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Chronic wounds are associated with significant clinical, economic and quality‐of‐life burden. Despite the variety of wound imaging systems available in the market for wound assessment and surveillance, few are clinically validated among patients of Asian ethnicity. We aimed to clinically validate the accuracy of a smartphone wound application (Tissue Analytics [TA], Net Health Systems Inc, Florida, USA), versus conventional wound measurements (visual approximation and paper rulers), in patients of Asian ethnicity with venous leg ulcers (VLU). A prospective cohort study of patients presenting with VLU to a specialist wound nurse clinic over a 5‐week duration was conducted. Each patient received seven wound measurements: one by a trained wound nurse clinician, and three separate wound measurements using TA on each of the iOS and Android operating systems. Inter‐rater and intra‐rater reliability between clinical and TA‐based measurements were analysed using intra‐class correlation statistics, with values of <0.5, 0.5 to 0.75, 0.75 to 0.9, and >0.9 indicating poor, moderate, good and excellent reliability, respectively. 82 patients (51% males), with a mean age at 65.8 years, completed the 5‐week study duration. 25 (30%) had underlying diabetes mellitus. Chinese, Malay and Indian ethnicity comprised 68%, 12% and 11%, respectively. The VLU healed in 26 (32%) of patients within the study period. In total, 358 wound episodes with 2334 wound images were analysed. Inter‐rater reliability for length, width and area between wound nurse measurements and TA application measurements was good (range 0.799‐0.919, P < 0.001). Separate measurements of intra‐rater reliability for length, width and area within the iOS or Android systems were excellent (range 0.967‐0.985 and range 0.977‐0.984 respectively, P < 0.001). Inter‐rater reliability between TA used on the iOS and Android systems was also excellent (0.987‐0.989, P < 0.001). Tissue Analytics, a smartphone wound application, is a useful adjunct for wound assessment and surveillance in VLU patients of Asian ethnicity. [ABSTRACT FROM AUTHOR]

In India, 15 nutrition interventions are delivered and financed through the National Health Mission (NHM). Programmatic know‐how, however, on tracking nutrition budgets in health sector plans is limited. Following the four phases of the budget cycle—planning, allocations, disbursements and expenditure, this paper presents a new method developed by the authors to track nutrition budgets within health sector plans. Using the example of the Anemia Mukt Bharat (AMB) or Anemia Free India strategy, it reports preliminary findings on the application of the first two phases of the method, that is, to track and act for improved planning and allocations, covering 12 states. The paper lists out the budget heads, cost norms and developed tools to plan adequately. Supportive action was undertaken through sharing trends and trainings for AMB's budgeting to create opportunities for improvements. It was observed that the AMB budget increased over 3 years despite the COVID situation. It increased from INR 6184 million in FY 2019–2020 to INR 6293 million, a 2% increase in FY 2020–2021, and to INR 7433 million, an 18% increase in FY 2021–2022. The difference in allocations and planned budgets were low (16%, 4% and 11%, respectively) while the difference in required budgets and planned budgets were significant but reduced consistently (41%, 31% and 22%, respectively). The paper concludes that the methods adopted for tracking and acting for improved nutrition budgets helped in informing national and state governments regarding yearly trends. Such methods can be effective and be developed for other nutrition interventions. Key messages: Tracking budgets and timely action can improve planning and allocation efficiency.Support to states in planning budgets is essential. No major gaps were found in approvals.Technical partners can assist in supporting governments for improving financial efficiency. [ABSTRACT FROM AUTHOR]

Objective: The objective of this paper was to present the results of our study of the utility of bone mineral density (BMD) measurements at various segments of distal forearm in predicting central‐site osteoporosis and deteriorated trabecular microarchitecture. Methods: This was a cross‐sectional study and BMD at the femoral neck, lumbar spine, and distal forearm were assessed using the dual‐energy X‐ray absorptiometry (DXA) scanner and bone microarchitecture at lumbar spine by trabecular bone score (TBS). The utility of forearm BMD in predicting osteoporosis as well as the deteriorated TBS was assessed by a receiver operating characteristic analysis. Results: A total of 352 postmenopausal women with mean (SD) age of 60.7 (6.8) years were included. The odds of having osteoporosis at femoral neck [odds ratio (OR) = 14.1, 95% confidence interval (CI): 7.8–25.2] and lumbar spine (OR = 7.5, 95% CI: 4.6–12.1) was highest with the mid‐distal radius. A derived T‐score cut off ≤ −1.6, −1.9, and −1.7 at any segment of the forearm was elucidated to predict osteoporosis at the central‐site, femoral neck, and lumbar spine, respectively, with sensitivity of 80%–88% and specificity of 60%–70%. The T‐scores at all three forearm segments ≤ −1.2 showed fair performance in predicting degraded trabecular microarchitecture. The T‐scores thus derived were further validated in cohort of 360 Bengali postmenopausal women. Conclusion: BMD assessment at the forearm may be utilized in prediction of trabecular microarchitecture and central site osteoporosis at the femoral neck and lumbar spine in postmenopausal women. [ABSTRACT FROM AUTHOR]

Prior research has identified a number of risk factors ranging from inadequate household sanitation to maternal characteristics as important determinants of child malnutrition and health in India. What is less known is the extent to which these individual‐level risk factors are geographically distributed. Assessing the geographic distribution, especially at multiple levels, matters as it can inform where, and at what level, interventions should be targeted. The three levels of significance in the Indian context are villages, districts, and states. Thus, the purpose of this paper was to (a) examine what proportion of the variation in 21 risk factors is attributable to villages, districts, and states in India and (b) elucidate the specific states where these risk factors are clustered within India. Using the fourth National Family Health Survey dataset, from 2015 to 2016, we found that the proportion of variation attributable to villages ranged from 14% to 63%, 10% to 29% for districts and 17% to 62% for states. Furthermore, we found that Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh were in the highest risk quintile for more than 10 of the risk factors included in our study. This is an indication of geographic clustering of risk factors. The risk factors that are clustered in states such as Bihar, Jharkhand, Madhya Pradesh and Uttar Pradesh underscore the need for policies and interventions that address a broader set of child malnutrition determinants beyond those that are nutrition specific. [ABSTRACT FROM AUTHOR]

Objective: In this study, our objective is to propose various models to estimate healthy life year lost (HLYL) and healthy life expectancy (HLE) in India. Methods: The HLYL and HLE were estimated and further these estimates were compared with the direct life table method and the World Health Organization (WHO) method. From the mortality perspective, we have developed a log‐logistic model for estimating the parameter (bx), which is characterized by HLYL. The results were compared with other models, such as the Gompertz and Weibull model. Here, we have also obtained the HLE by subtracting HLYL from the total life expectancy. Results: The result shows an increasing trend of HLYL among the male, female, and the total population in India. Conclusion: From the log‐logistic model, the HLYL was estimated as 8.79 years, 8.36 years, and 9.38 years for the total, male, and female populations, respectively, in India during 2019. [ABSTRACT FROM AUTHOR]

Objective: To investigate the trends and patterns of the cancer burden among the elderly in different regions of India at a subnational level. Methods: Data were extracted from the Global Burden of Disease (GBD) Studies India Compare 2019. Prevalence rate, disability‐adjusted life years (DALY), and annual percentage change techniques were used to analyze data. Results: The three age groups with the highest prevalence of cancer were those aged 60–64 years, 65–69 years, and 70–74 years. In 2019, The prevalence of cancer among the elderly ranged from 7048.815 in Karnataka to 5743.040 in Jharkhand. Kerala has the most significant annual percentage change in the cancer prevalence rate of 0.291 between 1990 and 2019. The highest DALY rate was observed among individuals aged 80–84 years in 2019. That year, the DALY rate among the elderly was 8112.283 in India. The top five cancers with higher DALY rates among the elderly in India in 2019 were tracheal, bronchus, and lung cancer (908.473), colon and rectum cancer (752.961), stomach cancer (707.464), breast cancer (597.881), and lip and oral cavity cancer (557.637). Conclusion: Elderly individuals demonstrated a higher vulnerable to cancer compared to other age groups. There is a need for state‐specific government intervention to minimize the risk of cancer among the elderly due to the heterogeneity in the burden of cancer across Indian states. [ABSTRACT FROM AUTHOR]

Nutrition‐sensitive agriculture (NSA) interventions offer a means to improve the dietary quality of rural, undernourished populations. Their effectiveness could be further increased by understanding how household dynamics enable or inhibit the uptake of NSA behaviours. We used a convergent parallel mixed‐methods design to describe the links between household dynamics—specifically intrahousehold power inequalities and intrahousehold cooperation—and dietary quality and to explore whether household dynamics mediated or modified the effects of NSA interventions tested in a cluster‐randomized trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN). We use quantitative data from cross‐sectional surveys in 148 village clusters at UPAVAN's baseline and 32 months afterwards (endline), and qualitative data from family case studies and focus group discussions with intervention participants and facilitators. We found that households cooperated to grow and buy nutritious foods, and gendered power inequalities were associated with women's dietary quality, but cooperation and women's use of power was inhibited by several interlinked factors. UPAVAN interventions were more successful in more supportive, cooperative households, and in some cases, the interventions increased women's decision‐making power. However, women's decisions to enter into negotiations with family members depended on whether women deemed the practices promoted by UPAVAN interventions to be feasible, as well as women's confidence and previous cultivation success. We conclude that interventions may be more effective if they can elicit cooperation from the whole household. This will require a move towards more family‐centric intervention models that empower women while involving other family members and accounting for the varied ways that families cooperate and negotiate. Key messages: Household cooperation and intrahousehold power inequalities may influence children's and mothers' dietary diversity in rural OdishaThese factors partly determine the effects of nutrition‐sensitive agriculture (NSA) interventions tested in Upscaling Participatory Action and Videos for Agriculture and Nutrition, indicating that NSA interventions may be more effective if they include multiple family members.There is wide heterogeneity in household dynamics and the constraints that families face. Further research is needed to identify how interventions can respond to this heterogeneity so that NSA interventions are effective in an inclusive and empowering way. [ABSTRACT FROM AUTHOR]

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self‐efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization‐recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change. [ABSTRACT FROM AUTHOR]

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. Key messages: The Comprehensive National Nutrition Survey (CNNS) 2016–2018 is the only nationally representative survey to measure haemoglobin, haemoglobinopathies, biomarkers of micronutrient deficiencies, diet and social factors in Indian adolescents aged 10–19 years.Using CNNS data, we found that 28.5% of adolescents (girls: 39.6%, boys: 17.6%) were anaemic, with variation by region or state.Our prevalence estimates translate to 72 million adolescents being anaemic, with Uttar Pradesh having twice as many anaemic adolescents as any other state.Iron deficiency, haemoglobinopathies, vitamin A deficiency and zinc deficiency were associated with an increased risk of anaemia; these associations may vary subnationally. [ABSTRACT FROM AUTHOR]

This study reviews the performance of a community‐based nutrition programme in preventing and treating wasting without complications among children under age three in urban informal settlements of India. Implemented by a non‐profit organization, with national (Integrated Child Development Services [ICDS]) and city‐level (Municipal Corporation of Greater Mumbai [MCGM]) government partners, the programme screened 7,759 children between May 2014 and April 2015. During this period, the programme admitted 705 moderately wasted and 189 severely wasted children into the treatment group and 6,820 not wasted children into the prevention group. Both prevention and treatment groups received growth monitoring, referrals to public health facilities, and home‐based counselling (if <6 months) by community health workers. Treatment groups received additional home‐based counselling and access to medical screenings. Severely wasted children also received access to ready‐to‐use therapeutic food. The study assessed default rates, wasting status, and average weight gain 3 months after admission. Factors associated with growth faltering in the prevention group were explored using logistic regression. Default rates for the severely wasted, moderately wasted, and prevention group were 12.7%, 20.4%, and 22.1%, respectively. Recovery rate was 42.4% for the severely wasted and 61.3% for the moderately wasted. For the moderately wasted, mean weight gain was 2.1 g/kg/day, 95% confidence interval (CI) [1.6, 2.6], and 4.5 g/kg/day for the severely wasted, 95% CI [3.1, 5.9]. Among prevention group children, 3.6% faltered into wasting—3.2% into moderate and 0.4% into severe. The paper gives insights into ways in which ICDS and MCGM can successfully integrate large‐scale community‐based acute malnutrition programming. [ABSTRACT FROM AUTHOR]

Introduction: Our aim is to evaluate the visually informed community mental health education materials cocreated in our research on youth substance misuse in Assam, India, and to reflect on what we might learn for similar initiatives in low‐ and middle‐income countries. Methods: Materials consist of: (i) images participants brought to the interview; (ii) 30 posters cocreated by participants to convey key messages from their interview; (iii) six short films on the implications of addiction, and (iv) an animation of our Pathways to Recovery model. We also created a community education package that incorporated these materials. We analyse feedback from three groups of events and a social media campaign, which drew variably across our materials and engaged a range of audiences. Results: Outcomes indicate the cocreation process and focus on the visual was successful in promoting young people's voice, increasing awareness and has potential for stigma reduction. Our educational package was deemed useful in increasing awareness and has potential for prevention and treatment. Conclusions: Our case study offers insights into community mental health education in low‐ and middle‐income countries, confirming the importance of cocreation, the usefulness of visual materials and the potential of social media campaigns while acknowledging the importance of local context in health messaging, particularly for stigmatized topics. Patient or Public Contribution: Service users were involved in the cocreation of the materials evaluated in this study and contributed as presenters in one of the events reported. Members of the public took part in events in which the materials were shared and provided us with the feedback analysed in this article. [ABSTRACT FROM AUTHOR]

There is limited information on the feeding practices of 9.42 million children living within institution‐based care (IBC) worldwide. Poor feeding practices can predispose or exacerbate malnutrition, illness and disability. Here we describe the feeding practices of children living within IBC based on a retrospective analysis of records from 3335 children, 0–18 years old, participating in Holt International's Child Nutrition Program (CNP), from 36 sites in six countries. Data analysed included demographic information on age, sex, feeding practices, disabilities and feeding difficulties. Descriptive statistics were produced. A generalised linear model explored associations between feeding difficulties and disability and 2 × 2 tables examined feeding difficulties over time. An additional set of feeding observations with qualitative and quantitative data was analysed. At baseline, the median age of children was 16 months (0.66–68 months) with 1650/3335 (49.5%) females. There were 757/3335 (22.7%) children with disabilities; 550/984 (55.9%) were low birth weight; 311/784 (39.7%) were premature; 447/3113 (14.4%) had low body mass index and 378/3335 (11.3%) had feeding difficulties. The adjusted risk of having a feeding difficulty was 5.08 ([95% confidence interval: 2.65–9.7], p ≤ 0.001) times greater in children with disabilities than those without. Many children saw their feeding difficulties resolve after 1‐year in CNP, 54/163 (33.1%) for children with disabilities and 57/106 (53.8%) for those without disabilities. Suboptimal hygiene, dietary and feeding practices were reported. In conclusion, feeding difficulties were common in IBC, especially among children with disabilities. Supporting safe interactive mealtimes for children living within IBC should be prioritised, to ensure overall health and development. Key points: Feeding difficulties are common among children living in institution‐based care (IBC), particularly but not exclusively among those children with disabilities.Suboptimal feeding practices were common in IBC and encompassed inadequate hygiene, limited support for self‐feeding, reading children's feeding cues (especially around pacing and satiety), addressing feeding difficulties, such as difficulty chewing or swallowing. These should be prioritised in training and supervision for caregivers.Addressing the needs of this vulnerable group should include support for safe feeding techniques. These should be prioritised to help ease the transition into eventual family‐based care if we are to move towards deinstitutionalizing children and strengthening families. [ABSTRACT FROM AUTHOR]

The motive of this study is to identify the factors influencing the willingness to pay (WTP) a premium price for socially responsible food products (SRFPs) in India. This study is based on primary survey of 398 respondents. Descriptive statistics and factor analysis have been used for data analysis. Further, logistic regression was used to examine the factors affecting the WTP a premium price for SRFPs. Results demonstrate that respondents of higher age are more likely to pay premium prices for SRFPs. Male consumers are two times more likely to have higher WTP for SRFPs. WTP a premium price is significantly influenced by the consumers' reference group, pro‐environmental intention, and concern for the animals. Gender, age, consumers' reference group, pro‐environmental intention, and concern for the animals determine WTP premium prices for SRFPs. There are relatively very limited researches on this topic in emerging economies including India, where the adoption of socially responsible products is in early stage. The practical implications of this study are to help in increasing the sales of the SRFPs and producers to develop appropriate policy design. [ABSTRACT FROM AUTHOR]

Double fortified salt (DFS) has proven efficacy in addressing iron deficiency and anaemia, thus improving maternal and child nutrition outcomes. However, DFS delivery in large‐scale settings is less understood, with limited documentation of its fidelity of implementation (FOI). We assessed the FOI of the DFS intervention in Uttar Pradesh, India, to improve the design and implementation of such programmes that aim to reduce the anaemia burden, especially in women of reproductive age (WRA). We conducted in‐depth interviews with DFS programme staff (n = 25) and end‐user WRAs (23), guided by a programme impact pathway. We transcribed and thematically analysed the interviews and used an adapted analytic framework to document FOI across four domains—objects of intervention, implementation staff, implementation context and target of implementation. DFS utilisation remained low due to a combination of factors including poor product quality, distribution challenges, ineffective promotion and low awareness amongst end‐user WRAs. Motivation levels were higher amongst district‐level staff compared to frontline staff, who lacked supervisory support and effective incentives to promote DFS. Three typologies of DFS users emerged—'believers', 'thrifters' and 'naysayers'—who indicated differing reasons for DFS purchase and its use or nonuse. The implementation of the DFS programme varied significantly from its theorised programme impact pathway. The adapted analytic framework helped document FOI and assess the programme's readiness for impact assessments and subsequent scale‐up. The programme needs product quality improvements, incentivised distribution and stronger promotion to effectively deliver and improve the realisation of its potential as an anaemia prevention strategy. [ABSTRACT FROM AUTHOR]

Maternal iodine (I) status is critical in embryonic and foetal development. We examined the effect of preconception iodine supplementation on maternal iodine status and on birth outcomes. Non‐pregnant women in Guatemala, India and Pakistan (n ~ 100 per arm per site) were randomized ≥ 3 months prior to conception to one of three intervention arms: a multimicronutrient‐fortified lipid‐based nutrient supplement containing 250‐μg I per day started immediately after randomization (Arm 1), the same supplement started at ~12 weeks gestation (Arm 2) and no intervention supplement (Arm 3). Urinary I (μg/L) to creatinine (mg/dl) ratios (I/Cr) were determined at 12 weeks for Arm 1 versus Arm 2 (before supplement started) and 34 weeks for all arms. Generalized linear models were used to assess the relationship of I/Cr with arm and with newborn anthropometry. At 12 weeks gestation, adjusted mean I/Cr (μg/g) for all sites combined was significantly higher for Arm 1 versus Arm 2: (203 [95% CI: 189, 217] vs. 163 [95% CI: 152, 175], p < 0.0001). Overall adjusted prevalence of I/Cr < 150 μg/g was also lower in Arm 1 versus Arm 2: 32% (95% CI: 26%, 38%) versus 43% (95% CI: 37%, 49%) (p = 0.0052). At 34 weeks, adjusted mean I/Cr for Arm 1 (235, 95% CI: 220, 252) and Arm 2 (254, 95% CI: 238, 272) did not differ significantly but were significantly higher than Arm 3 (200, 95% CI: 184, 218) (p < 0.0001). Nominally significant positive associations were observed between I/Cr at 12 weeks and birth length and head circumference z‐scores (p = 0.028 and p = 0.005, respectively). These findings support the importance of first trimester iodine status and suggest need for preconception supplementation beyond salt iodization alone. [ABSTRACT FROM AUTHOR]

Gender disparities in child undernutrition and mortality in India have been a topic of interest for a long time, but little is known on trends or geographic variability in recent periods. We examined the degree to which historic patterns in gender disparities in child undernutrition and mortality in India have persisted given recent progress in health and nutrition. Using two nationally representative datasets from India between 2006 and 2016, we estimated mortality rates and stunting by gender and by birth order among children under 5 years old. We then tested for differences between boys and girls within each survey round for both national and state levels using bootstrapped standard errors, controlling for cluster and sampling weights. We found striking progress in child mortality and stunting in India between 2006 and 2016 for both boys and girls. Boys were more likely to die than girls during the first year of life. Girls had a higher risk of mortality between age 1 and 5 years than boys in 2006, but the improvements in survival eliminated this gender gap in 2016. For stunting, we found no gender difference in 2006, but girls had higher height‐for‐age Z‐scores (HAZ) and lower stunting than boys in 2016. Trends in gender gaps in mortality and stunting vary substantially by birth order and between states. Our findings indicate that improvements in mortality and nutritional status among girls have started to close gender disparities. Policy efforts to close gaps must stay the course in states that have made progress and be accelerated in states where disparities are still prominent. [ABSTRACT FROM AUTHOR]

Mycotoxins are carcinogenic secondary metabolites of fungi that have been linked to infant growth faltering. In this study, we quantified co‐occurring mycotoxins in breast milk and food samples from Haryana, India, and characterized determinants of exposure. Deterministic risk assessment was conducted for mothers and infants. We examined levels of eight mycotoxins (Aflatoxin B1, B2, G1, G2, M1, M2; Ochratoxin A, B) in 100 breast milk samples (infants 2–4 months) using ultra‐high‐performance liquid chromatography tandem mass spectrometry. Aflatoxin B1 (AFB1), fumonisin B1 (FB1) and deoxynivalenol (DON) were detected in several food items (n = 298) using enzyme‐linked immunosorbent assays. We report novel data on the presence of mycotoxins in breast milk samples from India. Whereas breast milk concentrations (AFM1 median: 13.7; range: 3.9–1200 ng/L) remain low, AFM1 was detected above regulatory limits in 27% of animal milk samples. Additionally, 41% of infants were above provisional maximum tolerable daily intake (PMTDI) limits for AFM1 due to consumption of breast milk (mean: 3.04, range: 0.26–80.7 ng kg−1 bw day−1). Maternal consumption of breads (p < 0.05) was associated with breast milk AFM1 exposure. AFB1 (μg/kg) was detected in dried red chilies (15.7; 0–302.3), flour (3.13; 0–214.9), groundnuts (0; 0–249.1), maize (56.0; 0–836.7), pearl millet (1.85; 0–160.2), rice (0; 0–195.6), wheat (1.9; 0–196.0) and sorghum (0; 0–63.5). FB1 (mg/kg) was detected in maize (0; 0–61.4), pearl millet (0; 0–35.4) and sorghum (0.95; 0–33.2). DON was not detected in food samples. Mothers in our study exceeded PMTDI recommendations for AFB1 due to consumption of rice and flour (mean: 75.81; range: 35.2–318.2 ng kg−1 bw day−1). Our findings show the presence of Aflatoxin B1 and M1 at various levels of the food chain and in breast milk, with estimated intakes exceeding PMTDI recommendations. Aflatoxins are known carcinogens and have also been linked to stunting in children. Their presence across the food system and in breast milk is concerning, thus warranting further research to replicate and expand on our findings and to understand implications for maternal and child health. [ABSTRACT FROM AUTHOR]

Like several indigenous populations, Sauria Paharias, a vulnerable indigenous tribal group residing in a biodiverse environment of Jharkhand, India, have high levels of undernutrition. We assessed agroforestry and dietary diversity, food consumption especially indigenous food (IF) intake and nutritional status of Sauria Paharia women through a cross‐sectional study conducted in 18 villages of Godda district, Jharkhand. Household level information was elicited through household surveys including a dietary survey and a food frequency questionnaire. Twenty‐four‐hour dietary recalls (24 HDR) and anthropometric assessments were taken on one randomly selected woman per household. An index, Food Accessed Diversity Index (FADI) created to measure agroforestry diversity, showed a low mean score of 0.21 ± 0.15 and range: 0, 0.85. Fifty‐nine percent of women consumed any IF during 24 HDR. Median minimum dietary diversity score for women (MDD‐W) was 3 (acceptable score ≥5). More than 96% of women had intakes below estimated average requirements for all nutrients studied (energy; vitamins A, C, thiamine, riboflavin, niacin, pyridoxine; folate; iron; calcium and zinc) except protein; 41% women were underweight. IF consumption was independently associated with calcium and vitamin A intake. Decision trees developed for micronutrient consumption at different levels of MDD‐W score and IF consumption scenarios revealed 1.3 to 2.9 times higher consumption of micronutrients among women with MDD‐W ≥ 3 or 4. Strategies like agricultural extension programmes promoting indigenous varieties and nutrition education for increasing dietary diversity with IFs have potential to address undernutrition in Sauria Paharia women. [ABSTRACT FROM AUTHOR]

This research examines the nature of dynamic capabilities and the organizational conditions that enhance the dynamic capabilities of the organization. The analysis is carried out by using cybernetics theory and specifically the viable system model. It highlights the critical role played in the creation and maintenance of dynamic capabilities by three constructs at the organization level—organizational identity, organizational mindfulness, and organizational fragmentation. The research uses the concept of embedded case studies and focuses on three airlines in the Indian civil aviation sector from 2007 to 2017, a period that was highly competitive and turbulent for the domestic aviation sector, with the three airlines showing markedly differing growth trajectories through this period. [ABSTRACT FROM AUTHOR]

Multiple micronutrient deficiencies (MNDs) co‐exist, often because of poor intakes and adversely impact health. Habitual diets were assessed in 300 school children (6–17 years old) recruited from two government schools by simple random sampling. Probability of adequacy (PA) for 11 micronutrients and mean probability of adequacy (MPA) was calculated. Haemoglobin, plasma ferritin, folic acid, vitamin B12 and C‐reactive protein were estimated. Descriptive statistics and regression analysis were used to estimate magnitude and factors associated with MNDs. The contribution of fortified foods and/or supplements in addressing inadequacies and excessive intakes was modelled. The PA ranged from 0.04 for folate to 0.70 for zinc, and the MPA was 0.27. Prevalence of anaemia (53%), iron deficiency (57%; ID), iron deficiency anaemia (38%; IDA), folate deficiency (24%) and B12 deficiency (43%) was high. Dietary inadequacy of iron, zinc and a low MPA was associated with anaemia and IDA. Inclusion of double fortified salt (DFS), fortified rice (FR) or iron folic acid (IFA) supplements individually in habitual diet reduced probability of iron inadequacy significantly from 82% to ≤13%. Inclusion of DFS and FR simultaneously led to disappearance of iron inadequacy, but risk of excessive intake increased to 16%. Inclusion of DFS, FR and IFA together increased risk of excess iron intake to 40%. Nevertheless, intakes of folate and B12 remained inadequate even with FR and/or IFA. These results indicate a high risk of dietary MNDs in children and suggest need for more systematic intake measurements in representative sample and adjustment of iron dosages to avoid excessive intakes. [ABSTRACT FROM AUTHOR]

A cluster randomized trial design was used to test the efficacy of a behaviour change communication intervention on the quality of the home environment and infant development at 15 months of age. Children (n = 600) in rural South India were followed from 3 through 15 months of age. The control group (C group) received the standard of care, the complementary feeding group (CF group) received recommendations on complementary foods and the responsive complementary feeding and play group (RCF&P group) received recommendations on complementary foods plus skills on responsive feeding and play. The intervention was delivered in biweekly home visits to caregivers using flip charts. At postintervention, infants (n = 521) were assessed for development (Bayley‐II scales) and their home environment was assessed (Home Observation for Measurement of the Environment [HOME] scale). Cluster adjusted analysis of variance showed no significant differences at baseline. The HOME score at 15 months differed by group, F(2, 38) = 6.41, P = 0.004; the CF and RCF&P groups had higher scores than the C group. Scores on subscales 'Opportunities for Variety in Daily Stimulation' and 'Caregiver Promotion of Child Development' (CPCD) were higher for the RCF&P group than for the C and CF groups. Mental development index (MDI) scores differed by group, F(2, 37) = 3.31, P = 0.04, with the RCF&P group showing higher scores than the C group (P < 0.04); no differences were noted in psychomotor development index (PDI) scores (P = 0.48). The subscales of HOME associated with MDI at 15 months were 'CPCD' and 'Cleanliness of Child' (R2 = 0.076). 'CPCD' was also associated with PDI (R2 = 0.039). A responsive complementary feeding and play intervention delivered through home visits benefitted children's mental development and caregiving environment at 15 months. [ABSTRACT FROM AUTHOR]

Land size is an important equity concern for the design of 'nutrition‐sensitive' agricultural interventions. We unpack some of the pathways between land and nutrition using a cross‐sectional baseline survey data set of 4,480 women from 148 clusters from the 'Upscaling Participatory Action and Videos for Agriculture and Nutrition' trial in Keonjhar district in Odisha, India. Variables used are household ln‐land size owned (exposure) and maternal dietary diversity score out of 10 food groups and body mass index (BMI; kg/m2) (outcomes); and mediators investigated are production diversity score, value of agricultural production, and indicators for women's empowerment (decision‐making in agriculture, group participation, work‐free time and land ownership). We assessed mediation using a non‐parametric potential outcomes framework method. Land size positively affects maternal dietary diversity scores [β 0.047; 95% confidence interval (CI) (0.011, 0.082)] but not BMI. Production diversity, but not value of production, accounts for 17.6% of total effect mediated. We observe suppression of the effect of land size on BMI, with no evidence of a direct effect for either of the agricultural mediators but indirect effects of β −0.031 [95% CI (−0.048, −0.017)] through production diversity and β −0.047 [95% CI (−0.075, −0.021)] through value of production. An increase in land size positively affects women's decision‐making, which in turn negatively affects maternal BMI. The positive effect of work‐free time on maternal BMI is suppressed by the negative effect of household land size on work‐free time. Agriculture interventions must consider land quality, women's decision‐making and implications for women's workload in their design. [ABSTRACT FROM AUTHOR]

This study aimed to examine the association between breastfeeding and childhood obesity. A multinational cross‐sectional study of 4,740 children aged 9–11 years was conducted from 12 countries. Infant breastfeeding was recalled by parents or legal guardians. Height, weight, waist circumference, and body fat were obtained using standardized methods. The overall prevalence of obesity, central obesity, and high body fat were 12.3%, 9.9%, and 8.1%, respectively. After adjustment for maternal age at delivery, body mass index (BMI), highest maternal education, history of gestational diabetes, gestational age, and child's age, sex, birth weight, unhealthy diet pattern scores, moderate‐to‐vigorous physical activity, sleeping, and sedentary time, exclusive breastfeeding was associated with lower odds of obesity (odds ratio [OR] 0.76, 95% confidence interval, CI [0.57, 1.00]) and high body fat (OR 0.60, 95% CI [0.43, 0.84]) compared with exclusive formula feeding. The multivariable‐adjusted ORs based on different breastfeeding durations (none, 1–6, 6–12, and > 12 months) were 1.00, 0.74, 0.70, and 0.60 for obesity (Ptrend =.020) and 1.00, 0.64, 047, and 0.64 for high body fat (Ptrend =.012), respectively. These associations were no longer significant after adjustment for maternal BMI. Breastfeeding may be a protective factor for obesity and high body fat in 9‐ to 11‐year‐old children from 12 countries. [ABSTRACT FROM AUTHOR]

A quarter of 400 million urban Indian residents are poor. Urban poor women are as undernourished as or worse than rural women but urban averages mask this disparity. We present the spectrum of malnutrition and their determinants for more than 26,000 urban women who gave birth within 5 years from the last two rounds of Demographic Health Survey 2006 and 2016. Among urban mothers in the lowest quartile by wealth index (urban poor), 12.8% (95% CI [11.3%, 14.5%]) were short or with height < 145 cm; 20.6% (95% CI [19%, 22.3%]) were thin or with body mass index < 18.5 kg/m2; 57.4% (95% CI [55.5%, 59.3%]) had any anaemia (haemoglobin < 12 g/dL), whereas 32.4% (95% CI [30.5%, 34.3%]) had moderate to severe anaemia; and 21.1% (95% CI [19.3%, 23%]) were obese (body mass index ≥ 25 kg/m2). Decadal gains were significant for thinness reduction (17p.p.) but obesity increased by 12 p.p. Belonging to a tribal household increased odds of thinness by 1.5 (95% CI [1.06, 2.18]) times among urban poor mothers compared with other socially vulnerable groups. Secondary education reduced odds of thinness (0.61; 95% CI [0.48, 0.77]) and higher education of short stature (0.41; 95% CI [0.18, 0.940]). Consuming milk/milk products, pulses/beans/eggs/meats, and dark green leafy vegetables daily reduced the odds of short stature (0.52; 95% CI [0.35, 0.78]) and thinness (0.72; 95% CI [0.54, 0.98]). Urban poor mothers should be screened for nutritional risks due to the high prevalence of all forms of malnutrition and counselled or treated as per risk. [ABSTRACT FROM AUTHOR]

Evidence on strategies to improve infant and young child feeding in India, a country that carries the world's largest burden of undernutrition, is limited. In the context of a programme evaluation in two districts in Uttar Pradesh, we sought to understand the multiple influences on breastfeeding practices and to model potential programme influence on improving breastfeeding. A cross‐sectional survey was conducted among 1,838 recently delivered women, 1,194 husbands, and 1,353 mothers/mothers‐in‐law. We used bivariate and multivariable logistic regression models to examine the association between key determinants (maternal, household, community, and health services) and breastfeeding outcomes [early initiation of breastfeeding (EIBF)], prelacteal feed, and exclusive breastfeeding (EBF). We used population attributable risk analysis to estimate potential improvement in breastfeeding practices. Breastfeeding practices were suboptimal: EIBF (26.3%), EBF (54%), and prelacteal feeding (33%). EIBF was positively associated with maternal knowledge, counselling during pregnancy/delivery, and vaginal delivery at a health facility. Prelacteal feeds were less likely to be given when mothers had higher knowledge, beliefs and self‐efficacy, delivered at health facility, and mothers/mothers‐in‐law had attended school. EBF was positively associated with maternal knowledge, beliefs and self‐efficacy, parity, and socio‐economic status. High maternal stress and domestic violence contributed to lower EBF. Under optimal programme implementation, we estimate EIBF can be improved by 25%, prelacteal feeding can be reduced by 25%, and EBF can be increased by 23%. A multifactorial approach, including maternal‐, health service‐, family‐, and community‐level interventions has the potential to lead to significant improvements in breastfeeding practices in Uttar Pradesh. [ABSTRACT FROM AUTHOR]

Many interventions focus on preventing stunting in the first 1,000 days of life. We take a broader perspective on childhood growth to assess the proportions of children who suffer persistent stunting, recover, and falter and become newly stunted between birth and adolescence. We use longitudinal data collected on 7,128 children in Ethiopia, India, Peru, and Vietnam. Data were collected in five survey waves between the ages of 1 to 15 years. We use descriptive and graphical approaches to compare the trajectories of children first stunted by age 1, first stunted by age 5, and those remained not stunted until age 5. On average, 29.6% of children were first stunted by age 1, 12.9% of children were first stunted by the age 5, and 68.7% of children were not stunted at either age 1 or age 5. A larger percentage of children stunted by age 1 remained stunted at age 15 (40.7%) compared with those who were first stunted by age 5 (32.3%); 33.7% of children first stunted by age 1 and 31.1% of children first stunted by age 5 go on to recover, but then falter during later childhood. 13.1% of children who were not stunted at age 1 or age 5 become newly stunted between the ages of 8 and 15. Our results show that children both become stunted and recover from stunting into adolescence. More attention should be paid to interventions to support healthy growth throughout childhood. [ABSTRACT FROM AUTHOR]

Abstract: Maternal depression has been suggested as a risk factor for both poor child growth and development in many low‐ and middle‐income countries, but the validity of many studies is hindered by small sample sizes, varying cut‐offs used in depression diagnostics, and incomplete control of confounding factors. This study examines the association between maternal depressive symptoms (MDSs) and child physical growth and cognitive development in Madhya Pradesh, India, where poverty, malnutrition, and poor mental health coexist. Data were from a baseline household survey (n = 2,934) of a randomized controlled trial assessing an early childhood development programme. Multivariate linear and logistic regression analyses were conducted, adjusting for socio‐economic factors to avoid confounding the association of mental health and child outcomes. MDS (measured using the Center for Epidemiologic Studies Short Depression Scale) was categorized as low, medium, and high in 47%, 42%, and 10% of mothers, respectively. The prevalence of child developmental delay ranged from 16% to 27% for various development domains. Compared with children of mothers with low MDS, those of high MDS mothers had lower height‐for‐age, weight‐for‐age, and weight‐for‐height z‐scores (0.22, 0.21, and 0.15, respectively), a higher rate of stunting and underweight (~1.5 times), and higher rate of developmental delay (partial adjusted odds ratio ranged from 1.3–1.8 for different development domains and fully adjusted odds ratio = 1.4 for fine motor). Our results—that MDS is significantly associated with both child undernutrition and development delay—add to the call for practical interventions to address maternal depression to simultaneously address multiple outcomes for both women and children. [ABSTRACT FROM AUTHOR]

Abstract: India accounts for approximately one third of the world's total population of stunted preschoolers. Addressing global undernutrition, therefore, requires an understanding of the determinants of stunting across India's diverse states and districts. We created a district‐level aggregate data set from the recently released 2015–2016 National and Family Health Survey, which covered 601,509 households in 640 districts. We used mapping and descriptive analyses to understand spatial differences in distribution of stunting. We then used population‐weighted regressions to identify stunting determinants and regression‐based decompositions to explain differences between high‐ and low‐stunting districts across India. Stunting prevalence is high (38.4%) and varies considerably across districts (range: 12.4% to 65.1%), with 239 of the 640 districts have stunting levels above 40% and 202 have prevalence of 30–40%. High‐stunting districts are heavily clustered in the north and centre of the country. Differences in stunting prevalence between low and high burden districts were explained by differences in women's low body mass index (19% of the difference), education (12%), children's adequate diet (9%), assets (7%), open defecation (7%), age at marriage (7%), antenatal care (6%), and household size (5%). The decomposition models explained 71% of the observed difference in stunting prevalence. Our findings emphasize the variability in stunting across India, reinforce the multifactorial determinants of stunting, and highlight that interdistrict differences in stunting are strongly explained by a multitude of economic, health, hygiene, and demographic factors. A nationwide focus for stunting prevention is required, while addressing critical determinants district‐by‐district to reduce inequalities and prevalence of childhood stunting. [ABSTRACT FROM AUTHOR]

Policy Points: Per‐capita household health spending was higher in economically developed states and was associated with ability to pay, but catastrophic health spending (CHS) was equally high in both poorer and more developed states in India. Based on multilevel modeling, we found that the largest geographic variation in health spending and CHS was at the state and village levels, reflecting wide inequality in the accessibility to and cost of health care at these levels. Contextual factors at macro and micro political units are important to reduce health spending and CHS in India. Context: In India, health care is a local good, and households are the major source of financing it. Earlier studies have examined diverse determinants of health care spending, but no attempt has been made to understand the geographical variation in household and catastrophic health spending. We used multilevel modeling to assess the relative importance of villages, districts, and states to health spending in India. Methods: We used data on the health expenditures of 101,576 households collected in the consumption expenditure schedule (68th round) carried out by the National Sample Survey in 2011‐2012. We examined 4 dependent variables: per‐capita health spending (PHS), per‐capita institutional health spending (PIHS), per‐capita noninstitutional health spending (PNHS), and catastrophic health spending (CHS). CHS was defined as household health spending exceeding 40% of its capacity to pay. We used multilevel linear regression and logistic models to decompose the variation in each outcome by state, region, district, village, and household levels. Findings: The average PHS was 1,331 Indian rupees (INR), which varied by state‐level economic development. About one‐fourth of Indian households incurred CHS, which was equally high in both the economically developed and poorer states. After controlling for household level factors, 77.1% of the total variation in PHS was attributable to households, 10.1% to states, 9.5% to villages, 2.6% to districts, and 0.7% to regions. The pattern in variance partitioning was similar for PNHS. The largest interstate variation was found for CHS (15.9%), while the opposite was true for PIHS (3.2%). Conclusions: We observed substantial variations in household health spending at the state and village levels compared with India's districts and regions. The large variation in CHS attributable to states indicates interstate inequality in the accessibility to and cost of health care. Our findings suggest that contextual factors at the macro and micro political units are important to reduce India's household health spending and CHS. [ABSTRACT FROM AUTHOR]

Abstract: A community‐based cross‐sectional study was carried out with 603 children ages 5 and under and 500 of their mothers from 510 households to examine the prevalence of undernutrition and chronic diseases among the Khasis of North‐East India. Anthropometric measurements including Mid‐Upper Arm Circumference, height, and weight were taken. Dry blood spots to estimate haemoglobin and vitamin A were collected from children and women separately by finger prick. Mothers provided data about household socio‐demographic particulars and infant and young child feeding practices. The prevalence in children of underweight was 31%, stunting was 57%, and wasting was 10%. Undernutrition was higher among boys as compared to girls. Nutrient intakes were below recommended levels. The prevalence of anaemia among children ages 1 to 5 years old was 68%, and vitamin A deficiency was 59%, and they were 83% and 48%, respectively, among women. Hypertension was observed in 15% of women, whereas diabetes was less than 1%. Only about 20% of households were food secure, and this was associated with parental literacy, per capita income, and family size. Undernutrition was unacceptably high among the Khasis despite rich food biodiversity. Proper implementation of nutritional intervention programs such as Integrated Child Development Services, Mid Day Meal, and the Public Distribution System will improve the nutrient intake and nutritional status of the population. Additionally, preservation of forest lands and products paired with judicious use of the rich food biodiversity available will promote dietary diversity and ultimately better nutrition and health. [ABSTRACT FROM AUTHOR]

We analyse data from the 2012 Comprehensive Nutrition Survey in the State of Maharashtra, India, which surveyed 2,630 households. This is a unique dataset because in addition to nutritional status of mothers and children, it has information on diets of women and children and household food security. This rich dataset allows us to address three issues: whether household food security predicts higher diet diversity in children aged 6-23 months; whether household food security predicts lower risk of undernutrition; and whether the lower risk of undernutrition in children who live in food secure households is mediated by improved diet diversity for children. We find that children from moderately food insecure and severely food insecure households are more likely to have lower diet diversity scores. We find that the odds of a child being severely stunted, severely underweight, or severely wasted are higher in severely food insecure households. After controlling for children's diet diversity, and other child, maternal and household characteristics, we find that household food security is no longer statistically associated with stunting, wasting, or underweight. However, diet diversity of children is statistically significantly associated with whether a child is stunted or underweight. Our results although not causal provide evidence for understanding the extent to which household food insecurity affects children's diet diversity and how both these factors affect nutrition outcomes in children. Our analysis informs Government of Maharashtra's and India's National Nutrition Mission in their efforts for formulating appropriate policies and programmes to address child undernutrition. [ABSTRACT FROM AUTHOR]

With child malnutrition detected as a persistent problem in most of the developing countries, public policy has been directed towards offering community-based supplementary feeding provision and nutritional information to caregivers. India, being no exception, has initiated these programs as early as 1970s under integrated child development scheme. Using propensity score matching technique on primary data of 390 households in two districts of West Bengal, an Eastern state in India, the study finds that impact of being included in the program and receiving supplementary feeding is insignificant on child stunting measures, though the program can break the intractable barriers of child stunting only when the child successfully receives not only just the supplementary feeding but also his caregiver collects crucial information on nutritional awareness and growth trajectory of the child. Availability of regular eggs in the feeding diet too can reduce protein-related undernutrition. Focusing on just feeding means low depth of other services offered under integrated child development scheme, including pre-school education, nutritional awareness, and hygiene behavior; thus repealing a part of the apparent food-secure population who puts far more importance on the latter services. [ABSTRACT FROM AUTHOR]

The lipid composition of breast milk may have a significant impact on early infant growth and cognitive development. Comprehensive breast milk data is lacking from low-income populations in the Indian subcontinent impeding assessment of deficiencies and limiting development of maternal nutritional interventions. A single breast milk specimen was collected within 6 weeks postpartum from two low-income maternal cohorts of exclusively breastfed infants, from Dhaka, Bangladesh ( n = 683) and Kolkata, India ( n = 372) and assayed for percentage composition of 26 fatty acids. Mature milk (>15 days) in Dhaka ( n = 99) compared to Kolkata ( n = 372) was higher in total saturated fatty acid (SFA; mean 48% vs. 44%) and disproportionately lower in ω3-polyunsaturated fatty acid (PUFA), hence the ω6- and ω3-PUFA ratio in Dhaka were almost double the value in Kolkata. In both sites, after adjusting for days of lactation, increased maternal education was associated with decreased SFA and PUFA, and increasing birth order or total pregnancies was associated with decreasing ω6-PUFA or ω3-PUFA by a factor of 0.95 for each birth and pregnancy. In Dhaka, household prosperity was associated with decreased SFA and PUFA and increased ω6- and ω3-PUFA. Maternal height was associated with increased SFA and PUFA in Kolkata (1% increase per 1 cm), but body mass index showed no independent association with either ratio in either cohort. In summary, the socioeconomic factors of maternal education and household prosperity were associated with breast milk composition, although prosperity may only be important in higher cost of living communities. Associated maternal biological factors were height and infant birth order, but not adiposity. Further study is needed to elucidate the underlying mechanisms of these effects. [ABSTRACT FROM AUTHOR]

The World Health Organisation has called for global action to reduce child stunting by 40% by 2025. One third of the world's stunted children live in India, and children belonging to rural indigenous communities are the worst affected. We sought to identify the strongest determinants of stunting among indigenous children in rural Jharkhand and Odisha, India, to highlight key areas for intervention. We analysed data from 1227 children aged 6–23.99 months and their mothers, collected in 2010 from 18 clusters of villages with a high proportion of people from indigenous groups in three districts. We measured height and weight of mothers and children, and captured data on various basic, underlying and immediate determinants of undernutrition. We used Generalised Estimating Equations to identify individual determinants associated with children's height‐for‐age z‐score (HAZ; p < 0.10); we included these in a multivariable model to identify the strongest HAZ determinants using backwards stepwise methods. In the adjusted model, the strongest protective factors for linear growth included cooking outdoors rather than indoors (HAZ +0.66), birth spacing ≥24 months (HAZ +0.40), and handwashing with a cleansing agent (HAZ +0.32). The strongest risk factors were later birth order (HAZ −0.38) and repeated diarrhoeal infection (HAZ −0.23). Our results suggest multiple risk factors for linear growth faltering in indigenous communities in Jharkhand and Odisha. Interventions that could improve children's growth include reducing exposure to indoor air pollution, increasing access to family planning, reducing diarrhoeal infections, improving handwashing practices, increasing access to income and strengthening health and sanitation infrastructure. [ABSTRACT FROM AUTHOR]

Empirical evidence suggests that macroeconomic growth in India is not correlated with any substantial reductions in the prevalence of child undernutrition over time. This study investigates the two commonly hypothesized pathways through which macroeconomic growth is expected to reduce child undernutrition: (1) an increase in public developmental expenditure and (2) a reduction in aggregate income ‐ poverty levels. For the anthropometric data on children, we draw on the data from two cross ‐ sectional waves of National Family Health Survey conducted in 1992–1993 and 2005–2006, while the data for per capita net state domestic product and per capita public spending on developmental expenditure and headcount ratio of poverty were obtained from the Reserve Bank of India and the Government of India expert committee reports. We find that between 1992–1993 and 2005–2006, state ‐ level macroeconomic growth was not associated with any substantial increases in public development expenditure or substantial reductions in poverty at the aggregate level. Furthermore, the association between changes in public development expenditure or aggregate poverty and changes in undernutrition was small. In summary, it appears that the inability of macroeconomic growth to translate into reductions in child undernutrition in India is likely a consequence of the macroeconomic growth not translating into substantial investments in development expenditure that could matter for children's nutritional status and neither did it substantially improve incomes of the poor, a group where undernutrition is also the highest. The findings here build a case to advocate a ‘support ‐ led’ strategy for reducing undernutrition rather than simply relying on a ‘growth ‐ mediated’ strategy. Key messagesIncreases in macroeconomic growth have not been accompanied by substantial increases in public developmental spending or reduction in aggregate poverty headcount ratio in India.Association between increases in public development expenditure or poverty headcount ratios and changes in child undernutrition, in particular, child stunting, is small to null.Reducing the burden of undernutrition in India cannot be accomplished solely relying on a growth ‐ mediated strategy, and a concerted support ‐ led strategy is required. [ABSTRACT FROM AUTHOR]

In India most childhood nutrition recommendations and interventions are still not focused on infants under 6 months. Secondary data analyses of National Family Health Survey-3 data from India were analysed to compare the prevalence of wasting, stunting and underweight in infants less than 6 months and 6-59 months. Our results revealed that wasting was higher (31%) in infants less than 6 months (P < 0.05) as compared with children between 6 and 59 months. Thirteen per cent of infants less than 6 months had severe wasting, 30% were underweight and 20% were stunted. Most infants (69%) were exclusively breastfed (EB) for the first 2 months, but exclusive breastfeeding dropped to 50% at 2-3 months and to 27% at 4-5 months. There was no statistically significant difference in wasting and stunting in the EB and not exclusively breastfed (NEB) groups. Significantly fewer EB infants were underweight (28%) compared with NEB infants (31%) (P = 0.030). However, among EB children, 29% had wasting and 21% were stunted. Eleven per cent of EB infants were severely underweight, 13% were severely wasted and 9% were severely stunted. Diarrhoea was significantly lower among EB infants compared with NEB infants (P < 0.05). We conclude that infants less than 6 months of age are vulnerable to suffer from acute severe malnutrition irrespective of their breastfeeding status and need to be seriously considered for inclusion in national guidelines for early detection and management of undernutrition. [ABSTRACT FROM AUTHOR]

India's Integrated Child Development Services (ICDS) provides daily supplementary nutrition and other public health services to women and children. We estimated associations between exposure to early‐childhood ICDS nutrition and adult reproductive outcomes. During 1987–1990, a balanced protein–calorie supplement called "upma"—made from locally available corn–soya ingredients—was rolled out by subdistricts near Hyderabad and offered to pregnant women and children under age 6 years. In a controlled trial, 15 villages received the supplement and 14 did not. We used data from a 2010–2012 resurvey of adults born during the trial (n = 715 in intervention and n = 645 in control arms). We used propensity score matching methods to estimate the associations between birth in an intervention village and menarcheal age, age at first pregnancy, and fertility of adults. We found that women born in the intervention group during the trial, as compared with the control group, had menarche 0.45 (95% confidence interval [CI: 0.22, 0.68]; p <.001) years later and first pregnancy 0.53 (95% CI [0.04, 1.02]; p <.05) years later. Married women from the intervention group had menarche 0.36 (95% CI [0.09, 0.64]; p <.01) years later, first cohabitation with partner 0.8 (95% CI [0.27, 1.33]; p <.01) years later, and first pregnancy 0.53 (95% CI [0.04, 1.02]; p <.05) years later than married women in the control group. There was no significant difference between intervention and control group women regarding whether they had at least one childbirth or the total number of children born. The findings were similar when we employed inverse propensity score weighted regression models. [ABSTRACT FROM AUTHOR]

Inadequate dietary intake is a critical underlying determinant of child undernutrition. This study examined the association between anthropometric‐based and food‐based nutritional failure among children in India. We used the 2015–2016 National Nutrition Monitoring Bureau data where anthropometric outcomes and food intake were both measured for each child. We followed the World Health Organization child growth reference standards to define anthropometric failures (i.e., height‐for‐age z score < −2 SD for stunting, weight‐for‐age z score < −2 SD for underweight, and weight‐for‐height z score < −2 SD for wasting), and the Indian Council of Medical Research recommended dietary allowance (RDA) to define adequacy in intake of calorie, protein, and fat. We used descriptive and regression‐based assessments to test the association between the two indicators of nutritional failure and also computed the area under the receiver operating characteristic curve (AUC). The prevalence of stunting, underweight, and wasting was 28.6%, 24.3%, and 12.8%, respectively, whereas 78.2%, 27.4%, and 50.8% of the children had below RDA norms consumption of calorie, protein, and fat, respectively. We found weak‐to‐null correlation between anthropometric failures and food failures (Pearson correlation ranging from −0.013 to 0.147) and poor discriminatory accuracy (AUC < 0.62), suggesting that in the Indian context, anthropometric failures are not directly associated with food intake. This finding highlights the need for improving adequate intake of macronutrients and draws attention toward adopting a multifactorial approach to improve child nutrition in India. Poor food intake itself merits exclusive policy focus as it is an important nutrition and health concern. [ABSTRACT FROM AUTHOR]

Promoting exclusive breastfeeding (EBF) is a highly feasible and cost‐effective means of improving child health. Regulating the marketing of breastmilk substitutes is critical to protecting EBF. In 1981, the World Health Assembly adopted the World Health Organization International Code of Marketing of Breastmilk Substitutes (the Code), prohibiting the unethical advertising and promotion of breastmilk substitutes. This comparative study aimed to (a) explore the relationships among Code enforcement and legislation, infant formula sales, and EBF in India, Vietnam, and China; (b) identify best practices for Code operationalization; and (c) identify pathways by which Code implementation may influence EBF. We conducted secondary descriptive analysis of available national‐level data and seven high level key informant interviews. Findings indicate that the implementation of the Code is a necessary but insufficient step alone to improve breastfeeding outcomes. Other enabling factors, such as adequate maternity leave, training on breastfeeding for health professionals, health systems strengthening through the Baby Friendly Hospital Initiative, and breastfeeding counselling for mothers, are needed. Several infant formula industry strategies with strong conflict of interest were identified as harmful to EBF. Transitioning breastfeeding programmes from donor‐led to government‐owned is essential for long‐term sustainability of Code implementation and enforcement. We conclude that the relationships among the Code, infant formula sales, and EBF in India, Vietnam, and China are dependent on countries' engagement with implementation strategies and the presence of other enabling factors. [ABSTRACT FROM AUTHOR]

Limited evidence exists on socio‐economic status (SES) inequalities in infant and young child feeding (IYCF) in India. We examine trends and changes in inequalities for IYCF practices over 2006–2016 and identify factors that may explain differences in IYCF across SES groups. We use data from the 2015–2016 and 2005–2006 National Family Health Surveys (n = 112,133 children < 24 months). We constructed SES quintiles (Q) and assessed inequalities using concentration and slope indices. We applied path analyses to examine the relationship between SES inequalities, intermediate determinants, and IYCF. Breastfeeding improved significantly over 2006–2016: from 23% to 42% for early initiation of breastfeeding (EIBF) and 46% to 55% for exclusive breastfeeding (EBF). Minimum dietary diversity (MDD) improved modestly (15% to 21%), but adequate diet did not change (~9%). Large SES gaps (Q5–Q1) were found for EIBF (8–17%) and EBF (−15% to −10%) in 2006; these gaps closed in 2016. The most inequitable practices in 2006 were MDD and iron‐rich foods (Q5 ~ 2–4 times higher than Q1); these gaps narrowed in 2016, but levels are low across SES groups. Factors along the path from SES inequalities to IYCF practices included health and nutrition services, information access, maternal education, number of children < 5 years, and urban/rural residence. The improvements in breastfeeding and narrowing of equity gaps in IYCF practices in India are significant achievements. However, ensuring the health and well‐being of India's large birth cohort will require more efforts to further improve breastfeeding, and concerted actions to address all aspects of complementary feeding across SES quintiles. [ABSTRACT FROM AUTHOR]