ASSESSMENT OF NUTRITIONAL STATUS OF THE FARM FAMILIES WITH SPECIAL FOCUS ON PRIMARY SCHOOL CHILDREN IN PAKISTAN

Purpose of the study: The main purpose of this study was to assess the nutritional status of farm families with a special focus on primary school children in Punjab. Methodology: This study was conducted in tehsil Jaranwala, Faisalabad. Five villages and two primary schools were selected from each village randomly. From these schools, 323 children whose fathers were farmers were selected as samples. A cross-sectional research design was used for the present study. In this context, an interview schedule was prepared and face-to-face interviews were administered to collect the required data. Main Findings: The chi-square analysis confirmed that education, and income of parents associated factors had a statistically significant (P<0.05) and positive correlation with BMI. Descriptive statistics indicated poverty was ranked 1 st among reasons for malnutrition followed by inappropriate dietary choices and unavailability of healthy foods with mean values of 4.25 and 4.11, respectively. Whereas, children don't want to come to school due to poor health" was ranked 1 st in all effects of poor health with a mean value of 4.50. Applications of the study: This study has highlighted the importance of the nutritional status of primary school-going children and also investigates the different factors that inverse impact on their health. This study will be proved helpful among farm families by creating awareness about the nutrition of children. Based on the findings of this study, the urge to the government to take steps to improve the literacy level and build strategies to improve the awareness level of mothers about the nutrition of children, especially in rural areas. The novelty of the Study: This is the first study that investigates the assessment of the nutritional status of school-going children of farm families in Punjab, Pakistan especially in tehsil Jaranwala, Faisalabad.


INTRODUCTION
A balanced diet is a prerequisite need of every human being, as described in the "convention on children's rights." It is very important for every individual, especially for children, to be free from poverty and hunger to be physically fit and maintain better mental health (Neumann et al., 2004;World Bank Report, 2012;Joshi, 2012). But in Asian countries such as Pakistan, India, and Sri Lanka, microscopic nutrition is the leading cause of malnutrition among farm women and in their children (Raza et al., 2019). Malnutrition affects the physical and cognitive development of children (Ahami et al., 2020). It has longterm adverse effects on children particularly in middle and low-income countries (Umeokonkwo et al., 2020). It has longterm consequences on children leading to adolescence (Adetunji et al., 2019;Bansal, 2017).
It is an estimated about 38.2 million children under the age of 5 years were malnourished. At the same time, malnutrition is a severe problem that is silently increasing worldwide and causing about 3 lac deaths of children every year (WHO, 2020; Chattha et al., 2019). Pakistan is a country in transition and now facing both problems of overnutrition and undernutrition (Galal, 2002).
Large family size, early marriages, higher birth rate, low income, and lack of breastfeeding and exclusive breastfeeding were major reasons for malnutrition in children (Asim, 2018). Research revealed that nutrient deficiencies and poor health in children of primary school age are the main reasons for low enrolment in schools, low-level classroom performances, high absent rates, and early dropouts (Muller and Krawinkel, 2005). The effects of long-term malnutrition on children's health and physical well-being are as follows: delay in child's motor skills development and low physical growth, decreased I.Q. level, growing behavioral problems, lack of social skills, and more chances of getting sick (Black et al., 2003;Zengin and Karatas, 2019).

Data analysis
After the data collection, data were further investigated and interpreted to draw conclusions and make essential recommendations. The most suitable statistical methods engaged in computing the several values and their analysis were pronounced. Descriptive and inferential statistical tests were used with the help of the Statistical Package for Social Sciences (SPSS) to find out results and draw a conclusion.      Figure 2 displays 30.6% of the respondent's household income was less than 10,000. One-third of the respondent's household income (35.8%) was between 10,001 to 15000. Figure 3 indicates that a small proportion of students (2.8%) and (5.3%) of age 4-5 five years and 8-9 years respectively. The majority of the respondents had the age of 10-11 years old while less than one-fifth (15.7%) was aged 6-7 years and almost 23.1% of the respondents were above 11 years. Less than onethird (28.4%) had 2¬-3 siblings and one-third (35.2%) had 4-5 siblings. A small proportion of respondents (4.6%) had more than 7 siblings. Some respondents with 6-7 siblings were found 13.3% as presented in figure 4. Whereas, Figure 5 illustrates that 33% (107) of the mothers having passed primary and 25% (81) had studied up to matric. An only a small proportion of mothers (4.6%) had qualified above graduation. More than one-fifth of respondent's mothers (22.2%) were illiterate. Out of 323 respondents, only 14.8% of respondent's mothers were graduates. Mahmood et al. (2016) associated malnutrition of children with mothers' education as the prevalence of malnutrition was higher in children of mothers with no or deficient level of education. Figure 6 shows the father's education of respondents. Less than one-fifth (15.7%) of the fathers were illiterate. More than a third of the respondents were primary pass, which was 37.7% (122). Only a small proportion of fathers (10.5%) were qualified above graduation level, and less than one-fifth (17.6%) were qualified. Figure 6 also confirmations that less than one-fifth of the respondents (18.2%) were matric pass. Babar et al. (2010) stated that father education is an important determinant and positively impacts a child's nutritional status.  The gamma Value (.03) shows a positive correlation between mother qualification and BMI. The chi-square value (35.438) shows a significant relationship between mother qualification and BMI. The table shows that 33.3% of the illiterate mothers were underweight, 50% had normal nutritional status, while 8.3% and 8.3% of children of illiterate mothers were at the risk of being overweight and overweight, respectively. 68.2%, 74.1%, and 80% of children of the primary pass, matric pass, and above graduate mothers showed normal nutritional status. The gamma Value (.023) shows a positive correlation between household income and BMI. The chi-square value (96.284) shows a significant relationship between household income and BMI. Table indicated that 49.5% of children with a monthly household income of less than 10,000 had normal nutritional status, 33.3% were underweight and only 2% were found to be overweight. Prevalence of being overweight was found more in children. Prevalence of being overweight was found more in children who had a monthly household income of above 25,000 rupees as no child was found overweight whose monthly household income was 10,001 to 25000 rupees while 29.2% children were found overweight having a household income above 25,000 rupees. No child was found underweight whose monthly household income was above 25,000 rupees, while only 18.2% of children were underweight whose monthly household income was between 20,000 to 25,000 rupees. Consumption of teas was found at number one among all the food items that children take for breakfast, with a mean value of 3.70. The paratha was found in 2 nd place among all the food items taken by primary school children for breakfast with a mean value of 3.54. Biscuits/ cakes and rusk were ranked 3 rd among food items with a mean value of 3.47. Egg, pickle, and roti were ranked 3 rd , 4 th, and 5 th among food items with mean values of 3.06, 2.78and 2.58, respectively. Buttermilk, bread, and fruits were ranked 6 th , 7 th, and 8 th among food items with mean values of 2.37, 2.27, and 1.59 respectively. Different types of junk foods were ranked 1-10. The samosa was ranked 1 st among all junk foods eaten by children with a mean value of 3.20. Chips were at 2 nd position with a mean value of 2.75, followed by fitters with a mean value of 2.50.

Demographic characteristics
Chocolates and sweets were in 5 th and 6 th place among junk foods eaten by primary school children with a mean value of 1.66 and 1.59. Pizza was the last number among junk foods eaten by primary school children understudy with a mean value of 0.75. Junk foods have low or no nutritional value, and eating junk foods is increasing very rapidly in Pakistan. Children like to eat junk food due to its taste and the easy availability of these types of foods around the schools. Junk foods are the main cause of obesity and chronic diseases in children. 1=Never, 2=Rarely, 3=Sometimes, 4=Very Often, 5=Always Dairy products are an important source of protein which is a necessary element of the diet. Different types of dairy products were ranked 1-6. Tea was ranked 1 st among dairy products consumed by primary school children with a mean value of 4.08, followed by yogurt and milk with mean values of 3.40 and 3.21, respectively. Buttermilk was ranked 4 th in dairy products eaten by children with a mean value of 3.09. The cream was ranked at the last number among dairy products eaten by children with a mean value of 1.65. Apart from these dairy products, some other dairy products were ranked 5 th in the list with a mean value of 1.89.  Different types of meats eaten by primary school children were ranked 1-6. The chicken was ranked 1 st among animal meat consumed by primary school children with a mean value of 2.39, followed by fish with a mean value of 1.09. Beef, mutton, desi chicken, and other types of meats were ranked at 3 rd , 4 th , 5 th, and 6 th in the list with mean values of 1.00,0.80, 0.55, and 0.30, respectively. Meats such as chicken, beef, and mutton are all rich in protein. A balanced diet includes protein from meat. Red meat is the source of iron and different essential vitamins. The table indicates the nutrition status of children under study. Out of 323 children whose BMI was determined, 63% fall in the 5 th to 85 th percentile range of CDC growth charts which means they had normal nutrition status. 25.3% were below the 5 th percentile and 8.6% were between 85 th to 95 th percentile range which means 25.3% were underweight and 8.6% were at the risk of being overweight. Just less than 3% were found overweight as they fall in more than the 95 th percentile. 1=Strongly Disagree,2=Disagree,3= Neither disagree nor agree,4=Agree,5=Strongly Agree Different reasons for malnutrition were ranked 1-6. The above table indicated that poverty was ranked 1st in reasons of malnutrition with the mean value of 4.61 followed by Inappropriate dietary choices with a mean value of 4.25. Unavailability of healthy food was ranked at 3 rd position with a mean value of 4.11. Lack of awareness about healthy food, lack of access to healthy food, and parental other preferences were ranked at 4 th ,5 th, and 6 th positions with mean values of 2.80, 2.68, and 1.72, respectively. Poor health condition affects the educational performance of children. A different factor of poor health was rank 1-8. It is depicted from the table that "children don't want to come to school due to poor health" was ranked 1 st in all effects of poor health with a mean value of 4.50. "Children feel tired at school" and get poor grades due to poor health" were ranked 2 nd and 3 rd in effects of poor health with mean values of 4.19 and 3.98. Poor health also causes by the absence of children from school and "miss the school due to poor health" was ranked 4 th in effects of poor health with a mean value of 3.69. Children also lost interest in studies due to poor health and results showed "lost interest due to poor health" was ranked 5 th with a mean value of 3.59. Children also felt it difficult to do homework due to poor health and its mean value was 3.55 on the table, which meant children often found it difficult to do homework due to poor health. Mean values of "leaving the school due to poor health" and "miss the class due to poor health" was 3.32 and 2.56, respectively, and were ranked at 7 th and 8 th number.

CONCLUSION AND RECOMENDATIONS
Children under 15 years of age are mostly affected by malnourishment. Unhealthy dietary habits and ignorance about the proper eating schedule of farming families are important considerations that cause malnutrition. In a developing country like Pakistan, poverty, lack of government support and illiteracy are the leading causes of malnutrition in farming families. Natural disasters and warfare are also included in this list to increase malnutrition. Malnutrition leads to severe diseases and morality, especially in infants and adolescents, and puts extra pressure on a farming family's already minimal resources. Despite the increase in awareness about nutrition in Pakistan, for last few decades, there is still no major improvement regarding nutrition in villages, especially children of farming families with little or very little awareness about nutrition. Farm families were lower socioeconomic status, large family size, food insecurity and low literacy rates that are the leading causes of malnutrition This study recommended that social, economic, political changes and personal education are required to improve the nutritional status of school-going children.

LIMITATIONS AND FUTURE THRUST
This study was conducted in one district due to financial and time constraints. The current research would provide an indepth analysis of nutritional status of local students and the findings can be used for the policy level recommendations and for real benefits to the local district as well as other districts of Punjab.

AUTHOR'S CONTRIBUTION
Mr. Hussain Sardar conducted this research, Dr. Rana Muhammad Amir supervised this research, and others all authors are equally contributed to this research.