17 Health and Nutrition Education

Dr. Meenal Dhall

Introduction

Health is an important resource that needs to be maintained amend protected. In order to achieve this, all aspects of health that influence it must be given due attention. The health of individuals and populations is affected by various factors such as poverty, income inequality, education, nutrition, employment, housing, gender and social network. On the basis of these factors, there are widespread inequities in health within and between societies (Kelly et al 2007).The social factors have a direct impact on health status and maybe addressed as part of any comprehensive health plan. Education is strongly linked to health and to determinants of health such as health behaviours, risk factors and preventative service usage. Education is important for enhancing the health and well-being of individuals as it reduces the need for health care, the associated costs of dependence, and suffering. It also helps encourage and sustain healthy lifestyles and positive choices, supporting and nurturing human development, human relationships, and personal, faily, community and society well-being. There are many structural and functional changes influencing the health status of an individual at different stages of life. For instance there is a decline in stature with increase in age irrespective of altitude (Tandon&Kapoor 2003), gender (Tyagi Kapoor 2004), ethnicity (Tyagi Kapoor 1999, Kapoor et al 2009) etc. There is a decline in functional health status with age that has been evidenced by declining lung function and muscular strength influencing the quality of life (Tyagi Kapoor 2004; 2010). There is an age associated increase in fat mass and a decline in skeletal muscle (Santana et al 2001; Ross 2003). Many health parameters including adiposity, lung functions, muscular strength and blood pressure are reported to be inter linked with each other. Physiological changes which occur slowly over time in all body systems are influenced by life events, illnesses, genetic traits and socioeconomic factors. The sensory changes including a decline in sight and peripheral vision, hearing, smell and taste, affect nutritional intake and hence health status of an individual. Strategies need to be tailored to the diverse and evolving health needs of each community considering its specific social, economic and cultural contexts. The nutritional requirement of an individual keeps changing according to the stage of development as explained in Module 28. Now we know that appropriate food and good nutrition through infancy, childhood, adolescence, adulthood and old age, are important, for physical growth, mental development, performance, health and well-being at each life stage. Research evidences advocate that the education helps to provide better job market opportunities, good health, greater sense of political awareness, and increased gender equality (Friedman et al 2011). This module has been prepared with an objective to study the health education and importance of nutrition education towards health and well-being at different stages of life. Some nutrition interventions have been explained. The paper concludes with some relevant suggestions towards a healthy and quality life.

Health Issues

Poor nutrition prevents children from reaching their full cognitive and behavioural potential, thus influencing their lifetime learning. Some childrennever get enrolled in school because of severe health problems resulting from poor nutrition.There are more than 200 million children worldwide who fail to reach theirpotential in cognitive development due to early poor nutrition, inadequate health care, and poverty (Grantham-McGregor et al. 2007).Good nutrition is crucialfor full development of cognitive and motor skills, behavioural abilities, and physical growth of an individual. Some of the micronutrient deficiencies, predominantly iodine and iron, can lead to significant and irreversible cognitive damage (Engle et al., 2007).Malnutrition can leads to additional health problems and deprivation. Malnutrition can create and perpetuate poverty, which hampers economic and social development, and contributes to unsustainable resource use and environmental degradation (WEHAB, 2002). It commonly affects all groups in a community, but infants, young children and pregnant women are the most vulnerable due to their high nutritional requirements. A malnourished mother is at high risk of giving birth to a low birth weight (LBW) baby who may be predisposed to growth failure during infancy and early childhood, and at increased risk of morbidity and early death. Malnourished girls, are at risk becoming malnourished mother, thus contributing to the intergenerational cycle of malnutrition (Blossner 2005). Therefore the education level of the mother is the most important factor in determining a child’s health.

Malnutrition is a major public health problem in the developing world, especiallyin southern Asia and sub-Saharan Africa (Brabin and Coulter 2003; WHO 2004; FAO 2004). In populations of these regions the diet is frequently poor in macro nutrients (i.e.protein, carbohydrates and fat, leading to protein– energy malnutrition i.e. PEM) and micronutrients (electrolytes, minerals and vitamins, leading to specific micronutrient deficiencies)or both (WHO 2004; Mill ward and Jackson 2004). The high prevalence of bacterial and parasitic diseases in developing countries add significantly to malnutrition (Brabin and Coulter 2003; Stoltzfus, Chway, Montresor et al 2004). Malnutrition increases one‟s vulnerability and severity of infections, and it becomes a major cause of disease and death (Rice, Sacco, Hyder, Black 2000; Brabin and Coulter 2003; FAO 2004; Black 2004). It is the direct cause of about 300 000 deaths per year and is indirectly responsible for about half of all deaths among young children (Nemer, Gelb and, Jha 2001; Müller, Garenne, Kouyaté, Becher 2003; Black, Morris, Bryce 2003; FAO 2004). An adequate amount of macronutrients and micronutrients are essential for satisfactory growth and nutrition. The deficiency disorders may also occur as a result of aberrant food habits, prejudices, taboos, food fads etc. Health and longevity are likely to depend on many genetic, environmental and behavioural factors. There are several important health issues among adults and senior citizens. A health problem like „Metabolic Syndrome‟ occurs due to sedentary life style, poor cardio-respiratory fitness, unhealthy diet and increased overweight and obesity. The obesity is an important risk factor for serious non-communicable disorders such as diabetes, high blood pressure, high cholesterol levels, and hardening of arteries, some forms of cancer, strokes and heart attacks (WHO 1997). More than 250 million people are obese worldwide (WHO 2000) and obesity once attained in childhood and youth, tends to continue in adulthood (Gortmaker et al 1990). Obesity has a negative consequence for women‟s health throughout the life cycle with important psychosocial, economic and biological implications. Obesity is associated with conventional cardiovascular risk factors (eg. hypertension, dyslipidemia, and diabetes mellitus (Han, van Leer, Seidell et al 1995). Obesity has been reported to be the second most preventable cause of death in USA (Davis and Turner 2001). Increased visceral fat has been associated with increased plasma triglycerides (TG), decreased high-density lipoprotein (HDL), cholesterol, and increased glucose levels, as well as with type 2 diabetes (Fujioka, Matsuzawa, Tokunaga, et al 1987; Despres, Moorjani, Ferland, et al 1989;). Education about nutrition and health and related issues can help to manage health and associated problems to a great extent (Banerjee and Mandal 2005).

Health Education: Relevance

Health education was put as one of the components of Primary Health Care (PHC) during Alma Ata declaration of Primary Health Care in 1978 and it was recognized as a fundamental tool to the attainment of health for all. Health education has been defined by Lawrence Green as “a combination of learning experiences designed to facilitate voluntary actions conducive to health.” It emphasizes the importance of matching the multiple determinants of behavior with multiple learning experiences, create favorable conditions for action. The behavioral measures are undertaken by an individual, group or community to achieve an intended health effect with full understanding and acceptance. The term „IEC‟ (Information, Education and Communication) is increasingly being used for communication activities to promote health. The health education aims at change of behavior and a multidisciplinary approach is necessary for understanding of human behavior There are two approaches to health education i.e. the „Persuasion approach‟(or Directive Approach) which is a deliberate attempt to influence the other persons to do what we want them to do. The other is „Informed Decision Making Approach‟ which includes giving information, problem solving and judgment making skills to people to make decisions but leaving the actual choice to the people like family planning methods. The global health risk factors and their significance have led to a major emphasis in public health policy on education interventions. The education has traditionally focused on providing information and skills to help people make choices that can promote health and well-being. However, the contemporary health education has three objectives i.e. to reduce morbidity and mortality by changing the behavior and beliefs of individuals; to foster the appropriate use of health services; and to create an awareness of health issues. The health education aims to encourage personal growth through enhancing awareness, self-esteem and self-assertion (Katz, Peberdy and Douglas, 1997). The movement toward life skills encourages health literacy in addition to the simple transfer of information that allows individuals to make educated choices about their health (Renkert and Nutbeam, 2001).

The Health Education includes application of medical and related positive knowledge in the everyday life of the society. The acquired knowledge should transform into practical skills, activities and participation. It conveys skills for healthy life style (health promotion). Health education may be formal, non-formal, and informal (UNESCO 2006). The formal education is defined as regular schooling that follows a normal pattern and use acurriculum covering wide range of knowledge, skills, values and attitudes. Formal health education may take place in schools as well as in health settings (e.g. Primary health care centers). The non-formal education is defined as any structured and persistent educational activities that may take place both within and outside educational institutions, and serve to persons of all ages. It may cover educational programmes like adult literacy, life skills, work-skills, general culture, health and environmental education. The informal education is defined as education through learning channels, such as mass media and mass publicity campaigns, where there is slight or no individual attention.

The chronic health problems are projected to be the leading cause of disability throughout the world by the year 2020; if not successfully prevented and managed; they will become the problems with maximum financial expenditure. People with diabetes, for example, generate health care costs that are two to three times those without the condition, and in Latin America the costs of lost production due to diabetes are estimated to be five times the direct health care costs. However, many costly and disabling health problems like cardiovascular diseases, cancer, diabetes and chronic respiratory diseases – are linked by common preventable risk factors. Tobacco use, prolonged, unhealthy nutrition, physical inactivity, and excessive alcohol use are major causes and risk factors for these conditions. The current nutritional transition from increased consumption of high fat to high salt food products will contribute to the mounting load of heart disease, stroke, obesity and diabetes etc. more sedentary life style due to increasing usage of motorized transport, accumulativeleisure time activities including television watching is adding to the burden .Many diseases can be prevented, yet health care systems do not make the best use of their available resources in this direction. The health professionals need to inform patients about health promotion and disease prevention measures (WHO 2007b).Complete health education addresses the physical, mental, emotional, and social aspects of health. The goal of any health policy should be towards reducing inequities, promoting human rights and building social capital addressing the social determinants of health (Tones and Green, 2004).

Nutrition Education

Nutrition is an important foundation for health and development. Better nutrition means stronger immune systems, less illness, better health and healthy children can learn better. Healthy people are stronger, are moreproductive and more able to create opportunities to gradually break the cycles of both poverty and hunger in a sustainable way. Better nutrition is a prime entry point to ending poverty and a milestone to achieving better quality of life (WHO 2007b).For instance an adequate nutrition during infancy is important for long-term growth and health. Some of the nutritional risk for infants includes anemia, jaundice, breastfeeding complications, and specific medical conditions etc .Infants who do not receive an adequate iron after six months of age are at risk for developing anemia which may further result in poor growth, poor resistance to infection, fatigue, irritability, behavioral problems, and deficits in cognitive ability. Low birth weight infants are also at increased risk of developing anemia because of low neonatal iron stores (INM 2009). The primary or “baby” teeth begin to form in the jaw before birth and continue to develop throughout the first years of life. Good nutrition during pregnancy and infancy helps to form teeth that are strong and healthy. Several nutrients are necessary for the development of healthy teeth during infancy and the most important ones are protein, calcium, phosphorus, and fluoride. The fluoride supplements are recommended for infants starting at 6 months of age if the water supply does not have adequate fluoride. Good dental health, including daily cleaning of the gums and teeth, should be started early in life. Even before the teeth appear, parents can clean the infant’s gums with a clean cloth or gauze to remove residues from the mouth. When the teeth do appear, they should also be cleaned daily with a cloth or gauze. When an infant is near the age of one year, parents can begin to use a small, soft toothbrush to gently brush the baby’s teeth. Proper nutrition and hygiene are required to maintain good dental health (INM 2009). An adequate nutrition in earlier life can help to overcome some of the problems of childbirth like haemorrhage, infection and obstructed labour etc (UN/ACC/SCN 1992). For instance, anaemia, which may be due to an inadequate intake of iron-rich foods, lack of iron supplements or parasite infection, is responsible for a significant proportion of maternal deaths during pregnancy and childbirth (FAO/WHO 1992).

The nutritional conditions are assessed by anthropometry (Ostchega, et al. 2005 and 2006).Some of the important anthropometric index used to measure nutritional status are; Weight for age (chronic and acute malnutrition); Height for age (chronic malnutrition) and; Weight for height (acute malnutrition). These indexes measure different nutrition conditions like „Underweight‟ where children experience body changes resulting from both acute and chronic malnutrition, „Stunting‟, an indicator of chronic malnutrition or past growth failure due to inadequate intake of nutrients over a long period or due to long-term illness and „Wasting‟, when weight of a child is significantly below the weight expected for the child‟s height, an acute condition due to inadequate dietary intake or infection. Some other anthropometric measurements like mid-upper arm circumference (MUAC), Low birth weight (LBW) and Body mass index (BMI)are used to study the nutritional status. The MUAC helps to assess severe or mild-to-moderate malnutrition. Low birth weight (LBW) is an indicator of under nutrition in newborns and intrauterine growth retardation. WHO (1995) defines LBW as weight under 2.5 kg at birth and the different causes of LBW include inadequate maternal food intake during pregnancy, cigarette smoking by the mother, short maternal stature, and maternal infection. The Body mass index (BMI) is calculated to determine nutritional status of the adults. BMI compares weight and height and it measures body mass, ranging from underweight to obese.

Nutrition education is envisioned to achieve three important objectives i.e. It convey required information, or the facts about nutrition; change unhealthy attitudes to healthy eating practices and teach positive skills regarding nutritional goals (Collins et al 1995). These objectives need to be fulfilled in an age-appropriate ways while taking care of personal and cultural preferences of the individuals. Education and nutrition have a cyclic relationship. Well-nourished children are better able to reach their academic potential. Educated children especially girls can better understand and act on information, including use of health services, and become more empowered to take decisions like delaying marriage, first pregnancies, longer birth intervals and contraception use (WHO 1996).Nutrition education aims towards promotion of healthy nutrition including choice of food, food-preparation and storage of food. Healthy nutrition is understood differently in different nations and among different cultures. The healthy nutrition should be an integral part of daily life as it contributes to the physiological, mental and social well-being of individuals. It is the combined effect of food, health and care. Nutritional well-being is determined by consuming safe food and balanced diet that contains adequate amounts of nutrients in relation to bodily requirements. Nutrition education has been shown to have a significant effect in fostering healthful eating habits (Berg 1993). The nutrition interventions at schools can improve children’s health, their learning potential and school attendance (Levinger 1996; Miguel and Kremer 2004;Bobonis et al 2006; Afridi 2007). Schools‟ setting supports an effective, efficient and equal opportunities to promote health and healthy eating. At school, lifestyles, including eating patterns, are developed through social interactions between students, teachers, parents and others (Am hold et al 1996). Schools can effectively teach students how to resist unhealthy social pressures; since eating is a socially learned behaviour that is influenced by social pressures.

Human nutrition is a scientific discipline, concerned with the access and utilization of food and nutrients for life, growth, development, and well-being. Human nutrition range from biological and metabolic nutrition to the massive public health nutrition. It incorporates global prevention, control, and elimination of malnutrition and other nutritional disorders. WHO focuses on priority issues at all these levels, throughout the life span, and in nutrition policies and programmes for sustainable development (WHO/FAO 1996). Girls in particular benefit from good nutrition as their health status and eating habits have a major impact on pregnancy, lactation and nourishment of future generations. About 800 million people are estimated to lack access to food to meet their daily basic needs for energy and protein. More than 3 billion people are deficient in essential micronutrients such as iodine, vitamin A and iron (WHO 1997).There is need for the efforts to make healthy nutrition accessible for everyone.Good health and nutrition are needed to achieve one’s full educational potential as nutrition affects intellectual development and learning ability (Pollitt 1990). The nutritional status and cognitive test scores have been found to be significantly related (WHO 1996, Levinger 1996). Therefore nutrition intervention programmes encourages the health and nutrition education substantially.

Intervention Programmes:

There could be some health related Programmes And Policy Tools That Can Help Children To Perform Better In School. For Instance, Deworming Is A Cost-Effective Intervention To Increase School Participation and Boost Learning Capabilities (Church 1985). School Feeding Programmesh As Been Reported To Improve Enrollment, Attendance, Cognition, School Achievement and Overall Health (Gajre Et Al. 2008; Adelman Et Al. 2008; Whaley Et Al. 2003; Bundy Et Al 2009; Jomaa Et Al. 2011). The School Lunch Coupled With Other Programmes Like Deworming, Micronutrient Supplements, And Fortified Foods makes More Impact(Calloway Et Al 1988).Ensuring Adequate Facilities, Such As Safe water and sanitation (including the girl-friendly facilities) are needed. Children connect their learning at school to the community by bringing messages home to their families and further promoting good nutrition and healthy habits in society .When children receive skill-based health education, it enables them to make better choices and adopt healthier lifestyles. India‟s Integrated Child Development Services (ICDS)is one of the world‟s largest early childhood development programmes with integrated health, nutrition, and preschool education for children of 3 to 6 years old. The ICDS children were less likely to be severely malnourished and more likely to attend school (FAO/WHO 1992; Das Gupta et al 2005). A programme in Bangladesh reached 17,600 children with education about how to prevent worm-related infections through school based health and nutrition programmes. Teachers were trained to administer vision screenings, use first aid kits, and provide deworming tablets and vitamin supplements to children. The programme lead to decrease in annual worm-related diseases, reduced high worm loads in children, lower edanaemia rates, and boosted school attendance (UN 1996).The health education at the school level can teach how to maintain and improve the health; prevent disease; reduce health-related risk behaviors; and develop health knowledge, attitudes, and skills that help in better academic achievement, increase attendance rates, and improve behavior at school. As good nutrition also enables longer attention spans and better school attendance, allowing children to stay in school and learn, the policy- and decision-makers need to address nutrition as an educational issue. By supporting and investing in nutrition-sensitive education programmes, we can give all children and young students the opportunity to excel in life.

Nutrition interventions may be the policies, services, learning experiences and other actions implementedby schools, individuals or groups to make healthy nutrition a way of daily life. Nutrition interventions can be integrated into all aspects of the school and community life, including the physical and psychosocial environment; educational opportunities; school/community projects; school health services; health promotion for school staff; counseling, social support programmes; physical exercise, recreation, sport; and food programmes. The schools provide the most effective and efficient way to reach large sections of the population, including young people, school personnel, families and community members. The WHO‟s Global Strategy on Diet, Physical Activity and Health recommends that school policies andprogrammes support the adoption of healthy diets and physical activity (WHO, 2004). The WHO published a “School Policy Framework: Implementation of the Global Strategy on Diet, Physical Activity and Health to assist the Member States in implementing the Strategy at the country level (WHO, 2008). The guide recommends the inclusion of nutrition education in school policies and programmes, as a means of providing knowledge and skills about the relationship between a good diet, physical activity, and health .It addresses the safe preparation of food and its consumption as an essential positive and enjoyable aspect of life. It enables students to identify barriers for making healthy food choices and solutions to over come the barriers.Over the past 2 decades there has been an increasing use of technology in nutrition education. The E-learning can be delivered to groups and to individuals in specific settings. E–learning approaches specifically custom-made to individuals have emerged as a potentially cost-effective type of health promotion programme because they enable personalization of health education without the costs of interpersonal counselling (Maes et al., 2011b).

Suggestions:

Improving educational outcomes requires policies and programmes that improve nutrition for all families. Health education should be made an integral part of the education program in schools. Effective policies in the public health sector invites convergence of initiatives in different sectors involving food security, drinking water, women‟s literacy, better nutrition and sanitation etc. The public health policy should focus on the prevention of diseases by providing clean water and sanitation rather than fighting diseases. This requires training of public health specialists and development of health facilities at all levels. Crucial attention should be paid to the financing of healthcare. Public expenditure on health in the country constitutes only around 1per cent of the GDP (Bhat& Jain 2004). It should be adequately increased during the next five years.

There is need to promote policies for increasing food productivity as well as for enhancing land use and desirable cropping patterns to fight the malnutrition. There is need to expand early childhood education programmes that stimulate cognitive development and address nutrition. An integrated approaches to education, health, and nutrition is desired today. Convergence of the nutrition component of various plans made by the health department, sanitation committee, education department and the local Panchayats need to be encouraged. Besides monitoring of nutrition indicators should be undertaken for identifying areas of high malnutrition, evaluating programme outcomes, and documenting malnutrition trends. The malnutrition has many causes therefore multiple and synergistic interventions can be effective. A variety of actions are needed, including agricultural and micronutrient interventions and the provision of safe drinking water and sanitation, education about and support for better diets, special attention to gender issues and vulnerable groups such as pregnant women and young children, and quality health services (Nemar 2004; Victoria 2004). Nutrition education about locally available protein- and micronutrient-rich plants is effective (Penny et al 2005). During the United Nations Millennium Summit in 2000, 147 nations adopted 8 development goals especially the goal to reduce extreme poverty and hunger by the year 2015 by half relative to 1990 figures. The progress toward the other 7 goals (universal primary education; empowerment of women; improved maternal health; decreased child mortality; advances in the prevention and management of HIV/AIDS, malaria and other diseases; environmental protection; and global partnerships for development) would directly or indirectly contribute to major reductions of malnutrition in developing countries.

Women‟s empowerment by ensuring higher levels of schooling for girls, higher age at marriage and higher maternal age at the birth of the first child can contribute greatly towards reducing malnutrition. There is need for social mobilisation through informing the community about health and nutrition objectives and generating awareness at the family and local community levels (IHD 2010). The social roles of the women can also be enriched through nutrition interventions. Women‟s‟ nutritional knowledge enhancement may help them to ensure better preparation, preservation, handling and distribution of foods, which may further enhance women’s social and economic status . Thus, ensuring schooling with effective nutrition interventions for young girls can be one of the most important and effective means of improving women’s nutrition and health status and social development.

The existing health services can be modified and expanded to create more effective school health promotion programmes. Education about nutrition should be combined with efforts addressing other health issues, such as reproductive health, life skills, and alcohol and drug use prevention. Linkages of health and nutrition issues and related subjects can also be facilitated by co-teaching, sharing teaching resources, and conducting group activities involving students from different classes.Teacher training both pre-service and in-service, is an important factor in a successful school health education programme. The environmental changes (physical and psychosocial changes) are necessary to support the healthy nutrition. The physical environment of the schools including the presence of clean water, safe food and sanitary facilities as well as proper waste collection and disposal are essential to good health . Schools should strive to gain cooperation with vendors to offer nutritious food choices to encourage the school’s health. The psychosocial environment should support health-conducive perceptions and actions of all who work and learn in the school.

There is need to give careful consideration to the types of nutrition messages that are presented to adolescents. More effective nutrition messages should be conveyed with an idea that eating well will help the teen to have the energy to do what s/he wants to do and to become the person s/he wants to become. Educational methods such as lectures, discussions, debates, role-plays and audio-visual aids should be designed or selected to increase knowledge, build positive attitudes and values, dispel myths, and assist for the development of healthy lifestyles. They need to be appropriate for the developmental level of students The teenagers should give consideration to the potential long-term risks of an unhealthy diet and the likely benefits of healthy eating habits. The educational materials for health education should be written using the local or simple language. Parents need to be educated about the value of healthy meals and food safety practices and about their role as promoters of concepts and knowledge for better eating and learning.

There are evidences that a higher level of physical activity and cardio-respiratory fitness decrease the risk of developing metabolic syndrome (Hassinen, Lakka, Savonen et al 2008). A higher level of physical activity is found to be associated with decreased mortality and hospitalization which indicates that the lifestyle factors may influence health outcomes (Khokhar and Mehra 2001). The physical activity and nutrition must be addressed in a complementary manner when integrated into the components of a Health-Promoting Programme. The interventions should emphasize that all children and adults should have the opportunity to attain the healthy benefits of exercise, games, dance, sport etc. In regions with a prevalence of over nutrition, physical activity and sports should be encouraged to emphasize the benefits of reducing the risk of obesity and related disorders. Health promotion and disease prevention in older adults is complex, but effective .Some coping strategies with sensory changes with age may be adopted with an increasing age. Eating nutrient-dense foods becomes increasingly important in old age but vitamin and mineral needs remain high. For specific health problems like osteoporosis, some weight-bearing exercise and a diet high in calcium help gives protection.

Eating a variety of foods is key to good health, especially for people with special needs, such as infants and young children, pregnant and lactating women, and the elderly.