Knowledge, attitude and practices of ayurvedic medicine practitioners in Kerala towards millets and millet-based diet: a prospective cross-sectional online survey study (2025)

Introduction

Millets are nutrient-rich cereals from the Poaceae family and are considered as one of the oldest cultivated crops.1 But after the Green Revolution, the focus on millets waned.2 However, recognising their potential to combat malnutrition and bolster food security, India proposed declaring 2023 as the International Year of Millets (IYoM2023) to the United Nations. In this context, there has been a burgeoning global focus on the nutritional and health benefits of millets.3 4 IYoM2023 holds particular significance in Kerala (the southernmost state in India) as its gastronomic landscape stands out with its distinctive millet-based diet (MBD), historically devised to cater to the health needs of various segments of the population especially the tribal villages of Idukki and Palakkad districts of Kerala.5 6 The traditional milieu of Kerala intricately intertwines with the dietary principles of Ayurveda, forming a cohesive tradition deeply rooted in Ayurvedic dietary practices that serve as a cornerstone in shaping Kerala’s culinary landscape which is evident from ‘Hortus malabaricus’ a 17th-century AD Dutch publication written by H A Van Rheede.7 8

Millets are classified in Ayurveda as ‘Trinadhanya’ (grains derived from grass) or ‘Kshudra Dhanya’ (small grains). Ayurvedic treatises extensively discuss the categorisation of grains within the framework of ‘Dhanya varga’ (group of grains) recommending the incorporation of millets into the diet, especially for managing conditions like diabetes, obesity and other related diseases.9 The inclusion of millets as a staple ingredient in traditional recipes holds significant importance due to their high fibre content and essential nutrients which contribute to maintaining a balanced diet. Their nutrient density, high fibre content and low glycaemic index make millets appealing to individuals with lifestyle-related illnesses. The use of MBD will further enhance environmentally sustainable cultivation practices, contribute to dietary diversity and aid support local economies to sustain in this fast-paced world and finally address food security challenges.10 Consequently, millet consumption aligns with Sustainable Development Goal (SDG) No. 2 by offering essential nutrients through natural food sources.11

Given the paramount importance of diet and lifestyle in Ayurvedic preventive and therapeutic approaches, Ayurveda practitioners hold a distinctive position in offering guidance regarding the use of specific dietary interventions within clinical settings. These practitioners, deeply rooted in traditional wisdom, can offer valuable insights into the historical and professional understanding of millets. An exploration of their attitudes, practices and knowledge can shed light on the integration of millets into contemporary dietary and healthcare paradigms. The design, implementation and interpretation of Knowledge, Attitude and Practice (KAP) surveys represent pivotal steps in understanding complex behavioural patterns and informing targeted interventions across diverse domains and for their relative ease in conception, execution and analysis.12 Thus, this study endeavours to investigate the perspectives of Ayurvedic physicians in Kerala regarding millets and their role within the MBD through a KAP study.

Materials and methods

The study was reported as per the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.13 (see online supplemental file - STROBE checklist)

Results

In the final analysis, 386 responses were incorporated. The mean age of the participants was 33.8±8.89 where the majority of the respondents (56.7%) were in the age group of 28–38 years and 77.4% were women. Among the total participants, 59.1% (228) had BAMS (Bachelor of Ayurvedic Medicine and Surgery) qualifications and 38.1% (147) had MD (Doctor of Medicine)/(MS (Master of Surgery) degrees (table 1). Almost 72.5% of the respondents cited books or articles as sources of information followed by traditional Ayurveda treatises (30.3%). (online supplemental figure 1a). It is noteworthy to mention that 89.6% are aware of the use of millets in their diet. A substantial majority, accounting for 77.2%, exhibited awareness regarding the commemoration of the ‘IYoM2023’. A cross-tabulation of the respondent’s characteristics with KAP domains is given in online supplemental table 1.

Around 89.1% (344 individuals) demonstrated familiarity with the description of millets as outlined in Ayurveda treatises and 74.4% of the participants were cognisant of the properties attributed to millets within the Ayurveda repertoire. Around half of the participants (47.7%) possessed the knowledge to differentiate various types of millets. Only 31.9% of the practitioners indicated possessing awareness regarding potential adverse effects linked to the consumption of millets, while 56% of the respondents acknowledged being familiar with disease-specific dietary recommendations involving millets, as per Ayurveda.

An overwhelmingly high percentage of practitioners (97.9%) expressed support for the promotion of millets through the IYoM2023. Furthermore, 95.6% of practitioners endorsed the notion that millets should be advocated as part of a patient’s diet regimen. Despite this positive attitude, practice trends revealed a discrepancy with only 43.3% of participants regularly incorporating millets into their own diets. Nonetheless, a substantial proportion of respondents (83.9%) aligning with their supportive attitude reported prescribing millets as part of their patients’ dietary recommendations. A good proportion of participants (72.0%) responded that they favour MBR (Millet Based Diet) in specific diseases compared with other cereal-based recipes (table 2). A minority of respondents (26.4%) indicated withdrawing MBR from a patient’s diet due to their perceived lack of suitability for specific types of diseases. On evaluating attitudes towards the ease of inclusion of MBD, a diverse response emerged with 54.1% expressing a favourable view while 45.9% considered it not easy. Respondents cited several factors contributing to patients’ non-compliance with the inclusion of millets in their diet when advised such as lack of knowledge or familiarity, unfavourable taste, limited availability, deviation from staple food choices, high cost and perceived difficulty in cooking. (online supplemental figure 1b).

49.2% answered affirmatively about the safety of millets while 50.8% expressed reservations. The majority of practitioners indicated that they incorporate specific MBR by specifying their frequency of use (87.6%) and by mentioning the name of the millet and the particular recipe for consumption (85.8%) in their dietary recommendations to patients. Finger millet (96.3%) followed by little millet (38.3%) was the most commonly prescribed millet (online supplemental figure 1c). Respondents identified several barriers contributing to the limited utilisation including lack of familiarity, restricted accessibility, high cost and the perception that millets may not fulfil the necessary nutritional requirements compared with other food items (online supplemental figure 1d).

The comprehensive responses of practitioners across the KAP domains are outlined in table 1. In general, 67.9% of respondents exhibited a commendable level of knowledge, 94.6% displayed a positive attitude towards MBD and 75.9% showcased favourable practices supporting MBD. The overall mean domain score for Knowledge was 5.21±1.917, 6.36±1.147 for Attitude and 5.34±1.887 for Practice (table 1). The scores of 5 and above are deemed indicative of favourable levels in the context of this study.

Logistic regression analysis was performed to determine the association between gender, age group, educational qualification and knowledge about MBD. The results of the univariate analysis have been shown in (table 3). The distribution of knowledge about MBD varied among genders with 32 (36.8%) men and 55 (63.2%) women exhibiting good knowledge. The observed trend suggests a slightly higher likelihood of having good knowledge among women compared with men, although this association was not statistically significant at the conventional alpha level of 0.05. A statistically significant association was observed between specific age groups and knowledge about MBD. Respondents in the age group of 27–32 years (AOR: 1.93, 95% CI: 1.05 to 3.56, p=0.035) and those aged over 38 years (AOR: 2.334, 95% CI: 1.12 to 4.86, p=0.023) demonstrated a higher likelihood of having good knowledge regarding MBD as opposed to those with age less than 38 years (figure 1). Practitioners holding an educational qualification of MD/MS or higher were found to be more than twice as likely to possess knowledge about MBD compared with graduates (AOR: 2.126, 95% CI: 1.244 to 3.632, p=0.006).

The logistic regression analysis conducted to ascertain the predictors of Attitude towards MBD among Ayurveda practitioners revealed that age, gender and education revealed no statistically significant association to positive attitude towards the prescription of MBD. Practitioners with good knowledge demonstrated a three times higher likelihood of harbouring a positive attitude towards the prescription of MBD for patients (AOR: 3.04, 95% CI: 1.20 to 7.69, p=0.019) (figure 2).

The logistic regression analysis for exploring the association between gender, age, education and good practice behaviour among Ayurveda practitioners did not identify any significant relationships. However, it is important to note that the practitioners with good knowledge were eight times more likely to incorporate MBD in their practice (AOR: 8.59, 95% CI: 4.92 to 15.01, p=<0.001). This significant association demonstrates the pivotal role of knowledge as the single most influential predictor for practice behaviour favouring the use and prescription of MBD (figure 3).

Discussion

This survey is a pioneering effort, likely the first to systematically explore the KAP of Ayurvedic physicians in Kerala regarding MBD. It reveals complex behavioural patterns and guides targeted interventions.

The study portrays a commendable trend among respondents with the majority exhibiting favourable KAP towards MBD. The widespread awareness of millet usage and the significance of the ‘IYoM2023’ reflects the successful execution of government initiatives aimed at promoting millet integration into dietary practices. This level of awareness implies a significant stride in revitalising the inclusion of millets in diets indicative of a notable engagement of the public with such endeavours. Furthermore, the study revealed a substantial proportion of participants demonstrating familiarity with millet descriptions and properties outlined in Ayurveda treatises in alignment with Ayurveda principles and scriptural references. This highlights the practitioners’ profound engagement with ancient Ayurveda wisdom, underscoring the enduring relevance of Ayurveda in contemporary healthcare practices. The observed gaps in knowledge among practitioners regarding the contemporary nutritional profile of millets with approximately half demonstrating poor knowledge highlight a significant area for improvement. Scientific research has increasingly recognised the nutritional richness of millets which are known to be abundant sources of essential nutrients including dietary fibre, vitamins, minerals and antioxidants.16 17 Their protein content ranges from 6% to 13% with Proso millet and Foxtail millet being the richest sources. The quantity of dietary fibre in millets is nearly double that of rice with Barnyard millet and Kodo millet being prominent sources. Millets also provide significant amounts of micronutrients including calcium (10–348 mg/100 g), iron (2.2–17.7 mg/100 g), zinc (0.4–2.8 mg/100 g) and phosphorus (189–293 mg/100 g). Additionally, they are rich in vitamins such as thiamine (0.15–0.60 mg/100 g), niacin (0.89–4.6 mg/100 g) and riboflavin (0.09–0.28 mg/100 g). The detailed nutritional profile of commonly used millets in comparison to rice and wheat are given in the online supplemental table 2.9 Incorporating millets into diets has been associated with numerous health benefits such as improved blood sugar control, weight management and reduced risk of chronic diseases like diabetes and heart disease.18–20 Inadequate awareness of these nutritional attributes among practitioners may create a barrier to prescribing MBD.

It is noteworthy that despite positive attitudes towards the inclusion of MBD in daily diets, there exists a gap between endorsement and practice, specifically for themselves, indicating the need for targeted interventions to bridge this divide. The dichotomous response among practitioners regarding the ease of incorporating MBD into routine diet underscores the complexity inherent in promoting millets as a dietary staple in contemporary contexts which may be influenced by perceptions of millet safety, cultural beliefs, personal experiences and available information in the public domain. The practitioners had also listed several barriers contributing to the limited utilisation of millets including lack of familiarity with millets/millet recipes, restricted accessibility, high cost, limited culinary familiarity and the perception that millets may not fulfil necessary nutritional requirements compared with other food items. In the context of the divided opinion regarding the ease of inclusion of MBD, safety concerns and the barriers listed, individual practitioners’ specific attitudes play a significant role which is similar to some previous findings.21 Attitudes are acquired characteristics of an individual representing relatively enduring beliefs organised around an object, subject or concept which predispose one to respond in some preferential manner, based entirely on the individual.22 23 For instance, practitioners favouring the ease of inclusion may perceive millets as versatile and adaptable to diverse culinary practices. In contrast, those perceiving it as challenging may cite factors such as limited availability or unfamiliarity with preparation methods.

Finger millet followed by Foxtail Millet and Little Millet are reported as the most frequently prescribed millet by Ayurveda practitioners in Kerala which can be attributed to the fact that they hold the status of a staple food within various communities and are extensively cultivated in specific regions of Kerala.6 Addressing misconceptions and raising awareness about the nutritional benefits and culinary versatility are pivotal in fostering a positive attitude towards their inclusion in the diet. Educational initiatives targeting both practitioners and the general public can play a crucial role in dispelling myths and promoting informed decision-making regarding dietary choices. Enhancing accessibility to millets and implementing cost-reduction strategies are also essential components in promoting their wider adoption as sustainable food options.

The regression analysis to explore potential predictors of good knowledge unveiled associations with certain age groups, notably younger individuals (<27 years) and older practitioners (>38 years) as well as higher education levels. Younger practitioners may possess comprehensive knowledge owing to their updated information due to recent education, participation in IYoM2023, their willingness to explore and integrate novel concepts into their practice. Conversely older practitioners owing to their extensive experience and exposure to traditional dietary practices which often include millets could contribute to their robust understanding of millets. The study revealed positive associations between practitioners’ knowledge and their attitudes and practices towards MBD. Practitioners with good knowledge demonstrated a three times greater likelihood of having a positive attitude towards prescribing MBD while being eight times more likely to incorporate MBD into their practice. A thorough understanding of the nutritional value, health benefits and culinary versatility of millets along with Ayurvedic fundamental principles like the ‘Concept of Guna’ (physical attributes) and their influence on body constitution empowers practitioners to appreciate their maximum benefits in promoting overall health and well-being.

In the backdrop of the SDGs, particularly Goal 2 aimed at eradicating hunger, promoting food security and improving nutrition, there has been a growing emphasis on exploring sustainable and nutritious food options.24 Millets, being nutrient-rich grains with ecological benefits, have gained attention as an integral component of efforts to address global food insecurity and malnutrition. However, to fully leverage the potential of millets, it is imperative to enhance knowledge and awareness among healthcare practitioners. By equipping practitioners with a comprehensive understanding and practical skills related to MBR, healthcare systems can better integrate millets into dietary recommendations, thereby contributing to the achievement of SDG 2 and fostering a more sustainable food system.

Conclusions

This study underscored the importance of education and awareness in shaping favourable attitudes and practices related to MBD, aligning with Ayurvedic principles. Despite demonstrating good KAP towards MBD, gaps persist in certain aspects of contemporary knowledge and limitations in translating knowledge into practice. Addressing these barriers is essential to promote the widespread adoption and prescription of MBD. Targeted campaigns aimed at enhancing practitioners’ knowledge base and cultivating the ability to adopt best practices are necessary. Government-led awareness creation campaigns can also play a pivotal role in fostering a conducive environment for the integration of MBD into dietary practices.