Introduction:
The most important nutritional problem in the world today is the Protein Energy Malnutrition.1 The problem is more severe in third world countries affecting children of all ages especially the under fives. Nutritional deprivation is rampant in children of school age particularly primary school children ranging in magnitude from 20-80%.Since deficient physical growth is naturally reflected in their suboptimal mental achievement,2 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 conducted recently 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, 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 universally. To overcome this problem World Health Organization has recently recommended the use of Z-score system for classifying malnutrition in children.3
In the present study an attempt has been made to assess the nutritional status of school children using the Z-score system.
The area in which the present study was conducted is the rural block attached to the Department of Community Medicine. It is situated at a distance of 45 Kms from the college and has a population of 1.98 lacs. No reliable estimates of nutritional status are available from the mentioned area. The present work describes the findings of the survey being conducted as part of the School Health Program run by the department.
Material and Methods
The present study was conducted in the Rural Health Block attached to the Department of Community Medicine. The block is divided into three zones Ajas, Sumbal and Hajin. The School Health Program is being carried out on regular basis in the Rural Block. For the purpose of the present paper, the survey findings from schools surveyed from Sep.2008-Dec.2008 have been included.
The age of the children was determined using school records.
In the schools nutritional status of children was assessed as follows:
Weight: Measured using a floor type weighing scale with due respect to the standardization of the equipment and procedure. The measurements were taken to the nearest .5Kg.
Height: was taken using a measuring tape applied to the wall. The measurements were taken with children barefoot with their back of heels, buttocks and head touching the wall. Readings were taken to the nearest .5cm.
WHO z- score system was used to classify the nutritional status of children.
| Table 1: Anthropometric indices and cutoff points |
| Indicator |
5-9 years |
| Anthropometric variable |
Cutoff point |
| Stunting |
Height for Age |
<-2SD
|
| Wasting |
*Weight For Height |
<-2SD |
| Underweight |
Weight for Age |
<-2SD |
|
10-14 Years |
| Stunting |
Height for Age |
<-2SD |
| Thinness |
*BMI for Age |
< 5th Percentile |
| *In children 5-9 years age weight for height (W/H) was used and in children 10-14 years BMI for age was used<sup>4</sup> |
Results
A total of 940 children in the age group of 5-14 have been included in the study. The mean height and weight of girls was found to be higher than boys in all age groups.
| Table 2: Mean and Standard deviation of Height and Weight of study participants. |
| Age(Y) |
Sex |
No. |
Wt (mean ±SD) |
Ht (mean ±SD) |
| 5 |
M |
32 |
18.35(2.92) |
109.78(21.06) |
| F |
46 |
18.05(3.79) |
111.14(9.94) |
| 6 |
M |
51 |
18.72(3.33) |
115.4(8.42) |
| F |
39 |
20.15(3.37) |
117.29(8.40) |
| 7 |
M |
28 |
23.36(4.89) |
125.10(7.24) |
| F |
38 |
23.08(5.13) |
127.18(8.37) |
| 8 |
M |
44 |
23.18(3.61) |
127.76(9.30) |
| F |
36 |
23.06(3.71) |
128.04(9.43) |
| 9 |
M |
65 |
25.33(4.33) |
134.25(9.24) |
| F |
59 |
27.03(5.97) |
136.75(8.88) |
| 10 |
M |
47 |
28.12(5.25) |
135.00(10.21) |
| F |
41 |
30.17(6.50) |
141.07(10.82) |
| 11 |
M |
59 |
30.17(5.72) |
139.94(9.23) |
| F |
40 |
32.25(8.03) |
143.53(12.58) |
| 12 |
M |
49 |
31.48(5.32) |
138.98(15.36) |
| F |
70 |
34.85(7.82) |
146.11(10.46) |
| 13 |
M |
59 |
34.93(6.66) |
150.04(10.56) |
| F |
76 |
40.11(6.60) |
152.55(9.26) |
| 14 |
M |
33 |
39.46(9.89) |
153.96(13.26) |
| F |
28 |
41.38(7.14) |
157.27(6.50) |
The overall prevalence of under nutrition was 19.2%. We observed a prevalence of 11.1%, 9.25% 12.3% and 29% for underweight, stunting, wasting and thinness respectively. The prevalence of severe underweight, stunting and wasting was 2.05%, 2.65% and 2.05% respectively.
| Table 3: Prevalence of under nutrition in School age children in Block Hajin. |
| Indicator |
Males |
Females |
Total |
| Underweight |
41(18.6) |
8(3.66) |
49(11.1) |
| Stunting |
55(11.7) |
32(6.76) |
87(9.25) |
| Wasting |
36(16.3) |
18(8.18) |
54(12.3) |
| Thinness |
79(31.9) |
67(26.2) |
146(29.0) |
In all the age groups more males were found to be underweight than females (p<.01). In seven out of nine age groups the proportion of stunted children was higher among males (p<01) .The same trend was observed for wasting also (p<01). For the indicator thinness the prevalence was higher in females in lower age group and vice versa (p>.05).
| Table 4: Prevalence of underweight stunting and wasting in children aged 5- 9 Years |
| Underweight |
| Gender |
5 years |
6 years |
7 years |
8 years |
9 years |
| M |
1(3.12) |
11(21.5) |
3(10.7) |
8(18.1) |
9(13.8) |
| F |
0(0.0) |
2(5.12) |
3(7.89) |
2(5.55) |
1(1.69) |
| Total |
1(3.12) |
13(14.4) |
6(9.09) |
10(12.5) |
10(8.06) |
| Stunting |
| M |
1(3.12) |
5(9.80) |
0(0.0) |
6(13.6) |
1(1.53) |
| F |
1(2.17) |
3(7.69) |
1(2.63) |
3(8.33) |
2(3.38) |
| Total |
2(2.56) |
8(8.88) |
1(2.63) |
9(11.2) |
3(2.41) |
| Wasting |
| M |
1(3.12) |
5(9.80) |
5(17.8) |
9(20.4) |
16(24.6) |
| F |
2(4.34) |
1(2.56) |
3(7.89) |
4(11.1) |
8(13.5) |
| Total |
3(3.84) |
6(6.66) |
8(12.1) |
13(16.2) |
24(19.3) |
| Table 5: Prevalence of Stunting and thinness in children aged 10-14 years |
| Stunting |
| Gender |
10 years |
11 years |
12 years |
13 years |
14 years |
| M |
6(12.7) |
8(13.5) |
14(28.5) |
6(10.1) |
8(24.2) |
| F |
3(7.31) |
6(15.0) |
7(10.0) |
5(6.57) |
2(7.14) |
| Total |
9(10.2) |
14(14.1) |
21(17.6) |
11(8.08) |
10(16.3) |
| Thinness |
| M |
9(19.0) |
15(25.9) |
14(28.3) |
28(47.1) |
13(38.4) |
| F |
16(39.0) |
13(33.3) |
17(23.9) |
11(14.0) |
10(36.3) |
| Total |
25(28.4) |
28(28.2) |
31(26.0) |
39(28.6) |
23(37.7) |
Discussion
Among various problems encountered in school age children, malnutrition accounts for the majority. Since it is wisely said that only a healthy body can harbor a healthy mind. It is imperative that these disorders in children are efficiently and timely assessed and corrective measures employed accordingly. Assessment of nutritional status in school children is one such endeavor. In the present survey we observed a comparatively lower prevalence of under nutrition (11.1%,9.25% and 12.3% for underweight, stunting and wasting respectively) than that reported by G K Mendhi et al5 from Assam in 6-8 year old children wasting 21.1%, stunting 47.4% and underweight 51.7%.Bandopadyay et al6 from Navinagar Mumbai reported prevalence for wasting 17.0%, stunting 16.8%, and underweight 42.3%. Mitra et al7 from Chatisgarh reported prevalence of underweight 90.0% and stunting 47.5%. Similarly Chowdhary et al8 from Puriliya West Bengal also reported figures of underweight 33.7%,wasting 29.4% and stunting 17.0%. The proportion of severely underweight, stunted and wasted children in our study was 2.05%, 2.65% and 2.05% compared to higher figures of 7.92%, 4.98% and 9.51% reported by Chowdhary et al8 from West Bengal. The most probable reason for better results in our study could be a better socioeconomic status of people as the proportion of people living below poverty line is only 3.68% in J&K compared to much higher figures from other states. Also NFHS-3 while reporting findings on under nutrition in preschool children reported a prevalence of 29.4%, 27.6% and 15.4% for underweight, stunting and wasting respectively9 thus reporting a reduction of 32.5%,33.1% and 8.87% in these indicators over that reported by NFHS-2 and these improvements in nutritional status are likely to be reflected in older children. The prevalence of underweight and stunting did not show a definite trend across various age groups, similar observation has been reported by Mendhi et al5. Though prevalence of wasting was observed to increase from lower to higher age. We found a higher prevalence of underweight (18.6%,3.66), stunting (11.7%, 6.76%) and wasting(16.3%, 8.18%) in males than females. Similar trend has been reported by Mukherji et al10 from Pune (p> .05)
WHO recommends that in older children (>10 years) BMI for age should be used instead of weight for height to avoid errors in assessment due to changes of puberty.5 The overall prevalence of thinness was 29.0% with 31.9% males and 26.2% females falling below the cutoff, the difference being statistically insignificant. The figures are better than those reported by Mendhi et al5, males 51.8% and females 56.8%. We observed that in younger age group (10 & 11 year olds) a higher proportion of males was found to be thin while as in older group more females were thin. Only in 10 year and 13 year old children was the difference statistically significant. These observations seem to be due chance only since similar results have not been reported from anywhere. This could be either due to a smaller number of children included or the age of the some of the children could not have been ascertained accurately in spite the best efforts.
Our observations reveal that even though the situation in our setup is comparatively better, still a large number of children are malnourished in spite of the positive indicators like lower proportion of BPL, implementation of nutrition programs in schools etc.
During our survey we observed that the MDMP is being implemented halfheartedly with least consideration being given to guidelines from the concerned ministry. The selection of children, food quality, food quantity and continuous supply remains a major issue in the program. On short term basis measures like proper selection of children, continuous nutrition education in schools for encouraging judicious use of locally available foods, supervision of mid day meals to children at schools and uninterrupted supply of cooking material would go a long way to improve the nutritional status. On long term basis implementing nutritional monitoring of school children as part of school health program, improvement in school environment, improving the purchasing power of people, making foods available at affordable prices especially for weaker sections can be instrumental in bringing a much needed improvement.
Conflict of interest: None Declared
Source of funding: None.
Acknowledgements: We are extremely grateful to the officers of the education department and teachers of the surveyed schools for their cooperation during conduct of the survey.
References
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