INTRODUCTION:

Undernutrition is one of the greatest global health challenges affecting 462 million adults worldwide^[1]. National Family Health Survey-4 (2015-2016)^[2] reported 23% of women and 20% of men age 15-49 as thin in adult groups of Indian populations. Low and middle-income countries are more prone to be affected by different forms of malnutrition affecting all age groups throughout the world^[1].

Poverty, lack of proper nutrition, household food insecurity, micronutrient deficiency and poor access to health services and gender disparity are the major causes of developing undernutrition within individual, households and populations globally^[1,3]. According to Global Nutrition Report^[4], India is facing a serious form of undernutrition where more than half (51%) of the women and 23% of men of reproductive age (15-49 years) suffer from anaemia. Nutritional anaemia is an outcome of inadequate and imbalanced nutrition which affects children, pregnant and non-pregnant women adversely^[5,6]. In India, prevalence of nutritional anaemia ranges from 78.1% to 94.8% among females aged 18-59 in various states of India^[6].

Undernutrition poses to be a major health threat to the social and economic development of communities in developing and under-developed countries^[7]. India ranks 103^rd among 119 countries in the global hunger index, indicating towards serious hunger threats leading to mild to severe undernourishment in communities residing in the country^[8]. Poor nutrition is the most common cause of morbidity and mortality in children and women worldwide^[9,10,11].

In India, the tribal communities face higher risk of undernutrition due to discrimination, geographical isolation, limited access to health services, food inflation, meagre or no fixed wages, strenuous manual work^[12,13]. Gender disparity is prevalent in majority of communities in India, due to which females of all age group face the problem of lack of proper nutrition. Females are often oblivious regarding laws related to maternity leaves at organized or unorganized work sectors, and are not well aware about maternal health and well-being. They are frequently exploited and made to work in harsh conditions at workplaces and in their own household^[13]. Trends in healthcare indicators such as mortality rates, adolescent fertility rate, life expectancy for females, show a dismal picture for overall situation of women across India^[14,15,7]. Several studies have reported prevalence of undernutrition^{[16,17,18,12,19,7,2]}and anaemia^{[20,21,22,23]} among adult tribal groups of India. However, few studies have been conducted among adolescents of Indian tribes to address the issue of undernutrition and anaemia^{[24,25,26,27,28,29,30,31,32,33,34,35]}. Various studies have reported undernutrition on the basis of the body mass index (BMI) and mid upper arm circumference (MUAC) for the evaluation of nutritional status among Indian population groups^{[36,37,38,39,40]}. BMI and MUAC have been used as indicators of chronic energy deficiency (CED) among tribal populations of India^{[41,42,43,44]}. BMI is a widely used and an inexpensive method for the assessment of undernutrition in adults in large-scale studies^[45,46,47]. MUAC has been found to predict morbidity and mortality as accurately as deficits in weight^[48,49,50]. It can be seen from the above literature that not many studies have been undertaken on the population groups of India in general and tribal populations in particular regarding various aspects of undernutrition and nutritional anaemia. In this context, present study attempts to investigate sex-wise prevalence of undernutrition and gender disparities among two tribes of India.

MATERIALS AND METHODS:

Ethical statement:

Prior ethical clearance from the Ethical Committee of Department of Anthropology, University of Delhi, Delhi was obtained to conduct the research. Informed written consent from the participants was obtained prior to the actual commencement of the study.

Sample size:

This research work takes into account samples from two cross-sectional studies conducted in Gujarat (n=100) and Jharkhand (n=101). A total of 201 participants belonging to two tribes namely Santal (adults aged 18-60 years) and Kukna (adolescents aged 14-19 years) were taken into consideration for the present study.

Exclusion criteria: People with any type of growth and developmental disorders, severe health issues in the past year, and the existence of any secondary cause of hypertension were not included in the current study. People who were hesitant about being part of the study were also excluded.

Data collection and measurements:

A structured format was used to collect demographic information such as name, age, sex, name of tribe from each of the participants.

Standard techniques were followed while taking all the anthropometric measurements^[45]. The standing height was measured to the nearest of 0.1 cm using a movable anthropometer. Weight was recorded to the nearest 0.1kg with the help of Omron Karada Scan Body Composition Monitor (Omron Health Care Co., Kyoto, Japan). The participants were encouraged to remove their shoes and heavy clothing before taking measurements. Mid upper arm circumference (MUAC) was measured to the nearest of 0.1cm using a flexible steel tape.

2 millilitres(ml) of blood was drawn intravenously from the participants by a trained technician. Haemoglobin level was estimated using Drabkin’s haemoglobin cyanide (HiCN) method in samples drawn from adult Santals of Jharkhand and adolescent Kukna of Gujarat^[51].

Individual classification:

BMI was calculated as weight in kilogram (kg) divided by height in metre squared (m²)- (kg/m²). According to the World Health Organization (WHO) guidelines for Asian adult populations, individuals with BMI <18.5 kg/m² were considered as underweight; >18.5 kg/m² but <23 kg/m² as normal; >23 kg/m² but <27.5 kg/m² as overweight and >27.5 kg/m² as obese^[52,53]. BMI in adolescents were classified on the basis of percentiles given by Cole and Lobstein ^[54] in which individuals with BMI <50^th percentile (17.55 kg/m²) was considered as underweight; >50^th percentile but <85^th percentile (19.8 kg/m²) as normal; >85^th percentile but <90^th (20.3 kg/m²) percentile as overweight and >90^th percentile as obese.

The internationally accepted cut-off for MUAC i.e. a) MUAC <22cm was considered as undernourished and b) MUAC ≥ 22cm was considered as normal nutritional status^[49].

According to World Health Organization^[55], haemoglobin level in non-pregnant females aged 14 years and above and males aged 14 years and above were classified into 4 categories for determination of degree and severity of anaemia (Table 1).

Table 1: Individual classification of anaemia for adults and adolescents used for data analysis

Anaemia categories	Haemoglobin level (mg/dl) in non-pregnant Females age 14 years and above	Haemoglobin level (mg/dl) in Males age 14 years and above
Severe	<8	<8
Moderate	8-10.9	8-10.9
Mild	11-11.9	11-12.9
Non-anaemic	>12	>13

Statistical analysis:

Data entry was done in Microsoft Excel, and further analyses were carried out using SPSS version 16.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics, such as mean and standard deviation (S.D.) were estimated for the selected anthropometric measures such height, weight and mid upper arm circumference. Frequencies were calculated for categorized haemoglobin, BMI and MUAC data to estimate the prevalence of malnutrition among the selected tribal communities.

RESULTS:

Table 2 describes the mean and standard deviation for age, anthropometric measures and haemoglobin among the adolescent Kuknas and adult Santals of Gujarat and Jharkhand, respectively.

Table 2: Characteristics of the selected tribes of Gujarat and Santal (N=201)

Variables	Kukna (n=100)	Santal (n=101)
Variables	Mean± S.D.	Mean
Age (years)	15.12±1.27	33.64±11.22
Height (cm)	149.02±7.83	154.27±8.57
Weight (kg)	39.32±6.73	47.97±8.81
Mid upper arm circumference (cm)	20.33±2.98	23.61±2.49
Haemoglobin (g/dl)	11.80±1.53	10.97±1.71
Body mass index (kg/m²)	17.62±2.22	20.09±2.94

Table 3 describes the mean and S.D. of selected variables indicating undernutrition for males and females in Kukna and Santal tribe. The profound variations observed in the mean BMI values indicate towards the gender gap due to the problem of resource inflation and food security experienced by the tribal communities. Interestingly, it was found that the mean value of BMI in males was lower than females in adolescents Kukna, whereas lower mean BMI was visibly observed in the Santal females. The prevalence of undernutrition cannot be determined solely by observing BMI values, however, below normal level of BMI among females signifies the presence of gender disparity among the communities.

Figure 3 illustrates a comparative account of undernutrition on the basis of mid upper arm circumference among the males and females of Kukna and Santal tribes. It is evident that higher percentage of females in Kukna (80%) and Santal (42.9%) tribe were found to be undernourished than males of both the tribes. Overall, inter-tribe comparison highlighted greater percentage of undernourished individuals among adolescents of Kukna in comparison to adult of Santal tribe.

DISCUSSION:

The present study attempts to find out bisexual differences in undernutrition and gender disparity among adolescent Kuknas and adult Santals of Gujarat and Jharkhand, respectively. The findings of the current study showed a vulnerable status of both adolescent girls and adult women with respect to malnutrition and nutritional anaemia in comparison to their male counterparts. These results can be attributed to the intra-society gender discrimination in attending food security among Indian tribes which is highlighted in detail in other study^[7]. The grimmer state of undernutrition in females in comparison to males is supported by several studies conducted on population groups of India^[17,12,2].

Severe undernutrition is an additional risk factor among socio-economically marginalized groups^[56,57,58,7]. Due to poor socio-economic status and unpredictable living conditions, tribal people are forced to work in unfavourable work environment to fulfil their basic needs of shelter and food^[59]. Both males as well as females are engaged in workplaces. However, women continue to work hard in agricultural fields, gathering forest produce, walking long distances for fetching wood and fodder and also, manages household chores by themselves. In addition to this, many tribal women work as labourers in industries, coal mines, construction sites contributing to their family income. Menfolk on the other hand do relatively less amount of physical labour compared to women^[60,61,62]. However, due to low wages and inflation in food prices, they are unable to feed the family members and themselves adequately. In food and resource distribution within families, women give preference to male members and children, while they, themselves are forced to take inadequate amount of food ^[63,64,59]. Thus, the findings in the study indicated nutritional deprivation as part of social system vis-a-vis disparity which accentuate the conditions of malnutrition in tribal communities.

The current study also focussed on nutritional deprivation leading to anaemia in selected tribes. Females were observed to have higher prevalence of moderate to severe anaemia relative to males. This can be attributed to high menstrual blood loss, illiteracy, poverty, undernutrition and rural residence which are confounding factors of anaemia^[65,66,67]. Similar findings have been reported among adolescent girls and adult women in various communities residing in India^{[68,69, 66]}. Heath et al. ^[70] reported an association of high menstrual blood loss with increased risk of anaemia. At the national level, illiterate girls belonging to rural areas with low standard of living index have high prevalence of severe anaemia^[71,25].

This study demonstrated high prevalence of undernutrition among the tribal girls and women, which represents the issues of severe stunting and wasting in their childhood which has continued to the adolescence phase and further into their adulthood. Furthermore, high rates of early age marriage, subsequent conceptions and attainment of motherhood is rampant in most women belonging to various tribal communities in India^[72,73,7]. When underweight young or adolescent girl becomes a mother, she fails to support her own growth alongside the fetus, which often leads the young mother in giving birth to underweight babies^[74,75,76]. Low status of women and lack of nutritional knowledge adds to high prevalence of underweight children. UNICEF^[77] reported that half of world’s undernourished children reside in South Asia. In India, 30% children are born with low birth weight and almost 50% remain underweight by the age of three. The mothers of these low birth weight children have also been reported to be born with low weight (less than 2500gms)^[78,77]. So, undernutrition among women and their children when left unaddressed in one generation, may get carried on to the next generations forming a vicious circle which leads to the gross breakdown of the health of the community, leading to high prevalence of the nutritional extreme among them^[63,7,79]. The inter-generational cycle of undernutrition transmitted from mothers to children has a great impact on India’s present and future^[11].

The present study found highly discriminated prevalence and risk of undernutrition among females than males. Undernourishment is aggravated by the presence of social and cultural aspects like early age at marriage, high rates of school drop-outs, social discrimination on the basis of gender, which is quite frequently observed among Indian tribal groups and this significantly contributes undernutrition among females in their early developmental age^[80,81]. Few studies have highlighted easy accessibility of nutritional food, and various amenities to males as compared to female counterparts; as males are given preferential treatment in patriarchal societies of India^[82,83,7].

However, in the present study it was also found that the prevalence of undernutrition in males was higher than females whereas more females were recorded as overweight and obese in the adolescents of Kukna tribe of Gujarat. These observations revealed an interesting exception as an example of a cross-cultural diversity among Indian tribes in the country. Explanations in behavioural and socio-cultural aspects involving women that influence their access to food and affect various power dynamics, gender role etc. at household and community level will bring meaningful inputs to improve their nutritional status^[7].

In the present study, MUAC was also observed as an indicator of undernutrition along with BMI and Hb levels. Greater proportion of females in Kukna as well as Santal tribes were categorized as undernourished on the basis of MUAC classification. Similar findings were observed in various studies conducted among tribal groups in India^{[41,42,43,44,50]}. It may be worth mentioning here that MUAC could act as an additional tool to assess malnutrition among various age groups^[38]. Malnutrition could be properly evaluated with the help of combining two widely accepted anthropometric measures- BMI and MUAC among adolescent and adult populations ^[84]. However, MUAC may be highly preferred in the field and large studies because of the simple procedure of measuring it which do not required highly skilled individuals and use of minimum instruments^[42,85,86].

CONCLUSION:

Overall findings of the present study showed co-existence of undernutrition and nutritional anaemia among selected tribal groups of India. It was observed that females were more undernourished and anaemic than males. It is evident that undernutrition is also a gender issue as women require specific nutrition during adolescence, pregnancy and lactation which they are unable to get, hence they are undernourished.

India is a country where the issue of gender discrimination and disparity is widespread and often left unattended. Health professionals, clinicians, non-governmental organizations and government health policy makers should target nutritional interventions to prevent and treat undernutrition as part of a continuum of care particularly among children and women belonging to vulnerable communities. Anthropologists, academicians and social workers should educate them regarding proper nutritional intake, awareness about risks associated with poor nutrition and issues of gender biasness in order to minimize high rates of undernutrition and social disparities among socially disadvantaged groups. Additionally, studies focussing on various aspects of malnutrition among varied age groups of Indian tribes need to be undertaken in a more comprehensive manner for better healthcare delivery.

ACKNOWLEDGMENTS:

We sincerely acknowledge the support and cooperation of the participants of the selected villages for their active participation during fieldworks. We would like to acknowledge the technical help provided for blood collection by Mr. Bhavesh Kanhaiyalal Raicha and Mr. Manoj Parekh, Valsad Raktdan Kendra, Gujarat and Mr. Shambhu and Mr. Umesh from Dumka, Jharkhand.

FINANCIAL SUPPORT:

This study is a part of doctoral degree which is funded by UGC-JRF (ref. no. 602/ (NET-JULY 2016) and UGC-RGNF (ref. no. F1-17.1/2014-15/RGNF-2014-15-SC-JHA-61155).

CONFLICT OF INTEREST:

Authors declare that there is no conflict of interest.

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Received on 12.04.2019 Modified on 30.04.2019

Res. J. Humanities and Social Sciences. 2019; 10(2):351-358.

DOI: 10.5958/2321-5828.2019.00061.5

Variables	Kukna (adolescents) (n=100)			Santal (adults) (n=101)
	Mean± S.D.		t-value	Mean± S.D.		t-value
	Males	Females		Males	Females
MUAC (cm)	20.47±2.28	20.19±3.56	0.475	24.37±2.50	22.98±2.32	2.88*
Hb (g/dl)	12.66±1.53	10.95±0.95	6.688***	11.88±1.78	10.24±1.23	5.43***
BMI (kg/m²)	16.99±1.94	18.26±2.32	-2.972*	20.40±2.75	19.85±3.08	0.93