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close this bookSCN News, Number 16 - Nutrition of the School-aged Child (ACC/SCN, 1998, 80 p.)
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Nutrition of the Scholl-Aged Child

There are more children of school age, and more children going to school than ever before Around 90% of the world's children now survive beyond their 5th birthday1. These successes raise new concerns. Ill health and nutrition compromise both the quality of life of school-age children and the potential to benefit fully from what might be the only education they receive.

1 UNICEF. The State of the World's Children, 1995.

In many developing countries there are more teachers than health workers and more schools than clinics. The infrastructure of the school system therefore provides an opportunity for health services to reach children in a cost-efficient way.

This feature brings together a variety of articles, and reports of two new publications on the health and nutrition of school-age children. The papers range in content from the assessment of nutritional status in school-age children, to examples of school-based nutrition and feeding programmes in different countries. The nutritional concerns of school children in industrialised countries - concerns that are also emerging in some areas of the developing world - are also presented.

OVERVIEW TO THE FEATURE

The first article in this feature presents new data from the Partnership for Child Development, showing that nutrition problems of school children may be greater and more widespread than previously thought. Furthermore, anaemia data from the database on iron deficiency being developed by WHO indicate a higher prevalence of anaemia in school-age children than in pre-school children, although data are limited (see page 7 of this feature). It is likely, therefore, that the scale of nutritional problems in school-age children may have previously been underestimated. Indeed, one of the main conclusions from the meeting of the SCN Working Group on Nutrition of School-age Children2 in Oslo this year is that more data on the health and nutrition of school-age children are needed to assess the scale of their problems.


2 A copy of the report from the Working Group on Nutrition of School-age Children (summarised on page 25), is available on request from the SCN Secretariat, c/o WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 0456 Fax: 41 22 798 8891 Email: accscn@who.ch

A survey of donor and agency support for school health and nutrition programmes is presented on page 8 of this feature. This review reveals a surprisingly broad-based support for school nutrition and health programmes and calls for stronger collaboration between UN agencies, bilateral agencies, NGOs and the implementing countries.

The article on nutrition of school-aged children in Mongolia provides information about food and nutrient intakes of school children, and describes how the very low intake of fruit in school-age children is responsible for the intake of some essential vitamins and minerals falling below Mongolian normative values (see page 10). This description draws on information from an extensive dietary survey report, which is one of the few nutrition studies in Mongolia that has been translated into English.

There is concern that school-based systems fail to benefit children who are not enrolled in school, but who may be the most in need. Although this remains a problem, school feeding programmes can motivate children to attend school and can motivate parents to enroll their children. Food-for-school programmes, such as the national programme in India described on page 13, for example, provide 'take home' food to children with high attendance records, and are often implemented to increase enrolment and attendance, particularly for girls. Furthermore, 'school health days' could bring in non-enrolled children to receive treatments, and thus provide effective outreach to the community at large.

Practical experience gained by the Partnership for Child Development indicates that school-based health and nutrition programmes are feasible and effective, with clear potential to improve the nutrition and growth of school-age children (see below). Examples of school feeding programmes presented in this feature show varied success. In India, the government-funded Nutritional Support to Primary Education Programme (NSPE) is working well in rural areas. By the end of 1998, it is expected that the whole country will be covered by this programme. The new school feeding programme being implemented in designated 'poor' villages in Indonesia, is still in its early days. Funded entirely by the government, the recognition of its importance for the long-term future of Indonesia is signified by the fact that funding support has been maintained in spite of the recent economic crisis (see page 15). In South Africa, a case study has shown that vitamin and mineral fortification of biscuits results in a significant improvement of micronutrient status when given as a snack to school children. The biscuit is now commercially available and is actively marketed at the primary school level by the food industry (see page 16). School feeding programmes in Kenya however, have suffered from lack of funds. The Kenyan case highlights the need to monitor programme impact in order to develop more cost-effective approaches. Some other lessons that have emerged from Kenya include the key role of parents in sustaining school feeding programmes, the concerns of safety and quality of food from vendors and hawkers, and the problems of money given to children for food being spent on drugs.

The rising prevalence of obesity among school children, and the need for health education to focus on healthy eating is also presented in this feature. The article on page 22 provides an example of this focus on healthy eating, with the development of guidelines that promote healthy eating for school children in the USA. Nutrition concerns facing industrialised countries, and, increasingly, by some groups in developing countries include the problems of dietary excess and obesity, eating disorders and the future risk of chronic disease. The article on page 19 discusses these nutrition concerns. It also discusses the changing lifestyles and dietary patterns in industrialised countries, which are resulting in personal preferences driving the nutritional patterns of school children, rather than the availability of food itself. Finally, a study in Nepal has shown that in more affluent schools where convenience snacks are available, school children's food habits are changing towards a preference for modern convenience foods of poor nutritional quality.

We would like to thank Andrew Hall (PCD, Oxford University) for helpful comments during the preparation and editing of this feature.

THE PARTNERSHIP FOR CHILD DEVELOPMENT: PROMOTING THE HEALTH, NUTRITION AND EDUCATION OF SCHOOL-AGE CHILDREN

by Andrew Hall and Don Bundy

The Partnership for Child Development (PCD) was established in 1992 to conduct and promote operations research on school health and nutrition programmes, and to undertake research on the health and health education of school-age children (1). The establishment of the PCD was a response to the growing number of children who were surviving to school-age - a group which typically comprises between 20% and 30% of the population.

The 1993 World Bank Development Report, 'Investing in Health' identified school health and nutrition programmes as one of 5 priorities for public health initiatives. This, however, was based largely on theoretical analyses and there was little prior experience of large-scale programmes. The first aim of the PCD therefore, was to gain practical experience of the processes, costs and issues involved in establishing school health programmes in a variety of settings.


Figure

The PCD was set up as a consortium of donors, countries and technical institutions to develop the inter-sectoral collaborations necessary to establish or strengthen school health programmes. The Scientific Coordinating Centre for the PCD is based at Oxford University in the U.K. This international initiative helps to provide technical assistance and support in order that low-income countries can monitor and evaluate the costs, processes and impact of programmes. The programmes established so far have emphasised the development of national collaborations as a part of locally managed programmes, the core of which is the essential partnership between the health and education sectors. There are now PCD research programmes or activities in more than 14 countries around the world, supported by a broad range of international agencies (UNDP, WHO, UNICEF, World Bank), bilateral agencies (USAID, UK DFID), and charities (Rockefeller Foundation, Edna Mc-Connell dark Foundation, James S. McDonnell Foundation, Wellcome Trust and Save the Children Federation).

The practicality of the school-based approach

A core activity of the PCD is to evaluate large-scale demonstration school health and nutrition programmes. These are typically implemented by governments through the existing school system rather than through the traditional health infrastructure. The support for national programmes provides an opportunity for the typical unit of decentralised administration - usually the district - to develop methods and skills on a scale that is operationally informative and representative. In practice, the school-based health services evaluated so far have ranged in size from to 45,000 children in Viet Nam to over 3 million children in India. In Tanzania, for example, the PCD programme, called Ushirikiano wa Kumwendeleza Mtoto Tanzania, is being implemented by a collaboration between four ministries working in three districts of Tanga Region, and currently involves about 350 schools and 120,000 pupils.

The experiences of implementing these programmes have confirmed the practical benefits of the school-based approach and have led to some important conclusions (see Box below).

The effectiveness of the school-based approach

Although the impact of school health services on growth, nutritional status, parasitic infections and, in some countries, on cognitive functions, is being evaluated as a part of PCD programmes, this article will focus on nutrition. Evaluations are typically in the form of annual surveys of children both in districts where the programme is being implemented and in adjacent, comparison districts where programme implementation has not yet started.


The percentage of school children in five countries of the PCD showing evidence of undernutrition

The baseline surveys have shed new light on the extent of undenutrition and ill-health experienced by school-age children. A recent analysis of anthropometric measurements of about 14,000 schoolchildren in Ghana, Tanzania, Indonesia, Viet Nam and India (see graph above) found that a large proportion of children have stunted height and low weight when compared with NCHS reference values. Wasting is less common, although over20% of school children studied in Viet Nam and India have low weight-for-height (3). Data on the haemoglobin concentrations of 3,000 children in four of these same countries, reveal that anaemia is very common in Tanzania and Ghana (4), and is least common in school children studied in the Red River Delta of Viet Nam (see adjacent graph). This may be largely related to the occurrence of hookworm infection, urinary schistosomiasis and malaria in the African programmes. Urinary iodine and serum vitamin A data from Ghana, Tanzania and Indonesia have indicated that deficiencies of these micronutrients are more localised in nature.

Box: The practicality of the school-based approach - conclusions

· Simple, safe and effective health services such as deworming and micronutrient provision (required periodically but infrequently) can be provided through the school system.

· With minimal training, teachers can feel positive about providing health care to children, as long as the task doesn't take up too much of their time. In addition, children and parents are willing to accept teachers in this role and may perceive schools in a more favourable light as a result of such programmes.


· A school-based system is not expensive, mainly because an existing infrastructure is used. For example, in the African programmes of the PCD it costs 3-4 US cents per child to deliver an annual standard-dose tablet to treat intestinal worms. While a more complicated treatment, such as praziquantel to treat the disease urinary schistosomiasis, is more expensive to deliver at between 21-67 US cents per child, it is still relatively inexpensive compared with many other health, nutritional or educational interventions. The experiences of the PCD in both Africa and Asia have illustrated that the education and health sectors can implement a school-based programme at very low cost (2).

Surveys conducted after the programmes have been implemented are showing that school health services can have an impact on a broad range of health and educational outcomes. In Tanzania, for example, the children who had participated in the programme showed an average additional gain in height attributed to treatments with albenda-zole and praziquantel, of 1.5 cms over 16 months, and an average increase in haemoglobin concentration of 4.8 g/l. There is, however, a large margin for further improvement. In Ghana, where evidence of better growth and improvements in educational achievements were also observed, the PCD programme is now investigating whether teachers can administer iron tablets to children once a week for a school term, and assessing what impact it would have on haemoglobin concentrations.

"Baseline surveys have shed new light on the extent of undernutrition and ill-health experienced by school-age children"

Action-oriented research

The PCD also provides a focus for a broad range of research activities in the field of school health with the aim of improving interventions and health education, and to develop better measures of outcome. For example,

· a large study of the impact of treating parasitic infections on children's cognitive functions and educational performance is being undertaken in Tanzania;

· studies are being done in Ghana and Tanzania to see how children perceive the pictorial messages used in health education materials with the aim of making them more easily understood;

· studies have been done in Ghana of children to investigate the health and social factors that are associated with not being enrolled in school because such children will miss out on both education and school health services; and

· a randomised trial is being done in Viet Nam to see if health education prevents reinfection with intestinal worms.


The percentage of school children who were anaemic (haemoglobin <120g/l) in four PCD countries

The future

Efforts are now being made to scale up school health and nutrition programme activities and to help countries to develop and implement their own programmes by means of programme toolkits and guides. To this end, the PCD is working with WHO, UNICEF, the World Bank and with other international agencies working in the field of school health.

The PCD is also beginning new research studies. To strengthen the body of scientific evidence on the impact of school-based nutritional interventions, large-scale randomised trials are planned for Ghana and Tanzania to look at the outcome of programmes providing iron with and without anthelmintics in terms of growth, haemoglobin concentrations and educational achievements, and in Viet Nam of anthelmintics alone. Research studies are also underway in Uganda and India to look at the benefits of nutritional interventions such as vitamin A and anthelmintics as a part of early childhood development programmes, with the aim of improving the readiness of pre-school children for education.

Although experience of school health programmes and knowledge of the health and nutritional problems of school-age children is growing, there is still a lot to be done and much to be learned. The authors would be delighted to learn from others about their experiences and research and can place summaries of programmes and activities on a forthcoming School Health and Nutrition site on the Internet and look forward to hearing from you.

References

1. Partnership for Child Development (1997). Better health, nutrition and education for the school-aged child. Transactions of the Royal Society of Tropical Medicine and Hygiene 91,1-2.

2. Partnership for Child Development (1998a). Cost of school-based drug delivery in Tanzania. Health Policy and Planning, in press.

3. Partnership for Child Development (1998b). The anthropo-metric status of school children in five countries in the Partnership for Child Development. Proceedings of the Nutrition Society 57,149-158.

4. Partnership for Child Development (1998c). The health and nutritional status of school children in Africa: evidence from school-based health programmes in Ghana and Tanzania. Transactions of the Royal Society of Tropical Medicine and Hygiene, in press.

For further information, please contact Andrew Hall at the Scientific Coordinating Centre, Partnership for Child Development, Wellcome Trust Centre for the Epidemiology of Infectious Disease, Oxford University, South Parks Road, Oxford OX1 3PS, UK. Tel: 44 1865 281231 Fax: 44 1865 281245 Email: child.development@zoo.ox.ac.uk Web: http://www.ceid.ox.ac.uk/child/

Don Bundy (Head of Centre) and Andrew Hall (Field Programmes Coordinator) are at the Scientific Coordinating Centre for the Partnership for Child Development at Oxford University. Partnership country programmes are coordinated by: Dr. Sam Adjei (GPCD, Health Research Unit, P.O. Box 184, Accra, Ghana); Prof. Charles Kihamia (UKUMTA, P.O. Box 9383, Dar es Salaam, Tanzania); Prof. Satoto (Mitra, Research Institute, Diponegoro University, Semarang, Central Java, Indonesia), Prof. Tara Gopaldas (124/B, Varthur Road, Na-gavarapalayam, Bangalore 560016, India); Prof. Ha Huy Khoi (VPCD, National Institute of Nutrition, 48 Tang Bat Ho, Hanoi, Viet Nam).

ANAEMIA IN SCHOOL-AGED CHILDREN
by Bruno de Benoist and Yun Ling

Iron deficiency is the most widespread micronutnent deficiency in the world today. The anaemia it causes is a major problem among women and young children, but there is growing evidence that it is also a problem among school-aged children. Its importance as a public health problem in school-aged children deserves greater attention not only because of its deleterious effects, which include lower school achievement due to impaired cognitive development, fatigue and poor attention span, and increased morbidity because of reduced resistance to infection, but also because of the large numbers of school-age children affected. Indeed, recent estimates based on the WHO global database suggest that 7.8% of school-aged children in industrialised countries and 53% in developing countries are anaemic. Prevalences are highest in Asia (58.4%) and Africa (49.8%) where around half of school-aged children suffer from anaemia. Moreover, in developing countries, the proportion of school-aged children with anaemia is much higher than that of pre-school children (see graph).


Prevalence of anaemia in pre-school and school-age children

These estimates should be interpreted cautiously since they are based mainly on subnational surveys from a limited number of countries for the regions mentioned. They nevertheless serve to draw attention to anaemia as a problem of public health importance in this age group and highlight the need for more information on its magnitude and causes so that appropriate control measures can be adopted. Countries in general, and developing countries in particular, can ill afford to allow their youth be damaged by so devastating a public health problem as anaemia.

Data come mostly from subnational surveys. For pre-school children, data are from 118 countries equally distributed between regions; for school-aged children, data are from 30 countries mainly from Africa (9 countries), Asia (10 countries) and America (9 countries). Anaemia is defined from haemoglobin concentration using 110g/l as cut-off for the 0-4y age group, and 120g/l as cut off for the 5-14y age group.

The WHO Micronutnent Deficiency Information System (MDIS) includes three databases on iodine, vitamin A and iron. The database on iron deficiency (from which information has been taken for this article) is currently being developed, and WHO welcomes new contributions to this database. For further information about how to contribute to the database, please contact Bruno de Benoist, Programme of Nutrition, WHO, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 3412 Fax: 41 22 791 4156 Email: debenoistb@who.ch

SCHOOL-BASED HEALTH AND NUTRITION PROGRAMMES: A SURVEY OF DONOR AND AGENCY SUPPORT

by Don Bundy, Judy McGuire, Andrew Hall and Carmel Dolan

There are more children of school age and more children attending school than at any time in human history. These children are one of the most accessible population groups from a public health perspective because they are gathered together on an almost daily basis and because they are supervised by a trained workforce of teachers. They are also a group which can benefit considerably from nutrition and health interventions: good health and adequate nutrition promote both physical growth and learning, while good health and nutrition education at school age can lay the foundation for life-long good health.

Given the apparent opportunities for school-based health and nutrition programmes, the SCN Working Group on Nutrition of School-age Children commissioned a survey of what donors and agencies are actually doing for school children. The survey method was to conduct key informant interviews over a two-month period in early 1998, and to present the results for further discussion at the Working Group meeting in Oslo, April 1998. A major conclusion of this review process was that there was much more happening in school nutrition and health than was commonly perceived, and also that the activity involved UN, financial, bilateral and NGOs in partnership with implementing countries.

Many UN agencies have strategies or policies on school-based health and nutrition. UNICEF has articulated a school health and nutrition strategy that encompasses sound school policies and the rights of school children, skills-based health education, a healthy school environment, and improved access to health services for school children. UNDP was a founding co-sponsor of the Partnership for Child Development in 1992 and has continued to support operations research into the contribution to sustainable human development of health and nutrition at school age. WHO launched a Global School Health Initiative in 1996 with a focus on health promoting schools and regional networks1. The Health Education and Promotion Division is the focal point for the 8 Divisions which contribute to the steering group for school health and nutrition, but some 22 divisions at WHO are reported to be active in this area. UNFPA supports reproductive health programmes for adolescents in 98 countries, and school-based HIV/AIDS prevention activities in 95 countries. UNESCO supports the integration of HIV/AIDS education into the school curriculum and is a co-sponsor of UNAIDS, which has a specific working group on school based interventions. UNESCO also provides technical support for the WFP's school feeding activities which are underway in some 60 countries. FAO is currently field testing school-based nutrition education materials to promote dietary diversification and food security (see page 53).

1 Editor's note: A new WHO fact sheet (No.92; June 1998) on 'WHO'S Global School Health Initiative: helping schools to become "Health-Promoting Schools" is available on the web at http://www.who.ch/. The goal of the WHO Global School Health Initiative is to increase the number of schools that can be called 'Health-Promoting Schools'. Such schools are characterised by their constant strengthening of capacity to provide a healthy setting for living, learning and working. Further information can be obtained from the recent WHO publication 'Promoting Health through Schools', 1997, WHO Technical Report Series 870. pp.94 CHF 17 (CHF 11.90 in developing countries). Available from WHO distribution and sales, CH-1211 Geneva 27, Switzerland. Tel: 41 22 791 2477 Fax: 41 22 791 4857 Email: publications@who.ch

Perhaps because school health and nutrition programmes are necessarily intersectoral, many of these activities are being implemented in partnership. This has been achieved formally, for example, by UNAIDS efforts to promote HIV/AIDS education in schools, co-sponsored by UNICEF, UNESCO, UNFPA, WHO and the World Bank. A looser partnership was created by the UNICEF School Based Initiative in 1994 which, through a series of technical support group meetings in Asia, Africa and the Americas, brought together WHO, UNFPA, UNESCO, the World Bank and NGOs to create a 'Situation Analysis Tool for School Health and Nutrition Programming' (available on request from the PCD, see contact information). This partnership continues to grow: the tool has been evaluated by WHO in 5 African countries, with support from the Edna McConnell dark Foundation, and is currently being evaluated for use in Spanish-speaking and Francophone countries by PAHO and US-AID.

It appears that few bilateral agencies have specific policies which promote the health and nutrition of school children, but nevertheless most contribute significantly. Since 1992, CIDA has provided Can$87 million for nutrition projects. These actions specifically help school children: e.g., the elimination of iodine deficiency disorders (IDD) and vitamin A deficiency in school gins in the Indian Sub Continent, and school-based IDD monitoring in South America. The CIDA/WFP Women's Health and Nutrition Facility targets 0.9 million women and 2.2 million children, including school children, in 15 low-income countries with food, micronutrients and deworming. DFID, UK, supports the integration of health and nutrition education into school curricula, funds the School Health Action and Training Project for teachers in 700 schools in Delhi and Bombay, provides US$7 million worth of school-based health services in Andra Pradesh, and has provided water and sanitation for 800 schools in Kenya; yet DFID has no specific policy for the health of the school-age child. DANIDA, NORAD and SIDA also have no specific policy for the health of the school child, but provide major support for information-education-communication (IEC) and life skills to promote health - particularly reproductive health - to be integrated into school curricula. For example, the Regional Adolescent Social and Reproductive Health Project implemented by AMREF in Kenya, Tanzania, Uganda and Ethiopia is co-funded by NORAD and SIDA. In 1997, GTZ identified adolescents as a neglected group, and recommended increased programming in life skills training for youth health, HIV/AIDS and nutrition -particularly in Africa. USAID has both a policy for promoting the health of school children - in Africa and the Americas - and active programmes providing school-based health services, including interventions (such as micronutrient provision and deworming) and skills-based health education.

Much of the practical implementation of school health and nutrition activities is undertaken by international or local NGOs, even if funded by bilateral and other agencies. A survey of 10 major INGOs revealed that all were active in IEC and skills-based health education in schools, and a majority were promoting a healthy school environment and the provision of school-based health and nutrition services. These programmes are often very substantial. World Vision (Canada), for example, has a CIDA-sponsored Can$25 million programme in Ethiopia, Ghana, Malawi, Senegal and Tanzania that will, as one component, provide IEC, vitamin A and iron to school children and sanitation to schools. Catholic Relief Services is providing school-based IEC, feeding, specific micronutrients and first aid kits, in various combinations, in 10 countries, while Save the Children Federation (USA) is providing school-based IEC with or without micronutrient supplements and deworming in 15 countries. The coverage of IEC may be very extensive, for example, the

Children's Health and Environment magi zine supported by CARE in Thailand is read by more than one million students in 31,000 schools.

The multilateral financial organisations also play an increasingly important role. The Inter American Development Bank and the Asian Development Bank both provide loans in support of school nutrition and health programmes. The World Bank was amongst the first to identify school-based health and nutrition programmes as remarkably equitable and cost-effective interventions that contribute to human capital and social capital development. The World Bank, mainly through the International


Figure. (Courtesy of UNHCR)

Development Association, currently supports programmes that seek to deliver a simple package of locally-relevant health and nutrition interventions through schools, delivered on a scale that is a benefit rather than a burden on the education services. Such activities are typically small components (2% to 9%) of universal basic education projects (with total budgets in the range of US$35 to 60 million), but are also components of health and nutrition projects (with total budgets in a similar range), community funds for health, nutrition or education (with total budgets in the range of US$50 to 110 million), and Sector Investment Projects (with total budgets in the US$1 00s of millions). To enhance responsiveness to the needs of client countries, the World Bank has entered into productive partnerships with UN agencies (e.g., PAHO/WHO in Latin America and the Caribbean), INGOs (e.g. SCF (USA) in Africa) and technical groups (e.g. the PCD) as part of an International School Health Initiative (for further details of World Bank activity see page 22 'Class Action' by Joy del Rosso and Tania Marek).

Overall, this survey reveals surprisingly strong and broad-based support for school nutrition and health pro- grammes. There may be a need to explore ways to build beyond the current levels of collaboration, and perhaps the SCN Working Group on Nutrition of School-age Children can contribute to this. Almost all UN agencies, funds and organisations with a mandate in health, nutrition or education have a specific policy to promote the health and nutrition of the school-age child, and most have active programmes in this area. The bilateral donors are active in the area, but curiously few have articulated specific health and nutrition policies for school children. This may reflect the ambiguities of the intersectoral status of some school "health" activities; school feeding, for example, is often seen as promoting school attendance and learning, and thus as contributing to educational rather than health outcomes. Or it may reflect a lack of recognition that programmes to promote adolescent health - a major area of current emphasis for prevention of HIV/AIDS, substance abuse, and violence - are frequently school-based in low income countries. The INGOs have clearly grasped this concept, and are expanding their definition of school health and nutrition to include school-based services, such as snacks, micronutrient provision and deworming. It seems to be this minimum package - health education and simple, well-tried health and nutrition services, both deliv ered through schools - that is emerging as a practical definition of a school-based health and nutrition programme.

This survey is a work in progress. If you would like a copy of the latest draft of the report, or if you would like to contribute to the survey, please contact Andrew Hall at the Scientific Coordinating Centre of the Partnership for Child Development, The Wellcome Trust Centre for the Epidemiology of Infectious Disease, University of Oxford, South Parks Road, Oxford OX1 3PS, UK. Tel: 44 1865 281231 Fax: 44 1865 281246 Email: child.development@zoology.ox.ac.uk

The survey was supported by a World Bank Special Grant and was conducted by Carmel Dolan with the Partnership for Child Development. The Partnership for Child Development programmes and activities are supported by the UNDP, the WHO, the British Department for International Development, UNICEF, the World Bank, the Edna Mc-Connell dark Foundation, The Rockefeller Foundation, the James S. McDonnell Foundation, and the Wellcome Trust.

Don Bundy is at the Human Development Network Education Department at the World Bank, Washington D.C. and at the Wellcome Trust Centre for the Epidemiology of Infectious Disease, University of Oxford; Judith McGuire is at the Latin American and Caribbean Human Development Network at the World Bank, Washington D.C.; Andrew Hall is in the Scientific Coordinating Centre of the Partnership for Child Development, University of Oxford; Carmel Dolan is a Freelance Consultant.

NUTRITION OF SCHOOL-AGED CHILDREN IN MONGOLIA

by Ruth English

The population of Mongolia (2.3 million people) is relatively young, with 38% under the age of 15 years (1). Fifty-two percent of the Mongolian population live in urban areas and 48% live in rural areas, with approximately 20% of the population being nomadic. Since the break-up of the Soviet Union at the beginning of the decade, the economy of Mongolia has been in transition, changing from a communist-based to a capitalist-based economy. This has meant much hardship for the Mongolian people. As the support base for the agriculture system and the social welfare programme services has eroded, agricultural production has fallen drastically and unemployment and poverty are increasing. The cities have large numbers of people concentrated in ger (tent) settlements with 60,000 families in the capital city of Ulaanbaatar. There are associated problems relating to safe drinking water, adequate sanitation and waste disposal, and increased levels of soil pollution. These living conditions contribute to ill-health and an unsatisfactory quality of life.

Education situation

Educational achievement has been high with a 95% literacy rate, 98% primary school coverage, 88% coverage for 8 years of schooling and 15% in higher levels. However this may be falling with increasing poverty and unemployment.

Nutrition situation of school children - nutrient intake

From 1993 to 1996, the National Nutrition Research Centre conducted dietary surveys on some 21,000 persons, including school children. The data collection comprised a 24-hour recall of food eaten the previous day, using a questionnaire form for response. The report of the Nutritional status of the Mongolian population (2) details the nutrient intakes of pre-school and school-age children in four age groups: 4-7y, 6-10y, 11-14y, and 15-17y. For the two older age groups, the nutrient intakes of boys and girls were estimated separately.

Nutrient intakes of school children in Mongolia

Nutrients

Age Groups


4-7 y

8-10y

11-14y

15-17y


Boys

Girls

Boys

Girls

Protein (g)

75.6

69.0

64.7

56.2

73.0

57.4

Fat (g) - Plant

8.7

14.4

29.9

9.3

14.4

11.2

Fat (g) - Animal

22.4

25.4

40.6

28.9

34.0

29.0

Fat (g)-Total

31.1

39.8

70.5

38.2

48.4

40.2

Carbohydrate (g)

284.8

286.4

256.5

202.2

274.2

211.0

Energy (kcal)

1711

1780

1920

1378

1824

1435

Vitamin A (mg)

0.70

0.50

1.28

0.57

0.67

0.60

Vitamin B1 (mg)

0.88

0.90

0.94

0.75

0.98

0.82

Vitamin B2 (mg)

0.91

0.94

0.89

0.85

1.10

0.88

Niacin (mg)

8.54

8.87

20.3

7.70

10.5

8.00

Vitamin C (mg)

8.1

14.7

10.9

10.8

16.7

16.8

Calcium (mg)

180

202

720

186

217

227

Iron (mg)

11.0

15.0

---

12.1

16.0

12.4

% energy from protein:fat: carbohydate

18:16:66

16:20:64

14:23:53

16:25:56

16:24:60

16:25:59

The figures for vegetable consumption were not included in the report. The very low intake of fruit and possibly also vegetables was responsible for the low intake of some vitamins (e.g., vitamin C) and minerals, which fell well below the normative values for nutrient intakes developed for Mongolia in 1981 (3). It was noted that eggs and rice were not consumed at all. The low intake of milk and milk products explains the overall low intake of calcium and vitamin B-2, while the low consumption of vegetable oil, butter, milk and milk products result in the generally low intake of fat.

The energy intakes of the younger age groups are high in comparison with those in the 11-14y and 15-17y age groups - particularly in girls (see table above).

With regard to micronutrients, intakes of some essential vitamins and minerals in all age and sex groups are below the recommended levels developed for the Mongolian population (3). In particular, intakes of vitamin C, vitamin B-2, and calcium are low, although the calcium intakes of boys aged 11-14 years appear to be adequate. Iron intake could be considered low for girls of puberty age (11-14y and 15-17y). However, this level of intake may actually be adequate as a major source of the iron would be in the form of the more absorbable haem iron from meat products.

Food intake among school children

The average daily intakes of foods for school children (aged 4-17y) are as follows:

Meat and meat products

158.6g

Milk and milk products

282.4g

Flour and flour products

205.3g

Butter

6.0g

Fat

0.4g

Rice

211.6g

Fruit

4.6g

Nutrition situation of school children - malnutrition

There is evidence of nutrient deficiency diseases among school children in Mongolia. Meat and dairy products have traditionally formed the main part of the adult diet with flour and flour products. Dietary patterns have been changing over the period of economic transition, particularly in relation to the consumption of milk and milk products. Especially in the cities and towns, the availability of milk has been decreasing, partly due to a breakdown in the milk marketing systems from rural to urban areas.

Underweight

The National Nutrition Research Centre has conducted a series of anthropometric surveys in children under 5 years of age to determine the prevalence of undenutrition in young children in this country. While the overall prevalence of underweight (low weight-forage) has decreased from 1992 to 1996, there has been an increase from 29.4 to 42% amongst children aged 25-48 months and from 0 to 13% amongst children aged 49-60 months. These results are indicative of an increasing problem of malnutrition and growth failure in children as they enter the school system.

Micronutrient deficiencies

There are three priority micronutrition deficiency diseases in Mongolia that primarily affect women and children:

· Vitamin D deficiency. There is a major problem of vitamin D deficiency in Mongolia. Surveys have identified prevalence rates of rickets varying from 6% to 68% in different populations, with an average prevalence rate at 3 years of 26.5%. In the 1992 child survey, 44.7% of children under five had one or more signs of rickets with bowing of the tibia being the most common sign. The cause of vitamin D rickets in Mongolia is as yet ill-defined, but the data indicate that many children carry the handicap of bone malformation from rickets through their school years into adulthood.

· Iron deficiency anaemia: The prevalence of iron deficiency is now reported to be as high as 28.8% in pregnant women and 43.6% in children below five years of age. No data are available on the prevalence of iron deficiency anaemia in children of school-age.

· Iodine deficiency diseases: In 1992, 1490 children aged 7-12 years from eight schools, were examined to determine the prevalence of iodine deficiency disorders (IDD). Two of the eight schools were on remote state farms. The survey showed an overall prevalence of 41% (range 24-83%), with children in the Bulgan area or Aimag, most at risk. Clinical signs of dysfunction of the thyroid were identified in 1.5% of the children. Overall, it is estimated that 28% of the population has goitre. Iodine fortification of salt is the major strategy being pursued to reduce and control 100. Six plants produce salt in Mongolia. In 1996, it was estimated that 40% of households were using iodised salt. The small additional cost of fortified vs. unfortified is reported to be a deterrent to purchase of the iodised salt by poor families.

Other micronutrient deficiencies: In some country reports, reference is also made to the risk of vitamin A and vitamin C deficiencies in Mongolia. One survey indicated a prevalence of night blindness in 4.5% of a group of children, as reported by mothers. No evidence is available indicating that vitamin C deficiency has been clinically identified in school children or adults in Mongolia.

References

1. State Statistical Office of Mongolia. Mongolian economy and society in 1996. Uaanbaatar, 1997.

2. National Nutrition Research Center. Nutritional status of Mongolian population. Ulaanbaatar, 1997.

3. Ministry of Agriculture and Industry. Physiological norms for nutrient intakes for the Mongolian population. Ulaanbaatar, 1981.

Ruth English is a Nutrition Consultant and Honorary Research Consultant at the Department of Social and Preventive Medicine, University of Queensland, Australia. Postal address: P.O. Box 1491 Noosa Heads, Qld, Australia, Tel/Fax: 61 7 5449 2015 Email: renglish@ozemail. com.au This article is based on information obtained during a consultancy in Mongolia in May/June 1997.

SCHOOL FEEDING PROGRAMMES

School feeding programmes are one of several interventions that can address some of the nutrition and health problems of school-age children. If properly designed and effectively implemented, school feeding programmes can achieve a number of goals:

· alleviate short-term hunger, thus increasing attention and concentration span;

· encourage (or be used specifically to encourage) enrolment by gins and improve retention;

· motivate children to attend school and motivate parents to enroll their children in school;

· contribute to better nutrition and address specific micronutrient deficiencies in school-age children (especially iron and iodine deficiencies which directly affect cognitive development);

· increase community involvement in schools.


A series of three documents entitled "School Feeding Programmes: Food for Education" have been prepared by Joy del Rosso under the auspices of the Partnership for Child Development (see page 4) to provide governments, agencies and organisations with up-to-date information:

Part I: Summary of Major Issues and Recommendations
Part II: A Review and Annotated Bibliography
Part III: Guidelines for School Feeding Programmes to Contribute to Improving the Effectiveness and Efficiency of Education

Copies are available on request from the Partnership for Child Development, Wellcome Trust Centre for the Epidemiology of Infectious Disease, Oxford University, South Parks Road, Oxford OX1 3PS, UK. Tel: 441865 281231 Fax: 441865 281245 Email: child.development@zoo.ox.ac.uk Web: http://www.ceid. ox.ac.uk/child/

INDIA'S NATIONAL PROGRAMME OF NUTRITIONAL SUPPORT TO PRIMARY EDUCATION PROGRAMME (NSPE)

by Tara Gopaldas

On August 15th 1995 (India's 48th Independence Day), the Government of India launched the National Programme of Nutritional Support to Primary Education (NSPE). A number of converging and positive factors contributed towards the launch of NSPE. These were:

· a strong political commitment at both central and state levels to universalise primary education;

· the decision by the Government of India to redeem the national pledge of allocating 6% of the national income for primary education;

· successive bumper harvests, the success of the 'Green Revolution' and the development of a large-scale public distribution system;

· the excellent report of the Committee on Mid-Day-Meals (1) which is the Plan of Action instrument for the NSPE1;

1 The NSPE is the current Mid-Day-Meal Programme (see SCN News No.14p23).


· numerous research studies and publications in the 1980s and 1990s stressing the link between nutritional status and educational performance;

· a number of national and international surveys and studies to highlight the extremely poor nutritional and health status of the school child;

· some success stories of the cost-effectiveness of improving the micronutrient (iron, iodine, vitamin A) and health (intestinal parasites, impaired sight and hearing) status of the school child in the classroom itself;

· the strong recommendation of the Government of India that the NSPE should forge links with school health on the one hand, and with India's Integrated Child Development Services (ICDS - see SCN News No.15 p27) on the other.

Aims, coverage and budget of the NSPE

The main aim of the NSPE is to give a boost to the universalisation of primary education in India by increasing enrolment and attendance at schools, and simultaneously improving the nutrition education of the school child (aged 6-15y). It is much more a food for education scheme than a food for nutrition and health scheme as it is based on supplying those students with a good school attendance record with grain (wheat or rice) over a period of time. A school child with 80% attendance is supplied with 3kg grain per month for 10 academic months per year. The child or parent is expected to collect the grain from the designated ration (or public distribution) shop in the village.

The quantity of grain ration was guided by the findings of a 1990-1992 Eight-States Diet and Nutrition Survey conducted by the National Nutrition Monitoring Bureau (2). The survey found that the nutritional status of the rural school child was very poor, with only 6% classified as 'normal' when compared to the NCHS growth reference. The survey reported an average deficit of 620kcal and about 7g protein per day when compared to the Indian Recommended Daily Intake for this age group.


School boys eating a hot cooked meal in the classroom. (T. Gopaldas)

The NSPE has been operational for around three years. In 1995-6, 225,000 schools and 33.5 million school children were covered by the NSPE. This number rose to some 370,000 schools and 55.4 million school children in 1996-7. Attendance also increased from 21 million children in 1994 to 55 million in 1997. The NSPE has also helped to boost enrolment in primary schools.

All 32 states and union territories (UTs) of India are implementing the NSPE. Seven of these 32 states and UTs, namely, Gujarat, Haryana, Jammu & Kashmir, Kerala, Madhya Pradesh, Orissa, Tamil Nadu and the UT of Pondicheny, are providing school children with a hot cooked mid-day meal. This is usually a cereal-pulse preparation with some condiments and seasonal vegetables. The remaining states and UTs either prefer not to give meals, or are not ready at present to make the necessary arrangements for provision of a hot cooked meal and have opted to provide school children with 3kg of grain per month for an 80% attendance record.

Once the 'hot cooked meal' becomes the norm in India, with the majority of states and UTs providing hot meals, 5kg per month of grain per school child for 10 academic months will be supplied within those states and UTs that are not able to run a 'hot cooked meal' programme. This is based on the argument that other members of the family in addition to the school child will consume the 'take-home' grain ration.

The NSPE is a 100% Central Government sponsored scheme. The cost of the food grains and transportation are borne by the Central Government. In the case of hot cooked meals, the States or UTs have to bear all other costs (kitchens, cooks, fuel etc.) Rs.8000 million was spent in 1996-7 (equivalent to approx. 190 million US$), and Rs.9600 million has been allocated in 1997-8 (equivalent to approx. 225 million US$).

Preliminary reports indicate that the NSPE is working well in the rural sector but not so well in the urban sector where the ration shops may be located far away.


School girls receiving iron, vitamin A and anthelmintics in the classroom. (T. Gopaldas)

Monitoring and evaluation

The Government of India is developing a computerised Management Information System with the assistance of the National Informatics Centre in New Delhi in order to record data on enrolment, eligible beneficiaries for NSPE, and quantity of food grains allocated, collected and utilised. The system is not, as yet, fully operational as training at the state and UT level is required.

An all-India process and impact evaluation of the NSPE is urgently required. The reactions of the main actors, namely the school child, the teacher, and the local ration shop keeper are yet to be evaluated. Similarly, whether or not linkages have been formed with the primary health centres, the village Panchyats and the ICDS has to be ascertained. Furthermore, the advantages and disadvantages of the 'take home' grain ration versus the hot cooked meal variant have to be assessed. Above all, if the NSPE has an important nutritional status improvement objective, then its impact in this crucial area has to be evaluated.

How can the present NSPE be made to have a more nutritional and health slant?


· The NSPE must put nutrition and health objectives ahead of enrolment, retention and drop-out objectives.

· The NSPE must set a time-frame, say by the year 2000, where every primary and middle school child will receive a hot cooked meal.

· The NSPE must insist that a good brand of iodised salt be used in the hot cooked meal variant. India has the capability to produce the required quantity of iodised salt.

· In Indian communities, school-aged children are the age group most heavily infected with intestinal parasites. Hence, periodic deworming is a must. India has the capability to produce the required quantity of an-thelmintics and dosing can and should be given by the teacher in the classroom.

· Weekly iron supplementation can and should be given by the teacher in the classroom. India also has the capability to produce the required quantity of iron supplements.

· India is one of the most vitamin-A deficient countries in the world. Legislation should make it mandatory that red palm oil, which is abundantly rich in b-carotene, be used in the hot cooked meals.

At present, India has a school-age population of approximately 200 million children. Policy-makers and implementers of the NSPE must realise that it would benefit the school child more to give him/her a health package of deworming, iron, vitamin A and iodine, rather than just grain. At Rs.10 (approx. 0.2 US$) per child per year, such a health package, delivered in the classroom throughout India, would cost Rs.2000 million a year versus a yearly expenditure of some Rs.10 000 million for the grain. The best proposition would be to give the school child both the hot meal and the health package in the classroom.

References

1. Nutrition Support to Education: report of the Committee on Mid-Day-Meals, New Delhi, May 1995.

2. Diet and Nutrition Surveys in Eight States of India on Rural Children (6-11y). National Nutrition Monitoring (Rural) Surveys, National Institute of Nutrition, Hyderabad, 1990-2.


Tara Gopaldas is Director of Tara Consultancy Services, 124-B, Varthur Road, Nagavarapalya, Bangalore-93, India. Tel: 91 80 5242999 Fax:91 80 5288098

SCHOOL FEEDING IN INDONESIA: A COMMUNITY BASED PROGRAMME FOR CHILD, SCHOOL AND COMMUNITY DEVELOPMENT

by Lisa Studdert and Soekirman

In July 1996, Indonesia initiated a national school feeding programme. Initially implemented in all officially designated 'poor' villages except those on the islands of Java and Bali, the programme expanded in year-2 of implementation to include all 'poor' villages throughout Indonesia. The programme now provides a nutritious snack three times a week to 7.2 million primary school children. In developing this programme, the Government of Indonesia has adopted a unique approach to school feeding with community-based implementation involving several community groups, utilisation of local foods, and education and health components. This design is aimed at an overall programme goal of human resource development while addressing several objectives that target human, economic and social development at the community level. The sustainability of the programme will depend on the empowerment of all involved people -especially women. The objectives and the programme design recognise that improvement in children's health, nutritional status and educational achievements requires interventions that extend beyond the school child in the schoolyard or classroom.

Human resource development in Indonesia

The Government of Indonesia has recognised human resource development as a key objective of its second (current) 25-year Development Plan. In the 1970s, the government launched a primary school development programme ensuring that every village in the country has a primary school. Building on this, the current 5-year Development Plan (1994/95-1998/99) has directed that all children should receive a minimum of nine years of schooling. There was concern, however, that these efforts have focused more on the infrastructure and policy than on the child and the child's capacity and ability to be in school and learn and progress effectively. Surveys in the early 1990s showed that up to 70% of children in 'poor' villages were consuming less than 70% of the their daily energy requirements; up to 40% of children are anaemic and between 50-80% of children have worm infections. Moreover, it is estimated that each year around 1.2 million children - or 4.2% of the eligible population - drop out of school.

Thus, the Programme Makan Tambahan Anak Sekolah (supplemental food for the school child - PMT-AS) was pilot tested in several provinces in the early 1990s and introduced as a national policy, with presidential endorsement, in 1996. Expenditure in 1997/98 was over US$ 100 million.

PMT-AS: the why and how

The objectives of the PMT-AS programme are divided into those for the school child, those for the school and those for the parents and community.

PMT-AS Objectives

For the child:

-reducing absenteeism;
-alleviating short-term hunger;
-increasing total energy intake;
-educating children on topics of health and nutrition;
-reducing worm infection rates through the provision of deworming medication twice yearly.

For the school:

-improving teachers knowledge on teaching health and nutrition topics.

For the parents and community.

-knowledge and involvement of parents in children's health, nutrition and education;
-increased demand and appreciation for local agricultural produce.

Implementation of the programme revolves around the provision of a mid-morning 'snack' to primary school children three days per week through the school year (9 months). The term 'snack' is deliberately used so that there is no impression that the food is a meal that replaces food children would receive at home thus ensuring, as much as possible, that the snack received is additional and not substitutional. Children are also given deworming medication twice per year.

Funds, based on a per-snack, per-child, per-day amount are sent from the national level directly to the local level. Only the school principal may withdraw funds from the bank, and only with a snack menu plan co-signed by the heads of the local women's and parent's associations. The menu plans are prepared at the community level with technical advice from Ministry of Health personnel. It is stipulated that menus must use locally produced foods and that the snack must contain a minimum of 300 calories and 5g of protein. The compulsory use of locally produced foods is key to ensuring PMT-AS funding is directed into, and kept within, the local economy. Hence, PMT-AS provides incentives for intensified local production as well as for home garden produce and school gardens. Through this mechanism, PMT-AS is expected to contribute to national poverty eradication programmes (see diagram).


Figure

Hypothetical relation between PMT-AS and village economy

The process for food purchase and preparation is not strictly defined, but training and guidelines have been provided suggesting that the local women's association (PKK) and the school parents association (BP3) develop a system acceptable and appropriate to that community. Observations in the field have shown a wide range of practices involving between 1-15 women - some villages with a core group that does all the work, others with teams that work on a rotating basis. Support and guidance are expected from the village leader, local Ministry of Health and Education officials and school officials.

A programme for the future and in a crisis

It is intended that the PMT-AS school feeding programme will be a long-term government initiative in Indonesia. Funded entirely by government resources, the recognition of its importance for the long-term future of Indonesia is signified by the fact that funding support has been maintained in spite of the economic crisis that has recently affected Indonesia.

In the life of such a programme it is still early days. The government plans to start comprehensive monitoring and evaluation activities in the coming year - year 3 - of implementation. The results of these activities will be used to modify and enhance implementation processes and related training activities and guidelines. Moreover, these results should start to assess programme impacts so that the value of this programme can be analysed, appreciated and shared with other nutrition, health and education policy makers and programme planners around the world.

Lisa Studdert is a doctoral student at Cornell University, Ithaca, New York, USA, carrying out research in Indonesia in 1998 on the PMT-AS programme. Tel (c/o UNICEF, Jakarta): 62 21 570 5816 Fax: 62 21 571 1326 Email: lisa@cim.com.au or ljs10@comell.edu Dr Soekir-man is Professor of Nutrition at the Agriculture University, Bogor, Indonesia. Tel: 62 21 7987 993 Fax: 62 21 7987 130 Email: skirman@rad.net.id

ADDRESSING MICRONUTRIENT DEFICIENCIES IN PRIMARY SCHOOL CHILDREN WITH FORTIFIED BISCUITS

by Lize van Stuijvenberg and Spinnie BenadI>

Early in 1995, after having been approached by the community leaders of a rural village in KwaZulu-Natal, South Africa, the South African Medical Research Council undertook a cross-sectional nutritional survey in that community. The results showed deficiencies of iron, iodine and vitamin A; the prevalence of vitamin A and iodine deficiencies exceeded the level regarded by the WHO as a public health problem. These deficiencies were also present among the children attending the local primary school, despite the fact that a school feeding scheme, whereby the children received a cooked meal five days each week, had been in operation for a period of two years prior to the survey. 16% of the children were stunted and 2% were underweight.

An intervention study, in collaboration with the local community leaders and the food industry, was then undertaken to determine whether the micronutrient deficiencies present in the school children could be alleviated through food fortification. A shortbread type of biscuit was identified as a suitable vehicle for fortification. A similar biscuit is sold by the shops in the area and is very popular amongst the school children. The biscuit was fortified with b-carotene, iodine and iron (50% of the RDA), while a cold drink served as a carrier for vitamin C which was necessary to enhance the absorption of the iron. Two hundred and fifty-two 6-11-year-old children were randomly allocated to a group that received a fortified biscuit and cold drink, or to a group that received an unfortified biscuit and cold drink. The biscuits and cold drinks were distributed daily during the school week, during the first two hours of the school day, for a period of 12 months. No intervention took place during school holidays or on public holidays. Distribution and consumption took place under close supervision and compliance was recorded daily. To exclude parasitic infestations as a confounding factor, the children of both groups were dewormed.

The 12-month intervention resulted in a significant improvement in blood levels of vitamin A, ferritin, iron, haemoglobin, haematocrit and in urinary iodine levels in the group who received the fortified biscuits compared to the unfortified group. The greatest improvement in vitamin A and ferritin status was seen in children with low values at the start of the study, while the intervention had little effect on those with adequate status: i.e., those that needed it most benefited the most from the intervention. The prevalence of low serum vitamin A levels (<20 µ/dl) dropped from 39% to 12%, of low serum ferritin levels (<20 µg/l) from 28% to 14%, and of anaemia (<120 g/l) from 30% to 16%. There were no significant reductions in the group receiving the unfortified biscuit. The prevalence of low urinary iodine levels (<10µg/dl) in the fortified group decreased from 98% to 30% after 6 months, and to 5% after 12 months. In the unfortified group the prevalence decreased from 96% to 90% and 34% after 6 months and 12 months, respectively. The iodisation of salt became compulsory in South Africa during the second half of our study, thus contributing to the improvement in iodine status in both the fortified and unfortified groups. There was no reduction in the prevalence of goitre, which was 21% at the baseline assessment; a 12-month period may, however, have been too short to reverse an already enlarged thyroid. The biscuit was well accepted and 74% of the children indicated that they would prefer more than the three biscuits they were receiving. The price of three biscuits is US$0.05 per child per day and provides 191kcal. The cost of fortification itself is US$0.86 per child per year.

A danger of school feeding is that parents may reduce the food provided for children at home. Using a biscuit as a vehicle for fortification eliminates this problem, because it is seen as a snack rather than a meal and therefore unlikely to replace meals given to the child at home. In this study the biscuit intervention had no effect on the number of children who ate breakfast before coming to school, nor on the number of children bringing food to school. Additional advantages of using a biscuit are that it needs no preparation, is easy to distribute and has a long shelf life. It is also easy to monitor and therefore less open to misuse or corruption.

Dealing with the hidden hunger of micronutrient deficiencies through food fortification is regarded as a short- to medium-term solution to address an immediate need. Longer-term solutions will include nutrition education in schools and communities with regard to the need for diverse diets. Should a fortified biscuit be implemented in school feeding, it is recommended that it be accompanied by a relevant nutritional message which would put the fortified biscuit in the diet into perspective.

Using a micronutrient fortified biscuit and cold drink in school feeding is feasible, effective and practical, and can seriously be considered for addressing micronutrient deficiencies in school children. The role of nutrition education as a long-term solution should, however, not be overlooked.

The biscuit is now commercially available and is actively marketed at the primary school level by the food industry, using the scientific results to promote its use in school feeding programmes throughout South Africa. Once in place, an effectiveness study will be carried out.

Lize van Stuijvenberg, Senior Scientist, P.O. Box 19070, Tygerberg, 7505, South Africa. Tel: 27 21 9380911 x 264 Fax: 27 21 9380321 Email: Ivanstui@eagle.mrc.ac.za AJS Benads Programme leader of the Nutritional Intervention Programme, Medical Research Council, Cape Town, South Africa. Mailing address: Medical Research Council, PO Box 19070, Tygerberg 7505, South Africa. Tel: 021938 0283 Fax: 021 938 0321 Email: sbenade@eagle.mrc.ac.za The information contained in this article is also available as a technical report and a policy brief issued by the MRC. Both are available free of charge on request from DrBenad


Figure

SCHOOL FEEDING PROGRAMMES: LESSONS FROM KENYA

by Ruth Oniang'o and Agnes Kimokoti

The National School Milk Programme launched by Presidential Decree in 1978, was a move to contribute to better health and nutritional status of school children. The costs of running this programme, however, have become unaffordabte by the government, and as such, the operational targets of the programme can no longer be met. A second school feeding programme aimed at improving both nutritional and educational outcomes began in WFP-assisted areas where schools not only fed children, but also promoted nutrition education. This is now a nation-wide programme, although the phasing out of support by WFP means that its future is uncertain. In both of these cases, financial support seems to be the major constraint. There is a need to took into alternative mechanisms and more cost-effective strategies of supporting child nutrition.

Issues for consideration

Some issues to be borne in mind when considering school feeding programme design and implementation in Kenya include the following:

· Kenya has had a tradition of providing school lunches, either through government or community mechanisms. Parents play a key role in school feeding. Where they can, parents support a scheme that provides a hot meal for their children. In such cases, vendors and hawkers are discouraged because of food safety and quality concerns. In arid and semi-arid areas, where families have few resources, parents make only a modest contribution. Government- and WFP-supported schemes have targeted such areas with the aim of encouraging school enrolment and attendance. It is these areas where the majority of the population is illiterate and the enrolment is fragile so that incentives are required to motivate school enrolment and retention.

· Some parents are able to afford to give their children a packed lunch or money to buy food. However, it has been observed that when children are given money, they buy snack foods of low nutritional quality, or spend their money on something else entirely. With a growing drug problem among Kenyan youth, parents are hesitant to give food money to their children for fear that this will be spent on drugs.

· The Nutrition and Health Unit has developed recommendations relating to school feeding. The Unit advo cates the carrying of packed lunch to school by every child and discourages parents as much as possible from giving their children money. This applies especially to children who commute daily to school. The Nutrition and Health Unit is also encouraging schools to establish their own school gardens. This would go a long way towards minimisation of expenses of buying food, for both schools and parents.

· Apart from giving the actual food, the Unit is also concerned with providing nutrition education and sensitising the public to proper nutrition and feeding habits, diet diversification and food quality and safety. This is done deliberately through the school curriculum, posters and during parent-teacher meetings. According to the head of the Unit, considerable success has been achieved in this area.

· In urban and peri-urban slum areas, NGOs are involved with provision of food for school children. However, there is a need for the government to coordinate all school feeding activities. Continuous monitoring is also necessary in order to formulate a programme that is beneficial to children, manageable by the schools and affordable by the parents.

Ruth Oniang'o is an AGN Member and Professor of Food Science and Nutrition at the Jomo Kenyatta University, College of Agriculture and Technology, P.O. Box 62000, Nairobi, Kenya. Tel: 254 151 22646/9 Fax: 254 2 583294 Email: oniango@iconnect.to.co.ke Agnes Kimokoti is a Senior Lecturer at the University of Nairobi, Faculty of Education, P.O. Box 30197, Nairobi, Kenya.


Courtesy of UNHCR (23092/10.1983/L.Taytor)

MALNUTRITION AMONG SCHOOL CHILDREN IN INDUSTRIALISED COUNTRIES

by Andrew Tomkins

Poor nutrition in school children seriously compromises their health and learning capacity and sets up a disastrous trend towards damaging dietary patterns which affect the prevalence of disease in adults. There is disturbing evidence that the nutritional status among school children is deteriorating. In previous generations, anaemia, rickets and poor growth were associated with low socio-economic status. However, current radical changes in lifestyle among both poorer and better-off strata in industrialised countries, mean that personal preference about foods, fashion, physical activity levels and the media are now driving the nutritional patterns of school children more than the availability of food itself.

Traditional nutritional programmes focus on the provision of an adequate diet so that children can maintain a good level of health and benefit from the opportunities to learn at school. However, health and nutrition of school children are also of critical importance for determining the prevalence of adult diseases such as ischaemic heart disease, hypertension, certain types of cancer and diabetes. Failure to address the nutrition of school children probably explains why so many programmes aimed at preventing adult disease have had very limited impact.

This article concentrates on the nutritional problems facing industrialised countries, such as those in Europe and North America, but there are many communities in other continents where the nutritional status of children in better-off families is more akin to the industrialised nations, than to malnutrition syndromes of anaemia, hunger and stunting. Current epidemics of premature mortality among adults in less developed countries also have important origins in schoolchild nutrition.

Nutritional problems of school children

Obesity. There is a steadily increasing epidemic of obesity among school-age children. Age-adjusted body mass index (BMI: weight divided by height squared) cen-tiles are now available on the basis of which around 15% of UK children have a BMI of over 25. This figure has increased steadily over the last 2 decades. Using linked longitudinal data, up to 60% of obese children remain obese when they are restudied in their early 30s. Obesity in children is associated with a decreased willingness to become involved in physical activities and sports, leading to a much lower level of fitness. Obesity in children is also a major risk factor for adult disease.

Hypertension. Several longitudinal studies show an increase in levels of blood pressure among older children leading to hypertension in adulthood. While there are few immediately visible problems as a result of increasing blood pressure in adolescents, it is of concern that as such trends continue into adult life, they will increase the risk of heart attacks and strokes.

Eating disorders. While overweight is a major problem among school children, there is an increasing prevalence of anorexia nervosa and bulimia, especially among girls. The widespread, current social vogue, driven by the media and advertising agencies, which dictates that it is more beautiful to be thin, is a key factor driving the eating patterns of school children. This has devastating impacts on mental and physical health, school performance and family relationships.

Dental disease. Despite the enormous publicity and health promotion about the effect of confectionery on dental caries, dentists still find poor levels of dental health among many school-age children.

Anaemia is still a problem, especially in countries such as the UK where certain ethnic groups, such as Asians, may be disadvantaged and have dietary patterns which increase the risk of iron deficiency.

Antioxidant deficiency. Many adult diseases such as coronary heart disease and some forms of cancer are the result of the interaction between toxic agents, which generate free radical release, and lack of antioxidants which prevent disease by scavenging the free radicals. Toxic agents include excessive fat intake and cigarettes. There is a disturbing deficiency of certain antioxidants such as vitamin C because of rather low levels of fruit intake by many school children. Soft drinks and confectionery make up an increasing proportion of children's diets.

Hunger. Children who do not eat before coming to school do not perform so well at school. Increasingly, children "fend for themselves" and many leave home without breakfast.

Changing lifestyles and dietary patterns

Major societal change has occurred such that 'family meals', when parents and children sit down together to eat and talk, are much less common than in previous decades. Children are often given money to buy food during the day and even when they do eat at home, there are increasing trends towards use of convenience pre-prepared foods rather than traditional meals. The 'eat and go' culture and decreasing levels of social interaction between parents and children mean that children 'choose' rather than 'are told' what to eat.

Convenience foods frequently have high levels of dietary fat; many surveys show that school children eat over one third of their energy as fat. Children tend to have high sodium intakes as a result of the spices and sauces which are an integral part of many fast foods and snacks.

Physical exercise and fitness among children is decreasing. As a result of increasing community violence, danger and parental fear, children are more frequently taken to school by car or bus rather than walking or cycling. Many schools have sold playing fields in recent years in order to provide income to pay teachers and have reduced staff salaries for supervision of physical activities such as team games and individual exercise. Provision for physical activity in inner cities is a special problem. Recent studies show that children take very little exercise which is vigorous enough to increase heart rate significantly.

Increased consumption of toxic agents such as cigarettes, alcohol and drugs all put a stress on the antioxidant capacity on the body to overcome their degenerative effect. Advertising aimed at school children is now a major focus of the food industry. While most governments prohibit cigarette advertising aimed at the young, no government has any policy aimed at reducing the consumption of certain foods by school children.

Action for nutritional improvement

There are several ways of improving nutrition of school children. Children selves should be the focus. Few people, other than the marketing units of the major confectionery and snack food industry, have really addressed their needs or wishes. Health promotion which starts with children's own perceptions and enables them to look at their wishes for health and feeling "good" both now and in the future are essential. Participatory approaches are likely to be more acceptable and effective rather than lectures which are considered "boring".

Parents need guidance. With the decreasing tendency of many parents/carers to provide cooked meals for children, and in certain circumstances, a low level of knowledge of how to prepare even a basic meal, there is a need to improve parenting as a focal point for improving the family dietary intake.

Schools have a great potential. Nutrition and health issues should be incorporated into the curriculum from an early stage, with boys learning just as much about food, its values and preparation, as girls. Self-learning activities, such as 'Child-to-Child' approaches are effective at stimulating 'learning by doing'. In disadvan-taged areas, where many children come to school without breakfast, concerned school authorities can start 'breakfast clubs' where children can begin the day with a better nutritional state. Suitable foods include nutrient-dense porridges, suitably enriched or fortified biscuits or locally prepared nutrient rich-snacks.

School governors or councils have responsibility for monitoring academic standards in schools. They can also ensure adequate quality of nutrition within the curriculum and catering services. Only food of appropriate nutritional standards should be provided by school catering agencies. School governors also have the ability to limit the promotion and advertising of less nutritionally valuable foods obtainable by automatic vending machines which provide snacks for cash.

Community councils have statutory powers to licence fast food vendors who target their sales towards school children. They also have opportunities to provide local events which promote healthy diets and physical activity.

The media and food industry have enormous responsibility. The fashion industry has a responsibility for promoting beauty as something other than thinness. The food industry has a responsibility for promoting foods which can contribute to a better dietary intake.

Social services identify children from poor families who need particular income support and subsidise school meals for certain children. Despite their efforts, recent studies in the UK show that poor families still find it difficult to buy enough of certain foods such as fruit, even though energy intakes may be so great that their children are overweight.

Transport policies are crucial. Both city and rural councils need to develop a physical activity policy, especially within an overall transport policy such that children are able to cycle and walk to school safely and find safe places to take vigorous exercise.

Government policies. Improving nutrition of school children cannot be achieved by a government policy from one ministry alone. It needs concerted, focused work between ministries of health, agriculture, education, sports and social welfare. Governments need to liase with local community voluntary groups such as in the Health Cities Project of WHO and in the Health Action Zones now starting in the UK. If Governments recognised that such policies do not just address issues of childhood, but are crucial for longer term issues of adult health and national development they would take school child nutrition much more seriously.

Nutrition Professionals. It is the task and challenge for nutrition professionals to inform and stimulate action by government and community alike. With increasing independence, it is increasingly children, rather than their parents, who decide what to eat. The challenge for any policy maker or programme manager is to understand their needs and wishes and promote dietary intakes that will provide better health for themselves, both now and in their adult years.

Andrew Tomkins is Director of the Centre for International Child Health, Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK. Tel: 44171 242 9789 Fax: 44171 404 2062 Email: a.tomkins@ich.ud.ac.uk

TRENDS IN THE INTAKE OF READY-TO-EAT FOOD1 AMONG URBAN SCHOOL CHILDREN IN NEPAL

by Indira Sharma

1Ready-to-eat foods are defined in this article as 'industrially produced processed food characterised by food additives, low fibre, high salt and sugar containing foods that are expensive compared with home-made traditional foods'.

In 1996, a cross-sectional study was conducted in an urban Nepalese school to assess the food behaviour of school-aged children in relation to ready-to-eat food (REF) intake, its impact on nutritional status and nutritional composition of meals eaten. 610 school children aged between 9-11 years from middle income families were included in the study. Consumption of seven widely available REFs - namely biscuits, bread, noodles, snack packets, potato chips, low cost doughnuts and dalmoth (a snack prepared from beans) - was assessed. Demographic and socio-economic data were collected and a questionnaire was developed to gather information on food choices and preferences.

The frequency and amount of REF intake was recorded for each child over a period of one week. Results showed that children consumed at least one or two items of REF every day. The average frequency of REF intake was 1.9 times per day, and the amount consumed was 125g per day. This provided 439 (+/-127 SD) calories on average per day - approximately 20% of the total energy requirement of children in Nepal. When classified according to the level of REF consumption, the majority of children (59.6%) had moderate consumption (300-500 calories), 27.7% had high consumption (>500 calories) and 12.7% had low consumption (<300 calories).

Compared with traditional foods, REFs were preferred by the majority of school children (68.7%). Taste preference, convenience and affordability were the foremost criteria in choosing REFs. In the majority of cases, parents were responsible for introducing REFs into their children's diets. The role of advertising in influencing children's choices was also considered relevant by 80% of children. Among the many socio-economic factors, per capita income and mother's education level was found to be positively associated with REF consumption.

A subsequent, in-depth study conducted on a representative sub-sample of school children drawn from the low-, moderate- and high-consuming groups compared the nutritional status of the children in the three groups. There were no significant inter-group differences in height, weight, or in the energy and protein density of meals eaten by the children. The intake of pulses, green leafy vegetables, fruits and milk was, however, found to significantly decrease with increasing REF consumption.

Taste preferences for new food products are slowly changing children's food habits from eating conventional foods to preferring modern convenience foods. Presently, this change in eating behaviour is seen mainly in snacking patterns, however this may further extend to main meals. Thus, the results obtained from this study indicate changing food habits with an increase in REF intake by (middle-income) school children in Nepal. Is it expected that this trend will further accelerate in the future because of ongoing technological developments in the food industry - encouraged by government policies -leading to an increased rate of REF production. Furthermore, per capita income and women's education level are also expected to increase.

Considering these points, it is advisable to take timely precautions for the prevention of the deleterious effects stemming from the intake of industrially processed ready to-eat foods which are deficient in micronutrients such as calcium, iron, and vitamins A, B and C. The loss of various nutrients during processing suggests a possibility of their fortification with different nutrients. Caution must be taken however regarding the addition of harmful food additives, especially artificial colours and flavours. Labelling in all manufactured foods should be made mandatory. Nutrition education for mothers should include the adverse effects of food containing high levels of sodium, fat, sugar, food additives and low levels of fibre, and the improvement of children's diets by compensating the deficient components with other rich sources. Finally, the importance of balanced diet with special emphasis on the formation of good food habits should form an integral part of nutrition education for school children in Nepal.

Indira Sharma, Tribhuvan University, Padma Kanya Campus, Bag-bazar, Kathmandu, Nepal. Tel: 977 1 414482 Fax: 977 1 418907 Email: sushil@mos.com.np The full research article describing these studies was published in the journal of "Asian Regional Association for Home economics" 1996. Vol. 3 pp 22-27 (Editor Dr. Soojae Moon. Dept of Food and Nutrition, Yonsel University, Seoul, Korea).

CDC'S GUIDELINES FOR SCHOOL HEALTH PROGRAMS TO PROMOTE LIFELONG HEALTHY EATING

The key to promoting health in children of school-age is education, and the best opportunities for positively influencing the health of this age group are found in the school (World Health Report, 1998, p85). Most young people in the United States make poor eating choices that put them at risk for health problems. For example, over 84% of young people in the US eat too much fat; 51% eat less than one serving of fruit a day; and 8% of high school girls take laxatives or vomit to lose weight or prevent weight gain. The consequences of unhealthy eating include an increased risk of obesity (the percentage of young people who are overweight in the US has more than doubled in the past 30 years), lower intellectual performance, ill health and premature death in adulthood. On the other hand, the benefits of healthy eating patterns in childhood include promotion of optimal health, growth and intellectual development, the prevention of iron deficiency anaemia, obesity, eating disorders and dental carries, and the prevention of long-term problems such as coronary heart disease. Establishing healthy eating habits at a young age is therefore critical, and schools can help young people improve their eating habits by implementing effective policies and educational programmes.

The Division of Adolescent and School Health of the US Centers for Disease Control and Prevention, has developed a series of guidelines, one of which is the Guidelines for School Health Programs to Promote Lifelong Healthy Eating. These guidelines identify the most effective policies and programmes that schools can implement in order to promote healthy eating choices. Seven recommendations are included in the guidelines. These include the development of a school policy on nutrition, the implementation of nutrition education, the integration of school food services and nutrition education, suitable staff training, family and community involvement and programme evaluation.

These guidelines are available on the Internet at http://www.cdc.gov/nccdphp/dash. The document 'CDC's Guidelines for School Health Programs to promote lifelong healthy eating - at-a-glance' is available from CDC, National Center for Chronic Disease Prevention and Health Promotion, Division of Adolescent and School Health, ATTN, Resource room, 4770 Buford Highway, Mailstop K-32, Atlanta, GA 30341-3724. Tel: 1 7704883168.

Source: CDC. Guidelines for School Health Programs to promote lifelong healthy eating. MMWR 1996; 45 (No.RR-9), and brochure 'CDC's Guidelines for School Health Programs to promote lifelong healthy eating - at-a-glance'.

Agir a l'le. Pour de meilleurs resultats scolaires par l'amoration de la santt de la nutrition dans les pays non industrialises (Banque Mondiale, 1998) par Joy Miller del Rosso et Tonia Marek

A partir d'exemples concrets, cette publication montre qu'une santt une nutrition deficientes limitent l'acquisition du savoir par les ves et risent les taux d'inscription et de frequentation scolaires.

Plusieurs interventions d'un cout modique et d'une haute efficacitd ris ou ntreprendre par les Etats afin d'amorer la santt la nutrition des populations scolaires, y sont expos.

L'ouvrage rpitule comment ces ameliorations peuvent se traduire par un renforcement des capacitindividu-elles grace a une incidence bfique sur les taux de socialisation, l'assiduitles performances scolaires, la productivitconomique et sur la santes futures grations.

On distingue cinq chtres: "Les infants d'age scolaire: we population a risque"; ''Situation couteuse, rems peu couteux"; 'Accroissement de la productivitt amoration de la santommunautaire"; "Agir"; "Les a retenir". Deux annexes complnt l'ouvrage: "Informations necessaires pour une analyse de la situation des enfants d'age scolaire en nutrition et sant et une liste par pays de projets finances par la Banque Mondiale et lies a la nutrition et a la sante la population d'age scolaire.

Class Action. Improving School Performance in the Developing World through Better Health and Nutrition (World Bank, 1996)

by Joy Miller del Rosso and Tonia Marek


Figure

This publication shows concrete evidence that with poor nutrition and ill health, the learning capacity of children, and school enrolment and attendance rates are reduced.

A discussion on a variety of low-cost and highly efficient actions that governments have taken and can take to improve the health and nutrition of school age children is provided. The book summarises how improvements in these areas will lead to gains in human capital development through its beneficial effects on school enrolment, attendance, and performance, economic productivity, and the health of future generations.

60pp. US $10. English and French versions are available from The World Bank, P.O. Box 960, Herndon, VA 20172-0960, U.S.A. Tel: 703 661 1580 Fax: 703 661 1501 Email: books@woridbank.org World Bank publications can also be ordered via the World Bank website at http://www.woridbank.org/html/extpb/ordform/ordform2.htm

Nutrition, Health and Child Development (1998)

In the countries of Latin America and the Caribbean infant mortality rates have been steadily decreasing over the past few decades, with more children surviving past infancy than ever before. As more and more children live to school age, the quality of life and concerns for achieving optimal physical and psychological potential and to benefit fully from education become paramount. A child who has developed to the peak of his or her potential will be happier and learn better, and will ultimately grow up to become a more fully engaged, productive citizen.


Figure

This publication, arising from a workshop jointly organised by the Tropical Metabolism Research Unit (TMRU) of the University of the West Indies, and PAHO in 1995 in Jamaica, examines how and to what extent nutrition, health, and stimulation can affect children's cognitive and social development and their ability to learn in schools. By examining recent research, the authors explore such topics as undernutrition, iron and iodine deficiencies, neonatal feeding, short-term food deprivation, parasitic infections, and psychosocial deprivation. They also review results from early childhood interventions, including nutritional supplementation and psychological stimulation, as well as interventions in later childhood, including school feeding and deworming programmes.

Although no formal consensus statement of the workshop was issued, the technical editor, Sally Grantham-McGregor, summarises the main findings of the workshop in an appendix. With respect to school-age children, these include the following:

· There is now reasonably strong evidence to support a detrimental effect of undernutrition on school-age children's development.

· The effects of iodine deficiency on the cognitive development of school-aged children is equivocal and more data is needed.

· High risk school-aged children benefit from iron supplementation and school feeding programmes.

· New data are emerging on the interactions between different nutritional and health conditions, such as undernutrition and missing breakfast, or undernutrition and parasitic infections.

· Improving children's health and nutrition while they attend highly inadequate schools is unlikely to improve their achievement levels, thus, health and nutrition interventions for school-aged children should be integrated into educational improvement programmes.

268 pp. US $36 (US$26 in developing countries). A joint publication by the Pan American Health Organization, the Tropical Metabolism Research Unit of the University of the West Indies and the World Bank. Scientific Publication No.566. Copies of this book can be ordered from PAHO Sales and Distribution Center, P.O. Box 27, Annapolis Junction, MD 20701-0027, USA. Tel: 1 301 617 7806 Fax: 1 301 206 9789 Email: paho@pmds.com or via the PAHO website at http://www.paho.org