A key assessment indicator for food-based nutrition intervention programmes is the nutritional status of beneficiaries after the project’s implementation. The IHNDP promoted nutritional awareness among and improved nutritional knowledge levels of the beneficiaries.66 The evaluation tried to assess if the project helped improve nutritional levels through increased consumption of horticulture-based food. It was also considered essential to identify the factors influencing dietary intake.
For this, a food consumption and dietary assessment survey was conducted among project and non-project beneficiaries in collaboration with the Institute of Nutrition and Food Science, Dhaka University (INFS) between April and October 2004.
The assessment covered 474 project and 90 non-project households. Among project households, 21 percent were from hill regions and 79 percent from the plains. Thirty two percent of the project households covered by the assessment were landless, 40 percent were marginal landholders and 28 percent were small landholders. Of the 90 non-project households surveyed, 30 lived in the Kishoreganj, 30 in Rajbari and 30 in Barisal. For comparability with project households, the non-project households were selected from among landless households (with less than 50 decimal67 of cultivable land) in rural areas at least three miles from the project and with no NGO presence. Both project and non-project households did not differ significantly in mean family size and income.
The majority of project households (62 percent) lived in houses with tin walls and roof, 25 percent had brick houses and 13 percent lived in mud or straw houses. In comparison, 89 percent of non-project households lived in tin houses, 4 percent had brick abodes and 7 percent, mud or straw houses.
There was significant difference in house construction by project and non-project households.68 Almost all project households were trained and attended project demonstrations on production, preparation and preservation of horticultural foods, and were provided planting materials and nutrition counselling. Some also received micro-grants and other project services.
Clean water and a hygienic environment are important determinants of household health and nutrition. Ninety six percent of project households drank water from tube-wells and the rest from ponds, ring wells, rivers and canals. Almost all (99 percent) non-project households drank tube well water. There was no significant difference in the drinking water sources of project and non-project households.69 Seventy eight percent of project households used tube well water for cooking and washing and the rest obtained it from other sources, compared to 86 and 14 percent respectively among non-project households. There was no significant difference in the cooking and washing water sources of project and non-project households.70
Eight percent of landless households covered by the project were food-deficit throughout the year, 43 percent sometimes faced food shortage, another 43 percent were neither deficit nor surplus in food, and the remaining 6 percent had more food than their needs. A higher level of food insecurity was observed among landless households not covered by the project with 19, 40, 33 and 8 percent respectively facing degrees of food insufficiency or adequacy in the same order as the project households.71
Rice and vegetables were common field crops, pulses being cultivated less by project as well as non-project households. While 75 and 79 percent respectively of project households grew rice and vegetables, this was done by 83 and 59 percent of non-project households. Spices were cultivated by 31 percent of project households, fruits by 23 percent and pulses by 2 percent. Among non-project households, 21, 17 and 2 percent respectively cultivated spices, fruits and pulses.
Project households farmed cereals on 96 decimal, vegetables on 18 decimal, fruits on 11 decimal, spices on 4 decimal and pulses on 1 decimal. This compared to 32, 3, 2, 2 and less than 1 decimal respectively for these crops by non-project households. The differences were statistically significant for cereals72 and vegetables73 but insignificant for other crops.74
Horticultural crops have relatively higher value and an annual yield potential of up to 50 kg per square metre depending on the crop and technology used. An indicator of the project’s positive impact on production was the large number of households adopting garden cultivation.
As seen above, very few project-covered landless households were food-deficit or food-surplus throughout the year. The large majority either faced a shortage of food sometimes or always had adequate food. There was a significant difference with the food security situation of landless households not covered by the project, nearly one-fifth of them being food-deficit throughout the year, but a slightly larger proportion were food surplus compared to project households.
11.3.3. Horticultural production by season
The availability of land for individual home gardens varied from 0.50 to 0.99 acres75 in project areas, resulting in a variety of horticultural produce in winter and summer. On average, households harvested 128 kg of produce in winter and 108 kg in summer (see Table 25). This translates into 1.42 and 1.20 kg of horticultural produce per day in the two seasons, with an estimated per capita availability of 284 g in winter and 216 g in summer. This was an important achievement of the project.
Table 25. Horticultural produce by season
|
Horticultural produce |
Season (kg) |
|
|
Winter |
Summer |
|
| Fruit |
162 |
105 |
|
Leafy vegetables |
78 |
140 |
|
Non-leafy vegetables |
235 |
79 |
| Spices |
36 |
– |
|
Average |
128 |
108 |
The per capita availability of horticultural produce in Bangladesh is 87 g against the daily recommended intake of 400 g of fruits and vegetables excluding potatoes and other starchy tubers, for prevention of chronic ailments such as heart disease, cancer, diabetes and obesity.76
A significantly larger proportion of project households (72 percent) washed vegetables before cutting compared to only 26 percent among non-project households. Likewise, 80 percent of project households had fresh carrot, tomato, other vegetables, lemon or some sour fruit and green chili in daily meals and used coriander leaves in cooking. The corresponding dietary consumption percentages were significantly lower for non-project households. While 78 percent project households preserved vegetables using pickling as a method, only 47 percent of non-project households did so.
Twenty two percent of landless households covered by the project cooked meals once a day, 57 percent did so twice daily and the rest prepared more than two times a day. The corresponding figures for non-project landless households were 19, 69 and 12 percent respectively showing no significant difference in this regard between the two categories of households.77
While 72 percent of landless families in project areas washed vegetables before cutting, 24 percent did so after cutting and 4 percent did both. The corresponding numbers for non-project landless households were 26, 69 and 5 percent respectively, showing a significant difference which confirmed the study’s overall findings.78
Six percent of project households washed vegetables before cutting because the family did not object or on instruction from family elders. This being usual family practice was the reason given by 42 percent households while 51 percent said it was more convenient. In non-project households, the corresponding proportions were 22, 25 and 42 percent respectively, showing a significant difference in the reasons given by the two categories of households.79
Sixty five percent of project households habitually ate rice, salt and chili, 79 percent had rice, pulse soup and vegetables, 91 percent ate rice, fish and dark green leafy vegetables, and 59 percent had rice, beef or chicken. Similar food combinations were noted among 79, 70, 84 and 37 percent respectively of non-project households.
Only 54 percent of landless households in project areas and 18 percent of landless families in non-project areas preserved fruits and vegetables at home, showing significant difference in food preservation practices.80
Among project households, 58 percent preserved mango, 32 percent preserved jujube and 24 percent preserved Indian olives, compared to 26, 8 and 9 percent respectively by non-project households. Between 10 to 17 percent of project households preserved tamarind, cabbage and broad beans, while 2 to 9 percent preserved other fruits and vegetables.
Seventy eight percent of project households used salt, spices and oil to pickle food while 69 percent dried in the sun, compared to 47 and 74 percent respectively in non-project households. Sugar was used for preservation by 28 percent of project households but by none of the non-project households.
The project developed prevalent food preparation and processing methods to preserve nutritive value and retain the benefits of fruits and vegetables in composite traditional food varieties.
Project households prepared several recipes including those learned in the project while some were based on the technologies learned.
Table 26. Consumption of vegetables and fruits by landless households
|
Horticulture produce |
Season (kg) |
|
|
Winter |
Summer |
|
| Fruits | 77 |
60 |
|
Leafy vegetables |
28 |
35 |
|
Non-leafy vegetables |
71 |
24 |
| Spices | 15 | |
|
Average |
48 |
40 |
The average household consumption of vegetables was 48 kg in winter and 40 kg in summer (see Table 26) with per capita consumption of 53.3 and 43 g in winter and summer respectively. However, this was much less than the minimum quantity of vegetables recommended for a nutritious diet.
Raw vegetables were also eaten with 80 percent of project households having fresh carrot, all eating fresh cucumber, 76 percent having raw onion, 74 percent fresh radish, 98 percent eating uncooked tomato and 12 percent having fresh green chili. Among non-project households, the corresponding figures were 54, 91, 67, 66, 97 and 18 percent respectively. A small proportion of project households and none of the non-project households ate raw lettuce and red beetroot.
Only 69 percent of landless households in project areas and 62 percent of landless families in non-project areas used coriander leaves in daily cooking showing a significant difference in this regard between the two household categories.81 Only 45 percent of project households ate lemon or other sour fruit every day compared to 16 percent among non-project households, revealing a significant difference.82 There was also a marked difference in the daily consumption of green chilli among project and non-project households who were landless, with only 72 percent of the former and 57 percent of the latter, doing so.83
Fresh coriander and green chilli are excellent sources of beta carotene and vitamin C and their consumption was promoted through various recipes taught by the nutrition education programme. Sour lemon also has vitamin C and is a dietary enhancer, improving the bioavailability of micronutrients such as iron in a meal.
Among landless project households, only 1 percent did not eat leafy vegetables at all, 51 percent did one to three days per week and 48 percent four to seven days a week, compared to 12, 65 and 23 percent respectively among non-project landless households. The significant difference84 in the consumption of leafy vegetables by the two household categories confirmed the overall findings of the study (Figure 14).
Figure 14. Leafy vegetable consumption by landless households
While 26 percent of landless households in project areas did not eat yellow-orange vegetables at all, 67 percent ate one to three days a week and 7 percent four to seven days a week, compared to 48, 49 and 3 percent respectively among non-project landless households (Figure 15).
Figure 15. Yellow and orange vegetable consumption by landless households
The significant difference85 between project and non-project landless households in the weekly consumption of yellow and orange vegetables confirms the overall findings of the study.
Six percent of landless households in project areas did not eat yellow and orange fruits, 76 percent did one to three days per week and 17 percent ate four to seven days a week, compared to 47, 47 and 6 percent respectively among landless households not covered by the project. The significant difference86 between project and non-project landless households in the frequency of weekly consumption of yellow and orange fruits confirms the overall findings of the study (Figure 16).
Figure 16. Yellow and orange fruit consumption by landless households
Two percent of landless households covered by the project did not eat sour fruits and vegetables, 48 percent did one to three days a week and 49 percent ate four to seven days per week, compared to 8, 64 and 29 percent respectively among landless households not covered by the project. Less than 1 percent of the project households did not eat fruits rich in vitamin C, 99 percent ate such fruits one to three days a week and 1 percent did so four to seven days per week, compared to 10, 90 and 0 percent respectively among the non-project households, showing significant difference.87
Less than 1 percent of the project households did not eat fish, meat, egg or milk, 95 percent did one to three days a week and 4 percent ate such food four to seven days per week, compared to 9, 84 and 7 percent respectively of non-project households (Figure 17), showing significant difference.88
Figure 17. Fish, meat, egg and milk consumption by landless households
Animal food is one of the best sources of micronutrients, but vegetables and fruits are often the only affordable micronutrient sources for poor households. The production of fruits and vegetables by the project ensured the households direct access to important micronutrients that may not have been readily available to them or within their economic reach.
The experience89 of other home gardening programmes in Bangladesh shows that households with well-developed home gardens eat non-cereal food rich in micronutrients, more frequently than other households. This includes high-quality food such as dal (lentils) and animal products that can be purchased with the income from the garden. This is confirmed by the current study.
Only 2 percent of project households did not add fat or oil to their diet, no one consumed this for less than four days per week and 97 percent did for four to seven days every week. All non-project households had fat or oil four to seven days per week. No significant difference was noted between project and non-project households in the weekly consumption of fats and oils.90
While 9 percent of project-covered households did not eat iodized salt, no one consumed it for less than four days a week and 91 percent did 4 to 7 days a week, compared to 13, 0, and 87 percent respectively for non-project households, pointing to no significant difference91 between project and non-project households in the consumption of iodized salt.
In 13 percent of project households, breastfeeding of infants was practised till less than 12 months of age, while 34 percent of households did so till the infant was 12 to 24 months old, and 53 percent of households continued breastfeeding beyond 24 months. In comparison, breastfeeding was practised for less than 12 months, till 12 to 24 months and beyond 24 months by 7, 21 and 72 percent respectively of non-project households. There was no significant difference in the infant feeding practices of the two categories of households.92
Six months after birth, breast milk alone cannot meet the infant’s energy and micronutrient needs and complementary feeding should begin. Between 6 and 24 months of age, the child is highly vulnerable to nutritional deficiency. Malnutrition, as measured by growth retardation usually peaks between one and two years of age. During this period, the child needs frequent intake of age-appropriate and energy-dense food besides continued breastfeeding. With decreasing consumption of breast milk by the growing child, complementary feeding must meet a greater part of the energy needs.
Children aged between 6 and 24 months and older, require sufficient protein and micronutrients93 as well as energy for growth and proper metabolic functioning of the body. They need daily or frequent feeding of small quantities of vitamin-rich fruits and vegetables, meat, poultry or fish, fat, wholegrain cereals and iodized salt.
Sixteen percent of project-covered landless households began complementary feeding for the last child at less than five months of age, 59 percent did so when the child was between five to seven months old and 25 percent after seven months of age (Figure 18). This compared to 15, 38 and 46 percent respectively among non-project landless households (Figure 18), showing significant difference between the two types of households in the initiation of complementary feeding.94
Figure 18. Initiation of complementary feeding by landless households
Yellow and orange fruits, eggs, meat and fish, khichuri (made from rice and pulses) and suji95 (diluted wheat soup) were typical complementary foods for children in both project and non-project households. Among project households, yellow and orange fruits were used by 77 percent, eggs, meat and fish by 66 percent, khichuri by 59 percent and suji by 59 percent households respectively as complementary food compared to 58, 44, 40 and 28 percent respectively among non-project households. Diluted milk, biscuits and potatoes were other common complementary food items.
Slightly more than half of project households gave complementary food to children, compared to between 25 and 40 percent of non-project households. Formula food, boiled, puffed or pressed rice, leafy and non-leafy vegetables were less frequently used for complementary food.
Infants, older children, adolescent girls and adult women in landless project households had higher per capita intake of all food and nutrient varieties as compared to the non-project households. Food intake was significantly higher in children and adult women. Energy intake was significantly higher in children, adolescent girls and adult women while protein intake was significantly higher in adult women (see Table 27).
Table 27. Energy and protein intake of different target groups
|
Target group |
Project households |
Non-project households |
||
|
Energy (kcal) |
Protein (g) |
Energy (kcal) |
Protein (g) |
|
| Infants | 461 | 14 | 451 |
16 |
|
Children (2–9 years) |
929 | 28 | 684 |
23 |
|
Adolescent girls |
1 005 | 50 | 1 666 |
44 |
| Adult women | 1 989 | 56 | 1 654 |
42 |
Among project households, the mean energy intake for adolescent girls was 1 850 kcal, much below the RDA.96 The mean energy intake of adult women was 2 061 kcal, also below the RDA.97 The mean energy intake of non-project households was even lower, being 1 005 kcal for adolescent girls and 1 989 kcal for adult women.
The energy intake of adolescent girls appears to be grossly inadequate, meeting no more than 50 percent of the RDA while that of the women meets about 75 percent of the RDA.
The energy-deficient diet of mothers is also reflected in the women’s susceptibility to chronic energy deficiency and morbidity. Similar findings have been reported in other surveys in Bangladesh. Household energy intake is often used as an indicator of poverty. Households with an energy intake of less than or equal to 2 122 kcal/person/day are considered “moderate poor” and households with less than 1 805 kcal/person/day are considered as “extreme poor” (Bangladesh Bureau of Statistics, 1998).
Household energy intake is also used as an indicator of household food security (Bloem et al., 2003). However it does not indicate the quality of the household diet. Therefore, survey data on consumption of various food varieties, vegetables and fruits as well as micronutrients are needed to assess household dietary quality which, in turn, is an indicator of household food security.
Protein intake appears to meet the RDA among project households as compared to non-project households. For infants and young children, the intervention promoted a mixture of traditional food types providing energy, protein and micronutrients. Rice is the main source of protein in the diet of rural poor people in Bangladesh and is typically eaten with little vegetables, some fish and sometimes, lentils or eggs.
Although vegetables have vitamin A and iron, these micronutrients are not as well absorbed from plant as from animal food. With high-quality protein and vitamin A, eggs are a good complementary food. To improve protein intake, it is necessary to increase the availability and consumption of eggs.98
The dietary assessment strengthened the premise that increased production and consumption of diverse types of vegetables using homestead gardening, reduces micronutrient deficiency. This was also in keeping with the FAO recommendation 99 to boost vegetable and fruit production and availability to support food-based programmes to improve nutrition.
A comparison of micronutrient intakes by adult women and adolescent girls in landless project and non-project households is given in Table 28. All project-covered groups had higher intakes of all micronutrients. The difference in the intake of vitamin A was found to be statistically significant (p <0.05), while in the case of vitamin C, the difference was not statistically significant for adolescent girls (p >0.05) but significant for adult women (p <0.05). The difference in calcium intake was not statistically significant for adult women (p >0.05) but significant for adolescent girls (p <0.05), while the difference in iron intake was found to be statistically significant (p <0.05).
Table 28. Intake of selected micronutrients by adult women and adolescent girls
|
Micronutrient |
Project households |
Non-project households |
||
|
Adult women |
Adolescents |
Adult women |
Adolescents |
|
|
Vitamin A (retinol equivalents µg) |
1 604 | 1 212 | 567 |
767 |
| Vitamin C (mg) | 107 | 129 | 48 |
104 |
| Iron (mg) | 25 | 24 | 17 |
18 |
| Calcium (mg) | 626 | 646 | 476 |
425 |
Among women in project households, vitamin A intake of 1 604 µg was one and half times the RDA of 600 µg while women in non-project households had a daily intake of 567 µg, slightly below the RDA. The intake of iron did not meet the RDA for both project and non-project groups. An adult woman doing moderate work needs 30 mg of iron daily and an adolescent girl needs 28 mg of iron a day.
The micronutrient intake of infants and children in project households was higher than of those in non-project households (see Table 29). There were significant differences in vitamin A and vitamin C intake among the two groups of children (p <0.05 for both). There was no significant difference in calcium and iron intakes for both groups.
Table 29. Intake of selected micronutrients by infants and children
|
Micronutrient |
Project households |
Non-project households |
||
|
Infants |
Children |
Infants |
Children |
|
|
Vitamin A (retinol equivalent µg) |
234 | 609 |
100 |
290 |
| Vitamin C (mg) | 30 | 60 |
15 |
29 |
| Iron (mg) | 5 | 13 |
2 |
8 |
| Calcium (mg) | 223 | 358 |
483 |
303 |
Infants in both project and non-project households did not get the full RDA100 for vitamin A (350 µg retinol). Infants in non-project households got only about 28 percent of the RDA while those in project households had intakes closer to the RDA. Children between one to five years old had vitamin A intakes higher than the RDA in project households, and about 73 percent of the RDA intake in non-project households. As expected, both groups had low iron intake, with infants and children in project households having higher intake than those in non-project families. Based on the absorbed-iron requirement of different physiological groups and with iron absorption of 3 percent from common mixed cereal diets, the recommended dietary intake for iron is 12 mg for children between one to three years old and 18 mg for children between four to six years old.101
The increased consumption of leafy and yellow-orange vegetables as well as fruits in project households as a result of the intervention was reflected in vitamin A intake levels much above the RDA. A comprehensive approach to dietary improvement is needed to meet the dietary iron requirement, particularly more iron-rich animal food.
Consumption of nutritious food combinations based on horticultural produce along with meat, fish, vegetables and vitamin C-rich fruits was promoted, together with traditional food preparation and processing methods. This can enhance the bioavailability of iron and other micronutrients in the diet.
National nutritional surveillance data102 show that anaemia is still a public health problem among preschool children and pregnant women in Bangladesh, and a moderate public health problem in children of school age, adolescents and women who are not pregnant. To meet the UN Millennium Development Goals (MDGs), Bangladesh must reduce the prevalence of anaemia from 48 to 32 percent in preschool children, from 34 to 22 percent in children of school age, from 36 to 24 percent in adolescents, from 34 to 23 percent in non-pregnant women and from 51 to 34 percent in pregnant women by the year 2015.
The improved availability, preparation, preservation and consumption of food in project households can be attributed to project inputs. However, this cannot be certain in the absence of baseline data and due to the project’s short duration as well as the small number of control samples studied. The food consumption and dietary assessment study also shows that carefully collected semi- and quantitative data, practical experience and technical expertise can form a sound basis for a nutrition programme.
Although project households had relatively higher food and nutrient intake, the findings above highlight the need for continued efforts to improve their nutritional status. There is a need to increase household income and strengthen nutritional awareness and practices with households encouraged to use the maximum possible land to grow fruits and vegetables.
The food consumption and dietary assessment survey provides data to confirm the strengths and contributions of food-based interventions to address micronutrient and malnutrition problems. The second food consumption and dietary assessment will serve to validate the dietary improvement outcomes and findings of the first round.
66 Mid Term Evaluation Report, 2003.
67 237 decimal = 1 ha
68 Pearson Chi-square test (p = 0.00)
69 Pearson Chi-square test (p = 0.1)
70 Pearson Chi-square test (p = 0.1)
71 Pearson Chi-square test (p = 0.00)
72 Pearson Chi-square test (p = 0.00)
73 Pearson Chi-square test (p = 0.00)
74 Pearson Chi-square test (p >0.05)
75 2.37 acre = 1 ha
76 FAO/WHO. 2003. Diet, Nutrition and the Prevention of Chronic Diseases. Report of a Joint WHO/FAO Consultation. Geneva, World Health Organization.
77 Pearson Chi-square test (p = 0.10)
78 Pearson Chi-square test (p = 0.00)
79 Pearson Chi-square test (p = 0.00)
80 Pearson Chi-square test (p = 0.00)
81 Pearson Chi-square test (p = 0.00)
82 Pearson Chi-square test (p = 0.00)
83 Pearson Chi-square test (p = 0.01)
84 Pearson Chi-square test (p = 0.00)
85 Pearson Chi-square test (p = 0.00)
86 Pearson Chi-square test (p = 0.00)
87 Pearson Chi-square test (p = 0.00)
88 Pearson Chi-square test (p = 0.00)
89 Talukedar, A. 2000. Increasing the production and consumption of vitamin A-rich fruits and vegetables: Lessons learned in taking the Bangladesh homestead gardening programme to a national scale. Food and Nutrition Bulletin, 21: 165–172.
90 Pearson Chi-square test (p = 0.12)
91 Pearson Chi-square test (p = 0.12)
92 Pearson Chi-square test (p = 0.10)
93 Golden, M.H.N. 1995. Specific deficiencies versus growth failure: Type I and Type II nutrients. SCN News, No. 12.
94 Pearson Chi-square test (p = 0.10)
95 Semolina/wheat cream
96 RDA for energy for adolescent girls: 1 970 kcal for 10-12 years; 2 060 kcal for 13-15 years; 2 060 for 16-18 years; ICMR, 1992. Reprinted 2004.
97 RDA for moderate working adult woman: 2 225 kcal; ICMR, 1992; Reprinted 2004.
98 BBS. 2001. 1999 Statistical Yearbook of Bangladesh 20th edition. Dhaka, Bangladesh Bureau of Statistics.
99 FAO/ILSI. 1997. Preventing Micronutrient Malnutrition: A Guide to Food Based Approaches – A Manual for Policy Makers and Programme Planners. Washington, DC, International Life Sciences Institute Press.
100 For infants from 6 months to 1 year based on Indian RDA, ICMR.
101 ICMR. 1998. Nutrient Requirements and Recommended Dietary Allowances for Indians. Expert Group Report. New Delhi, Indian Council of Medical Research.
102 Bloem. 2003. Health and Nutritional Surveillance for Development, New York, United States, Helen Keller International.
