FNB v26 n2 supp2 book v8.indb - United Nations University

163 Pages·2005·3.99 MB·English

Contents
Proceedings of the International Workshop on Articulating the Impact of
Nutritional Defi cits on the Education for All Agenda
Osman M. Galal, Charlotte G. Neumann, and Judie Hulett, guest editors
Preface —O. M. Galal, C. G. Neumann, and J. Hulett ................................................................................S127
Introduction —E. Pollitt ..............................................................................................................................S131
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Can the provision of breakfast benefit school performance? —S. Grantham-McGregor ........................S144
Linking nutrition and education: A cross-generation model — T. D. Wachs ...........................................S159
Crucial role of nutrition in education: The Kenya experience —K. Mwiria .............................................S168
School feeding, school reform, and food security: Connecting the dots —B. Levinger ...........................S170
Nutrition education in Chilean primary schools —S. Olivares, I. Zacarias, M. Andrade, J. Kain, L. Lera, F.
Vio, and C. Morón ...........................................................................................................................................S179
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The long-term impact of preschool health and nutrition on education —M. Jukes ................................S193
Diet quality affects the playground activities of Kenyan children —M. Sigman, S. E. Whaley,
CCC... GGG... NNNeeeuuummmaaannnnnn,,, NNN... BBBwwwiiibbbooo,,, DDD... GGGuuuttthhhrrriiieee,,, RRR... EEE... WWWeeeiiissssss,,, LLL---JJJ... LLLiiiaaannnggg,,, aaannnddd SSS... PPP... MMMuuurrrppphhhyyy ................................................................................S202
Using the school feeding system as a vehicle for micronutrient fortification: Experience from
South Africa —M. E. van Stuijvenberg ....................................................................................................S213
Improved effect of school meals with micronutrient supplementation and deworming
—T. Gopaldas ...................................................................................................................................................S220
E-learning: A nutritionally ripe environment —G. S. Savige .....................................................................S230
The impact of child health and nutrition on education in developing countries: Theory,
econometric issues, and recent empirical evidence —P. Glewwe ...........................................................S235
Height, weight, and education achievement in rural Peru —S. Cueto ......................................................S251
Obesity among schoolchildren in developing countries —O. M. Galal and J. Hulett ..............................S261
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Schoolteachers’ awareness about scholastic performance and nutritional status of Egyptian
schoolchildren —O. M. Galal, I. Ismail, A. S. Gohar, and Z. Foster ......................................................S275
Micronutrient status and intervention programs in Malaysia —G. L. Khor ............................................S281
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Food and Nutrition Bulletin
Editor: Dr. Irwin H. Rosenberg, Friedman School of Nutrition Science
and Policy, Tufts University, Boston, Mass., USA
Senior Associate Editor: Dr. Nevin S. Scrimshaw
Associate Editor—Food Policy and Agriculture:
Dr. Suresh Babu, International Food Policy Research Institute (IFPRI),
Washington, DC, USA
Associate Editor—Food Science and Technology: Dr. V. Prakash, Central Food
Technological Research Institute (CFTRI), Mysore, India
Statistical Advisor—Dr. William M. Rand, Tufts University School of
Medicine, Boston, Mass., USA
Managing Editor: Ms. Susan Karcz
Manuscripts Editor: Mr. Jonathan Harrington
Copyeditor: Ms. Ellen Duff
Editorial Assistant: Ms. Shauna Sadowski
Editorial Board:
Dr. Ricardo Bressani, Institute de Investigaciones, Universidad del Valle
de Guatemala, Guatemala City, Guatemala
Dr. Hernán Delgado, Director, Institute of Nutrition of Central America
and Panama (INCAP), Guatemala City, Guatemala
Dr. Cutberto Garza, Professor, Division of Nutritional Sciences, Cornell
University, Ithaca, N.Y., USA
Dr. Joseph Hautvast, Secretary General, International Union of Nutritional
Sciences (IUNS), Department of Human Nutrition, Agricultural University,
Wageningen, Netherlands
Dr. Peter Pellett, Professor, Department of Food Science and Nutrition,
University of Massachusetts, Amherst, Mass., USA
Dr. Zewdie Wolde-Gabreil, Director, Ethiopian Nutrition Institute, Addis
Ababa, Ethiopia
Dr. Aree Valyasevi, Professor and Institute Consultant, Mahidol University,
Bangkok, Thailand
Food and Nutrition Bulletin, vol. 26, no.2, Supplement 2
© The United Nations University, 2005
United Nations University Press
Published by the International Nutrition Foundation for The United Nations University
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Preface
Background are in poor health and undernourished at school, the
synergistic relationship between deprivation, poor
Many developing countries have signed on to the health and malnourishment erodes the benefits of any
United Nations declarations on Education for All investments in education [13]. Efforts are needed to
promising basic education for all citizens by the year eradicate malnutrition and protect the potential of
2015. Together with international organizations, these schoolchildren to become productive adults [14].
governments are making massive efforts to increase
quantity and improve quality of basic education within
their national educational systems. These educational Schoolchildren’s health and nutrition
efforts raise urgent questions regarding the impact
of the health and nutrition status of the school-aged Resources and international focus have been centered
population on the education systems in developing on reducing infant and child mortality, but interest in
countries. The important role of school-based health schoolchildren has often been neglected [15]. Health
services and school feeding programs in the cognitive and nutritional deficits constrain the success of devel-
development and school performance of children opment and prevents poverty alleviation, which could
is well recognized and documented. During the last be achieved through education. Although there is a
two decades, child survival programs orchestrated growing body of knowledge on the health status of
by UNICEF have been very successful in fulfilling the children of school age, limited attention has been given
above UN declarations’ objectives. These programs to the nutritional well-being of these children. Further-
were mainly a response to the high morbidity and mor- more, clear articulation of health and nutrition issues
tality among infants and preschool children all over the is largely absent from the education policy agenda in
world. By successfully decreasing the infant mortality many countries.
rate by half, the effort was considered revolutionary. International commitment to improving educational
As a result of the child survival program, the number access in developing countries is not lacking. UNESCO
of children eligible to enter school has increased by and many non-governmental development agencies are
approximately 10 million per year, to a total of just actively engaged in projects and programs toward this
under 800 million [1]. However, approximately 25% end [16, 17]. Governmental commitment is also evi-
of these children remain undernourished [2]. dent from the significant percentage of national public
Malnutrition affects schoolchildren’s scholastic expenditure allocated to the education sector, even
performance, age of enrollment, concentration in in countries with demonstrably declining economic
class, attendance, and infection rates [3–5]. Recent performance [18]. However, the nutrition and health
available data detail the strong association between status and well-being of schoolchildren around the
nutritional insults and the health and school perform- world is seldom articulated in planning for the current
ance of children [4]. Further studies in Guatemala [6], goal of Education for All, except for attention given to
the Philippines [7], Jamaica [8], Kenya [9], and Egypt deworming and HIV/AIDS prevention in school cur-
[10] have come to similar conclusions. Children who ricula, which is a recognized international agenda [1].
are already at risk due to health nutritional problems Although there is a substantial body of literature attest-
come to school tired, hungry, and unable to cope or to ing to the causative links between health problems,
benefit from their lessons [11]. Absenteeism, delayed particularly malnutrition, and school performance
enrollment, lowered cognitive capacity, and reduced [19–21], this research focus is largely missing from the
academic achievement are all associated with an Education for All agenda in international development
under-supply of important nutrients [12]. If children [22–24]. The disconnect may be attributable to the fact
Food and Nutrition Bulletin, vol. 26, no. 2 (supplement 2) © 2005, The United Nations University. S127
S128 O. M. Galal et al.
that health and nutrition are perceived as problems to policies and programs to combat poor health and mal-
be dealt with in the health sector by health organiza- nutrition among school-age children. The workshop
tions and ministries rather than as integral to the addressed all these issues.
education sector [25].
The present workshop focused on one of the most The workshop
important issues facing global development today, The papers presented in the workshop were in five
namely the quality of the human capital being devel- sessions and ranged from comparatively abstract and
oped through educational systems for the future. Even theoretical considerations of, for example, strategies
as we recognize the impact of the HIV/AIDS pandemic to estimate child nutrition and school performance,
on the education sector through the loss of teachers to concrete reports on school feeding programs in, for
and students who drop out to take care of siblings at instance, Makueni District, Kenya. The first session,
home [1], we need to acknowledge and act upon the chaired by Dr. Paul Glewwe (Department of Applied
demonstrated negative impact of malnutrition on a far Economics, University of Minnesota), explored nutri-
larger proportion of children’s educational outcomes. tion and schoolchildren performance. The second,
The present workshop intended to bring to the fore- chaired by Dr. Sally McGregor (Institute of Child
front evidence demonstrating the role of malnutrition Health, UK), presented six papers on evidence-based
in the educational outcome indicators in developing nutrition and educational outcomes. The third, chaired
countries, where nutrition inadequacy and infections by Dr. Charlotte Neumann, discussed the positive
prevail. impact of animal source foods and improved diet
quality in school feeding-intervention studies in Kenya.
The fourth, chaired by Dr. Donald Bundy of the World
Scope and goals of the workshop Bank, evaluated “Food for Education” programs,
funded by the United States Department of Agriculture.
The workshop compiled and presented data from The fifth, chaired by Dr. Beryl Levinger (Education
various health and education agencies, ministries, and Development Center), dealt with micronutrients and
organizations (as well as data that are available and food programs. And the sixth and last session, chaired
unpublished in literature) on the health and nutri- by Dr. Osman Galal (UCLA School of Public Health),
tion status of schoolchildren. Some presentations consisted of a panel discussion, entitled “The Way
documented the interactions between poor health and Forward,” of what may be the most important ques-
nutrition and educational outcomes. Moreover, the tion facing researchers and policy makers in the area of
workshop participants presented information on the school child nutrition—what do we do now?
nature and magnitude of global efforts implemented As one would expect, the workshop did not yield
to improve the educational situation of schoolchildren easy solutions to malnutrition and poor health among
in developing countries. schoolchildren. Instead it helped identify questions
The workshop was the first step toward the long- and dilemmas that policy makers must confront and
range goal of projecting the impact of health and nutri- it presented the results of research that can help in
tion status on the success of investments in education. designing optimal policies and programs. For exam-
In addition, the workshop provided information for ple, because funding is always limited, how should it
the development of educational and health policy rec- be allocated to achieve the best results, however one
ommendations and helped advocacy efforts to encour- wishes to define that? Is it more important to feed
age international organizations to buy into improving younger (perhaps pre-school) children, and thus head
the nutrition status of schoolchildren worldwide to off the stunting and wasting that would result from
enhance their school performance and potential capa- poor nutrition, or is it more important to feed older
bilities to be productive adults. children, or the mothers who share responsibility for
By bringing together an international research group caring for younger siblings and thus can do a better
of scholars in economics, education, and public health job if they are adequately fed? If one can provide only
from Africa, Asia, Europe, Latin America, the Middle a single daily meal for schoolchildren, should it be
East, and North America, the workshop was able to breakfast or lunch? What should children be fed? How
move the role of poor health and malnutrition as an important is it to supplement vegetable-source foods
intervening factor in education from the margins of with meat? (Multiple micronutrient deficiencies are
scholarly discourse to the center. Although common highly prevalent with even moderate amounts of meat,
sense tell us that poor health, particularly malnutrition, fish, or fowl). What approaches to food and nutrition
contributes to poor school performance, and although education are most effective in combating the obesity
there is a substantial body of literature backing up that plagues children in much of the developed world?
this common sense, there has not been adequate dis- These are only a handful of the multitude of questions
semination of the research findings or implications addressed by the workshop.
nor adequate application of the research to establish The workshop was especially significant in that it
Preface S129
covered numerous regions of both the developing and Judie Hulett, Ph.D. candidate
the developed world that have grappled with malnu- International Health Program
trition. Community Health Sciences
UCLA School of Public Health
Osman M. Galal, M.D., Ph.D. Los Angeles, California
International Health Program
Secretary-General,
International Union of Nutritional Sciences Acknowledgment
Community Health Sciences
UCLA School of Public Health Thanks and appreciation goes to the editors of the
Los Angeles, California Food and Nutrition Bulletin who are devoting a special
supplement to this topic. It is hoped that the supple-
Charlotte G. Neumann, M.D., M.P.H. ment will help to guide future research and policy
Community Health Sciences and Pediatrics formulation.
UCLA School of Public Health and of Medicine
Los Angeles, California
References
1. UNESCO. Education for all: an achievable vision. Paris: school. London: New Policy Institute, 1999.
UNESCO Publishing, 2001. 12. Grantham-McGregor S. Linear growth retardation and
2. Alaimo K, Olson C, Frongillo E. Food insufficiency and cognition. Lancet 2002; 359:542.
American school-aged children’s cognitive, academic, 13. Levitsky D, Strupp B. Malnutrition and the brain:
and psychosocial development. Pediatrics 2001;108: Changing concepts, changing concerns. J Nutr 1995;
44–53. 125: 2212S–20S.
3. Levinger B. The effects of health and nutrition on a 14. Donovan N, Street C. How breakfast clubs meet health,
child’s school performance. Nutrition, health and edu- education and childcare needs. In: Donovan N, Street C,
cation for all, chapter 3. UNDP, New York, New York, eds. Fit for school. London: New Policy Institute, 1999.
1996. 15. Del Rosso J, Marek T. Class action: Improving school
4. Papamandjaris A. Breakfast and learning in children: performance in the developing world through better
a review on the effects of breakfast on scholastic health and nutrition. Directions in Development. Wash-
performance. Canadian learning foundation, Ontario, ington, DC: World Bank, 1996.
Canada 2000 http://www.breakfastforlearning.ca/ 16. Samoff J. Education sector analysis in Africa: limited
english/resources_a3/materials/papa_report.pdf national control and even less national ownership. Intl
(accessed December 28, 2004). J Educ Devel 1999;19(4,5):249–72.
5. Cueto S. Breakfast and performance. Public Health Nutr 17. Takala T. Making educational policy under influence
2001;4:1429–31. of external assistance and national politics: a compara-
6. Pollitt E, Gorman K, Engle P, Martorell R, Rivera J. Early tive analysis of the education sector policy documents
supplementary feeding and cognition: Effects over two of Ethiopia, Mozambique, Namibia and Zambia. Intl J
decades. Monographs of the Society for Research in Educ Devel 1998;18(4):319–35.
Child Development 1993; 58:1–119. 18. UNDP. Human Development Report. 2002. Washington,
7. Mendez M, Adair L. Severity and timing of stunting in D.C., Oxford University Press.
the first two years of life affect performance on cognitive 19. Ivanovic DM, Olivares M, Castro C, Ivanovic R. Nutri-
tests in late childhood. J Nutr 1999; 129:1555–62. tion and learning in Chilean school-age children:
8. Walker SP, Grantham-McGregor SM, Powell CA, Chang Chile’s Metropolitan Region Survey. Nutrition 1996;
SM. Effects of growth restriction in early childhood on 12(5):321–8.
growth, IQ, and cognition at age 11 to 12 years and the 20. Gross R, Landfried B, Herman S. Height and weight as
benefits of nutritional supplementation and psychoso- a reflection of the nutritional situation of school-aged
cial stimulation. J Pediatr 2000; 137:36–41. children working and living in the streets of Jakarta. Soc
9. Bwibo N, Neumann C. The need for animal source foods Sci Med 1996;43(4):453–8.
by Kenyan children. J Nutr 2003; 133:3936S–40S. 21. Powell CA, Walker SP, Chang SM, Grantham-McGregor
10. Wachs TD, Moussa W, Bishry Z, Yunis F, Sobhy A, SM. Nutrition and education: a randomized trial of the
Mccabe G, Jerome N, Galal O, Harrison G, Kirksey A. effects of breakfast in rural primary schoolchildren. Am
Relations between nutrition and cognitive performance J Clin Nutr 1998;68:873–9.
in Egyptian oddlers. Intelligence 1993; 17:151-72. 22. Banya K, Elu J. Implementing basic education: an Afri-
11. Ani C, Grantham-McGregor S. The effects of breakfast can experience. Intl Rev Educ 1997;43:481–96.
on children’s educational performance, attendance and 23. Christopher C, Al-Samarrai S. Achieving schooling for
classroom behavior. In: Donovan N, Street C, eds. Fit for all: budgetary expenditures on education in sub-Saha-
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ran Africa and south Asia. World Devel 2000;28(11): 25. Buchert L. The global initiative towards education
1927–44. for all: a framework for mutual understanding. Paris:
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Acknowledgments
Zoë Boutilier
The guest editors of this supplement express grati- The Micronutrient Initiative
tude for the unique opportunity to coordinate this
workshop and our sincere appreciation of the encour- Linda Rosenstock
agement and interest from the people who made this Dean
effort possible. UCLA School of Public Health
Geoffrey Garrett Montague W. Demment
UCLA International Institute Global Livestock CRSP, University of California,
Educating Global Citizens Davis (USAID)
Allen Roberts We are also indebted to our colleagues who made our
US Department of Education Grant to the James S. visiting scholars feel at home and provided invaluable
Coleman African Studies Center, UCLA service to the workshop through their assistance and
very hard work.
Edmond Keller
Globalization Research Center – Africa, UCLA Susan Silah
Mary Vardazarian
Mark Wahlqvist Ritesh Mistry
International Union of Nutritional Sciences Parisa Mirzadehgan
(IUNS)
Introduction
Ernesto Pollitt
This supplement to the Food and Nutrition Bulletin child is sensitive to the influences of adverse biophysical
includes a selection of papers presented at an inter- and social-cultural factors and the long-term outcomes
national meeting held from February 18–20, 2004, will generally depend on the life course events [6].
at the University of California, Los Angeles, titled Under conditions in which populations generally live
“School Children: Health and Nutrition.” The research (e.g., endemic poverty), these factors do not operate as
data presented and the questions that arose about the independent agents that cause particular quantifiable
effectiveness and efficiency of interventions presently changes in one specific developmental domain. Rather,
available (e.g., nutrition education, school feeding, the effects of such factors (e.g., iron deficiency anemia)
deworming) are at the forefront of this field of work. are, or can be, moderated by developmental stage (e.g.,
Although health and nutrition interventions in schools early infancy), health (e.g., infection), ecology (e.g.,
have a long history, the recognition of their potential altitude above sea level), and sociocultural (e.g., qual-
educational benefits to schoolchildren in low-income ity of caretaking) and economic conditions (e.g., level
countries has never been stronger than it is today [1]. of poverty), and together they influence the course of
The research work of many investigators, the leader- child development [7]. The strongest influences are
ship and funding of various international agencies, generally observed during infancy and the early years
the motivation and actions of several countries, and of life [8–10]. Further, the effects detected in one par-
the advocacy of interested parties have unleashed an ticular domain (e.g., cognition) are rarely isolated from
unparalleled movement to improve the well-being of other domains (e.g., motor, socio-emotional) because
schoolchildren and their learning of the competencies one of the characteristics of development is precisely
required by a modern economy. the reciprocal influences among subsystems within the
Contemporary theories and research in develop- organism [11, 12].
mental science have shed new light on old and new In agreement with the above considerations, young
data on the developmental effects of poverty and children could follow two different developmental
malnutrition as well as on the impact of health and courses in populations where poverty and malnutrition
nutrition interventions at different periods of chil- are typical. In one case, the psychobiologic develop-
dren’s development. These advances explain, in my ment of children will be continuously at risk whenever
view, part of the recent growth in the assessment and poverty, illness, and malnutrition characterize their life
implementation of health and nutrition policies and course and their effects join. Recall that it is the number
programs targeted toward schoolchildren. While there and relationships of socioeconomic and biologic stress
is no consensus, there is wide recognition today that factors and their cumulative effects that determine the
the psychobiologic development of children is plastic developmental course rather than any one particular
and it follows a course that uninterruptedly depends factor [11–15]. In the other case, with some important
on the interplay between the changing organism and exceptions (e.g., cretinism, extreme deprivation), there
its changing environment [1–5]. The development of a will be a significant shift of the developmental course
whenever there is a lasting improvement in their social
and economic status as well as in health and nutrition
Ernesto Pollitt is Professor Emeritus, University of Califor- [16]. This shift allows the reorientation of the devel-
nia, Davis, California. opmental course toward a comparative better level of
Please direct correspondence to the author: Ernesto Pol-
well-being.
litt, Malecon Grau 260, Chorrillos, Lima 9, Peru; e-mail:
[email protected]. There are no studies, to my knowledge, that have fol-
Mention of the names of firms and commercial products lowed children from birth to adulthood and have meas-
does not imply endorsement by the United Nations University. ured the independent and cumulative effects of poverty,
Food and Nutrition Bulletin, vol. 26, no. 2 (supplement 2) © 2005, The United Nations University. S131
S132 E. Pollitt
poor health, and malnutrition on intellectual develop- Studies conducted in a span of about 40 years have
ment and education through the generally recognized tested the functional effects of improving the health
developmental periods, across a variety of eco-cultural and nutrition of children in early life and during
settings. Nonetheless, several studies in developed and the school period [24–27]. A body of information is
developing countries have looked at selective aspects of now available that might not be complete to meet the
the overall perspective presented above. These studies, stringent criteria of established knowledge but is suf-
which can be characterized as partial approaches to ficiently strong to allow for responsible interventions
the overall picture, have focused on different degrees and policymaking [28]. Supplementary feeding during
of poverty, poor health, and malnutrition; have looked infancy and the preschool period led to significant
at different developmental domains and periods; have improvements in performance in school achievement
used different definitions of intellectual development tests administered in adolescence [29]. Within this
and widely different methodologic approaches, and same study, a subsequent follow-up of the women
have been conducted in a myriad of widely different when they were young adults showed a significant
eco-cultural contexts. This state of affairs in a specific effect on similar indicators of educational attainment
area of research parallels the vast difficulties faced by [30]. Of critical importance to education are the data
social and behavioral researchers to develop universally from recent studies, which show that the cognitive and
valid, widely accepted conceptual and methodologic school competence of schoolchildren will benefit from
approaches to study complex problems in different health and nutrition interventions during school even
cultures. However, owing to the social relevance of though they experienced multiple and continuous
the issue at hand, it is important to scrutinize find- biologic- and socioeconomic-induced stress in early
ings from available research that are well established. life [25, 27]. Qualitative and quantitative improvement
With careful consideration for basic issues of external of the diet of rural schoolchildren led to significant
validity [17], the generalizations presented in the next improvements in their educational performance and
paragraph regarding the cumulative effects of poverty social behavior [31, 32]. True, the health/nutrition
and malnutrition are efforts in this direction. intervention in schools is not likely to compensate for
In the different ecologic settings inhabited by eco- the educational loss over years of disadvantage; never-
nomically impoverished families in the develop- theless, school competence will improve. In some cases,
ing world, 2- to 3-year-old children who are ill and depending on the intervention, the effects will probably
malnourished carry an acquired initial disadvantage, be restricted to improvement of school attendance [33].
compared with children of the same age of middle-class Nonetheless, the benefits of school programs are such
parents in the urban centers, for the later learning of that the educational system should consider health/
the competencies taught in formal schools [18]. This nutrition interventions as one way of improving the
initial reduction in the chances for success to deal educational competency of schoolchildren.
effectively with problems considered important in There is need for further understanding of the
school settings will increase up to the time when they cultural and economic influences in the variability of
enter primary school even though their attendance in the responses of parents and teachers to some of the
a preschool might assuage somewhat the magnitude of effects produced by nutrition and health interventions.
the disadvantage [17]. Even larger differences will set in In some situations, these responses will moderate the
during primary schooling. The disadvantaged children effects of the interventions and such an understanding
will continue to experience the cumulative adverse helps wise policy decisions. For example, early supple-
effects of their poor socioeconomic background [19] mentary feeding improves physical growth in popula-
and, in addition, the schools they will attend will be of tions where poverty and malnutrition are endemic
a lesser educational quality than the schools available to [34]. While in some communities taller children were
children who are well off economically [20, 21]. Such a less likely to enroll late in school and drop out early
difference will endure if, before or at the end of primary [35], in other communities, comparatively taller chil-
school, the disadvantaged children drop out of school. dren were more likely to drop out from primary school
In the absence of major social and economic changes, to help their parents at work [36]. This latter case sug-
this one event generally prevents the acquisition of gests that the parents attributed greater value to the
the competencies presently required by fast changing contribution of the child to the family’s economy than
societies and modern technology [22]. In this sense, to the educational benefits from elementary schooling
schooling is a unique window of opportunity. Consider, [23]. In these latter communities, other indicators of
however, that this view is heavily influenced by the nutrition status (e.g., energy intake) among adult men
notion that there are certain competencies, valued in were related to work productivity [37].
Westernized societies, that are, or should be, taught in One concern is that studies on health/nutrition
schools so that the students will be eventually competi- interventions on schoolchildren are often guided by
tive in that kind of context [23]. definitions and values of Westernized societies given
Introduction S133
to health/nutrition (e.g., stature, activity) [38] and low tolerance for increments in physical activity. How
educational (e.g., competencies) outcomes [23]. For should the educational system proceed?
example, researchers usually value the increments in The large numbers of poor children in the developing
activity that follow the administration of supplemen- countries, the limitations of the funding for the social
tary micronutrients [39, 40] given to poorly nourished sector, the problems of organization and administra-
children. However, such increment in activity among tion of large-scale health and nutrition interventions,
schoolchildren might explain why iron supplements and the ideologic differences associated with any social-
given to schoolchildren in Zanzibar were associated political problem will challenge the implementation
with an increment in the repetition of grades from and maintenance of health and nutrition interventions.
first-to-second-to-third grade [41]. Mothers in Tanza- However, by any measure or standard, the progress
nia [42] and teachers in other sub-Saharan communi- made during the last 5 years in the implementation of
ties [43] value students with a receptive disposition and school health and nutrition policies and programs and
listen quietly without interrupting the transmission in the understanding of the effects of these programs
of information. In that context, teachers might have a has been remarkable.
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