RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PROFORMA FOR DISSERTATION SUBMISSION

BHANUPRAVA MALLICK 1ST YEAR M.Sc NURSING CHILD HEALTH NURSING 2010-2012

SEA COLLEGE OF NURSING K.R PURAM, BANGALORE-49 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

6. BRIEF RESUME OF THE INTENDED WORK 6.1 NEED FOR STUDY 1. NAME OF THE CANDIDATE BHANUPRAVA MALLICK AND ADDRESS 1 YEAR M.SC. (N) STUDENT SEA COLLEGE OF NURSING BANGALORE 49. NAME OF THE INSTITUTION 2. 3. COURSE SUBJECT OF STUDY AND M.SC. NURSING CHILD HEALTH NURSING ADMISSION TO 03-05 2010 SEA COLLEGE OF NURSING

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DATE COURSE

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TITLE OF TOPIC

AN EXPERIMENTAL STUDY TO ASSESS THE EFFECTIVENESS OF LOW COST HIGH PROTEIN DIET ON WEIGHT GAIN AMONG

MALNOURISHED CHILDREN, RURAL IN A

PRESCHOOL SELECTED AREA,

COMMUNITY

BANGALORE. Disease free young children are the pillars of our nation.

A nations health depends on healthy citizens. A healthy adult emerges from a healthy child.1 The concept of close association between diet and disease has been existing since ancient times in Indian history. Healthy eating maintains the childs physical wellbeing and boosts their immune system to assume that they will remain free from disease. Thus the health and nutrition of the child go hand in hand.2 India's economy is growing where its GDP growth is 9.0% from 2007 to 2008. The combination of people living in poverty and the recent economic growth of India has led to the co-emergence of two types of malnutrition: under nutrition and over nutrition. As we have entered the new millennium, the burden of new diseases in which nutritional deficiencies constitute a major public health problem in India and other countries of 3rd world and protein energy malnutrition is a biggest challenge our country is facing today. Child malnutrition is responsible for 22% of Indias burden of disease. Undernourishment not only an important cause of morbidity and mortality, but also leads to impairment of physical and mental growth and development of those who survive. Undernourishment also impairs immune function leaving them more susceptible to infection. It also costs lives. Recent data from the World Health Organization showed that about 60% of all deaths, occurring among children aged less than five years (under-five children) in developing countries, could be attributed to malnutrition. According to the 1991 census of India, it has around 150 million children, constituting 17.5% of India's population, who are below the age of 6 years. The World Bank, 2009 reports that child malnutrition is prevalent in 7 percent of children under the age of 5 in China and 28 percent in sub-Saharan African compared to a prevalence of 43 percent in India. 47 per cent are underweight and at least 16 per cent are wasted. 1 in 3 of the world's malnourished children lives in India.3

In Karnataka 37.6% of children are underweight 28.1% of the population is undernourished and 5.5% of children who die under the age of 5 die from hunger.4 In an article Assessing the nutritional status of children reports that the causes of PEM ranges from the physical, such as poverty, hunger and under nutrition, infection and diseases to poor governance mainly lack of health services of safe drinking water and hygienic sanitation and the socio cultural practices. Also this paper reveals that under weight prevalence is higher in rural area (50%) than urban areas (38%). It is logical therefore, that any strategy to combat malnutrition must begin from here.5 An article on Practical solutions for child malnutrition, reports that India has the largest nutrition programme in the world. There are many nutritional programmes like supplementary nutrition program, special nutrition program, and integrated child development services (ICDS) etc. Still we have the problem of PEM. Obviously, there is a great divide between the resources available and those actually acquired, between existing laws and their implementation and between rights and the tangible services provided. Dr Samir Chaudhuri, the founder of CINI Child In Need Institute, has come forward with sustainable approach to tackling child malnutrition having realized that giving out free food and supplies creates dependency and does not tackle the root of the problem. Dr Chaudhuri came up with Nutrimix, made of easily available, lowcost ingredients wheat and pulses -- which can be made at home and is easily consumed by young children.6 In a publication, Gujarat to promote finger millet cultivation. Recognizing the importance of ragi in beating undernourishment, the state finance minister Vajubhai Yala said ragi is a strong alternative to fight malnourishment in the state. The state government has proposed to promote cultivation and processing of ragi in the state so as to meet the challenges of malnourishment in the state.7

In India finger millet (locally called ragi) is mostly grown and consumed in Karnataka, Andhrapradesh, Rajasthan, Tamilnadu, Maharashtra and Goa. In Karnataka ragi is generally consumed in the form of ragi balls (ragi mudde in kanada).8 Ragi in its commonly consumed form as porridge. In south Karnataka, the regular meals consist of ragi, saaru, rice and yogurt. 9 In southern parts of India, paediatricians recommend finger millet based foods for infants of six months and above because of its high nutritional contents with calcium-3.4gms, iron-5.4gm, protein-7.3 gm, carbohydrate- 7.2gm, fat-1.3gm, fibre- 3.6gm, and kcl- 328 in each 100gm, digests easily from infancy through old age, and nutrients are highly absorbed, costs less than wheat, rice, or dairy milk, while delivering superior nutrition. It is a very nutritious cereal and if given in the right method, the impact of focusing in such diet that many people, not recognizing the value of their traditional home-grown, homemade food are choosing packaged foods made from refined wheat or rice.10 Hence the researcher feels there is a need to investigate with ragi porridge, which is locally available, culturally acceptable and cost effective in meeting immediate demands of protein and energy and also promote catch up growth. 6.2 Review of literature In a study conducted on prevalence of malnutrition in rural Karnataka South India to identify the prevalence of malnutrition among 256 children who attended the anganwadis. The study showed that the prevalence of wasting, stunting and wasting and stunting was 31.2%, 9.4% and 29.2% respectively. 11 A study on epidemiological study of malnutrition (under nutrition) among under five children in a section of rural area reports that Prevalence of

malnutrition is very high in India; especially in rural area. A cross sectional study was done in randomly selected six villages to estimate the prevalence of malnutrition. The prevalence of malnutrition among the under five children was 50.46%.Children from lower socioeconomic status .Out of 652 under five children studied, 329 were malnourished. The prevalence of malnutrition was 50.46%. 12 In an article Malnourished tribal children is there a way out? states that in Madhayapradesh the Korku community is one known for a high rate of malnutrition and deaths due to malnutrition. 85 deaths due to malnutrition and related diseases were reported in the state from March to September 2004.13 A study under taken on Morbidity pattern and its association with malnutrition in preschool children in desert areas of Rajasthan, India This study has been carried out in 17 villages of desert districts of Rajasthan, examining 834 preschool children. The prevalence of associated signs of protein calorie malnutrition (PCM) was observed to be significantly higher.14 In a study on Effects of weaning biscuits on the nutritional profile and the cognitive development in preschool children. A total number of 150 children were categorized in to 4 groups, about 80 primary school children with Grade II malnutrition were selected for the experimental study. Home diet without any supplementation was followed by Group I (control group), potato flour biscuits were supplemented to Group II, wheat biscuits were given to Group III and ragi biscuits were given to Group IV for the period of 3 months. Parameters like anthropometric measurements, haemoglobin content, clinical picture and cognitive performance were analyzed before and after supplementation. Results about Group I (control group) showed no significant difference in height, weight, clinical picture and cognitive performance after three months on their home diet. In Group II, III and IV significant

increase in all the above parameters was noticed. More increase was found in Group II children supplemented with potato flour biscuits. Also the study showed that for the overall acceptability the highest score 8.40 is obtained by potato biscuits followed by ragi biscuits with a score of 8.00 and least score are obtained by wheat biscuits with a score of 7.20.15 A study on effect of consuming quality protein maize or conventional maize on the growth and morbidity of malnourished Nicaraguan children 1 to 5 years of age. shows that Quality protein maize (QPM), with twice the amount of tryptophan and lysine than conventional maize, has improved the nutritional status of severely malnourished children. In a Nicaraguan day care centre, 48 children 1 to 5 years old who were malnourished (> 2 indicators with < -1 Z for weight-age, height-age or weight-height) were identified and randomly assigned to consume for 5 days/week for 3.5 months a snack prepared with QPM or conventional maize. QPM positively influenced children's growth: weight (0.80 vs. 0.19 kg gained from baseline to end line between the QPM and conventional maize groups, respectively), height (2.02 vs. 1.23 cm in QPM vs. conventional) and Z score for weight-age (0.17 vs. -0.26 Z in QPM vs. conventional) and height-age (0.06 vs. -0.23 Z in QPM vs. conventional). In conclusion, QPM improves the nutritional status of pre-school children who are mild or moderately malnourished but has no effect on the incidence of diarrheal episodes or respiratory infections.16 A study was conducted on Efficacy and effectiveness of community-based treatment of severe malnutrition, to examine the effectiveness of rehabilitating severely malnourished children in the community in nonemergency situations. A literature search was conducted of community-based rehabilitation programs delivered by day-care nutrition centres, residential nutrition centres, primary health

clinics, and domiciliary care with or without provision of food. Effectiveness was defined as an average weight gain of at least 5 g/kg/day. The study showed
that with careful planning and resources, all four delivery systems can be effective.

High energy intakes (> 150 kcal/kg/day), high protein intakes (4-6 g/kg/day), and provision of micronutrients, When done well, rehabilitation at home with family foods is more cost-effective than inpatient care.17 A study conducted on The High Density Diet (HDD) diet prepared with indigenous food items and is therefore inexpensive. Malnourished patients were inducted in three groups. Group A was given only high density diet (HDD) for 7 days and then given routine diet plus HDD for the next 7 days. Group B was given routine diet plus HDD for 14 days. Group C was given only routine diet for 14 days and was the control group. The results were best when HDD was used as a supplement to routine diet (group B), with average weight gain of 6gm/kg/day, where as in control group it was only 2.1gm/kg/day. The High Density Diet is hence, low in cost, easy to prepare at home by mothers and effective in bringing about rapid weight gain in malnourished.18 In a study on Evaluation of anthropometric indices of malnutrition in under five children.The authors compare common anthropometric measurements in an effort to determine which is the most suitable for the individual assessment of malnutrition. The efficiencies of anthropometric measurements in detecting malnutrition were compared on the basis of specificity, sensitivity, and predictive value. Weight, height, age, and mid-arm circumference measurements were taken for 163 children aged 5-60 months in a standard manner as recommended by Jelliffe. The entire population of preschool children in the selected area was surveyed. The study

identified using weight for age against body mass index as the best method of assessing malnutrition among various anthropometric measurements.19 Statement of the problem An Experimental Study to Assess the Effectiveness of Low Cost High Protein Diet on Weight Gain among Malnourished Preschool children, In a Selected Rural Community Area, Bangalore. 6.3 OBJECTIVES 1. 2. To assess the degree of malnutrition among the preschool children To assess the effectiveness of low cost high protein diet, by comparing pre-test and post test scores of experimental and control group. 3. To elicit the opinion from mothers regarding low cost high protein diet.

6.4 HYPOTHESIS H1- There is a relationship between low cost high protein diet and weight gain among malnourished preschool children. 6.5 Variables: Dependent variable-weight gain of malnourished children Independent variable: low cost high protein diet Demographic variables: boys and girls of age group of 3-5 years 6.6 OPERATIONAL DEFINITIONS

Experiment: In this study, an experiment is a method of investigating relationship between low cost high protein diet on weight gain or it is the method of testing the hypothesis i.e. there is a relationship between low cost high protein diet in

weight gain among malnourished preschool children. Assess: in this study, it refers to determination of the weight gain by low cost high protein diet among malnourished preschool children. Effectiveness: The significant weight gain among malnourished preschool children as measured by comparing pre test and post test weight scores in experimental group with control group. Low cost high protein diet: it is the porridge prepared by locally available, low cost cereal i.e. ragi with milk, jaggery. Weight gain: In this study weight gain refers to the increase in the body weight after providing low cost high protein diet. Preschooler: children between the age group of 3-5yrs. Malnutrition: in this study malnutrition refers to low weight for age that may result from varying degree of protein lack and calorie inadequacy 7.0 Materials and methods 7.1 Source of data The data will be obtained from malnourished preschool children and their parents by using anthropometric measurement and opinionnaries as per inclusion criteria. 7.2 Method of data collection

Research design: quasi experimental research design non equivalent control group design. Population: under five malnourished children Sample: malnourished preschoolers. Sample size: 60 nos Sampling technique: Purposive sampling 7.2.1 CRITERIA FOR SAMPLE SELECTION Inclusion criteria 1. 2. 3. 4. Children with 1st and 2nd degree of malnutrition Children between the age group of 3-5 years Children who are able to eat ragi Children in a selected rural community area

Exclusion criteria 1. 2. 3. 4. 5. Severely malnourished children Children <3 years and >5 years Malnourished children who are unable to eat ragi/allergic to ragi. Mentally challenged children Malnourished children with other physical illness

Setting: Selected rural community area, Bangalore.

7.2.2 Tool for data collection: The data will be collected using the tool consisted of Section A. consisting of two parts Part I- demographic variables Part II-anthropometric measurement (weight for age) Section B: Opinionnaires 7.2.3 METHOD OF DATA COLLECTION Malnourished preschool children will be selected by purposive sampling based on degree of malnutrition. The degree of malnutrition will be assessed by using anthropometric measurement based on Jelliffes classification of Protein energy malnutrition. Among 60 malnourished (with 1 st and 2nd degree malnutrition) samples, randomly selection will be done for experimental and control group. Ragi porridge will be given to the experimental group for 15 days. Post test anthropometric measurement will be taken in both the groups. 7.2.4 Plan for statistical analysis Data analysis will be done by using descriptive statistics like mean, standard deviation, frequency distribution and percentage will be used to assess the socio demographic variables. The inferential statistics like `T` test will be done to compare the pre test and post test score. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALS?

Yes, in the present study Ragi porridge will be given to malnourished preschool children for 15 days to assess its effectiveness on weight gain. 7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED? Yes, a written permission from the head of the community will be obtained. Consent will be obtained from parents before study. Confidentiality and anonymity of the subjects will be maintained.

8. 1.

LIST OF REFERENCES P. Muthumari. Effectiveness of structured teaching programme on protein energy malnutrition among mothers of under five children. Nightingale Nursing Times.2010 Jun; 6(3):61-5. 2. Jeyagowri Subash and S.Kamala. Mothers knowledge of protein energy malnutrition. Nightingale Nursing Times.2009 Apr; 5(1): 43 3. 4. .en.wikipedia.org/wiki/Malnutrition_in_India .en.wikipedia.org/wiki/Malnutrition_in_karnataka Veena S Rao. Assessing the nutritional status of children. Nightingale Nursing Times. 2009 Dec; 5(9):12 6. Shreya Sanghani. Practical solutions for child malnutrition info change children. 2010 Nov; 24. Available from: http://infochangeindia.org/201007138409/Children/Stories-of-change/Practicalsolutions-for-child-malnutrition.html

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7.

Gujarat to promote finger millet cultivation. Commodity online. 2010 Mar 3. Available from: http://www.commodityonline.com/news/Gujarat-to-promoteFinger-Millet-cultivation-26130-3-1.html

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Cuisine of Karnataka. http://en.wikipedia.org/wiki/Cuisine_of_Karnataka Finger millet. http://en.wikipedia.org/wiki/Finger_millet Ragi...a wonder grain. Available from: http://aidindia.org/main/content/view/459/354/

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11.

Joseph B, Rebello A, Kullu P, Raj VD. Prevalence of malnutrition in rural Karnataka, South India: a comparison of anthropometric indicators. J Health Popul Nutr. 2002 Sep; 20(3): 239-44. Available from http://www.ncbi.nlm.nih.gov/pubmed/12430761

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Shubhada S. Avachat, Vaishali D. Phalke, Deepak B. Phalke epidemiological study of malnutrition (under nutrition) among under five children in a section of rural area. Pravara Med Rev 2009; 4(2): 20-22. Available from: http://www.pravara.com/pmr/pmr-4-2-5.pdf

13.

Sr.Rose Chavian Vachaparampil. Malnourished tribal children-Is there a way out? Health action. 2009 Oct: 28

14.

Madhu B. Singh, K. R. Haldiya and J. Lakshminarayana. Morbidity pattern and its association with malnutrition in preschool children in desert areas of Rajasthan, India. Journal of Arid Environments. 2002 July; 51(3): 461-468: doi:10.1006/jare.2001.0944. Available from: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WH946T37WS-

B&_user=10&_coverDate=07/31/2002&_alid=1471389530&_rdoc=7&_fmt=hi gh&_orig=search&_origin=search&_zone=rslt_list_item&_cdi=6845&_sort=r& _st=13&_docanchor=&view=c&_ct=2554&_acct=C000050221&_version=1&_ urlVersion=0&_userid=10&md5=291f9dd418e24c14fd207930883626fe&searc htype=a children and prevalence 15. Peerkhan Nazni, Subramanian Pradheepa and Abul Hasan. Effects of weaning biscuits on the nutritional profile and the cognitive development in preschool children. Italian Journal of Paediatrics. 2010 Feb; 36: 18. Doi: 10.1186/18247288-36- 718. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2830220/ 16. Ortega Alemn Edel C, Coulson Romero AJ, Ordez Argueta LI, Pachn H. The effect of consuming quality protein maize or conventional maize on the growth and morbidity of malnourished Nicaraguan children 1 to 5 years of age. Arch Latinoam Nutr. 2008 Dec; 58(4): 377-85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19368299 17. Ann Ashworth. Efficacy and effectiveness of community-based treatment of severe malnutrition. SCN Nutrition Policy Paper No. 21. Available from: http://www.who.int/nutrition/publications/severemalnutrition/FNB_03795721.pdf#page=24 18. Bharmal FY, Akram DS. Rehabilitation of P.E.M. children. Indian J Pediatr. 2001 Nov; 68(11):1031-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11770236 19. Mohanan P, Kamath A, Motha B, Philip M. Evaluation of anthropometric indices of malnutrition in under five children. Indian journal of public health.

1999 Jul-Sep; 38(3): 91-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7774975

Signature of the Candidate

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Remark of the Guide

Considering the ragi porridge as low cost high protein diet in related to weight gain will us for better diet practices in reducing malnutrition.

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Name and Designation Guide Signature Co-guide

Prof. G. Priscilla Nirmal HOD, Child Health Nursing

Ms. N Subavathy Lecturer

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Signature

12.1

Remark of Chairman or Principal

Study on effectiveness low cost protein diet will help health personnel to modify diet for low socio economic background.

12.2

Signature