Chapter 4 Results and Discussion -...
62
133 Chapter 4 Results and Discussion This chapter furnishes the findings of the study entitled “Nutritional Profile and Impact of Nutrition Counseling on the Nutrition Knowledge, Mental Capacities and Physical Activity Level of Selected School Going Children of Kochi”. The results are presented in this chapter under the following headings: 4.1 Demographic Profile of the School Going Children 4.1.1 Gender and Age Distribution of School Going Children 4.1.2 Religion 4.1.3 Type of Family 4.1.4 Socio Economic Status 4.2 Dietary Habits 4.3 Nutrient Intake 4.4 Meal Skipped, Picky Eating and Time Schedule 4.5 Home Made Foods and Restaurant Foods 4.6 Analysis of Anthropometric Measurements of Subjects 4.6.1 Comparison with WHO Standards 4.7 Analysis of the Clinical Examination 4.8 Impact of Nutrition Counseling on Selected School Going Children
Transcript of Chapter 4 Results and Discussion -...
133
Chapter 4
Results and Discussion
This chapter furnishes the findings of the study entitled “Nutritional
Profile and Impact of Nutrition Counseling on the Nutrition Knowledge,
Mental Capacities and Physical Activity Level of Selected School Going
Children of Kochi”. The results are presented in this chapter under the
following headings:
4.1 Demographic Profile of the School Going Children
4.1.1 Gender and Age Distribution of School Going Children
4.1.2 Religion
4.1.3 Type of Family
4.1.4 Socio Economic Status
4.2 Dietary Habits
4.3 Nutrient Intake
4.4 Meal Skipped, Picky Eating and Time Schedule
4.5 Home Made Foods and Restaurant Foods
4.6 Analysis of Anthropometric Measurements of Subjects
4.6.1 Comparison with WHO Standards
4.7 Analysis of the Clinical Examination
4.8 Impact of Nutrition Counseling on Selected School Going
Children
134
4.9 Impact of Nutrition Counseling on Mental Capacity of the
Selected School Going Children
4.10 Impact of Nutrition Counseling on Physical Activity level of
the Selected School Going Children
4.11 Impact of Nutrition Counseling on the KAP of the Mothers
4.1 Demographic Profile of the School Going Children
Demography is the study of human populations – their size,
composition and distribution across place and the process through which
populations change. Births, deaths and migration are the ‘big three’ of
demography, jointly producing population stability or change. A population’s
composition may be described in terms of basic demographic features – age,
sex, family and household status and by features of the population’s social and
economic context – ethnicity, religion, language, education, occupation,
income and wealth. The distribution of populations can be defined at multiple
levels (local, regional, national, global) and with different types of boundaries
(political, economic, and geographic). Demography is a central component of
societal contexts and social change (Thomson, 2007).
The information on the profile of the school going children in terms of
their gender, age, religion, type of family, socio economic status were
analyzed. The results are presented here.
4.1.1 Gender and Age Distribution of School Going Children
The distribution of the selected school children according to their gender is
provided in Table X.
135
Table X
Distribution of School Children Based on their Gender and Age
No/Percentage
Gender
Boys Girls Total
Age 10
Count 165 176 341
% 48.4% 51.6% 100%
11
Count 189 182 371
% 50.9% 49.1% 100%
12
Count 215 131 346
% 62.1% 37.9% 100%
Total
Count 569 489 1058
% 53.8% 46.2% 100%
A g
them 265 b
boys (56.9%
1058 schoo
urban area
distribution
Izha
conducted
boys and 2
difference
education.
greater perce
boys (51.36
%) and 238
ol children p
while as it
n of school g
arul Hasan
in Bangalo
201(40.20%
may be du
entage of m
%) and 251
8 girls (43.9
participated
was revers
going childr
n et al., 20
ore stated th
%) were girl
ue to the
136
Figure 6
males (53.8%
1 girls 48.6%
9%) from u
d in this stud
e in the rur
ren.
011 in his
hat out of
ls. The ratio
more inclin
%) participa
%) were fro
urban areas
dy. Boys ou
ral area. Fig
study on
500 childre
o of Girls:
nation of p
ated in the s
om rural are
and a total
utnumbered
gure6 shows
the nutriti
en 299 (59
Boys was
parents tow
study.Out o
eas and 304
l number o
d girls in the
s the gender
ional status
.80%) were
1:1.49. The
wards boy’s
f
4
f
e
r
s
e
e
s
It is
girls, were
and 37.9 %
them,30.6 %
%who were
year olds, 3
were from t
Enr
seems to be
also improv
of primary
recent inde
an estimate
s also seen
10 years ol
% girls 12
%who were
e 12 year ol
35.2% who
the urban sc
rolment of g
e catching u
ved signific
education
ependent stu
ed 3.7 perce
from Table
d, 50.9 % b
2 years of
e 10 years o
lds were fro
o were 11 y
chool. Figur
girls in prim
up with that
cantly. The
especially
udy by the
ent of child
137
Figur
e X that 48
boys and 49
age who
old, 34.88%
om the rural
year olds an
re 7 shows t
mary schoo
t of boys. Th
improveme
after 2001
Ministry o
dren in the a
re 7
8.4% of sel
.1% girls11
participated
% who were
l school, and
nd 31.0 % w
the area wis
ol has been
he primary
ent in gende
is notewor
f Human R
age-group 6
lected boys
1 years and
d in the st
11 years ol
d 33.76% w
who were 1
se age distri
n particularl
school com
er parity in
rthy. Accor
Resource De
6-10 and 5.2
and 51.6%
62.1% boys
tudy.Out o
lds and 34.5
who were 10
12 year olds
ibution.
ly good and
mpletion rate
completion
rding to the
evelopment
2per cent in
%
s
f
5
0
s
d
e
n
e
t,
n
138
the age-group 11-13 were out of school in 2008. In terms of numbers, about
eight million children in the age-group 6-13are out of school, about 6.7 million
in rural and 1.3 million in urban areas (UNICEF, 2011). The findings of the
present study are in accordance with the above.
4.1.2 Religion
Distribution of the selected school children based on their religion is detailed
in Table XI.
Table XI
Distribution of School Children Based on Religion
Area
Total Rural Urban
Religion
Hindu Count 56 99 155
% 10.85% 18.27% 14.7%
Muslim Count 59 45 104
% 11.43% 8.30% 9.8%
ChristianCount 401 396 797
% 77.71% 73.06% 75.3%
Others
Count 0 2 2
% within Area
0.0% 0.37% .2%
Total
Count 516 542 1058
% within Area
100.0% 100.0% 100.0%
A
9.8% Mu
401were
(10.9%) w
(73.1 %),
(0.4%) pa
on their re
Bot
with a gr
children b
greater per
uslims and
Christians
who partici
99 Hindus
articipated.
eligion.
th in the rur
reater perc
belonged to
rcentage (7
0.2% othe
(77.7 %),
ipated in th
(18.3%), 4
Figure 8 sh
ral and urb
entage bein
o Hinduism
139
Figure 8
5.3%) were
er religions
59were Mu
his study. I
45 Muslims
hows the dis
ban areas, a
ng Christia
m (10.9%) a
e Christians
s.Out of th
uslims (11.
In the urban
(8.3%) and
stribution of
similar dis
ans. An alm
and Islam (
s, 14.7% w
hese in the
.4%), 56 w
n area, 396
d 2 from oth
f school chi
stribution w
most equal
(11.4%) in
were Hindus
rural area
were Hindus
6 Christians
her religions
ildren based
were noticed
number o
rural areas
s,
a,
s
s
s
d
d
f
s,
140
while in the urban area, 18.3% belonged to Hinduism and 8.3% Islam. The
other religion mentioned in the study is Jainism.
India is a secular country and is represented by all religions. When we
trace the Indian history to several centuries ago, we find that it was made up of
small Hindu kingdoms ruled by Hindu Kings. The advent of Mughals and
British brought in the other religions and the formal system of education
besides other scientific advancements. The British rule is responsible for
changes brought to the educational system which brought in lucrative jobs and
monetary gains. In the present days too, we find several schools run by
missionaries which provide high quality education. This could be one reason
for the greater enrolment of Christians in these schools.
4.1.3 Type of Family
The researcher classified the selected school children according to their type
of family and the results are presented in Table XII.
141
Table XII
Distribution of School Children Based on their Type of Family
No/Percentage
Area
Total
Rural Urban
Type
of
Family
Joint
Count 160 190 350
% 31.01% 35.06% 33.1%
Nuclear
Count 356 352 708
% 68.99% 64.94% 66.9%
Total
Count 516 542 1058
% 100.0% 100.0% 100.0%
66.9
from joint
from both r
69% (rural)
note that th
than it was
their family
Fam
most impo
persons un
husband an
It is a socia
and reprodu
% of the c
family. Ou
rural (31.1%
) and 65 %
here are mor
s before. Fig
y type.
mily is the b
ortant place
nited by m
nd wife, fath
al group cha
uction. It a
children stu
ut of them,
%) and urba
(urban) bel
re number o
gure 9 show
basic unit o
e in the so
marriage kin
her and mot
aracterized b
also provide
142
Figure 9
udied were
an almost
an areas (35
longed to n
of nuclear f
ws the distr
of the socie
cial structu
nship or ad
ther, son an
by common
es emotiona
from nucl
equal distri
5.06%) belo
nuclear fami
families in t
ribution of
ty and cons
ure. Family
doption an
nd daughter
n residence,
al, social an
lear family
ibution of t
onged to joi
ilies. It is in
the present
the school
sequently it
y refers to
d interactin
and brothe
, economic
nd financial
and 33.1%
the children
int families
nteresting to
generations
children on
t occupies a
a group o
ng roles o
er and sister
cooperation
l security to
%
n
s,
o
s
n
a
f
f
r.
n
o
143
its members. The resources of the entire family are responsible for meeting all
needs. The behaviour of individuals is to a great extent moulded by influences
within the family not only during the socialization process but also after they
have reached maturity (Wasim et al., 2008).
In India, the joint family system has been in existence since ancient
times. However with the passage of time, the joint family system has
disintegrated, giving rise to the nuclear family system. Job opportunities
available in the cities become the main cause of the disintegration of the joint
family system. There is a lack of living space in the cities. It is difficult to
accommodate all the members of a joint family in a single house in the city.
Also cost of living is very high in the cities (Bansal et al., 2014).
Mishra et al., (2006) in his study has stated that as far as family
structure is concerned, nearly two third families (65.00%) belonged to nuclear,
followed by joint (35.00%) structure. Joint families are breaking due to
industrialization, urbanization and for searching employment in the urban and
industrial areas. Generation gap is also responsible for the creation of nuclear
families. Generally joint families are headed by the oldest person of the family
having a traditional outlook restricting them to adopt modern culture technique
and living practices. On the other hand the new generation adopts these culture
and practices very easily to pace with the modernization and western culture.
These reasons have significantly affected increase of nuclear families.
Kashyap (1992), Mehrotra (2002) and Habib and Srivastava (2005) have also
reported similar findings. In an earlier study held in Varanasi, Mehrotra (2002)
reported existence of 57.82 and 42.18% nuclear and joint families
respectively.
According to Kumar (2011) nuclear families can have any number of
children. The advantages of nuclear families are: increased personal freedom
and space to grow, expression and exploration, much needed privacy to the
144
couples and avoidance of unnecessary meddling by others, financial stability,
ease of adjusting to the work, educational demands, and thus reduction in the
levels of stress and dependence.
Shenoy (2008) has opined that the joint family is an extended form of a
nuclear family. It is composed of parents, their children, and the children's
spouses and offspring in one household. In India, the joint family system has
been in existence since ancient times. The father is considered as the head of
the family. Then the wife, sons, daughters-in-law and grandchildren together
constitute a joint family. The head of the family feels proud of the great
number of members. However, with the passage of time, the joint family
system has disintegrated, giving rise to the nuclear family system.
Both family systems have a significant relation with the academic
achievements. Both, nuclear and joint family systems, effects on the academic
achievements of the students. In both nuclear and joint both family systems
the role of parents is more influential than any other member of the family.
The students get encouragement and confidence through the involvement of
the parents. The involvement and attention of the parents are the significant
factors that affect the academic performance of the students (Hafiz et al.,
2013).
Therefore, it may be concluded that the school going children are
influenced by both the family systems. The influence of grandparents and
other members of the family (apart from parents) is quite evident in the
amount of physical care that the child gets and also on the behavioural pattern
of the children who grow up in a joint family set up. Children who grow up in
a nuclear family are not totally isolated from their grandparents and other
family members in the Indian context as there is constant movement between
them resulting in long term stays which also has a significant impact on the
academic program and behavioural pattern of the children.
145
4.1.4 Socio Economic Status
Distribution of the selected school children according to socio-
economic status (SES) by modified Kuppuswamy scale is presented in Table
XIII and Figure 10.
Table XIII
Distribution of School Children Based on their Socio Economic Status
Socio Economic Status - Monthly Income
Monthly Income
Class No/PercentageArea
Total Rural Urban
Lower /Upper Lower Class
Count 363 0 363
% 70.3% .0% 34.3%
Middle/ Lower Middle Class
Count 153 165 318
% 29.7% 30.4% 30.1%
Upper Middle Class
Count 0 377 377
% .0% 69.6% 35.6%
Total Count 516 542 1058
% 100.0% 100.0% 100.0%
70.3
class and 2
upper midd
upper midd
and none fr
Det
determines
influences
on their ac
children stu
Bha
which inclu
3% of the c
29.70% from
dle class. 69
dle class an
rom the low
termining th
the amoun
their nutriti
cademic per
udied.
arvin (2014
udes educa
children in
m the midd
9.60% of the
nd only 30.
wer/ upper lo
he socio eco
nt and typ
ional and m
rformance.
4) has echo
ation, occup
146
Figure 10
rural areas
dle/lower m
e children fr
40% were
ower class.
onomic statu
pe of food
mental statu
The same
ed that the
pation, and
were from
middle class
from the urb
from midd
us of the chi
purchased
us. This will
can be ex
e socioecon
income det
the lower/u
and none
ban areas we
dle/ lower m
ildren is im
by the fam
l have a dir
xpected of t
omic status
termines th
upper lower
of from the
ere from the
middle class
mportant as i
mily which
rect bearing
the selected
s of parents
he cognition
r
e
e
s
t
h
g
d
s
n
147
and intelligence of their progeny. The socioeconomic status also affectsthe
nutrition of their children which influences the structural and functional
development ofbrain.
The economic level of the subjects determines the amount of money
spent on food and thereby, their nutritional and health status. It is a well-
known fact that the price index has been steadily going up over the last year;
Business Line (2008) has reported that the high index reduces the amount of
money spent on food.
On analyzing the socio economic status of children belonging to urban
areas, 61.4% families belonged to upper high socioeconomic category, 37.9%
to high and 0.7% to upper middle socioeconomic category. None of them
belonged to lower middle, poor or very poor socioeconomic status. Aggarwal
(2005) has similarly reported that 403rural families studied, a majority
(86.3%) of them belonged to high, followed by 8.9% to upper high, 4.6% to
upper middle categories.
NSSO (2008), survey results on the composition of household
consumer expenditure in terms of food and nonfood items indicate that the
share of nonfood items exceed the food items (rural – 59% and urban – 64 %).
The same pattern is observed at the all India level for urban households. But in
rural sector at the All India level the share of food (54%) was higher than non-
food (46%) in total consumer expenditure. Thus, in rural sector a reverse
relationship is observed between households of All India and Kerala. In Kerala
the districts with low average MPCE (Monthly Per Capita Consumer
Expenditure) tend to have higher food share and vice versa i.e. an inverse
relationship is observed between MPCE and expenditure on food items. The
food share was 34% in urban Ernakulum district.
148
Final Findings
The results show that out of the total number of 1058 school
children who participated in the study, boys outnumbered the girls in the
urban area while it was the reverse in the rural area. Both in the rural
and urban areas there was a greater percentage of Christians while
Hindus and Muslims were the other major religions. A greater percentage
of the children were from the nuclear family. More number of children in
rural areas belonged to lower/upper lower class and in urban areas to
upper/middle class. The socio economic status of the family is important
as it regulates the purchasing power and the food consumed which has a
direct impact on the health and academic performance of the school
children.
4.2 Dietary Habits
This section records the finding of the analysis of dietary habits of the
selected school children. The type of diet consumed by the school children is
summarized in Table XIV.
149
Table XIV
Distribution of School Children Based on their Dietary Habits
Dietary
Habit No/Percentage
Area
Total
Rural Urban
Vegetarian
Count 22 17 39
% 4.3% 3.1% 3.7%
Non
vegetarian
Count 260 506 766
% 50.4% 93.4% 72.4%
Lacto -
Ova
vegetarian
Count 234 19 253
% 45.3% 3.5% 23.9%
Total
Count 516 542 1058
% 100.0% 100.0% 100.0%
Nutritional status of the children solely depends on dietary habits.
Protein is very much essential for the construction and repair of tissues and
ultimately physical and mental growth of the children. Animal proteins have
been considered better than the vegetable proteins.
150
It is seen from Table XIV that 50.4 % of the selected children from
rural area and 93.4% from urban area were non vegetarians. The consumption
of non-vegetarian diet was less in rural area due to poor economic status and
non-availability of these diets. 4.3% of the children of rural area and 3.1% of
the urban area were vegetarians. It is also interesting to note that 45.3% of
children from the rural areas and 3.5% from urban areas were lacto ova
vegetarians.
Religious customs influence the frequency of consumption of non-
vegetarian foods. Among the vegetarians and non-vegetarians the
consumption of fruits and vegetables was poor and the diet was mainly cereal
based.
Consumption of milk and eggs will provide the proteins that are
required for growth provided they are consumed in adequate amounts. In low
socio economic families, these two food items may themselves be too
expensive to buy. Poorly planned vegetarian diets may be low in several
nutrients especially proteins which is the most important nutrient for children.
Kar et al., (2008) has reported that Protein Energy Malnutrition was
found to affect the continuous development of higher cognitive functioning
during childhood.
Erickson (2006) pointed out five key components, based on research,
required to keep the brain functioning correctly. The substances, all found in
food, are important to brain development and function. Proteins are found in
foods such as meat, fish, milk, and cheese. They are used to make most of the
body’s tissues, including neurotransmitters, earlier identified as chemical
messengers that carry information from brain cells to other brain cells. A lack
of protein, also known as Protein Energy Malnutrition, led to poor school
performance by children and caused young children to be lethargic,
151
withdrawn, and passive, all of which help affect social and emotional
development.
Good nutrition is important to supporting growth and maximizing
learning potential. Nutritional intake affects energy levels, physical stamina,
mood, memory, mental clarity, and emotional and mental well-being.
Research is proving good nutrition is pertinent for the brain, so the old age,
“You are what you eat” is proving to be true. Parents and educators need to
educate today’s children to make healthier food choices because they are
being raised in a culture of fast food (Meyer, 2005).
Therefore it is essential that the school children consume enough
quantity of protein rich foods. Children who are vegetarians should combine
the different pulses and also consume fairly good amount of milk. Ova
vegetarians and non-vegetarians should increase the frequency of consumption
of eggs and non-vegetarian foods.
4.3 Nutrient Intake
This section records the finding of the analysis of nutrient intake of the
selected school children. The nutrient intake of the five selected nutrients was
calculated for the subjects from the food intake records obtained by 24 hour
intake recall method. The mean nutrient intake and percentage deficit/ excess
of the selected school children are summarized in Table XV. The nutrient
intake was calculated using Microsoft Excel data analysis by uploading the
obtained data and comparing with the nutritive value of Indian foods (ICMR,
2004).
152
153
Figure 11
Figure 12
154
It is seen from Table XV and figures; 11 and 12 that all the selected
school children of both rural and urban areas did not meet the recommended
dietary allowances as per the ICMR standards.
Children of private schools who belonged to high socioeconomic class
were better nourished compared to Government school students who belonged
to low socioeconomic class. Studies by Ramesh (2010) in Kerala and Thekdi
et al., (2011) in Gujarat also stated the same. Being financially sound may
allow the children to indulge in the practice of purchasing calorie dense fast
foods and a lifestyle involving less of physical activity and more in-door
activities like playing games on computer, watching television, etc., As the
majority of children are not in the work force, the indicators of socioeconomic
status used in the studies on youth population are based on those of their
parents. However, the same level has not been reflected in the present
findings.
The mean nutrient intake of the boys from the urban area was
significantly lower than the recommended dietary allowances (RDA) as per
ICMR (2010) standards. The energy deficit that has been observed was
24.89%, (RDA 2190Kcal/day, Actual intake 1644.84Kcal/day), protein deficit
was 9%, (RDA 39.9gm/day, Actual intake 36.31gm/day), fat deficit was
23.97%, (RDA 35gm/day, Actual intake 26.61gm/day), Iron deficit was
29.48% (RDA 21mg/day, Actual intake 14.81mg/day), and calcium deficit
was 33.81 % (RDA 800mg/day, Actual intake 529.52mg/day), compared to
ICMR, RDA and statistically significant.
The mean nutrient intake of the girls from the urban area was also
significantly lower than the recommended dietary allowances (RDA) as per
ICMR (2010) standards. The energy deficit was 18.56%, (RDA 2010Kcal/day,
Actual intake 1636.91 Kcal/day), protein deficit was 1.68%, (RDA
40.4gm/day, Actual intake 39.72gm/day), fat deficit was 30.31%, (RDA
155
35gm/day, Actual intake 24.39gm/day), Iron deficit was 46.78%(RDA
27mg/day, Actual intake 14.37mg/day), and calcium deficit was 36.04 %
(RDA 800mg/day, Actual intake 511.68mg/day),compared to ICMR, RDA
and the results were statistically significant.
The deficit of energy, protein, fat, iron and calcium was 36.56%,
0.68%, 18.54%, 45.29% and 65.43% respectively in the boys from rural areas.
In the girls of the rural areas, energy intake was 30.17% lower (RDA
2010Kcal/day, actual intake 1403.49 Kcal/day), protein 10.10% lower (RDA
40.4gm/day, actual intake 36.32gm/day), fat 22.94% lower (RDA 35gm/day,
actual intake 26.97gm/day), iron 56.2% lower (RDA 27mg/day, actual intake
11.83mg/day) and calcium 64.09% (RDA 800mg/day, actual intake
287.29mg/day). The above results clearly indicate the consumption of
nutritious foods is inadequate.
Food consumption pattern and nutrient intake reveals that the mean
intake of most of the nutrients was low as the diet is predominantly cereal
based.
India is a heterogeneous country in terms of attitudes, food habits and
standard of living. Kerala is a state which has a progressively greater outlook,
food habits being predominantly rice based with fish and coconut oil being
popularly consumed, and a relatively cleaner and improved standard of living.
However, this is not reflected in the nutrient intake of the selected school
going children of the present study. This has been observed against a backdrop
of high awareness and improved economy. This paradox is reflected in terms
of poor nutrient intake. Similar were the findings of Sati and Dahiya (2012) in
their study on school going children of Haryana.
156
In a similar study by Santhosh (2011) 20.0% rural children were
deficient in protein intake than the recommended amount (41g/day). The
average intake by the deficient respondents was 27g/day. 15.3 per cent of the
respondents did not consume the recommended amount of fat (25g/day). The
average consumption of fat by these respondents was 18g/day. A majority of
the respondents (96.0%) had deficient carbohydrate consumption, average of
249 kcal/day compared to 390 kcal/day recommended. Energy deficiency was
exhibited by 54.0 per cent of rural respondents. However, 76.0 per cent of
rural respondents exhibited calcium deficiency. The average intake of calcium
was 229 mg/day in spite the recommended amount of 400mg/day. Also, 42.0
per cent of the rural respondents did not consume the daily recommended Iron
(26 mg/day). Their consumption was limited to 16mg/day. Among the urban
children 6 per cent of the respondents exhibited deficient consumption i.e.
only 34 g/day of their daily requirement of Protein (41 g/day). All urban
respondents were well fed with fats. Carbohydrate was one nutrient on which
both rural as well as urban respondents were found deficient with about 53.3
per cent urban respondents missing the recommended daily carbohydrate
consumption of 390 kcal/day. The average consumption of carbohydrates was
296 kcal/day by them. 11.3 per cent of the urban respondents did not consume
the recommended daily energy requirement, as over half of the children were
lacking carbohydrate intake. Proteins, fats and carbohydrates together make up
for the daily requirement of energy. 1.3 per cent of the respondents were
Calcium deficient and 70 per cent were not consuming the daily recommended
amount of Iron (26mg/day). The average calcium and iron intake by the
deficient urban respondents was 186mg/day and 16mg/day respectively.
In the present study the researcher finds a nutritional gap among both
the urban and rural children, which will affect the nutritional status of the
children hence imparting nutrition knowledge to the school going children and
the mothers who cook the food is absolute necessary. In the urban schools
157
where children bring their own lunch boxes to schools, parents should be
counseled about nutrition and a cooking demonstration be given to
mothers/care givers according to the requirement of the school going children.
This can keep a check as well as help in modifying the diet of the child and the
family. The same method can be employed in the rural area since children
have breakfast and dinner at home and lunch is provided by the government
through mid-day meal programme.
In both urban and rural children of the present study, the nutrient
intake showed a significant deficiency of nutrients. However no prominent
nutritional deficiencies signs were seen, clinically at the present stage. Since
the children were not meeting the RDA it will eventually create deficiency in
later part of life. The inadequate diet will lead to reduction of growth and
development of children. Girls being the future mothers, it is important that
their nutritional status is stabilized from school age so that they have a healthy
pregnancy and are able to deliver healthy children.
In the longer term, malnutrition can have a big impact on earnings
when children reach adulthood. The effects of malnutrition on physical stature,
the ability to do physical work, and on cognitive development, can lock
children into poverty and entrench inequalities. Children who are
malnourished go on to earn 20% less as adults than the children who are well
nourished (McGregor, 2007).
4.4 Skipping of Meals, Picky Eating and Time Schedule Of the
Selected School Children.
The pattern of meal skipped, picky eating and time schedule by the
selected school children are presented in Table XVI.
158
Table XVI
Distribution of Selected School Children
Based on their Meal Skipped, Picky eating and Time Schedule
*N – No, *NA – Not Applicable,*S – Sometimes,*Y -Yes
Type Response No/PercentageArea
Total Rural Urban
Meal Skipped
N* Count 238 301 539
% 46.1% 55.8% 50.9%
Y* Count 278 241 519
% 53.9% 44.5% 49.1% Total Count 516 542 1058
Picky Eating
NA* Count 0 1 1
% 0.0% 0.2% 0.1%
N* Count 485 285 770
% 94.0% 2.6% 72.8%
S* Count 0 2 2
% 0.0% 0.4% 0.2%
Y* Count 31 254 285
% 6.0% 46.9% 26.9% Total Count 516 542 1058
Time Schedule
N* Count 463 333 796
% 89.7% 61.4% 75.2%
NA* Count 0 1 1
% 0.0% 0.2% 0.1%
S* Count 0 2 2
% 0.0%) 0.4% 0.2%
Y* Count 53 206 259
% 10.3% 38.0% 24.5% Total Count 516 542 1058
159
Skipping meals can be considered as an unhealthy eating behavior. A
greater percentage (53.9%) of the children of rural area skipped meals.
Regular habit of skipping meals, long time inadequate intake of essential
nutrients will lead to nutritional deficiencydiseases.53.90 % of the rural and
44.50 % of the urban children skipped meals. The findings of the present study
also, indicate that constraints like lack of time as the major reason for
skipping, apart from mothers ‘lack of motivation and a monotonous type of
breakfast preparation.
Lakshmi (2011) has opined that at school age, most of the children
establish a particular pattern of food intake. The children may try new foods
which they normally do not consume. Children are generally restless and
spend very little at the table. Skipping meals affects their performance level
and the calorie and nutrient loss cannot be made up at any other time during
the day. Menu must include dishes that are quick to eat yet nutritionally
adequate. Also there should be variety in colour, texture and taste. Many of the
school children consume inadequate diet and so they are malnourished and
become underweight
School going children should eat three fourth of food that a father eats.
They should take a balanced diet and not miss meals especially breakfast
which is the brain’s food (Elizabeth, 2010).Studies have indicated that
students who eat breakfast see fewer vitamin deficiencies, are less likely to
experience chronic illnesses and are more likely to maintain a healthy BMI
(Brown, 2011).
Habit of skipping meals of the respondents of the present study shows
that, most of the respondents were skipping their breakfast. Breakfast is a
brain’s food; it enhances the cognition and academic performances. Missing
breakfast has adverse effect on cognition, particularly the speed of information
160
retrieval in working memory and reduces the learning capacity of children
(Chitra and Reddy, 2006).Eating breakfast is beneficial for both the body and
the mind in several ways. Breakfast is the first meal of the day and is the most
important because it supplies the body and brain with the necessary nutrients
after a night’s sleep. Data from USA has shown that children and adults who
eat breakfast have healthier weights than children who skip breakfast (Keski et
al., 2003).
Skipping of meals results in nutrient deficiency. Breakfast being
recommended as the heaviest meal of the day, if skipped will affect both the
physical and mental fitness of the child. Kumari and Singh (2001) and
Sankhala et al., (2004) in their study on nutritional status of the children
reported that low intake of iron, vitamin A and B complex vitamin and regular
habit of skipping meals will lead to nutritional deficiency diseases.
On analyzing the picky eating pattern of the selected school children
46.90 % of the children of urban area were picky eaters. On the contrary only
6% of the children of rural area were picky eaters. According to Carruth et al.,
(1998), Carruth et al., (2004), Dubois et al.,(2007a), Dubois et al.,(2007b),
Jacobi et al.,(2008), Lewinson et al.,(2005), Marchi and Cohen, (1990) picky
eating is a relatively common problem during childhood ranging from 8% to
50% of children in different samples and is characterized by the toddler or
child eating a limited amount of food, restricting intake particularly of
vegetables, being unwilling to try new foods, and having strong food
preferences often leading parents to provide their child a meal different from
the rest of the family
Studies found that children with eating problems gained less weight
than children without eating problems (Wright, 2007). Reduced intakes of
energy, carbohydrate, fat and protein have been found to be evident among
161
children with picky eating and feeding difficulties (Lindberg et al., 2006).
Picky/fussy eaters consume fewer amounts of foods containing vitamin E,
vitamin C, folate and fibre, probably due to their lower consumption of fruits
and vegetables (Galloway et al., 2005) compared to non-‘picky/fussy’ eaters.
Picky eating may cause parents considerable concern leading to physician
visits and may cause conflict between parents regarding the handling of their
child’s eating behaviour (Jacobi et al., 2008).
Skipping meals and picky eating if present in the same child will have
a greater adverse impact on the nutritional status of the child. The mother will
find it more difficult to provide nutritious combination of foods from the
limited choice that the child wants/likes.
On analysing the time schedule of eating 89.7% of the children of
rural area and 61.4% of urban area did not follow any time schedule for eating.
The irregular time schedule for eating followed by the children will result in
fatigue which will in turn affect their daily learning and play schedule.
Continuation of the irregular time schedule, in the long run will result in
nutritional deficiencies and associated diseases. In order to rectify the above
problems, it is essential to promote healthy eating habits and educate the
children and their mothers care givers on the importance of regular meal
pattern and adherence of nutritious traditional food.
Maryann (2012) has suggested that school age children can move
to a “3 meals and one afternoon snack” routine, but timing of breakfast and
lunch matter. For example, a child that starts school early (7:30), meaning
breakfast is at 7 or earlier, who doesn’t have lunch until 12:30, would need
something in between. The foods recommended in between meals are nutrient-
dense items to help fill nutritional gaps
162
4.5 Consumption of Home Made Foods and Restaurant foods
The pattern of homemade and restaurant foods by the selected school
children is summarized in Table XVII.
Table XVII
Distribution of School Children Based on their Eating Habits of Home Made Foods and Restaurant Foods
Type Response No/PercentageArea
Total Rural Urban
Home Made
N* Count 21 60 81
% 4.1% 11.1% 7.7%
NA* Count 0 1 1
% .0% .2% .1%
S* Count 0 7 7
% .0% 1.3% .7%
Y* Count 495 474 969
% 95.9% 87.5% 91.6% Total Count 516 542 1058
Restaurant
N* Count 483 236 719 % 93.6% 43.5% 68.0%
NA* Count 0 1 1 % .0% .2% .1%
S* Count 0 47 47 % .0% 8.7% 4.4%
Y* Count 33 258 291 % 6.4% 47.6% 27.5%
Total Count 516 542 1058
*N – No, *NA – Not Applicable, *S – Sometimes, *Y - Yes
163
Eating home cooked meals is healthier for the whole family and sets a
great example for children about the importance of food. Table XVII clearly
indicates 95.90% of children from rural and 87.50 % urban area always
enjoyed home food.
Restaurant meals tend to have more fat, sugar, and salt and it should be
saved only for special occasions. Restaurant meals will not supply the nutrient
needs of the school going children. Table XVII shows that 93.60% of the
children from rural and 43.50 % of the urban area children did not like eating
at restaurants. Prentice (2003) has also echoed that eating at restaurants was
significantly higher among urban students compare to rural students.
Fast food consumption is one factor often held responsible for the
obesity epidemic. Similarly, the increase of energy density and excess energy
intake associated with fast food consumption has been one of the factors held
responsible for the increase in public health problems (Bowman, 2004).
Higher concentration of restaurant foods in disadvantaged neighborhoods has
also been associated with the increasing the prevalence of obesity (Block,
2004).This indicates that children should be educated about the ill effects of
eating at restaurant / fast foods etc. and encouraged not only on eating home
cooked foods but also participate in the preparation as it will be a great
motivating factor for eating home foods.
It is hearting to note that a majority of the children of both the areas
preferred home cooked foods and this will ensure a healthier diet. Eating a
nutritious home cooked diet will help the child to gain the power required
through the day.
The results are in concurrence with that of Goyle, (2007) who has said
that home cooked meals are generally considered healthier than fast food. This
is because fast food meals typically contain high levels of calories, saturated
fat, sugar and salt, according to a 2007 article in "The New York Times Health
164
Guide," a medical reference accredited by the American Accreditation Health
Care Commission. Despite the health risks that come with fast food
consumption, people continue to eat it because many people have no time to
select and prepare food at home. Fast foods have poor nutritional quality as
they do not provide any proteins, vitamins and minerals but only supply empty
calories to our body. Thus, the excessive consumption of fast foods can lead to
many nutritional deficiency diseases and can also result in obesity a life
threatening condition.
What the family eats, how they eat, and when they eat reflects this
cultural identity. As children participate in these cultural traditions, they begin
to learn more about their heritage and their family’s history. A study from
Emory University found that children who knew a lot about their family
history, through family meals and other interactions, had a closer relationship
to family members, higher self-esteem, and a greater sense of control over
their own lives (Duke, Fivush, Lazarus and Bohanek, 2003).
Final Findings
The study outcomes indicate that the selected school children fall
in non-vegetarian, vegetarian and lacto ova vegetarians. The nutrient
intake reveals that the diet was lacking in all the major nutrients .The
habit of meal skipping and irregular time schedule will result in
nutritional deficiency and affect growth. It is absolutely essential to
educate the children as well as the mothers on the benefits of eating
nutritious food.
165
4.6 Analysis of Anthropometric Measurements of School Going
Children
Anthropometric measurements are useful criteria for assessing the
nutritional status. Anthropometric measurements can be divided into two
types; namely body size and body composition. In hospital, anthropometric
indices of body size (i.e. head circumference, weight, length and height) are
used primarily to distinguish between under and over nutrition and to monitor
changes after a nutrition intervention (Gibson, 2005). Weight and
length/height are also critical as a basis for calculating dietary requirements
(Shawet al., 2001).Anthropometric measurements have many advantages,
however it is important to note that the measurements are relatively insensitive
and cannot detect disturbances over short periods of time. It can also not
identify a specific nutritional deficiency, thus one is unable to distinguish
disturbances in growth and body composition that may be caused by nutrient
deficiencies (e.g. zinc) (WHO, 1995).Anthropometry therefore forms part of
one of the important components for the assessment of nutritional status, in
addition to dietary intake, clinical and biochemical assessment. Body Mass
Index (BMI) is a simple index of weight-for-height that is commonly used to
classify underweight, overweight and obesity. It is defined as the weight in
kilograms divided by the square of the height in meters (kg/m2).
The assessment of nutritional status of this segment of population is
essential for making progress towards improving overall health of the school
age children. NFHS-3 has not reported on nutritional status of children in
school age group. A number of studies have been conducted to assess the
nutritional status of children in which different classifications like IAP (Indian
Academy of Paediatrics), Gomez, Waterloo’s etc have been used; the most
commonly used being the IAP classification. Since different cutoff values for
normality have been used in different systems therefore these cannot be used
166
universally. To overcome this problem WHO has recently recommended the
use of Z score system for classifying malnutrition in children (WHO, 2007).
The WHO Reference 2007 is a reconstruction of the 1977 National Center for
Health Statistics (NCHS)/WHO reference). WHO standards were used for
comparison in this study.
The default classification system used to present child nutritional status
is that of z-scores or standard deviation (SD) scores. This classification system
has been recommended by WHO for its capability to describe nutritional
status including at the extreme ends of the distribution and allow derivation of
summary statistics, i.e. means and SDs of z-scores (WHO, 1995).Z-scores and
percentiles are derived using the exact age in days for the WHO standards and
months for the WHO reference 2007.
The WHO growth charts given in (Appendix 5, 6) were used as
reference for the results of the present study.
The pattern of Percentile/Z Score by the selected school children is
summarized in Table XVIII and shown in Figure 13
167
Table XVIII
Distribution of School Children based on their Percentile/Z Score - SD
Percentile No/PercentageArea
Total Rural Urban
3rd Percentile/-3SD Count 55 61 116
% 10.7% 11.25% 11.0%
15Th Percentile/-
2SD
Count 322 194 516
% 62.4% 35.79% 48.77%
50th
Percentile/Median
Count 100 143 243
% 19.4% 26.38% 23.0%
85th
Percentile/+2SD
Count 24 93 117
% 4.7% 17.15% 11.05%
97thPercentile/+3SD Count 15 51 66
% 2.9% 9.4% 6.2%
Total Count 516 542 1058
Out
rural area w
were obese
underweigh
were overw
143 (26.38%
was normal
A Z
mean in a g
mean. A Z
above or be
t of total 10
were severe
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ht from the
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Z-Score is a
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Z-score can
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058 children
ely underwe
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rural area
m urban are
ormal from u
ural area.
a statistical
cores. A Z-s
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168
Figure 13
n included
eight (3rdpe
7th percenti
(15th percen
ea (85th per
urban area
measureme
score of 0 m
ositive or n
y how many
in the study
ercentile or
ile or +3 S
ntile or – 2
rcentile/+2S
(50th perce
ent of a sco
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negative, in
y standard d
y 55 (10.7%
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D). 322 (6
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SD). At the
entile) and 1
ore's relation
core is the
ndicating w
deviations.
%) from the
nd 51(9.4%)
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e same time
100 (19.4%)
nship to the
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The presen
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169
study showed that a greater percentage of children fall in the - 2, and - 3
standard deviations. The observation also show that more number of children
(n=377) from the rural areas were in the -2 and -3 SD. When compared to 255
children from the urban areas. These results are in concurrence with those of
Gaishuddin et al., (2005) who reported from health survey data that stunting
and underweight of the rural children was almost two times higher than the
richest children, hence indicating higher rate of malnutrition among the
poorest class. Thus this inequality in growth and development of the children
can be explained in terms of income inequality. Hence, the results of several
studies have shown that the socio-economic status, family size and income
level play an important role in variation of growth and nutritional status of
children.
These observations confirmed the fact that the school going children
have to be given intervention to improve the nutritional status in order to
alleviate the problems of malnutrition.
Kumari (2005) conducted a study to assess the nutritional status of
school children from Bihar. The findings reported a high incidence of
malnutrition as revealed by anthropometry. Increment in height and weight
were more in girls than in boys although not much variation in intake of food
and nutrients.
The present results are also in agreement with those of Pushpa et al.,
(2005) who assessed the nutritional status of school age children of Raichur
region using the anthropometric measurements. Of the 560 children, 50 per
cent belonged to rural area and other half to schools of urban area. The
nutritional status of children from rural and urban areas was lower than the
NCHS standard, girls showing lower measurements than boys. The children
from urban area were better than their rural counterparts in all the
170
measurements though the percentage of wasted and stunted children was in
rural areas.
Anwer et al., (2003) in his study state that among the urban children,
33% were below the standard for height (stunted), and 32.3% were below the
standard for weight (underweight); 32.7% were wasted. Of the rural children,
40.9% were stunted, 64.7% underweight and 33.3% were wasted. The rural
female group was the most affected and malnourished with 61.8% stunted,
84% underweight and 67.1% wasted.
4.6.1 Comparison with WHO Standards
The comparison of the data of the nutritional survey was assessed by
using WHO AnthroPlus software for personal computers, version 1.0.4 for the
global application of the WHO reference 2007 for 5- 19 years to monitor the
growth of school age children and adolescents (WHO, 2009). The mean
weight for age of the children was not compared with the WHO standards as
weight for age reference data are not available beyond age 10 because this
indicator does not distinguish between height and body mass in an age period
where many children are experiencing the pubertal growth spurt and may
appear as having excess weight (by weight for age) when in fact they are just
tall.
Figures14 and 15 clearly show the comparison of BMI for age, and
height for age of the study subjects compared with WHO Standards. Figures16
and 17also clearly show the comparison of BMI for age, and height for age for
both boys and girls compared with WHO standards. The BMI for age for girls
is comparatively better than the boys which are far below the standards. The
mean BMI for age and height for age of the selected school children of both
171
the sexes and areas was for below the WHO standards. The BMI for age of
girls was almost the same as that of WHO however, that of boys was much
below WHO standards. The height for age of both the selected the boys and
girls of the study was lower than WHO standards.
WHO recommends that in older children (>10 years) BMI forage
should be used instead of weight for height to avoid errors in assessment due
to changes of puberty. Therefore in the present study the BMI for age height
for age were considered.
172
173
4.7 Analysis of the Clinical Examination
Clinical examination assesses levels of health of individuals. It is the
simplest and practical method. For clinical examination cooperation of the
subjects can be achieved easily because the symptoms are observed externally.
Early clinical symptoms and signs of malnutrition and often include weakness,
lethargy, irritability and light headness (Srilakshmi, 2006)
Apart from underweight and overweight no other clinical signs
suggestive of any nutritional deficiency were noted however dental caries was
predominant in both urban and rural area so was included in the study. In the
rural area very few children were noticed to have mild palor which was not
significant and therefore was not included in the study.
Dental caries are highly prevalent in school children. The most
important dietary cause is sugar, particularly sucrose – found in confectionary,
soft drinks, biscuits, cake, fruit juices, honey and added sugar. The frequency
of consumption as well as the total amount of the sugars consumed is
important in the etiology of caries (Sheiham, 2001). Furthermore, the rates of
dental erosion, related to extrinsic and intrinsic acids, appear to be rising. This
increase is mainly thought to be due to an increased consumption of acidic soft
drinks (Moynihan & Petersen, 2004).
The prevalence of dental caries is summarized in Table XIX.
174
Table XIX
Distribution of School Children Based on their Dental Caries
Observation No/Percentage Rural Urban Total
No
Count 431 439 870
% 83.50% 87.20% 82. 2%
Slight
Count 61 88 149
% 11.80% 16% 14.1%
Marked Count 24 15 30
% 16.40% 19.00% 2.8%
Total 516 542 1058
The Table XIX clearly indicates 16.40 % rural area and 19.00 %
children of urban area had marked dental caries, while 11.80% children of
rural area and 16% children of urban area had slight dental caries. However,
83.50 % children of rural area and 87.20 % children of urban area did not have
dental caries. The findings by Jose (2003) also show that more than 50% of
the children in the 12 to 15 years of age group in rural Kerala suffer from
some form of dental diseases. Boys and girls are equally affected and dental
caries is the most common problem encountered. This indicates that dental
caries is prevalent at an early age. If let unnoticed or untreated the children
may eventually loose their teeth at an early age. In order to rectify the
problem, the children have to be educated on the importance of intake of
175
fibrous foods and reducing chocolate consumption apart from proper brushing
habits.
Dental Caries is the commonest dental problem encountered. The teeth
showing discoloration, chalky appearance of enamel, softened enamel or
broken surface by visual examination or probing has been defined as caries
tooth (Genco, 2002).
A study conducted by Marshall (2003) has reported dental caries is the
most common chronic condition in children, with the greatest prevalence in
blacks and Mexican-Americans and in those who live in poverty. Pain from
untreated caries can affect school attendance, eating, speaking, and subsequent
growth and development. Dental caries is associated with sugar and full-
calorie soda consumption. Children who are obese have been found to have
higher rates of dental caries than their normal weight peers.
Final Findings
The study finds out that a greater percentage of the children fall in
the -2 and -3 standard deviations whereas the clinical sign of nutritional
deficiency was not noted other than a dental caries which was
predominant in both rural and urban areas. Nutrition for school-aged
children should promote growth, and meet energy and nutrient needs.
During the school years, children will experience increased opportunities
to make choices about their food intakes. Parents can help their children
make positive food choices by planning family mealtimes, keeping a
variety of foods on hand, and setting positive examples. Habits formed in
childhood are likely to carry into adult years.
176
4.8 Impact of Nutrition Counseling on School Going Children
Counseling starts with the interaction with the person to be counseled.
Before the actual interaction, it is helpful to determine the information needed
and then to formulate question. During the interaction, it is essential to
introduce and openly talk in order to get the confidence of the person to be
counseled. In addition, in order to seek information, people must be
encouraged to talk; meanwhile, it is suggested that the interviewer maintains
an attentive attitude and observe keenly. Counseling is more effective if
information is imparted in a very friendly way avoiding superiority and
authority. Counseling needs more than one meeting as well as follow up
(Thappa, 2003).
The scores obtained for the answers to test the nutrition knowledge
before and after nutrition counseling were graded as Low, Medium and High
respectively. The distribution of school children based on their pre and post
nutrition counseling is summarized in Table XX.
177
Table XX
Distribution of School Children based on
their Pre and Post Nutrition Counseling
No/
Percentage
Pre Nutrition Counseling
Total
P Value
Low Medium High
Post
Nutrition
Counseling
Low Count 20 0 0 20
0.0001
(Fisher's
Exact
Value =
316.323)
% 4.0% 0% 0% 1.9%
Medium
Count 403 252 5 660
% 80.8
% 56.8% 4.3% 62.4%
High
Count 76 192 110 378
% 15.2
% 43.2%
95.7
% 35.7%
Total Count 499 444 115 1058
The nutrition knowledge of499 out of 1058 children was low before
counseling, but after counseling, 80.8 % were upgraded to medium level and
15.2 % to high level and only 4% remained at low level. At the same time 115
children were graded as high before counseling, while after counseling it rose
to 378 and the results were statistically significant ( P = 0.0001, P<0.05).
178
The dramatic improvement observed in the study is due to the
interaction that occurred between the children and researcher. The study also
showed that only a relatively short period of counseling (3 months) with
excellent audio – visual aids helped to increase the children’s nutrition
knowledge and ability to understand the nutrition aspects. The results also
suggest that nutrition counseling will help to facilitate the consumption of
healthy locally available foods and limiting the consumption of junk foods.
Children are easily lured by the marketing strategies of the
commercials they view which target their age group. Frequent consumption of
such foods results in childhood obesity which not only has emotional
consequences, as many overweight children suffers from psychological stress,
poor body image and low self-esteem but may also result in non –
communicable diseases at a young age.
In the present study, the investigator used several types of nutrition
education tools including interactive sessions and explanation in vernacular
language to carry on the messages to obtain positive results. Strong (2005) has
also reinforced that nutrition education involves teaching the client about the
importance of nutrition, providing educational materials that reinforce
messages about healthy eating, teaching skills essential for making dietary
change, and providing information on how to sustain behavior change.
Information gathered during nutrition screening or assessment will provide the
necessary information on which nutrition issues need to be addressed during
nutrition education and counseling sessions. Prior to the education process, it
is helpful to assess what the children already know about nutrition and how
ready they are to adopt new eating behaviors, and if there are any language or
learning barriers that may need to be addressed in order to facilitate the
nutrition education process.
179
The investigator also noted that the children were highly receptive and
enthusiastic as they wanted to excel in academics and sports activities. They
were also quick to understand the concepts and posed several interesting
questions. Wardle et al., (2000) has reported that school aged children’s
aptitudes increases in memory and logic abilities are accompanied by reading,
writing and math skills and knowledge. This is the period in which basic
nutrition education concepts can be successfully introduced. Emphasis should
be placed on enjoying the taste of fruits and vegetables rather than to focus
exclusively on their healthfulness, because young children tend to think of
taste and healthfulness, as mutually exclusive.
The investigator affirms that nutrition and health education is one of
the important components in the children academic achievements. Sherman et
al., (2007) in his study have shown that nutritional knowledge has been
significantly associated to dietary habits including consumption of meat, dairy,
whole grains and water. Nutrition knowledge has a potential relationship with
dietary and health status of an individual. Importantly meeting nutrition needs
during growing period has greater impact on learning achievements.
The result of pre and post nutrition counseling shown in Table XX
clearly describes the significant improvement in the nutrition counseling. This
is evident from the right answers given by a large number of the children in
post nutrition counseling. The scores obtained in the post counseling session
had improved greatly thus indicating that the children being at a mouldable
age can be easily taught about the importance of nutritious foods. Nutrition
counseling not only enhances nutrition knowledge but also helps in improving
their nutrient intake and thereby improving the health and nutrition status.
Nutrition counseling assumes special significance in the Indian context
because the problem of malnutrition in India is mainly due to ignorance,
illiteracy, poverty and lack of knowledge regarding the value of foods. Inthe
180
present study poor knowledge of children regarding nutrition came to light
during diet survey. Rigid dietary habits, food fallacies and food beliefs were
rampant in abundance and played an important role in food selection.
The results also showed that a relatively short period of counseling
using simple methods as tools of education is enough to increase the children’s
nutrition knowledge, which will have positive impact on the nutrient intake of
children.
Final Findings
The study reveals all the 1058 school children were imparted
nutrition counseling and it was observed that the even the short duration
of 3 months can bring about the change in the knowledge of nutrition
among the school going children. This will eventually improve their
healthy eating habit and thus their nutritional status.
Therefore, from the results it can be said that hypotheses number 1 is
rejected.
4.9 Impact of nutrition counseling on Mental Capacity of the Selected School Going Children
The Median distribution of school children based on their mental
capacity of pre and post scores are summarized in Table XXI and shown in
Figure 18.
Distri
Mental Capacity
Pre Grades
Mental Capacity
Post Grades
From
was 3 (Min
was 2 (M
capacity in
statistically
ibution of S
Median
3
2
m Table X
nimum 1/Ma
Minimum 2/
n a short sp
y significant
School Chil
n Minim
1
2
XI it is inf
aximum 4)
/Maximum
pan of 3 m
t (p value =
181
Table XX
ldren BasedCapacity
mum Ma
ferred that m
and in med
5). This
onths betw
0.0001) at
Figure 18
I
d on their I
aximum
4
5
mental capa
dian mental
significant
ween pre and
5% level of
8
Impact of M
Z value
20.653
acity media
capacity th
difference
d post coun
f significanc
Mental
P value
0.0001
an pre score
he post score
in menta
nseling was
ce.
e
e
al
s
182
From Figure 18 it is inferred that there was a dramatic improvement in
the mental capacity grades. The figure Indicates that a greater percentage
(72.11%) of the selected children were in grade 3 in the pre counseling session
while in post counseling there were only (39.89%). It is also important to note
that none of the children were in grade I in the pre counseling session while
(38.47%) of the children were in this grade in the post counseling session.
Likewise the number of children (9.27%) who were in grade 4 in the pre
counseling session improved after counseling. Two percent of the selected
children were in grade 5 in the pre counseling session, while none were in
grade 5 after counseling.
Nutrition has long been considered as one of the most important
environmental factors affecting human intelligence. Several studies have been
performed in an effort to discern the relationship between nutrition and
intelligence or cognitive ability, with the majority focusing on childhood as an
important part of the life cycle. Some investigations have assessed
malnutrition in relation to cognitive ability (Leiva, 2001) and demonstrated
that nutritional supplementation can improve children’s cognitive ability, at
least among those with low dietary intakes (Stein et al., 2008). Other studies
have indicated that deficiencies of Fe, iodine, Cu and folic acid are associated
with lower intelligence status (Qian, 2008) and that children with low dietary
intakes of these micronutrients would benefit from supplementation
(Schoenthaler, 2000 ). In addition to considering nutrients, dietary patterns
have also been found to be associated with intelligence among children.
Theodore et al., (2009) concluded that consuming fish, breads and cereals
would probably improve children’s cognitive development. In contrast, daily
margarine consumption was inversely associated with cognitive functioning.
Schoolchildren are dramatically affected on their cognitive
development and school performance (Florence et al., 2008).
183
Therefore, from the results it can be said that hypotheses number 2 is rejected.
Chawla and Sharma (2007) conducted a study to find out the
nutritional status and mental ability of school girls (7-9 years) as influenced by
nutrition counseling. According to Raven’s classification of IQ level of the
respondents it was observed that 3.3 percent respondents were in intellectually
defective category before nutrition counseling however none was in this
category after nutrition counseling. Dietary survey that was conducted before
and after nutrition counseling revealed that daily intake of cereals, pulses,
fruit, milk and milk products, fats and oils and sugar and jaggery were less as
compared to suggested intakes by ICMR (1987) in both the groups. However,
the intake of all these food groups increased significantly in experimental
group after nutritional counseling. After nutrition counseling haematological
profile and IQ scores significantly increased in experimental group.
Pollitte (1998), Fernstrom et al., (2001) and Upadhyaya et al., (2001)
highlight the relationship between nutritional status and intelligence of the
children. They observed that there was a significant difference in the
performance of well-nourished and undernourished children during
intelligence test.
Fernstrom et al., (2001) have also found that malnourished children
with poor physical growth perform poorly in intelligence test and emphasized
that malnutrition during childhood can lead to irreversible impairment of
mental function in later life.
Upadhyaya et al., (2001) conducted a study on perceptual development
in relation to nutritional status. The perceptual skills of each child were
assessed with the help of Picture Ambiguity Test (PAT) on 180 children in the
184
age group (5-10 years).The result showed that there was a significant
difference in the performance of well-nourished and undernourished children
during PAT test. Well-nourished children recognized the ambiguous cards
quicker and consumed less time than undernourished children.
The results of the present study clearly indicate that improving the
mental health of school children is a coordinated effort by addressing all issues
including their nutritional and health needs. The mental health of the children
has maximum benefit when nutrition services are integrated into the
comprehensive education system. Hungry or malnourished children have a
harder time focusing on basic core subjects. Eating a sumptuous breakfast and
providing simple easy to carry snacks and lunch, a healthy tea time food after
school for the school children can improve the behavioural and emotional
functioning.
Final Findings
It is hoped that the nutrition counseling given to the children of the
present study will help to improve the dietary intake and nutritional
status of the children. This will in turn help them to be more attentive in
class and improve their academic performance. Consumption of
nutritious foods alters both the brain chemistry and nerve tissues by
altering the levels of neurotransmitters making the children more
energetic and improving their intelligence level and cognitive functioning.
185
4.10 Impact of nutrition counseling on physical activity level of the
selected school going children
The frequency and percent distribution of the selected school children
based on the impact of nutrition counseling on their physical activity level is
summarized in Table XXII and also shown in Figure 19.
Table XXII
Distribution of School Children Based on their Impact of Physical Activity Level
PRE PAL SCORE
Total P value Low physical activity
Medium physical activity
High physical activity
Post PAL
SCORE
Medium physical activity
Count 332 144 3 479
0.0001 Chi square
value=95.878
% 41.8% 70.6% 5.0% 45.3%
High physical activity
Count 462 60 57 579
% 58.2% 29.4% 95.0% 54.7%
Total Count 794 204 60 1058
The results of the pre and post counseling score on the physical activity
level show that 794 out of 1058 were in the category of low physical activity
before counseling while after counseling none of the children fell in this
category. Two hundred and four children were in medium physical activity
level before
children fro
children in
number ros
low physic
activity lev
Th
Therefore,
rejected.
The
children, w
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, from the
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A large num
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ndicate a lo
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at school.
186
er counselin
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physical ac
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nseling got d
ally signific
Figure 19
can be sai
ow to mod
reduction in
The overa
ng the frequ
ot upgraded
ctivity befo
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directly upg
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id that hyp
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umber 3 is
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187
children at this level is a matter of great concern with the likelihood of
physical activity tracking into adult hood. Imparting nutrition knowledge and
inculcating active life style habits in children is important as both urban and
rural children spend a third of the day in school. Nutrition counselling of the
children has also helped to improve the PAL. When the nutrition knowledge
of the children is improved they have a greater chance of following their
healthy food choices and improving their overall health status. The healthy
eating practices and importance of physical activity given through nutrition
counselling play a substantial role in preventing chronic diseases in the
children.
The physical fitness status of school children in Kerala was not known
till 1995. The sample survey conducted by the Directorate of Sports and Youth
Affairs Government of Kerala in Thrissur district shows that the physical
fitness standards of the school children is very low and do significantly differ
with their age and sex when compared to American Alliance Health Physical
Education Recreation and Dance (AAHPERD) Health Related Physical
Fitness Test (HRPFT) standards (Government of India, 2012).
Children who eat healthy food on a regular basis are also more likely
to engage in daily physical activity. Contento (2007) reports in her book that
nutrition education and physical education go hand in hand. Children who eat
right have more energy to play on the playground or to engage in sports
activities than children who eat a diet high in fat and sugar. Teaching nutrition
will also educate the children about how regular exercise works with healthy
foods to prevent dangerous illnesses. In a study examining the efficacy of a
school-based exercise and nutrition program 238 third-grade children from 3
different schools were used to evaluate a health-related fitness school-based
program and home program that required parents and children to complete
activities and earn points for nutrition and exercise activities. On the post-test
the treatment groups scored significantly higher than the control group on
188
exercise and nutrition knowledge and significantly lower on fat intake. The
study demonstrated that schools can adjust curriculum to meet some health
needs of students and achieve modest changes in exercise and nutrition
knowledge and diet (Hopper, Munoz, Gruber and Nguyen, 2005)
Similar studies have been carried out by Frenn, Malin, and Bansal
(2003) who conducted a stage-based intervention for low-fat diet with middle
school students. Low-income, culturally diverse students from an urban
middle school (n=60) received four classroom interventions with the use of a
combined Health Promotion/ Transtheoretical Model to control fat in diet and
increase physical activity.
The above results are in concurrence with the results of the present
study. Although there was no control on the dietary intake of the selected
school children, the intervention (counseling) was classroom based which had
a significant impact on the PAL.
Final Findings
The results suggest that a comprehensive counseling programme in
schools can produce significant behavioural modifications and increase
the PAL. Children if left untreated tend to have poor mental capacities
and lower the degree of PAL. The students’ academic success is strongly
related to their health as it has a direct bearing on their school
attendance, performance in tests/ exams and their ability to be attentive in
class. Such intervention will help in the long run to bring forth productive
healthy citizens of our country.
189
4.11 Impact of Nutrition Counseling on the KAP of the Mothers
The median distribution of the mothers of the selected school children
based on the KAP is summarized in Table XXIII.
Figures 20, 21, 22 indicate the pre and post median distribution of the
mothers due to counseling on their knowledge, attitude and practice
respectively.
Table XXIII
Distribution of the mothers of School Children Based on the KAP
Pre median score Post median score Z value P value
Knowledge 4 8 -26.75 0.00001*
Attitude 2 7 -21.68 0.00001*
Practice 5 8 -27.07 0.00001*
190
Figure 20
Figuree 21
The
and practic
mothers w
counseling
“high know
The results
the figures
0.0001) at
The
on the KA
aggregate i
among the
The
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. The abov
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191
Figure 22
mendous im
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knowledge)
this categor
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were also st
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nutrition co
wal (2003)
scores, die
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mothers wi
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while after
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(p value =
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192
importance of nutrition for improving the learning capacities and physical
activity of the children. It will also help to reduce the potential effects of
improper food choices on the nutritional status of children. Quite often
mothers are unaware of genuine information sources and the unhealthy food
choices that they may make. It can also be said that there exists a gap between
the knowledge and practice of several mothers. This gap was observed in both
the urban and rural school children.
A study conducted by Al – Ayed (2010) revealed that the mother’s
knowledge on child health matters is deficient and he has emphasized on the
proper effective practical means of disseminating information on child health
matters among mothers.
In children, food consumption is associated with foods that are
available and accessible at homes (Befort, 2006). Several studies have
reported that despite adequate nutrition awareness and knowledge and positive
attitude towards healthy nutrition, lack of food availability and accessibility
experienced by the children or individuals in low socioeconomic households
may remain as an important deterrent in the achievement of a healthy and
varied diet (Sherman, 2007).
Poor nutrition knowledge of mothers plays a role in most of the multi-
sector factors involved in the development of malnutrition, which is prevalent
in developing countries. Inadequate food intake and unhygienic dietary
practices are often related to poor knowledge of sound nutritional practices. In
developing countries it is combined with limited resources, deficiencies in
knowledge of sound budgeting, food purchasing and food preparation methods
leading to poor nutrition and problems arising from that (Garrow, 2000).
The results of the present study are in accordance of the above as it is
clear that children from higher socio – economic background and educated
193
parents have greater access to nutritious foods, however the question is how
much of this is actually translated to intake.
According to Garg (2006) counseling can be effective to the extent that
it affects health knowledge, dietary attitude and dietary practices. Counseling
must win acceptance of a practice, arouse a desire in mothers to benefit from
it, obtain the involvement of mother and support the maintenance of changes
in dietary habits. It is mostly direct communication with mothers to accept the
programme and to increase their motivation to benefit from it. There may be
many obstacles like culture, superstitions and human tendency to seek earliest
solution for everything.
In the present study, the nutrition counseling imparted to mothers will
help in providing nutritious foods to their children as also echoed by Poh et
al., (2012) who has also reported that mother’s nutritional knowledge has a
positive effect on their children’s eating habits.
Gibson, et al., (1998) has also opined that mother’s attitudes about
fruit, vegetable will protect from cancer risk to her child and she related
positively with fruit consumption of the child
Bevan et al., (2011) McCullough et al., (2004) are of the opinion that
nutritional education for the mothers will positively affect eating behaviours
and habits both mothers and children. Correct changes in mothers’ eating
habits can help having healthy nutritional behaviours. Families, especially
mothers are the most important sources in teaching nutritional knowledge. The
finding of the present study are in concurrence with the above study of Chawla
(1992) who has reported a significant improvement in the knowledge and
attitude of the women of Ludhiyana towards good nutrition after nutritional
education.
194
The counselling has aided both the children and their mothers by
promoting self-management skills in the child and parental care in terms of
proper food preparation. Nutrition education that involves parents is likely to
also result in dietary behaviour changes (Contento et al., 1992).
Final Findings
The results showed that counseling improved the knowledge,
attitude and practice on nutrition among the mothers. 53% of the
mothers were rated as poor (knowledge) before counseling, while after
counseling none of them were in this category. Parents shape the
development of children's eating behaviors, not only by the foods they
make accessible to children, but also by their own eating styles, behavior
at meal times, and feeding practices. This would definitely help in the
health and nutrition status of the family.
Therefore, from the results it can be said that hypotheses number
4 is rejected.
