Are 'fruits and vegetables' intake really what they seem in India?

Women's empowerment, household dietary diversity, and child anthropometry among vulnerable populations in Odisha, India

Women's empowerment has been promoted by researchers and development practitioners as one of the most promising strategies to address widespread hunger and malnutrition. However, the relationship between women's empowerment and dietary diversity and child nutrition has rarely been studied among vulnerable populations or individuals at greater risk of poor physical and social health status. Moreover, the effects of different domains of women's empowerment on nutritional outcomes, including dietary diversity and child anthropometry, have rarely been examined, especially with panel data. Using two rounds of panel data from 1900 households and fixed effects regression models, we analyze the effect of women's empowerment on household dietary diversity score (HDDS) and child anthropometry among the particularly vulnerable tribal groups in Odisha, India. We also estimate the effects of various decision-making domains of women's empowerment on HDDS and child anthropometry to understand which empowerment domains matter for nutrition. Results show that women's empowerment is positively associated with HDDS (coef. 0.41 food groups; p < 0.1) and reduces the prevalence of underweight (coef. 39%; p < 0.05) and wasting (coef. 56%; p < 0.1) in children but has no effect on the prevalence of child stunting. Women's empowerment in agricultural input use; output sales; income; food purchases; and credit, group membership, and employment contribute to improved dietary diversity and child nutrition. We conclude that women's empowerment contributes to improved dietary diversity and child nutrition and is a promising strategy to improve farm household diets and child nutrition among vulnerable populations. Strengthening women's empowerment through the promotion of women's access to land and other agricultural inputs, market participation, access to information, capital, and credit is important.

The effects of trade liberalization on inequality in nutrition intake: empirical evidence from Indian districts

BACKGROUND

Despite the positive impact of trade liberalization on food availability in India, severe inequality in nutrition consumption at the district level persists. Empirical evidence on the relationship between trade liberalization and nutrition consumption inequality often offers a country-level perspective and generates disputed outcomes. The study aimed to explore the effects of trade liberalization on inequality in nutrition consumption at the district level in India and to examine the heterogeneity of the impact on different nutrition consumption.

METHODS

Our study employed the Gini Index to measure nutrition consumption inequality of 2 macronutrients and 5 micronutrients at the district level in India during 2009-2011, utilizing the comprehensive FAO/WHO individual food consumption data. The import tariff was adopted as a proxy for trade liberalization, as its externally imposed nature facilitates a causal interpretation. We further identified the direct causal relationship between food trade liberalization and inequality in nutrition consumption using a fixed effects model.

RESULTS

The results show that more than 50% of the individuals in the survey districts did not meet the dietary standards for both macronutrients and micronutrients. Food trade liberalization hindered the improvement of inequality in nutrition consumption. As import tariffs were reduced by 1%, the inequality in intake of calories, zinc, vitamin B1, and vitamin B2 increased significantly by 0.45, 0.56, 0.48, and 0.66, respectively, which might be related to food market performance. The results also highlight the positive role of the gender gap, female-headed households, and caste culture on inequality in nutrition consumption in India.

CONCLUSIONS

To ease the shock of liberalization and minimize its inequality effects, complementary measures should be adopted, such as improving food logistic conditions in poor areas, and nutrition relief schemes.

Assessment of nutritional status and habitual dietary intake of Indian farm women: Evidence from a case study in central India

OBJECTIVES

Nutritional security for women working in agriculture is one of the most serious and persisting concerns in developing countries like India. The present study surveyed the dynamics of nutritional status based on dietary intake, namely calorie, carbohydrate, protein, fat, calcium, folic acid, iron, vitamin, carotene, etc., in the farm women in the central India state of Madhya Pradesh.

METHODS

A total of 225 farm women (ages 18 to 60 y) who were engaged in agricultural activities were selected for this study. The nutritional survey was done by personal interview on food intake with a pretested interview schedule and daily dietary intake. The survey questionnaire includes information on family, socioeconomic status, income, education, occupation, and food habits of the farm women. As "daily dietary intake", respondents were asked to list all foods and beverages consumed for a whole day.

RESULTS

The mean age, height, weight, and body mass index of the respondents were 34.93 y, 1519 mm, 49.47 kg, and 21.5 kg/m2, respectively. Based on different grades of nutrition, body mass index results indicated that 28% were underweight, 52.4% were normal, 17.8% were overweight, and 1.8% were obese. Inequality (estimated by Gini coefficient) analysis found that there is not much variation in the nutrient intake levels across the physical status of the respondents, with the exception of carotene and vitamin C. The classification and regression tree analysis indicated that with the exception of fat, the rest of the nutrients were not significant in determining the farm women's physical status in terms of weight. In the analysis of the waist-to-hip ratio, the risk of metabolic diseases (cardiovascular disease, diabetes, etc.) was higher in the 31- to 40-y age group.

CONCLUSIONS

Overall food frequency indicated that poor intake of micronutrients in their diet according to their work activity results in poor health status. The study affirmed that the actual intake of nutrients varied significantly across the physical status of the farm women, their physical activities carried out, and their monthly income level. The study also suggests various policy options to overcome the nutritional gap in farm women.

Identifying value chain trade-offs from fruit and vegetable aggregation services in Bangladesh using a system dynamics approach

Significant progress has been made in cereal production in Bangladesh due to an agricultural policy environment that prioritizes the productivity of staple crops over fruit and vegetables (F&V). However, many smallholder farmers remain poorly connected to markets, which may lead to a limited supply response of F&V that can reduce opportunities for sufficient intake in neglected, consumer-facing, smaller retail markets. To address this issue, aggregation schemes have been conceived that collect and transport F&Vs on behalf of multiple farmers. Given the volume of horticultural produce produced and the reliance on developed transport infrastructure, aggregation schemes tend to supply wholesale and urban markets rather than underdeveloped rural and isolated markets. To this end, we investigated how a particular aggregation intervention ('Loop') could potentially improve the distribution of F&V to smaller markets whilst improving farmer benefits. We used an innovative system dynamics modeling approach based on Loop`s aggregation services in Jashore, Bangladesh, and to identify the potential trade-offs between consumer outcomes in retail markets and farmer benefits. We find that combining aggregation with a quota at the smaller market, transport subsidy, and current price growth does not result in trade-offs between consumer purchases and farmers`benefits. However, combining aggregation with current price growth can increase demand without losing farmers`benefits. The findings emphasize that standalone and multiple market-oriented interventions generate broader win-win benefits to promote inclusive food systems.

Communication and Social Determinants of Cancer Preventive Behaviors in Adolescents From Low Socio-Economic Backgrounds in India: A Cross-Sectional Study

PURPOSE

Promoting cancer preventive behaviors among adolescents, especially those from lower socioeconomic backgrounds, is crucial due to the significant impact of health behaviors in adolescence on disease risk in adulthood. With India witnessing a rise in cancer incidence and mortality, adolescence becomes a pivotal stage for establishing healthy habits, emphasizing the need for early cancer prevention efforts.

METHODS

This cross-sectional study used survey data from 2242 adolescents attending public schools of Mumbai, India. Multiple logistic regression was conducted to determine the associations between cancer preventive behaviors and: (1) the individual and social determinants of health, and (2) media exposure.

FINDINGS

Merely 21.5% of the adolescents ate fruits and vegetables daily, 50% of the adolescents exercised 3 or more times a week, and 20% of the adolescents admitted having used tobacco and/or supari. Girls were found to have lower odds of exercising, as well as using tobacco and/or supari. Wealth and father's education were positively associated with all 3 cancer preventive behaviors. Media exposure was negatively associated, with television exposure linked to reduced fruits and vegetables consumption, while movies and social media exposure were associated with increased tobacco and/or supari use.

INTERPRETATION

Our findings suggest that individual and social determinants of health and media exposure can influence cancer preventive health behaviors in low socio-economic status (SES) adolescents. Efforts to increase awareness to promote cancer preventive behaviors among the adolescents, particularly low SES adolescents, a population more vulnerable to poor health outcomes, is critical.

Dietary intakes of hypertensive patients in rural India: Secondary outcomes of a randomised, double-blind, controlled trial

Background

Hypertension is highly prevalent in India; however, little is known about the dietary intakes of those living with hypertension, particularly in rural areas. The primary aim was to assess the dietary intakes of individuals living in rural India with self-reported history of hypertension. As secondary analyses, we explored the dietary impact of a salt substitute in this population group.

Materials and methods

This study used data from a large randomised controlled trial conducted in seven villages across rural India. Participants received either regular salt (100% sodium chloride) or the salt substitute (70% sodium chloride/30% potassium chloride) to replace all home salt use. Dietary intake at baseline and end-of-trial was assessed using 24-h dietary recalls. A range of dietary outcomes were assessed including energy intake, macronutrient intake and overall diet quality according to the Alternate Healthy Eating Index (AHEI).

Results

A total of 454 participants were included in the analysis. At baseline, mean (SE) energy intakes in regular salt group and salt substitute group were similar at 5240 (110) kJ/day and 5120 (106) kJ/day, respectively. This was largely attributable to intakes of carbohydrates (74.4% of total energy intakes for regular salt group vs 75.4% for the salt substitute group) followed by total fat (15.8% vs 15.4%) and protein (10.4% vs 10.3%). Both groups also had similar AHEI scores at baseline, with mean (SE) total scores equating to 33.0 (0.4) (out of a total 90) for the regular salt group and 32.7 (0.4) for the salt substitute group. Both groups received lowest AHEI scores across the following components: vegetables, fruit and wholegrains. At baseline, the mean (SE) intakes of sodium across the regular salt and salt substitute groups were similar at 2349 (67) mg/day and 2396 (64) mg/day, respectively. In the salt substitute group, there was a significant reduction in total sodium intakes over time (-264 mg/day, 95% CI, -442 to -85), driven by the use of the salt substitute.

Conclusion

This study found individuals with hypertension living in rural India had poor dietary intakes, including low intakes of fruits, vegetables and wholegrains, and high intakes of sodium. Salt substitutes may be an effective strategy for reducing sodium intake in this population group.

Barriers to consumption of fruits and vegetables and strategies to overcome them in low- and middle-income countries: a narrative review

This review provides an overview of the barriers to the consumption of fruits and vegetables (FVs) as well as strategies to improve the intake of FVs in low- and middle-income countries (LMICs). The importance of the consumption of FVs and its role in disease prevention are discussed briefly. Trends in the consumption of FVs in LMICs are also summarised. The WHO recommends that every individual should consume at least five servings or 400 grams of FVs per day. Epidemiological and clinical investigations have demonstrated that FVs contain numerous bioactive compounds with health-protecting activities. Despite their health benefits, the intake of FVs in LMICs remains low. Major barriers identified were socio-demographic factors, environmental conditions, individual and cultural factors, and macrosystem influences. These barriers may be lowered at the household, school, community, and national level through multi-component interventions including behaviour change communication (BCC) initiatives, nutrition education (NE), gardening initiatives, farm to institution programs (FIPs), food baskets, cash transfers, nutrition-agriculture policy and program linkages, and food-market environment-based strategies. This review has research implications due to the positive outcomes of strategies that lower such barriers and boost consumption of FVs in LMICs.

Understanding household and food system determinants of chicken and egg consumption in India

Poultry is one of the fastest-growing agricultural sectors in India and its demand is said to be rising. There is a perception that higher incomes, growing population, urbanisation, and increased productivity in the industry have influenced Indian poultry consumption. However, consumer surveys have shown that the average poultry consumption in India has remained low. With this in mind, the paper analysed household determinants of chicken and egg consumption within the Indian population, using two rounds of National Sample Survey data (1993-1994 and 2011-2012). By conducting a spatiotemporal analysis of household consumption and expenditure survey and by using truncated Double Hurdle and Unconditional Quantile regressions (UQR) models, this study explored socio-economic and food system determinants of chicken and egg consumption in India. Key results highlight that while consumption has increased marginally over twenty years, supply-side determinants, such as price and poultry production concentration, influenced heterogenous consumption patterns in India. We also find evidence that historically marginalised groups consumed more chicken and eggs in comparison to non-marginalised groups and preliminary evidence suggests how household gender dynamics influence different consumption patterns. Adequate consumption of poultry is important to improve nutrient-deficient diets of vulnerable groups in India. Our findings on demand side determinants of poultry products are crucial to support consumer tailored actions to improve nutritional outcomes along with the Indian poultry sector policy planning.

Yoga Programme for Type 2 Diabetes Prevention (YOGA-DP) Among High-Risk People in India: A Multicenter Feasibility Randomized Controlled Trial

INTRODUCTION

Many Indians are at high risk of type 2 diabetes mellitus (T2DM). The blood glucose level can be improved through a healthy lifestyle (such as physical activity and a healthy diet). Yoga can help in T2DM prevention, being a culturally appropriate approach to improving lifestyle. We developed the Yoga Programme for T2DM Prevention (YOGA-DP), a 24-week structured lifestyle education and exercise (Yoga) program that included 27 group Yoga sessions and self-practice of Yoga at home. In this study, the feasibility of undertaking a definitive randomized controlled trial (RCT) was explored that will evaluate the intervention's effectiveness among high-risk individuals in India.

METHODS

A multicenter, two-arm, parallel-group, feasibility RCT was conducted in India. The outcome assessors and data analysts were blinded. Adults with a fasting blood glucose level of 100-125 mg/dL (i.e., at high risk of T2DM) were eligible. Participants were randomized centrally using a computer-generated randomization schedule. In the intervention group, participants received YOGA-DP. In the control group, participants received enhanced standard care.

RESULTS

In this feasibility trial, the recruitment of participants took 4 months (from May to September 2019). We screened 711 people and assessed 160 for eligibility. Sixty-five participants (33 in the intervention group and 32 in the control group) were randomized, and 57 (88%) participants were followed up for 6 months (32 in the intervention group and 25 in the control group). In the intervention group, the group Yoga sessions were continuously attended by 32 (97%) participants (median (interquartile range, IQR) number of sessions attended = 27 (3)). In the intervention group, Yoga was self-practiced at home by 30 (91%) participants (median (IQR) number of days per week and minutes per day self-practiced = 2 (2) and 35 (15), respectively). In the control group, one (3%) participant attended external Yoga sessions (on Pranayama) for 1 week during the feasibility trial period. There was no serious adverse event.

CONCLUSIONS

The participant recruitment and follow-up and adherence to the intervention were promising in this feasibility study. In the control group, the potential contamination was low. Therefore, it should be feasible to undertake a definitive RCT in the future that will evaluate YOGA-DP's effectiveness among high-risk people in India.

FEASIBILITY TRIAL REGISTRATION

Clinical Trials Registry-India (CTRI) CTRI/2019/05/018893; registered on May 1, 2019.

Heterogeneity of Dietary practices in India: current status and implications for the prevention and control of type 2 diabetes

Diet is one of the important modifiable factors in prevention of type 2 diabetes (T2D), making it important to understand geographical variations of food consumption pattern, their similarities and differences across various regions. Asian Indian diet patterns are mostly carbohydrate-based and with vast regional diversity. Staple food, food groups consumed, meat consumption pattern, type of fermented foods, food preparations, type of cooking oil used and food ingredients vary with different regions of India. There has been a slow transition from consumption of coarse grains to refined grains owing to socio-economic, cultural and other factors. Consumption of fruits and vegetables, fats, ready-to-eat foods and sugar is higher in urban population whereas consumption of carbohydrates in the form of cereals and millets is higher among the rural population. Cereal grains followed by pulses and legumes are main sources of protein, given that the frequency of meat consumption is low even among non-vegetarians in India compared to other countries. Overall, there is a tendency towards consumption of calorie-dense foods at the cost of food diversity, which may also result in micronutrient deficiencies as well as development of T2D and related metabolic diseases. Public health strategies and policy level decisions involving stakeholders with diet and lifestyle modification as focal points are absolute priorities to prevent and manage the burden of obesity and T2D in India.

Feasibility Trial of Yoga Programme for Type 2 Diabetes Prevention (YOGA-DP) among High-Risk People in India: A Qualitative Study to Explore Participants' Trial- and Intervention-Related Barriers and Facilitators

Yoga-based interventions can be effective in preventing type 2 diabetes mellitus (T2DM). We developed a Yoga programme for T2DM prevention (YOGA-DP) and conducted a feasibility randomised controlled trial (RCT) among high-risk people in India. This qualitative study's objective was to identify and explore participants' trial- and intervention-related barriers and facilitators. The feasibility trial was conducted at two Yoga centres in New Delhi and Bengaluru, India. In this qualitative study, 25 trial participants (13 intervention group, 12 control group) were recruited for semi-structured interviews. Data were analysed using deductive logic and an interpretative phenomenological approach. Amongst intervention and control participants, key barriers to trial participation were inadequate information about recruitment and randomisation processes and the negative influence of non-participants. Free blood tests to aid T2DM prevention, site staff's friendly behaviour and friends' positive influence facilitated trial participation. Amongst intervention participants, readability and understanding of the programme booklets, dislike of the Yoga diary, poor quality Yoga mats, difficulty in using the programme video, household commitment during home sessions, unplanned travel, difficulty in practising Yoga poses, hesitation in attending programme sessions with the YOGA-DP instructor of the opposite sex and mixed-sex group programme sessions were key barriers to intervention participation. Adequate information was provided on T2DM prevention and self-care, good venue and other support provided for programme sessions, YOGA-DP instructors' positive behaviour and improvements in physical and mental well-being facilitated intervention participation. In conclusion, we identified and explored participants' trial- and intervention-related barriers and facilitators. We identified an almost equal number of barriers (n = 12) and facilitators (n = 13); however, intervention-related barriers and facilitators were greater than for participating in the trial. These findings will inform the design of the planned definitive RCT design and intervention and can also be used to design other Yoga interventions and RCTs.

Caste-Based Inequality in Fruit and Vegetables Consumption in India

Objective:

Fruit and vegetable (F&V) consumption is of central importance to many diet-related health outcomes. In India, caste is a major basis of socioeconomic inequality. Recent analysis shows that more disadvantaged “lower” castes consume less F&V than the rest. This article explores whether this consumption gap arises due to differential distribution of drivers of consumption such as income and education across castes, or whether behavioral differences or discrimination may be at play.

Design:

The Oaxaca-Blinder regression decomposition is applied to explain the gap in F&V consumption between “upper” castes and “lower” castes, using data from the 68th (2011-2012) round of the National Sample Survey Organization household survey.

Results:

Differences in the distribution of F&V drivers account for all of the 50 grams/person/day consumption gap between upper and lower castes. In particular, much of the gap is explained by income differential across castes.

Conclusions:

In the long run, India’s positive discrimination policies in education and employment that seek to equalize income across castes are also likely to help close the F&V consumption gap, leading to health benefits. In the medium run, interventions acting to boost lower caste income, such as cash transfers targeting lower castes, may be effective.

Investigation of pesticide residue removal effect of gelatinized starch using surface-enhanced Raman scattering mapping

This study investigated the effectiveness of gelatinized starch (GS) in the removal of surface and internalized pesticide residues from basil leaves. Surface activity of GS was confirmed by surface tension and fluorescence study. Surface-enhanced Raman scattering (SERS) mapping was applied for in situ and real-time tracking of pesticides over time. Results showed that gelatinized starch has better and safer pesticide removing effect compared to commercial surfactants. Simulation study showed that starch fragment can adjust its three-dimensional conformation according to the size of the guest with ~ four repeating α-1,4-d-glucopyranose residues interacting efficiently with pesticides. However, washing by small molecular weight surfactants will lead to a "secondary contamination" due to its amphilphilic nature and small molecular size, which can escort pesticide deeper into the leaf. Due to the wide availability, easy fabrication, efficient rinsing effect and bio-safety nature, GS should be highly recommended in family practice.

Tracing the Single and Combined Contributions of Home-Grown Supply and Health Literacy on Fruit and Vegetable Consumption: An Empirical Exploration in Rural India

Low fruit and vegetable consumption (FVC) remains a global health challenge. Fostering subsistence agriculture through the production and home-grown consumption (HGC) of fruits and vegetables are seen as potential strategies for improving overall FVC, in particular, for developing countries like India. In addition, educational strategies targeting FVC health literacy are also used. Little evidence has documented a connection between these two strategies. We examine the single and combined influence of HGC and health literacy with regard to benefits from fruits and vegetable consumption. Data were collected from 427 rural households in the state of Odisha, India. Three outcomes were examined: FVC, as well as fruit and vegetables separately. Linear and Poisson regression were used to examine the association among home-grown consumption (HGC), FVC health literacy, and the FVC outcomes. Findings show that HGC, but not FVC health literacy, was directly associated with FVC (β = 0.65, SE = 0.10, p = 0.008) and vegetable consumption (β = 0.57, SE = 0.11, p = 0.02). However, both HGC (β = 0.58, SE = 0.05, p < 0.01) and FVC health literacy (β = -0.07, SE = 0.02, p = 0.001) were associated with fruit consumption. In addition, HGC effect is concentrated among participants who reported low FVC health literacy, especially on overall FVC and vegetables alone. Results are discussed in relation to the beneficial role played by HGC in those particularly vulnerable households who perceived little FVC health literacy. Our results provide insights on novel improved FVC consumption across all population segments. Future research should explore the complex interplay between agricultural policies and educational programs in the design of interventions promoting fruit and vegetable production and consumption.

Identifying 'win-win-win' futures from inequitable value chain trade-offs: A system dynamics approach

CONTEXT

There is growing recognition that food systems must adapt to become more sustainable and equitable. Consequently, in developing country contexts, there is increasing momentum away from traditional producer-facing value chain upgrades towards efforts to increase both the availability and affordability of nutritious foods at the consumer level. However, such goals must navigate the inherent complexities of agricultural value chains, which involve multiple interactions, feedbacks and unintended consequences, including important but often surprising trade-offs between producers and consumers.

OBJECTIVE AND METHODS

Based around the 'Loop' horticultural aggregation scheme of Digital Green in Bihar, India, we develop a system dynamics modelling framework to survey the value chain trade-offs emerging from upgrades that aim to improve the availability of fruits and vegetables in small retail-oriented markets. We model the processes of horticultural production, aggregation, marketing, and retailing - searching for futures that are 'win-win-win' for: (i) the availability of fruits and vegetables in small retail markets, (ii) the profits of farmers participating in aggregation, and (iii) the sustainability of the initial scheme for Digital Green as an organisation. We simulate two internal upgrades to aggregation and two upgrades to the wider enabling environment through a series of 5000 Monte Carlo trajectories - designed to explore the plausible future dynamics of the three outcome dimensions relative to the baseline.

RESULTS

We find that 'win-win-win' futures cannot be achieved by internal changes to the aggregation scheme alone, emerging under a narrow range of scenarios that boost supplies to the small retail market whilst simultaneously supporting the financial takeaways of farmers. In contrast, undesirable producer versus consumer trade-offs emerge as unintended consequences of scaling-up aggregation and the introduction of market-based cold storage.

SIGNIFICANCE

This approach furthers ongoing efforts to capture complex value chain processes, outcomes and upgrades within system dynamics modelling frameworks, before scanning the horizon of plausible external scenarios, internal dynamics and unintended trade-offs to identify 'win-win-win' futures for all.

Yoga Program for Type 2 Diabetes Prevention (YOGA-DP) Among High-Risk People: Qualitative Study to Explore Reasons for Non-participation in a Feasibility Randomized Controlled Trial in India

Background: Yoga-based interventions can be effective in preventing type 2 diabetes mellitus (T2DM). We developed a Yoga program for T2DM prevention (YOGA-DP) among high-risk people and conducted a feasibility randomized controlled trial (RCT) in India. The objective of this study was to identify and explore why potential participants declined to participate in the feasibility RCT. Methods: An exploratory qualitative study, using semi-structured interviews, was conducted at a Yoga center in New Delhi, India. Fourteen people (10 women and four men) who declined to participate in the feasibility RCT were interviewed, and 13 of them completed the non-participant questionnaire, which captured their socio-demographics, diets, physical activities, and reasons for declining. Results: Three types of barriers were identified and explored which prevented participation in the feasibility RCT: (1) personal barriers, such as lack of time, perceived sufficiency of knowledge, preferences about self-management of health, and trust in other traditional and alternative therapies; (2) contextual barriers, such as social influences and lack of awareness about preventive care; and (3) study-related barriers, such as lack of study information, poor accessibility to the Yoga site, and lack of trust in the study methods and intervention. Conclusions: We identified and explored personal, contextual, and study-related barriers to participation in a feasibility RCT in India. The findings will help to address recruitment challenges in future Yoga and other RCTs. Clinical Trial Registration:www.ClinicalTrials.gov, identifier: CTRI/2019/05/018893.

Development of a Yoga Program for Type-2 Diabetes Prevention (YOGA-DP) Among High-Risk People in India

Introduction: Many Indians are at high-risk of type-2 diabetes mellitus (T2DM). Yoga is an ancient Indian mind-body discipline, that has been associated with improved glucose levels and can help to prevent T2DM. The study aimed to systematically develop a Yoga program for T2DM prevention (YOGA-DP) among high-risk people in India using a complex intervention development approach. Materials and Methods: As part of the intervention, we developed a booklet and a high-definition video for participants and a manual for YOGA-DP instructors. A systematic iterative process was followed to develop the intervention and included five steps: (i) a systematic review of the literature to generate a list of Yogic practices that improves blood glucose levels among adults at high-risk of or with T2DM, (ii) validation of identified Yogic practices by Yoga experts, (iii) development of the intervention, (iv) consultation with Yoga, exercise, physical activity, diet, behavior change, and/or diabetes experts about the intervention, and (v) pretest the intervention among Yoga practitioners and lay people (those at risk of T2DM and had not practiced Yoga before) in India. Results: YOGA-DP is a structured lifestyle education and exercise program, provided over a period of 24 weeks. The exercise part is based on Yoga and includes Shithilikarana Vyayama (loosening exercises), Surya Namaskar (sun salutation exercises), Asana (Yogic poses), Pranayama (breathing practices), and Dhyana (meditation) and relaxation practices. Once participants complete the program, they are strongly encouraged to maintain a healthy lifestyle in the long-term. Conclusions: We systematically developed a novel Yoga program for T2DM prevention (YOGA-DP) among high-risk people in India. A multi-center feasibility randomized controlled trial is in progress in India.

Environmental implications and socioeconomic characterisation of Indian diets

India is facing a double burden of malnourishment with co-existences of under- and over-nourishment. Various socioeconomic factors play an essential role in determining dietary choices. Agriculture is one of the major emitters of greenhouse gases (GHGs) in India, contributing 18% of total emissions. It also consumes freshwater and uses land significantly. We identify eleven Indian diets by applying k-means cluster analysis on latest data from the Indian household consumer expenditure survey. The diets vary in calorie intake [2289-3218 kcal/Consumer Unit (CU)/day] and dietary composition. Estimated embodied GHG emissions in the diets range from 1.36 to 3.62 kg CO_2eq./CU/day, land footprint from 4 to 5.45 m²/CU/day, whereas water footprint varies from 2.13 to 2.97 m³/CU/day. Indian diets deviate from a healthy reference diet either with too much or too little consumption of certain food groups. Overall, cereals, sugar, and dairy products intake are higher. In contrast, the consumption of fruits and vegetables, pulses, and nuts is lower than recommended. Our study contributes to deriving required polices for the sustainable transformation of food systems in India to eliminate malnourishment and to reduce the environmental implications of the food systems.

Yoga programme for type-2 diabetes prevention (YOGA-DP) among high risk people in India: a multicentre feasibility randomised controlled trial protocol

INTRODUCTION

A huge population in India is at high risk of type-2 diabetes (T2DM). Physical activity and a healthy diet (healthy lifestyle) improve blood glucose levels in people at high risk of T2DM. However, an unhealthy lifestyle is common among Indians. Yoga covers physical activity and a healthy diet and can help to prevent T2DM. The research question to be addressed by the main randomised controlled trial (RCT) is whether a Yoga programme for T2DM prevention (YOGA-DP) is effective in preventing T2DM among high risk people in India as compared with enhanced standard care. In this current study, we are determining the feasibility of undertaking the main RCT.

INTERVENTION

YOGA-DP is a structured lifestyle education and exercise programme. The exercise part is based on Yoga and includes Shithilikarana Vyayama (loosening exercises), Surya Namaskar (sun salutation exercises), Asana (Yogic poses), Pranayama (breathing practices) and Dhyana (meditation) and relaxation practices.

METHODS AND ANALYSIS

This is a multicentre, two-arm, parallel-group, feasibility RCT with blinded outcome assessment and integrated mixed-methods process evaluation. Eligible participants should be aged 18-74 years, at high risk of T2DM (fasting plasma glucose level 5.6-6.9 mmol/L) and safe to participate in physical activities. At least 64 participants will be randomised to intervention or control group with final follow-up at 6 months. Important parameters, needed to design the main RCT, will be estimated, such as SD of the outcome measure (fasting plasma glucose level at 6-month follow-up), recruitment, intervention adherence, follow-up, potential contamination and time needed to conduct the study. Semistructured qualitative interviews will be conducted with up to 20-30 participants, a sample of those declining to participate, four YOGA-DP instructors and around eight study staff to explore their perceptions and experiences of taking part in the study and of the intervention, reasons behind non-participation, experiences of delivering the intervention and running the study, respectively.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the following Research Ethics Committees: Faculty of Medicine and Health Sciences, University of Nottingham (UK); Centre for Chronic Disease Control (CCDC, India); Bapu Nature Cure Hospital and Yogashram (BNCHY, India) and Swami Vivekananda Yoga Anusandhana Samsthana (S-VYASA, India). The results will be widely disseminated among key stakeholders through various avenues.

TRIAL REGISTRATION NUMBER

CTRI/2019/05/018893.

What underlies inadequate and unequal fruit and vegetable consumption in India? An exploratory analysis

Adequate consumption of fruit and vegetables is key to improved diet-related health in India. We analyse fruit and vegetable consumption in the Indian population using National Sample Survey data. A series of regressions is estimated to characterise the distribution of household fruit and vegetable consumption and explore key socio-economic and food system drivers of consumption. Household income and price are important correlates, but consumption is also higher where households are headed by females, are rural, or involve agricultural livelihoods. Caste is an important source of inequality, particularly amongst those with low consumption, with Scheduled Tribes consuming less F&V than others. We also find preliminary evidence that formal agricultural market infrastructure is positively associated with fruit and vegetable consumption in India.

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Large proportions of the Indian population consume worrying low levels of fruit and vegetables.

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Income and price are key drivers of household consumption.

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Caste is an important source of consumption inequality, particularly amongst those with low consumption.

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Density of wholesale markets (mandis) is positively associated with fruit and vegetable consumption.

Future diets in India: A systematic review of food consumption projection studies

Against a backdrop of a rapidly changing food system and a growing population, characterisation of likely future diets in India can help to inform agriculture and health policies. We systematically searched six published literature databases and grey literature repositories up to January 2018 for studies projecting the consumption of foods in India to time points beyond 2018. The 11 identified studies reported on nine foods up to 2050: the available evidence suggests projected increases in per capita consumption of vegetables, fruit and dairy products, and little projected change in cereal (rice and wheat) and pulse consumption. Meat consumption is projected to remain low. Understanding and mitigating the impacts of projected dietary changes in India is important to protect public health and the environment.

Urban environment as an independent predictor of insulin resistance in a South Asian population

Background

Developing countries, such as India, are experiencing rapid urbanization, which may have a major impact on the environment: including worsening air and water quality, noise and the problems of waste disposal. We used health data from an ongoing cohort study based in southern India to examine the relationship between the urban environment and homeostasis model assessment of insulin resistance (HOMA-IR).

Methods

We utilized three metrics of urbanization: distance from urban center; population density in the India Census; and satellite-based land cover. Restricted to participants without diabetes (N = 6350); we built logistic regression models adjusted for traditional risk factors to test the association between urban environment and HOMA-IR.

Results

In adjusted models, residing within 0–20 km of the urban center was associated with an odds ratio for HOMA-IR of 1.79 (95% CI 1.39, 2.29) for females and 2.30 (95% CI 1.64, 3.22) for males compared to residing in the furthest 61–80 km distance group. Similar statistically significant results were identified using the other metrics.

Conclusions

We identified associations between urban environment and HOMA-IR in a cohort of adults. These associations were robust using various metrics of urbanization and adjustment for individual predictors. Our results are of public health concern due to the global movement of large numbers of people from rural to urban areas and the already large burden of diabetes.

Electronic supplementary material

The online version of this article (10.1186/s12942-019-0169-9) contains supplementary material, which is available to authorized users.