Nutritional Status and Dietary Intake of School-Age Children and Early Adolescents: Systematic Review in a Developing Country and Lessons for the Global Perspective

Development of knowledge, attitude and practice questionnaires on e-Huffaz ProHealth, a multicomponent lifestyle intervention module among Tahfiz students

e-Huffaz ProHealth is a lifestyle intervention module developed specifically for Tahfiz students. The e-Huffaz ProHealth consists of physical health, nutritional and psychological components. This study aimed to develop the knowledge, attitude and practice (KAP) questionnaires on e-Huffaz ProHealth among Tahfiz students. This cross-sectional pilot study was conducted in 2022. The first phase entailed developing the KAP questionnaires. The second phase involved determining the content validity and face validity. While the third phase involved evaluating the reliability. A total of six experts from public academic institutions participated in the initial evaluation stage to assess validity while five experts were involved in the second stage. Thirty-three and 41 respondents were involved for the face validity and reliability evaluation, respectively. The questionnaires were distributed via Google Docs and hard copies were handed out in person to Tahfiz school teachers and students at Madrasah Tahfiz Al-Amani and Pondok Moden Tahfiz Saadah Addaarain. The findings demonstrated that the Item Content Validity Index (I-CVI) for the three components of the KAP questionnaires at the second stage of evaluation was high (1.0). The scores for the Scale Face Validity Average Index (S-FVI/Average) in assessing the level of clarity and understanding for the three components were 0.89 and 0.88, 0.92 and 0.90, and 0.88 and 0.9, respectively. Meanwhile, the reliability of KAP for physical activity was moderate (0.43), very high (0.91) and high (0.7), respectively. For nutrition, the reliability of KAP was good and acceptable with the values of 0.63, 0.83 and 0.65, respectively. The results of reliability of KAP for psychological well-being was good with the values of 0.54, 0.56 and 0.84, respectively. The KAP questionnaires of e-Huffaz ProHealth was successfully developed with high content validity, good face validity and acceptable reliability. Hence, it can be used for future study to evaluate the effectiveness of e-Huffaz ProHealth among Tahfiz students.

Benchmarking the Determinants of Nutritional Status among Community Schools’ Children in Nepal

The government of Nepal initiated the Mid Day Meal Program (MDMP) to reduce hunger and increase educational outcomes, including health status. However, limited studies have been conducted on these issues covering the nutritional status of students at the lower basic level at community schools in Nepal. The main objective of the study is to determine the factors associated with malnutrition among children from community schools in Nepal. A school-based cross-sectional study was conducted in 98 (46 basic and 52 secondary) community schools from 44 municipalities in Nepal. Altogether, 2727 students participated in the questionnaire survey and anthropometric measurement. Data collection was performed on May 10-31, 2023. WHO Anthro plus and LMS (Lambda Mu and Sigma) parameters were used: weight for age for national health and nutrition survey recommended by CDC/National Center for Health Statistics for ages older than ten years to analyze nutritional status, including z scores. Descriptive analysis, including inferential analyses such as the chi-square test and logistic regression, was performed using IBM SPSS Statistics v25. The prevalence of weight-for-age Z-score[WAZ], height-for-age Z-score [HAZ], and body mass index-for-age Z-score [BAZ] were 72%, 75%, and 82%, respectively. Students with z-scores outside the range of ±2 were classified as malnourished. Of them, 27.3%, 23% and 16.6% were assessed as underweight, stunted and thin, respectively. Students' sociodemographic characteristics such as age, asex, family size and type, source of income, wealth status were significantly associated with malnutrition, while age group, gender, wealth status, residence setting, and geographical location were noted as significant predictors of nutritional status. The study found no statistical relationship between school feeding and good nutrition, questioning the quality of the midday meal program. The study concludes that existing school-based nutritional interventions need to be re-evaluated and re-designed since it is less potent to minimize malnutrition among students substantially. Policymakers could consider these findings when planning and implementing nutrition-related policies and programs.

Exploring the Multifaceted Influences on Childhood Nutritional Status: A Study Conducted in South Punjab, Pakistan

Introduction The double burden of malnutrition (DBM) in Pakistan is a rising concern affecting school-going children, marked by coexisting under- and over-nutrition within the same population. Key influences include shifts in dietary habits, socioeconomic status, and lifestyle changes due to rapid urbanization. With a focus on Multan, Pakistan, the study seeks to assess the proportion of underweight and overweight students while identifying the risk factors and sociodemographic characteristics associated with this incidence. The aim is to guide future health interventions addressing this multidimensional health challenge. Materials and methods This study, adopting a descriptive cross-sectional research design, collected data from female teenage students through interviews and anthropometric measurements. A total of 300 participants were randomly selected from a comprehensive school list representing diverse urban and rural settings. Participants' weight and height were measured to calculate their body mass index (BMI), categorizing them into underweight, normal weight, and overweight groups. The relevant risk factors were collected through an interview questionnaire. Collected data were analyzed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States), with the results stratified according to socioeconomic, dietary, and psychosocial factors and compared across different weight categories. Results The study collected data from 300 students, revealing a correlation between socioeconomic status, dietary habits, and BMI. Parental occupation significantly affected nutritional status, with children of laborers primarily falling within normal and underweight categories. Dietary habits like frequency of fast food and milk or dairy consumption showed notable associations with nutritional status. Psychosocial factors such as peer or teacher comments about weight and outdoor sports participation also influenced the students' nutritional status. However, factors like family income, video game hours, and the presence of pets at home did not show significant associations with nutritional status. Conclusions The study illustrates a multi-faceted association between socioeconomic status, dietary habits, and BMI among schoolchildren in Multan, Pakistan, emphasizing the need for comprehensive interventions.

Relationship Between School Food Environment and Eating Behaviors of Primary School Children in Dodoma: A Cross-Sectional Study

This cross-sectional study assesses the relationship between school food environment and eating behaviors of primary school children in Dodoma among 248 primary school children aged 6-13 years. School characteristics information and socio-demographic characteristics were collected. Multilevel modeling was employed to assess the individual-level variance in eating behaviors. Most of the variances in the investigated eating behaviors were at the personal level. Significant associations (p < .05) were between protein-rich food intake and fats and sugar-rich food with the death of either parent. And association between intake of vitamin and mineral-rich foods and the number of people living in household.

Association between modified youth healthy eating index and nutritional status among Iranian children in Zabol city: a cross-sectional study

Diet quality in childhood and adolescence can affect health outcomes such as physical and cognitive growth and preventing chronic diseases in adulthood. This study aimed to evaluate the relationship between diet quality using the modified youth healthy eating index (MYHEI) with socioeconomic factors and nutrition status in 7-12-year-old children in Iran. This descriptive-cross-sectional study was performed on 580 students in Zabol, Iran, selected through multistage cluster sampling. The diet was assessed through the 168-item food frequency questionnaire (FFQ) and eating behaviors. Then, the MYHEI scoring system was used to calculate the diet quality. In addition, we used the WHO growth indices, such as weight to age, height to age, and body mass index (BMI) to age ratios, to evaluate nutrition status. The mean total MYHEI score in children was 56.3 ± 11.2. Among children with the highest MYHEI score quartile, the number of girls was significantly higher than boys (p = 0.001). The prevalence of underweight, stunting, and wasting was 25.3%, 17.4%, and 21.7%, respectively. The prevalence of underweight (OR: 2.2; 95% CI  1.26, 3.90, p = 0.001) and stunting (OR: 3.2; 95% CI   1.65, 6.14, p = 0.006) were significantly lower in the higher MYHEI score quartile compared to the lower quartile. The overall diet quality of most children should be modified. Therefore, to improve the children's health and nutrition status, it is necessary to perform nutritional interventions such as training and promotional programs, especially in schools.

Risk Factors of Malnutrition among In-School Children and Adolescents in Developing Countries: A Scoping Review

Malnutrition among in-school children is a complex issue influenced by socio-economic, environmental, and health-related factors, posing significant challenges to their well-being and educational trajectories in developing countries. This review synthesized evidence on the multifaceted aspects of child malnutrition within the educational setting in developing countries. This review followed the six steps outlined by Arksey and O'Malley's framework. Four main databases (PubMed, CENTRAL, JSTOR, and Scopus) were searched. Additional searches were conducted in WHO Library, ProQuest, HINARI, Google Scholar, and Google. Reference lists of eligible papers were checked. This review found that low family income, varying family sizes, parental employment status, and educational levels significantly impact malnutrition among in-school children and adolescents. Environmental elements, including rural/urban residence, household sanitation, and living conditions, also influence malnutrition. In addition, nutrition knowledge, dietary habits, nutrient deficiencies, physical activity, and prevalent health conditions compound the risk of malnutrition. This study underscores the extensive health impact of malnutrition on general health, specific nutrient deficiencies, fetal/maternal health concerns, and overall morbidity. Also, malnutrition affects school performance and attendance, impacting cognitive abilities, and academic achievements. Addressing these challenges requires comprehensive policy actions aligned with Sustainable Development Goals, emphasizing poverty alleviation, health literacy, and gender equity.

Lifestyle-related determinants of noncommunicable diseases (NCDs) across various age groups in Pakistan

Noncommunicable diseases (NCDs) account for 58% of the total deaths in Pakistan. Modifiable risk factors, including physical inactivity, unhealthy diets, and tobacco and alcohol use, are the major contributors to NCDs. Their prevalence and causal factors vary among age groups, and the aim of this review is to assess these differences and their causes. A search in “Google Scholar” AND “PubMed” showed a total of 31,200 articles after using the appropriate keywords. After adjusting for time period and relevance, 66 articles were selected based on the inclusion criteria such as being in the English language, published within the last 10 years, and containing information on lifestyle risk factors of NCDs in adolescent, adult, and elderly age groups. The prevalence of physical activity in adolescents, adults, and the elderly is 20, 34.8, and 15.7%, respectively. Unhealthy diets have been observed in 20.9% of adolescents and 96.5% of adult NCD patients, while 78% of the elderly reported good eating habits. Smoking is prevalent in 15% of college students, 40% of adult males, and 22% of the geriatric male population. Interventions targeted toward the prevention and management of NCDs should consider the role age plays in the development of these diseases and how the prevalence of these risk factors differs among them. Specific considerations need to be put into place when dealing with adolescents and the elderly to reduce the national and global burden of disease.

Nutritional status of school-age children (5-19 years) in South Asia: A scoping review

Information on malnutrition for school-age children and adolescents (5-19 years) in South Asia is fragmented and inconsistent, which limits the prioritization of nutrition policies, programmes and research for this age group. This scoping review aimed to synthesize existing evidence on the burden of malnutrition for children and adolescents aged 5-19 years in South Asia, and on interventions to improve their nutritional status. Cochrane Library, EMBASE, Medline and Google Scholar were systematically searched for articles published between January 2016 and November 2022. Eligible studies reported the prevalence of undernutrition, overweight/obesity, micronutrient deficiencies and unhealthy dietary intakes, and interventions that aimed to address these in South Asia. In total, 296 articles met our inclusion criteria. Evidence revealed widespread, yet heterogeneous, prevalence of undernutrition among South Asian children and adolescents: thinness (1.9%-88.8%), wasting (3%-48%), underweight (9.5%-84.4%) and stunting (3.7%-71.7%). A triple burden of malnutrition was evident: the prevalence of overweight and obesity ranged from 0.2% to 73% and 0% to 38% (with rapidly rising trends), respectively, alongside persistent micronutrient deficiencies. Diets often failed to meet nutritional requirements and high levels of fast-food consumption were reported. Education, fortification, supplementation and school feeding programmes demonstrated beneficial effects on nutritional status. Comprehensive and regular monitoring of all forms of malnutrition among children and adolescents, across all countries in South Asia is required. Further, more large-scale intervention research is needed to ensure policy and programmes effectively target and address malnutrition among children and adolescents in South Asia.

The Value of an Ecological Approach to Improve the Precision of Nutritional Assessment: Addressing Contributors and Implications of the "Multiple Burdens of Malnutrition"

Globally, children are exposed to multiple health risks associated with diet and nutrition. Rather than simply being a condition of having too much or too little food, malnutrition is more a syndrome comprising multiple burdens of coexisting and reciprocal malnutrition, infection, or other conditions. Importantly, children with such syndromes (e.g., stunting and anemia, which are neither specific nor necessarily sensitive to nutritional status) are more likely to also have irreversible functional outcomes such as poor growth, impaired immune function, or cognitive delays. The global health community has identified nutrition-related targets (e.g., Sustainable Development Goals (SDGs) and World Health Organization (WHO) Global Nutrition Targets) that, for multiple reasons, are difficult to address. Moreover, as the complexity of the global health context increases with persistent pandemics of infectious diseases and the rising prevalence of noncommunicable diseases, there is a growing appreciation that conditions selected as nutrition/health targets indeed represent syndromes for which nutritional status serves as both an input and outcome. In recognition of the impact of these combined challenges and the role of the multiple manifestations of malnutrition, we suggest an approach to nutritional assessment that is intended to improve the precision of context-specific, equitable approaches to health promotion, disease prevention, and treatment.

Contribution of school meals to the recommended nutrient and energy intake of children enrolled in the National Homegrown School Feeding Program in Zaria, Nigeria

BACKGROUND

A poor nutritional status in children results in reduced physical and mental health and poor academic performance. The National Homegrown School Feeding Program (NHSFP) was introduced in Nigeria in 2016 to ameliorate short-term hunger and improve the nutritional status of school-aged children (SAC). At least 33% of the recommended nutrient intake (RNI) for the enrolled students should be met by the school meals. However, to our knowledge, the contribution of school meals served through the NHSFP to the RNI of SAC in Zaria, Nigeria, remains to be explored.

METHODS

We conducted a school-based cross-sectional study among 276 eligible SAC recruited from public primary schools in the Zaria Local Government Area. Portion sizes of the meals served through the NHSFP were determined using an electronic scale, meal samples were collected for nutrient analysis, and the average daily nutrient intake of the participants from the meals was calculated. The average daily intake of nutrients and energy of the participants was compared with the age- and sex-specific RNI to estimate the percentage contribution of the meals.

RESULTS

The portion sizes recorded were 199.3 ± 20.6 g, 263.9 ± 11.5 g, 242.1 ± 16.8 g, 311 ± 17.3 g, and 160.3 ± 1.9 mL, respectively, for moi-moi, jollof rice and beans, bean porridge, jollof rice and boiled egg, and yoghurt. In addition, the meals contained moisture (30.13-66.11%), ash (0.73-7.08%), crude fat (9-32.61%), crude protein (7.25-24.5%), crude fiber (0-2.45%), and total carbohydrate (2.19-29.74%) with an energy content ranging from 183.6 to 330.57 kcal. Similarly, the meals contained calcium (82.58-711 mg), potassium (133-797 mg), sodium (340-1720 mg), iron (0.078-8.60 mg), zinc (1.84-13.4 mg), vitamin A (2.38-100.56 RAE), and vitamin C (0.04-1.57 mg) per 100 g of the school meals. The meals contributed 18.2-19.1%, 102.8-183.7%, 13.04-13.6%, and 26.1%-35.8% of the RNI for carbohydrates, proteins, fiber, and energy, respectively. Furthermore, they contributed 137-175%, 314.3-502.2%, 87.6-142.1%, 21.5-25.1%, 279.2-348.5%, 3.3-5.9%, 24.7-48.8%, and 3.3-5.9% of the RNI for iron, zinc, calcium, potassium, sodium, vitamin A, and vitamin C, respectively.

CONCLUSION

The meals served through the NHSFP contributed at least 33% of the RNI for energy, protein, iron, calcium, sodium, vitamin A, and zinc. However, they could not meet the 33% of the RNI for carbohydrates, fiber, potassium, and vitamin C. Increasing the portion sizes and the diversity of the meals can address the suboptimal contribution of the meals to the RNI for carbohydrates, fiber, potassium, and vitamin C.

An Ecological Approach for Advancing the Understanding of Nutrition and Health

This Viewpoint discusses 2 new programs of the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Pediatric Growth and Nutrition Branch that apply an ecological approach to understanding nutrition and public health.

A systematic review and meta-analysis of the association of dietary diversity with undernutrition in school-aged children

BACKGROUND

Malnutrition in childhood has lasting consequences; its effects not only last a lifetime but are also passed down from generation to generation such as short stature, school-aged children are the most vulnerable section of the population and require special attention, including nutrition.

METHOD

We searched Medline through PubMed, Scopus, and Web of Science to identify all observational studies published before Jun 2022. Observational studies with a pediatric population aged 5-18 years that evaluated risk estimate with 95% confidence intervals the relationship between dietary diversity and undernutrition (wasting, stunting, and thinness) were included. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) were followed.

RESULTS

This is a first systematic review and meta-analysis with a total of 20 studies were eligible (n = 18 388). Fourteen data evaluated stunting resulting in a pooled effect size estimated odds ratio of 1.43 (95% CI: 1.08-1.89; p = 0.013). Ten data evaluated Thinness resulting in a pooled effect size estimated odds ratio of 1.10 (95% CI: 0.81-1.49; P = 0.542). Two studies were revealed wasting with a odds ratio of 2.18 (95% CI: 1.41-3.36; p-value < 0.001).

CONCLUSION

According to the conclusions of this meta-analysis of cross-sectional studies, inadequate dietary diversity increases the risk of undernutrition in growth linear but not in thinness in school-aged children. The findings of this analysis suggest that initiatives that support improvements to the diversity of children's diets to reduce the risk of undernutrition may be warranted in LMICs.