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Response to Correspondence from McDonald et al.

European Journal of Clinical Nutrition volume 76, pages 1202–1203 (2022)Cite this article

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We thank McDonald et al. [1] for graciously acknowledging the usefulness of the Indian Comprehensive National Nutrition Survey (CNNS) [2] and our analyses thereof to define serum zinc concentration (SZC) cut-offs for zinc deficiency in India [3] and perhaps in other low- and middle-income countries. However, they present arguments against the lower SZC cut-offs that we have proposed, which we wish to respond to.

First, McDonald et al. have a fundamental concern related to the way we have defined ‘healthy’ children to statistically derive a cut-off from their SZC distribution, using an approach that is similar to the IZiNCG method [4]. Healthy children were defined through the application of stepwise exclusion filters with rigorous qualifications at each step [3]. The cut-offs derived from the SZC distributions of the ‘healthy’ populations resulting from each filtering step did not differ significantly from each other. McDonald et al. [1] are particularly critical of the presence of severe underweight and wasting in some children in the primary sample. However, sensitivity analyses that excluded these children in subsequent filters did not change the SZC cut-offs. They then critique the presence of mild/moderate stunted children in the sample, and even suggest that these children might have been ‘mildly zinc deficient’. We therefore explored the effect of HAZ on SZC, adjusted for age and sex, in the primary analytical sample. This was 0.05 µg/dL (95% CI: −0.24,0.34) per 1 SD increase in HAZ. The same analyses for WAZ (<5y), BAZ (>5y) and WHZ yielded effects of 0.07 µg/dL (95% CI: −0.22,0.37), −0.26 µg/dL (95% CI: −0.50,−0.01) and 0.13 µg/dL (95% CI:−0.38,0.65) change in SZC per 1SD increase in each of these indices, respectively. These anthropometry-related effects on SZC were small (even in the opposite direction for BAZ), negating the contention that our healthy children sample was biased towards zinc deficiency.

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Data availability

The Ministry of Health and Family Welfare (MoHFW), Government of India, owns the CNNS data.

References

  1. McDonald CM, Manger MS, Krebs NF. Correspondence on article by Pullakhandam et al. Eur J of Clin Nutr. 2022. https://doi.org/10.1038/s41430-022-01152-z.

  2. Ministry of Health and Family Welfare (MoHFW), Government of India. Comprehensive National Nutrition Survey (CNNS) National Report. New Delhi: Ministry of Health and Family Welfare (MoHFW), Government of India; 2019.

  3. Pullakhandam R, Ghosh S, Kulkarni B, Reddy GB, Rajkumar H, Kapil U, et al. Reference cut-offs to define low serum zinc concentrations in healthy 1–19 year old Indian children and adolescents. Eur J Clin Nutr. 2022. https://doi.org/10.1038/s41430-022-01088-4.

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Authors and Affiliations

  1. ICMR-National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India

    Raghu Pullakhandam, Bharati Kulkarni, G. Bhanuprakash Reddy & Hemalatha Rajkumar

  2. St John’s Medical College, Bangalore, India

    Santu Ghosh & Anura V. Kurpad

  3. Institute of Liver and Biliary Sciences, New Delhi, India

    Umesh Kapil

  4. Sitaram Bhartia Institute of Science and Research, New Delhi, India

    Harshpal S. Sachdev

Authors
  1. Raghu Pullakhandam
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  2. Santu Ghosh
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  4. G. Bhanuprakash Reddy
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Contributions

HSS, AVK, SG, and RP wrote the manuscript. All authors reviewed and approved the submitted manuscript. HSS and AVK had final responsibility for the decision to submit for publication.

Corresponding authors

Correspondence to Anura V. Kurpad or Harshpal S. Sachdev.

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Pullakhandam, R., Ghosh, S., Kulkarni, B. et al. Response to Correspondence from McDonald et al.. Eur J Clin Nutr 76, 1202–1203 (2022). https://doi.org/10.1038/s41430-022-01161-y

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