When public health programs with single nutrients are perceived to have a poor impact on the target health outcome, the policy response can be to supply more, by layering additional mandatory programs upon the extant programs. However, we argue for extreme caution, because nutrients (like medicines) are beneficial in the right dose, but potentially harmful when ingested in excess. Unnecessary motivations for the reactionary layering of multiple intervention programs emerge from incorrect measurements of the risk of nutrient inadequacy in the population, or incorrect biomarker cutoffs to evaluate the extent of nutrient deficiencies. The financial and social costs of additional layered programs are not trivial when traded off with other vital programs in a resource-poor economy, and when public health ethical dilemmas of autonomy, equity, and stigma are not addressed. An example of this conundrum in India is the perception of stagnancy in the response of the prevalence of anemia to the ongoing pharmacological iron supplementation program. The reaction has been a policy proposal to further increase iron intake through mandatory iron fortification of the rice provided in supplementary feeding programs like the Integrated Child Development Services and the School Mid-Day Meal. This is in addition to the ongoing pharmacological iron supplementation as well as other voluntary iron fortifications, such as those of salt and manufactured food products. However, before supplying more, it is vital to consider why the existing program is apparently not working, along with consideration of the potential for excess intake and related harms. This is relevant globally, particularly for countries contemplating multiple interventions to address micronutrient deficiencies. Supplying more by layering multiple nutrient interventions, instead of doing it right, without thoughtful considerations of social, biological, and ethics frameworks could be counterproductive. The cure, then, might well become the malady.
Pulses (also known as legumes) are important in achieving nutrient adequacy in India due to their quality protein content. This study compared district-level pulse production and consumption across India, and household and district-level determinants of pulse intake, including availability, accessibility and affordability, using multi-level models in nationally representative datasets for 2011–12. The per capita consumption was about 50% of recommended intake (80 g/day), even in high-producing districts. District-level pulse production was associated with household pulse intake (2.73 × 10 −8 [5.19 × 10 −9 , 4.94 × 10 −8 ]) and market accessibility (−0.0077 [-0.0133, −0.0021]). Affordability (absolute price of pulse) was also associated with household intake. While agricultural policies relating to pulses have been oriented towards improving pulse output and productivity, forward-looking policies to improve pulse intake should focus on demand-side factors, such as improved market accessibility and the affordability of pulses relative to other foods.
ObjectiveThere are scant empirical data on the impacts of the COVID-19 pandemic on food security across the globe. India is no exception, with insights into the impacts of lockdown on food insecurity now emerging. We contribute to the empirical evidence on the prevalence of food insecurity in Bihar state before and after lockdown, and whether the government’s policy of cash transfer moderated negative effects of food insecurity or not.DesignThis was a longitudinal study.SettingsThe study was conducted in Gaya and Nalanda district of Bihar state in India from December 2019 to September 2020.ParticipantsA total of 1797 households were surveyed in survey 1, and about 52% (n=939) were followed up in survey 2. Valid data for 859 households were considered for the analysis.Main outcome measuresUsing the Food Insecurity Experience Scale, we found that household conditions were compared before and after lockdown. The effect of cash transfers was examined in a quasi-experimental method using a longitudinal study design. Logistic regression and propensity score adjusted analyses were used to identify factors associated with food insecurity.ResultsHousehold food insecurity worsened considerably during lockdown, rising from 20% (95% CI 17.4 to 22.8) to 47% (95% CI 43.8 to 50.4) at the sample mean. Households experiencing negative income shocks were more likely to have been food insecure before the lockdown (adjusted OR 6.4, 95% CI 4.9 to 8.3). However, households that received cash transfers had lower odds of being food insecure once the lockdown was lifted (adjusted OR 0.75, 95% CI 0.56 to 0.99).ConclusionThese findings provide evidence on how the swift economic response to the pandemic crises using targeted income transfers was relatively successful in mitigating potentially deep impacts of food insecurity.
The daily energy requirements are now based on replacing the measured daily energy expenditure (WHO/FAO/UNU 1985). When energy expenditure is equal to energy intake, energy balance is achieved, and is best indicated by weight stability. The specific energy requirement (expenditure) of a population is calculated using a factorial method that is based on the product of estimates of the basal metabolic rate (BMR), and the physical activity level (PAL). Some calculations also consider additional energy expenditure due to the thermic effect of food (TEF) which is typically about 10% of BMR. During pregnancy and in childhood, energy cost of deposition of tissues and optimal growth and during, lactation, energy cost of milk secretion is added. However, the factorial method is potentially problematic, as errors in any one factor propagate through to the final estimate of the requirement. For example, BMR is predicted from age and gender specific equations provided by the FAO/WHO/UNU, but these equations overestimate BMR of adult Indians by 5 to 12%. The PAL used for sedentary activities may also be wrong. In the latest recommendation of the Indian Council of Medical Research, the PAL is taken to be 1.53 for sedentary adults; this may need to be revised to a lower value as studies indicate that PAL of sedentary adult Indians is generally lower. In this context, the current energy recommendation may be overestimated in Indians, and should be reconsidered in the context of the dual burden of nutritional disease.
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