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Background/Objectives Most interventions to foster child growth and development in India focus on improving food quality and quantity. We aimed to assess the pattern in food consumption and dietary diversity by socioeconomic status (SES) among Indian children. Subjects/Methods The most recent nationally representative, cross-sectional data from the National Family Health Survey (NFHS-4, 2015–16) was used for analysis of 73,852–74,038 children aged 6–23 months. Consumption of 21 food items, seven food groups, and adequately diversified dietary intake (ADDI) was collected through mother’s 24-h dietary recall. Logistic regression models were conducted to assess the association between household wealth and maternal education with food consumption and ADDI, after controlling for covariates. Results Overall, the mean dietary diversity score was low (2.26; 95% CI:2.24–2.27) and the prevalence of ADDI was only 23%. Both household wealth and maternal education were significantly associated with ADDI (OR:1.28; 95% CI:1.18–1.38 and OR:1.75; 95% CI:1.63–1.90, respectively), but the SES gradient was not particularly strong. Furthermore, the associations between SES and consumption of individual food items and food groups were not consistent. Maternal education was more strongly associated with consumption of essential food items and all food groups, but household wealth was found to have significant influence on intake of dairy group only. Conclusions Interventions designed to improve food consumption and diversified dietary intake among Indian children need to be universal in their targeting given the overall high prevalence of inadequate dietary diversity and the relatively small differentials by SES.

Although broad-scale data might suggest low prevalence, millions of children in India still suffer from Vitamin A and Vitamin D deficiencies despite India's existing guidelines for Vitamin A deficiency. To address the issue, the Government of India has recommended fortification of oil and milk to improve Vitamin A and Vitamin D consumption. However, there is limited information on the health benefits and cost-effectiveness of fortifying oil and milk at scale. To estimate the health benefits and cost-effectiveness of supplementation programme and fortification of milk and oil among children under 5 years, pregnant women, women in the reproductive age group, and the elderly. To measure the health benefits associated with supplementation and fortification of oil and milk, the number of DALYs that are currently lost due to Vitamin A and Vitamin D deficiencies were estimated. For Vitamin A related mortality, a reduction of 4%, 12% and 23% were assumed while the assumptions for estimating morbidity benefits were derived from Global Burden of Disease. For the costing exercise, we considered the following two scenarios: (1) high-dose vitamin A supplementation for children and pregnant women; (2) industrial fortification of oil for children, pregnant women, women in the reproductive age group, and the elderly. Overall, intervention related to Vitamin A could avert 1,119,044 Years of Life Lost (YLLs) at a 23% reduction, 194,616 YLLs at 4%, and 583,849 YLLs at 12% and 28,534 YLDs. Intervention related to Vitamin D could avert 99,219 YLDs. The total cost for supplying supplements to approximately 109,965 thousand children and 26,920 thousand pregnant women is around 26 million USD. The cost to fortify is 7.6 million USD for oil and 9.8 million USD for milk fortification for children and women. The overall cost effectiveness ratio of the fortification programme is 150. Fortification could emerge as a potentially superior long-term solution, considering the widespread consumption of oil and milk, offering a broader reach to the population.

Although broad-scale data might suggest low prevalence, millions of children in India still suffer from Vitamin A and Vitamin D deficiencies despite India's existing guidelines for Vitamin A deficiency. To address the issue, the Government of India has recommended fortification of oil and milk to improve Vitamin A and Vitamin D consumption. However, there is limited information on the health benefits and cost-effectiveness of fortifying oil and milk at scale. To estimate the health benefits and cost-effectiveness of supplementation programme and fortification of milk and oil among children under 5 years, pregnant women, women in the reproductive age group, and the elderly. Overall, intervention related to Vitamin A could avert 1,119,044 Years of Life Lost (YLLs) at a 23% reduction, 194,616 YLLs at 4%, and 583,849 YLLs at 12% and 28,534 YLDs. Intervention related to Vitamin D could avert 99,219 YLDs. The total cost for supplying supplements to approximately 109,965 thousand children and 26,920 thousand pregnant women is around 26 million USD. The cost to fortify is 7.6 million USD for oil and 9.8 million USD for milk fortification for children and women. The overall cost effectiveness ratio of the fortification programme is 150. Fortification could emerge as a potentially superior long-term solution, considering the widespread consumption of oil and milk, offering a broader reach to the population.

The Integrated Child Development Services (ICDS) program launched in India in 1975 is one of the world’s largest flagship programs that aims to improve early childhood care and development via a range of healthcare, nutrition and early education services. The key to success of ICDS is in finding solutions to the historical challenges of geographic and socioeconomic inequalities in access to various services under this umbrella scheme. Using birth history data from the National Family Health Survey (Demographic and Health Survey), 2015–2016, this study presents (a) socioeconomic patterning in service uptake across rural and urban India, and (b) continuum in service utilization at three points (i.e., by mothers during pregnancy, by mothers while breastfeeding and by children aged 0–72 months) in India. We used an intersectional approach and ran a series multilevel logistic regression (random effects) models to understand patterning in utilization among mothers across socioeconomic groups. We also computed the area under the receiver operating characteristic curve (ROC-AUC) based on a logistic regression model to examine concordance between service utilization across three different points. The service utilization (any service) by mothers during pregnancy was about 20 percentage points higher for rural areas (60.5 percent; 95% CI: 60.3; 30.7) than urban areas (38.8 percent; 95% CI: 38.4; 39.1). We also found a lower uptake of services related to health and nutrition education during pregnancy (41.9 percent in rural) and early childcare (preschool) (42.4 percent). One in every two mother–child pairs did not avail any benefits from ICDS in urban areas. Estimates from random effects model revealed higher odds of utilization among schedule caste mothers from middle-class households in rural households. AUC estimates suggested a high concordance between service utilization by mothers and their children (AUC: 0.79 in rural; 0.84 in urban) implying a higher likelihood of continuum if service utilization commences at pregnancy.

A spatially representative statewide survey was conducted in Rajasthan, India to assess household coverage of atta wheat flour, edible oil, and salt. An even distribution of primary sampling units were selected based on their proximity to centroids on a hexagonal grid laid over the survey area. A sample of n = 18 households from each of m = 252 primary sampling units PSUs was taken. Demographic data on all members of these households were collected, and a broader dataset was collected about a single caregiver and a child in the first 2 years of life. Data were collected on demographic and socioeconomic status; education; housing conditions; recent infant and child mortality; water, sanitation, and hygiene practices; food security; child health; infant and young child feeding practices; maternal dietary diversity; coverage of fortified staples; and maternal and child anthropometry. Data were collected from 4,627 households and the same number of caregiver/child pairs. Atta wheat flour was widely consumed across the state (83%); however, only about 7% of the atta wheat flour was classified as fortifiable, and only about 6% was actually fortified (mostly inadequately). For oil, almost 90% of edible oil consumed by households in the survey was classified as fortifiable, but only about 24% was fortified. For salt, coverage was high, with almost 85% of households using fortified salt and 66% of households using adequately fortified salt. Iodized salt coverage was also high; however, rural and poor population groups were less likely to be reached by the intervention. Voluntary fortification of atta wheat flour and edible oil lacked sufficient industry consolidation to cover significant portions of the population. It is crucial that appropriate delivery channels are utilized to effectively deliver essential micronutrients to at-risk population groups. Government distribution systems are likely the best means to accomplish this goal.

The Integrated Child Development Services (ICDS) in the State of Telangana, India, freely provides a fortified complementary food product, Bal Amrutham, as a take-home ration to children 6-35 months of age. In order to understand the potential for impact of any intervention, it is essential to assess coverage and utilization of the program and to address the barriers to its coverage and utilization. A two-stage, stratified cross-sectional cluster survey was conducted to estimate the coverage and utilization of Bal Amrutham and to identify their barriers and drivers. In randomly selected catchment areas of ICDS centers, children under 36 months of age were randomly selected. A questionnaire, constructed from different validated and standard modules and designed to collect coverage data on nutrition programs, was administered to caregivers. A total of 1,077 children were enrolled in the survey. The coverage of the fortified take-home ration was found to be high among the target population. Nearly all caregivers (93.7%) had heard of Bal Amrutham and 86.8% had already received the product for the target child. Among the children surveyed, 57.2% consumed the product regularly. The ICDS program's services were not found to be a barrier to product coverage. In fact, the ICDS program was found to be widely available, accessible, accepted, and utilized by the population in both urban and rural catchment areas, as well as among poor and non-poor households. However, two barriers to optimal coverage were found: the irregular supply of the product to the beneficiaries and the intra-household sharing of the product. Although sharing was common, the product was estimated to provide the target children with significant proportions of the daily requirements of macro- and micronutrients. Bal Amrutham is widely available, accepted, and consumed among the target population in the catchment areas of ICDS centers. The coverage of the product could be further increased by improving the supply chain.

Micronutrient malnutrition is widely prevalent in school children in India. India's national school feeding program, the Mid-Day Meal (MDM) scheme, is the largest in the world and caters to 120 million children in primary schools. Complementary strategies such as deworming or fortifying meals provided through the MDM scheme could increase the nutritional impact of this program. India's Supreme Court has directed that only hot, cooked meals be provided in MDM, through a decentralised model. However, in urban areas, big centralised kitchens cook and serve a large number of schools, with some kitchens serving up to 150,000 children daily. The objective of this project was to test the operational feasibility of fortifying the school meal in centralised kitchens, as well as the acceptability of fortified meals by recipients. A pilot was conducted in 19 central kitchens run by the Naandi Foundation in four different States. Several food vehicles were used for fortification: wheat flour, soyadal- analogue and biscuits. More than 750, 000 children were reached with fortified food on all school days for a period of one year. Fortified food was found to be acceptable to all stakeholders. The government is in favour of continuing fortification. The Naandi Foundation has adopted fortification as their norm and continues to fortify all meals provided from their central kitchens. fortification of school meals with micronutrients can be integrated in the normal cooking process and is well accepted by all stakeholders. This pilot could hold lessons for other states in adopting fortification in MDM.

Being home to 31% of the world's children who are stunted and 42% of those who are underweight, and with many children and adults affected by micronutrient deficiencies, India is facing huge challenges in the field of nutrition. Even though the Indian Government is investing vast amounts of money into programs that aim to enhance food security, health and nutrition (the Integrated Child Development Services program alone costs 3 billion USD per year), overall impact has been rather disappointing. However, there are some bright spots on the horizon. The recent District Level Health Surveys (DLHS-4) do show significant progress, ie a reduction in stunting of around 15% over the past 6 years in a few states for which preliminary results are available. The reasons for this reduction are not unambiguous and appear to include state government commitment, focus on the 'window of opportunity', improved status and education of women, a lowered fertility rate, and combinations of nutrition- specific and nutrition-sensitive interventions. Apart from the government many other agencies play a role in driving improvements in nutrition. Since 2006 the Global Alliance for Improved Nutrition (GAIN) has worked with a range of partners to improve access to nutritious foods for large parts of the population, through public and private delivery channels. This supplement presents a selection of these activities, ranging from a capacityassessment of frontline workers in the ICDS system, large scale staple food fortification, salt iodization, fortification of mid-day meals for school children and decentralized complementary food production.

Integrated Child Development Services in India through its supplementary nutrition programme covers over 100 million children, pregnant and lactating women across the country. Providing a hot cooked meal each day to children aged between 3-6 years and a take-home ration to children aged between 6-36 months, pregnant and lactating women, the Integrated Child Development Services faces a monumental task to deliver this component of services of desired quality and regularity at scale. From intermediaries or contractors who acted as agents for procuring and distributing food to procurement directly from large food manufacturers to using women groups as food producers, different State Governments have adopted a variety of strategies to procure and distribute food, especially the take-home ration. India's Supreme Court, through its directive of 2004, encouraged the Government to engage women's groups for the production of the supplementary food. This study was conducted to determine the operational performance, economic sustainability and social impact of a decentralised production model for India's Supplementary Nutrition Program, in which women groups run smallscale industrialised units. Data were collected through observation, interviews and group discussions with key stakeholders. Operational performance was analysed through standard performance indicators that measured consistency in production, compliance with quality standards and distribution regularity. Assessment of the economic viability included cost structure analysis, five-year projections, and financial ratios. Social impact was assessed using a qualitative approach. The pilot unit has demonstrated its operational performance and cost-efficiency. More data is needed to evaluate the scalability and sustainability of this decentralised model.

Although broad-scale data might suggest low prevalence, millions of children in India still suffer from Vitamin A and Vitamin D deficiencies despite India's existing guidelines for Vitamin A deficiency. To address the issue, the Government of India has recommended fortification of oil and milk to improve Vitamin A and Vitamin D consumption. However, there is limited information on the health benefits and cost-effectiveness of fortifying oil and milk at scale. To estimate the health benefits and cost-effectiveness of supplementation programme and fortification of milk and oil among children under 5 years, pregnant women, women in the reproductive age group, and the elderly. Overall, intervention related to Vitamin A could avert 1,119,044 Years of Life Lost (YLLs) at a 23% reduction, 194,616 YLLs at 4%, and 583,849 YLLs at 12% and 28,534 YLDs. Intervention related to Vitamin D could avert 99,219 YLDs. The total cost for supplying supplements to approximately 109,965 thousand children and 26,920 thousand pregnant women is around 26 million USD. The cost to fortify is 7.6 million USD for oil and 9.8 million USD for milk fortification for children and women. The overall cost effectiveness ratio of the fortification programme is 150. Fortification could emerge as a potentially superior long-term solution, considering the widespread consumption of oil and milk, offering a broader reach to the population.