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 Epidemiology and Society Health Review| ESHR 
Vol. 4, No. 1, 2021, pp. 1-11 ISSN 2656-6052 (online) | 2656-1107 (print) 
 
 

      10.26555/eshr.v4i1.4641  

  
 

  
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Research Article  
 
A Community-Based Study of Milk Adulteration and 
Childhood Malnutrition in Bangalore Rural District, India 
 
Amita Mukhopadhyay1, Ipsita Debata2*, Ravikiran P Kamate2, Nagendra 
Nagaiah3, Priyanka Rodrigues4 
1 Associate Professor, Department of Community Medicine, Dr. Chandramma Dayananda 

Sagar Institute of Medical Sciences and Research (CDSIMER), Harohalli, Ramanagara 
District, Karnataka, India 562112 

2 Assistant Professor, Department of Community Medicine, Dr. Chandramma Dayananda 
Sagar Institute of Medical Sciences and Research (CDSIMER), Harohalli, Ramanagara 
District, Karnataka, India 562112 

3 MBBS student, Akash Institute of Medical Sciences and Research Centre, Prasannahalli 
Main Road, near Kempegowda International Airport, Devanahalli, Bengaluru, Karnataka, 
India 562110 

4 Statistician (Former), Department of Community Medicine, Dr. Chandramma Dayananda 
Sagar Institute of Medical Sciences and Research (CDSIMER), Harohalli, Ramanagara 
District, Karnataka, India 562112 

 
* Correspondence: drdebataipsita@gmail.com. Phone: +91-9972483237 
 
Received 08 August 2021; Accepted 25 August 2021; Published 14 September 2021 
 

ABSTRACT 

Background: Milk promotes child growth; however, adulterated milk reduces nutritional value 
and exposes children to harmful chemicals. Therefore, this study aimed to assess the nutritional 
status of children aged 1–5 years living in the selected study area and test milk samples from 
the children's households for common adulterants. The study further aimed to explore the 
association between malnutrition and milk adulteration. 
Methods: We used a community-based cross-sectional study design conducted in the service 
area of a tertiary healthcare institute in Bangalore Rural District, Karnataka state, India. 
Systematic random sampling was used to recruit 180 children aged 1–5 years. Primary data 
was collected through interviews, anthropometry, and strip tests for milk adulteration. Statistical 
analysis consisted of descriptive analysis, Chi-square tests, odds ratios, and 95% confidence 
intervals. 
Results: Prevalence of underweight, stunting, wasting, and low Body Mass Index (BMI) was 
13.33%, 38.33%, 15.0%, and 26.7%, respectively. General adulterants detected were 
neutralizers in 97 (53.9%) and maltodextrin in 90 (50%) samples. Higher proportions of stunting, 
underweight and low BMI were found in children drinking adulterated milk. Low BMI was 
significantly associated with joint family and lower maternal education. 
Conclusion: Our study found a high prevalence of malnutrition in children, particularly stunting. 
The study also detected widespread adulterants in milk and a potential association with 
malnutrition. The authors recommend further studies with a larger sample size to accurately 
delineate the relationship between milk adulteration and malnutrition. 

Keywords: Malnutrition; Milk adulteration; Under-five; Stunting; Underweight; Wasting  



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INTRODUCTION  

In India, 38 percent of under-5 children are stunted, a manifestation of chronic undernutrition. 
Malnutrition is responsible for nearly half of all child deaths globally (1). There are significant 
inequalities across states and socioeconomic groups, with rural areas and the poorest people 
being the worst affected (2). Bangalore Rural District in Karnataka state is below expected 
standards in key indicators of nutrition. The National Family Health Survey 2015-16 (NFHS-4) 
results reveal stunting in 38.5% of under-five children, wasting in 26.9%, and underweight in 
37.7%, a worrisome prevalence (3). 

In the Indian population, approximately 12% of the dietary intake consists of milk and 
food products derived from milk (4). In Karnataka state, as much as one-fifth (22.2%) of the 
population is lactovegetarian which means milk is the only source of animal-based protein 
for these families and their children (5). However, research has revealed that approximately 
80% of children in the 1–6 years age group in Karnataka consume less than 50% of the 
recommended daily intake (RDI) of milk and milk-based foods (6). Undernourished children 
who regularly drink milk show better growth and cognition and improvements in biochemical 
and functional indicators of nutrition, thereby enhancing health and reducing mortality (7). 
However, adulterated milk is a serious public health issue, with around 68.7 percent of milk 
not satisfying the standards of the Food Safety and Standards Authority of India (FSSAI) (8). 
Adverse consequences of drinking adulterated milk are well documented worldwide (9–11).  

Therefore, in our capacity as public health researchers working in a tertiary healthcare 
institution, we proposed the present study. Our objectives were to assess the nutritional status 
of children aged 1–5 years, to test milk samples from the children’s households for common 
adulterants, and further to explore the association of milk adulteration with malnutrition in 
children so that baseline data could be made available and utilized in future to confront these 
two important public health issues. 

METHOD 

This study was designed as a community based cross-sectional study in the catchment area 
of the Rural Health and Training Centre (RHTC) of a tertiary health institute. The RHTC serves 
a total population of over 25000, of which around 2500 were estimated to be children aged 
five years or less (approximately 10% based on Census 2011 data) (12). Among this group, 
children aged 1-5 years were included in the study as infants may be largely dependent on 
maternal nursing. 

We calculated a sample size of 180 based on an initial estimate of 150 using the formula n = 
z2P(1-P)/d2,(13) taking z = 1.96 at 95% confidence level,  d = 0.05, P = 0.11  taking 11% 
prevalence of severe wasting based on NFHS-4 data (3) and adding 20% for non-response. 
The inclusion criteria were age 1-5 years, residence in the area for at least the past six months, 
and the guardian's consent for the child to participate in the study and provide a sample of raw 
milk purchased the same day for testing. 

We carried out a house-to-house survey, using systematic random sampling, and collected 
data using a pretested objective questionnaire administered to the mothers of the selected 
children, or if the mother was absent, the following primary caregiver. The questionnaire 
contained basic identifier data, followed by education, occupation and income, and health-



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related information such as vaccination status, breastfeeding, recent illnesses, and others. 
This was followed by obtaining a sample of raw milk for testing and anthropometric 
assessment of weight and height/length as described in the World Health Organization (WHO) 
child growth standards training manual (14). Milk was tested for the presence of water, starch, 
urea, and detergent using methods recommended by FSSAI (15) and for maltodextrin, 
hydrogen peroxide, and neutralizers using strip tests, developed through technology transfer 
from National Dairy Research Institute (NDRI) (16). 

Raw data were tabulated and cleaned. Descriptive analysis was performed using 
classifications such as age group, educational level, and economic class. Socioeconomic 
status was coded using Modified Prasad’s Socioeconomic Scale criteria (17). Milk adulteration 
was defined according to FSSAI criteria (15). Underweight was defined as Weight for Age 
(WFA) less than two standard deviations (-2SD) below the median of the WHO Child Growth 
Standards (WHOCGS), Stunting as Height for Age (HFA) less than 2SD below the WHOCGS 
median, and Wasting as Weight for Height (WFH) less than 2SD below the WHOCGS median. 
Bivariate analysis was done using Chi-square tests. Odds ratios and 95% confidence intervals 
were derived. 

Ethical clearance for the study was obtained from the Institutional Ethics Committee of Akash 
Institute of Medical Sciences and Research Centre, Devanahalli, Karnataka (Reference ID 
AIMSRC/RP/EC/14/2019). 

RESULTS 

Demography 

We studied 91 girls and 89 boys, of mean age 29.3 7± 13.72 (SD) months. The age and gender 
distribution of the study sample are shown in Figure 1. 

 
Figure 1.  Age and gender distribution of the study participants 

 
 



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Among the 180 children, 67 (37.2%) belonged in the 12-23 months age group. The nuclear 
family was the predominant family type, with 115 (63.9%) children in this category. Almost all 
the children, viz., 175 (97.2%), fell in the lower and lower-middle-class socioeconomic 
category. (Table 1) 

Table 1. Socio-demographic profile of the participants 

Characteristic Frequency 
(N=180) 

Percentage 
(%) 

Religion   
Hindu 170 94.4 

Muslim 10 5.6 
Christian 0 0.0 

Type Of Family   
Nuclear 115 63.9 

Joint 65 36.1 
Socio-Economic Status*   

High 0 0.0 
Upper Middle 5 2.8 
Lower Middle 55 30.5 
Upper Lower 111 61.7 

Lower 9 5.0 
Mother’s Education   

Illiterate 7 3.9 
Primary  46 25.6 

Secondary  127 70.6 
Father’s Education   

Illiterate 11 6.1 
Primary  48 26.7 

Secondary  121 67.2 
Mother’s Occupation   
Unemployed/ Homemaker 173 96.1 

Employed 7 3.9 
Father’s Occupation   
Unemployed/ Homemaker 2 1.1 

Employed 178 98.9 
*As per Modified Prasad’s Socioeconomic Scale  

127 (70.6%) mothers and 121 (67.2%) fathers had received secondary level education among 
the parents. Most of the mothers were homemakers, and most fathers were employed in 
occupations outside the home. 

Anthropometry 

We did not note any significant gender differences in underweight, stunting, and wasting. 
Assessment of Body Mass Index (BMI) as per WHO BMI standards showed a statistically 
significant gender difference with more boys being overweight/obese compared to girls (16/89 
boys; 17.97% vs 5/91 girls; 5.49%, chi-square = 6.8, df = 1, P = 0.009, OR = 3.77, 95%CIOR = 
1.32–10.79). 

Table 2 shows the proportions of underweight, stunting, and wasting observed in the study 
participants. 

 

 

 



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Table 2. Anthropometric indices of the participants 

Characteristic Male (N=89) 
n (%) 

Female (N=91) 
n (%) 

Total (N=180) 
n (%) 

Weight For Age (WFA)*    
Underweight (median-3SD <WFA <median-2SD) 9 (10.11) 13 (14.29) 22 (12.22) 

Severely Underweight(WFA <median-3SD) 0 (0.0) 2 (2.19) 2 (1.11) 
Overweight (WFA>median+2SD) 4 (4.49) 1 (1.09) 5 (2.78) 

Height For Age (HFA)†    
Stunted (median-3SD <HFA < median-2SD) 22 (24.68) 20 (21.98) 42 (23.33) 

Severely stunted (HFA < median-3SD) 13 (14.60) 14 (15.40) 27 (15) 
HFA > median+2SD 0 (0.0) 2 (2.19) 2 (1.11) 
HFA >median+3SD 2 (2.19) 7 (7.69) 9 (5) 

Weight For Height (WFH)‡    
Wasted (median-3SD <WFH< median-2SD) 7 (7.86) 4 (4.39) 11 (6.11) 

Severely wasted (WFH< median-3SD) 11 (12.36) 5 (5.49) 16 (8.89) 
WFH>median+2SD 4 (4.49) 0 (0.0) 4 (2.22) 
WFH >median+3SD 8 (8.99) 0 (0.0) 8 (4.44) 

Body Mass Index (BMI)§    
Underweight (<18.5) 28 (31.46) 20 (21.97) 48 (26.7) 

Healthy Weight (18.5–24.9) 45 (50.56) 66 (72.53) 111 (61.7) 
Overweight (25.0–29.9) 4 (4.49) 2 (2.20) 6 (3.3) 

Obese (≥30.0) 12 (13.48) 3 (3.30) 15 (8.3) 
*Underweight: weight for age (WFA) less than WHOCGS median-2SD  
†Stunting: height for age (HFA) less than WHOCGS median-2SD  
‡Wasting: weight for height (WFH) less than WHOCGS median-2SD 
§ BMI: As per WHO BMI standards 

 

Milk adulteration 
A striking proportion of the milk samples in our study, 158 out of 180 (87.8%), were adulterated 
with water and/or other chemicals, with neutralizers being the most common adulterant. Urea 
as an adulterant was not detected in any sample (Figure 2A). We observed that 65 (36.1%) 
milk samples had two types of adulterants mixed, followed by any one type of adulterant in 58 
(32.2%) milk samples (Figure 2B). 

 
Figure 2. Types of adulterants (A) and Presence of multiple adulterants (B) in milk samples 

 



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Association between malnutrition and adulteration 
The proportions of underweight, stunting and low BMI were higher among children drinking 
adulterated milk, although these differences were not statistically significant. The proportion 
of wasting was found to be higher in children drinking unadulterated milk. This difference was 
also not statistically significant (Table 3). 

Table 3. Association between adulteration and malnutrition 
 

Variable: Underweight 
(WFA < median-2SD)  

Normal  Underweight  Total  χ 2   P value  
n  %  n  %   n  %  

Unadulterated milk 20   90.91  2  9.09  22  100  
0.39 

  
0.532 

  
Adulterated milk 136  86.08  22  13.92  158  100  

Total  156  86.67  24  13.33  180  100  

Variable: Stunting 
(HFA < median-2SD)  

Normal  Stunted  Total  χ 2   P value  
n  %  n  %   n  %  

Unadulterated milk 15  68.18  7  31.82  22  100  

0.45 0.502 Adulterated milk 96  60.76  62  39.24  158  100  
Total  111  61.67  69  38.33  180  100  

Variable: Wasting 
(WFH < median-2SD)  

Normal  Wasted  Total  χ 2   P value  
n  %  n  %   n  %  

Unadulterated milk 18  81.82  4  18.18  22  100  

0.199 0.656 Adulterated milk 135  85.44  23  14.56  158  100  
Total  153  85.00  27  15.00  180  100  

Variable: Low BMI 
(BMI < 18.5)  

Normal  Low BMI  Total  χ 2   P value  
n % n % n % 

Unadulterated milk 17 77.27 5 22.72 22  100  

0.199 0.656 Adulterated milk 115 72.78 43 27.22 158  100  

Total  132 73.33 48 26.66 180  100  

 
Socio-demographic associations of malnutrition 
We noted that odds of being undernourished were significantly lower in children living in 
nuclear families and significantly higher in children whose mothers were not educated beyond 
primary school level (Table 4). 

Table 4. Association between socio-demographic variables and malnutrition 
 

Socio-
demographic 

variables 

Undernourished 
(BMI < 18.5) 

Not 
Undernourished 

(BMI ≥ 18.5) Total χ2; 
P-value 

OR; 
95% CIOR 

n % n % 
Family type 

Nuclear 25 21.7 90 78.3 115 3.95; 
0.047 

0.507; 
0.258–0.996 Joint 23 35.4 42 64.6 65 

Mother's education 
Primary 21 39.6 32 60.4 53 6.448; 

0.011 
2.431; 

1.212–4.872 ≥Secondary  27 21.3 100 78.7 127 



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DISCUSSION  

The present study reported the overall prevalence of underweight/undernutrition, stunting, 
wasting, and low BMI as 13.33%, 38.33%, 15.0%, and 26.7%, respectively. This is similar to 
the findings of the study by Meshram et al. (18) among under-5 children in Surat, Gujarat. A 
notable finding of our study is that there were no significant differences in undernutrition 
between boys and girls, which points towards the absence of discrimination against girls in 
feeding and care. However, there was a marked gender difference in the overweight/obese 
category, significantly more boys than girls. This finding indicates that while girls may not be 
overtly mistreated, boys are still possibly receiving preferential care related to feeding and 
household chores. 

The observed prevalence of stunting (38.33%) in this study suggests widespread chronic 
malnutrition in our study population. This was consistent with findings of studies done by 
Sahoo et al. (42.2%) (19) and Popat et al. (46.1%) (20). Most children in this study, viz 115 
(63.9%), belonged to nuclear families. Malnutrition was found to be more common in children 
from joint families compared to nuclear families. Similar findings were reported by Gopinath et 
al. (21) and Kodavanti Rao et al. (22). 

This study also revealed a significant association between a mother's education and a child's 
BMI, which is concordant with results reported by Sahoo et al. (19) and Mittal et al. (23). This 
finding can be attributed to educated mothers having better knowledge about breastfeeding, 
complementary feeding, and immunization, which would profoundly affect the child's 
nutritional status. This is supported by research findings from India and other countries (24–
29). 

The commonest adulterants detected in our study were neutralizers found in 97 (53.9%) 
samples and maltodextrin found in 90 (50%) samples. In rural areas, dairy farms may not be 
modernized, and the cold chain may be faulty, leading to milk spoilage. Sowmya et al. 
observed that middlemen add neutralizers to extend the shelf life of milk by neutralizing the 
acids produced by bacterial activity, which can maximize the seller's profit but cause significant 
harm to consumers, especially children (30). The National Milk Safety and Quality Survey 
2018 report has also noted the presence of maltodextrin in 156 (out of 6432) samples (31). 
The report notes that while these may not directly threaten health, such instances of 
adulteration must nevertheless be prevented by instituting stringent curbs.  

Hydrogen peroxide was the next most common adulterant, found in 55 (30.6%) samples. 
Researchers have documented the longstanding and worldwide use of hydrogen peroxide 
(H2O2) as an adulterant in milk to preserve and lengthen its shelf life. (32, 33). However, it is 
not desirable to have this contaminant either in trace amounts as a residue of cleaning or due 
to active adulteration by profiteers. The addition of peroxides and detergents to milk may be 
responsible for symptoms of gastro-intestinal distress (34). 

This study showed that 47 (26.1%) of our milk samples were diluted with added water. 
According to Handford et al., the FSSAI 2012 national survey had reported extensive use of 
water to adulterate milk, making it the most common milk adulterant in India. This practice 
results in low-quality milk with poor nutritional value (9). Similarly, Grace et al., in their study 
on milk safety in North East India, reported finding water used to dilute milk in samples from 
all dairies  (35). 



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This study shows a trend of higher proportion of stunting, underweight and low BMI in the 
children drinking adulterated milk compared to those who drank milk without any detectable 
adulterants. However, our results were not found to be statistically significant.  The consistent 
trend of these indicators of malnutrition showing higher prevalence in children drinking 
adulterated milk is a pointer to the deleterious effect of adulterants, even in trace quantities, 
on young children. Handford et al. echo this concern, stating that diluting milk with water harms 
its nutritional value. This may lead to severe challenges with malnutrition in infants and 
children  (9). In India, milk is a chief source of protein for a largely vegetarian population. We 
must consider the possibility that the extensive prevalence of milk fraud in India, as reflected 
in the FSSAI 2012 milk safety survey, could be a causative factor in childhood malnutrition 
(36). 

The proportion of wasting in this study did not follow a similar trend of being higher in children 
drinking adulterated milk. However, wasting is related to acute nutritional deficiencies and 
infectious diseases compared to stunting, which is an indicator of chronic malnutrition. There 
may be confounding factors at play in the scenario of acute malnutrition, which may mask the 
effect of milk adulteration. Thus, stunting may be a more appropriate indicator of the effects of 
long-term consumption of diluted/contaminated milk that is nutritionally subpar and exposes 
the child to prolonged, sub-lethal doses of various harmful adulterants. 

A fundamental limitation of this study was that testing for milk adulterants was qualitative. The 
strip tests used in this study only indicated the presence or absence of adulterants and not the 
concentration in which they were present. Resource and feasibility constraints prevented 
quantitative analysis from assessing the exact amount of each adulterant in the samples. We 
observed a high proportion of adulterated milk samples, which resulted in correspondingly 
very few unadulterated samples. This may have affected the statistical analysis, in which a 
specific minimum count is required in each cell for the tests of association to be dependable. 

CONCLUSION 

This study attempts to elucidate the relationship between milk adulteration and childhood 
malnutrition. The key findings of this study were a high percentage of stunting (38.33%), low 
BMI (26.7%), wasting (15%), and underweight (13.33%) among children, and an alarming 
presence of adulterants in nearly 90% of the milk samples tested. Undernutrition was 
significantly associated with joint family and lower maternal education, and a potential 
association was detected between malnutrition and milk adulteration. Our findings emphasize 
the importance of maternal education. The results of this study warrant further research with 
larger sample sizes to accurately delineate the relationship between milk adulteration and 
malnutrition, and quantitative analysis of adulterants to gain a clearer picture of the extent of 
adulteration dose-response relationship, if any, between various adulterants and malnutrition.   

Authors' contribution 

AM: research design, analysis, and manuscript writing; ID: data collection, analysis, and 
manuscript writing; RPK: manuscript writing; NN: research design, data collection; PR: 
analysis. 
 
 



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Funding 

This project was carried out under a Short Term Studentship grant from the Indian Council of 
Medical Research (ICMR STS, reference ID 2019–04155). 

Acknowledgment 

The authors acknowledge the children who participated in this study and thank the parents for 
their consent. 

Conflict of interest 

The authors declare that there are no conflicts of interest. 

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