1. Child Malnutrition, Child Health and the Mid-Day Meal Opportunities for Action. By : Dr. T Sundaraman, Executive Director, NHSRC

2. Malnutrition.. not child specific IndicatorNFHS- 2NFHS- 3 Children< 3 Stunted 45.5038.40 Children <3 Wasted- 15.5019.10 School Child36.0% Women 15 to 24 BMI < 18.5 44.1 Men 15 to 24 BMI <18.5 34.2 Women 25 to 4935.6 M en 25 to 4934.2

3. But Children Most Vulnerable…  Almost one third low birth weight at birth.  Improved by about 6 th month  Then worsens and remains high in 0 to 6  Peaks again in adolescence- for the first and only time being male predominant.  Then declines moderately- over next three decades  Rises again in old age.

4. Malnutrition Rates  International comparisons show India performing very poorly  Adjusted for GDP per capita – it would be the worst performance.  Reasons relate to  Poverty and Economic Disparity.  Social inequities- gender, caste, geographic  Changing Dietary Patterns  Burden of ill health and sickness.

5. Govt. Schemes that Address Malnutrition….  Public Distribution System  NREGS  ICDS & Nutrition Supplement for Pregnant women, lactating mothers and children below 5  Mid-day meals in schools.  The Creche Programme  Management of Severe Acute Malnutrition….  Drinking water and sanitation schemes..

6. The Mid-Day Meal  Major tool – that has helped boost enrolment and retention of school children.  Possibly helped in reducing absence and in improving learning.  Meant to cover 30% of the nutrition needs of the growing child.  However it has not been consciously leveraged as an opportunity for increased child health.

7. School Health Programmes  As early as the Bhore Committee Report- A school healht service must include  Health Measures, preventive and curative, which include  Detection and treatment of defects and diseases  Creation and maintenance of a hygenic environment in and around schools  Measure for promoting positive health should include  Provision of supplementary food to improve the nutritional state of the child  Physical culture through games, sports and gymnastic exercises  Health education thru formal instruction and practice of the hygenic mode of life.

8. Health Screening and Management.( 6 monthly) Six Monthly  Nutritional Status- BMI  Anemia.  Common Skin diseases  Ear discharge/Eye redness  Common dental conditions Annually  Vision and Hearing Problems  Heart defects  Learning Disorders  Psycho-social assessment and assistance for the child.  Disability

9. For Management of Malnutrition and Anemia.  Preventive measures- the mid-day meal plus a weekly Iron and Folic Acid Tablet as supplement.  One could add micronutrients onto locally prepared food where indicated. – eg using iodised salt.  But for children with moderate or severe malnutriton or anemia- Test and Treat and monitor till cured!!!  Add more to food supplements- either as a morning snack or as a extra-portions on the meal- to help correct the gap.

10. Role of nutrition counseling…  Only within a setting where the school sees itself as responsible for addressing malnutrition and anemia.  Nutrition counseling and management is a complex skills- requires judgment, considerable subjective factors- individual dialogue, understanding of contexts….  But with the mid day meal in hand – one could supplement with nutrition for the needy child.

11. And Health Education…  Inclusion in the formal curriculum  Inclusion as special series of school health sessions- audited- not credited.  Informal methods- peer education  Promotion of Hygenic Practices  Physical education and Sports.  Adolescent Health- the whole area of sex education and sexual health.

12. Social Health…  Support to the physically challenged child  Support to the child with learning difficulties- mental problems,  Dealing with violence in the school and in the homes  The role of cultural activities and building solidarity and the spirit of caring.

13. In conclusion  The School is charged with not only producing an educated child – but a healthy child as well.  And Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity….  And school is one of the best opportunities to achieve this.