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BRIEF RESEARCH ARTICLE
Year : 2018  |  Volume : 62  |  Issue : 2  |  Page : 146-149  

A tool for quickly identifying gaps in diet of school children for nutritional educational interventions


1 Professor, Department of Community Medicine, Believers Church Medical College, Thiruvalla, Kerala, India
2 Assistant Professor, Department of Community Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India

Date of Web Publication14-Jun-2018

Correspondence Address:
Subhashini Ganesan
Department of Community Medicine, PSG IMS&R, Peelamedu, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_23_17

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   Abstract 


Compared to adults, assessment of dietary intake of school children has always been a great challenge in public health practice. Hence, this paper aims to share our experience in overcoming the problems in dietary assessment of large number of school children aged 6–17 years and the practicality of the tool for quickly identifying the broad gaps in the diet of individual Children for providing them dietary counseling. Based on the Indian Council of Medical Research/National Institute of Nutrition recommendations for balanced diet among school children, a simplified dietary gap assessment tool was developed to identify gross gaps in their diet and also a system of scoring it so as to measure effectiveness of the nutritional educational program. The simplified tool was effective in overcoming the challenge of making the children understand the concept of portion size by replacing it with inquiry of frequency of food intake in 'yes” or “no” terms and thereby making it easy to administer and is time efficient enough to enable a large number of students to be screened.

Keywords: Dietary gap assessment, faulty diet of school children, quick diet assessment


How to cite this article:
Chacko TV, Ganesan S. A tool for quickly identifying gaps in diet of school children for nutritional educational interventions. Indian J Public Health 2018;62:146-9

How to cite this URL:
Chacko TV, Ganesan S. A tool for quickly identifying gaps in diet of school children for nutritional educational interventions. Indian J Public Health [serial online] 2018 [cited 2019 Nov 13];62:146-9. Available from: http://www.ijph.in/text.asp?2018/62/2/146/234499



Compared to assessment of dietary intake in adults using recall methods, those done with children and adolescents have always been a great challenge in public health practice. Though there are several tools in assessing the food consumption of children and adolescents, the time and resource challenges of using these tools in large-scale screening in the community or ambulatory settings still remains.[1] Earlier studies have noted that the developmental stage and the cognitive abilities of children influence their ability to provide valid and reliable information about their food consumption.[2],[3] Younger school children also have difficulties in understanding, in recall, and in expressing different amounts of food consumed. Even with adolescent school children, there is misreporting of diet and an additional challenge of boredom of long diet survey inquiry that affects the accuracy of assessment.[4],[5]

Their view of literature shows that no single approach captures dietary intake perfectly and each assessment method has unique strengths and weaknesses.[6] Therefore, for doing dietary assessment on a large scale, logistics and resource constraints must be considered when selecting a diet assessment method.[7] Hence, this paper aims to share our experience about the problems encountered in making a dietary assessment of school children aged 6–17 years and the practical utility of an assessment tool developed by us for quickly identifying the broad gaps in the diet of school children. Furthermore, to facilitate better understanding for easy replication in similar settings, the process and basis for development of this tool is described in detail.

The context: Diet assessment as a part of school health project: This tool development exercise emerged out of the necessity of implementing a school health project aimed at improving health of 2500 school children aged between 6 and 17 years and the need for demonstrating measurable changes as indicator of effectiveness of the program. As a part of this project, diet assessment followed by individual counseling and health education to improve dietary habits of school children was done. Follow-up visits were made to monitor dietary behavior change, ensure compliance, as well as measure effectiveness of the intervention.

Doing a quick and pragmatic diet assessment of large number of school children within the time and budget constraints was a great challenge.

The objectives of developing the tool for the rapid diet assessment were:

  1. To identify the gaps in diet of school children aged 6–17 years in terms of their deviation from the Indian Council of Medical Research National Institute of Nutrition (ICMR-NIN) recommended dietary standards that can be administered to large number of children
  2. To introduce objectivity in capturing the effectiveness of the educational intervention by assigning and measuring the pre- and post-interventions scores.


Methodology: The process of development of the rapid dietary gap assessment tool: ICMR and NIN have made recommendations for a balanced diet for children and adolescents.[8] The recommendations are given in terms of number of portions recommended for each food group that constitutes a balanced diet.

Based on the recommendations, a dietary gap assessment tool was developed, keeping in mind the objectives of the survey and the target participants aged 6–17 years.[9],[10] The questions were simple direct, close-ended questions that inquired the frequency of intake of the recommended portions for each food group (whether daily, 3–4 times, or 1–2 times a week or never) and also other questions directed at identifying the faulty habits were placed toward the end of the tool. All the questions were included in the tool after detailed discussions with the experts to ensure content and construct validity. In short, it was a food frequency questionnaire assessing how frequently the children are taking recommended number of portions of dietary components for a balanced diet. In order to capture the effectiveness of the educational intervention in terms of change in behavior following the dietary counseling, a scoring scheme was developed.

After piloting the tool, the problems that were identified as hindering the process and purpose were: (1) younger children (6–7 years) could not understand the concept of frequency, i.e., number of times in a week, (2) difficulty in appreciating the portions or quantity of intake, (3) time consuming – took more than 20 min for each child, (4) lack of precision with respect to eliciting portion size and frequency, and (5) need for increased resources such as time and workforce for doing this repeatedly for large number of children.

The key issues and problems encountered in the field were then discussed with experts, and based on their recommendations, the tool was redesigned and simplified to focus on identifying their gaps in dietary habits rather than on the quantity or frequency of intake of recommended portions in their diet. This enabled us to quickly understand what was faulty in the child's diet and to observe the broad gaps in diet of the school children and target that in the diet counseling and health education sessions that followed the assessment.

In the revised simplified tool [Table 1], the simplification is achieved by directly asking question that checks in Yes/No terms, the compliance with daily recommended intake of cereals in the three main meals, daily intake of vegetables and green leafy vegetable, daily intake of milk and milk products, habit of taking a fruit daily, and intake of protein-rich foods in daily diet.
Table 1: Simplified dietary gap assessment tool eliciting daily consumption of various food groups in the recommended balanced diet among children aged 6-17 years

Click here to view


Additional questions were also added to identify other eating habits such as the habit of taking mid-day snacks and to capture certain faulty eating habits of students such as habit of skipping meals, taking junk food, and eating from street shops. Each student was then individually assessed, and counseling was given to students about their faulty eating habit.

Advantages in administering the revised simplified assessment tool

  1. Ease of administration and more time efficient: The newer tool designed for capturing gross faults in the dietary habits of the school children was less time consuming (took only 5–6 min per student compared to 20 min taken earlier) and so was easier to administer the questionnaire.
  2. Valid in identifying gaps in diet: The questions asked were easier for the children to understand and so answers in terms of “yes” or “no” were more valid reflecting the reality while assessing the diet habits even among the younger children.
  3. Effective in getting the desired information (identification of gross gaps): It was effective in identifying the food groups that were grossly deficient in the school children's diet. We found that though in our schools 92% of the children took cereals and 85% took proteins in their diet daily, only 34% took vegetables, only 4% of them took milk and milk products, and fruit consumption was only 2.5%. Daily consumption of green leafy vegetables was almost nil among the students. This suggests that they might have micronutrients deficiency even though they may have a normal body mass index.
  4. Usefulness as a program evaluation tool: Each item in the tool representing a dietary component was given a scoring with each response being scored as either 1 or 0 and all 10 items cumulatively yielding a potential maximum score of 10. This makes it possible to arrive at the initial scoring as the baseline score before a dietary intervention. Scoring done after the intervention reflected the degree of remediation in the faulty habits after the health education intervention. Pre-post difference would indicate the effect size and thereby the extent of effectiveness of the educational intervention capturing the degree of change in behavior/dietary habits. When this is applied to all children under the program, it serves as a program evaluation tool for evaluating the effectiveness of the health education program.
  5. Practicality at the field: The tool designed captured the habits of taking recommended portions of each food groups as “yes = 1” and for “No or faulty diet = 0”, with a maximum total score of 10. Any score <10 indicates a gap in the diet and the item in the checklist with a “0 score” was identified as requiring corrective dietary counseling to the child for that food group then and there and this can also be communicated to the parents/guardians accompanying the children for corrective measures.


Limitations and need for further study: The tool serves the limited purpose of identifying gross gaps in children's diet for that specific food group so that corrective counseling can be initiated during the screening itself. However, further studies may be needed to validate the tool to establish test-retest reliability and to investigate how this screening tool compares with standard dietary assessment tools.

The simplified dietary gap assessment tool was effective in overcoming the challenge among children relating to difficulty in understanding the complex concept of portion size and frequency of food intake. Furthermore, using this simplified dietary assessment tool, a large number of students could be assessed in the limited time available during school health program. Since the questions were simplified with responses from students becoming close ended as either “yes” or “no,” the chances of vague answers due to boredom and responder fatigue due to long time taken to elicit the answers were avoided.

Although further studies are needed to validate the tool against standard tools that are used for individual children under ideal conditions, consultation and vetting of the tool developed with experts in the department has ensured content and face validity for the tool to serve as an effective, rapid, and easy to use tool for identifying gross gaps in dietary habits of large number of school children. Since the purpose of the assessment was only to know the gross fault in dietary habits and to target that for tailor-made individual educational intervention, the revised tool served the purpose. When younger children have to be assessed in large numbers within the constraints of time and other resources, this tool has served as an effective alternative to meet the purpose and so is recommended for use in similar context.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Roberts K, Flaherty SJ. Review of Dietary Assessment Methods in Public Health. National Obesity Observatory: Oxford; 2010. Available from: http://www.noo.org.uk/uploads/doc/vid_7237_Review_new.pdf. [Last accessed on 2016 Aug 01].  Back to cited text no. 1
    
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Livingstone MB, Robson PJ, Wallace JM. Issues in dietary intake assessment of children and adolescents. Br J Nutr 2004;92 Suppl 2:S213-22.  Back to cited text no. 2
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Baxter SD. Cognitive processes in children's dietary recalls: Insight from methodological studies. Eur J Clin Nutr 2009;63 Suppl 1:S19-32.  Back to cited text no. 3
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Pérez-Rodrigo C, Artiach Escauriaza B, Artiach Escauriaza J, Polanco Allúe I. Dietary assessment in children and adolescents: Issues and recommendations. Nutr Hosp 2015;31 Suppl 3:76-83.  Back to cited text no. 4
    
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Forrestal SG. Energy intake misreporting among children and adolescents: A literature review. Matern Child Nutr 2011;7:112-27.  Back to cited text no. 5
    
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Sherwood NE. Diet assessment in children and adolescents. In: Elissa J, Ric G, editors. Handbook of Childhood and Adolescent Obesity. US: Springer; 2008. p. 73-89.  Back to cited text no. 6
    
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Serdula MK, Alexander MP, Scanlon KS, Bowman BA. What are preschool children eating? A review of dietary assessment. Annu Rev Nutr 2001;21:475-98.  Back to cited text no. 7
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8.
National Institute of Nutrition: A Manual on Dietary Guidelines for Indians. Available from: http://www.ninindia.org/dietaryguidelinesforninwebsite.pdf. [Last accessed on 2016 Aug 15].  Back to cited text no. 8
    
9.
Centre for Disease Control: Evaluation Briefs: Data Collection Methods for Program Evaluation. Available from: http://www.cdc.gov/Healthyyouth/evaluation/pdf/brief14.pdf. [Last accessed on 2016 Aug 17].  Back to cited text no. 9
    
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Centre for Disease Control: Questionnaire Design: Reproductive Health Epidemiology Series Module 4. Available from: http://www.cdc.gov/ReproductiveHealth/ProductsPubs/PDFs/Epi_Module_04_Tag508.pdf. [Last accessed on 2016 Aug 20].  Back to cited text no. 10
    



 
 
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