Impact of Dietary Intervention on Undernourished Farm Women

Background Women are vulnerable group for under nutrition, due to various physiological states in the life cycle. Especially in developing countries, despite the fact that women are predominantly the food producers for the nation, majority of them are anaemic, malnourished and have health problems due to insucient nutrient intake. Hence, a study was undertaken to develop a energy dense food product from regionally available food ingredients and to test its ecacy on farm women in improving nutritional status. A traditional food product ‘laddu’ was developed from combination of millet, cereal, legume, oil seeds, fats and sugars by application of simple processing techniques. The developed product was further subjected for nutritional evaluation and dietary intervention on farm women up to 120 days. Impact was studied on anthropometric measurements and nutrient intake of subjects. Findings indicated that, the product contained 516 kcal of energy per 100 gm. The protein, fat, total dietary ber, iron and calcium content of the product was 9.80 g, 31.60 g, 3.90 g, 2.47 mg and 159.60 mg respectively. Majority of the subjects belonged to lower middle socio-economic group with marginal land holding. Mean body weight of rural farm women increased signicantly from 40.67 ± 3.29 to 43.29 ± 4.51 kg and corresponding increase in BMI was also observed from 17.43 ± 0.49 to 18.75 ± 1.26 (kg/ m 2 ). The initial protein, fat and energy intake in experimental group was 31.99 ± 3.01 g, 23.46 ± 4.52 g and 1288 kcal respectively which was increased signicantly for all the nutrients after intervention. In the present scenario, providing nutrition security through development and popularization of nutri- dense food products from regionally available food ingredients among the vulnerable sections of the society of


Introduction
The millions of women engaged in agriculture across the globe are a heterogeneous group with vastly different realities, opportunities and challenges (Debevec and Gadeberg, 2018). In rural India, the percentage of women who depend on agriculture for their livelihood is as high as 84 per cent and onstitute major percentage of the agricultural labour force in the rural sector, producing much of the country's food. Women make up about 33 per cent of cultivators and about 47 per cent percent of agricultural labourers (Singh et. al. 2009). These statistics do not account for work in livestock, sheries and various other ancillary forms of food production in the country. Despite the fact that women are predominantly the food producers for the nation, majority of them are anaemic, malnourished and have health problems due to insu cient nutrient intake. According to NFHS-4, 39 per cent of rural women in the age group of 15-49 years suffer from chronic energy de ciency and 58 per cent are anemic.
Under nutrition denotes insu cient intake of energy and nutrients to meet an individual's needs to maintain good health (Maleta, 2006). Under nutrition in all its forms is responsible for an estimated 3.5 million preventable maternal and child deaths annually and has enormous human and economic costs in the long run (Bhuttaet al., 2013). Children born to women with low Body Mass Index (BMI) are more likely to be stunted, wasted, and underweight compared to children born to women with normal or high BMI (Sources: FNSA, 2019, WHO). In India women whose BMI is below normal (BMI < 18.5 kg/m 2 ) were 16.2 and 24.3 per cent in rural and urban respectively and in total it is, 20.7 per cent. One-fth of women in the reproductive age group were estimated to be suffering from chronic energy de ciency while another one-fth were obese in Karnataka (NSFH 2015-16). Low intake of nutrients reduce the physical capacity to work and increase the extent of fatigue accident rate and sickness. Improvement in work e ciency and output require adequate diet, su cient not only in calories but also protein, minerals and vitamins which must be made available.
Dietary intervention is one of the important and effective measure to address under nutrition. Though there are range of foods available in structuring ready to eat foods for under nutrition, millets are promising, nutri-dense, affordable and easily available. Adoption of food in dietary intervention is expected to be more, when the food developed for the intervention is traditional and prepared from regionally available ingredints. Hence, in the present research, a locally grown crop which is popular worldwide, nger millet in combination with cereal, legume, oil seeds, fats and sugars is transformed into energy-dense traditional food called laddu, to test its e cacy on undernourished farm women.

Materials And Methods
Methodological steps followed to conduct the dietary intervention for undernourished farm women is listed below. Development of energy dense food: A ready to use composite food mix was prepared from regionally available ingredients such as, nger millet (Eleusine coracana), rice (Oryza sativa), groundnuts (Arachis hypogaea), soy (Glycine max) our, desiccated coconut powder, puffed Bengal gram (Cicer arietinum) our and milk powder. All these ingredients were procured from nearest retail outlet at Bangalore, Karnataka, India. From the composite mix, a traditional energy dense food product namely laddu was prepared by addition of groundnut, sesame, cashew, ghee, sugar powder and cardamom. Protocol for preparation of laddu is presented in ow chart (Fig. 1).
Nutrient analysis : The developed energy dense product (laddu) was analyzed for protein, fat, ash and total dietary ber by using standard protocol (AOAC, 1990). Carbohydrate was calculated by difference method and calori c value was obtained by multiplying the carbohydrate and protein content by four and fat by nine Kcals. Dietary ber was estimated by an enzymatic gravimetric method (Prosky, 1990). Micro nutrients viz., iron, zinc and calcium were analysed using atomic absorption spectrometry (AOAC, 1990).
Ethical approval : Before implementation of the dietary intervention, a clearance certi cate was taken from the ethical committee formulated at University of Agricultural Sciences, Gandi Krishi Vigyan Kendra, Bangalore, Karnataka, India. Subjects with hyperthyroidism, diabetes and other related health problems were excluded from the study.
Selection of subjects: A total of 240 women involved in farm activity from seven villages of Bangalore north were screened for undernourished subjects. The basic criteria for selection of subject was Body Mass Index (BMI) below 18.5 kg/m 2 .
Anthropometric measurements: Anthropometric measurements viz., height, weight, waist circumference (WC) and hip circumference (HC) were taken for all the subjects. For measurement of body weight electronic balance (Atlas weighing equipment's, India) was used. The weight of individual was taken with minimum clothing, standing erect without shoes, or holding any support. Height was measured by using anthropometry on a levelled surface, without shoes, looking straight with heels together and toes apart. Waist (WC) and hip (HC) circumference were measured by measuring tape. Body Mass Index (BMI) and Waist Hip Ratio (WHR) indices were calculated. Among these subjects 60 individuals having BMI <18.5 (WHO, 2004) were selected and divided equally into control (n=30) and experimental (n=30) group.
Socio-economic status of selected subjects: A questionnaire was developed to elicit information on socioeconomic status and food habits of the participating subjects through personal interview method. In this data on age, educational status, land holding, occupation, source of income, food habit and meal consumption pattern of the subjects was also collected.
Dietary Survey: Dietary survey of the selected 60 farm women was conducted by using 24-hour recall method for three consecutive days during pre and post interventional period. To assist the subjects, recall better, a set of standardised cups and vessels were used to measure the food intake. Subjects were asked to recall the type of preparation made for breakfast, lunch, evening tea and dinner etc for the previous three days. Data on intake of different food groups was evaluated. Using the quantity of food consumed per day nutrients such as protein, fat, carbohydrate, energy, mineral, calcium, iron, zinc and dietary ber were calculated and compared against the (RDA 2010). To measure of adequacy or inadequacy of food and nutrient composition the below formula was used.
Dietary intervention: Dietary intervention was carried out for 120 days on selected undernourished farm women. For experimental group (n=30) along with their regular diet, developed energy dense laddu (90 g) providing 500 k cal energy and 8.5 g protein was given daily during mid morning. The subjects in experimental group were monitored throughout the intervention period to ensure the consumption of provided experimental food. The control group (n=30) was kept neutral without any dietary intervention.
Statistical analysis: Data obtained was statically analysed with suitable tests. Mean and standard deviation was calculated for each studied variable. Paired 't' test was applied for assessing impact of dietary intervention at 5 per cent signi cance level.

Results
Women selected in present study for dietary intervention are involved in farm activities. For their physical activity, when adequate energy is not consumed for prolonged period along with essential nutrients, leads to undernourishment resulting in low body weight. Hence, in the present study an attempt has been made to increase the daily energy intake of farm women by incorporating an energy dense product with substantial level of other nutrients and to test its e cacy in improving body weight and BMI of women. The ndings of the study are presented and discussed below.
Nutrient composition of energy dense laddu : The nutrient composition of energy dense laddu is presented in Table1. It was found that, the product contained 516 kcal of energy per 100 gm. Other proximate composition was 9.80, 31.60, 0.84 and 3.90 of protein, fat, ash and total dietary ber respectively per 100 g of the product. Micro nutrient content of the product was 159.60, 2.47 and 1.29 mg for calcium, iron and zinc per 100 gm respectively. It was observed that the developed laddu was rich source of energy, protein and fat along with good amount of micro nutrients. The dietary intervention was aimed to incorporate one third (1/3 rd ) energy need of the farm women along with regular diet. Accordingly the product formulated was found to be energy dense, mainly due to the ingredients such as, soy our, sugar powder and ghee. The protein, fat and energy content of laddu prepared from rice, foxtail and barnyard samples was ranged between, 3.04-5.00 g, 24.64-25.63 g and 68.40-503 kcal per 100 g (Verma et al., 2015). These ndings are in supportive to present research ndings for energy content, but protein content was also high in present research due to incorporation of ingredients such as soy our, puffed bengal gram our, cashew, sesame seeds and ground nut along with popped nger millet. It was observed that, the selected ingredients contributed to the nutritional composition of the developed food product (laddu) to make it nutritionally dense (especially in terms of protein, fat and energy) suitable for dietary intervention of underweight women. Socio-economic pro le of subjects: Information on socio-economic status of selected subjects both in control and experimental group was collected and presented in Table 2. It was observed that, in experimental group majority of the women belonged to below 30 years group (46.66%) whereas in control group they belonged to above 40-50 years (56.66%) age group. Collectively women were mainly in the age group of 30-50 years. Almost all the subjects in the study were married irrespective of study group. Nuclear family type was predominant both among control (80.0%) and experimental group (83.33%). In control group most of them were illiterates (50.0%) followed by studied up to middle school (20.0%). Similar trend was observed for experimental group also, where per cent of illiterates and subjects studied up to middle school was same (33.33%). Food Habits: Data on meal pattern and food habit of the subjects is as presented in Fig 2. Findings indicated that, though majority of them consumed three meals per day both in control (76.66%) and experimental (96.66%) group, 23.33 per cent subjects in control group consumed two meals per day. It was observed that non vegetarian food habit was predominant both in control (60.0%) and experimental group (80.0%). In rural areas the habit of consuming two meals per day was more prevalent but changing food consumption pattern due to various reasons has in uenced rural farm women in consuming three main meals per day. But the prevalence of underweight among these selected farm women reveals insu cient intake of food both in terms of quality and quantity leading under nutrition. Though subjects were non vegetarians the frequency of consumption of non vegetarians foods is twice or thrice in a month, as revealed during personal interview.
Effect of dietary intervention on anthropometric measurement: The pre and post interventional anthropometric ndings are presented in Table 3. Findings indicated, the average body weight of rural farm women increased from 40.67±3.29 to 43.29±4.51 kg. Corresponding increase in BMI was also observed from 17.43±0.49 to 18.75±1.26 (kg/ m 2 ) during intervention. These increases in parameters were observed to be statistically signi cant. Whereas no change was observed in control group. In experimental group, waist circumference was slightly increased from 67.17±5.93 to 69.83±5.44 cm after intervention. Also, small shift in WHR was observed post intervention (0.78±0.05 to 0.80±0.05). However, these impacts were statistically non signi cant. But in control group these positive changes were unseen.
Nutritional anthropometry is measurement of human body at various ages and levels of nutritional status. Comparison of pre and post evaluation of the anthropometric assessment indicates the signi cant in uence of the dietary intervention on subjects under study. In the present study it was observed that, the dietary intervention with additional calories and protein along with regular diet has contributed towards increasing body weight of the selected farm women. This is clearly indicated by BMI assessment, as the experimental subjects shifted from underweight category to normal after the interventional period. There are limited studies available to compare effect of dietary intervention on underweight women. Prentice et al., in 1987 reported that, energy dense prenatal dietary supplement (430 kcal/day) decreased the proportion of low-birth weight babies (less than 2501 g) from 23.7-7.5 per cent, emphasizes the importance of selective targeting of interventions to truly at-risk groups. Bene t of nutritional supplementation in free living, frail, undernourished elderly people was studied by Payette et al., in 2002 and reported that, nutrition intervention is feasible in free-living, frail undernourished elderly people and results in signi cant improvement of nutritional status with respect to energy and nutrient intake and weight gain. These ndings supports the present research work, that dietary intervention with adequate energy dense food supplements contribute to improvement in undernourished subjects. intervention. However, in control group the intake of these proximate was remained unchanged. It was also found that, post interventional increase in intake of micronutrients (Calcium, iron and zinc) among experimental group. Dietary ber intake was increased from 36 to 81 per cent adequacy in experimental group.
It was noticed that, dietary intervention in experimental group signi cantly increased the intake of all the essential nutrients with improved adequacy of the nutrients. Whereas in control group no difference was observed. Bhandari et al., in 2016 studied, dietary intake patterns and nutritional status of women of reproductive age in Nepal and reported that, the dietary intake patterns to combat against nutritional de ciencies are not appropriate and nutritional status of women of reproductive age is still poor, indicates the need for dietary intervention among women. Payette et al., (2002) reported that nutritional supplementation in elderly people has signi cantly improved the energy and protein intake. These ndings are in supportive to present study. The food product developed for dietary intervention was not only rich in energy, it also contained all the essential nutrients in optimum level, which is re ected in the increased nutrient intake among farm women. Increase in nutrient intake helps in improving the nutritional status of the women under study.

Conclusion
Under nutrition denotes insu cient intake of energy and nutrients to meet an individual's needs to maintain good health. In this regard, development and supplementation of nutritionally dense food product to combat malnutrition is an effective strategy. A traditional energy dense product 'laddu' has positive in uence on nutritional status of the farm women. Such, food based approaches are recognized as an essential part of an urgently needed more comprehensive strategy for improving nutrition by increasing the availability and consumption to combat nutrient de ciencies. It is also needed to ensure food and nutrient security through development and popularization of nutri-dense food products among the vulnerable sections of the society utilising locally available region speci c foods.

Declarations
Ethics approval and consent to participate: The study was undertaken with the institutional ethical approval certi cate provided with No. AICRP FN 2018001 dated: 10.02.2018. Written consent was taken from the subjects prier participation in to the study.

Consent for publication: Manuscript doesn't contain any individual persons data in any form
Availability of data and material : The datasets used or analysed during the current study are available from the corresponding author on reasonable request .
Competing interests: The authors declare that they have no competing interests  Meal pattern and food habits of subjects