Insulin Resistance Syndrome in IndiansA. Misra*, J.S. Wasir**, N.K. Vikram***

atrics, 56, 508-520,1975a

28. Rush D., Stein Z. & Susser M.: A randomizedcontrolled trial of prenatal nutritional supplementa­tion in New York city. Pediatrics, 65,688-697,1980

29. Prentice A.M., Cole J.J., Foord FA, Lamb W.H.& Whitehead R.G.: Increased birth weight afterprenatal dietary supplementation of rural Africanwomen Am J Clin Nutr, 46, 912-925,1987

30. Ghafoorunissa, Fat and fatty acid contents ofcereals and pulses and their relevance to Indiandiets. Eur J Clin Nutr 43:275-283,1989

31. Gopalan S., Patnaik R.and Ganesh K.: Feasiblestrategies to combat low birth weight and intra­uterine growth retardation, Journal of Pediatric

Gastroenterology and Nutrition, Vol 39(1), S37, 2004

32. OlsenS.F., Sorensen J.D., Secher N.J.,HildegaardM, Henriksen T.B., Hansen H.S. & Grant, A.: Ran­domized controlled effect of fish oil supplementa­tion on pregnancy duration. Lancet 339(8800), 1003­1007,1992

33. Rice R.: Fish and healthy pregnancy: more thana red herring! Professional care of mother and child

6(6). 171-173,1996

34. Hales, C.N. and Barker D.,J., P.: Type 2 (noninsulin dependent) diabetes mellitus; the thriftyphenotype hypothesis, Diabetologia, 35;1019-1022,1992

35. Hales C.N., Barker D.J., Clark, P.M., Cox L.J.,Fall C., Osmond C. et al.: Fetal and infant growthand impaired glucose intolerance at age 64,BMJ;303; 1019-22,1991

36. Yajnik, C.S.: Life cycle effects of nutrition andbody size on adult adiposity, diabetes and cardio­vascular disease, Obes. Rev, 3:217-224,2002

37. Bhargava S.K., Sachdev H.S., Fall C., OsmondC., Lakshmy R., Barker D.J., Biswas S.K.D., RamjiS., Prabhakaran D. and Reddy K.S.: Relation ofserial changes in childhood body mass index toimpaired glucose intolerance in young adulthood.The New Eng J of medicine; 350(9): 865-875, 2004

38. Prader A. Catch-up growth. Postgrad Med J:54:133-43,1978

39. Cooper E.S., Duff E.M., Howell S. and BundyD.A.: Catch-up growth velocities after treatment forTrichuris dysentery syndrome. Trans Soc Trop MedHyg, 89(6)-653, 1995

40. Callend J., Walker S.,·Granthan M.G.S., CooperE.: Growth and development four years after treat­ment for the Trichuris dysentery syndrome, Acta

Paediatrica, Vol 87, No 12(3):1247-1249,1998

41. Keet M.P., Moodie D.O., Wittmann W., HansenJ.D.L.: Kwashirokar: a prospective ten year follow­up study. S Afr Med J: 45:1427-29,1971

42. Satyanarayana K., Prasanna K.T., NarasingaRao B.S.: Effect of early chiidhood undernturitionand child labour on grow1h and adult nutritionstatus of rural Indian boys around Hyderabad. HumClin Nutr, 40 C: 131-40, 1986

43. Martorell R., Rivera J., Kaplowitz H. "Conse­quences of stunting in early childhood for adultbody size in rural Guatemala." Annales Nestle 48:85­92,1990a

44. Waterlow J.S.: Recent Trends in nutrition Chap­ter 2: Reflections on stunting, 18-34, 1993

45. Proos L.A.: Growth and development of Indianchildren adopted in Sweden. Acta UniversitiesUpasaliensis, Upasala University, 363,1992

46. Stewart R.J.C., Shephard H.G., Preece R.F.and Waterlow J.C.: The effect of rehabilitation at

different stages of development of rats marginallymalnourished for ten to twelve generations, Br J.Nutr, 403-412,1980

Type 2 diabetes mellitus (T2DM)and coronary heart disease (CHD) areimportant non-communicable diseases(NCDs) in developed as well as devel­oping countries. Migrant South Asianshave an unusually high predisposi­tion to develop both the NCDs'. Rapidnutritional transition and urbanizationhave resulted in an alarming increasein NCDs in India, while the communi­cable diseases are showing a down­ward trend. During the previous threedecades, the prevalence ofT2DM hasdoubled in both rural and urban areasof India2.

INSULIN RESISTANCE

Resistance to the insulin-medi­ated glucose uptake in liver, adiposetissue and muscle is the central fea­ture of insulin resistance syndrome(IRS)3, recently also termed as meta­bolic syndrome. The pancreas secretesexcessive insulin, thereby, causinghyperinsulinemia, which finally leadsto hyperglycemia. The excessive fluxof non-esterified free fatty acids fromthe excess adipose tissues and he­patic overproduction of very-low den­sity lipoprotein cholesterol are keymetabolic events resulting indyslipidemia.

The clinical definition of meta­bolic syndrome has been derived fromdata from Caucasians based on thepresence of abdominal obesity,dyslipidemia, hypertension and glu­cose intolerance4• The cut-offs laiddown for the definition of the meta­bolic syndrome, however, may not beapplicable to Indians5.

Migrant Indians:Features ofmetabolic syndrome were shown inmigrant South Asians in the UK nearlya decade ago'. These studies involvedpeople whose ancestral origins werefrom various South Asian countries,in particular India and Bangladesh.Subsequently, several other investi­gators in the UK have shown thatSouth Asians have a higher magni­tude of insulin resistance than whiteCaucasians6. Hyperinsulinemia anddyslipidemia have also been shownin South Asian children6. Further, SouthAsians also have significantprocoagulant tendency signified by

5

high plasminogen activator inhibitor­1 and plasma fibrinogen concentra­tions6,7 .

Research on migrant Indians inthe USA is recent. Furthermore, mostof this research is based on case­control and convenience samples andare not population-based studies. Astudy of healthy Indian physicians andtheir relatives residing in the USA,showed higher prevalence of T2DM,hypertriglyceridemia and lower levelsof HDL-C. However, the prevalence ofobesity was much lower as comparedto Caucasians. This study was notpopulation-based, and the investiga­tors did not measure abdominal obe­sityB. Raji et al. 9 indicated that healthyIndian migrants exhibit fastinghyperinsulinemia, higher glucose andinsulin levels during the oral glucosetolerance test, and reduced glucosedisposal rates as compared to Cau­casians, despite similar fasting plasmaglucose levels. Similar data have beenreported from other parts of the USA.

Indians residing in India: Dietand physical activity profiles of Indi­ans residing in India are extremelyheterogeneous. People in the ruralareas are physically active farmers orlabourers and consume frugal diets.However, increasing affluence, mecha­nization and dietary transition to 'en­ergy-dense' diets is seen in a stepwisemanner from smaller cities to metro­politan mega cities. The prevalencerates of obesity and T2DM in the ruralpopulations are low, but these ratesshow an increasing trend from smallerto larger cities, peaking in the metro­politan cities. Nearly 10-20% of urbanpeople have metabolic syndrome10. Amore worrisome feature is highly preva­lent insulin resistance in children andyoung adults who seem to be under­going 'lifestyle transitions' more rap­idly (Figure)11.

People belonging to low socio­economic strata (SES) are generallyleaner and have less T2DM than thosewith high SES. However, rural-to-ur­ban migrants who belong to low SESare adversely affected and showseveral features of metabolic syndromeand multiple cardiovascular riskfactors12-15.

FIGURE: Prevalence of high HOMA-IR values in post-pubertalAsian Indian children (n=396) residing in India

66.7

HOMA-IR: Insulin resistance estimated by homeostatic model assessment,BMI: Body mass index, BF: Body fat

4. A4. Executive Summary of the Third Report ofthe National Cholesterol Education Program (NCEP)Expert Panel on Detection, Evaluation, and Treat-

3. Reaven G.M.: Banting lecture 1988. Role ofinsulin resistance in human disease. Diabetes.

1988;37(12): 1595-607.

2, Gupta A., Gupta R., Sarna M" Rastogi S., GuptaV,P" Kothari K.: Prevalence of diabetes, impairedfasting glucose and insulin resistance syndrome inan urban Indian population. Diabetes Res Clin Pract.

2003;61 (1):69-76.

References:

protective against adiposity anddyslipidemia, Additionally, fibre intakemay be lower and homocysteine lev­els may be high in vegetarian Indians,contributing further to cardiovascularrisk24. Dietary acculturation of migrantIndians to the 'Westernized diets' maylead to further unfavourable metabolicchanges,

Physical inactivity: Physicallyinactive lifestyles are consistently seenin South Asians, particularly in women25.The important determinants includeurbanization, affluence and increas­ing mechanization26. Recent reportsalso indicate substantial physical in­activity in adolescents and youngadults27. Physical inactivity in Indianshas been linked to adiposity,dyslipidemia, and hypertension. Al­though only a limited number of in­vestigative studies are available, itappears that physical inactivity is acritical determinant of obesity and in­sulin resistance in Indians.

Genetic predisposition: The factthat Indians in disparate countries andlocations uniformly show a higher ten­dency to have insulin resistance be­speaks of underlying genetic predis­positions. Further, insulin sensitivityis reduced even when the role of adi­

posity is nullified in lean Indians ascompared with other ethnic groups2S.However, this issue has not been in­vestigated in any detail. The role ofcandidate genes lipoprotein lipase,plasminogen activator inhibitor-1,adiponectin, angiotensinogen andperoxisome proliferator activator re­ceptor-gamma remain to be investi­gated in insulin resistant Indians.

1, McKeigue P.M., Marmot M,G" SyndercombeCourt Y.D., Cottier D.E., Rahman S., RiemersmaR.A.: Diabetes, hyperinsulinaemia, and coronaryrisk factors in Bangladeshis in east London. Br

Heart J. 1988;60(5) :390-6

Authors: 'Professor "Pool Officer "'Asst Prof.

Deptt of Medicine, AI/MS, New Delhi

High BF

58.2

• Females

Normal BF

as well as children21. Importantly, theCRP levels in Indians are consistentlyhigher than in Caucasians22. The highCRP levels could be explained by excessabdominal adiposity, since the pre­dominant source of these cytokinesis abdominal adipose tissue. Indeed,high CRP levels in Indians were stronglyassociated with obesity, abdominalobesity, and excess subcutaneousbody faF3.

Whereas the relationship betweeninsulin resistance and sub-clinical in­flammation continues to be debated,CRP levels in Indians also correlate toinsulin resistance21, Finally, althoughCRP levels have predicted an increasedrisk of developing of CHD22 prospec­tive data are needed.

Diet: The link between Indian dietsand insulin resistance has been sus­pected but remains inadequately in­vestigated. In general, consumptionof saturated fat has increased in Indiain line with 'dietary Westernization',and this might be linked to overall aswell as abdominal adiposity. The highcarbohydrate content of Indian dietsmay cause hypertriglyceridemia andhyperinsulinemia. The vegetarian di­etary habits of Indians may not be

LIFESTYLE ANDGENETIC FACTORS

High BMI

o Males

Normal BMI

80

7060

Q)

() 50c ~ro> 40Q) '-D...

~30

0

20100

BODY FAT DISTRIBUTION

As compared to Caucasians inthe developed countries, the preva­lence of obesity is less in Indians. Anincreasing trend in obesity in Indianchildren and adolescents, however,has been recently reported16,17.

The paradox of high predisposi­tion to developing T2DM and CHD ata relatively lower average level of bodymass index (8MI) is not easily ex­plained; however, several peculiarfeatures in the body composition ofIndians have been noticed. It appearsthat migrant and urban Indians of bothsexes have excess of body fat, truncalsubcutaneous fat, and intraabdominalfat12,14,15,1S-20.Data showing a higherprevalence of abdominal adiposity,as defined by high ratio of waist-to­hip circumference, have been consis­tently recorded in migrant Indians ir­respective of their geographical habi­tat. It is generally believed by manyinvestigators that excess regionaladiposity as seen in Indians is the keydeterminant to the development ofinsulin resistance.

Subclinical inflammation: Sub­

clinical inflammation denoted by highC-reactive protein (CRP) concentra­tions, an important indicator of car­diovascular risk, has been recordedto be widely present in Indians, adults

ment of High Blood Cholesterol in Adults (AdultTreatment Panel III). JAMA. 2001; 285(19) :2486­2497.

5. Misra A., Wasir J.S., Pandey A.M.: An evalua­tion of candidate definitions of the metabolic syn­drome in adult Asian Indians. Diabetes Care.

2005;28(2):398-403.

6. Whincup P.H., Gilg J.A., Papacosta 0., et al.Early evidence of ethnic differences in cardiovas­cular risk: cross sectional comparison of BritishSouth Asian and white children. BMJ.

2002;324(7338):635.

7. Kain K., Catto A.J., Grant P.J.: Impaired fibrin­olysis and increased fibrinogen levels in SouthAsian subjects. Atherosclerosis. 2001 ;156(2):457­61.

8. Enas E.A., Garg A., Davidson M.A., Nair V.M.,Huet B.A., Yusuf S.: Coronary heart disease and itsrisk factors in first-generation immigrant Asian Indi­ans to the United States of America. Indian Heart J.

1996;48(4) :343-53.

9. Raji A., Seely EW., Arky R.A., Simonson D.C.:Body fat distribution and insulin resistance in healthyAsian Indians and Caucasians. J Clin Endocrinol

Metab. 2001 ;86(11):5366-71.

10. Misra A., Vikram N.K.: Insulin resistance syn­drome (metabolic syndrome) and Asian Indians.Curr Sci. 2002;83:1483-1496 (available at h11QJL

teias. serc. iisc. erne!. in/- cu rrsell.

11. Arya S., Misra A., Vikram N.K., et al. Fastinghyperinsulinemia and its relationship to measuresof obesity and lipid profile in urban adolescentsand young adults in north India. Diabetes Metab.2003;29:4S118-119.

12. Misra A., Chaudhary D., Vikram N.K., et a/.

Insulin resistance and clustering of atherogenicrisk factors in women belonging to low socio-eco­nomic strata in urban slums of North India. Diabe­

tes Res Clin Pract. 2002;56(1) :73-5.

13. Misra A., Pandey R.M., Sharma R.: Non-com­municable diseases (diabetes, obesity andhyperlipidaemia) in urban slums. Natl Med J India.2002; 15(4) :242-4.

14. Misra A., Pandey R.M., Devi J.R., Sharma R.,Vikram N.K., Khanna N.: High prevalence of diabe­tes, obesity and dyslipidaemia in urban slum popu­lation in northern India. Int JObes Relat Metab

Disord. 2001 ;25(11):1722-9.

15. Misra A., Sharma R., Pandey R.M., Khanna N.:Adverse profile of dietary nutrients, anthropometryand lipids in urban slum dwellers of northern India.Eur J Clin Nutr. 2001 ;55(9):727-34.

16. Kapil U., Singh P., Pathak P., Dwivedi S.N.,Bhasin S.: Prevalence of obesity amongst affluentadolescent school children in delhi. Indian Pediatr.

2002;39(5) :449-52.

17. Guleria R., Dhingra V., Chatterjee A., et al.Anthropometric profile in urban adolescents andyoung adults. J Assoc Physicians India. 2003;50:.1521.

18. Banerji M.A., Faridi N., Alturi R., Chaiken R.L.,Lebovitz H.E.: Body composition, visceral fat, leptinand insulin resistance in Asian Indian men. J Clin

Endocrinol Metab. 1999;84:137-144.

19. Dudeja V., Misra A., Pandey R.M., Devina G.,Kumar G., Vikram N.K.: BMI does not accuratelypredict overweight in Asian Indians in northernIndia. Br J Nutr. 2001 ;86(1):105-12.

20. Misra A., Athiko D., Sharma R., Pandey R.M.,Khanna N.: Non-obese hyperlipidemic Asian north­ern Indian males have adverse anthropometricprofile. Nutr Metab Cardiovasc Dis. 2002;12(4):178-83.

21. Chambers J.C., Eda S., Bassett P., et al. C­reactive protein, insulin resistance, central obesity,and coronary heart disease risk in Indian Asiansfrom the United Kingdom compared with Europeanwhites. Circulation. 2001;104(2):145-50.

22. Forouhi N.G., Sattar N., McKeigue P.M.: Rela­tion of C-reactive protein to body fat distributionand features of the metabolic syndrome in Europe­ans and South Asians. Int JObes Relat Metab

Disord. 2001 ;25(9):1327-31.

23. Vikram N.K., Misra A., Dwivedi M., et al. Corre­lations of C-reactive protein levels with anthropo­metric profile, percentage of body fat and lipids inhealthy adolescents and young adults in urbanNorth India. Atherosclerosis. 2003;168(2):305-13.

24. Vikram N.K., Pandev R.M., Sharma R., Misra A.:Hyperhomocysteinemia in healthy Asian Indians.Am J Hematol. 2003;72(2):151-2.

25. Kamath S.K., Hussain E.A., Amin D., et al. Car­diovascular disease risk factors in 2 distinct ethnic

groups: Indian and Pakistani compared with Ameri­can premenopausal women. Am J Clin Nutr.

1999;69(4):621-31.

26. Misra A.: Body composition and the metabolicsyndrome in Asian Indians: a saga of multipleadversities. Natl Med J India. 2003;16(1):3-7.

27. Dhingra V., Chatterjee A., Guleria R., et al.

Adverse physical activity pattern in urban adoles­cents. J Assoc Physicians India. 2002;50: 1521.

28. Dickinson S, Colagiuri S, Faramus E, Petocz P,Brand-Miller JC. Postprandial hyperglycemiaand insulin sensitivity differ among lean youngadults ofdifferent ethnicities. J Nutr. 2002;132(9):2574­2579.

FOUNDATIONNEWS

• Meeting on Food and NutritionSecurity in South Asia: (March 7 ­9,2005)

The Nutrition Foundation of In­dia, with the cooperation of the Gov­ernment of India and the United StatesDepartment of Agriculture, organizeda three-day meeting on Food andNutrition Security in South Asia.

DrC. Rangarajan, Chairman, Eco­nomic Advisory Council to the PrimeMinister, Government of India, deliv­ered the inaugural address.' An ex­cerpt from the address appears else­where in this Bulletin.

Delegates from seven countriesof South Asia, namely, Bangladesh,Bhutan, India, Maldives, Nepal, Paki­stan and Sri Lanka, participated in the

meeting.

In the first session, delegatesdescribed the experiences of theirrespective countries in promotingnutrition security through appropri­ate nutrition orientation to food pro­duction policies.

The second session dealt withpolicies and strategies to acceleratepoverty reduction.

The third session was devotedto discussions on ongoing programmesfor improving access to food. Thedelegates presented their experiencesin ensuring targeting and good cover­age under these programmes, andevaluated the impact ofthe programmeson the prevalence of undernutrition.

In the fourth session, the healthconsequences of under/overnutritionand country programmes for combat­ing these problems were discussed.

The rapporteurs presented sum­maries of the presentations in eachsession, and presented similarities andcontrasts between the countries. Theyalso summarized the recommenda­tions regarding policies, strategies andprogrammes for improving nutritionsecurity and the nutritional status ofthe populations of South Asian na­tions.

The report of the meeting is be­ing edited by Ms Malini Sheshadri.

The delegates to the meetingwere:

Bangladesh: Mr M.A. Hussain; Dr M.Hossain; Dr H.H. Akhter; Dr F. Naher

Bhutan: Ms C.P Wangdi; Dr D. Kinlay

India: Dr B.N. Yugandhar; Dr A. Sen;Dr V. Prakash; Dr P. Ramachandran

Maldives: Ms Shazla Mohamed; DrM. Shareef; Dr. A.S. Mohamed

Nepal: Dr S. Acharya; Mr A. Talukder;Prof B. Pyakural; Dr D. Paudyal

Pakistan: Dr Naeem I. Hashmi; DrM.A. Khan; Prof F.M. Anjum

Sri Lanka: Dr P. Soysa; Dr S.Weerasena; Dr R.M.K. Ratnayake; DrC. Piyasena

Resource Persons: Mr Chad R. Russel;Mr. David Kincaid; Dr C. Bantilan; DrB. Nandi; Dr M. Ali; Dr S. Babu; Dr C.Jackson

Rappoteurs: Dr M. Bamji; Dr K.Krishnaswamy; Dr N. Singh; Dr A.N.Kapoor

• Course in Practical PaediatricNutrition

Dr Sarath Gopalan and DrAnupamSibal, the Course Directors conductedthe Fifth Course in Practical Paediat­ric Nutrition on March 5th and 6th 2005at Indraprastha Apollo Hospital, NewDelhi.

• Nutrition in the Philippines: ThePast for its Template, Red for itsColor

Recently the Philippines Presslaunched a book "Nutrition in the Phil­ippines: The Past for its Template,Red for its Color", authored by DrCecilia A Florencio. The book de­scribes and analyses the advancesand shortfalls in the country's think­ing and efforts to address the long­standing, widespread, and layeredproblem of malnutrition in infants,children, adolescents, pregnant andlactating women, adults, and the eld­erly. The author puts forward recom­mendations for reflection and action,on specific and broad fronts, and whilerecognizing the reality of an increas­ingly borderless world; she calls forthe country to address its nutritionalsituation with the national interest andpriorities first. And yet, in a generalsense, the book is as much aboutmany other countries in both the Eastand West as it is about the Philip­pines. In the global community, it isestimated that 800 million people arefood insecure and 170 million youngchildren suffer from undernourishment.Copies of the book can be orderedfrom press@up.edu.ph oruppress@uppress.org (website:www.uppress.org).

• Mid-day Meal Programme in DelhiSchools

NFl has been collaborating withthe Municipal Corporation of Delhi(MCD) in the implementation of theMid Day Meal programme in Delhischools. A meeting to discuss futurecollaborations with MCD was held onJanuary 31st, 2005. The meeting wasattended by Mr Rakesh Mehta, Com­missioner, MCD, officials of MCD as­sociated with the NFI-MCD collabora­tive projects, and the NFl team.

NUTRITIONNEWS

Focusing on direct nutritionintervention programmes toaddress the needs of vul­nerable groups.

Countries of South Asia havea common heritage. They were allunder colonial rule till the middleof the last century. Newly inde­pendent, they face similar prob­lems. Ensuring food and nutritionsecurity is one such problem. Allthe countries in this region haveaddressed this problem in similarways. We need to know whichprogrammes have been success­ful and which have not. This meetingwill enable you to make an as­sessment.

All programmes aimed at en­suring food and nutrition securityinvolve heavy expenditure byGovernments. The conventionalbudget exercises focus on allo­cation of resources to differentheads without assessing how theseexpenditures get translated intooutputs and outcomes. Outputsare the direct result of govern­ment expenditure and outcomesare the final results. For example,in the context of education, open­ing a new school or appointing anew teacher is an output and rais­ing literacy ratio is the outcome.

The emphasis must, there­fore, be on output and outcomerather than allocation. Public ex­penditures must be guided by thecriterion of economy, efficiencyand effectiveness.

These are particularly impor­tant in the case of programmesaimed at improving the nutritionstatus of the population, since theexpenditures are large and goalsare specific.

partment of Medicine, AIIMS, New Delhi)spoke on Metabolic syndrome in Indi­ans: Trials and Tribulations.

• National Academy of Medical Sci­ences (NAMS)

Dr Prema Ramachandran, DirectorNFl has been elected as the Vice­President of NAMS. She will hold theoffice for two years.

Excerpts from the Inaugural Address byDr C Rangarajan

(d)Food security in India hasessentially meant food grain se­curity for meeting the requirementsof energy and protein. For nutri­tion security, food productionshould ensure availability of di­verse foods, which can enhancethe nutritional content, includingmicronutrients. Nutrition securityis thus a broader term. It includeswithin it food grain security butgoes beyond it.

Undernourishment has a del­eterious effect on the life of people.Malnourished children grow up tobecome adults unable to operateat full potential. Developmenteconomists and policy makers needto take into account the effects ofnutritional and health care depri­vation on human productivity. Thelinks between nutritional statusand the capacity for work havenot so far been adequately incor­porated in growth models. Poornutrition and under nourishmentresult in low productivity leadingto low wages which, in turn, re­sults in poor nutrition intake. Thusa vicious cycle is set in motion.One writer has described this asthe 'poverty trap'.

Ensuring nutrition securityrequires attention to programmesaimed at-

(a) Enhancing food grain pro­duction with a nutritional ori­entation;

(b) Improving the food distribu­tion system so that the poorhave access to food grain ataffordable costs;

(c) Augmenting the purchasingpower of the poor throughspecial schemes in times ofstress and vulnerability; and

• Study Circle MeetingsJanuary 18th, 2005.Dr Siddharth Ramji (Professor &

Head, Department of Neonatology,MAMC, New Delhi) delivered a talk on"Neonatal Feeding: Long Term HealthOutcomes" .

February 16th, 2005Dr Anoop Misra, (Professor, De-

Edited by Mrs Anshu Sharma for the Nutrition Foundation of India, C-13, Qutab Institutional Area, New Delhi 110 016. website: www.nutritionfoundationofindia.orge-mail: nfi@ren02.nic.in Designed and produced by Media Workshop India Pvl Ltd. e-mail: mwipl@touchtelindia.net