1. Introduction

“Healthy Children Today Make Healthy Nation Tomorrow” -

- Jawaharlal Nehru

According to World Health Organization term malnutrition refers to both under nutrition as

well as over nutrition. [1] Malnutrition is one of the major public health concern affecting a

significant number of school children influencing their health, growth and development and

school academic performance. Malnutrition is the largest health problem of children in

developing countries. Approximately 60 million children are underweight in India and child

malnutrition is responsible for 22% of the country's burden of disease. One in every three

malnourished children in the world lives in India. Malnutrition is more common in India than

in Sub-Saharan Africa. [2]

Children are the wealth of any nation as they constitute one of the important segment of

population. Children in the age group of 5-14 years are often considered age school age. The

foundation of good health and sound mind is laid during the school age period. So, it is a

basic milestone in the life of an individual and responsible for many changes that take place

during later life. School age is considered as dynamic period of growth and development

because children undergo physical, mental, social and emotional changes. Malnutrition has

been defined as “a pathological state resulting from a relative or absolute deficiency or excess

of one or more essential nutrient” [3]

The NFHS data shows that 53% of children in rural areas are underweight in India and this

varies across states.[2]

Anthropometry, the measurement of body size, weight and proportions, is an intrinsic part of

any nutritional survey and can be an indicator of health, development and growth.

Anthropometric values are closely related to nutrition, genetic makeup, environmental

characteristics, social and cultural conditions, lifestyle, functional status and health.

Anthropometry provides non-invasive, easy and cheap, but yet valuable information on

nutritional status. The most commonly used indices derived from the measurement of

anthropometric data are stunting (low height for age), wasting (low weight for height), and

underweight (low weight for age) and overweight (high/ more weight for age). Stunting is an

indicator of chronic under nutrition, the result of prolonged food deprivation and/or disease or

illness, wasting is an indicator of acute under nutrition, the result of more recent food

deprivation or illness, underweight is used as a composite indicator to reflect both acute and

chronic under nutrition. These indices reflect distinct biological processes and their use is

necessary for determining appropriate interventions.[4]

Nutritional status of an individual is influenced by nutrient intake and utilization in the body.

Malnutrition is major public health problem in developing countries. Freedom from hunger

and malnutrition is a basic human right and their alleviation is fundamental prerequisite for

human and national development. Usually malnutrition referred to as silent emergency, it has

devastating effects on children, society and future humankind.

Although the World Bank has included school health as one component of its essential public

health package for cost effective health program, the nutrition and health of school- age

children in the developing world has received a fewer attention .

WHO in 1997, developed 10 recommendations for school health, and initiated a global

school health initiative in ten countries, of which 8 were developing countries. Despite such

initiatives, school health has not been focused in India for many years and donor initiated

school health projects have come and gone sporadically over the decades.

In developing countries like India various forms of malnutrition affect a large segment of

population, both macronutrient as well as micronutrient deficiencies are of major public

health concerns. The school age period is nutritionally significant because this is the critical

phase of life to build up body stores of nutrients in preparation for rapid growth of

adolescence. Nutrition plays a vital role, as both over nutrition as well under nutrition during

childhood phase may lead to risk of malnutrition in the form of growth retardation, reduced

work capacity, poor mental and social development along with the risk of chronic disorder

later phase of life.

In children, protein/calorie excess or deficient diet results in overweight, obesity

underweight, wasting and lowered resistance to infection, stunted growth and impaired

cognitive development and learning.

Under nutrition continues to be a primary cause of ill-health and premature mortality among

children in developing countries. Under nutrition among children is prevalent in almost all

the states in India. The children living in rural areas of India disproportionately suffer from

under nutrition compared with their urban counterparts where risk over nutrition is more

common due to sedentary life style .

The best global indicator of children’s well being is growth. Poor growth is attributable to a

range of factors closely linked to overall standards of living and the ability of populations to

meet their basic needs, such as access to food, housing and health care. Assessment of growth

is the single measurement that best defines the nutritional and health status of children, and

provides an indirect measurement of the quality of life of the entire population.

According to modern concepts, school health service is an economical tool and powerful

means of raising community health and more important for future generations. By simply

doing periodic medical examination and daily morning inspection of students, we can simply

detect many common problems and treat accordingly. The health problems of students vary

country to country. The most prevalent health problems are malnutrition, infectious disease,

intestinal parasites, and diseases of skin, eye, ear and dental caries. [5]

# Children constitute the most important segment of any community. The Children’s health

of any community is a sensitive and important indicator of wealth of that community. India

being a developing country, undergoing a rapid epidemiological and nutritional transition

along with demographic transition, is posed by the double threat of under and over nutrition.

The country is still stressed with this major problem. The national family health survey

(NFHS) data show that 53% of children in rural areas are underweight and this varies across

states. The percentage of underweight children in the country was 53.4 in 1992; it decreased

to 45.8 in 1998 and rose again to 47 in 2006. More than half of the world’s undernourished

populations live in India. And more than half of Indian children are undernourished.

Although the growing prevalence of over-weight and obesity has received attention in many

states. Underweight, the condition resulting from faulty nutrition, weakens the immune

system and causes significant growth and cognitive delay. Growth assessment is the

measurement that best defines the health and nutritional status of children, while also

providing an indirect measurement of well-being for the entire population. Obesity related

morbidities are rare in children and are generally restricted to the severely obese. Such

morbidities include the Pick Wickian syndrome, orthopedic disorders such as genu valgum

and genu varum, respiratory disorders such as upper airway obstruction. The most prevalent

immediate consequences for obese children are social isolation and peer problems.

School age is the active growing phase of childhood. Especially during primary school age is

a dynamic period of physical growth as well as of mental development of the child. Research

indicates that health problems due to miserable nutritional status in primary school-age

children are among the most common causes of low school enrolment, high absenteeism,

early dropout and unsatisfactory classroom performance. Many social scientists reported a

high prevalence of overweight among school children in India; along with it some studies

reported a high prevalence of underweight among children. Excess weight in this age is the

leading cause of pediatric hypertension, and overweight children are at a high risk for

developing long term chronic conditions, including adult onset diabetes mellitus, coronary

heart disease, orthopedic disorders and respiratory diseases.[6]

The term malnutrition comprises of four forms –under nutrition, over nutrition, imbalance

and specific deficiency of nutrients. In developing countries like India various forms of

malnutrition affects large segment of population and both macro and micronutrient deficiency

are major concern, The most recent estimates in developing world, state that approximately

146 million children are underweight, out of these 57 million children live in India. At the

other end of spectrum are the urban affluent children among whom over nutrition has steeply

increased because of sedentary lifestyle and intake energy dense foods. In view of fact that

over nutrition in childhood and adolescence is associated with an increased risk of developing

non communicable disease in adult life, it is essential to improve physical activity and

promote balance food intake in school aged children.[7]

Therefore, it was proposed to carry out this study to asses and identify the prevalence of

underweight, overweight and obesity among school going children. The nutritional status of

children does not only directly reflect the socioeconomic status of the family and social

wellbeing of the community, but also the efficiency of the health care system, and the

influence of the surrounding environment. The present study carried out in rural and urban

area of Bareilly District in the state of Uttar-Pradesh (UP), To evaluate the overall prevalence

of underweight, overweight and obesity. Also to assess age sex trends in the level of

unhealthy weight, for correction of the nutritional deficit of the vulnerable population group

and to provide baseline data for future research.

2. Aim and Objectives

2.1Aim:

To estimate the prevalence and risk factors of malnutrition among school going children of

Bareilly district, Uttar Pradesh.

2.1 Objectives:

1. To assess the malnutrition of school going children.

2. To compare the extent of malnutrition among school going children of rural and urban

area.

3. To compare the extent of malnutrition among school going children of government and

private schools.

4. To find out the relationship between various risk factors of malnutrition and its association

with socio-demographic profile of these children.

5. To suggest suitable recommendation for control and prevention of malnutrition.

3. Review of Literature

3.1 Background:

Child growth is internationally recognized as an important public health indicator for

monitoring nutritional status and health in populations. Children who suffer from growth

retardation as a result of poor diets and recurrent infection tend to have more frequent

susceptible to several infectious diseases. A number of studies (Brown, 1998 Ojeifeitimi and

others., 2003; and Benson,and others.,2004) have demonstrated the association between

increasing severity of anthropometric deficits and mortality. The substantial contribution to

child mortality of all degrees of malnutrition is now widely accepted. In addition, there is

strong evidence that impaired growth is associated with delayed mental development, poor

school performance and reduced intellectual capacity (WFP, 2005).

3.2 Public Health Importance:

Nutritional status is the condition of health of an individual as influenced by nutrient intake

and utilization in the body. Malnutrition is major public health problem in developing

countries. Freedom from hunger and malnutrition is a basic human right and their alleviation

is fundamental prerequisite for human and national development. Usually referred to as silent

emergency, it has devastating effects on children, society and future humankind. [8]

Children are the wealth of any nation as they constitute one of major segment of the

population. Children in the age group of 5-14 years are often considered as school age. The

foundation of good health and sound mind is laid during the school age period. So, it is basic

milestone in the life of an individual and responsible for many changes that take place during

later life. [7]

The best global indicator of children’s well being is growth. Poor growth is attributable to a

range of factors closely linked to overall standards of living and the ability of populations to

meet their basic needs, such as access to food, housing and health care. Assessment of growth

is the single measurement that best defines the nutritional and health status of children, and

provides an indirect measurement of the quality of life of the entire population.

Although the World Bank has included school health as one component of its essential

public health package for cost effective health program, the nutrition and health of school-

age children in the developing world has received a little attention. WHO in 1997, developed

10 recommendations for school health, and initiated a global school health initiative in ten

countries, of which 8 were developing countries. Despite such initiatives, school health has

not been focused on in India for many years and donor initiated school health projects have

come and gone sporadically over the decades. [8]

3.3 Rationale for the Study:

Children are the future pillars of the nation and the future of the nation rests on the hands of

the children’s health today. The future of the society depends upon the quality of life of it’s

children. H.P.S.Sachdev and D.Shah ‘’Recent tends in nutritional status of children in India

Since 1947, India has made substantial progress in human development. Still the

manifestations of malnutrition are at unacceptable levels. Malnutrition in India is in a state of

silent emergency and thereby demands greater priority than ever before.

Nutritional Health Status of Primary School Children A study in Bareilly District MEHROTRA MONIKA*, ARORA SANTOSH**, AND

NAGAR VEENU***

Free and compulsory education till the age of 14 year is constitutional right, and institutional

commitment in India. Despite these measures, about 40% children drop out during their

primary schooling .

Low enrolment and higher school dropout rates are attributed to poor socio-economic

conditions, thus engaging in child labour; migration of family, helping the family in domestic

work and lack of educational motivation compounded by poor nutritional status. The scenario

worsens further due to superimposition of under-nutrition, anemia and infections among these

educationally depleted children. Unfortunately, a sizable portion of Indian children suffer

from low food intake induced under-nutrition potentially resulting from poverty, ignorance

etc. All these factors undoubtedly hamper their attendance and scholastic performance in

school. Malnutrition Scenario among School Children in Eastern-India-an Epidemiological Study Debottam Pal 1 , Suman Kanungo 1 ,

Baishali Bal 1 , Kalyan Bhowmik 1 , Tanmay Mahapatra 1   and Kamalesh Sarkar 1 , 2 *

Global Nutritional Status:

The global food system is broken. In total around 3.5 billion people — half the

people on the planet today — are malnourished.

Each day 795 million people go hungry.

Close to 2 billion people survive on diets that lack the vital vitamins and nutrients needed

to grow properly, live healthy lives, and raise a healthy family.

1.4 billion People worldwide struggle with overweight and obesity. That’s more than the

number of people who are hungry worldwide. Changing lifestyles and cheap calories

mean many people find it hard to balance their diets and lifestyles.

Each year, malnutrition undermines billions of people’s health. It kills 3.1 million

children under 5 and leaves 161 million stunted.

Rapid population growth and climate change pose new challenges to an already overburdened food system. http://www.gainhealth.org/about/malnutrition/

Problem Statement:

World wide-

Two billion people in the world suffer from various forms of malnutrition.

Malnutrition is an underlying cause of death of 2.6 million children each year – a third of

child deaths globally.

1 in 4 of the world’s children are stunted 4; in developing countries this is as high as one

in three. This means their bodies fail to develop fully as a result of malnutrition.

Under nutrition accounts for 11 per cent of the global burden of disease and is considered

the number one risk to health worldwide. http://www.gainhealth.org/knowledge-centre/fast-facts-malnutrition/

https://www.google.co.in/search?q=malnutrition+world+geography+who+figures&rlz=1C1CHZL_enIN717IN717&tbm=isch&imgil=Q0qI5RnfQB-TbM%253A%253BRIZ-rrJoRDfNdM%253Bhttps%25253A%25252F

%25252Fdata.unicef.org%25252Ftopic%25252Fnutrition%25252Fmalnutrition%25252F&source=iu&pf=m&fir=Q0qI5RnfQB-TbM%253A%252CRIZ- rrJoRDfNdM

%252C_&usg=__TRHyWCSHTzq2FZzx4TpkCAP3OvY

%3D&biw=1080&bih=469&ved=0ahUKEwjprLLhuavWAhXGto8KHZ0gCvwQyjcINQ&ei=MAO-

WenUJcbtvgSdwajgDw#imgrc=Q0qI5RnfQB-TbM:

India-

India, with a population of over 1.2 billion, has seen tremendous growth in the past two

decades. Gross Domestic Product has increased 4.5 times and per capita consumption has

increased 3 times. Similarly, food grain production has increased almost 2 times. However,

despite phenomenal industrial and economic growth and while India produces sufficient food

to feed its population, it is unable to provide access to food to a large number of people,

especially women and children.

15.2% of our population is undernourished

194.6million people go hungry everyday, 1 in 4 children malnourished

30.7% of children under 5 are underweight where as 38.7%  stunted

3,000 children in India die every day from poor diet related illness

24% of under-five deaths in India 30% of neo-natal deaths in India https://www.indiafoodbanking.org/hunger

https://www.google.co.in/search?

rlz=1C1CHZL_enIN717IN717&biw=1080&bih=469&tbm=isch&sa=1&q=malnutrition+in+india+map+unicef&oq=malnutrition+in+i

ndia+map+unicef&gs_l=psy-ab.3...4196.6753.0.7216.7.7.0.0.0.0.191.1028.0j7.7.0....0...1.1.64.psy-

ab..0.0.0....0.x5aP9DbADxE#imgrc=9vlL0N31ngf_2M:

Economic impact:

Adults who were malnourished as children earn at least 20% less on average than

those who weren’t. 

Countries may lose two to three percent of their Gross Domestic Product (GDP) as a

result of iron, iodine, and zinc deficiencies. 

Estimates show annual investments of US$ 347 million to provide micronutrients to

80 percent of the world’s malnourished would yield US$ 5 billion in improved

earnings and healthcare spending. 

It is calculated that each dollar spent on nutrition delivers between US$ 8 and US$138

of benefits. http://www.gainhealth.org/knowledge-centre/fast-facts-malnutrition

The 2016 Report in seven cities around the globe – Beijing, Johannesburg, Nairobi, New

Delhi, New York, Stockholm and Washington D.C. – and comes on the heels of renewed

international attention on nutrition. The Report highlights the staggering economic costs of

malnutrition, as well as the critical gaps in investments and commitments to date, including:

Societal costs: 11 percent of gross domestic product (GDP) is lost every year in Africa and

Asia due to malnutrition. Every year, global GDP losses from malnutrition are greater than

what was lost each year during the 2008-2010 financial crisis.

Family costs: In the United States, when one person in a household is obese, the

household spends on average an additional 8 percent of its annual income in healthcare

costs. In China, a diagnosis of diabetes results in an annual 16.3 percent loss of income for

those with the disease.

Financing gaps: Brand new analysis in the Report shows that nutrition-related

noncommunicable diseases received only USD 50 million of donor funding in 2014,

despite the fact that all noncommunicable diseases now cause nearly 50 percent of death

and disability in low- and middle-income countries. Of 24 low- and middle-income

government budgets analyzed in the Report, just an average 2 percent of spending is

allocated toward reducing undernutrition, while donor allocations to nutrition programs

are stagnating at USD 1 billion.https://www.ifpri.org/news-release/global-nutrition-report-malnutrition-becoming-

%E2%80%9Cnew-normal%E2%80%9D-across-globe

Various forms of malnutrition:

1. Undernutrition-

There are 4 broad sub-forms of undernutrition: wasting, stunting, underweight, and

deficiencies in vitamins and minerals. Undernutrition makes children in particular much

more vulnerable to disease and death.

a) Low weight-for-height is known as wasting. It usually indicates recent and severe

weight loss, because a person has not had enough food to eat and/or they have had an

infectious disease, such as diarrhoea, which has caused them to lose weight. A young

child who is moderately or severely wasted has an increased risk of death, but

treatment is possible.

b) Low height-for-age is known as stunting. It is the result of chronic or recurrent

undernutrition, usually associated with poor socioeconomic conditions, poor maternal

health and nutrition, frequent illness, and/or inappropriate infant and young child

feeding and care in early life. Stunting holds children back from reaching their

physical and cognitive potential.

c) Underweight: Children with low weight-for-age. A child who is underweight may be

stunted, wasted, or both.

d) Micronutrient-related malnutrition: Inadequacies in intake of vitamins and minerals

often referred to as micronutrients, can also be grouped together. Micronutrients

enable the body to produce enzymes, hormones, and other substances that are essential

for proper growth and development. Iodine, vitamin A, and iron are the most important

in global public health terms; their deficiency represents a major threat to the health

and development of populations worldwide, particularly children and pregnant women

in low-income countries.

2. Overweight and obesity-

Overweight and obesity is when a person is too heavy for his or her height. Abnormal or

excessive fat accumulation can impair health.

Body mass index (BMI) is an index of weight-for-height commonly used to classify

overweight and obesity. It is defined as a person’s weight in kilograms divided by the

square of his/her height in meters (kg/m²). In adults, overweight is defined as a BMI of 25

or more, whereas obesity is a BMI of 30 or more.

Overweight and obesity result from an imbalance between energy consumed (too much)

and energy expended (too little). Globally, people are consuming foods and drinks that are

more energy-dense (high in sugars and fats), and engaging in less physical activity.

3. Diet-related non-communicable diseases-

Diet-related non-communicable diseases (NCDs) include cardiovascular diseases (such as

heart attacks and stroke, and often linked with high blood pressure), certain cancers, and

diabetes. Unhealthy diets and poor nutrition are among the top risk factors for these

diseases globally.

Who is at risk?

Every country in the world is affected by one or more forms of malnutrition. Combating

malnutrition in all its forms is one of the greatest global health challenges. Women,

infants, children and adolescents are at particular risk of malnutrition. Optimizing nutrition

early in life—including the 1000 days from conception to a child’s second birthday—

ensures the best possible start in life, with long-term benefits.

Poverty amplifies the risk of, and risks from, malnutrition. People who are poor are more

likely to be affected by different forms of malnutrition. Also, malnutrition increases health

care costs, reduces productivity and slows economic growth, which can perpetuate a cycle

of poverty and ill health.

Health Challenges:

Undernutrition:

I. about 104 million children worldwide (2010) are underweight

II. undernutrition contributes to about one third of all child deaths

III. stunting (an indicator of chronic undernutrition) hinders the development of 171 million

children under age 5 according to 2010 figures

IV. 13 million children are born with low birth weight or prematurely due to maternal

undernutrition and other factors

V. a lack of essential vitamins and minerals in the diet affects immunity and healthy

development. More than one third of preschool-age children globally are Vitamin A

deficient

VI. maternal undernutrition, common in many developing countries, leads to poor fetal

development and higher risk of pregnancy complications

VII. together, maternal and child undernutrition account for more than 10 percent of the global

burden of disease

Overweight and obesity:

i. about 1.5 billion people are overweight worldwide, of whom 500 million are obese, in

2008 figures

ii. about 43 million children under age 5 were overweight in 2010

iii. growing rates of maternal overweight are leading to higher risks of pregnancy

complications, and heavier birth weight and obesity in children

iv. worldwide, at least 2.6 million people die each year as a result of being overweight or

obese http://www.who.int/nutrition/challenges/en/

Double burden of malnutrition

The double burden of malnutrition is characterised by the coexistence of undernutrition

along with overweight and obesity, or diet-related non-communicable diseases, within

individuals, households and populations, and across the life course. In the context of a

changing global nutrition landscape, influenced by economic and income growth,

urbanization, demographic change and globalization, diet-related epidemiology has seen a

significant shift in recent decades.

Opportunity

This double burden of malnutrition offers a unique and important opportunity for

integrated action on malnutrition in all its forms. Addressing the double burden of

malnutrition will be key to achieving the Sustainable Development Goals (in particular

Goal 2 and Target 3.4) and the Commitments of the Rome Declaration on Nutrition,

within the UN Decade of Action on Nutrition.http://www.who.int/nutrition/double-burden-

malnutrition/en/

The UNICEF conceptual framework for causes of malnutrition

Prevalence of malnutrition:

Prevalence of malnutrition at International level: Studies done and published by different researchers from different parts of world reported the Prevalence of malnutrition as follows:-

1. A cross-sectional study from Nigera conducted by Adedeji et al. reported the overall prevalence of malnutrition was 35.4%, with thinness, underweight, stunting, overweight, and obesity accounting for 11.1%, 10.7%, 10.1%, 2.9% and 0.5% respectively. Optimal IQ was recorded among 37.3%, while suboptimal IQ was documented among 62.7% of the pupils. The prevalence of suboptimal intelligence was significantly higher in the stunted and underweight pupils; 83% of the stunted and 80% of the underweight pupils had suboptimal intelligence (p=.005, p=.014 respectively). Furthermore, low socio-economic class was observed to be associated with increased prevalence of suboptimal intelligence among the undernourished children (p<0.001).

2. Study from Tanzania by Mgongo et al. stated the prevalence of children classified as underweight was 46.0%, stunting was 41.9%, and wasting was 24.7%. About 33% were both underweight and stunted, and 12% had all three conditions. In a multivariate logistic regression, child age, child being ill and birth weight were associated with all anthropometric indices. Child being breastfed was associated with being underweight and wasting. Mother’s education was associated with being underweight and stunting. Fathers aged 35+ years, and living in the Hai district was associated with stunting, and being female was associated with wasting. The prevalence of child undernutrition is high in this region. Strategies that target each risk factor for child undernutrition may help to reduce the problem in the region.

3. Shine et al. reported the prevalence of stunting among 6-59 months age children was 31.9%. Sex (AOR: 1.47, 95%CI 1.02, 2.11), age (AOR: 2.10, 95%CI 1.16, 3.80), maternal education (AOR: 3.42, 95%CI 1.58, 7.41), maternal occupation (AOR: 3.10, 95%CI 1.85, 5.19), monthly income (AOR: 1.47, 95%CI 1.03, 2.09), postnatal care visits (AOR: 1.59, 95%CI 1.07, 2.37), source of water (AOR: 3.41, 95%CI 1.96, 5.93), toilet availability (AOR: 1.71, 95%CI 1.13, 2.58), first milk feeding (AOR: 3.37, 95%CI 2.27, 5.02) and bottle feeding (AOR: 2.07, 95%CI 1.34, 3.18) were significant predictors of stunting.

4. Ebtihal et al. revealed that 14.7% of females were suffering from stunting compared to 12.6% in males (Odds Ratio OR = 1.1983 95% CI = 0.5860 - 2.4506), the prevalence among those who were consuming High protein foods rarely was 13.3% and 14.8% in children who were frequently eating high protein foods with no statistical association (Odds Ratio = 0.8889 and 95% CI = 0.3918 – 2.0168) as well as high carbohydrate foods (Odds Ratio = 0.0935 and 95% CI = 0.0410 – 0.2131), the percentage was 14.1% in children who their mothers education was low and 10.3% in case of high educated mothers (Odds Ratio = 1.4222 and 95% CI = 0.4066 – 4.9750)

5. Agbozo et al. stated underweight (13 % vs. 2 %, p = <0.0001), stunting (12 % vs. 3 %, p = <0.0001) and thinness (8 % vs. 1.4 %, p < 0.0001) were higher among pupils attending public schools compared to their private schools counterparts. Public school pupils had increased likelihood for underweight (AOR = 7.5; 95 % CI = 2.4–23; p = 0.001) and an increase risk for thinness (RR = 4.7; 95 % CI = 1.5–21.2; p = 0.028) but had decrease risk for overweight (RR = 0.3; 95 % CI = 0.1–1; p = 0.043). Overweight (9 %) was higher among private schools pupils compared to public schools (3 %). Underweight (14 % vs. 6 %), stunting (14 % vs. 4 %) and thinness (8 % vs. 4 %) were higher among pupils in rural

schools compared to urban dwellers. Rural schools children were twice likely to become stunted (AOR = 2.6; 95 % CI = 1.0–6.4; p = 0.043). However among pupils attending schools in urban areas, the prevalence of overweight was 7 % compare to 1 % in rural areas. Pupils who consumed only two meals per day were more likely to be underweight (AOR = 6.8; 95 % CI = 1.4–32.2; p = 0.016), stunted (AOR = 7.2; 95 % CI = 1.2–43.7; p = 0.033) and thin (RR = 9.4; 95 % CI = 2.0–47.8; p = 0.007) compared to those who had at least three square meals daily.

Prevalence of malnutrition in India:

1. Cross-sectional study from Assam by Dey et al reported that mean height of boys and girls of the study group was lower than WHO 2007 standards in all age groups. Of the 216 school children, 53, 31 and 111 were stunted/severely stunted, underweight/severely underweight, and thin/very thin, respectively. Both univariate and multivariate analysis revealed different associated sociodemographic factors contributing to poor nutritional status of children such as low socioeconomic status and poor educational background of their parents (p<0.05).

2. Study of Karnataka by Navya et al. showed that 25.5% of the children attending urban anganwadis were underweight, 10% severely underweight, 15.5% stunted, 2.5% severely stunted, 24% wasted and 8.5% severely wasted. 18.5% of children attending rural anganwadis were underweight, 6.8% severely underweight, 11.8% stunted, 3.2% severely stunted, 15.2% wasted and 4.5% were severely wasted. The prevalence of wasting was significantly higher (p=0.006) in children attending urban anganwadi centres compared to rural centres.

3. Nutritional status of school children from rural and urban area of Tamil Nadu by Caroline et al. reported that 67.33% of children were underweight, of which 29.67% were from rural areas; 6% were found to be overweight or obese, of which 4.67% were from urban areas. There is a significant statistical difference in the prevalence of underweight children in social class 4&5 as compared to class 1, 2 & 3. The mean calorie consumption of the study population was 1333 kcal which supplies only 50% of calorie requirement by ICMR standards; the mean calorie intake by children in rural area was much lower than in urban area.

4. Study of Trichy district, Tamil Nadu. by Mary et al. revealed anthropometric data out of total children screened (n=50) according to nutritional status of height for age (stunted) 90 % of student was normal, 5 % student was mild. Same as nutritional status of weight for height (wasted) found that 50 % of student was normal, 36 % was mild, 14 % student was moderate. The result shows that the nutritional status of school- aged children is considerably not satisfying.

5.  Malnutrition among school children of West Bengal, eastern India stated by Pal et al. as follow, Among 24,108 recruited students aged between six and thirteen years, prevalence of under-nutrition was alarmingly high (about twenty-three percent). Furthermore, over half of the students (fifty-four percent) were at-risk of developing malnutrition. On the other hand, only seventeen percent students had ideal nutritional status. Odds of being malnourished were higher among male students (compared to females), those belonging

to younger age (studying in primary compared to upper-primary classes), Muslim religion (with reference to Hindus), and under-privileged caste (in comparison with general caste) as well as those residing in rural areas (as opposed to urban). Parental education was negatively associated with the likelihood of under-nutrition. Those who had more than three siblings, unemployed father and students whose mother died were more likely to be under-nourished.

6. A cross-sectional study among rural adolescents in West Bengal by Pal et al. showed, about 54% of adolescents were stunted and 49% were thin. The adolescents belonged to lower social class were significantly more likely to be stunted (ORZ2.68) and thin (ORZ2.44). Other variables like father’s occupation, mother’s education, economic status and sanitation showed significant and negative association with undernutrition. However, mother’s working status showed significant and positive association with undernutrition. Adolescents of working mothers were more likely to be stunted and thin than those who do not worked outside of the home. The adolescents of women with higher education were less likely to be undernourished than adolescents of poor and uneducated women. Adolescents of nuclear families (family size <4) were more likely to be stunted and thin.

7. A cross-sectional study on malnutrition among school children in rural area of north Karnataka region by Malpani et al. The results showed the level of stunting and underweight in school children as per percentile standards from the WHO. Most of the boys and girls of the study fall under < 3rd percentile. Hence, malnutrition was significantly higher among the school children. The higher the level of the mother’s education, the lower the level of child’s underweight was observed. In the present study, growing children by and large are deprived of good nutrition on account of their poor socio-economic status, ignorance and lack of health promotional facilities.

8. Silva et al. reported nutritional Status of Anganwadi children under the integrated child development services scheme in a rural area of Goa. The overall prevalence of underweight, wasting, and stunting in the study population was found to be 33.4%, 24%, and 31.5%, respectively. Severe malnutrition (below -3 standard deviation cut-off) was found in the study population, with 9.2% of children severely underweight, 10.4% severely wasted, and 8.7% severely stunted. It was observed that the proportion of underweight children in the age group of 6-36 months was higher (38.1%) than the proportion of underweight children (24.9%) in the age group of 37-72 months, and this difference was found to be statistically significant (χ2 = 14.13, P = 0.0001). The proportion of underweight children was found to be the highest (51.3%) in lower class, and lowest (17.1%) in upper class and a statistically significant association between socio-economic class and nutritional status (χ2 = 37.02, P = 0.000) was found.

9. Nutritional status of mid-day meal programme beneficiaries: A cross-sectional study among primary schoolchildren in Kottayam District, Kerala, by Jayalakshmi et al. stated that prevalence of CIAF was 45.7% (95% CI: 40.3%–51.1%) and that of stunting, underweight, and wasting were 13.4% (9.7%–17.1%), 38.8% (33.5%–44.1%), and 30.7% (25.7%–35.7%), respectively. The prevalence of wasting (42.6% vs. 28.4%, P = 0.039) and severe underweight (20.4% vs. 7.1%, P = 0.002) was statistically significantly high among occasional/never users compared to regular users of MDM Programme. Children born with <2.5 kg showed an OR of 1.76 (95% CI:0.99–3.11) for being undernourished compared to children born with normal weight (≥2.5 kg) when adjusted for age, sex, birth order, and illness in the past 2 weeks.

10. Prevalence of malnutrition among school children in rural North Karnataka studied by Srividya et al. The results showed the level of stunting and underweight in school children as per percentile standards from the WHO. Most of the boys and girls fall under <3rd percentile. Hence , malnutrition was significantly higher among the school children. The higher the level of mother’s education, the lower the level of child’s underweight was observed.

Prevalence of malnutrition in Uttar Pradesh:

1. Prevalence of stunting and thinness among school-age children of working and non-working mothers in rural areas of Aligarh District. by Sultan et al. showed that overall prevalence of stunting (stunted +severely stunted) among children of working and nonworking mothers were 63.8% and 77.1% respectively. The overall prevalence of thinness (thin+ severely thin) among the children of non working and working mothers was 91.9% and 57.5% respectively. Significant association was found between maternal employment status and in the prevalence of stunting and thinness.

2. Nutritional status of primary school children through anthropometric assessment in rural areas of Moradabad. by Sharma et al. reported that, Out of total 295 students, 149 (50.50%) were boys and 146 (49.5%) were girl participants, Moderate malnutrition was more prevalent in children with housewife mothers while severe malnutrition was more commonly seen in children with working mothers. Regarding Maternal Education statistically significant relationship between mother’s education and under nutrition was found.

3. Study on nutritional deficiency disorders among adolescent girls in urban slums of Moradabad by Bahal et.al. revealed overall 88.5% adolescent girls were having any of the nutritional deficiencies. Most common finding was lustreless and easily pluckable hair. Variation in age wise distribution was found statistically significant only for vitamin A deficiency disorders, vitamin C deficiency disorders, koilonychias and easy pluckability of hair. Respondents belong to socioeconomic status III, IV and V and from joint family were maximally affected. Mothers’ educational status shows statistically significant correlation with occurrence of deficiency.

4. Study on socio-demographic factors affecting morbidity in primary school children in urban area of Meerut. By Saluja et al. stated out of 800 children (426 boys and 374 girls), 542 children (67.8 %) were found to be suffering from one or more morbid conditions. Prevalence of morbidity was found to be maximum in Muslim children ( 82.5%), children belonging to lower class ( 90%) and Schedule castes (75.5%). The association of morbidity with the type of family was also found to be significant (p<.01) being 73.1% in nuclear families and 49.7% in joint families. Morbidity was significantly higher (p<.001) in children who were non vegetarian (73.9%) as compared to vegetarians (62.5%) & also maximum (84.4%) in children with poor personal hygiene as compared to those with good personal hygiene (p<.001). The difference in morbidity with literacy status of

parents was found to be statistically significant (p<.001) being maximum in children of illiterate parents.

5. Nutritional status of government school children of adolescent age group in urban area of district Gautambudh-Nagar, Uttar Pradesh studied by Srivastav et al. reported the overall prevalence of thinness was found to be 23.2% and severe thinness was found to be 7.4%.The prevalence of thinness and severe thinness in boys was 24.1% and 8.6% respectively whereas in girls it was comparatively low thinness 20.6 and 3.9%. Overall 12.5% children were found to be suffering from stunting and 1.5% from severe stunting. Moderate stunting was found in 13.7% and 12% girls whereas severe stunting was found in 0.7% boys and 3.9% girls.

6. A cross-sectional study from Varanasi on nutritional status of rural primary school children and their socio-demographic correlates by Kaushik et al. stated that out of 816 study subjects 429 or 52.6% (201 boys and 228 girls) were underweight and 75 or 9.2% (39 boys and 36 girls) were stunted. Educational status of the parents was found to be significantly associated with nutritional status of children.

7. Study on body mass index for age criteria: a school based study in Meerut (U. P) by Parashar et al. On applying the BMI –for- age criteria 22.8% boys and 19.9% girls were found under weight while 04.1 % boys and 03.04 % girls were overweight , and 05.06% boys and 04.08% girls were found obese .22.8% government and (16.00%) private school children were found under weight while 03.4 % government and 5.6 % private school students were overweight , and 03.8 % government and 11.8 % private school students were found obese.

8. Rawat et al. studied the the prevalence of malnutrition among school children with reference to overweight and obesity and its associated factors. The prevalence of overweight and obesity was 9.8% and 3.7% respectively. Among dietary factors, a significant association was seen in the prevalence of overweight and obesity with consumption of >3 meals per day (P<0.001), habit of eating in between meals (P<0.05) and in having the diner as the heaviest meal of the day (P<0.02). Among physical activity factors, a significant association was seen in the prevalence of overweight and obesity with the habit of not playing outdoor games (P<0.001), not participating in household activities (P<0.001) using some vehicular transport to go to school (P<0.001) and watching TV for more than 3hrs/day (P<0.001)

Prevalence of malnutrition in Bareilly:

1. Study on nutritional status and morbidity among school going children from a rural area of Bareilly by Singh et al. This study shows that prevalence of under-nutrition in both male and female was 44.56 and 37.32% respectively. The prevalence of chronic malnutrition (stunting) in male was 26.31% and in females was 21.37%. The prevalence of acute malnutrition in both males and females according to the BMI-for-age was 38.24% and 34.05% respectively. The most common morbidities were upper respiratory tract infection 240 (42.78%), diarrhea 81 (14.44%), carbuncle/furancle 78 (13.90%) and scabies 63 (11.23%).Malnutrition in the form of underweight, stunting

and thinning were 41.00%, 23.28% and 36.18% respectively among school going children. URTI & Diarrhea were the most common morbidity.

2. Gupta et al stated, out of total 340 primary school children, 69.9%were underweight in total while according to sex wise 73.6% and 61.3% were underweight in male and female respectively. Male children have 21 % more chance of having increased BMI as compare to its counterpart.

3. Singh et. al reported that among total study subjects age group 0-5 yrs were 516. Total malnutrition cases were 394 with a prevalence of 76.36%. Here malnutrition was more common in males than females. Author observed that 53.86% children were underweight, 43.22% children were stunted and 60.67% were wasted. Malnutrition was more prevalent in 1-5 age group children and was found statistically significant.

4. Katyal et al. revealed age dependent criteria such as IAP (48.2% malnourished) and McLaren (48.3% malnourished) were followed by the age independent criteria such as Kanawati (74.3% malnourished), Dugdale (45.5% malnourished), and Rao (33.1% malnourished) to classify the mild to moderate malnutrition. ROC showed Dugdale as the best index for the judgement of malnutrition showing maximum area under the curve.

5. Srivastava et al. showed that mean height and weight of boys and girls in the study group was lower than the CDC 2000 (Centres for Disease Control and Prevention) standards in all age groups. Regarding nutritional status, prevalence of stunting and underweight was highest in age group 11 yrs to 13 yrs whereas prevalence of wasting was highest in age group 5 yrs to 7 yrs. Except refractive errors all illnesses are more common among girls, but this gender difference is statistically significant only for anaemia and rickets. The risk of malnutrition was significantly higher among children living in joint families, children whose mother’s education was [less than or equal to] 6th standard and children with working mothers.

6. Study of Gupta et al. found the prevalence of obesity, overweight was higher in boys than girls. There was significant relationship between BMI with gender and with age. Conclusion: Based on the results, although underweight was still relatively common in 4-14 year old children.

Study Design: A cross sectional observational community based study.

Study Area: Urban and rural area of Bareilly district.

Study duration: November 2016 to October 2017

Study population: School going children from 5 years to 14 years [8]

Unit of study: Unit of study is school going children of 5 years to 14years age group.

study population fulfilling the inclusion criteria.

Inclusion Criteria:

School going children from 5 years to 14 years

Parents of those students who will give consent to participate in study.

Exclusion criteria:

Students with known acute and/or chronic illness.

Students absent on the day of survey due to any reason.

Parents of those students who will not give consent to participate in study.

Sample size estimation: Sample size will be calculated taking the prevalence of malnutrition

(p=48%). According to NFHS-3 survey. [9]

q=100-P = 52

L (allowable error) = 10% of .

. Z = 1.96

n = Z 2x p x q/l2 .

. = (1.96)2 x 48 x 52 /(4.8)2 = 416.17

Taking non- response rate as 10%

Sample size = 416.17 x 10 / 9 = 462.41

Final sample size = 462

As per Census-2011 data of Bareilly district, 64.74% population lives in rural area where as

35.26% population lives in urban area.[10] Calculated sample size will be taken accordingly.

300 - From rural area

162 - From urban area

Sampling technique: Multistage random sampling technique.

Stage 1: (Sampling of Bareilly tehsils) by Simple Random Sampling.

Stage 2: (Sampling of blocks and wards) by Stratified Random Sampling using .

. Proportionate population sampling (PPS).

Stage 3: (Sampling of government and private schools) by Stratified Random Sampling.

Stage 4: (Sampling of section from class 1st to 8th class) by Simple Random Sampling

Stage 5: (Sampling of students) by Simple Random Sampling

Methodology:

Proportion of study participants in rural and urban areas was decided according to the

proportion of total rural & urban population of Bareilly district which consists of six tehsils.

In first stage, 10% tehsils was taken out of all six tehsils of Bareilly district (i.e. one tehsil).

Among selected tehsil, all wards and blocks was listed and 10% of 70 wards in urban area

(i.e. 7 wards) and 10% of 15 blocks in rural areas (i.e. 2 blocks) were selected by lottery

method. In every selected ward and block, 10% government and private schools was chosen

in each stratum for the study .i.e. 1 government and private school from each selected wards

and blocks. Total 14 schools from 7 wards and 4 schools from 2 blocks were selected

through lottery method of simple random sampling. If government or private school was not

found in the selected ward and block, Then the schools was selected from the alternate ward

or block.

In every selected school, one section of all classes from 1st to 8th will be selected randomly. In

every section, desired number of students was selected by SRS among all study participants

eligible after inclusion & exclusion criteria.

Sample size in each strata (Rural & Urban)(300R/162U) = 462 proportion of total

population in each strata in Bareilly district

Sample of students in each section = (300R/162U) / [Total school selected in each

strata(Rural & Urban) *8]

Study Tool: Study Tool: Semi- structured schedule containing open and closed ended

questions under following headings will be used for collecting the data. -(Annexure II)

Section-A: General Information

Section-B: Dietary Information

Section-C: Academic Information

Section-D: Hygiene and Sanitation

Section-E: Physical Activity

Data collection: After taking the institutional ethical committee clearance IEC/-------

Researcher went to the principal of each selected schools, for taking the permission and

explaining the purpose of study. Lists of students studying in class 1st to 8th were obtained

from the class attendance register. Eligible students were found in each class after applying

the inclusion and exclusion criteria.

Parents of every selected student for participation in the study were explained purpose and

objectives of study. Ensuring them for their anonymity and confidentiality of the study and

permission was taken from the parents in a written informed consent form through teachers /

or researcher personally. After obtaining the consent all measurements was taken by

researcher itself and interview of parents was done on parents-teachers meeting or any other

suitable day. Face-to-face interviews was conducted after explaining the purpose, benefits

and risks of the study.

Anthropometric measurements: - Selected students were measured for height and weight

without shoes and in light clothing. Weight was measured by the help of weighing machine to

the nearest 100 gram and height was measured using an ordinary measuring tape to the

nearest centimeter. BMI-for-age was used to assess physical growth and to determine the

prevalence of underweight, normal weight, overweight, obesity in children. Subjects standing

with their scapulae, buttocks and heels resting against a wall, the neck will held in a natural,

non-stretched position, the heels touching each other.

Body Mass Index (BMI): BMI of selected the students were calculated by using the formula:

BMI= Weight (kg)/ Height (m2)

Data analysis: Data coding and recoding was done according to need. After collection, data

was entered, checked, verified and analysed with the help of computer software Epi-Info

(version 7.2). Suitable statistical tests were used to find the association of the determinants

with malnutrition .The results were displayed with the help of tables according to the aim and

objectives of the study. Valid information were drawn and discussed with the other studies.

SOCIO DEMOGRAPHIC AND ENVIRONMENTAL PROFILE

Rural: People living in low density and small settlements and predominantly agriculturist.

Urban: Population of minimum 5000, with density being 400/ square kilometre or

more of which 75% of the male working population is non agriculturist by occupation.94

Type of Residence

Kutcha: Wall, floor and roof made up of mud

Semi- Pucca: Any of the above is made up of brick or plaster

Pucca: Floor, roof and walls are made up of bricks and fully plastered.

Type of Family

Family: Group of individuals related by blood or marriage or adoption, living together

under one roof and sharing food from single kitchen.

Nuclear Family: Couple with their dependent children, residing under same roof and sharing

food from single kitchen.

Joint Family: Consists of a number of couples and their children who live together in same

household. All men are related by blood and women of household are their wives, unmarried

girls and widows of the family kinsmen.

Income of Family: Family income includes sum of all type of income of family. Per capita

income is total family income divided by total number of family members.

Socio Economic Status- Socio Economic Status refers to an individual’s or group’s position

within a hierarchial social culture which is one of the important determinants of health status.

Socio economic status depends on a combination of variables including occupation,

education, income, wealth and place of residence.

Proposed classification for socio economic status during this period: Depending

upon the per capita monthly income, BG Prasad modified classification of SE status

2016 was used to assess the socio economic status of the family. It is applicable to both

urban and rural areas.

S. No. SOCIAL CLASS

PER CAPITA MONTHLY INCOME

Prasad’s Modified B.G Prasad

Classification (1961) Classification (2016)

1 Class I (Upper class) Rs. 100 & above Rs. 6277 and above

2 Class II (Upper

middle class)

Rs.50- 99 Rs. 3139 – 6276

3 Class III (Middle

class)

Rs. 30-49 Rs. 1883 – 3138

4 Class IV (Lower

middle class)

Rs. 15- 29 Rs. 943 – 1882

5 Class V (Lower class) Below Rs. 15 Below Rs. 942

The B.G Prasad scale was introduced in 1961 considering the base of Consumer Price Index

(CPI) for 1960 as 100. CPI is defined as a measure used for estimation of price changes

in a basket of goods and services representative of consumption expenditure in an

economy. The B. G Prasad scale was modified in 1982 and 2001 by introducing linking

factors to convert CPI (1982 and 2001) from the new base of 100 to the old base CPI (1960).

The linking factors for 1982 and 2001 were 4.93 and 4.63 respectively.

CPI- Industrial workers (IW) for December 2016= 275

Multiplication factor= Current index value (275) / Base index value in 2001 (100)

= 2.75

The new income value can be calculated using the following equation:

New income value = multiplication factor × old income value (base value for 1960)

×4.63 ×4.93 i.e. 2.75× 100 × 4.93× 4.63= 6277

[where, 4.93 and 4.63 are the linking factors given by Labour Bureau]. Therefore, families

whose per capita income is greater than Rs. 6277 belong to Class I as per Modified B.G

Prasad Socio economic classification. The updated values for the per capita monthly income

(Rs/ month) for Dec 2016 are given in the above mentioned table.

STUDENT PROFILE

Age: Age of student was taken in completed years.

Educational Profile of the Parents:

The process of reading, training, teaching and improving.

Illiterate: Person aged more than 7 years who can neither read nor write (no school

education)

Primary School: Educated upto 5th standard (Class 1- Class 5)

Middle School: Passed 8th standard

High School: Passed 10th standard

Intermediate: Passed 12th standard

Graduate: Any bachelor degree

Above: Higher than bachelor degree

Occupation: The very state of being employed in productive work or an activity that

occupies a person’s attention or free time

Unemployed: Unemployed mean those who have no employment or activity for their

livelihood.

Unskilled: Unskilled worker is defined as those workers whose work requires no intensive

training or special skill. The workers who engaged in field such as beedi, hotel, construction,

mason, fishing, sales, rag picking, street vending, head load work etc. were treated as

unskilled workers.

Semi skilled: Semi-skilled workers are those whose work requires some type of skill like

tailors, embroidery workers, weavers.

Skilled: Skilled workers are those workers whose work requires some sort of regular

training and skill which reflects in the quality of work done by them, like electricians,

welders, fitters, turners, plumbers and drivers of different motor vehicles.

Clerical/ shop/ farm: Clerk, shop owner, businessmen, farm or plantation owner.

government servants of class III category etc. were treated as the V category.

Semi professional: Semi - profession category includes school teachers, class I and

class II officers in Govt. services and companies.

Dietary habits:

a. Vegetarian –person who refuses to eat meat, fish, fowl, or, in some cases any food

derived from animal life

b. Non-vegetarian-persons who eat meat, fish or in some cases any food derived from

animal life.

Weight: Body weight of the subject was measured without any footwear and with minimal

clothing to the nearest 0.1 kilogram using a standard portable weighing machine and the scale

was zeroed before each session.

Height: Height was measured without any footwear using a standard calibrated bar. The

person stood straight and looking straight with heels, buttocks and back touching the vertical

limb of the instrument. The horizontal movable limb was then lowered until it touched the

head firmly and height was recorded to the nearest 0.1 centimetre.

Body Mass Index= Weight in kg (Height in meter)2

Diet History: Detailed account of dietary habits was collected from each subject. three days

dietary survey method was used for the estimation of total consumption of food item at

particular time of the day in terms of numbers and servings. Low consumption of fruits and

vegetables at less than five servings per day (one cup of raw leafy vegetables or half cup of

other vegetables (cooked) was considered one serving. One medium-sized piece of fruit or

half cup of chopped fruit was measured as one serving). Type and amount of cooking oil

consumed per month, and other fatty food intake like ghee, butter was also taken. This data

was converted to amount of calories, fat and proteins using standard conversion table. The

total calories and proportion of calories derived from fat and proteins was calculated.

Growth reference 5-19 years (WHO 2018)

BMI-for-age (5-19 years)

Interpretation of cut-offs

Overweight: >+1SD (equivalent to BMI 25 kg/m2 at 19 years) Obesity: >+2SD (equivalent to BMI 30 kg/m2 at 19 years) Thinness: <-2SD Severe thinness: <-3SD

References.

1. Blössner M, Onis MD. What is malnutrition? In: Üstün AP, Lendrum DC, Corvalán C,

Woodward A, editors. Malnutrition: quantifying the health impact at national and

local levels. Geneva: World Health Organization; 2005 p.1

2. Gupta DK, Maheshwari S, Shrotriya VP, Gupta SB, Singh AK, Kumar A,et al: A

Study on Prevalence of Malnutrition amongst Primary School; Children in a Rural

Area of District Bareilly- An Application of Poisson Regression. International

Journal of Health Sciences and Research. Sep 2015

3. Rawat R, Garg SK, Chopra H, Bajpai SK, Bano T, Jain S , Kumar A:Prevelence

of malnutrition among school children with reference to overweight and obesity

and its associated factors. Indian journal of community health. Jun 2012

4. Puranik SS. Nutritional status, Socio-economic- and hygienic condition of school

aged children of village of Pune District, Maharashtra. International Journal of

Medical Research & Health Sciences.2014; 3(3) DOI: 10.5958/2319-

5886.2014.00387.7

5. Singh JP, Kariwal P, Gupta SB, Singh AK , Imtiaz D. Nutritional status and

morbidity among school going children: A scenario from a rural India. Scholars

Journal of Applied Medical Sciences (SJAMS) 2014; ISSN 2320-6691

6. Gupta D, Maheshwari S, Gupta S, Shrotriya V, Singh A, Kumar A et al. An

anthropometric study on the primary school in a rural area of district Bareilly.

International Journal of Health. 2015;3(2):56.