Prevalence of Malnutrition and Relationship with Scholastic Performance among Primary and Secondary School Children in Two Select Private Schools in Bangalore Rural District (India).

BACKGROUND: Malnutrition is a serious problem among children in developing countries. In India; a school meal program is in place to combat malnutrition, but only in government schools. This study is an attempt to assess the prevalence of malnutrition in primary and secondary school children in private schools and to also assess the relationship between malnutrition and academic performance.
MATERIALS AND METHODS: All 582 students from class 1-7 from two select schools in rural Bangalore, India were included in the study. Information on age of study subjects were collected from school records. Height and weight measurements were taken. BMI was calculated. Children were clinically examined for pallor. Data on height, weight and BMI was transformed into WHO 2007 Z scores and then was categorized as < -3 SD, -2 to -3 SD, > -2 SD, > 2 SD. Mathematics and English scores of the previous two class tests were taken, average scores were calculated. Statistical tests used were Chi square test, Odd's ratio, Chi square for trend.
RESULTS: A total of 582 students participated in this study. Males were 54% (315) and females were 46% (267). One hundred and fifty-nine (27%) of the children had pallor, 81 (20%) had under nutrition, 38 (7%) had stunting, 197 (34%) had thinness and 5 (1%) were found to be obese. Positive relationship was found between weight for ageZscores and English as well as Maths; Height for age Z scores with English.
CONCLUSION: Hence we conclude that the prevalence of malnutrition is high among children in private schools also; and the nutritional status of the children is strongly associated with their academic performance.

Background

Malnutrition is the largest health problem of children in developing countries. Approximately 60 million children are underweight in India and child malnutrition is responsible for 22% of the country's burden of disease.(1) One in every three malnourished children in the world lives in India. Malnutrition is more common in India than in Sub-Saharan Africa.(2)

Malnutrition in early childhood has serious, long-term consequences because it impedes motor, sensory, cognitive, social and emotional development. Malnourished children are less likely to perform well in school and more likely to grow into malnourished adults at greater risk of disease and early death.(2)

Under nutrition increases susceptibility to infection and disease, further increasing the probability of being malnourished. It also costs lives: About 50% of all childhood deaths are attributed to malnutrition.(1)

Given its impact on health, education and productivity, persistent under nutrition is a major obstacle to human development and economic growth in the country, especially among the poor and the vulnerable, where the prevalence of malnutrition is highest.(1)

Most of the studies in India have estimated the prevalence of malnutrition in children attending government schools. In India government has taken steps to combat malnutrition among school children, by providing them one nutritious meal at school called ‘mid day meal’. But mid day meal is provided by the government only in government schools but not in private schools. There is dearth of studies focusing on the nutritional status of children in private schools and also those trying to assess the relationship between malnutrition and scholastic performance. Thus this study is an attempt to estimate the nutritional status of children attending private schools and also assess if there exists any relationship between malnutrition and academic performance. By doing so, we intend to provide evidence for the policy makers to focus on nutrition of school children; irrespective of the type of school they belong to.

Objectives

To assess the nutritional status primary and secondary school children of two select private schools in rural Bangalore district, India and also;

To assess the association between malnutrition and scholastic performance among them.

Materials and Methods

A cross sectional study was done in two villages Tarabanahalli and Silvepura around 25 kms from Bangalore, India.

Participants

The study population consisted of students from class 1-7 from two select schools. Total number of students were 582. All the students who were present on the days of data collection and whose parents gave informed written consent were taken for the study.

Tools

A validated translated interview schedule was used to collect data on demographic details, dietary habits, physical activity, symptoms of any illness etc. Participants were examined for pallor. Height and weight of each participant was measured. Stadiometer was used to measure height and bathroom weighing scale to measure weight.

Procedure

Information on age of the students was collected from the school records. English and Mathematics scores from previous two class tests were recorded. Average percentage scores were calculated.

Height, weight and Body Mass Index (BMI) were measured for all the study subjects. Height was measured using stadiometer and scale. Bathroom weighing scale was used to measure weight. All the investigators were trained to measure height and weight according to standard procedures. The same were followed by the investigators. Height was recorded to the nearest 0.1 cm and weight was recorded to the nearest 0.1 kg. BMI was calculated using the formula Body Mass Index = kg/m2 .

The actual height, weight and BMI were transformed to Z scores using Anthro + package of WHO. WHO ‘Z’ score charts were used to categorize weight for age (WAZ), height for age (HAZ) and BMI for age.

Z scores were categorized into < -3 SD, -2 to -3 SD, Normal and >2 SD according to WHO 2007 Z score charts.

According to WHO 2007 Z score charts; WAZ < -3 SD implies severe under nutrition, -2 to -3 SD implies mild to moderate under nutrition and >- 2 SD implies normal/healthy status. In case of HAZ, <- 3 SD implies severe stunting, -2 to -3 SD implies mild to moderate stunting and > -2 SD implies normal status. In case of BMI < -3 SD implies severe thinness, -2 to -3 SD implies mild to moderate thinness, > -2 SD was normal and > 2 SD implies obesity.

Data analysis

Mathematics and English percentage scores were categorized into percentage scores <65% (considered second class in India) and 65-100% (considered first class in India) for statistical analysis. Z scores were categorized into <-3 SD, -2 to -3 SD, Normal and > 2 SD according to WHO 2007 Z score charts. Chi square tests, Odd's ratio and Chi square for trend tests were used for statistical analysis.

P < 0.05 was considered statistically significant.

Results

A total of 582 students participated in this study. The proportion of males was 54% (315) and females was 46% (267). The children were aged between 5-14 years of age (from 1-7 standard).

Among the students 159 (27.3%) had pallor.

Among the 410 study subjects between the age 5-10 years (for whom WHO Z scores are available for WAZ), 81 (20%) had under nutrition. Among those who had under nutrition, majority that is 72 (89%) had mild to moderate under nutrition and 9 (11%) had severe under nutrition. Among the participants and 38 (7%) had stunting. Majority had mild to moderate stunting 35 (92%) and 3 (8%) had severe stunting. 197 (34%) had thinness based on BMI (BMI < -2 SD). 139 (70%) had mild to moderate thinness and 58 (10%) had severe thinness. Five (1%) of the participants were found to be obese (BMI > 2SD) [Table 1].

Table 1

Nutritional status of students

Gender and BMI were found to be significantly associated. Significantly more number of males were found to have thinness that is BMI < -2 SD [Table 2]. Whereas no significant association was found between gender and WAZ, gender and HAZ Z scores.

Table 2

Association between gender and Z scores of BMI, weight for age, height for age

WAZ Z scores were compared with mathematics percentage scores [Table 3]. Decreasing WAZ Z scores were associated with decreasing mathematics percentage scores and this trend was statistically significant. Odd's ratio (OR) also showed a declining trend. This implies that as the nutritional status deteriorated, mathematics percentage scores also deteriorated. Statistically significant association was found between WAZ Z scores and first language percentage scores [Table 4].

Table 3

Weight for age Z scores v/s Maths percentage scores

Table 4

Weight for age Z scores v/s English percentage scores

HAZ Z scores were compared with mathematics percentage scores [Table 5]. No specific trend could be elicited. But decreasing HAZ Z scores was associated with decreasing first language scores [Table 6]. Odd's ratio showed a declining trend. In other words as the HAZ Z scores deteriorated, first language scores also deteriorated.

Table 5

Height for age Z scores v/s Mathematics percentage scores

Table 6

Height for age Z scores v/s English percentage scores

BMI Z scores were compared with mathematics percentage scores [Table 7]. OR did not follow any particular trend. The same was true with BMI Z scores and first language percentage scores [Table 8].

Table 7

BMI Zscores v/s Mathematics percentage scores

Table 8

BMI Z scores v/s English percentage scores

Discussion

This study is a cross sectional study to find the prevalence of malnutrition among private school children and also to assess the relationship between nutritional status and academic performance. Apart from establishing a high prevalence of malnutrition among children attending private schools, this study has also established a positive relationship between several indicators of nutritional status and academic performance of students in English and Mathematics. Several other studies have found similar positive relationship.(345678)

In our study children were examined only clinically for pallor and about 27% of them were found to have pallor. In a study done in rural Vadodara, India by Rachana et al.,(9) anemia was diagnosed by hemoglobin estimation and 73% of the children were found to be anemic.

In this study 81 (20%) had under-nutrition using WHO 2007 standards. Whereas 64% were undernourished using the same tool in a study done in rural Vadodara, India.(9)

In this study, among those who had under nutrition, majority that is, 72 (89%) had mild to moderate under nutrition and 9 (11%) had severe under nutrition. Whereas in the before mentioned study, 27% of children had severe under nutrition.

In our study 38 (7%) had stunting. Stunting was more among boys than girls (55% v/s 45%) and 3 (8%) had severe stunting. Whereas in the study done in rural Vadodara, India, 30.9% had stunting and it was more in girls than boys (32.4%vs. 30.8%) and 9% had severe stunting. In a study done in Africa by Charles Daboné et al.,(10) prevalence of stunting was 8.8%, which is a bit higher than in our study.

In our study, 197 (34%) had thinness based on BMI (BMI < -2 SD). 139 (70%) had mild to moderate thinness and 58 (10%) had severe thinness. Five (1%) of the participants were found to be obese (BMI > 2 SD). In the previously mentioned study, 56.9% had thinness based on BMI Z scores and 25% had severe thinness. Prevalence of thinness was 13.7% in the African study, which is marginally lower than the prevalence of thinness in our study. Overweight/obesity was low (2.3%) in the African study, which is almost similar to our study.(10)

In this study significantly more number of males were found to have thinness (BMI < -2 SD). This finding is similar to the study findings of the previously mentioned African study.

All the nutritional status indicators are better in our study when compared to the study done in rural Vadodara, India.(9) The differences in the findings may be because, the children in our study belonged to private schools, they hailed from semi-urban area and had better socio economic status. Also there existed a system of periodic health check up followed by parent teachers’ association meeting in the schools which were included in this study. Nutritional education is delivered to the parents of malnourished children in such meetings.

In this study WAZ Z scores were associated positively with both English and Mathematics scores. In a study done in South Africa by M.J. Themane et al.,(11) among rural school children studying between first to seventh standards, WAZ was strongly positively related to Mathematical performance. Findings were similar to our study.

In this study, HAZ Z scores were positively associated with English scores, whereas were not significantly associated with mathematics scores. In the South African study, HAZ was positively related to Mathematical performance and was not related to English performance. The reason for this difference in the findings is not clear.

In our study, BMI Z scores were compared with mathematics percentage scores. Odd's ratio did not follow any particular trend. The same was true with BMIZ scores and 1st language percentage scores.

Thus in this study around one-third of the children had pallor, one-fifth had under nutrition, one-twelfth had stunting, one-third had thinness and one-in-hundred were found to be obese. Positive relationship was found between WAZ scores and English as well as Maths; HAZ scores with English. Many studies have found similar relationship between malnutrition and academic performance.

Limitations

The instruments used for this study are those generally used for measuring weight and height in the community. Standard procedures were followed in using those instruments for measurements. Inter observer variation in measurement of height and weight could be a possibility.

Apart from nutritional status there could be many other factors affecting academic performance.(121314151617) Factors like social environment, study environment, learning ability, hereditary factors, gender etc. are also found to influence academic performance. But in our study our focus was mainly on the relationship between nutritional status and academic performance. Furthermore, though we have established a strong positive relationship between school childrens’ nutritional status and academic performance, it is not clear whether nutritional status of school children has any influence on success in career. This is a potential area of future research.

Conclusion

This study throws light on the nutritional status of children attending private schools. This study also shows a definite positive relationship between several nutritional status indicators and scholastic performance. Hence we conclude that malnutrition is pretty high in children attending private schools also and the nutritional status of the children is strongly related to their academic performance.

Implications on school health

Many developing countries are providing a meal every day to the school children. In India mid day meal is provided to all the children studying in government schools and private aided schools in some states, in order to improve attendance and to combat malnutrition. But government is not providing meals in fully private schools. Mid day meal is shown to improve the nutritional status of children. Through this study it is obvious that the prevalence malnutrition is quite high in private schools also. This study has also established a strong positive relationship between nutritional status of the children and their academic performance. Thus this study tries to provide a foresight to the policy makers to focus on the provision of meals in private schools as well.

Human subjects’ approval statement

The study was approved by the institutional review board as well the ethical committee of St Johns’ Medical College, Bangalore, India.