Are advertising policies affirmative in restricting the marketing of foods high in fat, salt and sugar (HFSS) in India?: evidence from SWOT Analysis.

The regulatory Indian environment for advertising high fat, salt, and sugar (HFSS) foods and non-alcoholic beverages, on various media was reviewed. Identified national-level policies were categorised as mandatory or self-regulatory based on legal content. For each mandatory regulation, Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was undertaken to determine how existing policies could be strengthened to safeguard children from unhealthy food advertisements. Thirteen policies (nine mandatory; four self-regulatory) relevant to advertising in India were identified. Of the nine mandatory policies, Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements, 2022, is the only policy that restricts HFSS food advertisements to children across all media. There are key shortfalls, including limited scope of 'child-targeted' advertisements and lack of criteria to define HFSS foods. A robust regulatory framework is needed to protect children from HFSS food marketing, not just what is 'directed' at them, with clear evidence-based food classification criteria.

Prevalence of overweight and obesity and associated demographic and health factors in India: Findings from Comprehensive National Nutrition Survey (CNNS).

BACKGROUND: Childhood obesity (5-9 years) in India is likely to contribute 11% to the global burden by 2030. METHODS: Data from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018) was used to assess the prevalence and key associated factors of overweight and obesity. Multivariable logistic regression models were applied to identify potential determinants associated with being overweight and obese. RESULTS: Overweight prevalence (including obesity) varied from 1.6% (0-4 years) to 4.8% (10-19 years). The majority of states reported a higher proportion of adolescents overweight and obese, than younger age group 5-9 years. A significantly higher prevalence of children and adolescents with obesity was reported in higher wealth quintiles and residents of urban areas. The prevalence of overweight and obesity and associated demographic and health factors in India included: the presence of NCD risk factor (adolescents: 1.68, 95% CI [1.31-2.14]), micronutrient deficiency (5-9 years children: 1.72, 95% CI [1.30-2.28]), mother's education (5-9 years children: 4.84, 95% CI [2.92-8.03]; adolescents: 2.17, 95% CI [1.42-3.32]), wealth (adolescents: 1.92, 95% CI [1.16-3.19]), place of residence (5-9 years children: 1.68, 95% CI [1.39-2.03]; adolescents: 1.39, 95% CI [1.16-1.66]), child age (5-9 years children: 1.64, 95% CI [1.40-1.93], and screen-time (adolescents: 1.63, 95% CI [1.22-2.19]. CONCLUSION: The findings set out policy and research recommendations to pave the path for curtailing the increasing prevalence of overweight and obesity and achieving the World Health Assembly's Global Nutrition target of 'no increase in childhood overweight (Target 4) by 2025'.

Prevalence and determinants of anemia due to micronutrient deficiencies among children aged 12-59 months in India-Evidence from Comprehensive National Nutrition Survey, 2016-18.

The present study aimed to estimate the prevalence of anemia, and anemia with micronutrient deficiencies (iron/ vitamin B12/ folic acid) and their determinants among children aged 12-59 months in India. Comprehensive National Nutritional Survey (2016-2018) is Asia's largest nutrition survey conducted among 0-19 years aged children in India. We used generalised linear model (modified Poisson) with adjusted prevalence ratio (aPR) to assess the socio-economic and biochemical factors associated with anemia and anemia with micronutrient deficiencies amongst children aged 12 to 59 months. Out of the total of 11,237 children included in the study, 40.5% (95%CI:38·6-42·6) were anemic, 30.0% (95%CI:27·8-32·4) had anemia with micronutrient deficiencies and 60.9% (95%CI:58·2-63·5) had micronutrient deficiencies with or without anemia. Younger age (aPR(95%CI) for one year old: 1.9(1.5-2.4), two year old: 1.8(1.5-2.2), three year old: 1.4(1.2-1.7) compared to four year old children) and lower educational status of the mother (mothers without formal schooling aPR(95%CI):1.4(1.1-1.8); 1-9 standards: 1.4(1.2-1.7)) vs mother educated with high school and above, consumption of less than 100 iron-folic acid tablets during pregnancy (aPR(95%CI):1.3(1.0-1.7) vs consumption of ≥ 180 tablets, any self-reported illness among children within two weeks preceding the interview (aPR(95%CI):1.2(1.1-1.4) vs no-illnesses, iron deficiency (aPR(95%CI):2.2(2.0-2.6)) and zinc deficiency (aPR(95%CI):1.3(1.1-1.4)) were associated with anemia in children. Among anemic, the children from scheduled tribe (aPR(95%CI):1.4(1.1-1.8)) vs other caste categories, and those following unsafe child faeces disposal practices (aPR(95%CI):1.2(1.0-1.4)) vs those who follow safe faeces disposal practices had higher chance of having micronutrient deficiency. One third of children aged 12-59 months had anemia with micronutrient deficiency (iron/ folic acid/ vitamin B12). More than half of children had micronutrient deficiencies irrespective of anemia. Micronutrient deficiencies, antenatal IFA intake, safe hygiene practices need to be strengthened to leave no stone unturned in control of anemia among under-five children in India.

Nutritional status of school-age children (5-19 years) in South Asia: A scoping review.

Information on malnutrition for school-age children and adolescents (5-19 years) in South Asia is fragmented and inconsistent, which limits the prioritization of nutrition policies, programmes and research for this age group. This scoping review aimed to synthesize existing evidence on the burden of malnutrition for children and adolescents aged 5-19 years in South Asia, and on interventions to improve their nutritional status. Cochrane Library, EMBASE, Medline and Google Scholar were systematically searched for articles published between January 2016 and November 2022. Eligible studies reported the prevalence of undernutrition, overweight/obesity, micronutrient deficiencies and unhealthy dietary intakes, and interventions that aimed to address these in South Asia. In total, 296 articles met our inclusion criteria. Evidence revealed widespread, yet heterogeneous, prevalence of undernutrition among South Asian children and adolescents: thinness (1.9%-88.8%), wasting (3%-48%), underweight (9.5%-84.4%) and stunting (3.7%-71.7%). A triple burden of malnutrition was evident: the prevalence of overweight and obesity ranged from 0.2% to 73% and 0% to 38% (with rapidly rising trends), respectively, alongside persistent micronutrient deficiencies. Diets often failed to meet nutritional requirements and high levels of fast-food consumption were reported. Education, fortification, supplementation and school feeding programmes demonstrated beneficial effects on nutritional status. Comprehensive and regular monitoring of all forms of malnutrition among children and adolescents, across all countries in South Asia is required. Further, more large-scale intervention research is needed to ensure policy and programmes effectively target and address malnutrition among children and adolescents in South Asia.

Estimating the potential impact of a health tax on the demand for unhealthy food and beverages and on tax revenue in India.

Foods high in fat, sugar or salt are important contributors to the rising burden of non-communicable diseases globally and in India. Health taxes (HTs) have been used by over 70 countries as an effective tool for reducing consumption of sugar sweetened beverages (SSBs). However, the potential impacts of HTs on consumption and on revenues have not been estimated in India. This paper aims to estimate the potential impact of health taxes on the demand for sugar, SSBs and foods high in fat, sugar or salt (HFSS) in India while exploring its impact on tax revenues. PE of sugar was estimated using Private Final Consumption Expenditure and Consumer Price Index data while price elasticities for SSBs and HFSS were obtained from literature. The reduction in demand was estimated for an additional 10-30% HT added to the current goods and services tax, for varying levels of price elasticities. The results show that for manufacturers of sweets and confectionaries who buy sugar in bulk and assuming a higher price elasticity of -0.70, 20% additional HT (total tax 48%) would result in 13-18% decrease in the demand for sugar used for confectionaries and sweets. For SSBs, HT of 10-30% would result in 7-30% decline in the demand of SSBs. For HFSS food products, 10-30% HT would result in 5-24% decline in the demand for HFSS products. These additional taxes would increase tax revenues for the government by 12-200% across different scenarios. Taxing unhealthy foods is likely to reduce demand, while increasing government revenues for reinvestment back into public health programmes and policies that may reduce obesity and the incidence of non-communicable diseases in India.

Law matters - assessment of country-level code implementation and sales of breastmilk substitutes in South Asia.

Objectives: This study examines the status of implementation of the International Code of Marketing of Breast-milk Substitutes of eight countries in the South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), and describes the sales value and volume of commercial milk formula (CMF) marketed as breastmilk substitutes (BMS) and baby food in four countries (Bangladesh, India, Pakistan, and Sri Lanka). Design: A mix of descriptive methods is used to assess national status of Code implementation, including a desk review of the 2022 WHO/UNICEF/IBFAN Code Status Report, systematic content analysis of national Code measures, and insights generated from the participation of key government and UNICEF/WHO actors in a regional workshop that aimed to identify each country's barriers, gaps, and the status of Code implementation. Data on the sales value and volume of CMF and baby food between 2007 to 2021 and with the prediction to 2026 in Bangladesh, India, Pakistan, and Sri Lanka were obtained from Global Data. Findings: There are major gaps in Code implementation in countries even with legal measures considered substantially aligned with the Code, such as the inadequate age range of CMF covered in the scope, insufficient safeguards against conflicts of interest in the health system, lack of warning of risks of intrinsic contamination of powdered milk formula, and an absence of effective monitoring and enforcement mechanisms. Data on CMF sales shows health facilities and pharmacies sustain the highest sales. Lower sales volume of infant formula (including special formula), compared to other CMF such as follow-up formula and growing-up milk, has been observed in three of the four countries (Bangladesh, India, and Sri Lanka). Overall, GUM, followed by baby cereals, accounted for a large portion of CMF and baby foods sales in the same three countries. Recommended actions include: (1) Closing the gaps between national measures and the Code, (2) Ensuring effective monitoring and enforcement mechanisms, (3) Strengthening conflicts of interest safeguards in the health system, (4) Tackling digital marketing, and (5) Galvanizing political support and support from in-country public health and women's rights jurist networks.

Evaluation of impact of engaging federations of women groups to improve women's nutrition interventions- before, during and after pregnancy in social and economically backward geographies: Evidence from three eastern Indian States.

BACKGROUND: Undernutrition-before, during and after pregnancy endangers the health and well-being of the mother and contributes to sub-optimal fetal development and growth. A non-randomized controlled evaluation was undertaken to assess the impact of engaging federations of women's group on coverage of nutrition interventions and on nutrition status of women in the designated poverty pockets of three Indian states-Bihar, Chhattisgarh, and Odisha. METHOD: The impact evaluation is based on two rounds of cross-sectional data from 5 resource poor blocks across 3 States, assigning 162 villages to the intervention arm and 151 villages to the control arm. The cross-sectional baseline (2016-17) and endline survey (2021-22) covered a total of 10491 adolescent girls (10-19 years), 4271 pregnant women (15-49 years) and 13521 mothers of children under age two years (15-49 years). Exposure was defined based on participation in the participatory learning and action meetings, and fixed monthly health camps (Adolescent Health Days (AHDs) and Village Health Sanitation and Nutrition Days (VHSNDs)). Logistic regression models were applied to establish the association between exposure to programme activities and improvement in coverage of nutrition interventions and outcomes. RESULTS: In the intervention area at endline, 27-38% of women participated in the participatory learning and action meetings organized by women's groups. Pregnant women participating in programme activities were two times more likely to receive an antenatal care visit in the first trimester of pregnancy (Odds ratio: 2.55 95% CI-1.68-3.88), while mothers of children under 2 were 60% more likely to receive 4 ANC visits (Odds ratio: 1.61, 95% CI- 1.30-2.02). Odds of consuming a diversified diet was higher among both pregnant women (Odds ratio: 2.05, 95% CI- 1.41-2.99) and mother of children under 2 years of age (Odds ratio: 1.38, 95% CI- 1.08-1.77) among those participating in programme activities in the intervention arm. Access to commodities for WASH including safe sanitation services (Odds ratio: 1.80, 95% CI- 1.38-2.36) and sanitary pads (Odds ratio: 1.64, 95% CI- 1.20-2.22) was higher among adolescent girls participating in programme activities. CONCLUSION: Women's groups led participatory learning and action approaches coupled with strengthening of the supply side delivery mechanisms resulted in higher coverage of health and nutrition services. However, we found that frequency of participation was low and there was limited impact on the nutritional outcomes. Therefore, higher frequency of participation in programme activities is recommended to modify behaviour and achieve quick gains in nutritional outcomes.

Right message, right medium, right time: powering counseling to improve maternal, infant, and young child nutrition in South Asia.

Introduction: Quality counseling can positively impact maternal, infant and young child nutrition (MIYCN) behaviors linked to poor nutrition outcomes. Global guidance includes 93 recommendations on MIYCN counseling. Methods: A desk review and key informant interviews sought to assess compliance to the recommendations, reach and quality, systemic gaps and opportunities for MIYCN counseling in seven South Asian countries. Ninety-three (93) policies and guidelines, 180 counseling materials and over 50 documents were reviewed; 115 key informant interviews were conducted. Information synthesis captured eight domains. Data from national surveys were analyzed to determine MIYCN counseling reach, quality and association with nutrition behaviors. Results: Results showed that national guidelines were inconsistent with global recommendations for seven thematic areas. Coverage of contacts points like antenatal and postnatal care (ANC, PNC) with potential to deliver MIYCN counseling was highly variable. Having at least four ANC contacts was significantly associated with consumption of 100+ iron folic acid tablets in all countries. Rates of early initiation of breastfeeding (18% Pakistan to 90% Sri Lanka) were lower than institutional delivery rates, except for Bangladesh and Sri Lanka. PNC contact within 48 h of birth was positively correlated with exclusive breastfeeding in India, Pakistan and Sri Lanka (OR 1.4, 3.1, 3.2). Health worker contacts and wealth status equally influenced child's dietary diversity in India. MIYCN services were add-on roles for community-based workers, except in India. Supervision mechanisms exist but were not focused on quality of MIYCN services. Counseling resources were predominantly paper based (>70%), had rural-focused messaging on diets and mainly targeted women. Platforms to engage men were largely missing. Health management information systems included indicators on maternal contact points in all countries but not for children. Assessing funding for MIYCN counseling was challenging as costs were subsumed across several budget line-items. Discussion: The research findings can be used to (1) align country guidance with global recommendations, (2) review workforce responsibilities and capacity building with supervision, (3) assess the need for new counseling materials based on coverage of content, service providers and audience, (4) integrate MIYCN counseling indicators in information systems and (5) include MIYCN counseling services with activities and budget in country plans.

Women empowerment through involvement in community-based health and nutrition interventions: Evidence from a qualitative study in India.

Women's empowerment is fundamental for realizing unalienable human rights and is vital to sustainable development outcomes. In India, the SWABHIMAAN intervention program was an integrated multi-sectoral strategy to improve girls' and women's nutrition before conception, during pregnancy, and after childbirth. This study assesses the role of self-help-group (SHGs) in improving the effectiveness of community health interventions and its impact on their self-empowerment. Qualitative data gathered through in-depth interviews (IDI) with community-based SHG members involved as Nutrition Friend (Poshan Sakhi-PS) in the SWABHIMAAN program in 2018 was used for analysis. Informed consent procedures were followed, and only those who voluntarily consented to the interview were interviewed. Twenty-five IDIs of purposively selected PSs in three states (Bihar, n = 9; Chhattisgarh, n = 8; and Odisha, n = 8) were analyzed thematically, according to Braun & Clarke (2006). NVivo 12 software was used for organizing and coding data. Three central themes that emerged to explain women's empowerment were (1) Barriers & redressal mechanisms adopted by PS, (2) PS as a change-maker, and (3) Changes in the life of PS. The study found that women perceive themselves as more empowered through involvement in the SWABHIMAN intervention program, besides improving the community's and their households' nutritional status. The results suggest that policies and programs on health and nutrition interventions need to involve peer women from the community, leading to more effective outcomes. Empowering women and closing gender gaps in employment/work are critical to achieving the 2030 Sustainable Development Goals.

Integrating an algorithmic and health systems thinking approach to improve the uptake of government antenatal nutrition services in Vidisha, Madhya Pradesh (India), 2018 to 2021.

In 2018, the Government of Madhya Pradesh initiated the feasibility testing of integrating an algorithmic approach (assess, give, counsel, treat) to strengthen antenatal nutrition services in routine government-funded programmes coupled with a health system thinking approach to strengthen the health service delivery platform. Implementation phases included (1) an evidence review and stakeholder consultations (April 2018) and (2) a health systems strengthening preparedness phase (May-December 2018), including pilot testing in Vidisha district (January-December 2019) covering ∼54 100 pregnant women with 237 antenatal contact points through 241 government auxiliary nurse midwives/staff nurses. During 2020-21, feasibility testing was expanded to an additional 7 districts. We used programme registers of the Auxiliary Nurse Midwives Registers (2019-21) and National Family Health Survey data for 2016 and 2021 to show changes in the Vidisha district and 7 expansion districts. We compare the performance of Vidisha district with Ashok Nagar district, where no such intervention occurred. Comparing 2016 and 2021 data, the Vidisha district showed improvements in receipt of antenatal care in the first trimester (29 to 85%) and in four antenatal visits (17 to 54%). Using the difference-in-difference approach, a 42% net increase in first-trimester antenatal check-ups in Vidisha as compared to Ashok Nagar is observed. There was also an improvement in the maternal nutrition budget of the state from USD 8.5 million to USD 17.8 million during this period. The Vidisha initiative offers several lessons in time-effective workflow to deliver all constituents of nutrition services at various antenatal contact points through and via routine government health systems. Continued execution of the algorithm for screening, with longitudinal data on the management of all nutrition risks, will be critical to show its long-term impact on maternal morbidities and birth outcomes.

Integrating nutrition and mental health screening, risk identification and management in prenatal health programs in India.

Pregnancy is a period of major physiologic, hormonal, and psychological change, increasing the risk of nutritional deficiencies and mental disorders. Mental disorders and malnutrition are associated with adverse pregnancy and child outcomes, with potential long-standing impact. Common mental disorders during pregnancy are more prevalent in low- and middle-income countries (LMICs). In India, studies suggest the prevalence of depression is 9.8%-36.7% and of anxiety is 55.7%. India has seen some promising developments in recent years such as increased coverage of the District Mental Health Program; integration of maternal mental health into the Reproductive and Child Health Program in Kerala; and the Mental Health Care Act 2017. However, mental health screening and management protocols have not yet been established and integrated into routine prenatal care in India. A five-action maternal nutrition algorithm was developed and tested for the Ministry of Health and Family Welfare, aiming to strengthen nutrition services for pregnant women in routine prenatal care facilities. In this paper, we present opportunities and challenges for integration of maternal nutrition and mental health screening and a management protocol at routine prenatal care in India, discuss evidence-based interventions in other LMICs including India, and make recommendations for public healthcare providers.

Research priorities for nutrition of school-aged children and adolescents in low- and middle-income countries.

PURPOSE: A lack of data, intervention studies, policies, and targets for nutrition in school-age children (SAC) and adolescents (5-19 years) is hampering progress towards tackling malnutrition. To stimulate and guide further research, this study generated a list of research priorities. METHODS: Using the Child Health and Nutrition Research Initiative (CHNRI) method, a list of 48 research questions was compiled and questions were scored against defined criteria using a stakeholder survey. Questions covered all forms of malnutrition, including micronutrient deficiencies, thinness, stunting, overweight/obesity, and suboptimal dietary quality. The context was defined as research focused on SAC and adolescents, 5 to 19 years old, in low-and middle-income countries, that could achieve measurable results in reducing the prevalence of malnutrition in the next 10 years. RESULTS: Between 85 and 101 stakeholders responded per question. Respondents covered a broad geographical distribution across 38 countries, with the largest proportion focusing on work in East and Southern Africa. Of the research questions ranked in the top ten, half focused on delivery strategies for reaching adolescents and half on improving existing interventions. There were few differences in the ranked order of questions between age groups but those related to in-school children and adolescents had higher expert agreement than those for out-of-school adolescents. The top ranked research question focused on tailoring antenatal and postnatal care for pregnant adolescent girls. CONCLUSION: Nutrition programmes should incorporate implementation research to inform delivery of effective interventions to this age group, starting in schools. Academic research on the development and tailoring of existing nutrition interventions is also needed; specifically, on how to package multisectoral programmes and how to better reach vulnerable and underserved sub- groups, including those out of school.

Correction Equation for Hemoglobin Values Obtained Using Point of Care Tests-A Step towards Realistic Anemia Burden Estimates.

Digital hemoglobinometers have been used as point-of-care tests (POCT) to estimate the burden of anemia in community-based studies and national-level surveys in India. As the accuracy of hemoglobin estimated in POCT varies, there is a need for adjustments to the POCT-hemoglobin to ensure they are closer to reality and are comparable. We used data (collected between 2016 and 2020) (N = 1145) from four studies from India: three among pregnant women and 6-59-month-old children from Haryana and the fourth from a national nutritional survey among 1-19-year-old children. We compared the same individuals' POCT-hemoglobin (capillary blood) and automated hematology analyzers (AHA) hemoglobin (venous blood) and developed a predictive linear regression model to obtain the correction equation for POCT-hemoglobin. We analyzed paired data from 1145 participants. The correction equation for obtaining the true hemoglobin value = 3.35 + 0.71 × POCT-hemoglobin using capillary blood (adjusted R2-64.4% and mean squared error -0.841 g/dL). In comparison with the AHA-hemoglobin, the mean difference of POCT-hemoglobin was 0.2 g/dL, while with the predicted Hb obtained from the correction equation it was 0.01 g/dL. The correction equation was the first attempt at deriving the true hemoglobin values from the POCTs. There is a need for multi-country collaborative studies to improve the correction equation by adjusting for factors affecting hemoglobin estimation.

Gender Transformative Interventions for Perinatal Mental Health in Low and Middle Income Countries-A Scoping Review.

Perinatal mental health problems are linked to poor outcomes for mothers, babies and families. In the context of Low and Middle Income Countries (LMIC), a leading risk factor is gender disparity. Addressing gender disparity, by involving fathers, mothers in law and other family members can significantly improve perinatal and maternal healthcare, including risk factors for poor perinatal mental health such as domestic violence and poor social support. This highlights the need to develop and implement gender-transformative (GT) interventions that seek to engage with men and reduce or overcome gender-based constraints. This scoping review aimed to highlight existing gender transformative interventions from LMIC that specifically aimed to address perinatal mental health (partner violence, anxiety or depression and partner support) and identify components of the intervention that were found to be useful and acceptable. This review follows the five-stage Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Six papers that met the inclusion criteria were included in the review (four from Africa and two from Asia). Common components of gender transformative interventions across studies included couple-based interventions and discussion groups. Gender inequity and related factors are a strong risk for poor perinatal mental health and the dearth of studies highlights the strong need for better evidence of GT interventions in this area.

Anaemia in Indians aged 10-19 years: Prevalence, burden and associated factors at national and regional levels.

Anaemia control programmes in India are hampered by a lack of representative evidence on anaemia prevalence, burden and associated factors for adolescents. The aim of this study was to: (1) describe the national and subnational prevalence, severity and burden of anaemia among Indian adolescents; (2) examine factors associated with anaemia at national and regional levels. Data (n = 14,673 individuals aged 10-19 years) were from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018). CNNS used a multistage, stratified, probability proportion to size cluster sampling design. Prevalence was estimated using globally comparable age- and sex-specific cutoffs, using survey weights for biomarker sample collection. Burden analysis used prevalence estimates and projected population from 2011 Census data. Multivariable logistic regression models were used to analyse factors (diet, micronutrient deficiencies, haemoglobinopathies, sociodemographic factors, environment) associated with anaemia. Anaemia was present in 40% of girls and 18% of boys, equivalent to 72 million adolescents in 2018, and varied by region (girls 29%-46%; boys 11%-28%) and state (girls 7%-62%; boys 4%-32%). Iron deficiency (ferritin < 15 µg/L) was the strongest predictor of anaemia (odds ratio [OR]: 4.68, 95% confidence interval [CI]: [3.21,6.83]), followed by haemoglobinopathies (HbA2 > 3.5% or any HbS) (OR: 2.81, 95% CI: [1.66,4.74]), vitamin A deficiency (serum retinol <20 ng/ml) (OR: 1.86, 95% CI: [1.23,2.80]) and zinc deficiency (serum zinc < 70 µg/L) (OR: 1.32, 95% CI: [1.02,1.72]). Regional models show heterogeneity in the strength of association between factors and anaemia by region. Adolescent anaemia control programmes in India should continue to address iron deficiency, strengthen strategies to identify haemoglobinopathies and other micronutrient deficiencies, and further explore geographic variation in associated factors.

Coverage of iron and folic acid supplementation in India: progress under the Anemia Mukt Bharat strategy 2017-20.

High prevalence of anaemia is a severe public health problem in India. In 2018, India launched the Anemia Mukt Bharat (AMB) strategy that focuses on six beneficiary groups for coverage, six institutional mechanisms for health system strengthening and six programmatic interventions to accelerate reductions in anaemia prevalence. This paper uses the Health Management Information System data (2017-18 to 2019-20) to examine gains in IFA coverage across Indian states. A coverage-based AMB index is computed to review performance across states. After the launch of AMB strategy, the Iron and Folic Acid (IFA) supplementation coverage between 2017-18 and 2019-20 has increased for all beneficiary groups [pregnant women from 78% to 90%; lactating mothers from 34% to 49%; school going adolescent girls (boys) from 23% to 40% (21% to 42%); out-of-school adolescent girls from 6% to 23%; children 5-9 years from 8% to 3% and children 6-59 months from 7% to 15%]. Coverage was relatively low for target groups being served through a multi-departmental convergence mechanism (health and other departments such as education department for schools or women and child development department for Anganwadi centres) than compared to those served by health department alone. However, no major gender disparities are noted in the coverage of IFA supplementation among school-going girls and boys. Bulk of the variations in coverage is attributable to state-specific differences. Training and sensitization workshops for state and district officials are found to be associated with increased coverage across beneficiary groups. The paper argues that despite following international best practices in the field, it is important to harness synergy in programme implementation across line departments to eliminate coverage inefficiencies.

Food choice in transition: adolescent autonomy, agency, and the food environment.

Dietary intake during adolescence sets the foundation for a healthy life, but adolescents are diverse in their dietary patterns and in factors that influence food choice. More evidence to understand the key diet-related issues and the meaning and context of food choices for adolescents is needed to increase the potential for impactful actions. The aim of this second Series paper is to elevate the importance given to adolescent dietary intake and food choice, bringing a developmental perspective to inform policy and programmatic actions to improve diets. We describe patterns of dietary intake, then draw on existing literature to map how food choice can be influenced by unique features of adolescent development. Pooled qualitative data is then combined with evidence from the literature to explore ways in which adolescent development can interact with sociocultural context and the food environment to influence food choice. Irrespective of context, adolescents have a lot to say about why they eat what they eat, and insights into factors that might motivate them to change. Adolescents must be active partners in shaping local and global actions that support healthy eating patterns. Efforts to improve food environments and ultimately adolescent food choice should harness widely shared adolescent values beyond nutrition or health.

Strategies and interventions for healthy adolescent growth, nutrition, and development.

Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.