How Much Food Is Enough? Food Consumption Among School-Going Children

Abstract

Discussing the alternative methodologies for measuring food intake, this chapter describes the food intake of school-going children and how this has changed over time. It links the trend observed in national level data and other surveys that indicates that despite economic growth and improved incomes, there has actually been a decline in the overall consumption of food in terms of calories, as well as a decline in the consumption of specific types of foods that are considered essential for the healthy growth and development of the child. How does this vary between different groups of children? Using Food Frequency data collected from the respondents of our study, the chapter compares the actual food intake of different categories of students and measures this against the appropriate Recommended Daily Allowance prescribed by the National Institute of Nutrition (2010). The results are presented in a detailed set of graphs that clearly demonstrate the level of underconsumption of key food groups, disaggregated by age and sex. This chapter: (1) throws light on the particular vulnerability of specific groups of children, given their marginalization in other spheres; and provides evidence for the need to intervene urgently to address the causes of such vulnerabilities; (2) provides important insights into the methodological complexities of collecting and utilizing food frequency data, and adds to the literature on the challenges of estimating food intake; and (3) discusses the implications of such analysis for food and nutrition policy, particularly in schools.

This chapter has received substantial contributions from Suraj Parab, Research Coordinator, Health Development and Society Initiative, Azim Premji University.

Appendices

Annex 1: Methodology for Collecting Food Frequency Data

Food frequency data was collected in all the three surveyed districts. Table 5.5 shows the number of children selected using stratified random sampling from all the three districts, their age, gender, and caste.

Table 5.5 Sample selected from 3 districts for collecting food frequency data

A total of 1080 children were selected from the three districts in the age group 5–11 years of age. The interviewers were selected from social science background and trained by the research team to collect the food frequency data. FFQ questionnaire was translated in Kannada and piloted in Mysuru district and necessary changes were made accordingly.

Information on the child’s diet was collected from the mother of the index child on how often a child eats a particular type of food in cooked form. In case there were two or more siblings from the same household, a separate food frequency questionnaire was filled up for each child. A comprehensive assessment of dietary intake was attempted, with an exhaustive list of various familiar cereals, pulses, fruits, vegetables, meats and dairy products. Average consumption frequency was assessed using open-ended questions, with responses varying from “never” to “three times a day.” For foods that were consumed only seasonally, respondents were asked how frequently they were consumed and for what duration.

Estimating portion sizes has been a contested issue (Willett 2012). To measure the quantity of the food items consumed by each child, measuring cups were used for cereals, pulses, vegetables, and milk and milk products. In the “cereals” category, ragi consumption was measured in balls (size of tennis ball was shown to the mother to estimate the size of the average ragi ball consumed by the child, estimated to weight 150 g); cereals consumed in the form of chapattis or rotis were estimated in number of pieces consumed, with each piece estimated to weigh 27 g. Consumption of fruits, meat, and eggs was measured in the form of either pieces or bowls. The measurements and conversion factors used to convert from cooked to raw form for data analysis purposes are presented in Table 5.6.

Table 5.6 Measurements and conversion factors used from cooked to raw form

After multiplying the frequency of consumption using the scores from Table 5.7, the conversion factor was used for converting each food from cooked to raw form to get an estimate of the daily consumption of each food item in its raw form.

Table 5.7 Frequency of consumption score

All the foods were then clubbed into six main categories; cereals, pulses, vegetables, fruits, meat, and milk and milk products. Food items provided in school as part of the Midday Meal program (MDM) were also added to the child’s estimated food consumption at home. The MDM input was calculated based on the amount provided per child as per the child’s age under the program (see http://mdm.nic.in/Files/Schoolpercent20Healthpercent20Programme/Nutrition_Support/Nutrition_support_Introduction.pdf). Government of Karnataka also provides 150 ml milk for each child twice a week; this was converted into grams [300 ml = 309 g (conversion factor 1.03)] and added to each child’s daily consumption (44.14).

According to National Institute of Nutrition (NIN) guidelines, children should eat according to age-appropriate RDA; as age increases, the consumption of most of the foods should be increased. NIN food recommendations in grams (in raw form) for the particular age group of children included in the study are in Table 5.8.

Table 5.8 Recommended daily consumption for different age group and sex: NIN Standards

Box 5.1 Example of How We Calculated Daily Consumption of a Child Food Items and How We Related it to RDA

The following example illustrates the case of a 9 year old male child eating 2.5 small bowls of rice and 0.25 portion of ragi ball daily; and 2 pieces of chappatis and 1 small bowl of puffed rice 1–2 times a week. Calculations made for child’s cereals consumption can be seen below:

Cereals	Quantity consumed	Frequency (see Table 5.4 for scores)	Formulas used of calculating daily consumption	Conversion factors to compute into raw form
Rice	2.5 small bowls	Daily or 5–6 times a week	=2.5 × 75 = 187.50	187.50 × 0.36 = 67.5
Ragi	0.25 ball	Daily or 5–6 times a week	=0.25 × 150 = 37.50	37.50 × 0.29 = 10.88
Wheat	2 pieces (1 piece = 40 g)	1–2 times a week	=80 × 1.5 = 120/7 = 17.14	17.14 × 0.27 = 4.6
Puffed rice	1 small bowl	1–2 times a week	=1 × 75 × 1.50 = 112.5/7 = 16.07	16.07 × 0.36 = 5.7
Cereals consumption per day at home				88.68
Cereals consumption per day at school (MDM)				85.71
Total Cereals consumption at home and school				174.1

If a child is eating certain foods daily, then it is calculated directly by multiplying the quantity by 7 or by using the assigned frequency score (Table 5.7) divided by 7 to get the daily estimate. Once the daily quantity was calculated, the conversion factor (Table 5.6) was used based on the type of cereal consumed. Subsequently, all the cereals consumed were added to get the total consumption of cereals per day. In this example, the total daily consumption of cereals is 174.1 g which is less than RDA (180 g, as seen in Table 5.8) for his age. Similar calculations were made for pulses, fruits, vegetables, milk and milk products and meats for each child.

Annex 2: Review of Literature on Risk Factors for Over-/Undernutrition

Year	Reference	Location	Age group	N	Purpose of study	Results
Risk factors for malnutrition
2014	Gupta et al. (2014)	Delhi, India	10–19 years	811 from 851 households, M = 52.2%, F = 47.8%	To determine the magnitude of underweight, overweight and obesity in adolescents of an urban area in Delhi and to assess relationship of malnutrition with sociodemographic factors, nutritional intake and physical activity in the study subjects	Lower consumption of green leafy vegetables/fruits and more than once/week consumption of fast food, fried food or sweets was associated with being overweight and obese
2013	Hooshmand et al. (2013)	Awaz in Iran and Mumbai in India	6–9 years	4570, Iranian = 2234 (Boys = 1016 and Girls = 1218), Indian = 2336 (Boys = 1240 and Girls = 1096)	The aim of this study was to assess the effect of dietary scores and nutritional status of urban Iranian and Indian school children	Total dietary diversity scores were significantly higher for Indian children who had normal weight or who were overweight (F = 32.197, p = 0.000) and lowest for underweight children. Similar trends were observed for the children from Iran (F = 9.345, p = 0.000). Total food group scores increased with better height status of the children. In both countries, severely and moderately stunted children had lower total mean scores than those who had normal and above average height. Analysis of data for individual food groups showed that increasing weight was associated with higher scores for almost all food groups in India. Heights for age
2012	Kalra et al. (2012)	India		Systematic review		Nutritional status of the Indian population varies significantly across the regions. Certain regions are associated with extremely high rates of childhood undernutrition (ranging from 20 to 80%), whereas others have a high prevalence of adult undernutrition (>50%), and some have both
2011	Vohra et al. (2011)	Lucknow, India	5–12 grade	407	j	Overweight and obesity was found to be 4.17 and 0.73%, respectively; they together constitute 4.91% for overweight/obesity. The study revealed that the important correlates of overweight/obesity were father’s education, father’s occupation, class, children playing outdoor games for less than 30 min, and those consuming fast foods
2010	Goyal et al. (2010)	Ahmedabad, India	12–18 years	5664	To investigate the prevalence of obesity and overweight and their association with socioeconomic status (SES) and risk factors like diet, physical activity, sleeping in afternoon, eating junk food, eating out, family history of diabetes and obesity	Age adjusted overweight = 14.3% among boys and 9.2% among girls, obesity = 2.9% in boys and 1.5% in girls. Prevalence of overweight among children was higher in middle SES as compared to high SES group and obesity was higher in high SES group as compared to middle SES group. Eating habits like junk food, chocolate, eating outside at weekend and physical activity like exercise, sports, sleeping habit in afternoon had significant effect on prevalence on overweight and obesity among middle to high SES group. Family history of diabetes and obesity were also found to be positively associated
2009	Warraich et al. (2009)	Karachi, Pakistan	6–8 grade	284	To determine prevalence of obesity and malnutrition in school-going children, from grades 6th to 8th of different schools of Karachi and assess associations that affect the weight of the children	Underweight = 52%, Normal = 34%, Overweight = 8% and Obese = 6%. Of all obese children, 70% belonged to the higher socioeconomic status (SES) group, while of the underweight children, 63.3% were in the lower SES. Amongst obese children, 65% ate meat every day, compared to 33% of normal kids
2008	Aggarwal et al. (2008)	Ludhiana, India		1000 (equal no of boys and girls)	To study the prevalence of obesity among adolescents in public schools of Ludhiana, catering to the affluent segment of population	Overall incidence of obesity in the study group was 3.4%, with no significant difference between boys and girls. A significantly greater number of boys (15%) as compared to girls (10.2%) were overweight. 57.2% of boys and 52.8% of girls, spent 1–4 h/day viewing TV or sitting at the computer. Out of the total obese children, significant percentages (82.3%) were non-vegetarian. A normal body mass index was most characteristic of vegetarians. The incidence of obesity/overweight was significantly higher in those who ate meals outside home. The mean scores of replacing snacks for meals were significantly higher in obese and overweight adolescents as compared to adolescents with a normal BMI
2008	Bharati et al. (2008)	Wardha, Central India	5–7 and 8–10 grade	31 middle schools and high schools	To study the magnitude of overweight/obesity and its correlates among school going children	Overweight = 3.1% and Obesity = 1.2%. Multivariate logistic regression showed that important correlates of overweight/obesity were urban residence, father and/or mother involved in service/business, English medium school and child playing outdoor games less than 30 min
2007	Kuriyan et al. (2007)	BangaloreIndia	6–16 years	598, male = 324		The duration of sleep and TV viewing were significantly associated with overweight. Children who slept less than 8.5 h/day had significantly higher odds (6.7, p = 0.013) of being overweight when compared to children who slept more than 9.5 h/day, after adjustments for age, gender, location of stay and socioeconomic status. The adjusted odds of being overweight for children who viewed television for greater than or equal to 1.5 h/day was 19.6 (p = 0.001), when compared to children who viewed television for less than or equal to 45 min/day. Among eating behaviors, the consumption of fried food items, more than 6 times/week, was associated with significantly higher odds of being overweight (3.1, p = 0.014) when compared to fried food consumption less than 2.5 times/week. None of the other eating behaviors were found to be significantly associated with being overweight
2007	Chitra et al. (2007)	Secunderabad, Andhra Pradesh, India	10–15 years	802	To ascertain the breakfast habits of 10–15-year old schoolchildren and to assess the quality of this meal as well as its relationship to the food consumption pattern for the full day	Only 42.8% of the children ate breakfast regularly. Over half of the children skipped breakfast, ranging from daily to once in two weeks. The energy and protein composition of breakfasts eaten by the children indicated that those who did not skip breakfast met one-quarter to one-third of their total daily energy and protein requirements. Over half of the schoolchildren studied skipped breakfast frequently, the main reason being getting up late. Children who consumed breakfast had higher daily intakes of energy and protein than children who skipped breakfast
2006	Rasmussen et al. (2006)	Global data	Children and adolescents	98 papers were identified from Medline and PsycINFO	To find out the determinants of fruit and vegetable consumption among children and adolescents	The determinants best supported by evidence are: age, gender, socioeconomic position, preferences, parental intake, and home availability/accessibility. Girls and younger children tend to have a higher or more frequent intake than boys and older children. Socioeconomic position, preferences, parental intake, and home availability/accessibility are all consistently positively associated with intake
2006	Wiecha et al (2006)	Boston	11–12 years	N = 548 students 48.4% female	To test whether increased television viewing is associated with increased total energy intake and with increased consumption of foods commonly advertised on television, and whether increased consumption of these foods mediates the relationship between television viewing and total energy intake	After adjusting for baseline covariates, each hour increase in television viewing was associated with an additional 167 kcal/day (95% confidence interval, 136–198 kcal/day; p < 0.001) and with increases in the consumption of foods commonly advertised on television. Including changes in intakes of these foods in regression models provided evidence of their mediating role
2004	Mohan et al. (2004)	Ludhiana, India		3326, Urban = 2467 Rural = 859	To evaluate the prevalence of sustained hypertension and obesity in apparently healthy school children in rural and urban areas of Ludhiana using standard criteria	Prevalence of sustained hypertension was 6.69% (n = 165) and in rural area it was 2.56% (n = 24). Males outnumbered females in both rural and urban areas. There was significant increase in prevalence of hypertension in both rural and urban population with increased body mass index in urban students; those with normal body mass index had prevalence of hypertension of 4.52% (n = 96), in overweight it was 15.33% (n = 44) and in obese it was 43.10% (n = 25). In rural areas, prevalence of sustained hypertension among overweight students was 6.82% (n = 3) and in obese group it was 61.76% (n = 21). None of the students with normal BMI in rural area was found to be hypertensive. The mean BMI of hypertensive population in both rural and urban areas was significantly higher than respective normotensive population
2002	Hakeem et al. (2002)	UK and Pakistan	10–12 years	3 groups in Pakistan and 3 in UK	To examine the food habits and nutrient density of diets of six groups of rural and urban school children aged 10–12 years	With urbanization, the intake of sugar increased steadily. The intake of vitamin C, vitamin BI2, and folates was higher among the UK groups
2002	Ramachandran et al. (2002)	India	13–18 years	4700, M = 2382, F = 2318	To quantify the prevalence of overweight and its risk factors in adolescent children in urban India	Overweight was 17.8% for boys and 15.8% for girls. It increased with age, higher in lower tertiles of physical activity and in higher socioeconomic group. Birth weight and current BMI were positively associated. High prevalence of overweight in adolescent children in urban India. Life style factors influenced BMI in adolescent age
Policy issues
2014	Ochola et al. (2014)	42 countries		Literature Review (50 studies and 42 countries)	To characterize the dietary patterns and assess the adequacy of nutrient intake to identify the effects on public health and nutrition. The analysis was based on 50 studies performed in 42 countries, published from 2000 to 2014	Diets of schoolchildren and adolescents in developing countries are limited in diversity, with very little consumption of animal foods and fruits and vegetables. Consequently, many children are deficient in micronutrients. Consumption of high-calorie foods is increasingly becoming popular among schoolchildren and adolescents in urban areas
2010	Maliye et al. (2010)	Wardha, Central India	10–18 year	430 adolescent girls	To assess the nutrient intake of rural adolescent girls	Overall, 57% of the adolescents were thin (BMI for age <5th percentile for Center for Disease Control (CDC) 2000 reference) and 43% of the adolescents were normal (BMI for age between 5th and 85th percentile for CDC 2000 reference). The average energy intake, which was 1239.6 ± 176.4 kcal/day, was deficient of recommend daily allowance (RDA) by 39%. The average protein intake was 39.5 ± 7 g/day. It was deficient by 36% and the average iron intake, which was 13.2 ± 2.5 mg/day, was deficient by 48% Conclusion: The findings reiterate the dietary deficiency among adolescent girls which adversely affects the nutritional status
2010	Raj et al. (2010)	Global data		Systematic review		Worldwide (2.6 million deaths yearly), obesity trends are causing serious public health concern and in many countries threatening the viability of basic health care delivery. It is an independent risk factor for cardiovascular diseases and significantly increases the risk of morbidity and mortality. The last two decades have witnessed an increase in health care costs due to obesity and related issues among children and adolescents
2009	Kumar et al. (2009)	Davangere, KarnatakaIndia	10–15 years	1,496,975 boys, 521 girls	To study the prevalence of obesity in two groups of affluent school children in Davangere city, in classes 5–10; and identify factors influencing childhood obesity	Obese; boys = 4.10, girls = 8.82. The difference observed in prevalence of obesity between boy’s habit of snacking of high-energy foods and lack of physical activity were the important influencing factors of childhood obesity
2009	Cairns et al. (2009)	Previous systematic reviews and academic database		Systematic review	To review evidence on the global extent and nature of food promotion to children, and its effects on their food knowledge, preferences, behavior and diet-related health outcomes	The review confirms that in both developed and developing countries food promotion to children is common. Television advertising is the most dominant promotional channel but a range of promotion and marketing techniques and strategies are used. The emergence of new mass media channels such as website and mobile telephone SMS services offer less visible but highly direct targeted marketing opportunities. The evidence base for the effect and reach of these newer promotional channels is quite small, but to date, suggests it is gaining share rapidly and effectively
2007	Hawkes et al. (2007)	Global data		Systematic search which was done based on 2004 report	To examine the changes in the global regulatory environment around food marketing to children since 2004 (At the Fifty-seventh World Health Assembly in May 2004, the Member States of World Health Organization (WHO) adopted resolution WHA57.17, endorsing the Global Strategy for Diet, Physical Activity and Health (DPAS) (1). The Strategy provides a series of options which Member States can follow to help prevent obesity and diet-related chronic diseases)	From a global perspective, there has been more talk about regulation than action to implement regulations. Important changes have occurred in the global regulatory environment around food marketing to children. These changes are still ongoing, in some cases at a fast pace. This heightened level of discussion and action has been directly and indirectly stimulated by DPAS. Subsequently, there are now an increasing number of ideas and proposals on how food marketing to children can be regulated.
2006	Singh et al. (2006)	Delhi, India	10–18 years	510	To evaluate the prevalence of lifestyle-associated risk factors for non-communicable diseases in apparently healthy school children in an urban school in Delhi using standard criteria	The study documents the inappropriate dietary practices (fast food consumption, low fruit consumption), low physical activity, higher level of experimentation with alcohol and to a lesser extent smoking, high prevalence of obesity and hypertension in the school children. The study also showed an association between BMI, systolic and diastolic blood pressures amongst children and other lifestyle factors
2006	Hastings et al. (2006)	Two previous systematic reviews and academic database		Systematic review	To review of the extent and nature of food promotion to children and its effects on their food knowledge, preferences and	This review confirms that in both developed and developing countries: (1) there is a great deal of food promotion to children, particularly in the form of television advertising; (2) this is typically for highly-processed, energy dense, unhealthy products with evocative branding; and (3) that children recall, enjoy and engage with this advertising. More complex research from developed countries shows that it is having an effect, especially on their food preferences, purchase behavior and consumption. Although none Although none of these more complex studies was undertaken in the developing world, other research shows that children everywhere respond to food promotion in similar ways. There is, therefore, reason to believe that children in the developing world will be just as vulnerable to food promotion
1995	Chaturvedi et al. (1995)	Rajasthan, India	10–18 years	941 adolescent girls	To assess the nutrient intake of adolescent girls belonging to low socioeconomic group of rural Rajasthan	The diets were deficient in calories by 26–36%, and in proteins by 23–32%. Nutritional status as assessed by body mass index revealed that 8.1% of adolescent girls suffered from chronic energy deficiency (CED) grade I, 6.6% grade II CED, and 78.8% grade III CED. About 73.7% of subjects suffered from anemia and 43.6% had signs of vitamin B complex deficiency