic abnormalities among South Asians living in India and Canada.
PMCID: PMC3585827  PMID: 23356884
Birth cohort; South Asian; Adiposity; Insulin resistance; Early origins; India; Canada
8.  Minimizing risks and monitoring safety of an antenatal care intervention to mitigate domestic violence among young Indian women: The Dil Mil trial 
BMC Public Health  2012;12:943.
Domestic violence - physical, psychological, or sexual abuse perpetrated against women by one or more family members – is highly prevalent in India. However, relatively little research has been conducted on interventions with the potential to mitigate domestic violence and its adverse health consequences, and few resources exist to guide safety planning and monitoring in the context of intervention research. Dil Mil is a promising women’s empowerment-based intervention developed in India that engages with young women (daughters-in-law) and their mothers-in-law to mitigate domestic violence and related adverse health outcomes. This paper describes the design of a randomized controlled trial of Dil Mil in Bengaluru, India, with a focus on strategies used to minimize study-related risks and monitor safety.
A phase 2 randomized controlled trial using a parallel comparison of the Dil Mil intervention versus standard care will be implemented in three public primary health centers in Bengaluru. Young pregnant women in the first or second trimester of pregnancy will be recruited from antenatal services at study health centers and through community outreach. If eligible and willing, their mother-in-law will also be recruited. Once enrolled, dyads will participate in a baseline interview and then randomized either to the control arm and receive standard care or to the intervention arm and receive standard care plus the Dil Mil intervention. Additional evaluations will be conducted at 3 months and 6 months postpartum. Data will be analyzed to examine the feasibility and safety of the intervention and the effect of the intervention on intermediary outcomes (the empowerment of daughters-in-law and mothers-in-law), incidence of domestic violence among daughters-in-law, and health outcomes including perceived quality of life, psychosocial status and maternal and infant health outcomes.
This study offers approaches that may help guide safety planning and monitoring in other domestic violence intervention trials in similar settings. Moreover, given the staggeringly high prevalence of domestic violence against young women in India (and indeed globally) and the dearth of data on effective interventions, this study is poised to make an important contribution to the evidence-base for domestic violence prevention.
Trial registration Identifier: NCT01337778
PMCID: PMC3534227  PMID: 23116189
Domestic violence; Women’s empowerment; Randomized controlled trial; India
9.  Infant feeding practice and childhood cognitive performance in South India 
Archives of disease in childhood  2009;95(5):347-354.
Several studies have suggested a beneficial effect of infant breast-feeding on childhood cognitive function. Our main objective was to examine whether duration of breast-feeding and age at introduction of complementary foods are related to cognitive performance in 9-10 year old school going children in South-India.
We examined 514 children from the Mysore Parthenon birth cohort for whom breast-feeding duration (6 categories from <3 to ≥18 months) and age at introduction of complementary foods (4 categories from <4 to ≥6 months) were collected at the 1st, 2nd and 3rd year annual follow-up visits. Their cognitive function was assessed at a mean age of 9.7 years using 3 core tests from the Kaufman Assessment Battery for children and additional tests measuring long-term retrieval/storage, attention and concentration, visuo-spatial and verbal abilities.
All the children were initially breast-fed. The mode for duration of breast-feeding was 12-17 months (45.7%) and for age at introduction of complementary foods 4 months (37.1%). There were no associations between longer duration of breast-feeding, or age of introduction of complementary foods, and cognitive function at 9-10 years, either unadjusted or after adjustment for age, sex, gestation, birth size, maternal age, parity, socio-economic status, parents’ attained schooling, and rural/urban residence.
Within this cohort, in which prolonged breast-feeding was the norm (90% breast-fed ≥6 months and 65% breast-fed for ≥12 months), there was no evidence suggesting a beneficial effect of longer duration of breast-feeding on later cognitive ability.
PMCID: PMC3428883  PMID: 19946010
Breast-feeding; Complementary foods; Children; Cognitive performance; India
10.  Melioidosis of Chest Wall Masquerading as a Tubercular Cold Abscess 
Melioidosis caused by Burkholderia pseudomallei, an important human pathogen in the tropical regions causes protean and multisystem clinical manifestations. A 50-year-old man on treatment for pulmonary tuberculosis developed a chest wall abscess. With a suspicion of tuberculous cold abscess, pus culture was done and it revealed Burkholderia pseudomallei. He was treated with 10 days of ceftazidime and incision and drainage was done. Wound healed well and he has now completed three months of oral cotrimoxazole eradication therapy and is on follow-up without recurrence. We report this case for the unusual presentation of melioidosis and the diagnostic challenge posed due to clinical similarity with tuberculosis.
PMCID: PMC3673354  PMID: 23741590
Chest wall abscess; cold abscess; melioidosis; tuberculosis
11.  Comparison of three a-priori models in the prediction of serum lithium concentration 
Indian Journal of Pharmacology  2012;44(2):234-237.
Mathematical models are valuable for optimizing drug dose and dosing regimens.
To compare the precision and bias of three a-priori methods in the prediction of serum level of lithium in patients with bipolar disorder, and to determine their sensitivity and specificity in detecting serum lithium levels outside the therapeutic range.
Settings and Design:
Hospital-based, retrospective study.
Materials and Methods:
In a retrospective study of 31 in-patients, the serum level of lithium was calculated using three different a-priori methods. Mean Prediction Error was used as a measure of bias while Mean Absolute Error and Root Mean Squared Error were used as a measure of precision. The sensitivity and specificity of the methods was calculated.
All three models underestimated serum lithium level. Precision was best with the model described by Pepin et al., while bias of prediction was the least with the method of Abou Auda et al. The formula by Pepin et al. was able to predict serum lithium level with a mean error of 36.57%. The sensitivity and specificity of the models in identifying serum lithium levels outside the therapeutic range was 80% and 76.19% for Pepin et al., 90% and 74.19% for Zetin et al., and 90% and 66.67% for Abou-Auda et al., respectively.
The study demonstrates the difference in precision and bias of three a-priori methods, with no one method being superior to the other in the prediction of serum concentration.
PMCID: PMC3326919  PMID: 22529482
Drug level; monitoring; predictive model; serum lithium
12.  Vitamin B12 deficiency & levels of metabolites in an apparently normal urban south Indian elderly population 
Background & objectives:
There is no published literature on the extent of vitamin B12 deficiency in elderly Indians as determined by plasma vitamin B12 levels and methylmalonic acid (MMA) levels. Vitamin B12 deficiency is expected to be higher in elderly Indians due to vegetarianism, varied socio-economic strata and high prevalence of Helicobacter pylori infection. We therefore, studied the dietary habits of south Indian urban elderly population and measured vitamin B12, MMA red cell folate and homocysteine (Hcy) levels.
Healthy elderly urban subjects (175, >60 yr) were recruited. Detailed history, physical examination and neurological assessment were carried out. Food Frequency Questionnaire (FFQ) for dietary analysis for daily intake of calories, vitamin B12, folate and detailed psychological assessment for cognitive functions was carried out. Blood samples were analyzed for routine haematology and biochemistry, vitamin B12, red cell folate, MMA and Hcy.
The mean age of the study population was 66.3 yr. Median values for daily dietary intake of vitamin B12 and folate were 2.4 and 349.2 μg/day respectively. Sixty two (35%) participants consumed multivitamin supplements. Plasma vitamin B12 level and the dietary intake of vitamin B12 was significantly correlated (P=0.157). Plasma vitamin B12 and Hcy were inversely correlated (P= -0.509). Red cell folate was inversely correlated with Hcy (P= -0.550). Significant negative correlation was observed between plasma vitamin B12 and MMA in the entire study population (P= -0.220). Subjects consuming vitamin supplements (n=62) had significantly higher plasma vitamin B12 levels, lower MMA levels and lower Hcy levels. There was no significant correlation between plasma vitamin B12, MMA, Hcy and red cell folate and any of the 10 cognitive tests including Hindi Mental Status Examination (HMSE).
Interpretation & conclusions:
Our study is indicative of higher vitamin B12 (2.4 μg/day) intakes in urban south Indian population. Thirty five per cent of the study population consumed multivitamin supplements and therefore, low plasma vitamin B12 levels were seen only in 16 per cent of the study subjects. However, MMA was elevated in 55 per cent and Hcy in 13 per cent of the subjects.
PMCID: PMC3237239  PMID: 22089603
Cognitive assessment; geriatric; methylmalonic acid; nutrition; vitamin B12 deficiency
14.  “Blues” ain’t good for the heart 
Indian Journal of Psychiatry  2011;53(3):192-194.
PMCID: PMC3221172  PMID: 22135434
15.  Association of birthweight and head circumference at birth to cognitive performance in 9-10 year old children in South India: prospective birth cohort study 
Pediatric research  2010;67(4):424-429.
To examine whether birthweight and head circumference at birth are associated with childhood cognitive ability in South-India, cognitive function was assessed using 3 core tests from the Kaufman Assessment Battery for children and additional tests measuring long-term retrieval/storage, attention and concentration, visuo-spatial and verbal abilities among 505 full-term born children (mean age 9.7-y). In multiple linear regression adjusted for age, sex, gestation, socio-economic status, parent’s education, maternal age, parity, BMI, height, rural/urban residence, and time of testing, Atlantis score (learning ability/long-term storage and retrieval) rose by 0.1 SD per SD increase in newborn weight and head circumference respectively (p<0.05 for all) and Kohs’ block design score (visuo-spatial ability) increased by 0.1 SD per SD increase in birthweight (p<0.05). The associations were reduced after further adjustment for current head circumference. There were no associations of birthweight and/or head circumference with measures of short-term memory, fluid reasoning, verbal abilities and attention and concentration. In conclusion higher birthweight and larger head circumference at birth are associated with better childhood cognitive ability. The effect may be specific to learning, long-term storage and retrieval, and visuo-spatial abilities, but this requires confirmation by further research.
PMCID: PMC3073480  PMID: 20032815
16.  Aerobic Fitness and Cognitive Functions in Economically Underprivileged Children Aged 7-9 Years: A preliminary Study from South India 
This study examined the relationship between aerobic fitness and cognitive functions in 7-9 year old school going children hailing from a socio-economically disadvantaged background in Bangalore, India. Ninety eight children (51% boys and 49% girls) were assessed on height, weight, BMI, aerobic fitness (multistage 20 m shuttle test) and cognitive functions (verbal tests: comprehension, arithmetic, vocabulary, analogies; performance tests: block design, object assembly and coding). Number of shuttles was significantly positively correlated with two of the cognitive tests: comprehension (p=0.01) and block design (p=0.005). Multiple linear regression analysis showed that the number of shuttles emerged as an independent predictor of tests of comprehension and block design after adjusting for BMI and gender. The above findings provide preliminary evidence for the association between aerobic fitness and cognitive functions in children from poor socio-economic background.
PMCID: PMC3614816  PMID: 23675220
aerobic fitness; cognitive functions; economically underprivileged children; South India

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