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Good nutrition and regular tests important for women today: Experts

Changing an unhealthy lifestyle and diet, maintaining good hygiene, getting regular check-ups and increasing awareness of the body’s processes are all good ways for women in India to keep a check on their health, suggest top experts.

Shalini Bhardwaj

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Data has shown that only 12% of women in India take decisions regarding their own healthcare. In a country which has a large number of anaemic women, women who die during childbirth and women who fall prey to cervical cancer, how can we ensure better health for half of the population? Experts Dr Ruchi Malhotra, Senior Gynaecologist and IVF Expert at Fertile Solutions IVF Centre, Dr Sheetal Aggarwal, Senior Gynaecologist at Apollo Cradle Royale, Dr Richa Jaiswal, Dietician at AIIMS, and Dr Ekta Bajaj, Senior Gynaecologist at the Ujala Cygnus Hospital, weigh in on important questions about women’s health in an interview with The Sunday Guardian.

Dr Ekta Bajaj

Dr Ruchi Malhotra

Dr Richa Jaiswal

Dr Sheetal Aggarwal

Data has shown that only 12% of women in India take decisions regarding their own healthcare. In a country which has a large number of anaemic women, women who

Q: Why is nutrition so important for women’s health?

Dr Aggarwal: The woman is the backbone of society and if she is weak, society is weak. A woman menstruates every month and loses around 30-40 ml of blood per cycle, so she has to replace that. During the reproductive phase, she gives birth to children, who are just like parasites and draw nutrition from the body, irrespective of whether the mother has adequate iron or calcium reserves. This makes it important for the mother to replace all the nutrition she has lost during this time. Today, women are multitasking. They are going out to work as well as looking after their homes and this drains them physically and mentally. Thus, a woman’s nutrition should be a priority area in a national or a state budget.

Q: What is the reason for an increase in infertility, especially among younger women?

Dr Malhotra: This is a very important question. It is because most women are delaying getting married, as many of us are career-oriented, and age is directly related to fertility. Higher the age, lower the fertility. Lifestyles have also changed as there is too much stress. Having more junk food and alcohol, smoking and a sedentary lifestyle also lower fertility.

Q: Can you name the health tests which are a must for every woman?

Dr Bajaj: These are precautionary times so every healthcare approach should be more prophylactic than treatment. Women should go for proper health check-ups for cervical cancer and screening tests like the Pap smear (now called LBC and HPV test). According to the WHO, every woman should take this HPV test after the age of 24 every five years and the LBC Pap smear every three years. As far as breast cancer is concerned, after the age of 35, mammography is very important. If there is a history of breast cancer in the family, one can even go for it before the age of 35. We see young girls of 25-30 years of age in our OPD with lesions like fibroadenosis and fibroadenoma, for which we suggest an ultrasound or MRI. Routine blood tests to check complete blood count, thyroid function test, lipid profile, LFT and TFT should also be part of a woman’s healthcare, keeping in mind the increasing cases of anaemia in India.

Q: What kind of care is required during puberty?

Dr Aggarwal: Puberty is the time when a female starts menstruating. It is generally an anovulatory cycle, which is the period of the first two or three years when the ovaries are not producing eggs. So, a girl may not first bleed for two or three months and then bleed for one month or so. Concerned mothers often come to us saying, our child has not been having periods for three months or the bleeding is too heavy. This is why we need to counsel the mother and the child; we can’t simply put her on hormones. Secondly, diet is very important as we have to ensure that the girl doesn’t become weak. She has to take an iron-rich diet if she continues to bleed. We may give her some haemostatic agents so that bleeding reduces or stops, but never put her on hormones at such a young age to regularise them. Moreover, such young girls should not be put under any kind of stress.

Q: What are some healthy lifestyle choices that all women must make?

Dr Jaiswal: To summarise, meal timings are very important, as most women are driven by emotions and tend to give more time to family members rather than herself. Women shouldn’t skip meals, especially breakfast. Something ready-to-eat and nutritionally fulfilling should be in their bags so they can eat that anytime. Secondly, fibre is very important. Every age has a different demand and folic acid, iron and calcium are important at different stages. There is also a change in the hormones of a woman every ten years which requires support and a stress-free life. Along with nutrition, physical activities and a holistic approach to health should be taken. A good amount of fluid intake (non-carbonated) and fibre intake should be encouraged. Diet should be wholesome.

Q: Would you add anything about the importance of a healthy diet?

Dr Jaiswal: It is important to start reading about food levels. Food diversity is also very important and in a country like India, where we have very diverse foods available, we should not avoid seasonal foods. Women should embrace practices like ‘poshan ke liye paudhe’ (plants for nutrition) and grow plants for good foods. The importance of nutrition for women must also be inculcated among men in order to bring wider changes in society.

Q: Many women starve themselves to lose weight. How can it be harmful?

Dr Jaiswal: Starvation isn’t absolutely wrong but it should be time-bound and well-monitored, and the expected deficiencies should be taken into consideration. A team should work with a person for binding the time of fasting and what should be eaten after breaking the fast. Weight reduction should not be undertaken through starvation but a holistic approach with complete nutrition. The aim should be to maintain an ideal body weight and also provide basic nutrition according to their particular age group.

Q: How important is hygiene?

Dr Bajaj: Hygiene is very important as women are prone to infections like UTIs and vaginal infections. Hygiene plays a major role, even before any antibiotics do their work. There are campaigns on menstrual hygiene now and people are becoming more aware about it.

Q: Any tips regarding menstrual hygiene?

Dr Malhotra: During menstruation, one should change her pad every 4-6 hours and use clean toilets. Women also need to learn the importance of using sanitary pads rather than other products in the market.

Q: What other health problems need to be discussed more?

Dr Aggarwal: PCOD is a very common problem in which the ovaries ovulate but the eggs are not released into the fallopian tubes, making the ovaries polycystic. Because this is an anovulatory cycle, hormonal imbalance takes place. Hence, the testosterone level rises in the female, leading to hair growth on the upper lip and chin, acne formation and neck pigmentation. Since it is a lifestyle disorder, women also tend to become obese and have irregular cycles. This can also cause infertility and loss of confidence. Earlier, PCOD could be seen in younger age groups, but now I see it in the reproductive age groups too. To prevent it, lifestyle changes need to be made, the woman has to be put on a diet, and if she is obese, she has to lose weight. Even if she loses 10% of it, most problems would be solved. So, the main concerns are having a proper diet, being physically active and proper medication.

Q: Studies indicate that every eight minutes a woman in India dies due to cervical cancer, more than 48% of women are anaemic, only 21.8% mothers get full antenatal care, and more than 1 lakh women die every year due to pregnancy-related problems. What can be done to improve such a scenario?

Dr Bajaj: You have raised three issues: anaemia, cervical cancer and pregnancy-related problems. First of all, anaemia is very common in India because women lose too much blood every month. Iron and calcium supplements are very important to eradicate this, especially during pregnancy and lactation, as blood is comparatively thinner at these times. There is also no proper spacing between births and after one or two years, they are pregnant again, when their body is not prepared, and thus the situation worsens.

For cervical cancer, tests like LBC and HPV are very good as precautionary measures to reduce the number of cases. We cannot reach each and every woman in the country due to India’s high population but we should definitely try. Screening tests should be done too. Most importantly, the cervical cancer vaccine should be used frequently. There are two types of vaccines available and they are expensive—it costs between Rs 2,000 and Rs 3000—and needed in three doses which cannot be affordable for everyone. But the vaccine is very important and effective as it prevents cervical cancer. So, awareness programs for the vaccine must be promoted and this vaccine should be added to the national immunisation programme because the ideal age for this vaccine is 9-13 years. Secondly, screening should be done.

Regarding pregnancy issues, maternal mortality is very high in spite of all the efforts taken. The main reasons are anaemia and delivery-related complications. In spite of so many hospital services, people still deliver at home, which is really not good and may lead to the death of the mother. So, the government should also promote hospital deliveries.

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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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