Dietary Adequacy of Indian Rural Preschool Children Influencing Factors

Dietary Adequacy of Indian Rural Preschool Children Influencing Factors by A. Jyothi Lakshmi, Begum Khyrunnisa, G. Saraswathi, and Prakash Jamuna Department of Studies in Food Science and Nutrition, University of Mysore, Manasagangotri, India Summary The dietary adequacy (qualitative and quantitative) of preschool children residing in rural areas near Mysore (a district in south India) was assessed by the Food frequency method and 24-h recall method. Food intake assessed in three different seasons revealed that their diets were predominantly cereal based with negligible quantity of protective foods. The overall nutrient intake was found to be inadequate, irrespective of the seasons. The adequacy level of the nutrients (cereal dependence) was found to be comparatively better in monsoon and winter seasons because of better labour opportunities and availability. Food consumption pattern showed no gender differences. The nutrient adequacy also varied by the age of the children. The influence of food expenditure on the nutrient adequacy was not statistically significant. Nutritional status was found to be a factor influencing nutrient intake. Apart from age, nutritional status and food availability, feeding practices may also influence the nutrient intake of the preschool children. Introduction Food plays a vital role in the growth of a nation. Nutrient requirements and suggested dietary intakes of nutrients currently recommended by national and international organizations, are primarily intended for healthy normal growth and development during rapid stages of development such as infancy and childhood, and to meet the additional demands during pregnancy and lactation. 1 In India and other developing countries, it was found that 80 per cent of its populace subsisted on dietary intakes below the Recommended Dietary Allowance (RDA). 2 Assessment of dietary inadequacy among preschool children revealed that the extent of calorie inadequacy ranged from 10 to 50 per cent or more in rural areas and urban slums of the country 2 5 and it has been identified to be the prime cause of undernutrition in India. 6 Food security (qualitative and quantitative) at family and household levels is obviously a major determinant of food intake and national nutritional status. 7 At a national level it refers to the food production, imports and distribution within the country, and at the household level it is defined as access to food, Acknowledgements We acknowledge Rajiv Gandhi National Drinking Water Mission, Ministry of Rural Development, New Delhi, India for providing financial assistance for the study. The assistance rendered by Ms K. Sudha and Ms B. K. Poornima is also gratefully acknowledged. Correspondence: Dr Jamuna Prakash, Department of Food Science and Nutrition, University of Mysore, Manasagangotri, Mysore 570 006, India. E-mail <jampr55@hotmail.com>. i.e., adequacy, cultural acceptability, and intra-household distribution. 8 Certain studies have demonstrated a positive association between per capita income and calorie adequacy being better among landlords, followed by small farmers and landless labourers. 9 In contrast, other studies have demonstrated that at similar income levels there were significant variations in diets depending on the tastes, awareness, and literacy status of women. 10 Studies have shown that wide variations existed in the feeding practices between urban and rural areas, starting from the initiation of complementary feeding. 4,11 Wide variations exist between the nutrient intake from region to region and factors associated with it. There is very limited information on the dietary adequacy of rural preschool children, the majority of the reports being based on a single time assessment. Since the nutrient intake varies from day to day, only repeated assessment in the same population over a time period will give a near accurate picture of the dietary adequacy. Hence the present investigation was undertaken with the aim of assessing the dietary intake of rural preschool children and to trace out the factors associated with it. Materials and Methods Children between the age of 1 and 5 years were selected from five rural areas near Mysore (a district located in southern India). A sample of 205 children from 160 households were enrolled for the study. Information on the background characteristics as socio-economic status, family size and availability of basic requirements were obtained by interviewing Journal of Tropical Pediatrics, Vol. 51, No. 1 Oxford University Press 2005; all rights reserved 39 doi:10.1093/tropej/fmh072 Advance Access published on 15 December 2004

the mothers of the children with a pre-tested questionnaire. The weights of the children were recorded using a standardized portable spring balance at the initiation of the study. The recorded weights were compared with 50th centile of National Centre for Health Statistics (NCHS) standards and categorized into different grades of malnutrition based on Gomez classification. 12 Qualitative adequacy was assessed by the Food frequency method and quantitative adequacy by the 24-h recall method by interviewing the mothers using suitable questionnaires. A set of five cups ranging from 75 to 250 ml and tumblers (standardized in the laboratory for the commonly prepared foods in the selected areas) were used to obtain information on the foods and beverages consumed by the children during the preceding 24 h of the survey. 24-h recall was repeated in three different seasons to observe seasonal variations. The nutrient intake was calculated using Food composition tables 1 and nutrient adequacy was computed by comparing with RDA given by the Indian Council of Medical Research. 13 Information on the food expenditure of each family was obtained by interviewing the mothers of the children and the expenditure/consumption unit/month was calculated. The expenditure was based on the cost of the food stuffs in the rural areas in 1998. The children were categorized into three groups based on their food expenditure/consumption unit/month in rupees as: low (Rs. 150 250), medium (Rs. 251 375), and high (Rs. 376 475). The data was analysed using one way analysis of variance. A statistical package was specially designed to analyse the differences between the groups having unequal numbers with the help of a statistician. Results and Discussion The selected villages were at a distance of 17 40 km away from Mysore city (a district of Karnataka state). All the villages were served by Integrated Child Development Services (ICDS is a national intervention programme working for the welfare of women and preschool children). Lower primary schools existed within all the villages. Food commodities were available in small shops present within the villages but the cost and quality were not satisfactory. Fair price shops were present in all the villages. The availability of perishable foods were reported to be low. The majority of the residents were agriculturists; of the selected families 78 per cent had agricultural lands and for 63 per cent agriculture was the sole occupation. Around 18 per cent were industrial labourers and only 9 per cent were Government employees. The cultivated lands were rainfed. Commonly cultivated crops of the selected areas were ragi, jowar, some legumes, spices, and some seasonal vegetables. Approximately six members were present in each household. Around 50 per cent of the selected households belonged to nuclear families. Seventy per cent of mothers and 60 per cent of the fathers of the selected children were illiterates, reflecting poor literacy status. Assessment of nutritional status of the children by Gomez classification revealed that only 9 per cent of the selected children were normal, 5 per cent were severely malnourished, and the remaining exhibited mild to moderate degrees of malnutrition. This is similar to those reported for south India by NNMB (National Nutrition Monitoring Bureau) and the national nutrition picture. 5,14 The consumption pattern assessed by the food frequency method, revealed that rice and ragi/jowar were the staple cereals of the study areas. The consumption of wheat was rare, either due to lack of availability or due to superstitious beliefs. Of the legumes, horsegram and red gram dhal were more frequently consumed depending on the season. Green leafy vegetables were consumed only during the monsoon season by the majority of them. Consumption of other vegetables was twice/thrice a week by the majority of the families. The consumption of milk was regular by most of the families, but it was solely in the form of coffee or tea. Although the majority of the families were non-vegetarians, they were forced to practise vegetarianism due to economic constraints. Food intake assessed by the 24-h recall method (Table 1) suggested that their diets were predominantly cereal based. The consumption of protective foods, such as milk and milk products, flesh foods, green leafy vegetables and fruits, were found to be negligible. Seasonality was observed only in the consumption of cereals and pulses (being better during monsoon and winter seasons) but not in the consumption of vegetables or fruits. The mean intake of all the food stuffs was below the national average 14 in all the seasons in both the age groups, but was similar to those reported from southern India. 5 Nutrient intake seasonality The dietary intake of all the nutrients was found to be inadequate irrespective of the seasons, but the extent of inadequacy varied between the seasons. From Table 2 it is evident that the extent of calorie deficit in relation to RDA ranged between 40 and 50 per cent in all the seasons. The mean adequacy of calorie and proteins was significantly higher in monsoon and winter seasons. The levels of nutrient adequacy during summer and monsoon seasons were similar to those reported by several other investigators across the country. 2 Total fat comprised of invisible fat to a large extent, as the visible fat in their 40 Journal of Tropical Pediatrics Vol. 51, No. 1

TABLE 1 Average intake of food stuffs in different seasons Age No. Season Cereals Pulses Other Roots and Green leafy Milk and Sugar and Fats and Fruits and sex vegetables tubers vegetables milk products jaggery oils 1 3 years Male 51 Summer 116 (62) 12 (38) 15 (76)0 9 (87) 2 (7)0 32 (8)0 9 (30) 2 (9)0 10 45 Monsoon 137 (71) 12 (40) 16 (80)0 7 (70) 2 (7)0 32 (7)0 10 (33) 2 (8)0 8 69 Winter 158 (62) 14 (53) 18 (90)0 6 (60) 2 (7)0 28 (7)0 10 (33) 3 (13) 9 Female 68 Summer 132 (71) 16 (47) 13 (65)0 6 (63) 2 (8)0 21 (5)0 10 (33) 3 (11) 12 54 Monsoon 147 (79) 18 (60) 24 (120) 5 (50) 4 (13) 16 (4)0 9 (30) 2 (5)0 4 73 Winter 155 (83) 18 (60) 17 (85)0 7 (70) 10 (33) 17 (4)0 8 (27) 2 (8)0 18 NNMB 146 (83) 14 (83) 12 (803) 20 (83) 5 (0) 77 (0)0 13 (83) 4 (83) 4 6 years Male 15 Summer 157 (58) 17 (49) 26 (87)0 4 (18) 2 (3)0 44 (18) 10 (24) 1 (4)0 9 13 Monsoon 178 (66) 21 (60) 19 (63)0 2 (8)0 (0)0 34 (11) 13 (33) 3 (10) 11 18 Winter 207 (77) 22 (63) 15 (50)0 9 (45) 2 (3)0 13 (4)0 7 (18) 3 (12) 7 Female 27 Summer 161 (60) 15 (43) 25 (82)0 15 (75) 1 (2)0 12 (4)0 123 (30) 2 (6)0 2 18 Monsoon 195 (72) 18 (51) 22 (73)0 15 (75) 8 (16) 23 (8)0 11 (28) 3 (12) 1 23 Winter 225 (83) 23 (66) 22 (73)0 13 (65) 9 (18) 13 (4)0 7 (18) 1 (4)0 2 NNMB 236 (83) 21 (83) 21 (803) 29 (83) 7 (00) 68 (0)0 16 (83) 7 (83) Figures in parenthesis indicate percent adequacy. NNMB, National Nutrition Monitoring Bureau. Journal of Tropical Pediatrics Vol. 51, No. 1 41

TABLE 2 Percent adequacy of nutrients in different seasons Season No. Calories Protein Fat Calcium Iron Vitamin A Summer 158 45.94 66.23 4.73 32.51 22.19 20.67 Monsoon 129 55.41 79.28 8.70 34.96 29.19 17.16 Winter 181 55.41 77.13 5.20 44.35 28.22 23.44 SD (2 df) ±13.93 ±23.84 ±6.63 ±34.28 ±18.73 ±39.27 F (2,464 df) 23.17** 13.13** 2.84* 5.63** 5.81** 1.75 ns ns: not significant, * p 0.05, ** p 0.01. TABLE 3 Percent adequacy of nutrients in relation to sex of the children Sex Season Calories Protein Calcium Iron Vitamin A Male Summer 41.27 61.22 30.61 19.96 18.97 Female 49.04 79.28 33.77 23.98 21.80 SD (1 df) ±10.62 ±23.84 ±30.28 ±12.21 ±30.06 F (1,156 df) 20.28** 7.23** 0.41 ns 4.10* 0.76 ns Male Monsoon 54.28 76.60 33.60 27.35 16.64 Female 55.51 81.47 36.06 30.63 17.75 SD (1 df) ±13.64 ±28.54 ±26.22 ±21.80 ±28.06 F (1,127 df) 0.26 ns 0.93 ns 0.27 ns 0.72 ns 0.09 ns Male Winter 53.94 75.14 40.80 26.95 19.35 Female 56.73 78.93 47.57 29.08 27.67 SD (1 df) ±16.14 ±28.66 ±41.84 ±16.18 ±40.23 F (1,179 df) 1.35 ns 1.16 ns 1.07 ns 0.78 ns 1.96 ns ns: not significant, ** p 0.01. diets was negligible (Table 1). The percentage of calories contributing to the total energy by fat ranged from 4 to 11 per cent in summer, 5 14 per cent in monsoon and 3 7 per cent in winter, as against a recommendation of 30 per cent by ICMR. This is in line with the observations from rural areas of India. 2,4 One of the reasons for a comparatively higher adequacy during the monsoon was the consumption of groundnuts harvested during the season. The mean adequacy of micronutrients was also lower than the desirable levels in all seasons. The adequacy levels of calcium although lower than those reported for southern states, 5 was comparable to those reported for children of low socio-economic groups. 2 The adequacy level of iron was found to be one-third of the recommended levels. Since cereals formed the major source of micronutrients, it followed the same trend as macronutrients. The low consumption of green leafy vegetables and meat products (Table 1) is reflected in the low micronutrient adequacy levels. The mean adequacy of vitamin A in their diets was much lower, being below onequarter of the recommendations. This is in line with the observations of other workers across the country. 10,16,17 The preferential consumption of rice (devoid of vitamin A) among preschoolers accounted for such a low adequacy. As mentioned earlier, the consumption of green leafy vegetables and yellow vegetables was very rare and in negligible quantities due to lack of availability. Another reason was the low intake of fat, which is essential for the proper utilization and absorption of vitamin A. The possible reasons for a better adequacy of almost all the nutrients in monsoon and winter seasons were better availability of food grains, better labour opportunities, and receiving food grains as wages. Another observation that accounted for reduced intake was unacceptability of ragi or jowar by small children and the non-availability of fine cereals (rice) during summer in some families. Nutrient intake sex From Table 3 it is evident that the adequacy level of the nutrients was found to be higher among female than male children in all the seasons, but the differences were statistically significant only in summer. This contradicts with the observations of others reported from northern India who have reported that the calorie intake was higher among male children. 4,15 Thus it can be said that gender discrimination in food distribution is a regional problem. 42 Journal of Tropical Pediatrics Vol. 51, No. 1

TABLE 4 Percent adequacy of nutrients in relation to age of the children Nutrient Season Age in years SD F 1 2 3 4 5 Calories S 47.93 50.04 43.82 42.87 42.79 ±11.00 2.84* M 67.72 55.73 53.44 53.36 53.16 ±13.56 2.04 ns W 57.79 54.02 55.67 51.99 59.38 ±16.19 0.84 ns Protein S 67.03 74.04 65.55 55.48 66.43 ±18.73 4.03* M 95.07 82.28 89.37 73.53 74.36 ±30.26 1.87 ns W 84.58 75.59 69.73 75.97 87.84 ±23.14 3.08* Calcium S 31.07 24.90 34.71 42.88 28.27 ±29.99 2.45 ns M 62.72 55.73 53.44 53.36 53.16 ±13.56 1.05 ns W 36.40 42.49 50.08 45.93 56.00 ±41.92 2.45 ns Iron S 18.40 23.72 24.42 20.73 12.46 ±12.26 1.50 ns M 24.93 31.75 36.96 26.66 22.12 ±22.53 1.50 ns W 29.32 32.65 24.66 25.36 25.94 ±16.03 1.81 ns Vitamin A S 14.91 18.09 13.58 14.04 38.85 ±27.15 4.26** M 15.15 18.38 13.55 12.04 36.90 ±52.37 5.17** W 26.44 29.55 21.04 15.90 19.77 ±49.61 0.76 ns S, summer; M, Monsoon; W, winter. ns: not significant, * p 0.05, ** p 0.01. Nutrient intake age As seen from Table 1, the food intake of children increased with increasing age but the adequacy of calories (Table 4) followed a decreasing trend in two of the three seasons, indicating that the extent of increase in the food intake was not sufficient to meet their requirements. The percent adequacy of protein varied by the age of the children but did not follow any trend unlike calories. The differences between the age groups were statistically significant in two of the three seasons of the study period. On the whole, the adequacy level of protein was better than calories. The adequacy level of calcium and iron varied between the age groups, but the differences were not statistically significant in any of the seasons. One of the reasons for such a variation could be the consumption of green leafy vegetables by a few children, which reflected a higher SD. The adequacy level of vitamin A was more than two times among 5-year-old children in the summer and monsoon seasons. The differences in the adequacy levels between the age groups were found to be highly significant in two of the three seasons. One possible reason could be consumption of all foods, i.e., family diet by older ones compared with younger children, who are restricted only to certain foods and are also subject to restrictions imposed on them due to superstitious beliefs. From the above observations it can be said that the nutrient intake of preschool children did not increase with their age to match their requirements. The possible explanation for this could be lack of awareness of the mothers in child-care practices and also the poor growth attainment by the children leading their caregivers to treat them as small children. Nutrient intake economic status The nutrient adequacy in relation to their economic status, as seen from Table 5, did not show much variation. The adequacy of calories and protein were similar in low and medium categories but slightly higher in the high category, but the differences were not statistically significant (p > 0.05). The adequacy level of vitamin A was below one-fifth of the RDA and was comparable between different economic groups. The adequacy of calcium and iron followed the same trend because cereals formed the major source of both macro- and micronutrients in the diets, irrespective of their economic status. This is in line with the observations of several others, 5 who have shown that there was no correlation between food availability and food intake among preschool children. 18 Nutrient intake nutritional status As given in Table 6, the mean adequacy of energy was comparatively lower among undernourished children, and the level of inadequacy increased with the degree of undernourishment. Analysis of variance revealed the differences between the groups were significant at 5 per cent level. The adequacy levels of protein also followed the same trend. The adequacy levels of calcium was very low in all the groups, it was found to be higher in the moderately malnourished children than normal children and the differences between the groups were statistically significant. The adequacy levels of iron were found to be below one-third of the RDA, irrespective of the nutritional status, and the differences between the groups were not found to be statistically significant (p > 0.05). The adequacy Journal of Tropical Pediatrics Vol. 51, No. 1 43

TABLE 5 Nutrient intake in relation to economic status/food expenditure (percent adequacy) Economic level Energy Protein Calcium Iron Vitamin A Low 53.51 75.91 45.80 23.71 18.60 Medium 54.43 75.75 42.62 27.35 17.17 High 62.50 78.37 52.50 30.09 15.30 SD (2 df) ±15.95 ±23.68 ±42.68 ±16.46 ±28.70 F (2,162 df) 1.37 ns 0.06 ns 0.29 ns 0.13 ns 0.15 ns ns: not significant. TABLE 6 Percent adequacy of nutrients in relation to nutritional status Nutritional grade No. Energy Protein Calcium Iron Vitamin A Normal 16 63.06 37.77 29.28 34.12 29.81 Mild 81 57.10 77.79 25.78 27.74 20.68 Moderate 72 53.31 75.92 40.49 27.35 26.20 Severe 12 46.33 65.65 20.47 26.51 17.57 SD (3 df) ±15.86 ±23.45 ±29.57 ±16.19 ±39.53 F (3,177 df) 3.28* 2.18* 3.31* 1.05 ns 0.49 ns ns: not significant, * p 0.05. levels of vitamin A were slightly higher among normally nourished children, but the differences were not statistically significant. Thus it can be said that the dietary adequacy of rural preschool children in addition to factors such as age, season (availability), and nutritional status, may also depend on child feeding practices, intrahousehold distribution, caretaker s knowledge, and literacy status. The role of economic status in influencing the nutrient intake cannot be overlooked. Thus it can be said that the nutrient adequacy is an outcome of certain child factors (age, nutritional status) and caregiver s characteristics on whom the child is solely dependent. References 1. Gopalan C, Sastri BV, Balasubramanian SC. Nutritive value of Indian foods. National Institute of Nutrition, ICMR, 1994. 2. Rao NBS. Human nutrient requirements and dietary allowances: current concept and their relevance to undernourished population in India and other developing countries. Food Science and Nutrition An update. Nutri Soc Ind 1995; 32 48. 3. Bapat MM, Aspatwar AP. Nutritional status of preschool and school children in slums of Bombay suburbs. Ind J Nutr Diet 1993; 30: 127 33. 4. Dahiya S, Kapoor AC. Diet and nutritional assessment of selected infants and younger children in rural areas of Haryana. Ind J Nutr Diet 1992; 29: 233 39. 5. NNMB. Annual Reports National Institute of Nutrition, Hyderabad: India, 1988 90: 36 50; 1994 95: 51 64. 6. UNICEF. Strategies for improved nutrition of women and children in developing countries. UNICEF Policy Review. UNICEF, New York, 1990. 7. Gopalan C, Kaur S. Nutrition and environmental degradation. Towards better nutrition problems and policies. Special publication series no. 9, 1989; 15 22. 8. Gillepsie SR, Manson J. Nutrition relevant actions, ACC/SCN State-of-the-art-Series, Nutrition policy discussion paper no. 10, 1991, Geneva. 9. Osmani SR. Poverty and nutrition in south Asia, ACC/SCN symposium report, Nutrition Policy Paper No. 16. WHO, Geneva, 1996. 10. FAO. The state of food and agriculture. World Review 1998; 3 45. FAO Rome. 11. Subbulakshmi G, Udipi SA, Nirmalamma N. Feeding of colostrum in urban and rural areas. Ind J Pediatr 1990; 57: 191 96. 12. Gopaldas T, Seshadri S. Nutrition Monitoring and Assessment. Oxford University Press, New Delhi, 1989. 13. ICMR. Nutrient requirements and recommended dietary allowances for Indians. Indian Council of Medical Research, New Delhi, India, 1989. 14. GOI. India nutrition profile. Department of Women and Child Development. Ministry of Human Resources Development. GOI, New Delhi, 1998. 15. Kanwar P, Kishatwaria J, Kharwara PC. Nutritional status of scheduled caste preschool children: A study in district Kangra of Himachal Pradesh. Ind J Nutr Diet 1984; 31: 293 98. 16. Khamgoakar MB, Ramakrishnan S, Ghuliani KK, Murthy GVS, Nayar S, Vidwan SP. Vitamin A intake and vitamin A deficiency in rural children. Ind Pediatr 1990; 27: 443 46. 17. Reddy V. Observations on Vitamin A requirements. Ind J Med Res 1971; 59: 34 7. 18. Chirmulay D. Child nutrition, care and poverty. ACC/SCN symposium report, Nutrition policy paper no. 16. WHO, Geneva, 1997. 44 Journal of Tropical Pediatrics Vol. 51, No. 1