INTRODUCTION:

“Today’s children are Tomorrows world or Tomorrows Leaders”

-Pandit Nehru

This slogan is riding a massive wave of concern throughout the world. But children all over the world are deprived of many facilities. Underweight and malnutrition make them worst sufferers and these pose potential threats to mankind as a whole or to civilization itself. Early years of life are crucial for future growth and development. Globally nutritional status is considered the best indicator of the well-being of young children. Malnutrition is a state in which a prolonged lack of one or more nutrients retards physical development or causes specific clinical disorder.¹

The importance of the first 5 years of life of a child for its growth and development is well known. Any adverse influences operating on children during this period (malnutrition and infection) may result in severe limitation in the development, some of which at least are irreversible. The concept of vulnerability calls for preventive care and special action to meet the biological and psychological needs inherent in the process of human growth and development. Young children are “vulnerable” to social and health hazards which can retard or arrest the physical and mental development during this critical year; they deserve special attention by the administration, general population and the family.²

Infants and preschool children are dependent on their mother for nourishment, and if her selection of foods for them is incorrect, they may suffer from malnutrition. During the process of weaning most poor children are a prey to faulty nourishment since they may fed sago kanji (gruel) a substitute for milk and no others foods providing good quality protein. Undernourished children do not grow to their full potential of physical and mental abilities, malnutrition in infancy and childhood leads to stunted growth. The problem facing the health worker in the developing world like India, more evident in the field of child care. The main health problem encountered in the child population that is, low birth weight, malnutrition, infection parasitizes accidents and behavioral problems.³

The quantity of protein required is about 20g/day between 6 months and 3 years. As an indication, the mother who gives 800ml of milk provides her child with just 8g of protein a day. The weaning pap thus has to supply the child with the missing 12g of protein. Ideally, the amino acid composition of these supplementary proteins should be identical to that of breast milk, i.e. contain the same proportions of the nine essential amino acids (including lysine, 2threonine and tryptophan). These amino acids are called essential because the child’s organism is incapable of synthesizing them and they have to come from the food. Some proteins of animal origin have an amino acid composition very close to that of breast milk.

The World Health Organization have reported hunger and related malnutrition as the greatest single threat to the world's public health. Improving nutrition is widely regarded as the most effective form of aid. Nutrition-specific interventions, which address the immediate causes of under nutrition, have been proven to deliver among the best value for money of all development interventions. Emergency measures include providing deficient micronutrients through fortified sachet powders or directly through supplements. WHO, UNICEF, and the UN World Food Programme recommend community management of severe acute malnutrition with ready-to-use therapeutic foods, which have been shown to cause weight gain in emergency settings. The famine relief model increasingly used by aid groups calls for giving cash or cash vouchers to the hungry to pay local farmers instead of buying food from donor countries, often required by law, to prevent dumping from hurting local farmers.¹⁰

Globally, malnutrition is the most important risk factor for illness and death. It affects children and pregnant women disproportionably. It is the direct cause of about 300,000 deaths per annum and indirectly responsible for about half of all deaths in young children (malnutrition increases the risk of death from diarrhea, lower respiratory tract infection, malaria and measles). The World Health Organization (WHO) estimates that by 2015 prevalence of malnutrition worldwide will be 17.6% - with the vast majority living in developing countries in southern Asia and sub-Saharan Africa. An additional 29% will have stunted growth due to poor nutrition.¹¹

NEED FOR THE STUDY:

“One can survive without vision but difficult without nutrition”

Since large majority of pre-school children in developing countries consume inadequate diets and suffer from malnutrition. There is an urgent need to institute supplementary feeding programs in the developing countries such supplementary should be based on locally available foods such as legumes, oil seeds, and nuts. Studies carried out by several workers have shown that a daily supplement of about 30gram of processed legumes or roasted groundnut or processed protein foods based on blends of cereals, oil seeds, meals and legumes will help to overcome malnutrition among pre-school children.¹²

Weight gains in forty-seven malnourished infants have been studied in relation to the type of diet given during the recovery phase. Twenty-three (group P) were given substantially more calories than the rest (group O). Group P gained weight at a significantly greater rate (10·6 as against 7·65g. per kg. per day). The response was particularly striking in marasmic infants, who grew more rapidly than those admitted to hospital with kwashiorkor. The rapid weight gains were achieved with relatively modest protein intakes (about 4g. per kg. per day). This finding will be important in countries where malnutrition is a serious problem and where it is easier to provide calories than protein.¹³

A recent (2005) analysis by the Maternal and Child Malnutrition Study Group (MCUSG) of data from 388 national surveys from 139 countries [2] has provided new estimates of the global prevalence of underweight, stunting, and wasting among children below 5 years of age, based on the new WHO Child Growth Standards. Of the 556million children under 5 years of age in low-income countries, 20% (112million) were underweight, 32% (178million) were stunted, and 10% (55 million) were wasted, including 3.5% (19million) who were severely wasted. Thus, about 36million children are suffering from moderate wasting. Underweight, stunting, and wasting each contributes to child mortality and disease burden. Of the almost 10 million deaths annually among children below 5 years of age, it was estimated that the attributable fractions of underweight, stunting, and wasting were 19%, 15%, and 15%, respectively, whereas intrauterine growth restriction and low birthweight accounted for only 3.3%. Altogether, these anthropometric indicators of malnutrition, using –2 z-scores as cutoffs, accounted for 21.4% of child mortality and 21.1% of child disease burden [2]. Of the 14.6% of deaths attributable to wasting, only 4.4% were due to severe wasting, and hence 10.2% of the deaths, or about 1 million, were due to moderate wasting.¹⁴

Intestinal parasites such as hook worm and tape worm common in tropical and semitropical climate of many less developed countries reduce the absorption of protein and certain vitamin and may cause malnutrition even in a child who has a relatively good diet.¹⁵

A childhood mortality study in America showed that number less than 57percent of the children who died before the age of 5 years were found to have malnutrition as underlying or associated causes of death. An earlier analysis of trends from 1980-2005 based on 241 national survey indicated that childhood malnutrition remains a public health problem worldwide, stunting rather declining in the majority of countries at about 1% per year or less more over in some countries, rates of stunting were raising while in many other. They remained high.¹⁶

South Asia has staggeringly high levels of underweight prevalence with more than 40% of all children underweight. Three countries in this region Bangladesh, India, and Pakistan. Children aged less than five years under weight for age in South East Asia region by World Health Organization (WHO) in 2009, Thailand–7.0, Koria-17.8, Indoniasia-19.7, Srilanka-22.8, Maldives-25.7, Myanmar-29.6, and India-43.5.¹⁷

Around one quarter of all under five in the developing world are underweight. This accounts for about 148 million underweight children in developing countries WHO, Central Disease Control (CDC) of these 148 million underweight children nearly 3 quarters live just in 10 countries. The highest levels of underweight prevalence are found in south Asia, where more than 40% of children under five are underweight. In sub-Saharan Africa around one quarter of children are underweight.¹⁸

The prevalence of underweight children in India is among the highest in the world by WHO estimates it said about 49% of underweight children, 34% of stunted children and 46% of the world wasted children live in India.¹⁹

Moderate malnutrition (MM) includes all children with moderate wasting defined as a weight-for-height between -3 and -2 z-scores of the WHO child growth standards and all those with moderate stunting defined by a height-for-age between -3 and -2 z-score of the WHO child growth standards. Most of these children will be moderately underweight (weight-for-age between -3 and -2 z-scores). MM affects large numbers of children in poor countries placing them at increased risk of mortality. A recent analysis of data from 388 national surveys from 139 countries from 2005 has provided an estimate that about 36 million children aged 6-59 months are suffering from moderate wasting. Approximately 178 million are estimated to be stunted. MM increases the risk of death from common diseases and, if not adequately treated, may worsen, resulting in severe acute malnutrition (severe wasting and/or oedema) and/or severe stunting (height-for-age less than -3 Z-scores) which are both life threatening conditions. Therefore, the management of MM is a public health priority.²⁰

During 1996-2004 more than 26 per cent of the world’s children under the age of 5 years were underweight for their age. There proportion ranged from 1.0 per cent of children developed countries to 26 per cent in developing countries. According to national family health survey in India during the period of 1992-1993 nutritional status of young children both chronic and acute under nutrition were found to be high in all the seven states for which reports have so far been received, namely Haryana, Karnataka, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh and Goa.²¹

At present in India 65 per cent children under 5 years age are underweight. This includes 47 per cent moderate to severe cases, 18 per cent severe malnutrition, of these 16 per cent have moderate to severe wasting and 46 per cent moderate to severe stunting. “According to M.C Steinhoff” a cross sectional survey of the nutritional status of 1223 preschool age children was carried out in a development area in the southern Indian state of Tamil Nadu. Altogether 45% of the children were underweight (low weight for age) 51% were stunted (low height for age) and 21% was wasted (low weight for height) surveys that are designed to produce information on stunting and wasting are important in the planning and evaluation of nutritional intervention programme.²²

Vijayaraghavan (2002), diet and nutritional status of reveal preschool children in Punjab, Multistage random sampling method was adopted by following probability proportion to population four hundred households were covered in each district of Punjab for social economic and demographic information. The entire individuals were included for anthropometry and clinical examination. Every 4th household was covered for 24-hour recall. At the state level, the intake of macro and micronutrient with foods such as cereals, pulses and green leafy vegetables, milk and milk products and fat and oils were lower than the daily requirement except for protein, calcium, and thiamine, the mean intake of all the nutrients was lower than the recommended level. About half of the preschool children were undernourished. 60% were stunted 12% were waster, a higher proportion of preschool children were consuming diets, which are inadequate with respect to energy, fat, iron. A prevalence of under nutrition was high as was found in other states of India.²³

Elio Castagnola (2002), evaluate the effect of oral nutritional supplementation and Dietary counseling on the growth and nutritional status of at risk of malnutrition. A total of 174 samples aged 12 month to 10 years received a daily nutritional supplement and nutritional counseling was provided to the parents, almost all the child (97%) had dietary intake at base line that was insufficient or slightly insufficient are not well balanced. Following four month of nutritional intervention adequate intake was observed in 72% of samples with weight for height below the 25th percentile decreased from 56 % at base line to 45% after two month and 42% after four month of nutritional intervention. These differences were statistically significant at four month. Supplementation together with nutritional counseling can improve food intake and growth in children at risk for malnutrition.²⁴

Most foods contain a mixed of proteins that complement one another. In a mixed diet, animal and plant foods provide a wide variety of many nutrients and proteins that supplement each other. Animal origin protein like egg, milk, cheese and meat. Plant origin protein like grains, legumes, nuts, seeds, vegetables and fruits.²⁵

The principles of complimentary protein food providing adequate amount of essential amino acids forms the basis of planning vegetarian diets indicates that even a mixture of plant protein can provide adequate amount of amino acids when our basic use of various grains are expanded to include soya proteins and other dried legumes. A normal eating pattern through the day, together with the body reserve supply of protein. Usually ensures a complimentary amino acid balance, underlying requirement for vegetarian, as for all people, is to eat sufficient amount of variety of food to meet normal nutrient and energy needs.²⁶

Recently in Madhya Pradesh 25 children died in two villages of Jhabua district in October 2009. Alarmingly enough most of the children were in the age group of 0-6 years. In Amaravathi District, the total 36,264 children below the age 6 in Milghat, only 13,604 were of normal weight, the rest are in the various grade of malnutrition, every year at least 400–500 children below the age of 6 die in Melghat because of malnutrition. India is a developing country; today’s children are tomorrows pillars of our India. So children health is very important for our developing country like India. Nutrition is a important factor which will decrease the mortality and morbidity rate among children. The investigator felt that there is a need to conduct a study to undernourished children to improve the nutrition status and prevent malnutrition.²⁷

Objectives of the Study:

· To assess the nutritional status among undernourished children.

· To evaluate effectiveness of protein rich diet on improving physical parameters among undernourished children.

· To find out the relationship between weight and MAC among undernourished children

· To determine the association between knowledge score and the selected demographic variables such as age, sex, religion, educational status of care taker, occupation of care taker, income of the family, type of food in the family, child birth order, birth weight of the baby and source of information.

Hypotheses:

H₁: There will be significant difference between pre-test and post-test score of physical parameters among undernourished children after administering protein rich by paired’ test at 0diet.05 level.

H₂: There will be a significant relationship between weight and MAC among Undernourished children.

H₃: There will be significant association between the selected demographic variables such as age, sex, religion, educational status of care taker, occupation of care taker, income of the family, type of food in the family, child birth order, birth weight of the baby and source of information by chi-square test (χ²) at 0.05 level.

ASSUMPTIONS:

The study assumes that,

· The care takers may not have adequate knowledge regarding the importance of Protein rich diet.

· Care takers will have interest to know more about the importance of Protein rich diet.

· Nutrition status will be different among children.

· Protein rich diet will help to improve the physical parameters of undernourished children.

LIMITATIONS:

· This study is limited to the underweight children among the age group of 4-5 years in selected schools at Bangalore.

· The study is limited to children comes under the mild, moderate and severe malnutrition according to Gomez classification

· The study is delimited to 30 days of nutritional intervention to the child.

METHODOLOGY:

Research methodology is one of the effective ways to solve research problems systematically. It involves a series of procedures in which the researcher starts from initial identification of the problem to its final conclusion. The chapter deals with the description of methodology, which was undertaken for gathering and organizing data for the investigator.

Research Approach:

Research approach tells the researcher from whom the data was to be collected, when the data is to be collected and how to analyze them. It also suggests possible conclusion and helps the researcher in answering a specific research question in the most accurate and efficient way possible.

A quantitative approach will be used to determine the effectiveness of protein rich diet on improving the physical parameters of the undernourished child.

Research Design:

The research design is the plan, structure and strategy of investigations of answering the research question, is an overall plan or blue print. The researcher selects to carry out the study.

A pre-experimental design which consists of one group pre-test post-test design was used for analyzing the effectiveness of protein rich diet on improving physical parameters among undernourished children. Assessment of weight done according to the Gomez Classification and assessment of MAC by Shakir’s tape before nutritional intervention, during the intervention on 15^th day, and after the intervention on 30^th day.

Setting:

Setting refers to the area where the study is conducted. It may be natural setting or laboratory setting depending upon the study topic and researcher’s choice.

The study was conducted in K.T.G Matric Higher Secondary School at Bangalore. It is located half kilometer away from National College of Nursing. The school is having classes from pre-kg to 12^th standard. In UKG class having 3 sections. The school is built with 2 floors. One year once special health checkup conducted for children.

Population:

Population is a group whose members possess specific attributes that a researcher is interested in study.

Target population for the present study was under nourished children from UKG classes. 90 children are available from UKG classes.

Sample and Sample Size:

Sample is a subset of population selected to participate in a research study. Sampling is the process of selecting a group of people, events and behaviour on other elements with which to conduct a study.

The samples for the present study were 40 undernourished children from UKG classes according to Gomaz classification ≤ 89% of weight and MAC below 13.5 cms.

Sampling Technique:

The process of selecting a portion of the population is to represent the entire population. In this present study sample were selected by non randomized purposive sampling technique among 90 children 40 children were selected by using Gomaz classification for weight ≤ 89% and MAC< 13.5cm based on inclusion and exclusion criteria.

Criteria for Selecting the Sample:

1. Inclusion Criteria:

· Children between 4-5 years are included.

· Children those who have ≤ 89% of weight according to Gomez classification and MAC<13.5 cm.

· Children those who are willing to participate in the study.

2. Exclusion Criteria:

· Children those who have chronic illness

· Children those who absent to the school frequently.

· Children those who are taking protein rich diet.

Data Collection Instrument:

An instrument selected in a research should be as far as possible the vehicle that would best obtain data for drawing conclusions, which were pertinent to the study.

Based on the objectives of the study, the Structured interview schedule is developed in English after a extensive review of literature and experts opinion. The standardized Gomez classification scale for weight, and Shakir’s tape for measuring MAC.

Selection and Development of the Tool:

The tool was developed on the basis of objectives of the study. The tool was developed after:

· Review of literature and text books provide adequate content area and information.

· Consultation and discussion with experts from community health nursing departments.

· Discussion and consultation of the statistician.

Scoring Procedure:

According to Gomez classification weight assessment done for the child which involves 3 classifications such as mild, moderate and severe.

75% - 89% : Mild malnutrition

60% - 74% : Moderate malnutrition

<60% : Severe malnutrition

MAC is measured by Shakir’s tape which involves two categories

12.5 – 13.5cms : Mild malnutrition

Below 12.5cms : Moderate to severe

Protein Rich Diet Intervention:

The protein rich diet in the form of dhal payasam, cow pea poriyal, dhal laddu and soya bean cutlut, are the item. In this item 1^st week morning payasam, evening cow pea poriyal, 2^nd week dhal laddu in morning and soya bean cutlet in the evening. 3^rd week the 1^st week item was repeated. 4^th week the 2^nd week item was repeated.

Testing of the Tool:

1. Content Validity of the Tool:

Content validity refers to the degree to which an instrument measures what it is supposed to measure.

Validity of the tool was established after consultation with experts from the field of community health nursing. Minor modifications were made on the basis of recommendations, suggestion of experts. After consulting guide, co-guide and statistician, final tool was reframed. Later the tool was edited by an English language expert and translated into Kannada by language experts without changing the meaning of the tool. It was found to be valid and suitable for primary school teachers.

2. Reliability of the Toolp:

Reliability is the degree of consistency that the instrument of procedure demonstrates whatever it is measuring, it does so consistently.

The reliability of the tool was established by using Split Half technique which measures the co-efficient of internal consistency. The reliability of Split Half test was found by using Karl Pearson correlation by deviation method. Spearman Brown’s Prophecy formula was used to find out the reliability of the full test.

R = ------

1 + r

R — reliability co-efficient of correlation of whole test

r — reliability co-efficient of correlation of half test

The reliability co-efficient of correlation of the knowledge tool was found to be 0.949 which indicates that the tool was reliable.

RESULTS:

In order to find a meaningful answer to the research questions, the collected data must be processed, analyzed in some orderly coherent fashion, so that patterns and relationships can be discussed.

Analysis is the categorizing, ordering, manipulating and summarizing of data to obtain answers to the research questions. The interpretation of tabulated data can bring light to the real meaning and effectiveness of the findings.

In this study, quantitative approach was adopted to assess the effectiveness of protein rich diet on improving physical Para meters. Data collected from 40 selected respondents were tabulated, analyzed and interpreted by using descriptive and inferential statistics based on the formulated objectives of the study. These are:

· To assess the nutritional status among undernourished children.

· To evaluate effectiveness of protein rich diet on improving physical parameters among undernourished children.

· To find out the relationship between weight and MAC among undernourished children

MAJOR FINDINGS OF THE STUDY:

Major finding of the study were in demographic variables, majority of the undernourished child belonged to 5 years of age (75%), most of the child belonged to male (70%).

With regard to the religion, most of the them belonged to Hindu. With regard to education status of care taker, most of them belonged to +2 (25%). With regard to occupation of care taker, most of them belonged to housewife (75%) with regard to the Income of the family, most of them belonged to Rs 6000 (40%), with regard to type of food in the family most of the samples were non-vegetarian (82.5%), with regard to child birth order, most of the child were belonged to II order of birth (57.5%), with regard of birth weight of the baby, most of the samples were belonged to 2.3 kg & 2.5 kg 37.5%, with regard of source of information regarding protein rich diet most of them got information by neighbor 27.5%.

With regard to diet history, weaning food was started to the child most of the samples were belonged to 6 month 27%.With regard of protein supplementation, none of them were taken protein supplement (40%) with regard of breast feeding stopped to the child most of the samples belonged to 1 year of age (70%), with regard of allergic of food item, none of them were allergic to food (40%), with regard to consult the physician for undernourished problem, none of them were consulted. (100%), with regard of frequency of food intake per day, most of the children belonged to 3 times a day (52.5%).

With regard of dislikes of food by the child, most of them were not interest to have Egg 21(52.5%). With regard to child refuse to take food, 35% were regular refuser, 35% with regard to adequate amount of food and (72.5%) of children were fed by care giver regularly.

SUMMARY:

The aim of this present study was to evaluate the effectiveness of protein rich diet on improving physical parameters among undernourished children in a selected school at Bangalore.

CONCLUSION:

The main conclusion drawn from the study was protein rich diet is effective in improving the physical growth of undernourished children in a selected school at Bangalore. The investigator understood that proper protein rich diet for undernourished children will improve the physical growth of the undernourished child.

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Received on 31.03.2020 Modified on 17.04.2020

Int. J. Nur. Edu. and Research. 2020; 8(3):324-330.

DOI: 10.5958/2454-2660.2020.00070.8