INTRODUCTION Page 1

Chapter -1

INTRODUCTION

The future of the society depends on the quality of life of the children. The health of children and

youth is of fundamental importance. Over 1/5th of our population comprises of children aged 5-

14 years i.e. the group covering primary and secondary education. As today’s children are the

citizens of tomorrow’s world, their survival, protection and development are the prerequisite for

the future development of humanity. Without ensuring optimal child growth and development

efforts to accelerate economic development significantly will be unsuccessful (Raghava 2005).

Once a child crosses the age of five, they are considered more or less safe from nutritional

disorders. But little attention is paid to the quality of life. School age children are hardly thought

of as “at risk” population but this period is a unique intervention point in the life cycle.

Malnutrition is common among school children and is usually coupled with iron deficiency

anemia. Asia has the largest number of malnourished children in the world (WHO-UNICEF

2004). About 21.8% of the country’s population comprises of school going children and there are

still about 21 million children who are unable to attend school. According to National Family

Health Survey(NFHS-3), 90.1% of the 6-10 years & 74.2% of 11-14 years old children attended

primary school in 2005-06.Though the number of children of primary age group who were out of

school has dropped by 33 million since 1999 still 72 million children worldwide were denied the

right to education in 2007.

Primary school years are busy ones and children need good nutrition to help them

concentrate at school and to fuel their day- to- day activities (play and sport). Children of this age

are also constantly growing. Middle childhood (7 – 12 years) has been called the latent time of

growth as the rate of growth slows down and body changes occur gradually. Brain areas continue

to develop during childhood. In India, 30 per cent of the school age children have moderate to

severe malnutrition. Major nutrition problems and iron deficiency anemia. Dietary inadequacies

have been considered as predominant etiological factors in the causation of all deficiency

diseases. Growth and nutritional status of pre-school and school going children are profoundly

influenced by the diet consumed by them. Therefore, the school children, in their existing

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nutritional conditions are in great need of health promotion, health appraisal and health

restoration.

Nutrition plays on student achievement. The importance of early childhood nutrition and

insuring that in the early stages of life that there is a sufficient allowance of daily nutrients is

critical for healthy development and future abilities to learn. Good nutrition is essential for

healthy bodies as students grow, develop, and do well in school. For example, iron deficiency

can lead to shortened attention span, fatigue and difficulty in concentration. These can lead to

learning difficulties. There are concerns that a diet high in fat can have a negative direct effect on

obesity and cognitive functions. There may be a correlation between offering breakfast and lunch

to students and academic achievement (Larkin 2008).

Nutrition and Food intake are closely related to nutritional status and health an

individual, adequate amount of nutrients in the form of diet is essential for the maintenance of

good health. Health is defined by World Health Organization (WHO 1995) as “A state of

complete physical, mental & social wellbeing & not merely the absence of disease or infirmity.”

To maintain good health & nutritional status we must eat balanced food, which contains all the

nutrients in correct proportion. Nutritional needs change throughout life, depending on genetics,

rate of growth, activity and many other factors. Nutritional status is the condition of health of the

individual as influenced by the utilization of nutrients. Nutritional needs also vary from

individual to individual. Improved nutrition has been the corner stone upon which all modern

societies and economics were built. Adequate nutrition frees a nation and its people to purse

goals that improve the human condition. A nation whose basic nutritional needs are met is

healthier, more productive, and can focus its energies on educational attainment, improved

housing, enhanced medical care, and the provision of goods and services associated with a highly

developed society.

Malnutrition is still considered one of the major public health problems in many countries,

affecting more than 30% of children under 5 years of age. Under nutrition is the most important

cause of death in this age group in developing countries, in which nutritional deficit is common.

Generally, three anthropometric indicators are often used to assess nutritional status during

childhood: under weight (low weight-for-age), stunting (low height-for-age), and wasting (low

weight-for-height). Growth during childhood is widely used to assess adequate health, nutrition

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and development of children, and to estimate overall nutritional status as well as health status of

a population. It is well documented that chronic under nutrition is associated with slower

cognitive development and serious health impairment later in life which reduce the quality of

life. The majority of deaths associated with malnutrition occur in children who are marginally

malnourished. About 50% of the children under 5 years old in India are moderately or severely

undernourished. Moreover, several studies have shown that the degree of under nutrition is

higher among the under privileged communities. In general, tribal populations are considered to

be under privileged in India.

Malnutrition in India

The Word Bank estimates that India is ranked 2nd in the world of the number of children

suffering from malnutrition, after Bangladesh (in 1998), where 47% of the children exhibit a

degree of malnutrition. The prevalence of underweight children in India is among the highest in

the world, and is nearly double that of Sub-Saharan Africa with dire consequences for mobility,

mortality, productivity and economic growth. The 2011 Global Hunger Index (GHI) Report

ranked India 15th, amongst leading countries with hunger situation. It also places India amongst

the three countries where the GHI between 1996 and 2011 went up from 22.9 to 23.7, while 78

out of the 81 developing countries studied, including Pakistan, Nepal, Bangladesh, Vietnam,

Kenya, Nigeria, Myanmar, Uganda, Zimbabwe and Malawi, succeeded in improving hunger

condition (Global Hunger Index Report, 2011).

The latest report (10Feb2013) of the Ministry of Statistics and Programme

Implementation has punched holes in the tall claims made by the central government about

addressing malnutrition in children. According to the report - Children in India 2012 - 48 per

cent children under the age of five are stunted (too short for their age), which indicates that half

of the country's children are chronically malnourished.

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Table 1.1 Percentage of malnourished children in different states

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India is one of the fastest growing countries in terms of population and economics, sitting at

a population of 1,139.96 million (2009) and growing at 10–14% annually (from 2001–2007)

(World Bank Report 2009). India's Gross Domestic Product growth was 9.0% from 2007 to

2008; since Independence in 1947, its economic status has been classified as a low-income

country with majority of the population at or below the poverty line. Though most of the

population is still living below the National Poverty Line, its economic growth indicates new

opportunities and a movement towards increase in the prevalence of chronic diseases which is

observed in at high rates in developed countries such as United States, Canada and Australia.

The combination of people living in poverty and the recent economic growth of India has led to

the co-emergence of two types of malnutrition: under nutrition and over nutrition.

Malnutrition in Uttar Pradesh

Uttar Pradesh, the most populous Indian state is home to 166 million people or one-sixth of the

country’s population. Almost 34.5 million persons comprising 20.8 percent of the population live

in urban areas of the state spread over 704 towns and cities. Estimates for poverty levels are at

31% for urban UP. Nutritional status is a major determinant of the health and well being of

children. Malnutrition among children is often caused by the synergistic effects of inadequate or

improper food intake, repeated episodes of parasitic or other childhood diseases such as

diarrhoea, and improper care during illness. Malnutrition is an important factor contributing to

high morbidity and mortality among children.

Under nutrition is more common for children of mother who are malnourished. The

nutritional status of urban poor children in Uttar Pradesh is as follows : " The rich-poor divide in

urban areas is evident as children from poor urban families (58.3 %) are more likely to be

undernourished as compared to children from rich families (35.6 %). " More than half of (58.3

%) of the urban poor children are underweight. This is worse in comparison to other urban

categories and the urban average of 42.6. " 65 percent of the urban poor children are stunted.

Malnutrition continues to be a primary cause of ill health and mortality among children in

developing countries. It is a major public health problem and accounts for about half of all child

deaths worldwide1. About 150 million children in developing countries are still malnourished

and more than half of underweight children live in South East Asia Region (SEAR). The high

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levels of under nutrition in children in South Asia pose a major challenge for child survival and

development. Besides poverty, there are other factors that directly or indirectly affect the

nutritional status of children. Several studies showed that maternal education emerges as a key

element of an overall strategy to address malnutrition. The best global indicator of children’s

well being is growth. Assessment of growth is the single measurement that best defines the

nutritional and health status of children, and provides an indirect measurement of the quality of

life of the entire population.

Malnutrition is more common in India than in sub-Saharan Africa. It is estimated that one

in every three malnourished children in the world live in India. Malnutrition however varies in

different states from 13% - 55% from Meghalaya to Madhya Pradesh respectively. Malnutrition

is considered to be a leading cause of child mortality in India. Non availability of food seems to

be the major cause of malnutrition. Protein-energy malnutrition (PEM) and Micronutrient

deficiencies are major contributors to higher mortality rates from illnesses and diseases such as

pneumonia, malaria, diarrhea and measles in the developing world. Stunting and wasting are

significant effects of malnutrition.

Stunting: It is seen with chronic malnutrition. Several studies have documented an inverse

correlation between stunting, cognitive and physical development in preschoolers and

consequently lower intelligence levels in older children and functional impairment in adulthood

both in terms of intellectual and physical aspects.

Wasting: It is seen with acute malnutrition. While stunting has long term implications for adult

health and productivity; wasting is closely linked to child mortality.

Malnutrition & Infection: The vicious cycle of malnutrition, impaired immune response,

increased infections and decreased food intake is well recognized. Malnutrition (both micro &

micronutrients) affect epithelial and mucosal integrity, mucociliary clearance, immunoglobulin

synthesis, lymphocyte differentiation and thus lead to impaired immunity which leads to

recurrent infections.

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Source: sciencedirect.com

Figure.1.1 Chronic malnutrition in India

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Form of Malnutrition: protein malnutrition (kwashiorkor of hypoalbuminemic malnutrition)

and protein calorie (marasmus or protein - energy) malnutrition. The term protein energy

malnutrition applies to a group that included-

Kwashiorkor (protein malnutrition)

Marasmus (deficiency in both protein and calorie)

Marasmic kwashiorkor

Kwashiorkor and Marasmus are the two classical syndromes and severe PEM. They occur

mostly in children between 1-4 years when they are weaned from breast milk to the adult diet.

Because of the bulk, a child cannot consume adequate quantities of the diet and fails to gain

weight.

KWASHIORKOR:

The term kwashiorkor is taken from the Ga language of Ghana and means “the sickness of

weaning”. Williams first used in 1933, and it refers to an inadequate protein intake with

reasonable caloric (energy) intake. Kwashiorkor also called the disease of weaning in a child

when the mother fails to supplement the proteins required but feeds the cereals and malt which

are rich in carbohydrate but poor in protein.

SIGNS AND SYMPTOMS:

Growth failure: This is manifested by decreased body length and low weight in spite of

retention of water in the body.

Mental changes: The child becomes inactive and irritable. He/She is dull and withdrawn and

makes few attempts to talk and move about general apathy and refusal to food is very common.

Oedema: Oedema occurs at first at the feet and lower legs and then may involve the hands, the

things and face. The oedema is mainly due to lowered serum albumin and probably also due to

high sodium and low potassium levels in serum.

Muscle Wasting: Muscle wasting and constant feature of kwashiorkor and a reduction in the

Circumference of upper arm in usually evident.

Moon face: The full well-rounded face, known as moon face, is often present in kwashiorkor.

Liver changes: Liver is slightly enlarged and fatty infiltration of liver is usually present.

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Gastro-intestinal Tract: Loss of appetite and vomiting are common. Diarrhea is present in

most cases.

Skin and Hair Changes: The characteristic skin changes of kwashiorkor are known as ‘crazy

pavement’ dermatitis. In the hair many changes like dispigmentation of hair, easy pluckability of

hair, flag sign.

MARASMUS:

The term marasmus is derived from the Greek word maramos, which means withering or

wasting. Marasmas involves inadequate intake of protein and calories and is characterized by

emaciation. Marasmus most commonly occurs in children younger than 5 years. This period is

characterized by increased energy requirements and increase susceptibility to viral and bacterial

infection. Weaning (the deprivation of breast milk and the commencement of nourishment with

other food) occurs during this high risk period. Weaning is often complicated by geography,

economy, hygiene, public health, culture and dietetics.

SIGNS AND SYMPTOMS:

Growth retardation: This is usually very severe loss of weight is much more marked than

decrease in height. The child is usually below 60% of the standard weight.

Wasting of muscle and of subcutaneous fat: The subject is severely emaciated. The muscles

are wasted. The arms are thin and the skin is 100 se. subcutaneous fat is practically absent.

Other Changes: The skin is dry and atrophic. The subject shows sign of dehydration. Eye

lesions due to vitamin A deficiency and anemia may be present.

MARASMIC KWASHIORKOR:

In countries where the incidence of protein calorie malnutrition (PCM) is high, large

number of cases shows signs and symptoms of marasmus and kwashiorkor. These intermediate

forms are called marasmic kwashiorkor. In addition, the interrelationship between two major

syndromes is such that changing circumstances may result in a transition from on a clinical

picture to another. A child with early kwashiorkor can develop nutritional marasmus by severe

infective diarrhea and ill advised prolonged under feeding. In 2000, the WHO estimated that

malnourished children numbered 181.9 million (32%) in developing countries. In addition, an

estimated 149.6 million children younger that 5 years are malnourished when measured in terms

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of weight for age. In south central Asia and Eastern Africa about half the children have growth

retardation due to protein energy malnutrition.

Causes of Poor Nutritional Status in Urban Slum Children

1. Inadequate food intake

• Improper infant feeding practices

• Lack of exclusive breastfeeding

• Late introduction of solid mushy foods

• Dilution of milk

• Poor caloric and nutritional content of food

• Inequitable intra-familial distribution (Age and gender differences)

2. Illness (Recurrent diarrheal and ARI morbidity)

• Poor environmental and housing conditions.

• Lack of hygiene and sanitation facilities

• Inadequate access and utilization of health care

• Poor food hygiene

3. Deleterious caring practices

• Absence of responsible adult caregiver.

• Lack of knowledge regarding food requirements.

• Traditional beliefs

• Parental illiteracy

• Poverty

4. Service issues

• Lack of reach and co-ordination of public sector services.

• Inadequate training and supervision of service providers in nutritional counseling.

• Missed opportunities for counseling.

• Compromised efficiency of services and programs (Urban ICDS, PDS and

others).

• Inadequate targeting of the urban poor.

Malnutrition is the condition that results from taking an unbalanced diet in which certain

nutrients are lacking, in excess (too high an intake), or in the wrong proportions(Arthur 2003).

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A number of different nutrition disorders may arise, depending on which nutrients are under or

overabundant in the diet. In wealthier nations it is more likely to be caused by unhealthy diets

with excess energy, fats, and refined carbohydrates. Because it contributes to both over nutrition

and under nutrition, malnutrition is said to be a “double burden”(Shafique, 2007).

CLASSIFICATION OF PEM

PEM is a spectrum of conditions ranging from growth failure to overt marasmus or kwashiorkor,

hence classification has to be based on arbitrary cut-off-points. It is to identify children requiring

nutritional or health interventions. Some of the classification are as follows:

Gomez’s classification

Gomez’s classification is based on weight retardation. It locates the child on the basis of his or

her weight in comparison with a normal child of the same age. In this system, the “normal”

reference child is in the 50th percentile of the Boston standards. The cut-off values were set

during a study of risk of death based on weight for age at admission to a hospital unit. This

classification therefore, has a prognostic value for hospitalized children.

Weight for age (%) = weight of the child/weight of a normal child of same age X 100

Between 90 and 110% : normal nutritional status

Between 75 and 89% : 1st degree, mild malnutrition

Between 60 and 74% : 2nd degree, moderate malnutrition

Under 60% : 3rd degree, severe malnutrition

Weight is widely recorded and the classification is easy to compute. The disadvantages are (a) A

cut-off-point of 90 per cent of reference is high (80 per cent being approximately equivalent to -2

SD or the 3rd percentile), thus some normal children may be classified as 1st degree

malnourished. (b) By measuring only weight for age it is difficult to know if the low weight is

due to a sudden acute episode of malnutrition or to long-standing chronic under nutrition.

Waterlow’s classification

When a child’s age is known, measurement of weight enables almost instant monitoring of

growth : measurements of height assess the effect of nutritional status on long-term growth.

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Waterlow’s classification defines two groups for protein energy malnutrition :

Malnutrition with retarded growth, in which a drop in the height/age ratio points to a

chronic condition- shortness, or stunting.

Malnutrition with a low weight for a normal height, in which the weight for height ratio

is indicative of an acute condition of rapid weight loss, or wasting.

This combination of indicators makes it possible to label and classify individuals with

reference to two poles : children with insufficient but well-proportioned growth and those

with a normal height, but who are wasted.

Weight/Height(%) = Weight of the child/Weight of a normal child at same height X 100

Height/Age(%) = Height of the child/Height of a normal child at same age X 100

Nutrition status Stunting

(% of height/age)

Wasting

(% of weight/height)

Normal > 95 > 90

Mildly impaired 87.5 – 95 80 – 90

Moderately impaired 80 – 87.5 70 – 80

Severely impaired < 80 < 70

Source: K. park (2009)

Clinical signs of malnutrition by Grover, 2009

Site Sign

Face Moon face (kwashiorkor, simian facies (marasmus)

Eye Dry eyes, pale conjunctiva, Bitot's spots (vitamin A), periorbital edema

Mouth Angular stomatitis, cheilitis, glossitis, spongy bleedng gums (vitamin C), parotid

enlargement

Teeth Enamel mottling, delayed eruption

Hair Dull, sparse, brittle hair, hypopigmentation, flag sign (alternating bnds of light

and normal color), broomstick eyelashes, alopecia

Skin

Loose and wrinkled (marasmus), shiny and edematous (kwashiorkor), dry,

follicular hyperkeratosis, patchy hyper- and hypopigmentation, erosions, poor

wound healing

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Nail Koilonychia, thin and soft nail plates, fissures or ridges

Musculature Muscles wasting, particularly in the buttocks and thighs

Skeletal Deformities usually a result of calcium, vitamin D, or vitamin C deficiencies

Abdomen Distended - hepatomegaly with fatty liver, ascites may be present

Cardiovascular Bradycardia, hypotension, reduced cardiac output, small vessel vasculopathy

Neurologic Global development delay, loss of knee and ankle reflexes, impaired memory

Hematological Pallor, petechiae, bleeding diathesis

Behavior Lethargic, apathetic

Mortality

According to the World Health Organization, malnutrition is by far the biggest contributor

to child mortality, present in half of all cases. Six million children die of hunger every year.

Underweight births and intrauterine growth restrictions cause 2.2 million child deaths a year.

Poor or non-existent breastfeeding causes another 1.4 million. Other deficiencies, such as lack of

vitamin A or zinc, for example, account for 1 million. Malnutrition was previously seen as

something that exacerbates the problems of diseases as measles, pneumonia and diarrhea.

Nutrient deficiencies and excesses

Nutrients Deficiency Excess

Food energy Starvation, Marasmus Obesity, diabetes mellitus,

Cardiovascular disease

Simple

carbohydrates

none diabetes mellitus, Obesity

Complex

carbohydrates

none Obesity

Saturated fat low sex hormone levels Cardiovascular disease

Trans fat none Cardiovascular disease

Unsaturated fat none Obesity

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Fat

Malabsorption of Fat-soluble vitamins,

Rabbit Starvation (If protein intake high) Cardiovascular disease

Omega 3 Fats Cardiovascular disease Bleeding, Hemorrhages

Omega 6 Fats none Cardiovascular disease, Cancer

Cholesterol none Cardiovascular disease

Protein kwashiorkor Rabbit starvation

Sodium hyponatremia Hypernatremia, hypertension

Iron Iron deficiency: Anemia Cirrhosis, heart disease

Iodine

Iodine deficiency: Goiter,

hypothyroidism Iodine Toxicity

Vitamin A

Vitamin A deficiency: Xerophthalmia

and Night Blindness, low testosterone

levels

Hypervitaminosis A

Vitamin B1 Beri-Beri

Vitamin B2 Ariboflavinosis

Vitamin B3 Pellagra

dyspepsia, cardiac arrhythmias,

birth defects

Vitamin B12 Pernicious anemia

Vitamin C Scurvy diarrhea causing dehydration

Vitamin D Rickets Hypervitaminosis D

Vitamin E nervous disorders Hypervitaminosis E

Vitamin K Vitamin K deficiency: Hemorrhage

Calcium

Osteoporosis, tetany, carpopedal spasm,

laryngospasm, cardiac arrhythmias

Fatigue, depression, confusion,

anorexia, nausea, vomiting,

constipation, pancreatitis, increased

urination

Magnesium Magnesium deficiency: Hypertension Weakness, nausea, vomiting,

impaired breathing, and

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hypotension

Potassium Hypokalemia, cardiac arrhythmias Hyperkalemia, palpitations

The World Health Organization estimates that malnutrition accounts for 54 percent of child

mortality worldwide (Walker et al. 2008). Even mild degrees of malnutrition double the risk of

mortality for respiratory and diarrheal disease mortality and malaria. This risk is greatly

increased in more severe cases of malnutrition. There are three commonly used measures for

detecting malnutrition in children: stunting (extremely low height for age), underweight

(extremely low weight for age), and wasting (extremely low weight for height). According to a

2008 review an estimated 178 million children under age 5 are stunted, most of whom live in

sub-Saharan Africa. A 2008 review of malnutrition found that about 55 million children are

wasted, including 19 million who have severe wasting or severe acute malnutrition (Bhutta,

2008).

PROGRAMS TO ADDRESS THE CAUSES OF MALNUTRITION IN INDIA

The Government of India has launched several programs to converge the growing rate of under

nutrition children. They include ICDS, NCF, National Health Mission.

Midday meal scheme in Indian schools

In order to tackle the malnutrition, the Government of India initiated the school meal program

which is called as MDM (Mid Day Meal). This school based meal program is going on in

Gujarat since 1984. There was a need to relook at the nutritional scenario of children with regard

to the prevalence of malnutrition and IDA (Iron Deficiency Anemia).

Integrated child development scheme

The Government of India has started a program called Integrated Child Development Services

(ICDS) in the year 1975. ICDS has been instrumental in improving the health of mothers and

children under age 6 by providing health and nutrition education, health services, supplementary

food, and pre-school education. The ICDS national development program is one of the largest in

the world. It reaches more than 34 million children aged 0–6 years and 7 million pregnant and

lactating mothers. Other programs impacting on under-nutrition include the National Midday

Meal Scheme, the National Rural Health Mission, and the Public Distribution System (PDS).

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National Children's Fund

The National Children's Fund was created during the International Year of the Child in 1979

under the Charitable Endowment Fund Act, 1890. This Fund Provides support to the voluntary

organizations that help the welfare of children.

National Plan of Action for Children

India is a signatory to the 27 survival and development goals laid down by the World Summit on

children 1990. In order to implement these goals, the Department of Women & Child

Development has formulated a National Plan of Action on Children. Each concerned Central

Ministries/Departments, State Governments/U.Ts. and Voluntary Organisations dealing with

women and children have been asked to take up appropriate measures to implement the Action

Plan. These goals have been integrated into National Development Plans.

United Nations Children's Fund

Department of Women and Child Development is the nodal department for UNICEF. India is

associated with UNICEF since 1949 and is now in the fifth decade of cooperation for assisting

most disadvantaged children and their mothers. Traditionally, UNICEF has been supporting

India in a number of sectors like child development, women's development, urban basic services,

support for community based convergent services, health, education, nutrition, water &

sanitation, childhood disability, children in especially difficult circumstances, information and

communication, planning and programme support.

National Rural Health Mission

The National Rural Health Mission of India mission was created for the years 2005–2012, and its

goal is to "improve the availability of and access to quality health care by people, especially for

those residing in rural areas, the poor, women, and children."

The subset of goals under this mission are:

Reduce infant mortality rate (IMR) and maternal mortality ratio (MMR)

Provide universal access to public health services

Prevent and control both communicable and non-communicable diseases, including

locally endemic diseases

Provide access to integrated comprehensive primary healthcare

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JUSTIFICATION

Nutrition plays a vital role as inadequate nutrition during childhood may lead to malnutrition,

growth retardation, reduced work capacity and poor mental and social development. Nutrition

education is a sinequanon for bringing a permanent and favorable solution to the problem of

malnutrition. Imparting nutrition education to mothers helps to improve the dietary status of

family as mother’s concept about balanced diet and how to provide it, can be changed. With the

improvement in nutrition knowledge of mothers, nutritional status of children also improves.

In India many dietary studies and surveys of nutritional status of children have been conducted

for different age groups. But the age group of school going children is such a group which

requires proper guidance at this growing age and needs to be free from nutritional disorders. 7-8

years of children were selected because today’s children are their self decision maker and due to

peer pressure they want to eat what eat by their friends. Most of the time mother decide their

food but sometimes they self decide their food what they eat. That’s why the knowledge of

nutritious foods is given to the children.

The main objective of the present study is to evaluate the level of malnutrition and impact of

some socio-economic and demographic factor of households on the nutritional status of children

7-9 years of age in Faizabad. The present study was also aimed to reduce the prevalence of

malnutrition and also improve the nutritional education in children. Outcomes from this research

study provide a better understanding of the problem which is turn would help to modify suitably

the existing children care services or even to design more appropriate strategies for their overall

development.

OBJECTIVES

The study was conducted keeping in view the following objectives:-

1. To find out the prevalence rate of malnutrition in 7-9years old school going children.

2. To assess the dietary pattern and nutritional status of selected school going children.

3. To develop teaching aids to create awareness through nutrition education in 7- 9years old

school going children.

4. To determine the impact of Nutrition education in preventing malnutrition.