Quantitative and Qualitative Analysis of Food Consumption in Household Kitchen of Rural Haryana: A Community-based Cross-sectional Study

1. Postgraduate, Department of Community Medicine, BPS Government Medical College for Women, Khanpur Kalan, Sonepat, Haryana, India. 2. Associate Professor, Department of Community Medicine, BPS Government Medical College for Women, Khanpur Kalan, Sonepat, Haryana, India. 3. Professor, Department of Community Medicine, BPS Government Medical College for Women, Khanpur Kalan, Sonepat, Haryana, India. 4. Postgraduate, Department of Community Medicine, BPS Government Medical College for Women, Khanpur Kalan, Sonepat, Haryana, India.

Abstract

Introduction: Food availability is essential for addressing malnutrition. However, nutritional adequacy, which includes both the quantity and quality of food, is equally important. In India, the household serves as the fundamental unit of food consumption, and the health of all household members reflects the nutrient adequacy at this level.

Aim: To assess the quantity and quality of food prepared in household kitchens in rural India.

Materials and Methods: A community-based cross-sectional study was conducted from July 2021 to June 2022 in village Juan, Haryana, India. Ninety households were selected using systematic random sampling. A dietary assessment was conducted to evaluate the food consumed at the household level. Additionally, a general physical examination was performed on all household members (n=405). The data were analysed using Statistical Package for Social Sciences (SPSS) version 20.0, and the Chi-square test was applied to identify associations between micronutrients (iron, calcium, and folic acid) and socio-demographic variables (social caste, socio-economic status, and household size).

Results: Out of the 90 households, the majority (52.2%) followed a lacto-vegetarian diet and had adequate calorie intake (more than the Recommended Daily Allowance (RDA)) (80%), protein intake (97.8%), and fat intake (86.7%). However, only 34.4% (n=31) and 20% (n=18) of households had sufficient iron and folic acid intake, respectively, resulting in over half (51.1%) of the household members being clinically anaemic. Approximately one-third (31%) of the household members were found to be overweight.

Conclusion: Despite the majority of households having an adequate quantity of food, there was a high prevalence of anaemia and malnutrition. Therefore, it is not only the quantity of food that is crucial for an individual’s health but also the quality and source of food.

Anaemia, Malnutrition, Nutrient adequacy, Overweight

Despite economic growth in developing countries, such as India, lack of access to adequate food has been a public health issue, leading to hunger and eventually malnutrition, with serious consequences for individuals, families, societies, and nations as a whole (1),(2). However, food availability is crucial to address malnutrition. Nutritional adequacy is equally important, meaning that food must meet the dietary needs of essential nutrients for individuals, considering many factors like age, gender, body size, and physical activity level, as expressed by the RDA recommended by national and international organisations for healthy growth and development (3),(4). Evidence suggests that 8.9% of the global population suffers from undernourishment in terms of energy intake. In India and other developing countries, approximately 80% of the population consumes dietary intakes below the RDA. India is home to roughly half of the world’s malnourished population (4),(5). In India, the household serves as the basic unit of food consumption. If sufficient food is available, individual household members can consume diets with recommended nutrient densities to meet their specific requirements (3).

Household nutrient inadequacy indicates a high vulnerability to various health consequences, including an increased risk of Non Communicable Diseases (NCDs) in adults and transgenerational consequences like adverse birth outcomes (preterm births and low birth weight), growth retardation, and poor cognitive development in children, leading to reduced productivity in adulthood (6),(7),(8),(9). Nutrition inadequacy remains disproportionately concentrated in rural India, especially among poor farmers and agricultural workers, resulting in significant nutritional problems like protein-energy malnutrition and micronutrient deficiencies (5). People in rural areas consume home-cooked food more frequently than those in urban areas (10). A household survey in four regions of India revealed that a considerable portion of the population consumes excessive amounts of cereals but inadequate amounts of protective foods such as legumes, milk, nuts, vegetables, and fruits (11). Dietary calories primarily come from sugar, carbohydrates, and saturated fat, with low micronutrient intake [10,11]. North India reportedly has the highest daily fat intake (67.3 g), leading to a higher prevalence of overweight, obesity, and abdominal obesity compared to other regions (11).

In the rural part of the northern state of Haryana, the reported mean calorie intake per day is higher (2441 Kcal/day) compared to the national average (2233 Kcal/day). However, one-fourth of children under the age of five had one or more anthropometric failures. Furthermore, two-thirds of Women of Reproductive Age group (WRA) suffer from anaemia, and nearly one-third of adults are overweight or obese (11),(12). Therefore, homemade food does not guarantee a healthy diet and can significantly impact the nutritional quality of the food consumed. Consequently, it is important to assess the nutrient adequacy of food at the household level. To the best of our knowledge, there is no reported data on the nutritional quality of food consumed in rural households in North India. Based on this background, present study was conducted to assess the quantity and quality of food cooked in the household kitchens of rural Haryana, India.

Material and Methods

A community-based cross-sectional study was conducted from July 2021 to June 2022 among households in the village of Juan, which is the field practice area of the Department of Community Medicine, Bhagat Phool Singh Government Medical College, Khanpur Kalan, Sonipat, Haryana, India. The village has a population of approximately 6,200 people residing in 1,153 households, as per the records maintained by the Department of Community Medicine.

Based on the guidelines of the Helsinki Declaration of 1973, which was later modified in 2013, ethical approval was obtained from the Institutional Ethics Committee (IEC) of BPS GMC (W), Khanpur Kalan, Sonipat (Reg. no. BPSGMCW/RC 637/IEC/20). The purpose and procedures of the study, as well as the right to withdraw from the study at any point, were explained to the households. No biological samples were collected from the participants. Written informed consent was obtained from the head of the households and household members after they were provided with all necessary information. Strict confidentiality and anonymity of the households were maintained, and access to data was restricted to the investigators of the study.

Inclusion criteria: Households that provided written informed consent were included in the study.

Exclusion criteria: Household members below six months of age, those who were seriously ill (currently or in the past month), or those on a prescribed special diet were excluded from the study.

Study population: The sampling frame included all households in Village Juan. A list of households and their members, who had been residing for atleast six months or more, was obtained from the Department of Community Medicine.

Sample size: Since there was no published data on the nutritional quality of household food in rural northern India, a prevalence of 50% was assumed to yield the maximum sample size. The calculated sample size was 384 participants (using the formula

n=Z²pq/d²,

where Z=1.96 at a 95% confidence interval, p=50%, q=1-p, and absolute precision (d)=5%). On average, it was estimated that one household had five members, so the number of households selected was calculated to be 77 (384/5) (13). Considering a 10% dropout rate, the total number of households to be selected was 85. Therefore, a nearest round-off value of 90 households was selected for data collection.

Sampling technique: A systematic random sampling technique was used to select the study households. As there were more than 1,150 households and 90 households were chosen, the calculated sampling interval was 12. The first house was selected randomly through a lottery method, and then every 12th household was selected for data collection.

Study tool: An adult female involved in purchasing and cooking food in the household was approached through a house-to-house visit. A predesigned, pretested, semi-structured interview schedule was used to collect socio-demographic information and details about the foods consumed (cooked and raw) in the household.

General physical examinations and anthropometric measurements were conducted for all household members included in the study using a nutrition assessment schedule (14).

Operational Definitions

The quantity of food was assessed using the following technique in the dietary survey: an inventory of total food consumed (cooked and raw, excluding food eaten from outside) was conducted.

Food categorisation: The foods were classified into major food groups, including cereals, millets, pulses, milk and milk products, fruits, green vegetables, roots and tubers, other vegetables, sugar and jaggery, fats and oils, eggs, fish, and meat. Food items were 6categorised based on their purchasing frequency. The number of food items purchased yearly, such as wheat and rice, was divided by 365 to determine the amount consumed per day. Food items purchased monthly were divided by 30, and those purchased weekly were divided by seven to calculate daily consumption. Highly perishable food items purchased daily were calculated based on daily consumption. The average daily intake of food consumed in a household was calculated and converted into principal food categories, such as grams of cereals per day, grams of pulses per day, and grams of leafy vegetables per day, per household.

Calculation of consumption units: This was done following the practice of nutritional surveys conducted in India by the National Nutrition Monitoring Bureau (NNMB) (15). After calculating the household’s average daily intake, the average amount of each food item was divided by the consumption units to obtain the intake per consumption unit by the household. This intake of each food group per consumption unit was compared against the recommendations of the Indian Council of Medical Research-National Institute of Nutrition (ICMR-NIN) (15).

Quality of food: The quality of food was assessed by calculating the intake of each nutrient per consumption unit under study, including total amount of carbohydrates, proteins, fats, iron, folic acid, calcium, and vitamin A, by the household. This intake was compared against the recommendations of the ICMR-NIN (15).

Overweight: The weight for height Z-score was calculated and compared against the standard value (16).

Statistical Analysis

The data collected from the study households were entered into Microsoft Excel spreadsheet 2019. After data cleaning, it was analysed using SPSS for Windows, Version 20.0, developed by SPSS Inc., Chicago. Quantitative data were expressed as median and Interquartile Range (IQR), while qualitative data were presented as frequency and proportion. The Chi-square test was applied to assess the association between categorical variables such as social caste, household size, and socio-economic status with the consumption of iron, calcium, and folic acid in the diet. A p-value <0.05 was considered statistically significant.

Results

A total of 90 households participated in the study, and among them, 405 household members underwent general physical examination and anthropometric measurements.

The majority of the heads of the households were unemployed 28 (31.1%) and had a literacy rate of 74.4%. Nearly half of the households 44 (48.8%) belonged to the “others” caste category, and one-third 29 (32.2%) had a Class-I and II socio-economic status. A greater proportion of households 55 (61.1%) had a household size of four and above. More than half of the households 47 (52.2%) followed a lacto-vegetarian diet (Table/Fig 1).

The study households had a median (IQR) intake of macro and micronutrients per consumption unit above the recommended levels, except for iron and folic acid. Among the surveyed households, 72 (80%) consumed more than the RDA for energy, and almost all of them (88, 97.8%) consumed more than the RDA for proteins. Only one-third of the households had adequate (more than RDA/category I) iron intake, while only 18 (20%) had adequate folic acid intake. However, all households had adequate vitamin A intake (Table/Fig 2).

A greater proportion of households belonging to the scheduled caste had adequate iron intake, while adequacy of calcium and folic acid was found to be higher in the “others” caste category. There was a statistically significant association between household size (four or less) and nutrient adequacy of calcium and folic acid. Households with a socio-economic status of Class-I and II had higher adequacy of folic acid, which was also statistically significant (p-value <0.05) (Table/Fig 3).

On general physical examination, more than half of the household members had pale conjunctiva, tongue, and nails. A substantial proportion of household members were underweight (68, 16.8%), as well as overweight (125, 31%) (Table/Fig 4).

Discussion

Dietary assessment is a process designed to determine the nutritional adequacy of the foods an individual consumes and the quantity in which they are consumed. The adequacy of nutrients in the household diet reflects the overall health of individuals. Therefore, the current study aimed to assess whether households were meeting their dietary needs both quantitatively and qualitatively and qualitatively. Present study assessed the nutrient intakes per consumption unit and compared them with the RDA standards to determine nutrient adequacy in the diet.

When assessing the adequacy of macronutrients, it was found that the majority of households had sufficient intake of calories (80%), protein (97.8%), and fat (86.7%) compared to the recommended allowances. These values were higher than the average intake reported in studies conducted Haryana, India (15). Moreover, the nutrient adequacy observed in present study was higher compared to the studies conducted in Sri Lanka, Africa, Ghana, Nepal, Andaman and Nicobar Islands, Southern India, and West Bengal (2),(17),(18),(19),(20),(21),(22). This could be attributed to the fact that most of the households in present study had livestock, a quarter of them owned agricultural land, and their per capita income was higher than the national average. This led to better accessibility and availability of protein and fat-rich foods such as pulses, milk or dairy products, meat, and eggs, which are more expensive than cereals (23),(24). In contrast, households with lower incomes rely more on cereals, which are mainly supplied through the Public Distribution System (PDS) (25).

However, the prevalence of overweight and obesity among the study households is concerning, as nearly one-third (31%) of household members were found to be overweight or obese. This could be due to the high intake of fat (72 g/CU, i.e., 1.4 times the RDA).

While assessing the nutrient adequacy of micronutrients, it was revealed that the median intake of iron per Consumption Unit (CU) per day was lower than the recommended values (87.7% of RDA), and only one-third of households had adequate iron intake. The main source of iron in their diet was wheat, which is a plant-based rich source of iron and is the staple food in northern India (25). Additionally, the intake of folic acid in their diet was also found to be insufficient (76.6% of RDA), and only one-fifth of the households had adequate folic acid intake. On general physical examination, more than half of the study participants were found to be anaemic. The high prevalence of anaemia could be attributed to the lower bioavailability of iron and folic acid, as the main sources of these nutrients were plant-based (25). These findings are comparable to the study conducted in Sri Lanka but not with the studies conducted in Ghana and the Andaman and Nicobar Islands (2),(19),(21). Present study reports a median intake of calcium higher than the recommended values. This could be due to the better socio-economic status of the households and the availability of cattle in most rural households, leading to a higher consumption of milk and dairy products produced at home.

In the present study, the availability of nutrients under study was higher for household members in smaller household sizes. This was because the amount spent on food would be sufficient to meet the food requirements of all household members (3),(7). These findings were in line with a study conducted by Sarkar S (23). The current study reveals that higher socio-economic status (in terms of per capita income) was associated with a higher adequacy of calcium. This was because as household incomes improve, absolute food spending is likely to increase, leading to improvements in both food quantity and quality. These findings are supported by a study conducted by Bhattacharjee S et al., which found that socio-economic status was a major predictor of micronutrient deficiencies (3). An adequate diet is also determined by social caste, as income and resources are unequally distributed (26). In present study, iron adequacy was higher among households belonging to the scheduled caste. This could be justified by the inclusion of animal-based foods in their diet compared to the other two social castes.

Based on the findings, several recommendations can be made. Firstly, targeted interventions should be implemented to address the issue of overweight and obesity among the study population. This could involve promoting healthier eating habits, increasing physical activity levels, and providing education on the importance of maintaining a healthy weight. Secondly, there is a need to promote the consumption of nutrient-dense and affordable foods among households. This could be achieved through various strategies such as promoting the cultivation of nutritious crops, providing subsidies for nutrient-rich foods, and educating households on the importance of a balanced diet. Furthermore, it is recommended to incorporate iron and folic acid-fortified items in the PDS. This would help to ensure that households have access to these essential nutrients, especially those that are at risk of deficiency. Lastly, further research is needed to assess the long-term impact of interventions on the nutritional status and health outcomes of the rural population. This would help to determine the effectiveness of different strategies and provide insights for future interventions.

The present study had several strengths. It was a community-based study with a high participation rate, which enhances the generalisability of the findings. The use of systematic random sampling reduced the chances of selection bias. Additionally, a validated and pretested questionnaire was used, and data collection was conducted by a single trained investigator, reducing the potential for inter-observer bias.

Limitation(s)

However, there were some limitations to this study. The information on monthly family income and food intake was self-reported, which may be subject to bias due to social desirability. Additionally, the presence of bleeding gums and caries observed during the general physical examination may be indicative of nutritional deficiencies or poor oral hygiene, but the assessment of these specific nutrients was not conducted in this study.

Conclusion

The study revealed that the majority of rural households had adequate intake of the macronutrients, but there were deficiencies in micronutrients, specifically iron and folic acid, leading to a high prevalence of anaemia. Socio-economic factors such as household size, socio-economic status, and caste had a significant impact on nutrient adequacy.

Acknowledgement

The authors would like to express their gratitude to all the participants for their valuable participation and support.

DOI and Others

DOI: 10.7860/JCDR/2023/63400.18288

Date of Submission: Feb 18, 2023
Date of Peer Review: Mar 18, 2023
Date of Acceptance: May 09, 2023
Date of Publishing: Aug 01, 2023

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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