Iron Fortification through Universal Distribution of Double-Fortified Salt Can Increase Wages and Be Cost-Effective: An Ex-Ante Modeling Study in India.

BACKGROUND: The alleviation of iron deficiency through iron supplementation has not effectively reduced anemia in India, mainly due to low compliance. Food fortification with iron is considered a viable alternative, and the provision of double-fortified salt (DFS; with iron and iodine) has been mandated in public health programs. Limited evidence exists on its benefit-cost ratio. OBJECTIVE: In this study we sought to estimate the economic benefit in terms of increased wages in relation to introduction of DFS in reduction of anemia and the cost of doing so. METHODS: The economic benefit of introducing DFS in India was derived using a series of mathematical, statistical, and econometric models using data from national surveys capturing earnings and dietary iron intake of the population. Anemia status was predicted from data on dietary intake, sanitation, and for women, menstrual losses. The impact of iron deficiency anemia (IDA) on wages was estimated using a Heckman Selection model and 2-stage least squares procedure. Benefit of DFS was estimated through increased wages attributed to anemia reduction compared with its cost. RESULTS: Men and women with IDA had lower wages (by 25.9%, 95% CI: 11.3, 38.1; and by 3.9%, 95% CI: 0.0, 7.7, respectively) than those without IDA. Additional iron intake through DFS was predicted to reduce prevalence of IDA (from 10.6% to 0.7% in men and 23.8% to 20.9% in women). The economic benefit-cost ratio of introducing DFS at a national level was estimated to be 4.2:1. CONCLUSIONS: Iron fortification delivered through DFS under a universal program can improve wages and be sufficiently cost-effective for its implementation at scale in India.

Factors influencing household pulse consumption in India: A multilevel model analysis.

Pulses (also known as legumes) are important in achieving nutrient adequacy in India due to their quality protein content. This study compared district-level pulse production and consumption across India, and household and district-level determinants of pulse intake, including availability, accessibility and affordability, using multi-level models in nationally representative datasets for 2011-12. The per capita consumption was about 50% of recommended intake (80 g/day), even in high-producing districts. District-level pulse production was associated with household pulse intake (2.73 × 10-8 [5.19 × 10-9, 4.94 × 10-8]) and market accessibility (-0.0077 [-0.0133, -0.0021]). Affordability (absolute price of pulse) was also associated with household intake. While agricultural policies relating to pulses have been oriented towards improving pulse output and productivity, forward-looking policies to improve pulse intake should focus on demand-side factors, such as improved market accessibility and the affordability of pulses relative to other foods.

Are 'fruits and vegetables' intake really what they seem in India?

BACKGROUND/OBJECTIVES: Fruits and vegetables are integral parts of a healthy diet. This study evaluated the quantity and diversity of the fruit and vegetable intake in India, with a focus on its distribution across sectors and wealth quintiles. SUBJECTS/METHODS: A secondary data analysis on the nation-wide NSSO Household Consumer Expenditure Survey 2011-2012 was performed to estimate the amount (g/capita/day) and diversity of household intake of fruits and vegetables in the rural and the urban sectors of India. Using the expenditure data, households in both the sectors were further divided into wealth quintiles and differences in the diversity of intake was evaluated across these quintiles separately for each sector. RESULTS: The per capita household vegetable and fruit intake was found to be 145 and 15 g, respectively, for rural India, and 155 and 29 g for urban India. A significant portion of this intake came from energy-dense food items; potatoes and bananas for vegetable and fruit intake respectively. Further, while wealth marginally improved the diversity in vegetable intake, no such trend was observed in fruit intake. CONCLUSIONS: Given the high proportion of energy-dense fruits and vegetables in the Indian total intake, the focus should be on improving the diversity of vegetables, as well as on increasing the intake and diversity of fruits.

Protein quality & amino acid requirements in relation to needs in India.

The relevance of protein and its constituent amino acids (AAs) in the structure and function of the human body is well known. Accumulating evidence has conferred specific functional and regulatory roles for individual AAs, adding relevance to their requirements across different age groups. The methods for measuring AA requirements have progressed from the classical nitrogen balance to the current stable isotope-based AA balance methods. Requirements of most of the indispensable AA (IAA) have been estimated in healthy Indian population by the best available balance method and has shown to be higher than earlier 1985 WHO/FAO/UNU (World Health Organization/Food and Agriculture Organization/United Nations University) recommendations. In addition, potential changes in the requirement, through adaptation to chronic undernutrition or to infection, have also been evaluated. In 2007, the WHO/FAO/UNU released a recommendation that increased the daily IAA requirement, based on primary evidence from Indian balance studies. This meant that to ensure that the new IAA requirements were met, individual foods or mixed diets needed to be assessed for their protein quality, or their ability to deliver the required amount of IAA. The recent FAO report on protein quality evaluation recommends the use of a new chemical AA score, the digestible IAA score (DIAAS), to replace the earlier protein digestibility corrected AA score. The DIAAS requires the determination of individual AA digestibility at the ileal level. A minimally invasive dual stable isotope tracer-based approach has been developed in India and has been used to determine digestibility of various foods in Indian adults and children. The increase in IAA requirements and subsequent protein quality requirements have implications for national regulatory frameworks, growth and development, and in turn, for economic and agricultural policy.

Dietary Protein and the Health-Nutrition-Agriculture Connection in India.

The connection between the production, availability, and consumption of high-quality food is becoming very important in developing countries. The requirement of protein is linked to its quality, or its digestibility and ability to meet human indispensable amino acid requirements. This requirement is particularly relevant in India, where commonly consumed cereal-based diets and cereal-based food subsidy programs offer low-quality protein and therefore pose a risk of quality protein deficiency. The production of and access to sustainable sources of high-quality protein will be important parts of mitigating risks to human health. Although milk production has risen in India, its consumption by the poor remains low. On the other hand, leguminous grain production, which has greater climate resilience and soil improvement properties, has fallen, yet this can help resource-poor farmers increase their intake of quality food. Nonetheless, concerns about the nutritional quality of plant protein exist and may be more relevant in settings where environmental enteric dysfunction already affects nutrient absorption. With the use of nationally representative household protein consumption data in India, the percentage of the population at risk of quality protein deficiency was found to vary between 4% and 26% among different age groups and between the urban or rural sector. Mitigating these risks requires a greater intake of high-quality proteins, such as pulses and milk, and that food subsidy policies move beyond cereals and become more quality conscious.