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Study population

The selected area for the study was the village of Sheriguda in the Ibrahimpatnam block of the Ranga Reddy district in Andhra Pradesh state (Map 6). This state is in the midsouthern part of India, known as the rice-bowl because of its fertile soil in certain areas. However, in many villages in the Ranga Reddy district, such as Sheriguda, the lands are dry and mostly staples, such as sorghum (jowl) and pearl millet (badger), that do not require as much water as rice are grown. Crops commonly grown in this area include paddy, jowl, sajja (pearl millet), red gram, castor, and sunflower. Other vegetables such as okra, tomatoes, and green leafy vegetables, such as palak and gogu are grown seasonally.

MAP 6. Sheriguda Village in Andhra Pradesh State

Sheriguda is a typical village of Ranga Reddy district where all religion and caste groups are represented. Looking at the caste distribution of the village, it was found that about 40% of the families belonged to the forward communities, such as Reddys and Vysyas (merchants), and 30% to the backward castes, that include skilled occupational castes like blacksmiths, carpenters, goldsmiths, and others such as shepherds, muthrasi, munnurukapu, and chakali. The harijan households (scheduled castes) comprised about 21% and the scheduled tribes about 8%. Less than 1% were Muslims.

The better-off families are either large landowners, possessing more than 100 acres of agricultural land, tenant cultivators, or the business community who buy produce from smaller landowners and sell it in the city. The poorer families are involved in one or two of the following occupations:

• agricultural laborers, who are paid either money or staples and vegetables as wages;

• other laborers, such as workers in a nearby poultry farm and those who work in the Ibrahimpatnam block headquarters;

• petty shops owners and vendors who sell vegetables and other food items;

• artisans, such as pot makers, blacksmiths, goldsmiths, tailors, and masons, etc.;

• professional occupations, such as electricians, teachers, postmen, etc.

The traditional joint family system is still common in this community. However, a large number of families follow the nuclear family system. The average family size varies from five to seven members including children in the nuclear families, and eight to ten members in the joint families. The joint family structure is of particular benefit in rural areas because the total wages earned by all the members make up the family budget. On average, men employed as agricultural laborers earn a wage of twenty to twenty-five rupees ($1 US dollar is currently equal to thirty-one rupees) per day and women earn around ten to fifteen rupees per day. However, agricultural laborers are out of work for three months during summer. For the remaining nine months they work an average of twenty days a month which totals to about six months of continuous work. These landless laborers constitute about 25% to 30% of the total population. Agricultural work is the main source of livelihood for these families. Some laborers are employed in a nearby poultry farm owned by the sarpanch (village headman), and they occasionally get free eggs or poultry.

A recent study of vitamin A deficiency, undertaken by the National Institute of Nutrition, Hyderabad, found a prevalence of 4. 5% for Bitot's spots in preschool children and a few cases of nightblindness in villages around Ibrahimpatnam block. This figure is comparable with other regions in Andhra Pradesh where such studies have been conducted. The prevalence of Bitot's spots in Sheriguda, was found to be 4.2% in preschool children. This figure far exceeds the WHO cut-off level of 0.5%, indicating that vitamin A deficiency is a significant health problem in this area.

Since the auxiliary nurse midwife (ANM) and the anganwadi worker (the grassroots functionary of the Integrated Child Development Services Programme (ICDS) operating nationwide) are expected to impart health and nutrition education to young mothers and interact with preschool children, they were interviewed for information regarding vitamin A deficiency. Neither had ever seen a child with Bitot's spots, nor they had come across any case of nightblindness. Since the survey by the NIN demonstrated a high prevalence of Bitot's spots (4.2%) in preschool children in Sheriguda, it is possible that these children did not participate in the ICDS program.

Community food sources

Members of the community either cultivate their own land or purchase food in weekly shandies and from vendors, local petty shops, and subsidized ration shops. People also buy food in the nearby towns and cities during occasional visits. They also hunt and gather certain foods, and a few families grow greens, such as spinach, or fruits, such as papaya. Most of the low-income groups avail themselves of the opportunity to get subsidized staple food from the fair price shops, but this is limited to wheat, oil, rice, and sugar.

Some wild greens are collected during the rainy season. Their common local names are ponnaganti, kodijutukura, chenchalaku, gangavailaku, koyikura, pindikura, duggalkura, and bankotikura. Some wild berries and fruits are also locally harvested, however, they are not significant sources of vitamin A or b -carotene.

On the whole the consumption of green leafy vegetables and other vitamin A-rich food was seasonal, and depended upon availability. It was highest in the rainy season (when they were plentiful) and lowest in summer. However, certain households did not consume green leafy vegetables, even when they were available in their own fields. These households mostly sold their produce in the city.

Home grown vegetables are mostly greens, such as bachali (Indian spinach), fruits, such as papaya and guava, and other vegetables, such as gourds and broad beans. Vegetables, mostly creeper varieties, are grown around the homes. Some families trade the staple food available in the home for vegetables. Both animal and plant foods are purchased by many families depending on availability and season.

The following foods are regularly grown locally: paddy, jowar, sajja, kandi, cow peas, pesaru, castor, sunflower, and tomato. No foods are imported from outside the country.

Market Days

Market days are held once a week. Every Thursday, there is a shandy in the nearby town six to eight kilometers away. Locally grown vegetables and fruits are available, but onions, condiments, spices, tamarind, chilies, and perishable foods, such as meat and dry fish are predominant.

People from Sheriguda travel to the market and 70% to 75% of them purchase one or two day's supply of perishable foods. All villagers purchase spices from the shandy. Vendors and petty shop owners buy nonperishable for the entire week, and sell them at a profit in the village to people who subsist on daily wages.

Vitamin A-Rich Foods

Greens, the main source of vitamin A, are bought more frequently from the nearby town, as there are no storage facilities. For this reason, the availability of greens in the village petty shops is comparatively less than other vegetables that can be stored longer. This is the main reason for the poor availability of greens, especially during the dry season.

Greens, pumpkin, mango, papaya, and carrots are the major nonanimal sources of vitamin A in this region. Papaya is available and affordable. All other foods are seasonal, including some varieties of greens. Carrots and pumpkin are available but expensive, even in season. Mangoes, on the other hand, are available only in summer and some of the local varieties are inexpensive, and are consumed particularly during this season. Although people can afford greens all year round, the smaller quantities are consumed in summer, when they are more expensive. Pumpkins and carrots are purchased only for festive occasions and as snacks for children. Drumstick leaves are the richest source of vitamin A and plentiful, but they are not consumed because of their unpopular taste. Pumpkin leaves are considered inedible.

Eggs are available all year because there is a poultry farm nearby. However, they are mostly not affordable. Also, the local community believes that eggs are "hot." Those who consume eggs prefer those from free ranch birds rather than from the poultry farm. Milk, fish, liver, and eggs are comparatively more expensive and not affordable by most families at risk for vitamin A deficiency.

Home Gardens and Gathering

Very few people have home gardens, even though most have open yards. People have a poor concept of home gardens and feel that foods such as vegetables and fruits should only be grown in or around the fields. Except for perennials, greens, gourds, and broad beans are grown in the rainy and winter seasons. Most of the home grown produce is consumed by the family or shared with neighbors. Some people grow green leafy vegetables, such as gogu, among their staple food crops during the rainy season.

People gather foods from the wild, especially greens, berries, and fruits. They occasionally hunt small birds and animals, such as rabbit. During the rainy season ponnaganti, kodijuttukura, chenchalaku, gangavailaku, koyakura, pindikura, duggalkura, and bankotikura are gathered once or twice a week.

Food consumption pattern

A three meal pattern is followed. Breakfast includes tea, rice, or jowar roti, or leftover foods from the previous day, such as rice and curry. During summer, ragi porridge or kalli (fermented washings of rice) or conjee (excess water drained after boiling the rice) is consumed by some families who feel these foods are "cooling." Such practices are prevalent mostly among lower socioeconomic groups. Higher socioeconomic groups prefer to consume items like wheat roti (unleavened bread) or idli (fermented and steamed cereal-pulse preparations), buttermilk, curds, and other foods.

For lunch and dinner cereal and/or millet preparations are the major items. The accompanying dish is either a chutney (ground red chilies, ginger, garlic, and salt with or without tamarind), a vegetable curry, a pulse preparation, or occasionally a meat dish. Curds or buttermilk is seldom consumed by lower socioeconomic groups. On weekends animal food is generally prepared for dinner, which is a larger meal than lunch.

Food is cooked twice a day, for lunch and dinner at the convenience of the housewife, who is generally an agricultural laborer or who looks after her farm. While the mother is at work the children consume the leftover food from lunch, whenever they are hungry between meals. All members of the family meet and share the food at dinner time. Seasonal variations in availability and preferences occasionally determine the food choice and preparation. Vegetables and fruits are consumed more frequently during October to February when they are abundant. At other times of the year consumption declines. Jowar is consumed extensively during the lean period from April to October. During festive occasions, calorie-dense sweets, snacks, and other pulse and vegetable items predominate. Animal foods, such as meat and chicken, are a must during festivals, especially for lower socioeconomic groups like Harijans.

The female head of the family distributes the food among the members. Staple food preparations with cereals and millets are distributed without any restrictions, as they are cooked in large quantities. The more nourishing foods such as vegetables, meat, and fruits are served in smaller quantities to reduce costs. The male head of the family is given liberal helpings of all food items, especially meat and chicken. No such distinction in distribution of food is made among the other family members.

In the low-income groups, there is no set place for eating. Meals are eaten either inside or outside the house. Food is served on individual plates with spoons, and family members squat on the floor while eating. Members of the higher income families eat inside the house, at a set place, and some of them even sit at a table. Irrespective of economic status all families use their fingers for eating, which is a tradition in India. Lower income groups use an aluminum bowl, but if they can afford it, they use a stainless steel plate (which is a status symbol). Aluminum vessels or earthenware pots are used for cooking in all communities.

Boiling and frying are two common methods used for cooking legumes and vegetables. Certain greens are cooked in excess water and the water discarded. Rice is cooked with kalli (fermented rice washings) or with plain water and the excess water discarded. Very few women reported cooking rice in just sufficient water. Some foods like raw custard apple, sweet potato, and dry fish are smoked or roasted.

Food taboos are widely prevalent. Beliefs center on hot, cold, and vatham (wind or gaseous) properties of food, that prevent their use as regular dietary items. However, certain processing methods are said to alter properties in food and render it suitable for consumption. There are some beliefs that some foods cause joint pains, cold and cough, excessive bleeding, indigestion, diarrhea, etc. These beliefs restrict the consumption of some nutrient-rich foods. Some dislikes are also related to negative health attributes, whereas likes are related to taste, availability, and familiarity with the food.

Cultural/ecological pattern

Food Habits in pregnancy. Food restrictions are observed during pregnancy. Papaya is believed to cause miscarriages, and therefore is avoided. Certain other foods are promoted. Fresh toddy (local liquor made from palm sap) and kalli (fermented rice washings) are believed to facilitate intrauterine movement of the fetus. This practice has declined, as it is considered to indicate low status, and tea is consumed instead. If women crave specific foods, they are permitted to eat them. It is believed that if the mother does not eat the food she craves, the umbilical cord may heal slowly and the infant will drool excessively.

Food Habits During Lactation

Among many traditional families, the diet during lactation has three distinct stages. A severely restricted diet, consisting of cooked rice mixed with spice powder (mixture of roasted ginger, garlic, pepper, and red chilies), is eaten during the first three days of lactation. It is believed that this practice stimulates lactation and prevents numbness of hands and feet. From the fourth to the twenty-first day, a semi-restricted diet of only a few plant and animal foods is allowed. After twenty-one days, there are no diet restrictions. On the other hand, the lactogenic effect of certain foods such as meat, dry fish, and garlic are recognized, and efforts are made to consume as much of these foods as one can afford during lactation. Some families who used allopathic medicines had no dietary restrictions from the day of delivery. Boiled water is given to the women until twenty-one days following childbirth. This is believed to prevent infection in the mother and cough and cold in the infant.

Food Habits Related to Children

Initiation of breastmilk within twenty-four hours of delivery was reported by those who had a hospital delivery (a small group of the total). The majority initiated breastmilk on the third day and most of the older mothers rejected the colostrum. Contrary to this, some younger mothers fed colostrum to their newborns. It is generally believed that milk is not secreted before the third day after delivery and hence the newborn is put to the breast only then. Severe food restriction immediately after delivery may be a major factor responsible for this belief.

The common prelacteal food is wet nursing among the low socioeconomic groups. Sugar water, honey, diluted cow's milk, and glucose water are the prelacteal foods used by those having hospital deliveries, and by higher socioeconomic groups. Prelacteal foods are given in minute quantities mostly in an unhygienic way. Prolonged breastfeeding is a common practice in this region. The duration ranges from twelve to more than thirty-six months. Prolonged breastfeeding therefore acts as a natural contraceptive method. The weaning age ranges from five to twenty-five months or more. Those with a higher income and educated mothers tend to wean as early as six months.

The common liquid supplements given are milk (often diluted with water), coffee, tea, or thin cereal gruels. Solid foods given are well mashed plain rice, pieces of roti (unleavened bread), seasonal fruits, locally available inexpensive biscuits or other snack items. Small quantities of the adult diet are introduced once the child can eat alone and withstand hot, spicy foods. The lower income groups tend to give tea or coffee in addition.

No special supplementary foods are prepared and the child is fed Bitter on demand or at the mother's convenience. Reasons for discontinuing breastfeeding are subsequent pregnancy, the ill health of the mother, the child naturally stops breastfeeding, or the mother's conviction that the child has grown sufficiently.

Green leafy vegetables are the major vitamin A sources available and consumed. Others include pumpkin and fruit, such as papaya and mango. All are consumed seasonally in small quantities by children.

Summary and policy strategies

Dietary Modification

Although vitamin A supplementation is a simple and effective intervention, it is only a short-term measure. It should be combined with dietary modification for long-lasting effects. Education, although an important component of all health and nutrition programs, has been one of the weakest linkages, mainly because the health functionaries are not properly oriented and do not have the necessary tools to impart nutrition education. There is a need to strengthen information, education, and communication strategies using a multimedia approach to bring about desirable changes in dietary practices. Special attention must be paid to pregnant and lactating women to ensure adequate intake of vitamin A-rich foods. Promotion of breastfeeding is important as it protects infants against all nutritional deficiencies during the first four to six months. Appropriate weaning foods based on locally available carotene-rich foods can be developed for young children between six and twenty-four months of age.

Horticulture Intervention

Nutrition education programs will be more successful if they are combined with horticultural interventions to increase the availability of carotene-rich foods at the community level. Although India is one of the leading producers of vegetables, green leafy vegetables constitute only 16% of the total vegetable production. Horticultural crops must be increased to meet the requirements. Promotion of home gardening is important to increase availability at the household level. Emphasis should be put on perennial varieties of green leafy vegetables that are relatively easy to grow, such as basella and agathi Efforts are being made in this direction by the Department of Agriculture and Social Forestry. The Indian Council of Agriculture Research has established a number of Krishi Vigyan Kendras or Farm Science Centres in various parts of the country to train farmers in agriculture technologies to improve production. There is a need to develop a mechanism of coordination between the various departments involved in horticultural and educational activities for optimum benefit of the community.

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