The document presents a nutritional survey of school-going children in rural and urban areas of Mardan District, Pakistan, highlighting issues of malnutrition, particularly protein and energy deficiencies. It outlines the study's objectives, methodology, and expected results, indicating significant malnutrition rates with variations based on socioeconomic conditions. The study aims to assess the nutritional health of children aged 5-10 years through dietary, clinical, and anthropometric assessments.

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Nutritional survey of school going children in rural
and urban areas of district Mardan in relation to
protein and energy consumption
Muhammad Ihsan
2015-ag-1994
MSc(Hons) HND
Supervisor: Prof. Dr. Nuzhat Huma

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Road map
• Malnutrition
• Nutritional Assessment
• World view
• Situation in Pakistan
• Experimental case study
• Objectives
• Study plan
• Materials and methods
• Expected results and references

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Malnutrition
• Group of conditions related to
– Poor quality, insufficient quantity of nutrient intake, absorption or
utilization.
• Types of malnutrition
• Over nutrition - when there is an excess intake of nutrients, it results
in over nutrition.
• Under nutrition - the condition of health of a person that results due to
the lack of one or more nutrients is called under nutrition. .
• Protein-energy malnutrition - insufficient protein and calories
• Micronutrient deficiency diseases - resulting from a deficiency of
specific micronutrients.
– Major problem in children is deficiency of protein and calories
(Nazemi et al., 2015)

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Malnutrition
• Uncontrolled in school going children
• Mainly 5-10 years of children
• Reflected by their suboptimal mental achievement
(Tiwari et al., 2013)
• Reduces the immune response against various infections
• Major causes of mental retardation
• Growth depends on nutritional and health condition
• Growth can be judged through nutritional assessment
(Srivastava et al., 2012).

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Nutritional Assessment
A comprehensive nutritional assessment includes
1.Anthropometric measurements of body composition
2.Biochemical measurements of serum
3.Clinical assessment of altered nutritional requirements
4.Social or psychological issues that may preclude adequate intake
(Ong et al., 2014)

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World view
• Half of the world malnourished population
– In Pakistan, Bangladesh and India.
• Children are more affected than adults. According to an estimate in 2011,
3.1 million children deaths per year or
– 45 percent due to malnutrition with other chronic diseases
• WFP estimated US $3.2 billion per year for combating 66 million
malnourished school-age children
(Black et al., 2013)

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Situation in Pakistan
– almost 40% of these children are underweight
– Over half the children are affected by stunting and
about 9% by wasting
• Significant provincial variations in malnutrition rates
– lowest in Punjab
– highest in Balochistan
• Anthropometric deficits are systematically higher in rural areas due to
– lower socio-economic status
– very poor access to basic health services (Di Cesare et al., 2011)

9. National Nutrition Survey 2011
Micronutrients Deficiency
Vit- A Deficiency
( 0-59 months)
56 58 53 81 100 37 78 82
Zinc Deficiency
(0-59 months)
37 39 35 34 34 49 34 33
Vit- D Deficiency
(0-59 months)
41 43 42 40 26 33 30 32
Iodine Deficient
( 6-12 years)
37 35 39 35 10 65 26 70
Indicators National Sindh Punjab Balochistan FATA AJK KPK Gilgit
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Nutrients Deficiency in KPK
Micronutrients Deficiency
Vit- A Deficiency ( 0-59 months) 78
Zinc Deficiency (0-59 months) 34
Vit- D Deficiency (0-59 months) 30
Iodine Deficient (6-12 years) 26
Indicators
KPK Indicators KPK
Growth
Severe Stunting (0-59months) 25
Wasting rate 18
Under weight 24
Anemia
Anemia 47
Ferritin deficiency 21
Iron deficiency anemia 13

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Case study
• A study conducted in school students of Lahore, Pakistan
• Students selected: 1860
Following values was compared in contrast to the global growth standards
– gender , age, weight, height, BMI percentiles, nutritional health
• Results after comparing with International Obesity Task Force ,WHO and USCDC shows that
• Both girls and boys
– had lower BMI
– Lower weight
• In younger age groups, boys had same height and girls were taller
• But after nine years of age both boys and girls fell short
(Mushtaq et al., 2012)

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Why this study was conducted?
• Many studies on school age children of Pakistan
• Limited studies are available for Khyber Pakhtunkhwa (KPK)
• Urgent need to evaluate the nutritional health of KPK children

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Objectives
• Nutritional status assessment of school going children (5-10
year) in urban and rural areas of district Mardan
• Dietary, clinical, and anthropometric assessment of school going
children in the study area

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Study plan
• Sample size was of 300 students
• Total number of selected schools were 12
– 7 from rural and 5 from urban
• From both urban and rural schools 150 students were selected
• From each school students between age 5-10 were randomly
selected

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Methodology
Questionnaire was designed which includes
1. Student personal information
2. Anthropometric assessment
3. Child activity status
4. Demographic & socio-economic status
5. Clinical signs and symptoms
6. History of previous disorders or disease
7. Dietary history

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Cont…
• Parameters of Anthropometric and clinical assessment
– MUAC, Weight, Height, Age, BMI,
• MUAC : Mid-point between the elbow and the shoulder
• Procedure
• Measuring tape was used and placed around the left arm
– the arm should be relaxed and hang down the side of the body
• MUAC measures while ensuring that the tape neither pinches the arm nor is left
loose
– The MUAC value recorded to the nearest 0.1 cm or 1 mm
(Rema and Vasanthamani, 2011)

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Cont…
• Body Weight : was measured by using digital weighing scale
(Kuczmarski et al., 2000).
• Body Height: was measured by using stadiometer
(Kuczmarski et al., 2000)
• Age: From school record

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Analysis and results
• WHO z-score system
– WHO Z- score system was used to classify the nutritional status of
children age limit 5 to 12 years
(Mushtaq et al., 2012).
• Dietary History
– Food frequency questionnaire was established to assess complete diet
history and protein and energy consumption
(Rockett and Wolf, 1995)
• Data will be statistically evaluated

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Expected Results and Discussion
Following raw results were been found:
• Health of urban areas children is better than rural areas
• Anthropometrical measurements was 85% normal
• Clinical sings and symptoms shows some micronutrients deficiencies
– Skin colour, hair strength, nail colour, mouth, eyes, bones
• Further Research and data analysis is continue

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References
Black, R.E., C.G. Victora, S.P. Walker, Z.A. Bhutta, P. Christian, M. De Onis, M.
Ezzati, S. Grantham-Mcgregor, J. Katz and R. Martorell. 2013. Maternal and
child under-nutrition and overweight in low-income and middle-income
countries. The Lancet. 382:427-451.
Di Cesare, M., Z. Bhatti, S. B. Soofi, L. Fortunato, M. Ezzati, and Z. A. Bhutta.
2015. Geographical and socioeconomic inequalities in women and children's
nutritional status in Pakistan in 2011: an analysis of data from a nationally
representative survey. The Lancet Global Health 3:229-239.
Kuczmarski, M.F., R.J. Kuczmarski and M. Najjar. 2000. Descriptive
anthropometric reference data for older Americans. Journal of the American
Dietetic Association. 100:59-66

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Cont…
Mushtaq, M.U., S. Gull, K. Mushtaq, H.M. Abdullah, U. Khurshid, U. Shahid, M.A. Shad and J.
Akram. 2012. Height, weight and BMI percentiles and nutritional status relative to the
international growth references among Pakistani school-aged children. BioMed Central Pediatrics.
12:31.
Nazemi, L., I. Skoog, I. Karlsson, S. Hosseini, M. R. Mohammadi, M. Hosseini, M. J. Hosseinzade,
S. A. Mesbah-Namin, and M. Baikpour. 2015. Malnutrition, prevalence and relation to some risk
factors among elderly residents of nursing homes in Tehran, Iran. Iranian Journal of Public Health.
44:218.
Ong, C., W. M. Han, J. J.-M. Wong, and J. H. Lee. 2014. Nutrition biomarkers and clinical outcomes
in critically ill children: A critical appraisal of the literature. Clinical Nutrition. 33:191-197.
Rema, N and G. Vasanthamani. 2011. Prevalence of nutritional and lifestyle disorders among school
going children in urban and rural areas of Coimbatore in Tamil Nadu, India. Indian Journal of
Science and Technology. 4:131-140.

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Cont…
Rockett, H.R., A.M. Wolf and G.A. Colditz. 1995. Development and reproducibility of a
food frequency questionnaire to assess diets of older children and adolescents. Journal
of the American Dietetic Association. 95:336-340.
Srivastava A, SE Mahmood, PM Srivastava, VP Shrotriy and Bhushan, 2003. Diet,
nutrition, and the prevention of chronic diseases in Uttar Pardesh. Health and
Population-perspectives and Issues. 28:17-25.
Tiwari, H.C., A. Gahlot and R. Mishra. 2013. Health profile of primary school children:
study from a rural health block of Kanpur. Journal of Evolution of Medical and Dental
Sciences. 2:6941-6946.
Witvliet, M. 2014. World health survey: a useful yet underutilized global health data
source. Austin Journal Public Health Epidemiology.1:1012.

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