Table Of ContentShreelata Rao Seshadri
Jyoti Ramakrishna
Nutritional Adequacy,
Diversity and Choice
Among Primary
School Children
Policy and Practice in India
Nutritional Adequacy, Diversity and Choice
Among Primary School Children
Shreelata Rao Seshadri Jyoti Ramakrishna
(cid:129)
Nutritional Adequacy,
Diversity and Choice
Among Primary School
Children
Policy and Practice in India
123
Shreelata RaoSeshadri JyotiRamakrishna
Schoolof Development Floating Hospital for Children at Tufts
AzimPremji University MedicalCenter
Bangalore, Karnataka TuftsUniversity
India Boston
USA
ISBN978-981-10-3469-5 ISBN978-981-10-3470-1 (eBook)
https://doi.org/10.1007/978-981-10-3470-1
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Acknowledgements
This book would not have been possible without the dedicated efforts of several
people and institutions who have contributed their valuable time, resources, and
ideas over the past couple of years.
Firstandforemost,weacknowledgethesupportoftheAzimPremjiFoundation
in providing a fertile topic of inquiry, based on their longstanding and rich expe-
rience in the field of school education. Knowing the larger interest of the
Foundation in matters relating to school-age children provided the impetus for
exploringthehealthandnutritionstatusofthesechildren.Thisledtotherealization
that the evidence was patchy and needed to be strengthened by a comprehensive
study. The Foundation provided generous material support to the proposal which
we drafted, fleshing out the questions and concerns that would guide the 3-year
study: “Do we know what they eat, and why? A Study on School-level Dietary
AdequacyandImpactofCulturalBeliefsinRemoteRuralAreasinSouthernIndia”
(referred to in this book as the “Nutrition Study”).
Theactualimplementationofthestudywasateameffort;overtimeseveralteam
members joined the team, while some left it for various reasons. We would par-
ticularlyliketoacknowledgeProfessorShubhadaKanani,fromtheMSUniversity,
Baroda, who (as visiting faculty at Azim Premji University) was instrumental in
developingthestudytoolsandtrainingofthefirstfieldteam.Alongwithherwere
Kalyani Subbiah and Rajveer Sangha, who contributed significantly in the early
phase of data collection. Later, the management of the project was taken over by
Nilanjan Bhor; and he along with the team at GRAAM (Mysuru) completed the
difficulttaskofcollecting,cleaning, organizing, andcompletingtheinitial analysis
ofthedatacollectedfromthetribalareasofHDKote,Mysuru.Herewewouldalso
like to thank Latha N, who provided invaluable support in the field, in all three
study locations. Her knowledge of Kannada, as well as her ability to establish an
easy rapport with the community, made her the natural choice for conducting and
transcribingtheFocusGroupDiscussionsandinterviews,bothofwhichhaveadded
rich qualitative insights to our work. Suraj Parab led the data analysis and helped
v
vi Acknowledgements
makesenseofthehugeamountofquantitativeandqualitativedatageneratedbythe
study.
Our partners in the field were a wonderful support. Both Swami Vivekananda
Youth Movement (SVYM)/GRAAM in Mysuru and the Azim Premji Foundation
District Institutes in Yadgir and Mandya provided operational and intellectual
support to the project. We particularly thank Dr. Balasubramaniam, Director,
SVYM; Basavaraju, Executive director, GRAAM; Umashankar Periodi, who led
theYadgirDistrictInstitute;Nirmala,whowaspartoftheYadgirteamatthetime;
and Umesh who led the Mandya District Institute and his team.
WewouldliketothankPriyaIyer,whoputtogetherthebookproposalbasedon
her conversations with us and various documents that we shared with her. Her
patient pursuit of this project was critical to its success; her departure to greener
pastures was sorely felt.
We as a team (Shreelata, Jyoti, Nilanjan, Suraj and Latha) have been able to
organize several important meetings and consultations to support and strengthen
our research effort: the Nutrition Round Table in April 2015; presentations of
various aspects of the larger study at multiple conferences, including the Indian
Health Economics and Policy Association annual conference in Pune, December
2014;EvidenceinPublicHealthPolicyConferenceinBangalore,2016;theHealth
SystemsGlobal Conference inVancouver, November 2016;theTribal Confluence
in Jamshedpur Jharkhand, October, 2016, among others. This has extended the
work into new areas, thus transforming the “Nutrition Study” into a “Nutrition
Project,” by looking at malnutrition among the children of migrant laborers,
developing a set of curricula for a School Health Program, creating in-class exer-
cises for the MA Development curriculum at the Azim Premji University, writing
case studies—all of which have broadened and deepened our understanding and
abilitytocontributetotheimportantissueofnutritionofchildreninprimaryschool.
Finally, we would like to thank our families for their consistent emotional
support, tolerating our absences in the field and long absences after our return,
hours spent in discussion and documentation of all that we learned from our data
and observations. We hope that the joint effort of all the people gratefully
acknowledgedherehasresultedinabookthatwillmakeadifferencetothewaywe
look at supporting school children to live up to their full potential both as indi-
viduals and as members of society.
Shreelata Rao Seshadri, Ph.D.
Jyoti Ramakrishna, MD, MPH
Contents
1 Nutritional Status of School-Going Children:
What Do We Know?. .... ..... .... .... .... .... .... ..... .... 1
1.1 Setting the Context... ..... .... .... .... .... .... ..... .... 1
1.2 An Overview of Nutritional Status of Children in India..... .... 3
1.3 Nutrition of School-Age Children in India.. .... .... ..... .... 4
1.3.1 Prevalence of Malnutrition Among Primary School
Children . .... ..... .... .... .... .... .... ..... .... 6
1.4 The Need for Action.. ..... .... .... .... .... .... ..... .... 7
1.5 The Book: What It Covers and How It Is Organized.. ..... .... 8
References.. .... .... .... ..... .... .... .... .... .... ..... .... 12
2 Measuring Child Malnutrition: A Review of Assessment Methods
of the Nutritional Status of School-Going Children in India ... .... 15
2.1 Measuring Child Malnutrition: Some Important Concepts ... .... 16
2.1.1 Growth Standard Versus Growth Reference:
What Is the Difference?... .... .... .... .... ..... .... 16
2.1.2 Nutritional Indicators for School-Aged Children..... .... 17
2.1.3 Percentiles and z-Score (or SD Score)
in Anthropometry ... .... .... .... .... .... ..... .... 18
2.2 An Overview of Available Measures of Childhood
Malnutrition .... .... ..... .... .... .... .... .... ..... .... 20
2.2.1 Definitions of Growth References Applicable
to Indian School-Aged Children .... .... .... ..... .... 20
2.3 Comparison of Nutritional Status by Multiple
Growth References... ..... .... .... .... .... .... ..... .... 26
2.4 What Do the Data Tell Us? . .... .... .... .... .... ..... .... 29
Annex 2.1 Methodological review of literature on “Nutritional Status
of School-going Children in India”... .... .... ..... .... 31
References.. .... .... .... ..... .... .... .... .... .... ..... .... 41
vii
viii Contents
3 Malnutrition Among Students in Primary School:
A Profile of Government School Students. .... .... .... ..... .... 47
3.1 Introduction .... .... ..... .... .... .... .... .... ..... .... 47
3.2 Nutritional Outcomes of Government School-Going Children .... 49
3.2.1 Profiles of the Study Districts and Blocks. .... ..... .... 49
3.2.2 Performance on BMI- and Height-for-Age by District .... 52
3.3 Household Characteristics of Government School-Going
Children ... .... .... ..... .... .... .... .... .... ..... .... 55
3.3.1 Socioeconomic Characteristics of Sample Households .... 55
3.3.2 Degree of Variation in Nutritional Status of Children
by Different Characteristics.... .... .... .... ..... .... 56
3.4 Concluding Reflections..... .... .... .... .... .... ..... .... 57
References.. .... .... .... ..... .... .... .... .... .... ..... .... 60
4 VulnerabilityandChildhoodMalnutrition:NarrativesfromTribal
Households. .... .... .... ..... .... .... .... .... .... ..... .... 63
4.1 Introduction .... .... ..... .... .... .... .... .... ..... .... 63
4.2 Methodology ... .... ..... .... .... .... .... .... ..... .... 65
4.3 Nutritional Status of Tribal Children: All-India and Karnataka.... 66
4.3.1 Prevalence of Malnutrition Among Tribal School
Children of Mysuru and Yadgir Districts . .... ..... .... 66
4.4 Dietary Adequacy and Diversity of Tribal Households. ..... .... 69
4.5 Determinants of Dietary Choice.. .... .... .... .... ..... .... 73
4.5.1 Structural. .... ..... .... .... .... .... .... ..... .... 73
4.5.2 Programmatic . ..... .... .... .... .... .... ..... .... 76
4.5.3 Household/Individual .... .... .... .... .... ..... .... 77
4.6 Addressing the Nutritional Vulnerability of Tribal Children.. .... 78
References.. .... .... .... ..... .... .... .... .... .... ..... .... 80
5 How Much Food Is Enough? Food Consumption
Among School-Going Children.. .... .... .... .... .... ..... .... 83
5.1 The Construction of an Adequate Diet: Preconditions and
Impacts.... .... .... ..... .... .... .... .... .... ..... .... 83
5.2 Changing Household Food Intake in India.. .... .... ..... .... 87
5.2.1 NSSO Data... ..... .... .... .... .... .... ..... .... 87
5.3 What Do Measures of Food Frequency Tell Us? . .... ..... .... 90
5.4 Food Intake of School Children in Rural Karnataka... ..... .... 93
5.5 Implications of Food Frequency Analysis... .... .... ..... .... 100
Annex 1: Methodology for Collecting Food Frequency Data ..... .... 102
Annex 2: Review of Literature on Risk Factors
for Over-/Undernutrition .... .... .... .... .... ..... .... 106
References.. .... .... .... ..... .... .... .... .... .... ..... .... 121
Contents ix
6 What Do the Children Eat in Schools? Teachers’ Account..... .... 125
6.1 The Role of the Teacher in School Health
and Nutrition Programs..... .... .... .... .... .... ..... .... 125
6.2 Teacher’s Evaluation of the Midday Meal Scheme.... ..... .... 128
6.2.1 Teachers’ Role in MDM.. .... .... .... .... ..... .... 129
6.2.2 Positive Impact Due to MDM.. .... .... .... ..... .... 129
6.2.3 MDM Menu .. ..... .... .... .... .... .... ..... .... 129
6.2.4 Likes and Dislikes of Food Items in MDM ... ..... .... 130
6.2.5 Challenges Faced in Implementing MDM. .... ..... .... 131
6.3 Students’ Health and Nutrition: The Teacher’s Point-of-View .... 131
6.3.1 Health and Nutritional Status of Children in Schools:
Teachers’ Perception. .... .... .... .... .... ..... .... 132
6.3.2 Major Health Problems Among Students . .... ..... .... 133
6.3.3 Reasons for Poor Health and Nutrition... .... ..... .... 134
6.4 Suggestions to Improve Health and Nutrition in Schools.... .... 137
6.4.1 Create More Responsive Systems... .... .... ..... .... 137
6.4.2 Increase Awareness Programs.. .... .... .... ..... .... 138
6.4.3 Place Restrictions on Junk Food.... .... .... ..... .... 138
6.4.4 Improve the Quality of the MDM... .... .... ..... .... 138
6.4.5 Outsource MDM.... .... .... .... .... .... ..... .... 138
6.5 Teachers’ Reflections for the Future... .... .... .... ..... .... 139
References.. .... .... .... ..... .... .... .... .... .... ..... .... 140
7 Food and Nutrition Policy: The Government Response.. ..... .... 143
7.1 Introduction .... .... ..... .... .... .... .... .... ..... .... 143
7.2 Government Policy: The National Nutrition Policy and Food
Security Act.... .... ..... .... .... .... .... .... ..... .... 144
7.3 Programmatic Response to Malnutrition.... .... .... ..... .... 147
7.4 Policy Implications... ..... .... .... .... .... .... ..... .... 154
References.. .... .... .... ..... .... .... .... .... .... ..... .... 156
8 A Health and Nutrition Framework for Primary Schools: Policy
Recommendations ... .... ..... .... .... .... .... .... ..... .... 159
8.1 Health and Nutrition of Primary School Children: Why Should
We Care?.. .... .... ..... .... .... .... .... .... ..... .... 159
8.2 AFrameworkforAddressingtheHealthandNutritionofSchool
Age Children ... .... ..... .... .... .... .... .... ..... .... 161
8.2.1 The Role of Policy Makers.... .... .... .... ..... .... 161
8.2.2 The Role of Program Implementers . .... .... ..... .... 165
8.2.3 The Role of the Community... .... .... .... ..... .... 167
8.2.4 The Role of the Family... .... .... .... .... ..... .... 169
8.3 Conclusion. .... .... ..... .... .... .... .... .... ..... .... 169
References.. .... .... .... ..... .... .... .... .... .... ..... .... 170
About the Authors
Shreelata Rao Seshadri, Ph.D. is a Professor and anchor of the Health,
Development and Society Group at Azim Premji University, Bangalore, India.
Jyoti P. Ramakrishna, MD, MPH is the Division Chief of Pediatric
Gastroenterology and Interim Vice Chair Ambulatory Affairs, Department of
Pediatrics,attheFloatingHospitalforChildrenatTuftsMedicalCenterDivisionof
Pediatric Gastroenterology and Nutrition, Boston, USA.
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