A Study to Investigate the Impact of Fortified Malt Based on Immunity Outcomes in School Children

Number of episodes of GI and respiratory illnesses was calculated at month 9 using a diagnosis form (DF) which were used to note the diagnosis, severity, and school absenteeism due to GI and respiratory illnesses only, as defined in the study protocol. The DF captured the start and end date of all occurrences of GI and respiratory illnesses in the week. The frequency was calculated as total number of GI and respiratory illness episodes, divided by duration of intervention, where each episode is defined as each incidence of illness followed by at least uninterrupted 3 symptom free days. Therefore, the formula for calculation used was: frequency (per month) = number of episodes multiply (x) 30 and divided by (/) number of days between first and last visit.

Severity of GI illness was calculated at month 9 using DF with observations listed by study physician based on assessment of severity grade: classified as, diarrhea (Mild, increase of less than [<] 4 stools per [/] day over baseline; Moderate, increase of 4 to 6 stools/day over baseline; Severe, increase of more than or equal to [>=]7 loose stools/day over baseline) and vomiting (1-2 episodes, separated by 5 minutes[min] in 24 h; Moderate, 3-5 episodes, separated by 5 min in 24 h; Severe, >=6 episodes, separated by 5 min in 24 h. The count of participants was calculated based on the episode of worst severity. Lower severity indicates no illness of participant.

Intensity of respiratory illness was calculated at month 9 using DF with observations listed by study physician based on assessment of severity grade classified as, Mild or Grade1 is asymptomatic or mild symptoms; clinical or diagnostic observations only; intervention not indicated; Moderate or Grade 2 is minimal, local or non-invasive intervention indicated; limiting age-appropriate instrumental activities of daily living (ADL). Instrumental ADL refer to school attendance, playing, studying, participating in school activities; and Severe or Grade 3 and 4: Grade 3 is severe or medically significant, but not immediately life-threatening; hospitalization or prolongation of hospitalization indicated; disabling; limiting self-care ADL. Self-care ADL refers to bathing, dressing and undressing, feeding self, using the toilet, taking medications, and not bedridden; Grade 4 is life-threatening consequences; urgent indication indicated.

School absenteeism was calculated as number of days when a participant failed to attend school because of GI and/or respiratory illnesses. DF was used to note school absenteeism , however it was marked for absenteeism due to GI and respiratory illnesses only.

Change in Body Mass Index (BMI) was calculated at month 9 using anthropometric measurements. For measuring participant's height, portable stadio-meter was used with the participant standing barefoot; to the nearest 0.1 centimeters (cm) and average of 3 measurements were recorded. All data recorded in cm were converted to meters (m) for BMI calculation. For measuring participant's weight, standardized weighing scale was used in standard clothing to the nearest 0.1kilograms (kg) and average of 3 measurements were recorded. BMI value was calculated using the formula weight divided by square of height (weight [kilogram (kg)/ Height [meter (m)]^2)

Improvement in gut wall integrity was considered a possible factor to assess the micronutrient absorption. Lactulose mannitol test was used to evaluate change in gut wall permeability status to assess impact on micronutrient absorption. After 3h of fasting, pre-measured amount of lactulose/mannitol solution (2 milliliter/Kilogram [mL/Kg] of body weight) containing lactulose (250 milligram/milliliter [mg/mL])] and mannitol (50 mg/mL) was administered as a test solution. Participants were allowed to return to their regular diet 30 minutes after ingestion of the test solution. During the 2.5 h time, participants were offered liquids frequently in order to permit collection of an adequate volume of urine. After 2.5 h, urine collection was performed. All urine passed over duration of 2.5 h was collected and analysed. High Performance Liquid Chromatography (HPLC) test method was used to measure the levels. The normal range of urinary lactulose: mannitol is less than [<] 0.035.

Improvement in gut wall integrity was considered a possible factor to assess the micronutrient absorption. Neopterin test was used to evaluate change in gut wall permeability status to assess impact on micronutrient absorption. Spontaneous random urine was collected from the participants and a volume of 2mL per participant was stored and analysed. Urine sample for this test were collected prior to administration of Lactulose/Mannitol solution. Enzyme-linked immunosorbent assay (ELISA) test method was used to measure the levels. The values were measured in Millimoles per moles of creatinin (mmol/mol creatinin). The normal range of urinary neopterin is 0.10-5.00 mmol/ mol creatinin.

Quantity of salivary IgA was used to measure the impact of fortified malt based food on mucosal immunity. Saliva was collected using saliva collection aid (SCA). Ribbed-end of the SCA were securely placed into a pre-labeled collection vial. Participants were instructed to pool the saliva in mouth. SCA was placed on mouth entry. Then, participants were asked to tilt the head forward, and gently force saliva through the SCA into the vial to fill with at least 50 microliters (mcL) of volume. A small amount of air space was reserved in the vial to accommodate liquid expansion during freezing. After collection of sample, SCA was removed and discarded and cap was attached to collection vial and tightened. ELISA test method was used to detect the salivary IgA levels. The normal range of salivary IgA is 25.00-168.00 milligrams per liter (mg/L).

Quantity of micronutrients, serum vitamin-A and of trace elements Zn, Cu and Fe levels in serum were used to assess the impact of fortified malt based food product on nutrient biochemistry at month 9. To quantitate the nutrient biochemistry, a total volume of approximately 14 milliliters (ml), 7ml each at screening and at month 9, whole blood sample was collected from each participant after application of an anesthetic patch/ointment. The test methods used were ELISA for vitamin-A and colorimetric assays for Zn, Cu and Fe as 5-Br-PAPS; 3,5-Dibromo-PAES and TPTZ, respectively. The normal range of serum Vitamin-A is 26.00-49.00 micrograms per deciliter (mcg/dL) and serum Zn is 78.00-105.00 (male and females aged 7-9 years), 78.00- 118.00 (females aged 10 years) and 78.00-98.00 (males aged 10 years) mcg/dL. The normal range of serum Cu is 51.00-121.00 mcg/dL and serum Fe is 50.00-120.00 mcg/dL.

Quantity of the trace element, serum Se was used to assess the impact of fortified malt based food product on nutrient biochemistry at month 9. To quantitate the nutrient biochemistry, a total volume of approximately 14 milliliters (ml), 7ml each at screening and at month 9, whole blood sample was collected from each participant after application of an anesthetic patch/ointment. The test method used was inductively coupled plasma mass spectrometry (ICP-MS). The normal range of serum Se is 55.00-134.00 micrograms per liter (mcg/L).

Quantity of micronutrient, serum vitamin-B12 was used to assess the impact of fortified malt based food product on nutrient biochemistry at month 9. To quantitate the nutrient biochemistry, a total volume of approximately 14 milliliters (ml), 7ml each at screening and at month 9, whole blood sample was collected from each participant after application of an anesthetic patch/ointment. The test method ELISA was used to measure the levels. The normal range of the serum vitamin B12 is 312.00-1237.00 is picograms per milliliter (pg/mL).

Quantity of serum vitamin-D (25-hydroxycholecalciferol) and serum folate micronutrients were used to assess the impact of fortified malt based food product on nutrient biochemistry at month 9. To quantitate the nutrient biochemistry, a total volume of approximately 14 milliliters (ml), 7ml each at screening and at month 9, whole blood sample was collected from each participant after application of an anesthetic patch/ointment. The test method ELISA was used to measure the levels. The normal range of serum Vitamin-D is 30.00-100.00 nanograms per milliliter (ng/mL) and serum folate is 5.00-21.00 ng/mL.

Quantity of micronutrient, serum vitamin-E was used to assess the impact of fortified malt based food product on nutrient biochemistry at month 9. To quantitate the nutrient biochemistry, a total volume of approximately 14 milliliters (ml), 7ml each at screening and at month 9, whole blood sample was collected from each participant after application of an anesthetic patch/ointment. The test method ELISA was used to measure the levels. The normal range of serum vitamin-E is 0.30-0.90 milligrams per deciliter (mg/dL).

Quantitative analysis of serum ferritin was studied to measure iron status. Its value was adjusted by other acute phase proteins such as C-reactive protein (CRP) and Alpha 1-acid glycoprotein (AGP) which are not related to iron status and played a role as a part of assessment on inflammatory status and to adjust ferritin status. To quantitate this load, a total volume of approximately 14 milliliters (ml), 7ml each at screening and at month 9, whole blood sample was collected from each participant after application of an anesthetic patch/ointment. The turbidimetry test method was used to measure the levels.The normal range of serum ferritin is 7.00-140.00 nanograms per milliliter (ng/ml).

Quantitative analysis of sTfR along with serum iron and serum ferritin was studied to measure iron status. In cases of a high prevalence of infection and inflammation, sTfR becomes the choice of iron status marker. To quantitate this load, a total volume of approximately 14 milliliters (ml), 7ml each at screening and at month 9, whole blood sample was collected from each participant after application of an anesthetic patch/ointment. The immunoturbidimetry test method was used to measure the levels. The normal range of sTfR is 1.90-4.40 milligrams per liter (mg/L).

Quantitative analysis of acute phase proteins such as serum CRP and serum AGP were studied to assess inflammatory status and adjust ferritin status. To quantitate this load, a total volume of approximately 14 milliliters (ml), 7ml each at screening and at month 9, whole blood sample was collected from each participant after application of an anesthetic patch/ointment. The immunoturbidimetry test method was used to measure the levels of CRP and turbidimetry for AGP. The normal range of the serum CRP is less than (<) 0.50 milligrams per deciliter (mg/dL) and serum AGP is 50.00-120.00 mg/dL.

IDDS-measure of nutritional quality of individual's diet-assessed by questionnaire based on Guidelines for measuring household and individual dietary diversity set by Food and Agriculture Organisation (FAO) of United Nations[FAO guidelines dietary diversity,2011].Based on data of foods and beverages consumed in last 24h as captured by 24h dietary survey,appropriate food groups were selected. IDDS was calculated by adding number of food groups consumed by child over 24h recall period. Scoring 0-9with 1 point for foods that were consumed from each of food groups in previous 24h:starchy staples,dark green leafy vegetables,other vitamin A rich fruits and vegetables,other fruits and vegetables,organ meat, meat and fish, eggs, legumes, nuts, and seeds, milk and milk products. Based on IDDS,participants were listed into 3 food groups: a) less than or equal to [<=]3-low dietary diversity (DD);b)4-5-medium DD;c) greater than or equal to [>=]6-high DD. High score indicates nutrition rich food.

Quantity of dietary intake was measured by protein, carbohydrate, and fat intake which was assessed from 24h dietary recall form. A structured interview was conducted based on a questionnaire. Parent/LARs provided the majority of information, with the child/ participant making additions to fill in the gaps. Both participants and parents/LARs recalled all food and beverage consumed by the child during previous 24h and information such as list and amount of ingredients, cooking method and portion size was recorded. Calculation on energy, protein, carbohydrates and fat were made using Dietsoft software based on Indian data (NIN [National Institute of Nutrition] and ICMR [Indian Council of Medical Research]) was used.

Quantity of dietary intake was also measured by energy intake which was assessed from 24-h dietary recall survey. A structured interview was conducted based on a questionnaire. Parent/LARs (legally appropriate representative) provided the majority of information, with the child making additions to fill in the gaps. Parents/LARs recalled all food and beverage consumed by the child during previous 24-h and information such as list and amount of ingredients, cooking method and portion size was recorded. Calculation on energy, protein, carbohydrates and fat were made using Dietsoft software based on Indian data (NIN and ICMR) was used.