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ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 122-128

Assessment of the effect of nutrition on academic performance in primary school students in Dangriga Belize


1 Department of Public Health, Texila American University, Guyana
2 Department of Public Health, Jackson State University, Jackson Mississippi, USA
3 Department of Public Policy and Administration, Jackson State University, Jackson Mississippi; Department of Pathology and Laboratory Medicine Service, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA

Date of Submission20-Apr-2021
Date of Acceptance20-May-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Udensi K Udensi
Pathology and Laboratory Medicine Service, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way (S 113), Seattle, Washington 98108
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njecp.njecp_10_21

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  Abstract 


Background: Malnutrition is a serious problem among children in developing countries and undernutrition negatively affects child development and academic performance. Methods: A cross-sectional study was done in six primary schools in Dangriga, Stann Creek Region of Belize, involving children (5–12 years) to assess malnutrition prevalence and determine if there is a relationship between nutritional status and academic performance. About 353 students were surveyed at a confidence level of 95%, with a 5% margin of error. Mathematics and English scores were recorded and compared between the groups. Results: A positive relationship was found between weight for age Z-scores and English and Mathematics; Height for age Z-scores with English. Conclusion: This study did not establish a conclusive positive relationship between several indicators of students' nutritional status and academic performance in English and Mathematics.

Keywords: Academic performance, Belize, malnutrition, nutrition, school meal, Z-scores


How to cite this article:
Onyia EN, Onyia AU, Udensi UK. Assessment of the effect of nutrition on academic performance in primary school students in Dangriga Belize. Niger J Exp Clin Biosci 2021;9:122-8

How to cite this URL:
Onyia EN, Onyia AU, Udensi UK. Assessment of the effect of nutrition on academic performance in primary school students in Dangriga Belize. Niger J Exp Clin Biosci [serial online] 2021 [cited 2021 Dec 4];9:122-8. Available from: https://www.njecbonline.org/text.asp?2021/9/2/122/323666




  Introduction Top


Belize is located on the eastern coast of Central America. It shares a border with Mexico to the North, Guatemala to the West and South, with the Caribbean Sea to the East.[1],[2] The total land area of Belize is 22,700 km2. The country has a culturally diverse population estimated at 380,010 (170,397 males and 170,395 females), according to the Statistical Institute of Belize.[3],[4],[5] Belize comprises six administrative districts: Belize, Cayo, Corozal, Orange Walk, Stann Creek, and Toledo.[4],[6] The Belize Multiple Indicator Cluster Survey is the part of the United Nations Children's Fund (UNICEF)-Government of Belize Program of Cooperation to monitor the progress of boy's and girl's development in Belize.[7] According to the Statistical Institute of Belize, 2016, children between 0 and 14 years make up 34.41% of the Belizean population (male 62,139/female 59,611).[4],[5],[6] About 49% of all children in Belize live below the poverty line.[5]

Nutritional status is an indicator of a balance between the intake of diets required by the body and the outlay of the nutrients in the maintenance of normal metabolic activities. It is defined as the intake of dietary products enough to maintain or exceed the daily body requirements. The nutritional status indicators include anthropometric measurements, biochemical tests (laboratory tests), clinical indicators, and dietary assessments.[8],[9] Undernutrition increases susceptibility to infection and disease. In 2015, 156 million children under five were estimated to be stunted (too short for age), 50 million were said to be wasted (too thin for height), and 42 million were overweight or obese worldwide. About 5.9 million children under the age of 5 years died in 2015. Moreover, 45% of child deaths are attributed to undernutrition.[10],[11] A World Health Organization (WHO) report shows that about 6 million children die each year from malnutrition-related conditions. However, most of the deaths in children below 5 years old occur in developing countries.[11] Undernutrition increases susceptibility to infection and disease. According to the World Bank reports, half of all children under 5 years of age in South Asia and one-third of those in sub-Saharan Africa are malnourished.[12] In Belize, malnutrition prevalence among children under 5 years was reported at 19.3% in 2011. Due to nutritional deficiencies and anemia in children between 1 and 4 years of age, death was 5.3% in 2011, decreasing from 11.4% in 2008.[6],[10] Since the prevalence of malnutrition and its effects has the most significant impact on this demographic group, the study of their nutritional status will be of utmost importance, and observations and conclusions will guide policy-makers in deciding the type and extent of nutritional intervention that may be necessary. While appreciable studies have been carried out on children from 0 to 5 years, not much has been done for 5–19 years.[9]

Having adequate and balanced nutrition ensures proper organ development and functioning infants, builds a healthy immune system, and enhances neurological and cognitive development. A nation's economic growth and development of human resources requires a healthy and well-nourished population that can think critically and acquire new skills to make meaningful contributions to society.[9],[13] According to a UNICEF 2006 Multiple Indicator Cluster Surveys in Belize, the national malnutrition rate among children under 5 is 18%, with a reported 44% among the indigenous population.[7] About 2.8% of children under 5 years seen in health clinics in 2005 were obese. Belize District had the highest percentage (36.4%), and Corozal District, the lowest (4.4%). In the rural areas, the severity of malnutrition was higher for females than for males, while in the urban areas, it was about equal.[9]

The government, through the Ministry of Education (MoE), launched School Feeding Program (SFP) as a national effort to reduce child malnutrition and provide elementary school students with adequate food to enable schoolchildren to develop their physical and intellectual capacities.[14] The SFP was strengthened in Belmopan on November 16, 2017 when it became an inter-ministry venture. The Ministry of Agriculture signed a memorandum of understanding, Fisheries, Forestry, the Environment, Sustainable Development, and Immigration, in collaboration with the MoE, Culture, Youth and Sports, the Ministry of Health, and the Mexican Agency for International Development Cooperation.[14] This led to the formation of The National Sustainable School Feeding Technical Committee with the support of the Food and Agriculture Organization of the United Nations,[15] UNICEF, Belize, Pan American Health Organization Belize, and Institute of Nutrition for Central America and Panama.[16]

This study evaluates the prevalence of malnutrition in primary school children (5–12 years) in Dangriga, Belize, to help determine the relationship between malnutrition and academic performance. Several studies in other countries have found a positive correlation.[17],[18],[19]


  Methods Top


A cross-sectional study was done in six primary schools in Dangriga, Stann Creek of Belize. The study population consisted of students from standard 1 to standard 6 of select schools. From the 1958 students, a sample of 353 was surveyed at a confidence level of 95% with a 5% margin of error. Parents gave informed written consent for the study. Anthropometric parameters such as age (date of birth), height, and weight were used to calculate the body mass index (BMI) of each student surveyed.[20],[21] Nutritional status indicators such as weight for age (WFA) and height for age (HFA) were calculated and used in conjunction with the BMI to determine the nutritional status.[22] The WHO Anthro Plus software was used to calculate BMI, HFA, and WFA and the standard deviation (SD) for each parameter. The Chi-Square and Odd ratios were calculated using the Wikipedia odds ratio (OR) tool. Survey assistants were pretrained for the collection of data. Information on the age of the students was collected from the school records. English and Mathematics scores from the previous two class tests were recorded. The average percentage of scores was calculated. Height, weight, and BMI were measured for all the study participants. Height was measured using a stadiometer and scale. A weighing scale was used to measure weight. Height was recorded to the nearest 0.1 cm, and weight was recorded to the nearest 0.1 kg. BMI was calculated using the following formula BMI = kg/m2. Participants were examined for edema.

Data processing and analysis

BMI is the weight of a child or adult in kilogram (kg) divided by their height in meters squared: Weight (kg)/Height (m2). The actual height, weight, and BMI were transformed to Z scores using the Anthro + package of WHO. The WHO “Z” score charts categorize weight for age Z (WAZ), height for age Z (HAZ), and BMI for age Z scores into < −3 SD, −2 to −3 SD, Normal, and >2 SD. WAZ < −3 SD implies severe undernutrition; −2 to −3 SD signifies mild to moderate undernutrition, and > −2 SD implies normal/healthy status. In the HAZ case, < −3 SD implies severe stunting, −2 to −3 SD signifies mild to moderate stunting, and > −2 SD implies normal status. In the case of BMI < −3 SD implies severe thinness, −2 to −3 SD signifies mild to moderate thinness, > −2 SD was normal, and >2 SD suggests obesity.[22] The indicators of underweight and malnutrition in children used in this study are shown in [Table 1]. Mathematics and English percentage scores were categorized into percentage scores <65% (considered below Average in Belize) and 65%–100% (considered average/above average in Belize) for the statistical analysis. Chi-square tests, Odd's ratio, and Chi-square for trend tests were used for the statistical analysis. P <0.05 was considered statistically significant. An expert Committee led by Barlow was constituted to review and revise the 1998 recommendations on childhood obesity. The special committee was to develop new approaches to prevent, understand, assess, and treat childhood obesity.[23]
Table 1: Indicators of underweight and malnutrition are derived from the weight and height of children relative to their age

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  Results Top


A total of 353 students were surveyed in this study, comprising males 48% (169) and females were 52% (184), as shown in [Figure 1] and [Table 2]. [Table 2] also showed that 7% of boys and 9% of girls were underweight. As shown in [Figure 2], 22% of the boys and 23% of the girls were overweight, whereas 7% of the boys and 11% of the girls were obese.
Figure 1: Distribution of male and female participants in the study

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Figure 2: Prevalence of overweight and obesity by sex

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Table 2: Summary of children's body mass index-for-age

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The schools surveyed had more girls than boys, as reflected in [Figure 1].

[Figure 2] shows that 11% of the girls and 7% of the boys surveyed were obese.

[Table 1] summarizes how indicators of underweight, wasting, and malnutrition are derived from the weight and height of children relative to their age, with the cutoff values (column 2) for each indicator (column 1) based on the SD of the child's measurement from the norm for a child of that age.

Only 8 (2%) of the children had pallor and 22 (6%) had stunting growth. [Table 3] illustrates the nutritional status of the children, and 18 (5%) fell within the undernutrition category, 14 (4%) were too thin for their age, and 51 (14%) were found to be obese. Furthermore, 9 (2.6%) had mild to moderate thinness with a (BMI < −2 SD) and 5 (1.4%) were severely thin while 51 (14%) (BMI < −3 SD) were obese (BMI >2SD).
Table 3: Nutritional status of students

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The mathematics percentage scores were compared with the WAZ scores, as shown in [Table 4]. A positive relationship was found between weight for age Z-scores and Mathematics scores. However, decreasing WAZ scores did not cause a decrease in mathematics percentage scores. Moreover, the P = 0.76, and the critical value was higher than the test statistic.
Table 4: Weight for age Z scores versus math percentage scores

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In [Table 5], the WAZ scores v/s English percentage scores were compared with those of the normal students. A positive relationship was observed between the WAZ scores and English language scores. There was a declining trend with the OR. This suggests that the nutritional status deteriorated with English percentage scores. However, no statistically significant association was found between WAZ Z scores and English language percentage scores.
Table 5: Weight for age Z scores versus English percentage scores

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[Table 6] illustrates the height for age Z scores v/s Mathematics percentage scores. The OR showed a declining trend when the height for age Z (HAZ) scores were compared with the Mathematics percentage scores. A decrease in the HAZ score was associated with a reduction in mathematics score/, but the association was not statistically significant at P = 0.12.
Table 6: Height for age Z scores versus mathematics percentage scores

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The same methods were used in [Table 7] for height for age Z scores VS English percentage scores. The table shows that 67% of students have mild to moderate stunting at P = 0.17. No specific trend was found when HAZ Z-scores were compared with English scores. English scores were not significantly affected by a drop in HAZ Z scores.
Table 7: Height for age Z scores versus English percentage scores

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[Table 8] shows the comparison between BMI Z scores and Mathematics percentage scores. The OR did not show any particular trend, and a reduction in BMI Z score is not associated with a decrease in mathematics scores [Table 8].
Table 8: Body mass index Z scores versus mathematics percentage scores

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[Table 9] illustrates the BMI Z scores v/s English percentage scores. Here also, there was no clear trend in the OR ratio. The test statics shows that BMI Z scores do not affect performance in English tests. Although there is a positive association, it is not statistically significant.
Table 9: Body mass index Z scores versus English percentage scores

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  Discussion Top


A cross-sectional study was carried out to assess the prevalence of malnutrition among school children in Dangriga Belize and determine if there is a relationship between nutritional status and academic performance. The results showed a low prevalence of malnutrition among children in Dangriga schools. Unlike other studies such as Rashmi et al. 2015,[22] Kleinman et al. 2002,[24] Ghosh and Bhattacharya 2013,[25] and Ross 2010,[17] this study did not establish a conclusive positive relationship between several indicators of nutritional status and academic performance of students in English and Mathematics. This observation agrees with Nyaradi et al., who found inconclusive evidence associating obesity and cognition.[26] Socioeconomic status significantly contributes to academic performance, similar to what was observed in adult graduate students.[6] A study has demonstrated an association between diet quality and academic performance and identified specific dietary factors contributing to this association.[27]

[Table 4] shows that weight is less likely to affect the students' mathematics scores under study because the P values compared with the normal students were not significant. However, obese and underweight students are less likely to score pass marks in Math than normal students. [Table 6] showed no significant difference between the performance of normal growing students and above-average developing students. However, the Math scores were affected by stunted growth. Students who are fast-growing are 2.2 times more likely to pass Math than normal students. [Table 5] shows that weight is not a severe factor in English test scores. Comparing the study groups with the normal students' group shows that any observed deviations are not statistically different. However, some over-weight students have odds of 1.1 times to score a passing grade in English than normal-weight students in the study. Although stunted growth was expected to affect English scores, it was not statistically significant when compared with normal growing students, as shown in [Table 7]. Furthermore, normal students are to score passing grades in English than students with abnormal growth tendencies. [Table 8] and [Table 9] show the comparisons between normal students and others in the Math and English scores, respectively. Both tables show that Math and English scores are not significantly affected by the students' BMI under study. The low level of malnutrition observed among the students could be attributed to the Belize MoE's feeding program in 2013 in the South Side of Belize City, which has been replicated in other parts of Belize, including Dangriga.[14],[15]

The WHO convened an Expert Committee to reevaluate anthropometry use at different ages for assessing health, nutrition, and social well-being. Growth monitoring is the single most helpful tool for defining health and nutritional status in children at individual and population levels. This is because disturbances in health and nutrition, regardless of their etiology, almost always affect growth.[20],[21] A previous study among school children in Egypt suggested that irregular eating habits such as missing breakfast cause students to lack concentration and thus poor performance. The teachers did not blame malnutrition (in this case, low body weight) as the cause of low academic performance. However, the lack of food leads to malnutrition. However, some underweight students outperformed some healthy and obese students.[28],[29] It is concluded that proper school-feeding programs and nutrition education programs could help improve student's physical and cognitive health, especially when the government, teachers, and parents are involved in the process.[26],[28]

Previous studies on children's nutritional status <5 years in Belize reported that 7.3% were undernourished, 17.9% were stunted, and 11.3% were overweight. Contrasting patterns of nutrition status were seen in the Belize and Toledo Districts. In Belize District, more children showed signs of being over-nourished. However, there are few children exhibiting symptoms of undernutrition. Children in Toledo had the highest levels of undernutrition manifested by stunting or low height for age. Reported also is the tendency of children in the urban area to be taller and overweight than those in rural areas. There were no significant differences among ethnic groups. Maya children were more stunted than other ethnic groups. There was evidence that stunting increased with age and revealed the prevalence of wasting (low weight for height) among children less than 24 months.[9]


  Conclusion Top


We could not conclude from this study that nutritional status is the sole cause of students' low academic performance. Further research to understand other factors contributing to students' low academic performance from Dangriga Education District compared with other regions in Belize is needed. According to the UNICEF report on India, the attendance to early childhood education has soared from 31.7% in 2011 to 54.8% in 2015.[30] This could be possible in Dangriga Belize if the same approach is adopted. There is a strong indication that early child school attendance and malnutrition will improve due to strong government support and involvement. Since food insecurity is a determinant of health, improved SFPs such as providing healthy breakfast and parents' involvement in their children's education could help improve academic performance.

Ethical considerations

A letter of consent was sent to the district education officer, and upon approval, a letter of informed consent was sent to the principals of the selected schools. Also, the permission of the parents of the students to be sampled was obtained. Numerical ID will be used to tabulate English and mathematics test scores to maintain privacy and confidentiality.

Limitations of the study

It was difficult to sample the entire students in Dangriga; hence, a randomly selected sample size was used. Furthermore, the number of assistants and the required training made it difficult to attain the maximum sampling. Although the sampling was randomly done, there may have been some biased elements in picking the students. The school principals and teachers were relied upon in scheduling the survey to minimize class time loss for the children, which inevitably prolonged the survey periods. There is limited information on nutritional statistics in Dangriga and no official records of nutritional assessment of children between the age group of 5 and 19 years.

Acknowledgment

We acknowledge the District education officer Dr. Tanya Nunez for the approval to carry out this survey in the primary schools under her jurisdiction and the staff of the district education office Dangriga for the information provided. We also thank the principals, teachers, and students of Dangriga's primary schools for cooperating during sample collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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