School Children in the Developing World: Health, Nutrition and School Performance

School Children in the Developing World: Health, Nutrition and School Performance

A two-day international workshop under the Global Impact Research Initiative

On February 18–20, an international workshop on "School Children: Health and Nutrition," with nearly fifty participants from thirteen countries, was held at UCLA as part of the research project Malnutrition and the "Education for All" Agenda, with Charlotte G. Neumann (Professor of Public Health) as principal investigator and Osman Galal (Professor of Public Health) as co-principle investigator. Dr. Galal was mainly responsible for organizing the workshop.

The research project is funded by the UCLA International Institute as part of its Global Impact Research Initiative, launched in 2003-04. Under the initiative, the Institute supports several innovative interdisciplinary research programs bringing together UCLA faculty and students, as well as experts from around the world. These cutting-edge scholarly research programs also promote innovations in the classroom and seek to inform and stimulate debate among a broad audience of citizens, opinion leaders, and policy makers.

The Project: Scope and Goals

The project explores the effects of malnutrition on educational outcomes in the developing world. By bringing together an international research group of scholars in economics, education, and public health from Africa, Asia, Europe, Latin America, the Middle East, and North America, the project seeks to move the role of poor health as an intervening factor in education from the margins of scholarly discourse (and government policy) to the center. Although common sense tell us that poor health, particularly malnutrition, contributes to poor school performance, and although there is a substantial body of literature backing up this common sense, there has not been adequate research of the subject, nor adequate dissemination of the research that has been done, nor adequate application of the research, in the sense of policies and programs to combat ill-health and malnutrition among school-age children. The project seeks to remedy some of these inadequacies.

Even as many developing countries have signed on to the World Education Forum declaration promising basic education for all citizens by the year 2015, the educational impact of ill health among school children has been relatively neglected. Together with international organizations, governments are making massive efforts to improve basic education, a core component for building development capacity. However, these efforts raise urgent questions about the impact of the health and nutrition on the school-aged population and the role diet plays in the cognitive development and school performance of children in these countries.

Few if any parts of the developing world are free of childhood malnutrition. For instance, in Thailand, where children make up over 30 percent of the population, nearly 60 percent -- six million children -- of primary school age are undernourished; nearly one million are critically malnourished. And this in a country that ironically is a major producer and exporter of food. In some areas of the world, the situation is even more depressing. In conflict-ridden areas of Sri Lanka, for example, the UN World Food Program found alarming levels of malnutrition. A quarter of the children in these areas are "stunted,” or too short for their age, and nearly one in three is severely "wasted,” that is, far too thin for their height. And in still other places, children face outright starvation. A news report from Zimbabwe, once a breadbasket of Southern Africa, quoted a 32-year-old mother waiting in a queue for a bag of corn meal and a portion of beans passed out by the World Food Program: "I want my children to go to lessons to learn, but the walk is too much for them some days when they are so famished. How can they learn when they have no food in their stomachs?"

Are Children Losers in Economic Development?

An international commitment to improving educational access in developing countries is not lacking. UNESCO and non-governmental organizations are actively engaged in projects and programs toward this end. Governments are also committed to expanding opportunities for education as is evident in the significant percentage of public expenditure allocated to education, even in countries with demonstrably declining economic performance. However, the role of poor health as an intervening factor in education has not been fully recognized. The participants in the February workshop pointed out the urgent need to acknowledge and act upon the demonstrated deleterious impact of malnutrition on children's education. In developing countries, where economic growth in a universal goal, feeding children may not constitute a high priority for public policy because it does not lead to immediate, demonstrable, and measurable economic growth. In fact, aside from "child indicators” such as birth rates, birth weight, infant mortality rates, immunization rates, malnutrition status, school enrolment and literacy rates, children may hardly appear at all in discussion -- and policy -- on issues involving employment, poverty, migration and the like. This does not mean that children are absent, so to speak, from these issues, but rather than they -- a constituency that has no voice of its own -- are often unseen, or overlooked, or ignored.

However, "as the sapling is bent, so shall the tree grow”: the economic effects of the neglect of children's health and nutrition will inevitably appear in the long run: a poorly educated and unhealthy population, which will act as a drag on economic growth and development. What is most needed now in the area of children's nutrition, as Dr. Anthony Worsley (Professor in the School of Exercise and Nutritional Health at Deakin University, Melbourne, Australia) argued in his keynote address, is a movement from research to practice.

The Workshop

The goal of the workshop was to assemble widely dispersed data on child nutrition and related health considerations and on educational outcomes in order to examine the relationships between them.

The papers presented in five sessions ranged from comparatively abstract and theoretical considerations of, for example, strategies to estimate child nutrition and school performance, to concrete reports on school feeding programs in, for instance, Makueni District, Kenya. The first session, chaired by Paul Glewwe (Department of Applied Economics, University of Minnesota), explored nutrition and school children performance. The second, chaired by Dr. Sally MGregor (Institute of Child Health, UK), presented six papers on evidence-based nutrition and educational outcomes. The third, chaired by Dr. Charlotte Neumann, discussed feeding-intervention programs in Kenya. The fourth, chaired by Dr. Donald Bundy of the World Bank, evaluated "Food for Education” programs, funded by the United States Department of Agriculture. The fifth, chaired by Dr. Beryl Levinger (Education Development Center), dealt with micronutrients and food programs. And the sixth and last session, chaired by Dr. Osman Galal, consisted of a panel discussion -- under the title "The Way Forward” -- of what may be the most important question facing researchers and policy makers in the area of school child nutrition: what do we do now? Dr. Galal rounded up the discussions and clarified the out put of the workshop. He also pointed out the path toward what should be done next.

As one would expect, the workshop did not discover easy solutions to malnutrition and ill health among school children. Instead it helped identify questions and dilemmas that policy makers must confront and it presented the results of research that can help in designing optimal policies and programs. For example, since funding is always limited, how should it be allocated to achieve the best results, however one wishes to define that? Is it more important to feed younger (perhaps pre-school) children, and thus head off the stunting and wasting that would result from poor nutrition, or is it more important to feed older children, who share responsibility for caring for younger siblings and thus can do a better job if they are adequately fed? If one can provide only a single daily meal for school children, should it be breakfast or lunch? What should children be fed? How important is it to supplement vegetable-source foods with meat? What approaches to food and nutritional education are most effective in combating the obesity that plagues children in much of the developed world? These are only a handful of the multitude of questions addressed by the workshop.

The workshop was especially significant for the fact that it covered so many regions of the world, that it grappled with malnutrition in both the developing and the developed world, and that it delved into what might be called the interconnectivity of heath among school children, involving both nutrition and disease, such as malaria. The results of the workshop will be published and, it is hoped, will help guide future research and policy making.

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Donald Bundy
Lead School Health Specialist, World Bank, Washington DC, USA
School Health and Nutrition Programs in Practice

Over the last decade, school health and nutrition programs have become an increasingly common component of the education sector response to "Education for All."

There is now clear evidence that: 1) ill health and malnutrition adversely affect education, 2) simple health and nutrition interventions delivered through education systems can improve educational outcomes, and 3) school based delivery is the most cost-effective approach. Acting on this evidence, a consortium of agencies (UNESCO, UNICEF, WHO and the World Bank) launched a multi-agency effort to promote school health programming at the World Education Forum in Dakar 2000. This partnership developed a planning framework to help countries Focus Resources on Effective School Health (the FRESH framework), as part of global efforts to ensure that every girl and boy is able to complete a quality basic education. This marked the entry of school health programming into the education mainstream, and has led to FRESH being designated by UNESCO as a "Flagship Program” of global efforts to achieve EFA. It has also provided the momentum, and the technical and financial support, for basic school health programs to be adopted increasingly by governments. Current estimates suggest that school health programs target more than 50 million school children in low-income countries.

Nimrod Bwibo
Professor of Pediatrics, University of Nairobi, Kenya
Community Based Efforts to Provide School-Feeding and Its Impact on School Performance: The Case of Makueni District

Makueni District of Embu province in Kenya provides school lunches at every school. This program is supported by the World Food Program and by parents, who provide maize and beans, to be cooked at school and consumed by every child. In some schools children bring packed lunches. The aim is to ensure that children are not hungry and unable to concentrate on schoolwork. The schools also promote hygiene and the use of toilets. As a result of these efforts, the performance of schools in this district has been excellent. The district has been consistently at the top of Kenya's Certificate of Primary Education, a national examination taken by the primary school leavers, which forms the basis for selection to the few places in the secondary schools.

Santiago Cueto
Senior Researcher and Executive Director at Group for the Analysis of Development, Peru
Height and Weight as Predictors of Achievement, Grade Repetition, and Dropout in Rural Peru

The educational system in Peru faces several challenges, including inequality between the rich and the poor. Among the latter, it is clear from several indicators that rural students have lower levels of achievement. Many of these students speak an indigenous language (in a country where the predominant language is Spanish). Rural classrooms are often multigrade, with students from different grades sharing one teacher. There are few studies in Peru on factors associated with performance. Among these could be variables associated with the schools, the family of the students, or the students themselves. In this study we analyzed via a longitudinal design the achievements of students from 20 public schools in two rural zones in Peru.
The original data were collected in 1998, when all students were in the fourth grade. At that time, mathematics and reading comprehension achievement tests were administered. In 2000 the same tests were administered (plus a new set of more difficult questions), and in 2001 the grade the students were enrolled in, if they had not dropped out (by then they should be in first grade of high school) was registered. Dropouts were tested at home, and students at school. The results show that 20% of the original sample had dropped out, and 43% had enrolled in the first grade of high school. The remainder had repeated a grade one or more times. The factors associated with achievement and enrollment in high school or dropping out were often specific to the dependent variable. For instance, higher achievement in 2000 was highly associated with higher achievement in 1998 (which was also associated with enrollment in the first grade of high school in 2001). On the other hand, dropping out of school was not associated with achievement. Female students, older students, students not living with either parent, or taller students (as measured through height-for-age in 1998, we had no data for later time points) were more likely to drop out of school. Weight-for-height was not related to dropping out of school or achievement. This suggests that educational success should be planned with interventions that are specific to the outcomes sought. In this case, the results might indicate that relatively poorer students of certain age and height are no longer perceived as school-age, but working-age (all the drop-outs declared working at home, in the fields, or in other places).

Lesley Drake
Coordinator of Partnership for Child Development, London, UK
Simple School Health and Nutrition Interventions in Action: Clever Pills?

The past decade has seen many governments in low income countries express increased interest in incorporating a school health and nutrition (SHN) component into their strategic plans to achieve "Education for All.” This is primarily due to the mounting body of evidence that the delivery of simple health and nutrition to school children by teachers is a cost-effective mechanism that can lead to an improvement in educational outcomes.

The government of Zambia was one of these countries. Incorporation of this component into their long term strategic plan, however, required justification and guidance as to how the program could be taken to scale and effectively monitored and evaluated. A three-year impact assessment of pilot phase activities was undertaken. The health, nutrition, learning ability and educational achievement of a cohort of children were monitored. A tool was developed that enabled teachers to deliver tests of learning ability at the classroom level allowing large numbers of children to be assessed.

The results of this impact assessment helped convince the government to go to scale with this program and to incorporate a SHN component into their long term strategic plan. The program is now primarily funded by government resources and is currently being implemented in five of the nine Provinces in Zambia. Further expansion is planned.

Judhiastuty Februhartanty
Academic Staff, SEAMO TROPMED Regional Center for Community Nutrition, University of Indonesia, Indonesia
Nutrition Education: Never an Easy Case for Indonesia

The roots of Indonesia's education can be traced back to the Dutch colonial period hundreds of years ago. Indonesia has adopted a 6-3-3-4 system of education that includes six years in the elementary, three years in the junior secondary, three years in senior secondary, and four years in the university/tertiary levels.This system includes public schooling, Islamic schooling, and out-of-school education. In 1995, the school system enrolled more than 42 million students. In addition, the country has also used distance education. The need for this type of education arises from Indonesia's geography, which can make face-to-face instruction difficult. Distance education in Indonesia is not of recent vintage. The National Center for Teacher Training and Development by correspondence was established in 1950, and the most recent distance learning organization is the Indonesian Distance Learning Network, which was established in 1993 to assist distance learning institutions in Indonesia.

Studies on nutrition education in Indonesia have covered various topics and teaching methods. The effects on improved knowledge and attitudes were more marked than that of practices in relation to each nutrition topic. Nutrition and its related topics are covered in various school subjects, such as, biology, sport and health science, and home economics. This became particular prominent since 1999, after the establishment of the Law no. 22 on Local Government. Moreover, as the country faces an ongoing malnutrition problem, the Indonesian government through its Ministry of Health has run a feeding program, which covers only children in elementary school aged 6-12 years old, both in urban and rural areas. Due to a limited budget, the program does not seem to have had a great impact. However, private sector and NGO feeding programs for school children complement the existing state program.

Training of nutrition professionals was started in the early 1950s when a school for food scientists was first established. The development of the education system in this field of expertise is observable through two streams: vocational training, and formal courses in the university. However, the human resources responsible for delivering nutrition-related topics in schools are the school teachers, most of whom have never received relevant training or courses for delivering such topics. This is an alarming situation which requires prompt action on the part of the government of Indonesia.

Paul Glewwe
Assistant Professor, Department of Applied Economics, University of Minnesota, USA
Child Nutrition and School Performance: Estimation Strategies and Recent Empirical Evidence

This paper examines different methods of estimating the impact of child health and nutrition on school performance, describing the implicit or explicit assumptions needed to ensure consistent estimates, and the plausibility of those assumptions. The paper then examines research in the past ten years in light of these estimation issues.

Tara Gopaldas
Director, Tara Consultancy Services, India
Improved Effects of School Meals with Micronutrient Supplementation and Deworming

Tara Consultancy Services (TCS), India -- a member of the Partnership of Child Development, Oxford University -- evaluated Gujarat's Improved Mid-Day-Meal Program (1993-1996). The implementer was the Commissionerate of MDMP, government of Gujarat, and the program involved nearly 3 million school children. The nutrition health problems of the deprived school children included raw hunger, unsafe water, intestinal worms, URI and GIT infections, malaria, IDA, VAD & IDD. The older boys and girls (11-15 years) were more undernourished than younger children. Impediments to active learning were: impaired cognition, and physical work capacity, night blindness and impaired vision, absenteeism due to illness, tiredness and irritability. The improved MDMP consisted of deworming and vitamin A dosing twice a school year; ferrous sulphate (60 mg elemental iron tablets) 2 times/week in the classroom and iodized salt in the cooked meals. In 2003 the "health package” inclusive of capacity building and IEC may cost US 50 cents per schoolchild per year. Some of the major results were:

Focus Group Discussions: The government, the teachers, the pupils, the parents and the community actively participated. A high level of awareness was created.
Process Evaluation: Logistical delivery by the pharma companies was 100%; efficiency of logistics to the schools was 100%; coverage as stated by the implementer was 94-100% (urban) and 42-94% (rural), and as stated by the school children was 71-79% (urban) & 50-67% (rural).

Impact Evaluation: On average, the dosed vs. the undosed schoolchild was 1.1 kg heavier and 1.1 cm taller; Hb levels were >12 g / dl; intestinal parasite prevalence rates dropped from 71% to 39%; prevalence of night blindness and vitamin A deficiency fell from 67% to 34%.

Important Lessons Learned: India must give top priority to the improved MDMP, and it should follow the ‘Gujarat model'; e-governance, good management, forward planning, and an adequate flow of finances and stocks are essential. Take care of your "walking injured,” namely 90% of school children in the classroom.

Sally McGregor
Professor, Institute of Child Health, UK
Can the Provision of Food Help Children's School Performance?

Children who are stunted, anemic, experience hunger or have poorer dietary intakes tend to have poorer school performance including late enrolment, and poor attendance, behavior, cognition and achievement levels. Thus they are more likely to drop out of school early and repeat grades. There is less information on their psychosocial function. These children also come from the poorest homes and are likely to have frequent or chronic infections. The challenge is to determine whether and to what extent these relationships are causal and whether providing appropriate nutritional and health intervention at school age will improve the children's performance. The available evidence from trials of the effects of providing food is discussed based mainly on work done in Jamaica. In addition there is a now a serious emerging problem of orphans in sub-Saharan Africa. These children are less likely to enroll and attend school regularly. Many are exposed to hunger and are depressed. Among other stressors, hunger and school attendance independently predict of their depression. There is thus an urgent need for nutritional interventions.

Ismail Ibrahim
Professor, National Institute of Nutrition, Egypt
Awareness of Teachers of the Relationship between Students' Performance and Nutrition Status: Egypt's Experience

Malnutrition disorders affect more than 30% of school children in Egypt. Iron deficiency anemia is by far the most common nutritional disorder. But subclinical vitamin A deficiencies and other micronutrient deficiencies are also present. Malnutrition disorders affect the cognitive and the intellectual power of these children. School teachers did not prioritize nutrition as a cause of poor scholastic performance. School teachers perceived malnutrition only as low body weight. They did not correlate malnutrition with scholastic performance except with regards to eating breakfast. This lack of awareness, either about nutrition facts or the role of nutrition in education, leads to misdiagnosis or delayed management of these children. The teachers perceived that the unhealthy feeding habits of the school children, especially lack of breakfast, affecting the interaction between the school children and the teachers. They also observed that school children in rural areas are more regular in eating breakfast. The school teachers observed that the active child in class is usually the child who receives breakfast at home and is at the same time the more intelligent child with good scholastic performance. School teachers appreciated the role of school-feeding programs in increasing the scholastic performance of the school children, but at the same time they are disappointed because it is not regular and does not cover the whole academic year. They suggested an integrated program between MOHP, MOE, teachers, and parents to overcome malnutrition disorders through nutrition education and regular school-feeding program to improve the health/nutrition status and the education abilities of school children.

Matthew Jukes
Professor, Partnership for Child Development, UK
The Long-term Effect of Early Childhood Malaria on Cognitive and Educational Outcomes 13 Years Later: Follow-up to a Randomized Trial in the Gambia

Background. It has been suggested that malaria infection in early childhood effects cognitive development and educational outcomes. We assessed the long-term effects of malaria chemoprophylaxis in early childhood on cognitive abilities and education in young adults.

Methods. 1,268 children aged 3-59 months received malaria chemoprophylaxis (maloprim) or placebo for between one and three malaria transmission seasons from 1985-88. We assessed the cognitive abilities, education history, height and weight of 568 (45%) of them in 2001, mean age 17 years 5 months.

Findings. All findings were adjusted for demographic and background household variables, anthropometry (for cognitive and educational variables), testing conditions (for cognitive variables) and participation in mass treatment offered at the end of the trial. Girls receiving treatment were more likely (OR=2·49; p = ·031) to enter formal primary education than girls in the placebo group. All treated participants achieved just over one grade higher in school (SE = 0·27; p < ·001) compared to the placebo group. treatment participants also scored 0·3 sds more than the placebo group in a measure of working memory (se = 0·10; p = ·003) but scores on a measure of general intelligence did not differ between groups. there were no significant group differences in either height or weight.

Interpretation. After discounting explanations in terms of follow-up bias we conclude that malaria chemoprophylaxis in early childhood had a long-term effect on cognitive function and education across a whole community cohort. This strengthens the case for malaria prevention in under 5s and suggests this may be an effective way to promote school enrolment and achievement.

Geok Lin Khor
Professor, Department of Nutrition and Health Sciences, Faculty of Medicine and Health Sciences, University of Putra, Malaysia
Nutritional Status and Academic Performance among Children in Primary Schools in Kuala Lumpur, Malaysia

Rapid socioeconomic development in Malaysia since independence in 1957 has been accompanied by a considerable improvement in the nutritional status of the population in general. Compared to other developing countries, the prevalence of undernutrition and micronutrient deficiency problems is markedly low in Malaysian children. Underweight and stunting in children from urban primary schools is generally below 10%. However, the magnitude is significantly higher – from 25% to 50% -- in children from rural schools and low-income households in urban schools. Besides protein-energy malnutrition, iron deficiency anemia and a subclinical form of vitamin A deficiency have been reported in young children. To what extent does undernutrition affect the academic performance of these children? Since data are lacking in Malaysia, a study was undertaken to provide information on the relationships between socioeconomic background, nutritional status, dietary intake, and academic performance in children from primary schools in the capital city of Kuala Lumpur. A sample of about 340 children was measured for weight, height, hemoglobin concentration, dietary intake using 24-hour recall for 2 days, and McCarthy Scales of Children's Abilities. Mothers were interviewed on household socioeconomic characteristics and food security, and maternal involvement with schoolwork and child feeding. The results will be discussed with implications for the country's national nutrition policy in general and the school health programs in particular.

Beryl Levinger
Senior Director, Education Development Center, USA
Food for Education: A Programmatic Approach That Improves Educational Outcomes and Food Security

This brief paper explores four interlocking ideas that, taken collectively, constitute a powerful rationale for the continuation of Food for Education programs: 1) The universalization of primary school education is a prerequisite for food security; 2) Food for Education is a program that boosts primary school participation and, hence, food security; 3) the effects of primary school education on food security are greatest wherever "quality standards" are met; however, important effects are present even when educational quality is modest; (4) Efforts to improve primary education participation (demand) and efforts to improve primary education quality (supply) are highly interrelated and mutually reinforcing. Policy and program design implications of this "idea set" are discussed.

Kilemi Mwiria
Assistant Minister for Education and MP for Tigania West, Kenya
The Crucial Role of Nutrition in Education

Improved health and nutrition status among children contributes to high enrolments, better school attendance, lower rates of dropout, improved performance in academic work and to social equity and economic growth as healthy persons have the energy to work.

In fact, the exemplary performance of Makueni children in the KCPE examination has partly been credited to a sustainable school-feeding program supported by parents and the World Food Program. If we agree that one has to be physically fit to engage in any productive work, then it is easy to appreciate why children need to be well fed not only to grow but also to concentrate on learning while at school. In any case, health, even more than education, is a basic human need.

Because the poor may not view educating their children as a priority in the context of more pressing problems, many of their children are not only under-fed (and on imbalanced diet) before attending school but are also made to take part in family labor. Thus, investment in education that is not accompanied by investment in the health and nutrition of school goers is a net loss for the country, if those invested in are unable to learn effectively or drop out of school due to illness.

A number of interventions are likely to promote the health and nutritional status of our school children. Most important of is a national policy on health and nutrition education. Thus the current national nutrition policy needs to be integrated much more with educational programs. Such a policy should be clear on the objectives of health and nutrition program and their bearing on education.
In addition, departments that coordinate such programs and a funds/votes for nutrition and health programs need strengthening. If the policy has to have the support of the general populace, communities should be involved in its preparation, implementation and evaluation. An enforceable legal framework should back the policy.

Second, a comprehensive program should guide the implementation of the identified policy goals through an inter-ministerial coordinating unit comprising representatives of the most concerned ministries.

Third, health and nutrition curricula need to be expanded following consultations with key stakeholders. Under such curricula, nutrition and heath education should be a teaching and examinable subject. In addition, the teaching of related subjects (science, agriculture, life skills and physical education and sports) should be strengthened. All schools must have adequate and clean toilets, clean drinking water and sanitary facilities for girls and must keep their compounds clean.
In addition, facilities for the physical maintenance of school health and nutrition and minimum health (first aid kits, etc) need to be in place. Where possible, regular medical check-ups could be undertaken. Future school designs should also take account of kitchen and minimum health facilities while school nutrition and health committees and food production units should be part of a new school environment. This means that schools will need a vote for such facilities and not just for books and teachers, a vote which may be supported through cost-sharing.

Sonia Olivares
Professor of Nutrition Education, Institute of Nutrition and Food Technology, Chile
Nutrition Education in Chilean Primary Schools

In Chile overweight and obesity are the main public health problems among school children and are considered a health policy priority. Between 2001 and 2003, the Institute of Nutrition and Food Technology and the Ministry of Education participated jointly with FAO technical support in the development of a food and nutrition educational program for the curricula of the third to eighth grades. The project outputs are validated educational materials for children and teachers, available in print, CDs, and on the internet. Workshops for training primary school teachers at the country level have been carried out in 2003, in order to use these materials in the public school system.

Gayle Savige
Research Fellow, Monash Asia Institute, Australia
E-learning: Nutritionally Ripe Environments?

Schools provide a social context in which children learn and develop, thus making schools a desirable environment for nutrition promotion. The is a web-based technology that has been used in Australian primary schools as a model for nutrition promotion. It provides interactive activities, role models, and opportunities for children to learn from their peers through bulletin boards and storytelling. This web-based technology is readily accessible to all schools, overcoming problems associated with geographical location and socioeconomic status. This model can be adapted to meet the needs of different school communities and has the capacity to connect children from different backgrounds and cultures.

Malick Sembene
Professor, Ministry of National Education, Division of School Health, Senegal
Control of Anemia in Senegalese School Children: An Operational Study

As part of its policy to improve school performance through improved health and nutrition status, the Ministry of Education of Senegal conducted an operational study in three regions to control iron deficiency and parasitic infections in 2,245 elementary school children. At baseline, all children were given albendazole against hookworm and children infected with schistosomiasis received praziquantel. Children were randomly assigned to one of the following groups: weekly Fe 30 mg, weekly Fe 60 mg, weekly multiple micronutrient supplement including 30 mg of iron, or a placebo. The impact of the intervention was assessed on health and micronutrient status, parasitic loads, and school performance. Only the results on parasitic load, anemia, and school performance will be presented. Preliminary results showed that helminth (p < 0,12) and shistosomiasis (p < 0,18) infections decreased significantly in all four groups. hemoglobin concentration improved after treatment with iron 30-mg (p< 0,13), iron 60 mg (p < 0,08), multiple micronutrient (p < 0,05). the prevalence of anaemia was reduced (46 %). the proportion of children who successfully passed the mathematics and french tests was higher in the groups which received fe 60 mg (p < 0,085). it is planned that the results of this operational study will provide some guidance to the government to scale up the distribution of supplements and antiparasitic drugs in senegalese schools.

This project was supported by a grant from the Micronutrient Initiative, Ottawa, Canada.

Marian Sigman
Professor, Psychiatric and Biobehavioral Sciences, UCLA, USA
Diet Quality Impacts the Playground Behavior, Activities and Cognition of Kenyan Children

Five hundred forty children in rural Kenya participated in a study aimed at determining whether enhanced caloric intake or diet quality influenced their behavior on the school playground. The first standard (grade) classes were randomly assigned to groups provided for 21 months with school breakfasts of equivalent caloric value while families with children in the control group were given a cow at the end of the study. Supplemented children were more active and showed more leadership behavior and initiative than non-supplemented children. In addition, children in the meat condition showed fewer periods of low activity and more leadership behavior and initiative than children provided entirely with vegetable-source foods. The results of this study support our previous findings from naturalistic studies in the same community that both diet quantity and quality are important for children's development.

Augustinus Soemantri
Professor, Department of Pediatrics, Diponegro University, Indonesia
Iron Deficiency and Educational Outcomes in Pre-School Children

Several studies in Indonesia have shown that iron deficiency anemia and iron deficiency without anemia influence educational outcomes. Malnutrition which occurs early in life will impact educational outcome at the primary school level. Data have shown that the educational outcome of school age children in the group with a normal height/age ratio was better than in the group with a height/age ratio below normal. Low nutritional status, iron deficiency anemia, and iron deficiency without anemia are still public health problems in developing countries such as Indonesia.
For this reason, we must improve the nutritional status of children before they enter the primary school. If nutritional status is still below normal by the age of 5 years, the educational outcome is lower than for children with good nutritional status. If we manage nutritional problem before the age of 5 years, educational outcomes in primary school children will improve.

To overcome the problems, iron supplementation, multinutrient supplementation as well as improvement in nutrient intake are needed. In addition, attention must be paid to increasing the quality of teachers and the facilities for training teachers.
In order to improve educational outcomes, an attachable continuing program must be undertaken and which can be easily evaluated. Such a program must be supported by the both the relevant government agencies and the community.

Aryeh Stein
Assistant Professor, Department of International Health, Emory University, USA
Effects of Early Life Nutrition on Schooling and Cognitive Functioning in Adulthood: Evidence from a Longitudinal Study in Guatemala

We have been following the cohort who were exposed to the INCAP Longitudinal Intervention Study in the 1969-77 period, a randomized control trial of nutritional supplementation in pregnancy and childhood conducted in four villages in eastern Guatemala. Our most recent round of data collection is nearing completion. Unlike most studies of schooling and cognitive functioning, our study is well suited to explore the potentially divergent roles of family characteristics, pre-school cognition, and improved nutrition on both the quantity of schooling obtained and the impact of this schooling on adult cognitive functioning. A unique feature of our study is the integration of an assessment of the role of community assets and resources, as well as environmental and economic shocks that may have affected the individuals' access to schooling opportunities.

Lize van Stuijvenberg
Specialist scientist at Nutritional Intervention Research Unit, Medical Research Council, South Africa
Using the School Feeding System as a Vehicle for Micronutrient Fortification: Experience from South Africa

School feeding was introduced on a national scale in South African primary schools in 1994. A brief overview of this program, which was implemented by the government's Department of Health and recently taken over by the Department of Education, will be given. One of its main aims is to alleviate short-term hunger by providing 25% of the energy requirement of the child per day; micronutrient requirements are, however, not always met, and studies have shown that micronutrient deficiencies persists in some SA schools, despite this program. School-age children are often a neglected group in terms of micronutrient interventions, because they are not reached by the intervention strategies aimed at the preschool child or the pregnant women. School feeding, however, offers an excellent opportunity for targeted intervention in this age group, especially with regard to fortification. This presentation will focus on a number of trials conducted in SA schools examining the feasibility of various food items as potential fortification vehicles, with positive effects on outcomes such as vitamin A status, iron status, iodine status, growth, morbidity, as well as cognitive function.

Ted Wachs
Professor, Department of Psychological Sciences, Purdue University, USA
Linking Biology and Education across Generations: Parent Education and Offspring Nutrition

Over the past half century a major focus of both developmental research and theory has been on the role of environmental influences upon children's development. Much of this research and theory has focused on the nature and impact of the child's psychosocial environment, as exemplified in studies on the family (e.g., parental rearing styles) and non-family environments (e.g., school characteristics). What has not been widely appreciated by developmental scientists is that, in addition to the psychosocial environment, children also live in and are influenced by characteristics of the bioecological environment. The bioecological environment of the child includes climatic conditions, degree of exposure to parasites or infectious agents, and availability of nutrients. Although children simultaneously live in both environments, research or theory generally tends to focus on the isolated contributions of either the bioecological or psychosocial environment rather then on their combined contributions. In the present paper I describe a theoretical framework that explicitly links the contributions to development of the child's bioecological and psychosocial environments. In support of this theoretical framework I present converging data from two studies carried out in two different cultures (Egypt and Peru) illustrating how one aspect of the psychosocial environment (level of mothers education) operates cross-generationally to influence the nature of the child's bioecological environment (quality of offspring nutrition).

Tony Worsley
Professor, Public Health Nutrition, Deakin University, Australia
Children's Healthy Eating Programs: From Research to Practice

This paper will briefly review Western interventions on children's eating habits. The strengths and deficiencies of these controlled studies will be outlined, especially their general ignorance of the social and economic contexts in which children and their families live. An alternative action-research model of children's nutrition promotion, embedded in children's families and communities, will be described along with its implications for health and education systems, local food policy development and monitoring of progress toward national and international goals for children's nutrition status and food security. Examples of action research approaches at the family, school, local area and national government levels will be discussed. A simple information system to facilitate international collaboration and knowledge and skills exchange between education and health workers will be proposed.

Published: Tuesday, March 16, 2004