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Physical Health Examinations

Initially it was decided to have a physician carry out a physical examination of each respondent every month. This turned out to be an extremely difficult task as the respondents were often unavailable and it was also discovered that a single individual with an illness could take up a disproportionate amount of time. After the third round of examinations a schedule was worked out that involved covering ten households during each of the weekend visits so that most respondents were seen quarterly.

TABLE 9. Morbid conditions recorded by the investigators

Anthropometry

As poor growth may be a reflection of both biological and environmental factors, including illness and the level of nutrition, the respondents' height, weight, and arm circumference were monitored monthly. To record the height and weight of older children and adults, a standard beam balance was used with an anthropometer attached to it. Younger children were weighed in the arms of an adult and the difference calculated. Children under the age of two were laid on a flat surface with the head held straight up and with two pieces of cardboard held straight against both head and feet. The distance between the two was then measured. Light clothing was worn by adults; if sandals were worn, they were removed. Children generally wore scant clothing and no footwear. No adjustments were made for this extra weight in the analysis of the data. Height was measured in centimetres and weight in kilograms to the nearest 0.1 kg. Arm circumference was determined using a fibreglass tape: the mid point was measured and marked and the circumference taken. The tape was marked in centimetres and each measurement was recorded to the nearest 0.1 cm.

Both Indian and Western standards were used to analyse the height and weight data. The Indian standards used were those supplied by the National Institute of Nutrition and are composed of expected heights and weights for boys and girls up to the age of 19 (girls) and 21 (boys). These data were provided by Hyderabad children of diverse, but predominantly Telugu, backgrounds, who were for the most part from middle socio-economic backgrounds or above. The following were chosen as values for adults of Indian origin: 2,800 kcal/kg for men and 2,200 kcal/kg for women, except for the second half of pregnancy and the first year of lactation, for which the values are 2,500 and 2,900 kcal/kg respectively.

The Western standards used included the Harvard standards as published in Jelliffe [10] for weight for height to the age of 18. For adults, the composite standards published by Jelliffe were used.

Economic Transactions

Every week each investigator asked the household head and other adult members of the household to recount the previous week's income and expenditures. To facilitate both the investigator's and the respondent's understanding of what constituted an economic transaction, a special form was used which outlined typical agrarian transactions while dividing them into income or expenditure. The investigators were instructed not to bother with extremely minor items such as a few paise spent on a sweet or a teaspoonful of a spice; rather, they were urged to emphasize the important transactions that would help our understanding of the village economic system. It should be noted that the transaction schedule recorded not only the item transacted, but the quantity, the unit value and the value of the transaction. This permitted the investigators to check their calculations if doubts arose.

Labour Force Participation

Who participates in the labour force and what is earned has been a topic of interest for many years, and, in recent years, the field of labour market economics has expanded. We decided to monitor labour-force participation for the entire family using a weekly recall method because we

believed that this information would be extremely relevant to our understanding of the role of food availability in nutritional and health status. For each day of the previous week the following information was gathered for each family member, including working children:

• general labour pattern, i.e. on-farm work or agricultural labour
• principal work pattern for the given week;
• days spent on agricultural work;
• days spent working on own farm;
• days spent working as agricultural labourer;
• days spent as a permanent servant;
• days spent shepherding animals or on animal care;
• days spent doing other business;
• income in cash or kind (if in kind, product and quantity); and
• days not worked and reasons for each.

Crop Production

Crops produced by each of the families were recorded at times of harvest. As the decisions for disposal were generally made soon after harvest, the quantities allocated to each of the following categories were recorded: sold; stored for family consumption; given away to labourers as payment for services, or given as debt repayment. The value of each transaction, that is, the quantity of the crop transacted and its market value at that time, was also recorded. The market value used was that provided by the farmer, but little variation was found between farmers for a given week, although there was of course variation from season to season.

Assets

Collection of reliable asset data has long been known to be a difficult task; it was therefore decided not to attempt collection of information in this area until fairly near the end of the study period. The household head and/or other adult members of the family provided the detailed information on household and farm assets. These included not only the obvious assets such as house, land, and farm equipment, but possessions as well, cooking vessels and gold and silver jewellery (if any) were all included. The land values were ascertained by the village patwari and sarpanch.

TABLE 10. Average intakes (as percentages of standards) of key nutrients for all respondents

a. N = approximately 14,700.
b. An insignificant amount of the diet is preformed vitamin A.

Results

Food Consumption

In 30 of the 40 families, all dietary recalls were completed, and in 38 of the 40 families all but two of the planned recalls were completed.

The percentage intake of the average energy requirement or of the recommended dietary allowance for other nutrients was used as a means of examining dietary adequacy across age groups in order to give a general picture of the problems at a village level [8]. Protein intake generally exceeded the recommended daily allowance (RDA). Intakes of energy were below the Indian estimated average energy requirements (AER), and other nutrients were below the RDA, as summarized in table 10. The deficiencies of calcium, vitamin A, riboflavin, and ascorbic acid follow the typical Indian pattern mentioned previously. The figures are not the average of the percentage intake of the RDA for all individuals; rather, they represent the total intake over the total requirement. Therefore, individual deficiencies are masked in table 10.

Distribution of Energy by Age and Sex

The averaged percentages of the AER by age group and sex indicate that children from six months to two years of age are most energy-deficient, followed by those from two to three years of age (table 11). Male children fare better than female children from the age of one until their teens, when females meet a higher proportion of their requirement. Below the age of one, the energy intakes of female babies meet or exceed that of male babies. Males, once again, surpass females from 19 to 40 years of age. After that age, there is no difference between the two adult groups.

TABLE 11. Energy intake as a percentage of the average energy requirement (AER) by age and sex

a. Includes calculation of breast milk from data supplied by Rao et. al., for any child receiving breast milk [19].

Table 12 breaks down the percentage of the AER into four arbitrary groups for each of eight age groups in order to examine the severity of energy deficits. Over 75 per cent of all respondents received an average of over 80 per cent of their recommended levels. Slightly over half (51 per cent) of the children under three years of age received less than 60 per cent of the recommended allowances. From the age of six months until two years females were more likely to fall into the more severe energy deficit categories than males. After that age, there were approximately equal numbers of males and females in the various categories. It should be noted that these calculations take into consideration values for breast-milk consumption of rural South Indian children [19]; however, it is the authors' opinion that these values are too low

Mean percentage of the AER for energy met by round: ages 0-5, 6-15, and adults (A)

Mean percentage of the AER for energy met by round: ages 0-5, 6-15, and adults (B)

Adequacy of Mean Weekly Energy Intake

The percentage of the AER was averaged by week for three age groups: 0 to 5 years old, 6 to 15 years old and 16 years old or above. A striking picture emerges of severely in. adequate energy intake for very young children (`x = 67 to 89 per cent of the AER) as contrasted to a generally adequate intake for those older than five (6 to 15 years: `x = 91-109 per cent of the AER; 16 years and older: `x = 88 to 107 per cent of the AER). From figure 1 it is possible to see that there are no clear patterns of increased or decreased consumption during post- or pre-harvest seasons. The reason for the gap at week 31 is a festival during which the investigators did not collect dietary information.

Adequacy of Household Mean Energy Intake

An examination of household energy intake reveals sharp differences in the percentage of the AER averaged over the year. All but 5 of the 20 households averaged more than 80 per cent of the AER. Of the five deficient households (<80 per cent), three were from the "labour" group and two from the "on-farm" group. All five families were of average size (four to six members), except one, which contained 11 members. Each of the "labour" families averaged 69, 76, and 78 per cent respectively of the AER throughout the year, while the two "on-farm" families each averaged 79 per cent. In a subsequent section these five families, who were chronically short of food, will be discussed in depth.

Summary of Weekly Energy Levels by Individual Families

Nearly all 40 families exhibited substantial variation in their aggregated energy intake from week to week. The periods of peak and slack, however, did not always correspond to harvest periods or times of intense employment (cash or in-kind payment). This phenomenon will be discussed later. Table 13 outlines the number of weeks during the year in which families averaged less than 80 per cent of the AER. Clearly, families whose adult females generally worked as hired labour were more likely to fall below acceptable levels of caloric sufficiency.

TABLE 12. Distribution of energy deficits by age group

Intra-family Food Distribution

The aggregated information presented up to this point masks the important aspect of the intra-family food district button. Thus far, a general picture of near-adequacy has emerged by taking the total energy intake over the total requirement. This procedure was necessary, as averaging the percentage of the AER masks total availability to the household, which is, for this study, a critical feature. However, equitable distribution of food to each family member is clearly a problem among these 40 rural families. Using the previously defined categories (see table 12), the number 0 was applied to those receiving more than 80 per cent of the AER and 3 to those receiving less than 60 per cent of the AER, with 1 and 2 for the intermediate categories. Thirty-four of the 40 families (85 per cent) had one or more members in the energy deficit categories (1, 2, or 3). Among the 34 families, the most frequently malnourished were young females followed by young males and then young adult females. Further analysis of the determinants of this maldistribution is under way.

TABLE 13. Number of weeks during the year in which families averaged less than 80 per cent of the Indian AER

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