Optimizing the nutritional intake of schoolaged children of ASSIST schools in Markapur and Piduguralla to reduce malnutrition, Andhra Pradesh, India

(1)

Thesis number: 2019215

Maaike Hoogenboom and Maaike Kaptijn Amsterdam University of Applied Sciences Faculty of Sports and Nutrition Nutrition and Dietetics, Health Promotion Academic year 2018/2019, semester 8 Graduation project Version 1 June 8th_{, 2019}

Optimizing the nutritional intake of

school-aged children of ASSIST schools in Markapur

and Piduguralla to reduce malnutrition,

Andhra Pradesh, India

(2)

1

“Optimizing the nutritional intake of school-aged children of ASSIST schools in

Markapur and Piduguralla.”

Authors Mrs. M.U.J. Hoogenboom 500729160 maaikeuj@gmail.com; maaike.hoogenboom@hva.nl Mrs. M. Kaptijn 500731226 m.kaptijn@hotmail.com; maaike.kaptijn@hva.nl Thesis number 2019215 Principal Mr. J. R. Rao

Operational director ASSIST, India ranga@assist-india.org

Lecturer H. Ozturk Msc.

Amsterdam University of Applied Sciences, Nutrition and Dietetics Dr. Meurerlaan 8 1067 SM Amsterdam

h.ozturk@hva.nl

Examiner Dr. ir. M.F. Engberink

Amsterdam University of Applied Sciences, Nutrition and Dietetics Dr. Meurerlaan 8 1067 SM Amsterdam

(3)

2

Word of gratitude

For our graduation project during our study in Nutrition and Dietetics on the Amsterdam University of Applied Sciences, we got the unique opportunity to perform our fieldwork in Andhra Pradesh, India. During the period of the 7th_{of February to the 7}th_{of April 2019, we have lived, worked and performed} research in the rural areas of Andhra Pradesh, India. This research would not have been possible without the help, support and dedication of several people from the Netherlands and India.

Firstly we would like to express our deepest appreciation to organisation ASSIST for creating this unique and challenging opportunity. We would like to say a special thank you to Jashti Ranga Rao, Jashti Vishnu Priya, Katakam Vianney, Talluri Rama Rao, Pavuluri Ravi Babu and Avinash Aluri for assisting and supporting us during our entire stay. Secondly we would like to thank the entire staff of ASSIST Chilakaluripet, Markapur, Piduguralla, Bollapalle and Vetapalem for making us feel safe, welcome and showing us the beautiful Indian food, culture and country.

We would like to extend our deepest gratitude to organisation FEMI for giving us this unique and challenging opportunity. We would also like to express our deepest gratitude to Wendy Walrabenstein for her inspiration, guidance and never ending enthusiasm. You made us feel confident and excited throughout the project, which made it very inspiring to work with you.

We would also like to thank our academic supervisor Halime Ozturk for the guidance and critical feedback during this process. You gave us an invaluable insight into the quality of research.

Finally, we would like to thank all the children who took part in this research. You made this research unforgettable and rewarding. We enjoyed spending time with you and wish you all the best in the future.

We jumped into this adventurous graduation project without knowing what to expect. Looking back on this period we enjoyed every bit of it and learned a lot. This resulted in a final product that we are extremely proud of.

Amsterdam, June 8th_{, 2019}

(4)

3

Definition of terms

Acronyms

ASSIST ASSIST is a registered non-governmental organisation working for the development of poor and marginalised communities in rural areas of Andhra Pradesh and Telangana, India

AUAS Amsterdam University of Applied Sciences

BMI Body-Mass Index

DGI Dietary Guidelines for Indians, a manual

FEMI Foundation to Earth, Mankind trough Inspiration and Initiative

IFCT Indian Food Composition Tables

NGO Non-governmental Organisation

NIN National Institute of Nutrition

RDA Recommended Dietary Allowances

SD Standard Deviation

SES Social Economic Status

SPSS Statistical Package for the Social Sciences, program WHO World Health Organization

NEVO Nederlands voedingsstoffenbestand (Dutch Nutrient Database)

Malnutrition determination

The definition of malnutrition is when a person’s intake of energy and/or nutrients is inadequate, excessive or out of balance. Three forms of malnutrition can be distinguished (1):

- Undernutrition

• Wasting (low weight-for-height, caused by acute undernutrition) • Stunting (low height-for-age, caused by chronic undernutrition) - Micronutrient deficiencies

- Obesity and overweight

Stunting is determined when a child scores -2 Standard Deviation (SD) scores on the growth curve: height-for-age. Thinness is determined when a child scored -2 SD scores on the growth curve: weight-for-height (2). To determine the prevalence of malnutrition among school-aged children, the cut of points of the World Health Organization (WHO) Child Growth Standards are used (3,4). In this thesis possible macro- and micronutrient deficiencies are determined, and the analysed dietary intake is compared to the Dietary Guidelines for Indians (DGI) (5).

(5)

4

Summary

Background: All countries are affected by one or more forms of malnutrition. 90 Percent of chronically malnourished children in developing countries live in Africa and Asia. India accounts for more than three in ten stunted children worldwide. Recent evidence shows that one in four children in India is too thin with a significantly higher prevalence in rural areas than in urban areas. Many countries have not gathered the necessary data, to completely understand the nature of malnutrition. Organisation FEMI in cooperation with local partner ASSIST want to address these nutrition problems and reduce malnutrition by implementing a new menu that meets the nutritional demands of school-aged children of 8-15 years old.

Methods: A cross-sectional study was performed to examine possibilities to improve nutritional intake of school-aged children (8-15 years) of boarding schools in Markapur and Piduguralla, Andhra Pradesh, India. A nutritional assessment was performed using the four-day weighed food record method to identify macro- and micronutrient deficiencies. Anthropometric measurements were performed to classify Body-Mass Index for age and height-for-age. To determine malnutrition, anthropometric data was compared to the World Health Organization growth reference 5-19 years dataset.

Results: Results showed an overall prevalence of thinness of 9,9%, of which 2,2% was severe thin. Based on height-for-age data, 39,2% of the studied children were classified as stunted. The estimated intake of energy, total fat, fibre, vitamin A, B1, B2, B3, B5, B6, calcium, potassium, selenium and iron did not meet the Recommended Dietary Allowances laid down by the Dietary Guidelines for children. The intake of protein, carbohydrates, vitamins B12 and D and showed to be sufficient for all children. This can be explained by excessive consumption of refined grains, low consumption of animal origin foods and low consumption of visible fats.

Conclusion: To reduce malnutrition and meet the Recommended Dietary Allowances for all children, a new menu needs to be implemented. This menu is based on found food deficiencies, food availability, present facilities, Dietary Guidelines for Indians, local food culture and budget. Alongside the menu additional recommendations are given to meet the nutritional demands of school-aged children in Piduguralla and Markapur.

Key words: Nutritional intake, Andhra Pradesh, schoolchildren, malnutrition, weighted food record

(6)

5

1. Introduction

Today, almost one in three people worldwide suffers from at least one form of malnutrition: wasting, stunting, vitamin and mineral deficiency, excessive weight or obesity, and nutrition-related non-communicable diseases (6,7). Malnutrition is one of the biggest health problems worldwide. All countries across the globe are affected by one or more forms of malnutrition (7,8). Malnutrition and nutrition-related health problems increase healthcare costs, lower productivity and slow down economic growth, continuing the cycle of poverty and ill health (8).

New evidence keeps indicating a continuous rise in world hunger. After a period of prolonged decline in undernutrition, the number of undernourished people has increased to approximately 821 million. Although progress has been made in reducing childhood stunting, the prevalence remains unacceptably high. Globally more than 10 per cent of school-aged children (5-19 years) have a Body-Mass Index (BMI) for their age below -2 standard deviation from the median of the World Health Organization (WHO) growth curve (9). Regardless of prosperity, school-age children and adolescents are consuming too many refined grains and sugar rich foods and drinks. Inadequate quantities of foods that promote health such as fruits, vegetables, legumes and whole grains are eaten. To meet the demands of pubertal development and brain maturation, nutrient intake in adolescence needs to increase. A growing number of international studies shows the improvements in nutritional intake can be important for possible ‘catch up’ growth, improved cognition and a lower risk of non-communicable diseases (NCDs) in adult years (7).

90 Percent of chronically malnourished ("stunted") children in developing countries live in Africa and Asia (10,11). India accounts for more than three in ten stunted children worldwide (10). In India, thinness among school-aged children is tremendously high. Recent evidence shows that one in four children are too thin (9). The prevalence of undernutrition is significantly higher in rural areas than in urban areas (10).

Childhood stunting is to a great extend an irreversible outcome of poor nutrition and returning infections during the first 1000 days of a child's life. Stunting has lifelong effects on individuals and communities. These effects consist of reduced cognitive and physical development, reduced productivity, ill health and an increased risk of regressive diseases such as diabetes (12,13). Studies show that the growth retardation in the first five years of life cannot be made up (13). However, a healthy, nutritious diet does contribute to better school performance, a stronger immune system and a reduced risk of diseases (14). Studies also show a greater risk for malnourished adolescent girls to become stunted mothers of low birth weight babies. To break the viscous cycle of malnutrition, adolescence provides a second chance to optimize nutrition and health status. Nevertheless, studies on dietary sufficiency, nutritional status and its determinants during adolescence is inadequate (7,15). To completely understand the nature of the burden of malnutrition, diet or signs of development, many countries have not gathered the necessary data yet. Globally, the full profile of micronutrient deficiencies across populations remains unknown. Furthermore, knowledge about the overlap between different forms of malnutrition and the consequences on health and diseases is limited (7). Organization Foundation to Earth, Mankind trough Inspiration and Initiative (FEMI) has been involved for several years in mapping and improving the food intake of children in Andhra Pradesh, India. In consultation with local partner ASSIST, it was decided to apply this project to other schools in the Andhra Pradesh area. FEMI is an organization that considers cooperation with the local community as the most important element in the success or failure of their mission. FEMI’s most important target group are the children of a community (16).

ASSIST is a registered non-governmental organization (NGO). ASSIST is engaged in the development of the poor and diminished communities in the rural areas of Andhra Pradesh and Telangana, India. To strengthen child development, ASSIST supports multiple schools. They want to give children from poor communities in rural Andhra Pradesh an opportunity for a brighter future (17).

(8)

7 The goal of this thesis is to design a menu for school-aged children (8-15) from schools in Markapur and Piduguralla. This menu is based on found food deficiencies, food availability, present facilities, Dietary Guidelines for Indians, local food culture and budget. The menu will be passed on to the cooperating boarding schools via ASSIST. The changes will ultimately have to be implemented by the schools themselves. The goal of these adjustments is to reduce healthcare costs, improve children's school performance and prevent further nutrition-related health problems. The following research question will be answered in this thesis:

“How can participating boarding schools in Markapur and Piduguralla optimize the nutritional intake of school-aged children aged 8-15 to reduce malnutrition?”

(9)

8

2. Methods

2.1 Research design

A cross-sectional, community-based research method was used to study the possibilities of improving nutritional intake of school-age children (8-15 years) of boarding schools in Markapur and Piduguralla, Andhra Pradesh, India. This study is conducted by two Nutrition and Health Promotion students of the Amsterdam University of Applied Sciences. Mapping of the local market, dietary intake of the children and nutritional status are used to examine the possibilities of improvement in nutritional intake. To illustrate the design of the research the following flowchart is given (Figure 1):

2.2 Study area

The fieldwork was conducted in Andhra Pradesh, India during the period of the 16th_{of February 2019} until the 6th_{of April 2019. This fieldwork was performed by two students of the Amsterdam University} of Applied Sciences.

Andhra Pradesh is a state in the South East of India. The primary official language is Telugu. Agriculture is an important source of income for the state and its main crops; rice, tobacco, cotton, chillies, pulses, bananas, turmeric, mango, citrus and sugar cane (18,19). The climate in this state is characterised by summer periods and monsoons. Summer season in this state ranges from March to June with an average temperature between 21 and 40 degrees Celsius. Summer season is followed by the monsoon season which lasts from October until November. The monsoon plays a major role in the determination of the climate (20). The failure of monsoons in the past few years has a catastrophic effect on the agriculture sector. Because the population heavily relies on the agriculture sector,

Figure 1: Flowchart of research process Research question Dietary data gathering Nutrition analysis Comparing to guidelines Local market mapping Purchase prices of school mapping Nutrition analysis of market Recommendations in form of menu Anthropometric data gathering Analysing anthropometric in SPSS Comparing to WHO growth curves Recommendations according to results

(10)

9 drought causes a vicious cycle of socio-economic impacts such as crop yield failure, unemployment and poor nutrition (19).

2.3 Study population

The research group consisted of two groups of children (n=181) attending boarding schools in Markapur and Piduguralla. The research group covers both boys and girls, from eight to fifteen years old. The children stay internally for seven days a week, ten months a year. From April to May, the children have a holiday and stay elsewhere. Because the children stay internally, we speak of a closed environment. Within this environment, it is decided for the children what the daily meals look like. Because of this, a great deal of influence can be exerted on this group.

A school-aged child at the school in Markapur or Piduguralla is included in this study when: • The participant is aged between 8-15 years.

• The participant can be measured with a measuring tape on the wall. • The participant is present during the measuring days.

A school-aged child at the school in Markapur or Piduguralla is excluded from this study when: • The participant is younger than 8 years or older than 15 years.

• The participant has (visible) handicaps that have a major influence on growth and weight increase or decrease.

• The participant is not staying internally. • The participant receives adapted nutrition.

2.4 Ethical consideration

In this report, names of the study population are never mentioned. Only the villages and locations where this research was conducted were described, with a reference to age groups and gender. Data is not traceable to individuals. Names remain available for the board of FEMI, only if aftercare for a specific child is required. Everything is dedicated to proper healthcare and nutrition.

According to Bryman and Bell (21) the following four points represent the most important principles related to ethical considerations:

• The study should do no harm to those who are participating in it. • The research requires the informed consent of its participants. • The privacy of participants should not be invaded.

• The study should not involve deception.

2.5 Assessment of anthropometric data

In this study, anthropometric measurements are performed in the period of February 2019 among children attending the participating schools in Markapur and Piduguralla. The measurements are performed between breakfast and lunch (Appendix I). Children from the participating schools were called for measurement according to classes and received a brief explanation and demonstration of the procedures. The health worker assisted with translation. To prevent measurement errors, the measurements require to be carried out by two specialized people at all times. Reading and entering data is checked and controlled by both specialists. Anthropometric measurements (height and weight) are performed in a room with a flat surface. The height of the children is measured with a measuring tape in centimetres. The child must be placed barefoot with heels, calves, buttocks and shoulders against the wall and should face straight forward. A horizontal headpiece is used to determine the exact height of the child in centimetres. The weight of the children is measured to the nearest 0,5 kilogram using an analogue person weighing scale, which was standardized regularly by calibrating it to zero before each measurement. Weight was not corrected for the weight for clothing. The

(11)

10 reference data used to identify the cut-off points were taken from the WHO 2007 dataset for growth reference for boys and girls aged 5-19 years (3,4). The weight-for-age indicator cannot be applied in children above 10 years because they could possibly experience pubertal growth spurt. This could put children at risk of misdiagnosis of excessive weight when in fact they are tall for their age. Therefore, weight-for-age reference data is not available for children beyond the age of 10 and not included in the analysis of this study.

2.6 Nutrients

Literature indicates protein, vitamin A, iron, iodine and the B vitamins as the most common deficiencies among Indians (5). Earlier research has shown that the children from the Andhra Pradesh region are also deficient in vitamin D, calcium, fats, potassium, fibre, vitamin C and selenium (22). Because of this, the content of those macro- and micronutrients are included in an Excel database. In addition, beta-carotenoids (provitamin A) content is included to look at effectiveness of beta-carotene rich foods in improving vitamin A intake (23). Because the Indian Food Composition Tables (IFCT) did not provide the nutritional values of boiled grains and legumes, this information is collected from McCance and Widdowson’s composition of foods integrated dataset. Missing values are complemented with the use of the online Dutch nutrient database (NEVO-online). The estimated intake of Biotin (B8) was difficult to determine since the Biotin content of many consumed staple foods were missing and therefore excluded from this study. This study excluded estimated iodine intake, because data on the iodine content in Indian foods is not available (24). The final Excel database will be handed over to organisation FEMI.

2.7 Nutritional assessment

The nutritional assessment was performed using the weighed food record method, performed by two researchers. Using this method, the consumed food is observed, weighted and noted for four or more days on a designed observation form (Appendix II). The observation forms are filled in during mealtime and worked out in the Excel database.

An observation period of three to four days, showed to be sufficient to map the nutrient intake of a large population. The duration of this period is determined by the stability of the meal pattern (25). Because weekly menus are imposed by ASSIST for an undetermined period, the diet of the research group is stable. Therefore, an observation period of four days will cover the average intake of the children.

The nutritional intake is measured during all meals (breakfast, lunch, dinner and snack) with a digital kitchen scale. Prior to observation, meal components are noted. During every meal, three random plates were chosen to determine the average grams of serving size. It is important that the person serving the food is not aware of which plate is being weighed, so the portion size cannot be adjusted. After serving a component, the plate is measured again to determine the exact weight of the component in whole grams. By counting serving rounds in household units per component, the minimum and maximum intake can be determined.

2.8 Food availability data

In order not to exceed ASSIST’s budget per meal per child, prices of the local products are determined. The budget per meal per child is 20-25 rupees (INR). Using Excel, nutritional value, prices and percentages of RDA are calculated per meal per child. The possibilities of menu options within the budget are investigated to improve the nutritional value.

Fresh products for the meals are purchased every week from the local market in Markapur and Piduguralla. Monthly, grains, pulses, oil and spices are delivered from ASSIST in Chilakaluripet. The supply of these three markets is mapped. Observation of foods at the markets was conducted according to a checklist (Appendix III), based on the Indian Food Composition Tables (26). Three markets where included in this observation to determine the possible local variations within the

(12)

11 menu. To determine the availability and price of products a local translator requested the price per kilogram or unit from the vendor.

2.9 Data analysis

To analyse similarities in group characteristics, several statistical analyses are used. Using the Statistical Package for the Social Sciences (SPSS), the descriptive statistics were analysed. Crosstabs are used to define mean weight, height and age and distribution of gender per location. Mean weight, height and age have been tested using the SPSS Independent Samples Test to find significant differences between Markapur and Piduguralla.

To determine the forms of malnutrition among the research group, anthropometric data was analysed using the SPSS ‘WHO 2007 growth reference for 5-19 years’ dataset (3,4). Each child was provided with an anonymous ID number to protect their privacy. The height, weight, sex and age of the children was connected to their ID number. For all boys and girls, height, weight and age are compared to the WHO growth curves height-for-age (HAZ) and weight-for-height (BMI). This results in a calculated Z-score that shows the SD of the average Z-score per child. Using the WHO dataset, the prevalence of low weight-for-height and height-for-age was determined per age. The syntax was manually adjusted to sort data by location, sex and age group. The age groups are identified as according to the DGI (5). The cut-off values for stunting were <-2 SD and <-3 SD for severely stunted on the height-for-age data tables. The cut-off values for thinness were <-2 SD and <-3 SD for severe thinness on the weight-for-height data tables. Overweight is classified with a cut-off value of >+1 SD on the weight-for-weight-for-height data tables.

To determine the daily estimated intake of the children, a nutritional value database is created. This database is based on the local available products as found in the market observation. The nutritional values per 100 grams of edible portion are collected from the IFCT.

The observation of consumed foods is complemented with local recipes to determine the exact grams of ingredients per component. The ingredients are linked to the corresponding macro- and micronutrients in the nutritional value database. The total minimum and maximum nutrients intake per day is calculated for each location. From this total of minimum and maximum intake, an average is calculated to represent the daily estimated intake. Because the main purpose of this study is reducing malnutrition, this study mainly focused on the minimum daily estimated intake. The daily estimated intake is then compared to the RDA’s as laid down by the DGI. During analysis of the data, age categories as drawn up in the Dietary Guidelines for Indians are used. The categories consist of age groups 7-9, 10-12 and 13-15 years (5). These categories are distinguished because of the differences in RDA’s. Percentages of intake compared to the RDA’s per age groups and sex were calculated to determine deficiencies and excesses for each location.

To create a new weekly menu that can be applied for both locations, the present menu is used. The market prices per kilograms are converted to prices per 100 grams of edible portion. These prices are linked to the corresponding ingredients in the nutritional value database. The estimated daily intake and price is calculated based on an average of seven days. Deficient nutrients are compared to local available products which are able to bridge the gap between Recommended Dietary Allowances (RDA’s) and dietary intake. Food items are added, meals are enriched, and portion size is adjusted to meet the RDA’s within the budget. Per meal, multiple options are given to support variation during different seasons. Eventually percentages of estimated daily intake of the RDA’s are calculated to determine improvement and nutritional completeness.

(13)

12

3. Results

3.1 Population characteristics

Two hundred thirteen children in the participating schools of Markapur and Piduguralla were identified. Eleven children were excluded from the research because they were not conform to the 8-15 years age criteria. Of the remaining 202 children, 21 children from Markapur suffered from seasonal chickenpox and were absent during anthropometric measurement and nutritional assessment. Thus, 181 children were studied with 63 children from Piduguralla and 118 children from Markapur. Gender distribution for the study sample (n=181) was approximately equal (52 % boys, 48% girls). No significant difference (P=0,31) was found in gender distribution. The age-range from the total group varied from 8 to 15 years with a mean age of 11,4 (SD= 1,96). The mean age of children in Markapur was 11,9 (SD= 1,96) and of children in Piduguralla was 10,4 (SD= 1,52). There was a significant difference (P= 0,00) in mean age of the total group of children in Markapur and Piduguralla. The height-range of the total group varied from 107,0 to 168,0 centimetres with a mean height of 136,3 (SD=12,9). The mean height of children in Markapur was 141,4 (SD=11,8) and of the children in Piduguralla was 126,6 (SD=8,94). There was a significant difference (P=0,00) in mean height of children in Markapur and Piduguralla. The weight-range varied from 16,0 to 54,0 kilograms with a mean weight of 31,2 (SD=8,81). The mean weight of children in Markapur was 34,6 (SD=8,34) and of children in Piduguralla was 24,9 (SD=5,66). There was a significant difference (P=0,00) in mean weight of the total group of children in Markapur and Piduguralla.

Table 1: Group characteristics

Group characteristics Markapur N= 118 (58 boys, 60 girls) Piduguralla N= 63 (36 boys, 27 girls) Total N=181 (94 boys, 87 girls)

Mean +/-SD Mean +/-SD Mean of total +/-SD P of total

Age Boys 12 1,94 11 1,62 11 1,96 0,00* Girls 12 1,98 10 1,35 Total 12 1,96 10 1,52 Height Boys 140 13,5 128 8,72 136 12,9 0,00** Girls 143 9,74 126 9,28 Total 141 11,8 127 8,94 Weight Boys 33 9,30 26 5,79 31 8,81 0,00*** Girls 36 7,18 24 5,45 Total 35 8,34 25 5,66

% within location % within location % of total

Sex Boys 49 57 51,9

0,31

Girls 51 43 48,1

Total 100 100 100

Note: Independent samples T-test P<0,05, statistically significant difference

*= There was a significant difference (P= 0,00) in mean age of Markapur and Piduguralla **= There was a significant difference (P=0,00) in mean height of Markapur and Piduguralla ***= There was a significant difference (P=0,00) in mean weight of Markapur and Piduguralla.

(14)

13

3.2 Prevalence of malnutrition

To determine the prevalence of malnutrition among the children of Markapur and Piduguralla, anthropometric data was analysed. For all boys and girls, height, weight and age are compared to the WHO growth curves height-for-age (HAZ) and weight-for-height (BMI). This results in a calculated Z-score that shows the standard deviation (SD) of the average Z-score per child. The prevalence of low weight-for-height and height-for-age was determined per age, sex and location. Stunting is determined when a child scores -2 SD scores on the growth curve: height-for-age. Thinness is determined when a child scored -2 SD scores on the growth curve: weight-for-height (2).

3.2.1 BMI-for-age

Based on BMI-for-age data, 9,9% of all studied children in Markapur and Piduguralla (N=181) were classified as too thin (SD=1,09) according to the WHO growth reference (4). A BMI-for-age with a SD of <-2 was present among 15,9% of the children in Piduguralla and in 5,8% of the children in Markapur. The highest prevalence of thinness was shown in the age group of 10-12-year-olds for both sexes. Severe thinness is shown in 2.2% of the children (Piduguralla 1.6%, Markapur 2.5%). The prevalence of overweight was 4.4% (Piduguralla 1.6%, Markapur 3.3%). Thinness was not found in almost all sexes of 7-9 years, except for the 7-9-year-old boys in Markapur (thinness 12,5%, severe thinness 12,5%). As shown in table 5 of appendix IV, none of the children were classified as obese according to the WHO growth reference (4).

(15)

14

3.2.2 Height-for-age

Based on height-forage data, 39,2% of all studied children (N=181) were classified as stunted (SD=-1,52) according to the WHO growth reference (3). A height-for-age with a SD of <-2 was present among 77,8% of the children in Piduguralla and in 18,6% of the children in Markapur. None of the children had a height-for-age score with a SD > +1. All 13-15-year-old boys from Piduguralla (100%) were stunted, while the same group from Markapur scored the lowest rate of stunting in within their gender. As shown in table 2, 7-9-year-old girls from Markapur showed the lowest rate of stunting (0%) followed by the 13-15-year-old boys from the same location (4,8%).

Table 2: Height per age group, sex and location

HT age SD HT age SD <-3 HT age SD <-2 HT age SD > +1 HT age SD Mean HT age SD std. dev Location Sex Age group N

Piduguralla Male 7-9 years 9 22,2% 55,6% 0,0% -2,16 0,85

10-12 years 20 5% 65% 0,0% -2,08 0,61 13-15 years 7 42,9% 57,1% 0,0% -2,34 1,13 N 36 16,7% 61,1% 0,0% -2,15 0,77 Female 7-9 years 9 0% 55,6% 0,0% -2,09 0,44 10-12 years 18 22,2% 66,7% 0,0% -2,27 0,9 N 27 14,8% 63% 0,0% -2,21 0,77 Subtotal location 63 15,9% 61,9% 0,0% -2,18 0,77

Markapur Male 7-9 years 8 0% 37,5% 0,0% -1,69 0,67

10-12 years 29 0% 17,2% 0,0% -1,14 1,03 13-15 years 21 0% 4,8% 0,0% -0,95 0,77 N 58 0% 15,5% 0,0% -1,15 0,92 Female 7-9 years 9 0% 0% 0,0% -0,87 0,5 10-12 years 20 5% 5% 0,0% -0,83 0,83 13-15 years 31 3,2% 32,3% 0,0% -1,5 0,86 N 60 3,3% 18,3% 0,0% -1,18 0,86 Subtotal location 118 1,7% 16,9% 0,0% -1,16 0,89 Grand total 181 6,6% 32,6% 0,0% -1,52 0,97

(16)

15

3.3 Results of nutritional assessment

The two selected ASSIST schools are provided with the same weekly menu. The aim of this study was to design a new weekly menu that can be implemented in both schools. To see whether one menu could meet the nutritional needs of children in both schools, the similarities and differences had to be examined.

Both schools are provided with three main meals, prepared by the school’s cooking staff. The diet is predominantly vegetarian, using a variety of grains, legumes and vegetables. The use of products of animal origin is minimal, due to religious beliefs and costs. Authentic spices such as turmeric, ginger, garlic and chillies are used for flavouring and medicinal properties. All meals are prepared from scratch, using fresh ingredients. Large quantities of white rice are consumed at least two times a day, alongside with components such as curry, dal, chutney, rasam and sambar. The meal is always completed with buttermilk, because it is believed to cool the stomach down after a spicy meal. Weekly, children are provided with one boiled egg during lunchtime and one piece of fruit as a snack. Monthly, children are provided with a portion of chicken (60-70 gram).

During the nutritional assessment, the intake of all macronutrients is determined for four days using the weighed food record method. The estimated daily proportion of energy is calculated per macronutrient. In addition, intake of iron, vitamin A, B vitamins, vitamin D, calcium, potassium, vitamin C and selenium is included. Β-carotenoids (provitamin A) content is included to look at effectiveness of beta-carotene rich foods in improving vitamin A intake. The nutritional assessment of children is performed in Piduguralla and Markapur, therefore results will be discussed separately. The estimated daily intake of macro- and micronutrients is examined per sex and age group of 7-9, 10-12 and 13-15 years.

3.3.1 Nutritional assessment of children in Piduguralla

3.3.1.1 Daily estimated intake of energy

As a result of the four-day weighed food record method, the average estimated intake of energy showed to be 1575 kcal per day. In figure 2, the proportion of macronutrients is shown. 79% of calorie intake is derived from carbohydrates, 10% from protein, 8% from total fat (of which 2% saturated, 6% unsaturated) and 2% from fibre.

Figure 2: Estimated daily proportion of energy per macronutrient, Piduguralla (N=63) Carbohydrates 79% Protein 10% Fibre 2% Saturated fat 2% Unsaturated fat 6% Fat 8%

Estimated daily proportion of energy per macronutrient

Based on estimated 1575 kcal per day Piduguralla (N=63)

(17)

16

3.3.1.2 Estimated daily intake of macronutrients

Using the four-day weighed food record method, the average estimated intake of energy, carbohydrates, protein, fat and fibre is determined and then compared to the RDA’s per sex and age groups. As shown in figure 3, the majority of the macronutrient RDA’s were not met. The daily estimated, minimum intake of energy, total fat, unsaturated fat and fibre showed to be inadequate for children of all age groups. The estimated percentage of carbohydrate intake showed to be sufficient and possibly excessive (158%) for children of all age groups. The protein intake was sufficient for children in the 7-9- and 10-12-year age groups but did not meet the RDA for the 13-15-year-old children (78% of the RDA for girls, 75% of the RDA for boys). The average consumption saturated fat did not meet the RDA’s for any age group.

Figure 3: Estimated percentage of average daily intake per macronutrient compared to RDA, Piduguralla (N=63)

0 50 100 150 200 Boys, 7-9 years Boys, 10-12 years Boys, 13-15 years Girls, 7-9 years Girls, 10-12 years Girls,13-15 years

Estimated percentage of average daily intake compared to RDA

Macronutrients Piduguralla (N=63) Fibre in g Protein in g Unsaturated fat in % Saturated fat in % Total fat in % Carbohydrates in % Energy (kcal)

(18)

17

3.3.1.3 Estimated daily intake of micronutrients

Using the four-day weighed food record method, the average estimated intake of vitamin A, B1, B2, B3, B5, B6, folate, B12, C, D, calcium, potassium, selenium and iron is determined and then compared to the RDA’s per sex and age groups. As shown in figure 4, the majority of micronutrient RDA’s were not met. The daily estimated minimum intake of vitamins A, B1, B2, B3, B5, B6, calcium, potassium, selenium and iron showed to be inadequate for children of all age groups and sexes. The estimated intake of vitamins B12, C, D showed to be sufficient for all children. The estimated intake of folate was sufficient for all children in the 7-9-year age group but did not meet with the RDA for the 10-12 and 13-15-year-old children.

Figure 4: Estimated percentage of average daily intake per micronutrient compared to RDA, Piduguralla (N=63)

0 20 40 60 80 100 120 140 160 180 200 Boys, 7-9 years Boys, 10-12 years Boys, 13-15 years Girls, 7-9 years Girls, 10-12 years Girls,13-15 years

Micronutrients Piduguralla (N=63) Vitamin A, including β-carotenoids Selenium in µg Potassium in mg Calcium in mg D total in µg C in mg B12 in µg Folate in µg B6 in mg B5 in mg B3 in mg B2 in mg B1 in mg

(19)

18 3.3.2 Nutritional assessment of children in Markapur

3.3.2.1 Estimated daily intake of energy

As a result of the four-day weighed food record method the average estimated intake of energy showed to be 1227 kcal. In figure 5, the proportion of macronutrients is shown. 73% of calorie intake is derived from carbohydrates, 11% from protein, 14% from total fat (of which 3% saturated, 10% unsaturated) and 3% from fibre.

Figure 5: Estimated daily proportion of energy per macronutrient, Markapur (N=118) Carbohydrates 73% Protein 11% Fibre 3% Saturated fat_3% Unsaturated fat 10% Fat 14%

Estimated daily proportion of energy per macronutrient

Based on estimated 1227 kcal per day Markapur (N=118)

(20)

19

3.3.2.2 Estimated daily intake of macronutrients

Using the four-day weighed food record method, the average estimated intake of energy, carbohydrates, protein, fat and fibre is determined and then compared to the RDA’s per sex and age groups. As shown in figure 6, the majority of the macronutrient RDA’s were not met. The daily estimated, minimum intake of energy, total fat, unsaturated fat and fibre showed to be inadequate for children of all age groups. The estimated percentage of carbohydrate intake showed to be sufficient and possibly excessive (146%) for children of all age groups. The protein intake was sufficient for children in the 7-9 age group but did not meet the RDA for the 10-12 and 13-15-year-old children. The average consumption of saturated fat did not meet the RDA’s for any age group.

Figure 6: Estimated percentage of average daily intake per macronutrient compared to RDA, Markapur (N=118)

0 20 40 60 80 100 120 140 160 Boys, 7-9 years Boys, 10-12 years Boys, 13-15 years Girls, 7-9 years Girls, 10-12 years Girls, 13-15 years

Macronutrients Markapur (N=118) Fibre in g Protein in g Unsaturated fat in % Saturated fat in % Total fat in % Carbohydrates in % Energy (kcal)

(21)

20

3.3.2.3 Estimated daily intake of micronutrients

Using the four-day weighed food record method, the average estimated intake of vitamin A, B1, B2, B3, B5, B6, folate, B12, C, D, calcium, potassium, selenium and iron is determined and then compared to the RDA’s per sex and age groups.

As shown in figure 7, the daily estimated minimum intake of vitamins A, B1, B2, B3, B5, B6, C, calcium, potassium, selenium, folate and iron did not meet the RDA’s for children of all age groups and sexes. The estimated intake of vitamins B12 and D met the RDA’s for all children in Markapur.

Figure 7: Estimated percentage of average daily intake per micronutrient compared to RDA, Markapur (N=118)

0 50 100 150 200 250 Boys, 7-9 years Boys, 10-12 years Boys, 13-15 years Girls, 7-9 years Girls, 10-12 years Girls, 13-15 years

Micronutrients Markapur (N=118) Vitamin A, including β-carotenoids Selenium in µg Potassium in mg Calcium in mg D total in µg C in mg B12 in µg Folate in µg B6 in mg B5 in mg B3 in mg B2 in mg B1 in mg

(22)

21

3.4 Results of improved menu

As a result of exploring the found food deficiencies, food availability, facilities, Dietary Guidelines for Indians, the present menu and budget, a new menu is designed to fit both locations (Appendix V). Food items are added, meals are enriched, and portion size is adjusted to meet the RDA’s within the budget. Per meal, multiple options are given to support variation during different seasons. The estimated daily intake and price is calculated based on an average of seven days. The price per meal per child is estimated on 15 INR.

Percentages of estimated daily intake of the RDA’s are calculated to determine improvement and nutritional completeness. If implemented correctly, the menu improves the intake of nutrients according to the following percentages for Piduguralla (Table 3) and Markapur (Table 4) respectively:

Table 3: Percentage of improvement with implementation of the new menu, Piduguralla

Nutrient Percentage of improvement Energy (kcal) +27% Carbohydrates -15% Total fat +121% Saturated fat +225% Unsaturated fat +91% Protein +57% Fibre +112% Vitamin A +47% Vitamin B1 +165% Vitamin B2 +137% Vitamin B3 +48% Vitamin B5 +81% Vitamin B6 +142% Folate +129% Vitamin B12 +203% Vitamin C +128% Vitamin D +83% Calcium +136% Potassium +115% Selenium +27% Iron +112% Vitamin A, β-carotenoids included +118%

Table 4: Percentage of improvement with implementation of the new menu, Markapur

Nutrient Percentage of improvement Energy (kcal) +63% Carbohydrates -8% Total fat +31% Saturated fat +78% Unsaturated fat +16% Protein +97% Fibre +83% Vitamin A +154% Vitamin B1 +159% Vitamin B2 +122% Vitamin B3 +37% Vitamin B5 +80% Vitamin B6 +139% Folate +154% Vitamin B12 +167% Vitamin C +180% Vitamin D +67% Calcium +169% Potassium +127% Selenium +39% Iron +162% Vitamin A, β-carotenoids included +133%

(23)

22

4. Discussion

This study was held to determine the prevalence of malnutrition and explore the nutritional intake of schoolchildren in Markapur and Piduguralla. School children are considered to be found in a dynamic period of growth and development because children undergo physical, mental, emotional and social changes (27). In this paragraph the most important findings of this study are discussed and compared to other studies.

4.1 Population characteristics

There was a significant difference (P= 0,00) in mean age, height and weight of the total group of children in Markapur and Piduguralla. The significant difference in mean age could be explained by the smaller age-range of Piduguralla. The age-range of Piduguralla reached up to 13 years, compared to 15 years in Markapur. The significant difference in mean height and weight could be explained by the significant difference in mean age between Piduguralla and Markapur. Naturally, children grow and gain each year until they reach their adult height and weight.

4.2 BMI-for-age

In this present study, school children of Markapur were found to be less thin than the school children in Piduguralla. The prevalence of thinness (BMI age <-2 SD) among children in Markapur was 6,8% (Appendix IV, table 5), this is lower than the 41% reported in another recent study that explored nutritional status among school-aged children in India (28,29,30). The prevalence of thinness (BMI age <-2) among children in Piduguralla was 15,9%. This result was the lowest as compared studies in India and other developing countries. The total percentage of children with overweight (BMI age >1 SD) was 4.4%. The prevalence of overweight is lower than reported in another study among school going children in Andhra Pradesh (29). Because ASSIST provides the children in Markapur and Piduguralla with breakfast, lunch and dinner, this could explain the different results in schoolchildren from government schools who possibly only receive lunch.

Children who were suffering from illness during the anthropometric measurements were not included in this study. The conditions resulting from poor nutrition, weakens the immune system and causes significant growth and cognitive delay (31). Perhaps the children that have a weaker immune system and are more prone to diseases could have a great influence on the prevalence of thinness in Markapur.

Another possible explanation may be the use of the WHO growth standards from 2007. Even though the WHO 2007 growth reference was derived from a combination of growth study samples, including India, the height and weight curves may not be optimal fits in all cases. The differences between national or ethnic group means are large enough that using the WHO charts could put many children at risk for misdiagnosis. (32). Furthermore, BMI is a useful tool for determining weight in relation to body height, but experts have expressed uncertainty about its reliability. The BMI by itself cannot show whether a child’s weight is healthful and should therefore be used in combination with other indicators to provide a more complete picture (33).

4.3 Height-for-age

The prevalence of overall stunting (HGT age <-2 SD) among children in Markapur was 18,6%, out of which 1,7% were severely stunted (HGT age <-3 SD) (Table 2). This is lower than the 19,9% reported in another recent study that explored nutritional status of school-age children in urban slums of Bareilly, India (31). This rate of stunting is also lower than the 25.5-51% stunting found in a cross-sectional survey among adolescent boys and girls between 10-16 years old (34).

The school children of Markapur in the present study were found to be less stunted than the school children in Piduguralla. Regardless of gender and age, the overall prevalence of stunting among children in Piduguralla was 77,8%, out of which 15,9% were severely stunted (HGT age <-3 SD). This

(24)

23 rate is higher than found in other recent studies among school-age children in India and Ethiopia (24,27,31).

The high rate of stunting among children in Piduguralla could be explained by several determinants. A possible explanation for the difference in stunting rates between Piduguralla and Markapur could be the years they have been attending school. The mean years at school of the children in Markapur was 4.5 years while children from Piduguralla only had been at school for 1 year and 10 months. A growing number of international studies shows improvements in nutritional intake can be important for possible catch up growth in early adolescent years (36).

Another possible explanation for the difference in stunting rates between Piduguralla and Markapur could be the absence of 20 children who were suffering from illness during anthropometric measurements. The conditions resulting from poor nutrition, weakens the immune system and causes significant growth and cognitive delay (31). Perhaps the children that have a weaker immune system and are more prone to diseases could have a great influence on the prevalence of stunting in Markapur.

According to the principal of the school in Piduguralla, children are not always used to consuming dairy products such as buttermilk. This suggests that during early childhood, children had low intake of buttermilk and that their intake of animal-based protein, calcium, vitamin B2 and B12, was also possibly lower. Growth failure may be caused by inadequate intake during early childhood of one or more nutrients including energy, protein, or micronutrients such as iron, zinc, and vitamins A, C or D (36). This could explain the difference in stunting rates between Markapur and Piduguralla.

4.4 Nutritional assessment

The Indian cuisine consists of a wide variety of regional and traditional cuisines, native to the Indian subcontinent. Given the range of diversity in soil type, climate, culture, ethnic groups, and occupations, these cuisines vary substantially from each other and use locally available vegetables, fruits, herbs and spices. Traditional Indian food is also influenced by religious beliefs, in particular Hindu, cultural choices and traditions (37). Different cereals/millets and pulses are used as staple food. The average Indian diet shows that consumption of green leafy vegetables, pulses and other vegetables is grossly inadequate throughout the nation. Intake of visible fats also shows to be less than 50% of the RDA (5).

4.4.1 Intake of macronutrients

Prior to this study, the dietary intake of the school children in Markapur and Piduguralla was expected to be comparable. Because the children come from rural poor communities and are classified in the same age groups, similar results of the nutritional assessment were expected. The estimated minimum intake of energy (kcal) of children in Piduguralla was higher than Markapur, but the proportion of macronutrients was corresponding. Both groups derived over 70% of energy from carbohydrates, 10% from protein, 8-14% from fats and 2-3% from fibre.

Both groups showed deficiencies in macronutrients such as energy, total fat and fibre for all age groups as compared to the RDA’s laid down by the Dietary Guidelines for Indians.This can be explained by excessive consumption of refined grains, low consumption of foods of animal origin and low consumption of visible fats. This corresponds to results of the average Indian diet according to the National Nutrition Monitoring Bureau (5). The deficiency in energy could be explained by the focus on minimum intake and the absence of complementary snacks.

The estimated protein intake of the studied children was sufficient for boys and girls from the 7-9 years and 10-12 years age groups in Piduguralla but did not meet with the RDA for the 10-12 years and the 13-15 years age groups in Markapur. The DGI indicate protein as the most common macronutrient deficiency. Therefore, the result of this study does not fully correspond to the most common macronutrient deficiencies in India (5). This can be explained by daily intake of buffalo

(25)

24 buttermilk and legumes during lunch and dinner, and weekly consumption of a boiled egg. This contributes to a sufficient protein intake for most age groups.

4.4.2 Intake of micronutrients

Contrary to expectations, the intake of vitamins B12, C and D showed to be sufficient for all children. This result is not similar to previous studies on B12 status among South Indian children (38). An adequate intake of vitamin B12 while eating mostly vegetarian can be explained by the low RDA for vitamin B12 compared to other countries (39). Alongside caused the intake of one boiled egg, adequate intake of vitamin B12 on average in four days. The adequate intake of vitamin D can be explained by using the latest publication of the Indian Food Composition Tables, that presented content of vitamin D2 in plant foods for the first time (40). Earlier research possibly did not include this in their calculation of total vitamin D intake.

This present study also showed that the majority of the micronutrient RDA’s for school aged children were not met. Both the children in Markapur and Piduguralla had inadequate estimated intake of vitamins A, B1, B2, B3, B5, B6, calcium potassium, selenium and iron. The intake of folate was not sufficient for all children in Markapur and showed to be insufficient for children of the 10-12 years and the 13-15 years age groups in Piduguralla. The inadequacy of B-vitamins, iron and calcium can be explained by the small portion size of legumes and vegetables. The inadequacy of vitamin A, iron and selenium can be explained by the lack of products from animal origin such as egg, dairy products and chicken. Finally, the weekly intake of one piece of fruit did not supply the required amounts of vitamin C, potassium and folate.

Our findings are similar to previous studies that define nutritional status of Indian children. Earlier research in Andhra Pradesh reported inadequate intake of vitamin C, D, calcium, fats, potassium, fibre and selenium (22). Also, the DGI indicate vitamin A, iron, iodine and B-vitamins as the most common deficiencies among Indian people, particularly among the rural poor communities. Rural populations are prone to undernutrition due to poor healthcare, recurred infections and lower income (5).

4.4.3 Comparability of dietary intake of children in Piduguralla and Markapur

The proportion of energy and the intake of macro- and micronutrients in both Markapur and Piduguralla showed to be similar to a large extend. Therefore, the menu can be designed to fit the nutritional demands of most children in both locations.

4.5 Strong points and limitations

A strong point of this cross-sectional study was the relatively large sample of 181 children from similar, socio-economic backgrounds. The sample is representative for school children aged 8-15 years from ASSIST schools in Andhra Pradesh region only, based on a similar dietary intake in our studies and other studies conducted in children in Andhra Pradesh area.

All anthropometric measurements and collection of dietary data were performed, controlled and checked by two people. To make a reliable, objective analysis, it is ensured that both researchers interpreted and analysed the data.

To get a good indication of the nutritional status of the children in Markapur and Piduguralla, intake of all vitamins and the majority of minerals were included in this study. Since most of the studies relating to the Indian scenario focuses on the micronutrient deficiencies of iron, vitamin A and iodine. Less attention has been given to vitamin B deficiencies (41). By focusing a wide variety of vitamins and minerals, the menu can be adapted to meet the nutritional demands for the majority of the children. To avoid socially desirable responding (SDR) and its elusive effects on the validity of our assessment, during every meal observation three random plates of children from different age groups and sex were measured. The person serving the food was not aware which plate was going to be weighed by the digital kitchen scale, so this person could not adjust the serving sizes of these plates to a bigger portion.

(26)

25 A limitation of this study was due to the time constraints, children who were suffering from illness during the anthropometric measurements were not included. The conditions resulting from poor nutrition, weakens the immune system and causes significant growth and cognitive delay (31). Perhaps the children that have a weaker immune system and are more prone to diseases could have a great influence on the overall prevalence of thinness and stunting. Hence a more comprehensive study involving all children in ASSIST schools can be done to increase the reliability of the results. Another limitation is the use of the WHO growth charts from 2007. The use of a single international standard for height to age and BMI-for-age may not be the optimal fit in all cases (32). When assessing and diagnosing chronic malnutrition in children, a combination of diagnostic parameters should be used to get a more accurate estimate of its prevalence (33,42). Data points such as nutritional intake, growth reference and chronic protein energy malnutrition (PEM) should be collected to determine the nutritional status.

Finally, when looking at the intake of a large group of children, using an average bandwidth might not give accurate results of individual nutritional intake. Because this study focussed on minimum intake, the actual intake of the children could be underreported. Therefore, recommendations based on these results might not be suitable for each individual child.

(27)

26

5. Conclusion

In this cross-sectional study the nutritional intake of Indian school-aged children in Markapur and Piduguralla was explored to find possible macro- and micronutrient deficiencies and aimed to improve nutritional intake to reduce malnutrition.

Anthropometric measurements were performed to determine the prevalence of malnutrition. Results showed an overall prevalence of thinness of 9,9%, of which 2,2% was severe thin. Based on height-for-age data, 39,2% of the studied children were classified as stunted. Stunting was present among 77,8% of the children in Piduguralla and in 18,6% of the children in Markapur.

Based on quantitative research methods, such as the weighed food record method, the dietary intake is determined. The high intake of refined grains, the low intake of products of animal origin and the lack of variety within meals caused the intake of vitamin A, B1, B2, B3, B5, B6, calcium, potassium, selenium and iron to be insufficient for all children. Contrary to expectations, the intake of vitamins B12 and D and showed to be sufficient for all children. This result can be explained by daily intake of buffalo buttermilk and weekly consumption of a boiled egg. Furthermore, the IFCT provided vitamin D content of plant foods. Schools are the main entry point in promoting healthy nutrition and improving the nutritional status of all children, with emphasis on micronutrients is a priority.

To reduce malnutrition and meet the RDA’s for all children, a new menu needs to be implemented. White rice and refined grains should be replaced by less polished and wholegrain products to improve the intake of fibre and the intake of B-vitamins, calcium and iron. The portion size of legumes and vegetables should be bigger to improve the intake of plant-based protein, fibre, B-vitamins, iron and calcium. All children should drink buffalo buttermilk twice a day to improve the intake of protein, vitamin B2, B12 and calcium. The new menu should provide children with fruit twice a week, to improve the intake of vitamin C, potassium and fibre. Furthermore, the new menu should provide children with a boiled egg twice a week to improve the intake of protein, unsaturated fats, vitamin A, D, B2, B12, folate, selenium and iron. Children aged 10-15 years have higher needs of macro- and micronutrients, therefore these age groups must be provided with a second round of serving. Finally, the participating boarding schools in Piduguralla and Markapur should pay attention during meals whether all children receive all meal components and finish their plates.

(28)

27

6. Recommendations

6.1 Nutritional improvements

To make implementation of the recommendations possible, a weekly menu is set up which can be implemented on both schools (Appendix V). This recommended menu is based on the most important results in which points of discussion have been included. The menu provides the schools with options to promote variation within the components. This study and the implementation as conducted in the example of a weekly menu, shows that changes in added food items, enriched meals and adjusted serving size improves the nutrient intake of children of all age groups.

6.1.1. Portion size

The new menu must provide enough calories, proteins and micronutrients to achieve maximum growth potential during different stages of life (5). To make sure every child gets the recommended daily intakes, it is important to make consumption of all menu components obligated for at least one serving round. All children should take their glass and plate to eating moments. Sharing makes the intake of nutrients less and should therefore be avoided.

During every meal containing curry or chutney, two serving spoons must be obligated. This way children will not miss out on important nutrients. To be able to control this, staff should be present every day during all meals to serve or check servings. All children need to finish their meals to obtain all the needed nutrients. If a child does not finish all the components, a staff member must ask about the reason behind it. Because children aged 10-15 years have higher needs of macro- and micronutrients, children from these age groups must be provided with a second round of serving. Children are not allowed to decline a meal component due to personal taste preference. Children can learn to accept foods and flavours by repeated exposure (43). The personal taste preference changes during stages of life, influenced by social, environmental and biological factors. According to previous

(29)

28 studies, it takes up to 15 exposures until a food is trusted to be tasted. It takes another 10 to 15 exposures before children start liking new flavours (44).

6.1.2. Cereals, legumes, beans and dairy

Cereals, legumes and beans take up 70-80% of total calorie intake in a traditional Indian diet. These products provide the body with energy, fibre, proteins, B-vitamins and iron. Whole grains contain more vitamins, minerals and fibres then refined grains. Because of this, diets rich in fibre are healthier then low-fibre diets which are based on refined and processed foods (5). Therefore, every meal containing rice, should be prepared with parboiled rice instead of white rice to increase the level of fibre, minerals and vitamins.

No single cereal, legume or bean provides all the nutrients to fulfil the nutritional needs of the children. A diet with a variation of cereals, legumes and beans provide more of the required nutrients for a balanced diet (5). To improve the nutrient intake, children must be provided with 150 grams of legumes or beans as a snack, twice a week. These legumes and beans complement the carbohydrate, protein, B-vitamins, iron, calcium and fibre intake. Variation in provided beans and legumes is important to fulfil the required nutrients.

Milk provides proteins, Vitamin B2, B12 and calcium and are for that reason an important component of the diet. Every lunch and dinner must contain buttermilk, and two serving spoons should be obligated for each child.

6.1.3. Vegetables and fruits

Fresh and local vegetables and fruits must be part of the menu to meet the mineral and vitamin requirements. Fruits and vegetables contain carbohydrates, fibres, carotenoids, antioxidants, and various vitamins and minerals like vitamin C, folate, B-vitamins and carotenoids. No single fruit or vegetable provides all the nutrients to fulfil the nutritional needs of the children. A diet with a variation of fruits and vegetables provide more of the required nutrients for a balanced diet. Green leafy vegetables particularly contain a high level of vitamin, minerals and carotenoids and should therefore be consumed regularly. Because of this, children must be provided with green leafy dal, at least three days a week. In addition, children must be provided with one piece of fruit (100 grams) during lunch or as a snack, two days a week.

6.1.4. Animal source foods, oils and nuts

Animal source foods like chicken and eggs are rich sources of proteins. The quality of proteins in animal source foods is very high, and therefore provide a complete protein profile. Meat and eggs contain vitamin B1, B2, B6, B12, zinc, iron, phosphor and selenium. Because vitamin B12 is only available in animal origin products, regular consumption of these products is recommended. Children must be provided with eggs during lunch, three days a week. In addition, children must be provided with chicken at least once a month.

Fats are a source of energy, help to absorb fat-soluble vitamins and provide essential fatty acids. Groundnut, sesame and olive oil are rich in unsaturated (good) fatty acids. Vanaspati, ghee and coconut oil contain a lot of saturated (bad) fatty acids and should therefore be avoided. Groundnut, sesame and olive oil are healthy options to use in meal preparation.

Nuts provide proteins, vitamin E, B1, fibre, and minerals like folate and iron. In addition, nuts are a great source of unsaturated (good) fatty acids. To complement vitamins, minerals, proteins and fats, nuts operate as a nutritious additional snack. Therefore, children must be provided with nuts as a snack, two days a week.

6.1.5. Highly processed foods

Processed foods like chips, candy, biscuits etc. are considered as unhealthy. The majority of these refined products are rich in fat, salt, sugar and calorie dense. Refined products often contain less fibre

(30)

29 and micronutrients and not nutritionally balanced. The use of processed and refined product should therefore be discouraged (5).

6.1.6. Water

The human body consists around 70% of water and loses this water through sweat, urine and faeces. To replenish the body with water, it’s important to drink enough water. Adequate water intake is crucial to avoid dehydration and constipation. Children should drink at least 2000 cc / 2 litres / eight glasses or four bottles of water each day. During hot weather, physical activity and illness this requirement should be increased to make up for the water lost through sweat.

During the fieldwork, an interim presentation was given to provide the schools with important points to ponder, considering hygiene, health and food safety. These points to ponder are included in this document (Appendix VI), because these points still must be taken into account.

6.1.7 Supplementation

Even though the prevalence of anaemia is not examined, anaemia among Indian girls is found to be 60% (45). According to the WHO, daily iron supplementation is recommended as a public health intervention in menstruating adolescent women in settings where the prevalence of anaemia is 40% or higher (46). Where possible, girls should be supplemented with 30-60 mg elemental iron tablets by the school’s healthcare worker on a daily basis for three consecutive months in a year (47).

(31)

30

6.2 Recommendations for future research and implementation

Considering similarities in socio-economic status, dietary pattern and food consumption, the same may be expected throughout the region. The prevalence of stunting reported in the current study might be useful for comparison with studies carried out in other schools in Andhra Pradesh area. This study could also facilitate the ASSIST organisation to initiate appropriate measures for the prevention and control of malnutrition among schoolchildren.

Many screening assessments make use of simple indicators such as weight-for-height and height-for-age. To give an accurate representation of the prevalence of malnutrition the use of a combination of indicators such as Mid-Upper Arm Circumference (MUAC), body composition and muscle function is needed (32).

A well-designed data system can provide data on the nutrient content of foods. Ideally, India should have a complete, easy to use nutritional database. This database should have few missing data, food descriptions should be clear, and values should be expressed in raw and edible portion.

Another priority research need is for well-controlled studies on the serum levels of micronutrients to measure bioavailability. This will show the extent to which the micronutrients are absorbed and becomes available for activity. Many previous studies have used food frequency questionnaires to determine nutrient intake, which may not give an accurate representation of nutritional status. Changes in food availability, facilities, DGI, budget and ASSIST school staff could impact the implementation of the recommendations. Therefore, every three years follow-ups should be carried out within the same setting, to maintain proper nutrition for the ASSIST schools in Markapur and Piduguralla.

Prevention should be carried out by tackling the determinants of malnutrition. Especially impaired growth (stunting) as a result of chronic malnutrition, can be prevented by exclusive breastfeeding until the age of six months, and by the adequate intake of energy, macronutrients and micronutrients up to the age of two years (48). This could be achieved by ASSIST through nutritional intervention programs focussed on pregnant women and children up to the age of two years.

Fortification of staple foods with nutrients may be a cost-effective intervention for reducing nutrient deficiencies. Future research is needed to explore possibilities, benefits and harms of fortification of staple foods on nutritional status in the general population.