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Foods are perceived by the mothers in relation to availability, source and form of preparation, as well as to health and growth. A picture of how these foods were grouped, as analyzed by multidimensional scaling and superimposed clustering using Anthropac software, is seen in Figure 1.
Food sources and forms of preparation
Mothers grouped the key foods according to their source and regularity of use. For example, cereals and peas were grouped together as they are cultivated locally. Other foods were grouped if they were prepared or consumed together, for example, hot pepper, carrot, and lard are fried together as flavoring. Green herbs were grouped together as used in the green soup, and foods that are prepared with potato was another group. Foods that are eaten separately, such as fruit or sweet potato, is another example of how foods were grouped. The storing capacity of foods was another criteria for classification.
"Hot" (caliente) or "cold" (fresco)
Foods are perceived according to their attributes or properties in relation to nutrition and health. A prime classification is related to the humoral system of "hot" (caliente) and "cold" (fresco), predominant in the Andean culture. These attributes are applied to all age groups but are particularly important in certain circumstances, mainly to compensate changes in the body due to external effects or illness. There are particular circumstances, such as after childbirth, when certain foods that are caliente are required and fresco can be harmful.
Herbs are caliente as are cereals processed with ash. Tubers and fruits are considered fresco unless they have been left in the sun. Foods such as sweet potato and carrot are fairly neutral. However, these states are not static and much depends upon their use and circumstances.
Foods to give strength
The ability to "give strength" and "combat weakness" is an important attribute of food. This is particularly relevant for growing children and mothers after childbirth, although they can be applied to all ages and both sexes. Wheat, peas, potatoes, and animal products, such as eggs, chicken, and mutton, are examples. Certain foods are classified as being good for children, to help them to grow well, be healthy, and good for thinking and for the memory. Eggs particularly, as well as wheat, quinoa, and potato, fall in this category. Among the vegetable sources of vitamin A, carrot is perceived to give strength yet green herbs and green leaves are not.
Good tasting is a quality appreciated by all members of the family and is one of the first mentioned in the classification of foods. Potato and animal products, including breastmilk, are considered good tasting, as well as sweet potato, rice, beans, and fruit. The wild green leaves of amaranth and flower of ñapush are among the least attractive tastes. All respondents reported that children particularly like fruit; sweet potato, potato, meats, and rice are other foods mentioned.
The relative cost of food is important in this population with limited monetary resources and determines the selection of foods purchased. The foods that are considered cheapest are chamcua, gathered from the wild, breastmilk, green leaves collected from fields or the wayside, and herbs. Hen's meat and staple foods, when they have to be bought (as at the time of the study), are the most expensive items. Sweet potato and eggs are more expensive, and carrot, mango and, oranges the cheaper foods.
Foods not suitable for children
A number of mothers (60%) considered that certain foods are not suitable for small children; maize, wheat, or beans can harm the child since they are heavy and can cause digestive problems or impair memory. Similarly dry flours could choke a small child. Certain tubers (oca, ulluco) could cause diarrhea in some circumstances as they are fresco. The "hairy bits" of mangoes can "stick to a child's stomach" and cause diarrhea. If mango has been in the sun it becomes caliente and can cause a stomach-ache and diarrhea. Green soup is not given to children until they are one year old as it is considered caliente. These are widespread perceptions.
Foods for pregnancy
There is a belief that a woman may not eat during the first three months of pregnancy because the infant impedes her wanting to eat, in contrast to when she is "empty" (not pregnant) and eats whatever she wants. Too much work or effort could cause a stomachache or diarrhea.
Certain foods, such as meats, legumes, some cereals, tubers, fruits, and vegetables are considered beneficial during pregnancy by 55% of mothers. These foods primarily protect the infant from being malnourished and the mother from weakness. Thirty percent of mothers consider that certain foods should not be eaten during pregnancy. These are primarily wheat and maize flour as they can be harmful and heavy and are a poor man's food; certain foods that are fresco should be avoided
Foods for the postpartum period
The most attention is placed on a women's diet after birth. Most respondents (88%) considered certain foods were necessary during the postpartum period to help a woman regain her strength. Broth made from mutton, the sheep's stomach (as well as the meat itself), or chicken, is necessary to replace the woman's strength and blood lost during childbirth. These foods, together with potato, sweet potato, pasta, and rice should be given for eight days, by which time the woman will have her strength back. Foods that are fresco should not be consumed as they "cool the blood which is retained," nor those that could irritate the stomach or the wound including fish, particularly salted fish, hot pepper, and onion. In some circumstances foods that are caliente should not be consumed as they "can give heat" or "cook the body." In other circumstances they are considered necessary to protect the mother from illness. A balance between warm and cold is required particularly at this time.
Foods to give milk
An important attribute of foods is related to their perceived ability to stimulate milk production in lactating women. The liquid obtained from boiling sweet potato is considered particularly good for producing milk, as is mutton, and to a lesser extent herbal infusions and sweet potato itself. These liquids enable "the milk to come together;" dry foods such as boiled cereals and stews do not help milk production.
The mothers of San Vicente grouped foods in relation to type, how they are used and prepared, taste, and cost. Attributes are also related to perceived nutritional value with a number mentioning vitamin content.
Types of foods and preparation
Foods are grouped primarily according to how they are combined or prepared. Those that are prepared and eaten together either in soups, as a main course, or fried together as flavoring are grouped together, rather than foods that can be prepared in a similar way. Thus noodles and chicken giblets are combined in soup, as are carrots, squash, and eggs. Lentils and rice are eaten together and oca and milk are prepared together as a sweet. Foods are also classified according to type: green plants are grouped together as are fruits. The diagram of the analysis using Anthropac software of the grouping through the multi-dimensional scaling and clustering for San Vicente is shown in Figure 2. It can be seen that food groups varied from those shown in Figure 1.
Mothers in San Vicente perceived foods according to nutritional qualities. Breastmilk and cow's milk, followed by other animal foods, particularly fish are considered most nutritious. Legumes, especially lentils, and yellow vegetables such as squash and carrots are also considered to be nutritionally good. Of the staple foods potato and maize flour are considered the most nutritious.
Herbs, including those used in green soup as well as other flavoring agents, are not considered particularly nutritious; nor are sugar, oil, rice, noodles, sheep's blood, and green quinoa and amaranth leaves. In fact these green leaves are not highly valued and are eaten "because they are there," and "when we don't have other food."
Good for children and babies
Those foods considered good for children are similar to those mentioned as nutritious, with breastmilk, fish, eggs, cow's milk, and chicken's offal heading the list. Yellow foods including squash (although little used), carrots, sweet potato, and fruits, such as papaya and mango are also considered good. Sweet potato is considered filling and soft. Pasta and potato are the preferred staples in this aspect. They are considered good for children because they contain vitamins and are nutritious.
Only a few foods were mentioned as inappropriate for small children. These include legumes that are considered heavy in that the skin can cause diarrhea. Maize, particularly the toasted grain, was considered "heavy" and caused empacho.
Foods considered good to combat or prevent weakness are those associated with vitamins. They are similar to those mentioned above, with milk, eggs, chicken's offal, and carrots mentioned the most, along with papaya and some green leafy vegetables.
Animal products, particularly milk and fish, are considered the most delicious foods. Pasta, potato, and legumes are the most liked staple foods, and papaya among the fruits. Herbs and sheep's blood are the foods least liked. Children are reported to like fruit more than other foods, followed by meats and legumes.
Calido or caliente (hot)
Foods are perceived in relation to the humoral system although much less defined and applied than in Chamis with wide variations in the classification. In general, the foods are classified similar to that described for
Chamis, with green herbs, such as rue, and beef examples of foods considered as calico, and eggs and papaya as those considered fresco. Other animal products and carrots are considered fairly neutral. However, these states are not static; much depends on the treatment of the different foods, particularly their processing or time left in the sun to sweeten.
The cost of a food is an important quality that determines choice. Pasta and legumes are the key foods considered most expensive, followed by oil, eggs, potato, and sugar. Carrots, squash, and fish are intermediate in price, and herbs and leafy vegetables are among the cheapest. Sweet potato is one of the cheapest foods in San Vicente, in contrast with Chamis.
Thirty percent of mother-respondents mentioned that certain foods should not be eaten during pregnancy. These included flours that can cause empacho and can be harmful to the baby; similarly, oil was mentioned in this context. Heavy foods were mentioned by some as not good during pregnancy. Women reported that they should eat only what is necessary during pregnancy to avoid a difficult birth.
However, 86% considered that some foods, such as cow's milk, fruits, vegetables, fish, eggs, and beans should be consumed, so the infant will grow well, have the necessary vitamins, and be born healthy. Drinking plenty of liquid during pregnancy is perceived as facilitating more milk after birth. Nevertheless it is probable that actual practices do not change much as they eat "what there is."
Foods for the postpartum period
As in Chamis the postpartum period is considered to be a critical time for the nutrition of the mother. During the first three to five days after giving birth a woman needs to recuperate energy and blood lost. All the women interviewed reported that mutton or chicken broth is necessary to facilitate a quick recovery; broth is perceived as "giving blood." Broths were considered nutritious and good to help her recover from the "weakness."
Seventy-three percent of the mothers commented that certain foods should not be eaten during this period. Those mentioned most were legumes, as these can cause a stomachache and gas, hot pepper, as it is fresco and can irritate, fish, since it can cause an infection and irritate the wound, as well as other foods perceived as fresco, such as orange. Dry foods and flours should not be consumed as these could limit milk production.
considered that some foods stimulate milk production,
predominantly liquids such as, vegetable or meat soups. Drinks
made with oats, juices, chocolate, or boiled sweet potato water
are also considered beneficial.
Clinical symptoms of vitamin A deficiency, as described in the manual, are not recognized in these two communities. An exploration of hypothetical case scenarios of mothers and children with symptoms of vitamin A deficiency led to the description of their suffering from "weakness" in Chamis, related to insufficient consumption of foods that "give strength." Another diagnosis proposed by mothers was that the child suffered from "fear of the spirits;" an "eye illness" and "a mental problem" were also mentioned.
Mothers said that they would first try treating this type of problem themselves. If home treatments (encouraging the child not to be afraid, or bathing the eye in the case of a recognized eye problem) were not effective, the hospital or local traditional healer (medico del campo) would be sought. For an eye problem hospital treatment seemed to be an appropriate first resource.
Certain foods are considered "good for eyesight" by 36% of the respondents. Carrots were mentioned by three mothers (11.5%); the other foods mentioned did not contain vitamin A. Thirty-five percent of the mothers had heard the word vitamin and associated it with giving strength to children, enabling them to think or study, and protecting them against weakness.
In the exploration of hypothetical case scenarios of women and children with symptoms of vitamin A deficiency, the more common description was that the child was "afraid" (in general or specifically of the dark), that he or she was "affected by the spirits," suffered from "weakness" from not eating adequately, had a vision problem or was tired. Improved food intake, including carrot juice, was a recommended treatment, and if not effective the child should be taken for medical care. For women suffering from weakness, which could "darken the eyesight," the consumption of more vegetables, meat, milk, and juices was recommended. If the condition did not improve medical care should be sought.
Most respondents (81%) cited carrot or carrot juice as good for the eyesight. Other foods mentioned also contained vitamin A, with the exception of apple. In contrast to Chamis 89% of the mothers had heard of vitamins that were described as nutritional substances that give energy strength, and health to the body.
Comparisons Between Chamis and San Vicente
The perceptions of the population of San Vicente towards food and health reflect a process of urbanization. In Chamis foods are grouped according to their source, whether locally grown or not, and whether prepared in similar ways. In San Vicente foods that are prepared and eaten together are grouped together.
Classification and use of foods according to the humoral system is more pronounced in Chamis. In San Vicente this is less defined and applied, at least among those who have lived in the city for a longer period of time. The qualities of "giving strength" and "combating weakness" and thus being "good for children" are important to both communities; in San Vicente this is associated with nutritious foods. Most of the population in San Vicente has heard of vitamins and associates them with the nutrient value of foods, however, only a minority of those in Chamis have heard this term.
Undoubtedly "good-tasting" is an important food attribute for both communities, as is cost. Nevertheless the perceptions in this regard are relative: sweet potato, considered a cheap food for the urban community is expensive in Chamis. Herbs and the gathered green leaves are not valued in San Vicente and are considered a poor man's food; in Chamis they are considered good-tasting and add variety to the diet when in season.
Apart from the green leaves and herbs, vitamin A-containing foods are generally well-positioned in relation to the perceived attributes in both populations and thus have a potential for promotion through interventions.
There is no clear recognition of vitamin A deficiency in either community, yet the diagnoses of the hypothetical case scenarios are not dissimilar. There were, nevertheless differences in the health-seeking behavior of both populations as shown in Table 7.5.
In Chamis there is greater reliance on home treatments recommended by "people who know" within the family, particularly the grandmothers, whereas the major resource for those in San Vicente is the city hospital. Attention from the health post and traditional healer was reported similar for both populations.
Health-Seeking for Illness-Chamis and San Vicente
% of Respondents (each
respondent could give more than one answer)
Signs and symptoms of vitamin A deficiency in these populations are not clear, but there may be indications of some effects, such as nightblindness, that have not been demonstrated previously in Peru, particularly in the rural community of Chamis. These need to be explored further with the diagnosis of vitamin A status and a closer examination of symptoms to elucidate these possible manifestations of deficiency. Rates of infectious diseases among children are high in both communities. The seeking of healthcare is related to the perception of the severity, duration, and cause of illness with a mix of local traditional and modern resources used.
Vitamin A intake is very low in Chamis, markedly less than in San Vicente at the time of the study, yet mean intakes did not meet recommended levels in either population. The diet in Chamis is monotonous and less varied than in the urban community where a wider variety of foods are available from the market, the major food source. The study was conducted during a season of low availability of foods.
Breastmilk is the major source of vitamin A for small children in both communities and particularly protected children in Chamis for two years or more. For other members of the family carrots were a major source of vitamin A at the time of the study. Other vegetable sources included green herbs, also squash and sweet potato in San Vicente. It appears that carrots, although consumed in small quantities yet frequently, contributed more total vitamin A to the diet than the larger portions of foods consumed less frequently, such as sweet potato.
In Chamis very few animal products were consumed; eggs are the major contributor of vitamin A. Cow's milk, eggs, and fish are important animal sources in San Vicente. The higher vitamin A intake in San
Vicente is due to a larger consumption of milk and carrots compared with Chamis; the milk donation program in San Vicente contributes significantly. Although fat intake was low in Chamis, there appears to be sufficient in the food preparations to permit absorption of vitamin A.
The rural community is more affected by seasonal variation in food availability than the urban population that has access to many foods all year through the city market, although choices are influenced by seasonal fluctuations in price. In Chamis food intake is primarily determined by local production; thus vitamin A intake is higher during the summer months when green leafy vegetables and herbs are more available. This period coincides with availability of sweet potato and mango in the market. It is necessary to conduct evaluations during these times of the year to determine seasonal vitamin A intakes and whether the higher levels are sufficient to provide adequate body stores for the leaner periods.
The vitamin A-rich foods are generally well-positioned in terms of attributes and qualities, which gives potential for their promotion. Foods that could be increased in terms of intake are those perceived as "giving strength" and "good for children" in Chamis, and those considered "nutritious" and "prevent weakness" in San Vicente.
Intrafamily distribution of foods did not appear to be an issue influencing vitamin A intake for vulnerable members of the family in either community. The food prepared is consumed by each member, although the amount depended on age. Nevertheless, certain foods, including vitamin A-rich items, are not given to small children. In Chamis consumption of vitamin A foods is limited in children during the weaning period, with the exception of breastmilk. Infants in San Vicente are given a wider variety of complementary foods, although breastfeeding is stopped earlier. The availability of food to the family is more important than the distribution within It.
This study highlighted the problem of nutrition during the weaning period that is especially severe in the rural population. Low food consumption lead to inadequate intake of energy and nutrients, particularly during the six- to twelve-month age period and continued to two or three years of age. Mothers are extremely passive in the rural communities, responding only to the perceived demands of the child for food.
Chamis and San Vicente a variety of vitamin A-rich foods are
available throughout the year and perceptions toward many of
these are favorable. Thus dietary modification is a possible
strategy to improve vitamin A status.
An intervention strategy to improve nutritional status of vitamin A through dietary modification in these communities is feasible and should be implemented. The availability and perceptions of the population towards vitamin A-rich foods provide a potential for increasing dietary intake. An educational campaign can be developed using the information obtained in this study, both in the selection of the foods to be promoted and the formulation of appropriate messages for urban and rural populations of this region.
Vitamin A status and deficiency symptoms, especially nigh/blindness, require closer examination, particularly in the rural populations, so that the severity of deficiency can be defined adequately.
Seasonal variation in vitamin A status and food intake needs further exploration. Times when vitamin A-rich sources are available can be exploited. This includes foods such as sweet potato, vitamin A-rich fruits, and green leafy vegetables.
Increased frequency and amount of carrots used in food preparations can be promoted, particularly in rural populations, as can squash where it is available. These foods consumed regularly in common food preparations can contribute important amounts of vitamin A to the diet during the year.
Ways to increase the in rake of animal products, such as eggs and fish in Chamis, and eggs, fish, and offal in San Vicente, need to be explored, particularly for small children. If food distribution programs are an alternative micronutrient-rich foods, such as milk, must be included.
The modification of perceptions towards little-used potential vitamin A sources through a carefully designed communications campaign can be explored. This could be applied to green leafy vegetables or sheep's blood where appropriate.
The promotion of home gardens with greater availability of seeds is an appropriate intervention for increasing local production of vitamin A-rich foods in rural communities. This can potentially provide more variety as well as increasing intake of vitamin A and other nutrients.
The promotion of improved infant feeding practices is necessary in both populations, particularly complementary feeding from six months of age. Solid foods need to be introduced at six months and the quantity, quality, and frequency need to be improved for better nutrition, health, and growth. The preparation of appropriate, nutrient-dense foods for this age group, using ingredients from the family pot and including micronutrient-rich foods, needs to be promoted. Children should be given priority for certain nutrient-dense foods, such as eggs. Dietary intake between six and eighteen months is inadequate particularly in rural areas, and ways of stimulating mothers to adopt a more active behavior towards feeding children need to be explored and promoted.
Exclusive breastfeeding during the first six months and breastfeeding into the second year need to be promoted in urban populations and reinforced in rural areas.
The development of nutritious preparations acceptable to the different groups of the population, particularly young children, can be conducted through a participatory process of recipe trials with mothers, focusing on selecting vitamin A-rich foods. The feasibility of these dietary modifications can be evaluated through household trials in each of the communities.
The vitamin A content of many of these foods needs to be determined. The amount in the mixture of herbs as served in green soup and other preparations needs to be analyzed.
The bioavailability of vitamin A from the local preparations of green leafy vegetables, herbs, and other cooked and processed vegetable dishes, needs to be determined.
Whether the higher intakes of vitamin A food sources, at the time of greater availability, provide sufficient body stores to prevent deficiency for the rest of the year needs to be explored.
Breastmilk vitamin A levels and its variation in the different seasons need to be determined.
I wish to acknowledge the dedication of the field teams under the super vision of Rocio Narro, the secretarial support given by Aida Miranda and
Narro, the assistance in the compiling of data by Ira Heidemann,
and the generous participation of the authorities and members of
the Comunidad Campesino Chamis and of the Barrio San Vicente. Dr.
Isidoro Sanchez gave valuable advice in the identification of the
Shahnaz Vazir, Uma Nayak, Vinodini Reddy, and P. Pushpamma
Team members and task
Current status of the problem
Community food sources
Food consumption pattern
Summary and policy strategies
Several reviews of programs to improve the nutritional status of at-risk groups pointed out that traditional methods of nutrition education do not have the desired impact. In recent years, attempts were made to use techniques and methods hitherto confined to the behavioral sciences or other disciplines, such as anthropology and ethnography. In order to achieve effective nutrition interventions an extensive understanding of the existing sociocultural matrix of the community is necessary. This study was undertaken, in a rural community of Andhra Pradesh, to obtain information on availability and use of food sources of vitamin A. Culturally appropriate techniques were used.
The team consisted of four investigators with a team leader, a programmer/statistician, a stenographer, and a field assistant as follows:
Dr. Shahnaz Vazir, Ph.D. (Psychology): Team leader and Senior Research Officer National Institute of Nutrition, Hyderabad.
Dr. Anjali, Ph.D. (Nutrition), Lecturer, Women's College, Osmania University, Hyderabad.
Ms. Uma Nayak, M.Sc. (Nutrition), Research Assistant, National Institute of Nutrition, Hyderabad.
Ms. Anita, M.Sc. (Nutrition), UAS, Bangalore.
Ms. Saroja, M.Sc. (Nutrition), APAU, Hyderabad.
Data entry and analysis:
Mr. P. Vidyasagar, M.Sc. (Statistics), Technical Research Officer, National Institute of Nutrition, Hyderabad.
Mrs. P. Prashanthi, Stenographer, National Institute of Nutrition, Hyderabad.
Mr. K. Narasimha Reddy, become, Field Assistant, National Institute of Nutrition, Hyderabad.
ethnographic protocol described previously and outlined in the
Appendix was implemented in Sheriguda Village by this team. The
protocol and report took approximately eight weeks to complete.
Vitamin A deficiency is recognized as a significant health problem in India. Severe forms of the deficiency lead to irreversible blindness and death in children. Surveys conducted in different parts of the country showed that 2% to 5% of children in poor communities have mild xerophthalmia, like Bitot's spots and nigh/blindness. Prevalence rates are higher in school age children than in younger groups, but severe forms of deficiency resulting in corneal xerophthalmia and blindness are confined to those under three years of age. A national blindness survey carried out earlier showed that 2% of the total blindness in the country was due to vitamin A deficiency, while in a 1989 survey this was reduced to 0.04%. Hospital studies also showed few admissions due to corneal xerophthalmia. However, milder forms of vitamin A deficiency are still widely prevalent.
Vitamin A deficiency has been viewed largely as a medical problem that can be controlled with periodic doses of vitamin A. Under the National Vitamin A Prophylaxis Programme, in operation in several states in India, bi-annual doses of vitamin A are given to preschool children at risk. Although this was envisaged as an interim measure to reduce the incidence of vitamin A deficiency, it has been going on for the last twenty years. Experience shows that the efficacy of this medical approach is limited by the inefficient delivery system. The ultimate solution to the problem lies in improving the diet and increasing the intake of vitamin A.
In the current strategy, greater emphasis is placed on food-based interventions. Since vitamin A-rich animal foods are expensive, attention is focused on plants containing provitamin A and carotenoids. One of the limitations in developing food-based strategies for combating vitamin A deficiency is the lack of reliable information on the carotenoid content of foods. Most of the values given in food composition tables represent total carotene and not b-carotene, which is the major source of vitamin A.
Another limitation is a lack of understanding of the dietary factors influencing the bioavailability of carotene, and the effects of cooking and preservation techniques on carotene losses. Recently, the National Institute of Nutrition (NIN) carried out a number of studies to obtain information on these aspects. Food analysis showed that traditional varieties of green leafy vegetables, like amaranth and spinach, and the leaves of a large number of plants that grow wild in the countryside are rich sources of b-carotene. These bushes and trees include agathi, drumstick (moringa), and channangi. Basella is a creeper that can grow along a fence or roof top when space is limited. These plants are relatively easy to grow, require little water, and more importantly, are perennial sources of leafy vegetables. Efforts are being made to propagate such plants through home gardening programs.
experience with horticultural projects in several villages of
Andhra Pradesh, shows that the villagers can be persuaded to grow
vegetables in their backyards or on the farms where they work.
This was combined with an education program to create awareness
and to encourage consumption of locally available vitamin A-rich
foods. In the past, education without community involvement
failed to have any impact. The emerging field of social marketing
has opened new vistas for meaningful nutrition education imparted
to the community through culturally accepted ways. NIN's
experience shows that a social marketing approach can be used
effectively to learn about community needs, beliefs, and
attitudes in order to produce desirable changes in dietary
behavior. Effective implementation of programs using social
marketing strategies on a large-scale can help eliminate vitamin
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