DOCTOR, HEAL THYSELF: INDIA NEED TO MANAGE PHYSICIAN BURNOUT AND ‘VIOLENCE’ AGAINST DOCTORS - The Daily Guardian
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DOCTOR, HEAL THYSELF: INDIA NEED TO MANAGE PHYSICIAN BURNOUT AND ‘VIOLENCE’ AGAINST DOCTORS

Dr Kishore Kumar

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Today is July 1 and every year this day is observed as National Doctors’ Day in India to express gratitude and acknowledge the dedication and commitment of the doctors’ towards our society. The observance of the day honours legendary physician and West Bengal’s second Chief Minister, Dr. Bidhan Chandra Roy whose birth and death anniversary coincides on the same day. As we continue to fight the second wave of the pandemic and prepare ourselves to beat the third wave, as a practicing neonatologist, I am deeply concerned about two issues that still continue to affect the medical fraternity i.e. physician burnout amidst the ongoing pandemic and violence against doctors adding insult to the injury.

I have always been debating and seeking answers to the question at several forums “why always only doctors are answerable to the society”. Most often and almost regularly for any incident that relates to the health and wealth of the society, a doctor is responsible and straightway it is termed as medical negligence? Why? Are we trying to say other professions like judiciary, administration, banking and so on do not have any negligence? Our doctors, nurses, carers and paramedics around the world are facing an unprecedented workload in overstretched health facilities, and with no end in sight.

WHY THE BURNOUT?

“Please, please wear masks. I don’t know about other people but I’m physically and mentally exhausted with crazy shifts and calling more deaths than I did in all my years of service combined,” reads a tweet by Dipshikha Ghosh, a doctor in critical care medicine, per her Twitter bio.

Mounting deaths, long hours, low pay, lack of resources, and the risk of contracting COVID-19, India’s healthcare workers are facing a mental health crisis. The stress of long hours, no sleep, poor eating, inadequate protection, the fear of contaminating loved ones, the fear of dying and seeing patients die no matter what you do, the disrespect by hospital administrators and the fear of being fired, all remain the reality for those who are in the thick of things. Adding to this, the junior doctors have been in the limbo for over a year – without qualifying, but working and expected to work as doctors – without proper pay as doctors – all adding to the burnout even befoVre they start their career. Physician burnout costs the United States healthcare industry $4.6 billion a year – a number that was pre-pandemic and during the pandemic it was expected to have costed double this. No such estimates are known for India. While burnout is increasingly being recognized globally as a major concern, affecting physical and mental well-being of HCWs, with the current pandemic, closing down of international and state borders, strict city, and also area wise lockdown has affected HCWs and their families as well, causing excessive negative psychological effects. Besides, negative consequences for the physicians, and patients, and the health-care system, available data also suggests that it is important to recognize burnout at the earliest and use preventive strategies for emergence of the same. Many people have lost their loved ones to COVID including healthcare workers & their families. There are times when people blame their doctors for their loss. If this was true, then no doctor or their family members would have lived forever. However, no one considers the physical and mental stress of the doctors while fighting new strains.

India needs to have clear-cut guidelines for the management of burnout which is currently missing. Some of the individual-level interventions, which are thought to be helpful for burnout should be practiced such as cognitive-behavioral techniques, meditation and relaxation techniques, development of interpersonal skills, and development of knowledge, work-related skills and proper recognition & appreciation of their work. In addition to this, various interventions carried out at the level of organization and the physician–organization interface should be proposed to address physician burnout. It is important to understand that when patients were left to fend for themselves by relatives, it was doctors and nurses who risked their lives for them. We need to have a national study on the mental state of healthcare workers especially during this pandemic which will be a proof that our healthcare workers are overworked and those who took COVID duty also found themselves without enough sleep.

Violence against Doctors: Growing epidemic?

Recently, an on-duty doctor was attacked by a policeman in Kerala. Doctors serving in COVID wards have been beaten and brutally assaulted in Bihar, West Bengal, Assam, Uttar Pradesh, and Karnataka. Just few weeks ago, a Pediatrician was attacked in Tarikere and a intensive care physician was attacked in Bangalore private tertiary hospital. There have been numerous incidents highlighting violence inflicted on the healthcare staff. Over 80% of doctors in the country are stressed and 75% of doctors deal with abuse and assault, as per an IMA report. What may seem like impulsive outbursts of violence by patients or their attendants against doctors actually points to the chronic neglect of public health by the Indian state?

Workplace violence against doctors is not new, but in recent times, it has grown up in epidemic proportions. Doctors are more worried about their safety and life in the workplace. Meager government spending on healthcare associated with the poor socioeconomic status of the patient and the ever-rising cost of treatment had worsened the situation in present times.

Healthcare in India is complicated, spanning across acute care, preventive and public health. And private healthcare delivers nearly 80 per cent of the country’s needs. But doctors in both public and private sectors are at the receiving end of violence. The public sector is in general blamed for most of the faults of the services sector.

In a land where swamis and soothsayers make more television appearances than doctors, society needs a strong medical role model. Hospitals need to improve its services on par with global standards and ensure that enough doctors and para medical staff are employed to handle patients. We need to see a change in government policies like increased government spending on healthcare, improving the infrastructure of the hospitals, stricter implementation of rules, laws, and punishment for violence under the Prevention of Violence against Doctors and Hospitals according to appropriate Acts and relevant sections of the Indian Penal Code (IPC), violence against health-care personnel and hospitals should be made a non bailable offense and damages should be recovered from the persons responsible for the violence. The government should take responsibility for the safety of healthcare workers. Australia had a spike of violence against healthcare workers in late 1990s & early 2000s, immediately the government reacted and introduced 12 years imprisonment for any person convicted of violence against healthcare workers. Soon the violence against them virtually disappeared. Clearly it shows that only stricter imposition of the rules & law enforcements can save the profession and professionals.

In addition, all institutions should have a standard operating procedure and code purple should be declared and all measures should be taken in case of violence. Security staff to respond and assist immediately.

Patient awareness is the key. Patients need to be educated and be informed that doctors practice medicine and they cannot be held responsible for every death occurring in the hospital on the ground of negligence. Cost increases with the type of treatment & its advancement. Our medical schools, along with the medical subjects they should also teach about patient-doctor relations, communication with the patient in an effective way, empathy towards the patients and their relatives. The school should also teach them how to handle tactfully when the patients or their relatives behave aggressively and the situation turns chaotic and violent. They should teach them how to remain calm and responsible during those times without compromising the quality of patient care as well as safety.

Unless there is an entire overhaul of the prevailing healthcare system& a political will to protect the healthcare workers, it is a herculean task to curb violence against doctors, which will be a disaster much worse than covid-19.

The Author is the Founder Chairman & Neonatologist, Cloudnine Group of Hospitals, Bengaluru. Author is also a healthcare delivery graduate from Harvard Business School

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FASTING REQUIRED TO SEE FULL BENEFIT OF CALORIE RESTRICTION

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Over the last few decades, scientists have discovered that long-term calorie restriction provides a wealth of benefits in animals: lower weight, better blood sugar control, even longer lifespans.

Researchers have largely assumed that reduced food intake drove these benefits by reprogramming metabolism. But a new study from the University of Wisconsin-Madison researchers finds that reduced calorie intake alone is not enough; fasting is essential for mice to derive full benefit. The team published their findings in the journal Nature Metabolism.

The new findings lend support to preliminary evidence that fasting can boost health in people, as trends like intermittent fasting continue to hold sway. These human and animal studies have added to the growing picture of how health is controlled by when and what we eat, not just how much.

The research further emphasizes the complexity of nutrition and metabolism and provides guidance to researchers trying to untangle the true causes of diet-induced health benefits in animals and humans.

The researchers discovered that combined with eating less, fasting reduces frailty in old age and extends the lifespan of mice. And fasting alone can improve blood sugar and liver metabolism. Surprisingly, mice that ate fewer calories but never fasted died younger than mice that ate as much as they wanted, suggesting that calorie restriction alone may be harmful.

The research was led by UW School of Medicine and Public Health metabolism researcher Dudley Lamming, his graduate student Heidi Pak and their colleagues at UW-Madison and other institutions.

Pak and Lamming were inspired to conduct the study because researchers began to realize that previous studies had unintentionally combined calorie restrictions with long fasts by providing animals with food just once a day. It was difficult, then, to distinguish the effects of one from the other.

“This overlap of treatment — both reducing calories and imposing a fast — was something that everybody saw, but it wasn’t always obvious that it had biological significance,” said Lamming, who has long studied the effect of restricted diets on metabolism. “It’s only been in the past few years that people started getting interested in this issue.”

To untangle these factors, Lamming’s group designed four different diets for mice to follow. One group ate as much as they wanted whenever they wanted. Another group ate a full amount, but in a short period of time — this gave them a long daily fast without reducing calories.

The other two groups were given about 30 per cent fewer calories either once a day or dispersed over the entire day. That meant that some mice had a long daily fast while others ate the same reduced-calorie diet but never fasted, which differed from most previous studies of calorie restriction. It turned out that many of the benefits originally ascribed to calorie restriction alone — better blood sugar control, healthier use of fat for energy, protection from frailty in old age and longer lifespans — all required fasting as well. Mice who ate fewer calories without fasting didn’t see these positive changes.

Fasting on its own, without reducing the amount of food eaten, was just as powerful as calorie restriction with fasting. Fasting alone was enough to improve insulin sensitivity and to reprogram metabolism to focus more on using fats as a source of energy. The livers of fasting mice also showed the hallmarks of a healthier metabolism. The researchers did not study the effect of fasting alone on lifespan or frailty as mice age, but other studies have suggested that fasting can provide these benefits as well.

While the mice that ate fewer calories without ever fasting did show some improved blood sugar control, they also died younger. Compared with mice who both ate less and fasted, these mice that only ate less died about 8 months earlier on average.

“That was quite surprising,” said Lamming, although other studies have also shown some negative effects from restricting calories. The team also measured frailty through metrics like grip strength and coat condition. “In addition to their shorter lifespans, these mice were worse in certain aspects of frailty, but better in others. So, on balance, their frailty didn’t change much, but they didn’t look as healthy.”

The primary studies were done in male mice, but Lamming’s lab also found similar metabolic effects of fasting in female mice. The research reveals how difficult diet studies are, even in a laboratory environment. That difficulty is magnified for human studies, which simply can’t match the level of control possible in animal models. The new study can provide direction to future work trying to answer whether fasting improves human health.

“We need to know whether this fasting is required for people to see benefits. If fasting is the main driver of health, we should be studying drugs or diet interventions that mimic fasting rather than those that mimic fewer calories.” Lamming said.

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Common dialysis treatment for patients with acute kidney injury can lead to poor outcomes

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Patients with acute kidney injury who receive continuous renal replacement therapy (CRRT), a common dialysis method, have a high incidence of needing this dialysis method reinstituted after having it removed. This contributes to poor 90-day outcomes, according to recent research led by an international team of scientists.

The study was published in the journal Mayo Clinic Proceedings. Though CRRT is a common dialysis method for critically ill patients with acute kidney injury, little research has been performed to determine at what point in kidney function recovery the patient should be “liberated” from CRRT.

This study, by researchers at Mayo Clinic and Zhongnan Hospital of Wuhan University in China, is believed to be the first to investigate outcomes for patients with acute kidney injury who were not successfully liberated from CRRT.

The retrospective cohort study examined the records of 1,135 patients with acute kidney injury who were treated with CRRT at Mayo Clinic in Rochester between January 2007 and May 2018. Of those patients, 20 per cent were successfully liberated from CRRT. In 39 per cent of patients, CRRT had to be reinstituted within 72 hours, and 41 per cent of these patients died.

Successful CRRT liberation was marginally associated with fewer major adverse kidney events and improved kidney recovery at the time of 90-day follow-up, though the causal relationships could not be established.

“In current clinical practice, CRRT liberation is typically based on physicians’ personal experience because there has been only limited and inconsistent research available,” says Kianoush Kashani, M.D., a nephrology intensivist at Mayo Clinic and the study’s senior author.

Kianoush added, “Our study demonstrated a high occurrence of CRRT liberation failure, as well as poor 90-day outcomes. Thus, there is a critical need for identifying preventive measures to avoid the need for CRRT or interventions that lead to early liberation from CRRT among critically ill patients with advanced acute kidney injury.”

Acute kidney injury is a common complication for patients in ICUs. As many as 57 per cent of ICU patients have acute kidney injury. Dialysis is used to treat about 13 per cent of those patients, and this treatment is associated with 60 per cent mortality, according to research.

“There are limited data and little consensus on how and when to liberate patients from CRRT properly, the high rate of liberation failure observed in our study may reflect variations in clinical practices. Development of consistent approaches that can guide decision-making on when to remove CRRT should be a top priority of future research,” he added.

CRRT is frequently used as a dialysis mode for critically ill patients because it provides continuous control of fluid status during treatment and doesn’t interfere with the body’s normal blood flow while achieving uremic control.

But recent studies have found that prolonged CRRT may lead to adverse events and impede kidney function recovery, while premature CRRT liberation also can lead to complications.

Other dialysis options are associated with even lower changes in kidney recovery, says Dr. Kashani, the study’s senior author. The study clearly indicates that CRRT liberation, when successful, can be associated with improved clinical outcomes for critically ill patients and lower costs of care, he says.

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INCREASE IN DAIRY INTAKE LOWERS RISK OF FRACTURES AMONG OLDER HOME RESIDENTS

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Increasing intake of foods rich in calcium and protein such as milk, yoghurt, and cheese, reduces falls and fractures in older adults living in residential care, finds a new study led by an international team of scientists.

The randomised controlled trial was published in ‘The BMJ’ (British Medical Journal). This is one of only a few studies to examine whether getting these nutrients from foods (as opposed to supplements) are effective and safe, and the researchers say this approach has “widespread implications as a public health measure for fracture prevention.”

Older adults living in residential care often have low calcium and protein intake, which can lead to weak bones and an increase in the risk of falls and fractures. It is estimated that older adults in aged care are the source of about 30 per cent of all hip fractures.

It is well known that foods rich in calcium and protein, such as milk, yoghurt, and cheese help prevent bone fragility, but few studies have investigated whether increasing daily intake of these foods is an effective and safe way to reduce fracture risk in older adults.

So researchers based in Australia, the Netherlands and the US set out to examine whether achieving recommended daily intakes of calcium (1,300 mg) and protein (1 g/kg body weight) from food sources would reduce the risk of fragility fractures and falls among older adults in residential care facilities.

The two-year trial involved 60 aged care facilities in Australia housing 7,195 residents (72 per cent women; average age 86 years) replete in vitamin D but with daily calcium and protein intakes below recommended levels.

Thirty intervention facilities were randomised to provide residents with additional milk, yoghurt, and cheese, achieving intakes of 1,142 mg calcium/day and 1.1 g protein/kg body weight/day. The remaining 30 control facilities continued with their usual menu (700 mg/day calcium and 0.9 g protein/kg body weight/day).

Data from 27 intervention facilities and 29 control facilities were analysed and a total of 324 fractures (135 hip fractures), 4,302 falls, and 1,974 deaths occurred during the study period.

The intervention was associated with risk reductions of 33 per cent for all fractures (121 v 203), 46 per cent for hip fractures (42 v 93), and 11 per cent for falls (1,879 v 2,423). There was no group difference in all-cause mortality.

The relative risk reduction for fractures was similar to that found in trials using potent drug therapy to increase bone strength in people with osteoporosis.

A randomised controlled trial is considered the most reliable way to determine whether an intervention actually has the desired effect, but the researchers do point to some limitations. For example, the loss of participants limited their ability to examine the possible mechanisms that may contribute to fewer fractures and falls.

Nevertheless, they say, improving calcium and protein intakes by using dairy foods “is a readily accessible intervention that reduces the risk of falls and fractures commonly occurring in institutionalised older adults.” They also added that this nutritional intervention has widespread implications as a public health measure for fracture prevention in the aged care setting and potentially in the wider community.

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ENHANCING VACCINATION IS THE RIGHT STEP IN CURBING SPREAD OF COVID

Mumbai for the first time has recorded no Covid-related deaths recently.

Dr Rahul Pandit

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From battling the most tumultuous second wave of Coronavirus to driving the world’s largest vaccination program, India’s journey in tackling Covid-19 has been exceptional. Today, India has achieved a milestone by inoculating 100 crores of its population. Adding to this, Mumbai for the first time has recently recorded no Covid-related deaths. This is truly a moment of pride as we can now be certain that we can tackle Covid-19 in a better way and save more lives. If we continue following protocols and actions to save more lives, we will be able to achieve the goal of zero deaths due to Covid in India.

India has already provided more than one billion vaccinations covering around 1/7th of the population. So about 70% of the eligible population has received at least one dose, and nearly 25 % have received both the doses. With the introduction of vaccines for children, this program will take a new leap. The progress made so far is thus, commendable. It takes 5-10yrs to test and develop vaccines, but India researched and developed an in-house vaccine, ensuring that all necessary arrangements such as complex manufacturing, the humongous logistics involving setting up cold chains, airport transfers, vaccines to states, local storage, and last-mile connectivity were set up in no time. Moreover, India devised an excellent strategy to encourage pharma companies to produce vaccines within the country. This coupled with the efforts put by healthcare providers, media, and health activists in spreading awareness and reiterating time & again the significance of vaccination in saving lives, has been huge.

Enhancing the vaccination process is the right step in curbing the spread of the virus, as well as saving as many lives as possible. Mumbai is a case in point. After a concerted effort made by the government, local bodies, private hospitals, doctors, nurses, paramedics, and the public at large for the last 18 months, the city saw a day with zero deaths. This is how the nation needs to work against the infection. However, one needs to note that Mumbai’s achievement is a result of multiple factors put together, and among these, vaccination is the key. Around 50% of Mumbai’s population has been fully vaccination and more than 90% have received the first dose. Maharashtra’s vaccination drive across districts has brought the state closer to the 10Cr mark; that too, at record breaking speed.

For any infectious disease, the first line of action is to save lives and prevent the spread. That’s what Mumbai did. From being a highly impacted region, to becoming a city with zero deaths, our actions delivered.

However, staying cautious is critical, as it is yet too early to declare victory over the virus. At present, we are better equipped to confront any new challenge. People should however, not lower their guards and continue following Covid-19 protocols. Even after vaccination continue to mask up and follow Covid-19 protocol. Get vaccination and encourage others to do so. Only then can we together someday win the war against Covid-19. It’s not too long before we’d be vaccinating another 10Cr nationals, setting golden examples for the world to follow.

The writer is Director-Critical Care, Fortis Hospitals Mumbai & Member of the honorable Supreme Court appointed National Covid-19 Task Force.

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PGIMER releases documentary titled ‘Front of Package Labeling: A Game Changer for Healthy India’

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A documentary titled ‘Front of Package Labeling: A Game Changer for Healthy India’, prepared by the Department of Community Medicine and School of Public Health (DCM & SPH), Post Graduate Institute of Medical Education and Research, Chandigarh.

This documentary is a part of a project being undertaken by the Institute in collaboration with Government of Punjab and Strategic Institute of Public Health Education and Research (SIPHER) and is supported by Global Health Advocacy Incubator, USA.

“A rapid rise in hypertensive cases is being observed in Punjab, which is worrisome. Through the project, we are collaborating with the Government of Punjab to prevent and better manage hypertension through sensitization of media and the general public regarding the risk factors like trans fats in food. We strongly feel that warning labels on food items are effective way of helping people to make nutritious food choices. The documentary drives home the importance of Front of Package Labeling (FOPL) for averting a cardiovascular health, obesity and diabetes crisis in India.” said Dr. Sonu Goel.

As per WHO, Non-communicable diseases (NCDs’) account for 70% of the global deaths. The state of Punjab has become a capital of hypertension with one out of three people suffering from this silent killer.

Excessive intake of fats, sugar and salt available in packaged foods such as cake, pizza, pastry, french fries, ice cream, etc. are the primary cause of NCDs. Under this project which started in 2019, PGIMER Chandigarh has signed a pact with Food and Drug Administration, Punjab to implement and regulate the trans-fat surveillance in Punjab.

The documentary highlights key features such as transition of food practices from traditional to modern, ways to making healthy food choices, identifying good and bad food, diseases associated with bad food. etc.

It was released at the juncture of festivals such as Diwali, aims to generate awareness among policymakers, implementers, and the general public about the importance of healthy and wholesome food to keep Non-Communicable Diseases (NCDs’) like hypertension at bay and to generate support for an intense Front-of-Pack Labelling (FOPL) policy to be developed by Government of India. It took around two months to prepare this documentary of approximately 7 minutes, which is a collaborative effort of the project team. The documentary has been conceptualized and narrated by Dr. Sonu Goel, Professor, Dept. of Community Medicine and School of Public Health, PGIMER, Chandigarh and Principal Investigator of the project.

Dr. Geeta Mehra, Head, Dept. of Food Sciences, MCM DAV College, Chandigarh emphasized the importance of reading food labels while purchasing any packaged food product. She stressed that “FOPL, if implemented in India, will allow the consumers to identify products containing excess sugars, trans-fats, oils, and sodium easily, quickly, and correctly and help them to make informed food choices.”

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STUDY SHOWS REGULAR MILLET CONSUMPTION CAN COMBAT ANAEMIA

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A new study has shown that regular consumption of millets can improve haemoglobin and serum ferritin levels to reduce iron deficiency anaemia, which is rising globally.

The findings of the study were published in the journal ‘Frontiers in Nutrition’. The research, a meta-analysis of 22 studies on humans and eight laboratory studies on millets consumption and anaemia, was undertaken by seven organisations across four countries and was led by the International Crops Research Institute for the Semi-Arid Tropics (ICRISAT).

“The study concluded that millets can provide all or most of the daily dietary iron requirements of an average person. Although the amount of iron provided depends on the millet variety and its form of processing, the research clearly shows that millets can play a promising role in preventing and reducing high levels of iron deficiency anaemia,” highlighted Dr S Anitha, the study’s lead author and Senior Nutritionist at ICRISAT.

The researchers found that millets increased haemoglobin levels by as much as 13.2 per cent. Four studies in the review also showed serum ferritin increasing by an average of 54.7 per cent. Ferritin is an iron-containing protein in the blood and is a clinical marker for iron deficiency.

The studies in the analysis involved nearly 1,000 children, adolescents and adults, and six different millet types – finger millet, pearl millet, sorghum and a mixture of kodo, foxtail and little millets. The participants in the studies were found to have consumed millets for anywhere between 21 days and 4.5 years. The findings were published on 14 October in Frontiers in Nutrition.

“1.74 billion people were anaemic in 2019. That number is rising,” said Dr Jacqueline Hughes, Director General, ICRISAT.

“It has been proven that iron deficiency anaemia affects cognitive and physical development in children and reduces productivity in adults. The need for a solution is critical, and therefore bringing millets into mainstream and government programs is highly recommended,” added Dr Hughes.

“Now that there is strong evidence of the value of millets in reducing or preventing iron deficiency anaemia, it is recommended that one major research study be undertaken on anaemia covering all the different types of millet, common varieties and all major forms of processing and cooking, using a uniform testing methodology. This will provide the detail required for designing interventions needed to have a major impact on reducing anaemia globally,” said Professor Ian Givens, a co-author of the study and Director at the University of Reading’s Institute of Food, Nutrition and Health (IFNH) in the UK.

“It has often been claimed that iron in millets is not highly bioavailable due to the supposed high levels of antinutrients. Our analysis proves this is a myth. Instead, millets were found to be comparable to typical iron bioavailability percentages for plants. Also, the levels of antinutrients in millets were identified to be similar or lower than common staples,” said Ms Joanna Kane-Potaka, former Assistant Director-General, ICRISAT, and Executive Director of the Smart Food initiative who is a co-author of the study.

The research also showed that processing can significantly increase the amount of iron bioavailable. For example, millet snacks made by expansion (extrusion) increased bioavailable iron 5.4 times, while fermentation, popping and malting more than tripled the iron bioavailable. Germination (sprouting) and decortication (dehulling) more than doubled the bioavailable iron.

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