Amaranthus crop for food security and sustainable food systems.

MAIN CONCLUSION: This review ascertains amaranth grains as a potent crop for food security and sustainable food systems by highlighting its agricultural advantages, health benefits and applications in the food, packaging, and brewing industry. The global population surge and rapidly transitioning climatic conditions necessitate the maximization of nutritional crop yield to mitigate malnutrition resulting from food and nutrition insecurity. The modern agricultural practices adopted to maximize the yield of the conventional staple crops are heavily contingent on the depleting natural resources and are contributing extensively to the contamination of these natural resources. Furthermore, these agricultural practices are also causing detrimental effects on the environment like rising emission of greenhouse gasses and increased water footprints. To address these challenges while ensuring sustainable nutrient-rich crop production, it is imperative to utilize underutilized crops like Amaranthus. Amaranth grains are gluten-free pseudo-cereals that are gaining much prominence owing to their abundance in vital nutrients and bio-active components, potential health benefits, resilience to adverse climatic and soil conditions, minimum agricultural input requirements, potential of generating income for small holder farmers as well as various applications across the sustainable value chain. However, due to the limited awareness of these potential benefits of the amaranth grains among the consumers, researchers, and policymakers, they have remained untapped. This review paper enunciates the nutritional composition and potential health benefits of the grains while briefly discussing their various applications in food and beverage industries and accentuating the need to explore further possibilities of valorizing amaranth grains to maximize their utilization along the value chain.

Food fortification strategies to deliver nutrients for the management of iron deficiency anaemia.

A rising trend in the global prevalence of anaemia is still prevailing. To combat micronutrient deficiencies, World Health Organisation/Food Agriculture Organisation (2006) guidelines recommended four chief strategies - supplementation, fortification, nutrition education and dietary diversity. Of the four strategies, food fortification has been considered as the most efficacious and economical approach. However, it is the directives themselves that highlight two major bottlenecks associated with conventional fortification - uniform dissemination of the fortifier in food vehicle that mostly include staple foods, and internal and external compliance evaluation of fortification regulations and standards by the producers. As a result, researchers envisaged a new strategy - Food-to-food fortification that complements conventional fortification. This strategy involves fortification of food vehicles with nutrient-rich food-based fortifiers. The major advantage of utilising food-based fortifiers is that they hold the potential of enhancing the bioavailability of the fortified food and providing additional nutrients and thus, resulting in dietary diversification. It also facilitates the utilisation of underutilised crops as food-based fortifiers. Underutilised crops have been recognised as potential beneficial food source accounting to their nutritional, ecological, and fiscal benefits. This review paper delves into the strengths and shortcomings of conventional iron fortification. It delineates the concept of food-to-food fortification, while precisely discussing about the best practices to be followed to address the possible challenges associated with this strategy. It also promotes the utilisation of underutilised iron rich foods to develop fortified foods and avert global food insecurity. Furthermore, it provides a summary of the studies conducted around the world to develop fortified foods using iron compounds and iron-rich foods, and to investigate their efficacy in managing iron deficiency anaemia.

Indigenous Foods of India: A Comprehensive Narrative Review of Nutritive Values, Antinutrient Content and Mineral Bioavailability of Traditional Foods Consumed by Indigenous Communities of India.

India is endowed with several indigenous foods (IFs), that hold special cultural significance among local and ethnic caommunities, yet no attempts have been made till date to systematically compile their nutritive values. As per FAO's recent mandate on creation of "Global-Hub on Indigenous Food Systems," IFs have received renewed global recognition for their potential to contribute to improved food security while enhancing biodiversity across the world. Hence, the useful properties of wild IFs require proper study and documentation in order to bridge the gap between scientific evidence generation and indigenous peoples' ancestral knowledge. For this purpose, we conducted a literature search in two scientific databases: PubMed and Google Scholar, between July 2020 and December 2021, to identify studies reporting nutritive values and/or antinutrient content of IFs (not included in Indian food composition database), consumed by Indian indigenous communities. A total of 52 Indian research articles were included, from which data was selected and extracted, to create a compendium on nutrient (n = 508) and antinutrient (n = 123) content of IFs, followed by computation of antinutrient-to-mineral molar ratios for 98 IFs to predict their mineral bioavailability. Maximum nutritive values were available for green leafy vegetables (n = 154), followed by other vegetables (n = 98), fruits (n = 66), cereals (n = 63), roots & tubers (n = 51) and nuts and legumes (n = 36). Several IFs seen to have better nutritional content than conventional foods and were found to be rich (i.e., >20% Indian recommended dietary allowances per reference food serve) in iron (54%), calcium (35%), protein (30%), vitamin C (27%), vitamin A (18%), zinc (14%) and folate (13%). Some IFs displayed high levels of antinutrients, however, anti-nutrient-to-mineral molar ratios were found to be low (for mainly leafy vegetables, other vegetables, and roots and tubers), thus indicating high mineral bioavailability. Hence, efforts are desirable to encourage the inclusion of these nutritionally superior IFs into the usual diets of indigenous communities. The IF database collated in our review can serve as a resource for researchers and policymakers to better understand the nutritional properties of region-specific IFs and promote them through contextual food-based interventions for improved dietary quality and nutrition outcomes in indigenous population of India.

Diet Quality, Nutritional Adequacy and Anthropometric Status among Indigenous Women of Reproductive Age Group (15-49 Years) in India: A Narrative Review.

In India, indigenous communities are nutritionally vulnerable, with indigenous women suffering the greater burden. Studies and surveys have reported poor nutritional outcomes among indigenous women in India, yet systematic documentation of community-specific nutrition data is lacking. We conducted a narrative review of 42 studies to summarise the nutritional profile of indigenous women of India, with details on their food and nutrient intakes, dietary diversity, traditional food consumption and anthropometric status. Percentage deficits were observed in intake of pulses, green leafy vegetables, fruits, vegetables, flesh foods and dairy products when compared with recommended dietary intakes for moderately active Indian women. Indices of diet quality in indigenous women were documented in limited studies, which revealed poor dietary diversity as well as low consumption of diverse traditional foods. A high risk of nutritional inadequacy was reported in all communities, especially for iron, calcium, and vitamin A. Prevalence of chronic energy deficiency was high in most communities, with dual burden of malnutrition in indigenous women of north-eastern region. Findings from this review can thus help guide future research and provide valuable insights for policymakers and program implementers on potential interventions for addressing specific nutritional issues among indigenous women of India.

Field sales force model to increase adoption of a novel tuberculosis diagnostic test among private providers: evidence from India.

BACKGROUND: Impact of novel high-quality tuberculosis (TB) tests such as Xpert MTB/RIF has been limited due to low uptake among private providers in high-burden countries including India. Our objective was to assess the impact of a demand generation intervention comprising field sales force on the uptake of high-quality TB tests by providers and its financial sustainability for private labs in the long run. METHODS: We implemented a demand generation intervention across five Indian cities between October 2014 and June 2016 and compared the change in the quantity of Xpert cartridges ordered by labs in these cities from before (February 2013-September 2014) to after intervention (October 2014-December 2015) to corresponding change in labs in comparable non-intervention cities. We embedded this difference-in-differences estimate within a financial model to calculate the internal rate of return (IRR) if the labs were to invest in an Xpert machine with or without the demand generation intervention. RESULTS: The intervention resulted in an estimated 60 additional Xpert cartridges ordered per lab-month in the intervention group, which yielded an estimated increase of 11 500 tests over the post-intervention period, at an additional cost of US$13.3-US$17.63 per test. Further, we found that investing in this intervention would increase the IRR from 4.8% to 5.5% for hospital labs but yield a negative IRR for standalone labs. CONCLUSIONS: Field sales force model can generate additional demand for Xpert at private labs, but additional strategies may be needed to ensure its financial sustainability.

Population estimates, consequences, and risk factors of obesity among pregnant and postpartum women in India: Results from a national survey and policy recommendations.

OBJECTIVE: To examine prevalence, risk factors, and consequences of maternal obesity; and provide evidence on current policies and programs to manage maternal obesity in India. METHODS: This is a mixed-methods study. We analyzed the National Family Health Survey (NFHS)-4 data (2015-16) to estimate the prevalence and risk factors of obesity, followed by a desk review of literature and stakeholder mapping with interviews to develop policy guidance. RESULTS: National prevalence of obesity (defined by WHO as body mass index ≥25) was comparable among pregnant (12%) and postpartum women (13%) ≥20 years of age. A high prevalence of obesity (>40%) was observed in over 30 districts in multiple states. Older maternal age, urban residence, increasing wealth quintile, and secondary education were associated with increased odds of obesity among pregnant and postpartum women; higher education increased odds among postpartum women only (OR 1.90; 95% CI, 1.44-2.52). Dietary variables were not associated with obesity. Several implementation challenges across healthcare system blocks were observed at policy level. CONCLUSION: Overall prevalence of obesity in India during and after pregnancy is high, with huge variation across districts. Policy and programs must be state-specific focusing on prevention, screening, and management of obesity among pregnant and postpartum women.

Leveraging Providers' Preferences to Customize Instructional Content in Information and Communications Technology-Based Training Interventions: Retrospective Analysis of a Mobile Phone-Based Intervention in India.

BACKGROUND: Many public health programs and interventions across the world increasingly rely on using information and communications technology (ICT) tools to train and sensitize health professionals. However, the effects of such programs on provider knowledge, practice, and patient health outcomes have been inconsistent. One of the reasons for the varied effectiveness of these programs is the low and varying levels of provider engagement, which, in turn, could be because of the form and mode of content used. Tailoring instructional content could improve engagement, but it is expensive and logistically demanding to do so with traditional training. OBJECTIVE: This study aimed to discover preferences among providers on the form (articles or videos), mode (featuring peers or experts), and length (short or long) of the instructional content; to quantify the extent to which differences in these preferences can explain variation in provider engagement with ICT-based training interventions; and to compare the power of content preferences to explain provider engagement against that of demographic variables. METHODS: We used data from a mobile phone-based intervention focused on improving tuberculosis diagnostic practices among 24,949 private providers from 5 specialties and 1734 cities over 1 year. Engagement time was used as the primary outcome to assess provider engagement. K-means clustering was used to segment providers based on the proportion of engagement time spent on content formats, modes, and lengths to discover their content preferences. The identified clusters were used to predict engagement time using a linear regression model. Subsequently, we compared the accuracy of the cluster-based prediction model with one based on demographic variables of providers (eg, specialty and geographic location). RESULTS: The average engagement time across all providers was 7.5 min (median 0, IQR 0-1.58). A total of 69.75% (17,401/24,949) of providers did not consume any content. The average engagement time for providers with nonzero engagement time was 24.8 min (median 4.9, IQR 2.2-10.1). We identified 4 clusters of providers with distinct preferences for form, mode, and length of content. These clusters explained a substantially higher proportion of the variation in engagement time compared with demographic variables (32.9% vs 1.0%) and yielded a more accurate prediction for the engagement time (root mean square error: 4.29 vs 5.21 and mean absolute error: 3.30 vs 4.26). CONCLUSIONS: Providers participating in a mobile phone-based digital campaign have inherent preferences for instructional content. Targeting providers based on individual content preferences could result in higher provider engagement as compared to targeting providers based on demographic variables.

Initiative for Promoting Affordable and Quality Tuberculosis Tests (IPAQT): a market-shaping intervention in India.

A majority of patients with tuberculosis (TB) in India are diagnosed and treated in the private sector. Yet, most private providers do not use most recent WHO-endorsed microbiological tests such as liquid cultures, line probe assays and Xpert MTB/RIF due to a combination of factors such as lack of awareness, misaligned incentives and high prices that are unaffordable for patients. We designed a market-based approach to transform a high-price, low-volume market equilibrium into a low-price, high-volume equilibrium to improve the uptake of these tests. Toward this end, a non-profit consortium of private laboratories, called Initiative for Promoting Affordable and Quality Tuberculosis Tests (IPAQT) was formed in India in March 2013. It negotiated lower pricing on equipment and reagents with manufacturers, closer to that offered to the public sector. In return, IPAQT assured that this discount was passed on to patients, who typically paid for these tests out of their pockets, through an informally agreed on retail ceiling price. IPAQT also invested in demand generation activities that complemented the supply-side effort. IPAQT membership grew from 56 laboratories in 2013 to 211 in 2018. During this period, the initiative resulted in a 10-fold increase in the uptake of Xpert and a 30%-50% reduction in price. This initiative is planned to be expanded to other South Asian countries with similar TB epidemic and private market structure and dynamics. However, long-term sustainability of the initiative would require developing more cost-effective marketing activities and integration with broader private sector engagement agenda of the national TB programme.