Introduction:
Tribes are one of society's most exploited and deprived groups. Although various policies and programmes have been pursued and implemented for their social and economic upliftment in post-independence India, all development indicators show them most excluded from the mainstream. Needless to say, the tribal people's quality of life has suffered as a result of their exclusion from the fruits of development. Poverty, low illiteracy, contaminated drinking water, poor conditions, poor sanitation, lack of basic health care, and traditional practices contributes to malnutrition among tribal children. Malnutrition puts these children at risk of various infections and infectious diseases, which leads to a high death rate. One set of critical factors discussed and studied concerning tribal communities poor social development indicators is a lack of infrastructure facilities, schools, health centres, and personnel[1].
The nutritional status of a population is determined primarily by food consumption related to food availability and needs influenced by purchasing power. Socio-economic conditions, such as agricultural patterns and occupational profiles, vary from tribe to tribe and are determined by ecosystems. Many studies have shown a strong relationship between a tribe's ecosystem and nutritional status. Tribal population depends on primitive agricultural practices and are at risk of malnutrition due to instability in food security. Inadequate healthcare facilities and environmental degradation exacerbate the situation[2].
A sustainable food system that ensures food security and nutrition while reducing adverse environmental effects and improving socioeconomic conditions well-being of all people, particularly the poor and vulnerable [3]. These sustainable food production systems are based on sustainable crops and ecosystems, are widely accessible, cost-effective, secure, and nutritious, and contribute to environmental sustainability[4].
Nutrition in children is mainly associated with more severe food insecurity in the family, poor complementary foods, an increasing burden of intestinal parasites, several infectious diseases, low socioeconomic background, low birth weight (LBW), delayed intrauterine growth, and persisted despite recent economic improvements[5]. It has also been associated with a synergistic increase in mortality from infections such as diarrhea, respiratory disease, and measles. Stunting has long-term consequences, including delays in achieving motor skills such as walking [6]. Dietary diversity can proxy for nutrient adequacy in individuals' diets and provides information about household access to various foods. Increased nutrient adequacy of the diet is associated to higher individual dietary diversity scores [7]. One of the food-based interventions that can help alleviate the multifaceted burden of malnutrition is dietary diversity or the consumption of a diverse range of foods. Indeed, it has been included as one of the indicators for tracing the triple burden trends of malnutrition, alongside wasting, stunting, micronutrient deficiencies, and obesity rates [7]. India ranks 70th out of 187 countries for nutritional quality when based on a less diversified diet and overall diet that includes deficiencies in dairy products, fruits, vegetables and protein-rich foods. Food and nutritional insecurity leads to malnutrition due to inadequate quantity and quality of food consumed.
A healthy diet includes a balanced diet, including fruits and vegetables, fresh organic natural foods and foods enriched with vitamins and minerals. Additionally, it encompasses healthy eating habits and behaviours that promote physical and mental well-being. On the other hand, low socioeconomic status and food insecurity wreak havoc on adolescent diets [8]. The diet of the Indian tribal community is severely undersupplied with milk and other dairy products, fruits and greens, legumes and meat products [9,10]. This makes them insufficient in micronutrients such as iron, Vit A, C and zinc, possibly due to the high phytate content in staple foods like rice [11]. Geographic isolation and other socio-ecological factors exacerbate this nutritional deprivation.
The Dietary Diversity Scores (DDS), which can quantify dietary diversity, has gained popularity for its association with various measures of well-being, including nutrition and health. DDS is significantly associated with nutritional adequacy and socioeconomic status in children [12,13].There is a scarcity of data on tribal food consumption, dietary patterns, and socio-economic status. As a result, an effort was made to evaluate the dietary pattern and nutritional status of tribal children under the age of five in Indian states.
Methods
Individual data from the National Family Health Survey (NFHS-4), a nationally representative cross-sectional survey conducted between 2015 and 2016, is used in this analysis. The study was carried out in collaboration with the International Institute for Population Sciences in Mumbai by the Ministry of Health and Family Welfare of the Government of India. In India, 628,900 households were surveyed for NFHS-4 across 29 states and seven union territories. A total of 259,627 children were surveyed, with a 98 percent response rate. Following our inclusion criteria, a total of 13,963 tribal children were included in the study. (Figure 1).
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Figure 1: Sample selection |
The predictors variables used in the analysis were grouped into three categories: sociodemographic variables, variables related to women, children, and dietary characteristics. Among socio-demographic variables, we looked at house type (kaccha, semi-pucca, and pucca), type of family, religion, no religion and others (not well-defined). The wealth index was calculated using a standard set of assets reported by interviewers, indicating that the household to which they belonged possessed wealth or assets, and was divided into five categories (quintiles), namely: poorest, more destitute, middle, richer and richest, then we categorized as poor (poorest, poorer), middle and rich (richer, richest). The educational attainment of women was divided into four categories: no education, primary (1 to 5 years of schooling), secondary (six to twelve years of education) and higher education (more than 12 years of education). We also looked at the gender of the children, their ages (6 to 11, 12 to 23 months) and their birth order (1, 2, 3, 4+).
Mothers were asked to recall foods and groups given to their child over 24 hours in the NFHS-4 survey. Data were collected on twenty-one foods consumed by the child the previous day. The following foods are solid/semi-solid: fish, crustaceans; beans, peas (or lentils); cheese (or other dairy products); bread (or other grains); potatoes (or any other root vegetables); eggs (or other types of eggs); carrots; dark green leafy vegetables (or other types of vegetables with dark green leaves); mangoes (or other fruits with vitamin A); any other fruits.
In accordance with WHO IYCF guidelines, the food was categorized into seven food groups:
(i) Cereals, roots and tubers (including clear soups/broths and bread, noodles, other cereals), (ii) Beans and nuts (including legumes, peas or lentils). (iii) Meat foods (including liver, heart, other offal, fish, crustaceans, duck, chicken, or other birds), (iv) Dairy products (including formula milk, powdered milk/canned milk, cheese, yogurt, other dairy products), (v) Eggs (vi) Vitamin-rich vegetables and fruits (including carrot, green leafy vegetables, pumpkin, squash, mango, papaya, vitamin A fruit) and (vii) Other vegetables and fresh fruits (including any other fruits).
For each child, food intake information was compared to construct a dietary diversity score, resulting between 0 to 7, where 0 means that there is zero consumption of the listed twenty one items listed and 7 denotes the has child consumed some food (at least one from each of the 7 listed groups). Based on an overall assessment of dietary diversity, a binary variable was established to point out whether the child’s diet varied sufficiently over the past 24 hours. A score of 3 or higher is considered Adequately Diversified Dietary Intake (ADDI) for Children. Therefore, ideally, children should eat at least four foods from the 7 recommended food groups.
Statistical analysis
Descriptive statistics and multinomial regression were performed. Descriptive statistics were used to determine the proportion and frequency of each of the characteristics included. Additionally, after adjusting for all variables included, adjusted multinomial regression was used to generally determine the association between maternal education, wealth index, food groups and dietary diversity. Two models were constructed for the study. Model 1 is fully adjustable for age, gender, birth order, mother's education, religion, home type, and family type. Model 2 is only adjusted for the age and gender of the child. P-value < 0.05 was considered statistically significant. RStudio Version 1.2.1093 was used for statistical analysis. (RStudio Team (2020). RStudio: Integrated Development for R. RStudio, PBC, Boston, MA URL http://www.rstudio.com/.)
Results
Table 1 shows the sample distribution for selected traits, food groups, and different diets. Of the 13,963 babies, the median age (Inter Quartile Range) was 14 (10-19) months, with a female to male ratio of 1:1.06, the majority being males (51.4%) and firstborns (33.4%). More than half (65.2%) of their children belong to households with the lowest wealth index. Nearly 43% of mothers had secondary education and 34.3% had no education. The majority (51.9%) are Hindu, 63.1% live in semi-buck homes, and half of the children live in nuclear-free homes.
| Table 1: Distribution (N, %) of tribal children by selected characteristics and consumption of specific food groups, and diversified dietary intake in the last 24 h, among children aged 6-23 months using NFHS-4, India during 2015-2016 |
Selected characteristics |
Number (N) |
Percent (%) |
Age of child (in months) |
6-11 |
4649 |
33.3 |
12-23 |
9314 |
66.7 |
Sex of child |
Male |
7176 |
51.4 |
Female |
6787 |
48.6 |
Birth order |
1 |
4665 |
33.4 |
2 |
3986 |
28.5 |
3 |
2414 |
17.3 |
4+ |
2898 |
20.8 |
Mother education |
No education |
4783 |
34.3 |
Primary |
2370 |
17.0 |
Secondary |
6048 |
43.3 |
Higher |
762 |
05.5 |
Wealth index |
Poor |
9099 |
65.2 |
Middle |
2529 |
18.1 |
Rich |
2335 |
16.7 |
Religion |
Hindu |
7250 |
51.9 |
Christian |
5132 |
36.8 |
Muslim |
565 |
04.0 |
Others |
1016 |
07.3 |
House type |
Kutcha |
1632 |
11.7 |
Pucca |
3526 |
25.3 |
Semi pucca |
8805 |
63.1 |
Family type |
Nuclear |
6151 |
44.1 |
Non-nuclear |
7812 |
55.9 |
Specific food groups |
Grains, roots and tubers |
10458 |
74.9 |
Legumes and nuts |
2407 |
17.2 |
Dairy products |
5098 |
36.5 |
Flesh foods |
2799 |
20.0 |
Eggs |
3319 |
23.8 |
Vit A rich fruits and vegetables |
6724 |
48.2 |
Other fruits and vegetables |
3624 |
26.0 |
Diversified dietary intake |
Inadequate |
10212 |
73.1 |
Adequate |
3751 |
26.9 |
Grains, roots and tubers (74.9%) were consumed more in the seven food groups, preceded by Vitamin A rich fruits and vegetables (48.2%), dairy products (36.5%), and other fruits and vegetables (26%), lowest - eggs (23.8%), meat products (20%), legumes and nuts (17.2%) in the past 24 hours. The overall mean score for dietary diversity was low (2.47, 95% CI 2.44–2.49) and the prevalence of ADDI was only 26.9 percent (Table 1).
Table 2 shows that adjusted ORs with 95% CIs for wealth index on the intake of seven food groups among tribal children aged 6–23 months. After adjusting for all the variables (Model 1), compared to poor households, those from the richer household were more likely to consume dairy products (aOR 2.20; 95% CI 1.90-2.54) and eggs (aOR 1.28; 95% CI 1.06-1.55). Children from middle households were more likely to consume dairy products (aOR 1.65; 95% CI 1.47-1.85) and eggs (aOR 1.24; 95% CI 1.06-1.45) than poor households.
Table 2: Multinomial regression was performed for the association between wealth index and specific food groups and diversified dietary intake among tribal children aged 6-23 months using NFHS-4, India during 2015-2016 |
Selected characteristics |
Model 1 |
Model 2 |
Middle vs poor (aOR 95% CI) |
Richer vs poor (aOR 95% CI) |
Middle vs poor (aOR 95% CI) |
Richer vs poor (aOR 95% CI) |
Specific food groups |
Grains, roots and tubers |
1.02 (0.89-1.16) |
1.03 (0.87-1.22) |
1.06 (0.94-1.20) |
1.10 (0.97-1.25) |
Legumes and nuts |
0.91 (0.78-1.06) |
0.81 (0.67-0.99) |
0.98 (0.86-1.13) |
0.87 (0.76-1.01) |
Dairy products |
1.65 (1.47-1.85) |
2.20 (1.90-2.54) |
1.64 (1.48-1.81) |
2.27 (2.05-2.52) |
Flesh foods |
1.06 (0.90-1.25) |
0.91 (0.75-1.10) |
1.20 (1.05-1.39) |
1.05 (0.91-1.22) |
Eggs |
1.24 (1.06-1.45) |
1.28 (1.06-1.55) |
1.63 (1.42-1.86) |
1.99 (1.74-2.29) |
Vit A rich fruits and vegetables |
0.91 (0.80-1.04) |
0.88 (0.74-1.04) |
0.87 (0.78-0.98) |
0.83 (0.73-0.94) |
Other fruits and vegetables |
1.04 (0.89-1.21) |
0.97 (0.81-1.17) |
1.05 (0.92-1.19) |
0.98 (0.86-1.13) |
Diversified dietary intake |
Inadequate |
Ref |
Ref |
Ref |
Ref |
Adequate |
0.98 (0.79-1.22) |
1.12 (0.85-1.46) |
1.00 (0.82-1.21) |
1.16 (0.95-1.41) |
Table 3 presents the adjusted ORs with 95% CIs for maternal education on utilizing seven food groups among tribal children aged 6–23 months in two separate models. After adjusting for child’s age and gender (Model 2), compared to mothers who had no education, mothers having secondary education were more likely to consume grains, roots and tubers (aOR 1.11; 95% CI 1.01-1.23) and flesh foods (aOR 1.28; 95% CI 1.12-1.45).
Table 3: Multinomial regression was performed for the association between mother education and specific food groups and diversified dietary intake among tribal children aged 6-23 months using NFHS-4, India during 2015-2016 |
| Selected characteristics |
Model 1 |
Model 2 |
Primary vs no education (aOR 95% CI) |
Secondary vs no education (aOR 95% CI) |
Higher vs no education (aOR 95% CI) |
Primary vs no education (aOR 95% CI) |
Secondary vs no education (aOR 95% CI) |
Higher vs no education (aOR 95% CI) |
Specific food groups |
Grains, roots and tubers |
1.13 (0.99-1.30) |
1.08 (0.97-1.20) |
0.97 (0.78-1.20) |
1.17 (1.03-1.33) |
1.11 (1.01-1.23) |
1.01 (0.82-1.24) |
Legumes and nuts |
1.15 (0.98-1.36) |
1.21 (1.05-1.38) |
1.10 (0.85-1.42) |
1.18 (1.00-1.38) |
1.18 (1.04-1.34) |
1.04 (0.81-1.32) |
Dairy products |
0.99 (0.87-1.11) |
1.15 (1.05-1.27) |
1.52 (1.26-1.83) |
0.96 (0.86-1.08) |
1.33 (1.22-1.45) |
2.11 (1.77-2.50) |
Flesh foods |
0.93 (0.78-1.10) |
1.02 (0.88-1.17) |
0.98 (0.76-1.27) |
1.19 (1.01-1.40) |
1.28 (1.12-1.45) |
1.16 (0.91-1.49) |
Eggs |
1.16 (0.98-1.37) |
1.21 (1.05-1.39) |
1.32 (1.02-1.69) |
1.49 (1.27-1.75) |
1.69 (1.49-1.92) |
1.93 (1.52-2.44) |
Vit A rich fruits and vegetables |
1.09 (0.96-1.25) |
1.05 (0.94-1.17) |
1.08 (0.87-1.34) |
1.04 (0.92-1.19) |
0.96 (0.87-1.06) |
0.95 (0.78-1.17) |
Other fruits and vegetables |
1.02 (0.87-1.19) |
1.08 (0.95-1.22) |
1.32 (1.04-1.67) |
0.98 (0.84-1.13) |
1.02 (0.91-1.15) |
1.27 (1.01-1.59) |
Diversified dietary intake |
Inadequate |
Ref |
Ref |
Ref |
Ref |
Ref |
Ref |
Adequate |
1.03 (0.82-1.29) |
0.88 (0.73-1.06) |
0.68 (0.48-0.96) |
1.04 (0.84-1.30) |
0.93 (0.78-1.10) |
0.77 (0.55-1.07) |
After adjusting for all the variables (Model 1), compared to mothers who had no education, mothers having higher education were more likely to consume dairy products (aOR 1.52; 95% CI 1.26-1.83), eggs (aOR 1.32; 95% CI 1.02-1.69) and other fruits and vegetables (aOR 1.32; 95% CI 1.04-1.67). Compared to no education, mothers having secondary education are more likely to consume legumes and nuts (aOR 1.21; 95% CI 1.05-1.38), dairy products (aOR 1.15; 95% CI 1.05-1.27) and eggs (aOR 1.21; 95% CI 1.05-1.39).
Discussion
Our study attempted to describe the social-economic status, dietary intake and dietary patterns, emphasizing food consumption in the tribal children in India. Tribal communities have reported regular consumption of root vegetables, tubers, legumes, and similar dietary patterns seen in other studies[14,15]. Many indigenous foods reported in studies are rich in protein, various vitamins and minerals, particularly calcium, iron, vit A and folic acid.
There was a high correlation between maternal education and the consumption of all food groups, including essential foods, but only dairy consumption was associated with household wealth. Previous studies have found a correlation between socioeconomic status and the consumption of specific foods and food groups and a variety of dietary intakes. It is consistent with previous studies [16,17] in LMICs and India that found an association between socioeconomic status and specific food consumption and food variety at the individual level.
Foods like vegetables, dairy products, eggs, and fruits were found to have a significant impact on maternal education. As a result, the consumption of a wider diversity of foods and food groups may be influenced more by the mother's education. Edible crops and dietary patterns from Indian tribes elsewhere, of course, focus on the proper calorie consumption of by high-energy staple foods that do not meet the needs of micronutrients. Complementary strategies, such as incorporating regional indigenous foods into nutrition programmes, can benefit this strategy by increasing dietary variety and food security.
The current scenario requires additional strategies to develop programs that promote indigenous food security while optimizing agriculture and barren land use. This can be achieved through efforts to increase food intake from the region, increase the production of native nutritious foods, and disseminate knowledge about the nutritional value of foods. This strategy has the potential to be a very cost-effective approach for improving consumption even as combating tribal community malnutrition, micronutrient deficiencies, and food security[18,19].
Conclusion
The promotion of nutrient rich foods, as well as appropriate nutrition education and behavioural changes about the importance of dietary diversity, can help Indian tribal children in obtaining more micronutrients.
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