Strengthening agriculture-nutrition linkages to improve consumption of nutrient-dense perishable foods in India - existing evidence and way forward

The triple burden of malnutrition in India is largely contributed by poor quality diets lacking adequate intake of nutrient dense perishable foods (NDPFs) - milk, eggs, fruits and vegetables. This is intriguing because India is one of the largest producers of NDPFs. This review examines possible reasons for this disparity. Poor post-harvest infrastructure, price volatility, unorganized supply chains, long-standing government policies favouring cereals and increasing consumer preference of convenience foods are identified as major reasons for the low intake of NDPFs. While nutrition-sensitive agriculture interventions appear promising to improve intakes of NDPF, stronger evidence is needed to scale up these interventions

Eggs for Improving Nutrition, cognitive development and reducing linear growth retardation among Infants and young Children (ENRICH) : Protocol of an egg supplementation trial among children aged 9-18 months in Hyderabad, India

SKB, SRC and BK: conceptualised, designed the study and wrote first draft. LFA, TD, DPP, MC, KS and PA: developed detailed protocols, planned data collection, critical input to manuscript. RM, HD-K, CH, SFR, RPullakhandam, RPalika, RRK, RNK, MLJ and PH: concept, design, critical inputs to manuscript.Peer reviewe

Anthropometric, biochemical, dietary, morbidity and well-being assessments in women and children in Indonesia, India and Senegal : A UKRI GCRF Action Against Stunting Hub protocol paper

HD-K and EF were responsible for the overall design, training and overseeing implementation of the research. UF, MKH, BK, BF, RM, RPullakhandam, RPalika, TD, SFR, SD, RPradeilles, SA, AW, JPW, PH and CH were involved in its design. UF, MKH, BK, BF, DY, DS, NLZ, TCA, RM, RPullakhandam, RPalika, TD, SFR, SKB KS, DPP, DY, SD, PL-S, BD, PM, SF, ID, AD, TDVI, FT, AD, SS, BMK and DTT implemented the research. HD-K and EF wrote the manuscript. All authors read, provided comments on and approved the final version of the manuscript.Peer reviewe

Eggs for Improving Nutrition, cognitive development and reducing linear growth retardation among Infants and young Children (ENRICH): protocol of an egg supplementation trial among children aged 9-18 months in Hyderabad, India.

INTRODUCTION: Evidence on the impact of nutrient-rich animal source foods such as eggs for improving child growth and cognition is inconsistent. This study aims to examine the impact of an egg intervention in children, along with behaviour change communication (BCC) to the mother, on linear growth and cognition, and nutritional status in children aged 9-18 months. METHODS AND ANALYSIS: A 9-month open-labelled randomised controlled trial will be conducted in three urban slums in Hyderabad, India, as a substudy of an observational cohort study (n=350) following pregnant women and their children until 18 months of age in a population at risk of stunting. The children born to women enrolled during the third trimester of pregnancy will be block randomised in a 1:4 ratio into the intervention (n=70) and control (n=280) groups. Children in the intervention group will be supplemented with one egg per day starting from 9 months until 18 months of age. BCC designed to enhance adherence to the intervention will be used. The control group will be a part of the observational cohort and will not receive any intervention from the study team. The primary outcome will be length-for-age z-scores, and the secondary outcomes will include cognition, blood biomarkers of nutritional status including fatty acid profile and epigenetic signatures linked with linear growth and cognition. Multivariate intention-to-treat analyses will be conducted to assess the effect of the intervention. ETHICS AND DISSEMINATION: The study is approved by the Institutional ethics committees of ICMR-National Institute of Nutrition, Hyderabad, India and London School of Hygiene and Tropical Medicine, UK. The results will be published in peer-reviewed journals and disseminated to policy-makers. Findings will also be shared with study participants and community leaders. TRIAL REGISTRATION NUMBER: CTRI/2021/11/038208

Investigating market-based opportunities for the provision of nutritious and safe diets to prevent childhood stunting: a UKRI-GCRF action against stunting hub protocol paper

Background Inadequate access to affordable, safe, desirable and convenient nutrient-dense food is one of the underlying causes of child stunting. While targeted nutrition-sensitive interventions (e.g., backyard ‘nutri-gardens’) may increase dietary diversity within farming households, such interventions have limited scalability across the wider food system where markets remain underdeveloped. This research aims to develop and assess market-based interventions for key nutrient-dense foods to help improve the diets of women and children in the first 1000 days of life. Methods Data collection uses four parallel approaches in each of the three study countries (India, Indonesia and Senegal). (1) A novel food environment tool will be developed to characterise the accessibility and affordability of nutrient-dense foods in the study countries. The tool will be validated through pretesting using cognitive interviewing and piloting in purposively sampled households, 10 (cognitive interviewing) and 30 (piloting) households in each country; (2) stakeholder interviews (e.g., with producers, intermediaries and retailers) will be conducted to map out nutrition-sensitive entry points of key value chains (e.g., animal-sourced foods), before hotspots of potential food safety hazards will be identified from food samples collected along the chains; (3) the Optifood and Agrifood tools will be used to identify foods that can address food system nutrient gaps and engage key stakeholders to prioritise market interventions to improve nutrition outcomes. Optifood and Agrifood parameters will be informed by publicly available data, plus interviews and focus groups with value chain stakeholders; (4) informed by the previous three approaches and a campaign of participatory ‘group model building’, a novel system dynamics model will evaluate the impact of alternative market-based solutions on the availability and affordability of nutrient-dense foods over time. Ethics and dissemination The study has received ethical approval in the United Kingdom, Senegal, Indonesia and India. Dissemination comprises peer-reviewed journals, international disciplinary conferences and multistakeholder dissemination workshops

Anthropometric, biochemical, dietary, morbidity and well-being assessments in women and children in Indonesia, India and Senegal: a UKRI GCRF Action Against Stunting Hub protocol paper.

INTRODUCTION: Child stunting has a complex aetiology, especially in the first 1000 days of life. Nutrition interventions alone have not produced expected impacts in reducing/preventing child stunting, indicating the importance of understanding the complex interplay between environmental, physiological and psychological factors influencing child nutritional status. This study will investigate maternal and child nutrition, health and well-being status and associated factors through the assessment of: (1) anthropometry, (2) biomarkers of nutrition and health status, (3) dietary intakes, (4) fetal growth and development, (5) infant morbidity, (6) infant and young child feeding (IYCF) and (7) perinatal maternal stress, depression and social support. METHODS: This study will be conducted in a prospective pregnancy cohort in India, Indonesia and Senegal. Pregnant women will be recruited in the second (Indonesia, Senegal) and third (India) trimester of pregnancy, and the mother and infant dyads followed until the infant is 24 months of age. During pregnancy, anthropometric measures will be taken, venous blood samples will be collected for biochemical assessment of nutrition and health status, dietary intakes will be assessed using a 4-pass-24-hour dietary recall method (MP24HR), fetal ultrasound for assessment of fetal growth. After birth, anthropometry measurements will be taken, venous blood samples will be collected, MP24HR will be conducted, infant morbidity and IYCF practices will be assessed and a sample of breastmilk will be collected for nutrient composition analyses. Perinatal maternal stress, depression, social support and hair cortisol levels (stress) will be measured. The results from this study will be integrated in an interdisciplinary analysis to examine factors influencing infant growth and inform global efforts in reducing child stunting. ETHICS AND DISSEMINATION: Ethical approval was granted by the Ethics Committee of the London School of Hygiene and Tropical Medicine (17915/RR/17513); National Institute of Nutrition (ICMR)-Ministry of Health and Family Welfare, Government of India (CR/04/I/2021); Health Research Ethics Committee, University of Indonesia and Cipto Mangunkusumo Hospital (KET-887/UN2.F1/ETIK/PPM.00.02/2019); and the Comité National d'Ethique pour la Recherche en Santé, Senegal (Protocole SEN19/78); the Royal Veterinary College (URN SR2020-0197) and the International Livestock Research Institute Institutional Research Ethics Committee (ILRI-IREC2020-33). Results will be published in peer-reviewed journals and disseminated to policy-makers and participating communities

Characterising the fruit and vegetable environment of peri-urban Hyderabad, India

Low fruit and vegetable consumption is a key contributor to all forms of malnutrition. This qualitative study examined the perceptions of people living in peri-urban villages of Hyderabad, India, to characterise the sources of fruit and vegetables, the fruit and vegetable environment, and to inform future interventions to increase fruit and vegetable consumption. Health and food quality were primarily seen through a food safety lens and negative aspects were frequently attributed to increased pesticide use. Availability, price and affordability of fresh fruit and vegetables were important drivers of their acquisition and consumption. Promoting communal gardens may increase the availability of affordable fruit and vegetables, as would promoting cold storage facilities. Financial incentives would likely be effective in increasing consumption of fruit and vegetables

Process evaluation of a financial incentive scheme to increase fruit and vegetable purchasing from unorganised retailers in rural Telangana, India

Objective: To evaluate a randomised controlled trial of a financial incentive scheme (coupon providing ∼20% cashback on purchase of fruits and vegetables from village vendors) aimed at increasing the purchase of fruits and vegetables from unorganised retailers in rural India. Design: The process evaluation used a mixed-methods approach, incorporating semi-structured interviews, routine coupon use data, repeat fruit and vegetable purchase and sales surveys, an end-line survey, and examination of study documentation. Setting: Six rural villages, Telangana, India. Participants: Intervention village residents (maximum N=1,719), fruit and vegetable vendors (N=36), local stakeholders (N=5), intervention implementors (N=3). Results: Share of households reaching the fruit and vegetable purchase target (and receiving the cashback) increased steadily from 13% to 42% across the 12-week trial period. Fruit and vegetable purchasing data suggest that households increased fruit and vegetable purchasing to receive the cashback, and households reported using the cash to purchase additional fruits and vegetables (42% and 73%, respectively). Unexpected consequences included community members’ efforts to receive the cashback without purchasing the target amount of fruits and vegetables, changes in shopping patterns, entry of new vendors into the local market, and potential reductions in vendor sales. Lower socioeconomic position (SEP) households reported using the intervention more and participants felt the intervention was most useful for lower SEP households. Conclusion: Our findings demonstrate the potential of even small financial incentives for changing healthy dietary-related behaviours. However, in unorganised retail settings, care should be taken to ensure that such interventions benefit both consumers and sellers