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Ongoing
Is One Egg Enough?
Eggs alone, although nutritious, may not curb anemia.

During the 2008/09 school year, REAP conducted their first study of anemia, its causes and its consequences in Shaanxi Province. According to results from the study, we found that anemia, or severe iron deficiency, is widespread in poor rural areas of the province, affecting nearly 40 percent of the students in the sample.


Problem

Poor nutrition was identified as the main source of anemia. When children received vitamins with minerals tablets (21) or 21 SUPER-VITA on a daily basis, anemia rates of these children fell and educational test scores rose.

Partly in response to our work and the policy briefs that were written based on the study results (and also due to their own commitment to better nutrition), in September 2009 the provincial governor of Shaanxi announced that he would be committing the province to providing every student in the province one egg (or one glass of milk) per day. His hope was that improved nutrition would result in healthier students and better educational performance. By any metric, the efforts of the provincial leadership are laudable. Eating an egg a day is beneficial for many students in Shaanxi's poor rural schools.

However, there was still another problem. If anemia is one of the most severe nutritional problems in Shaanxi's schools, then it contributes to low test scores. Unfortunately, the new initiative of the Shaanxi provincial governor should not be expected to do anything to overcome anemia. The reason is because eggs--despite being a nutritious food--contain almost no iron, and neither does milk. This then is the origins of our current project: Is One Egg Enough?

In the defense of the top leadership in the province, as soon as this was brought to their attention, they took immediate action. A document was sent, cautioning and reminding school principals that while giving one egg a day was required and improved nutrition, eggs only supply certain nutrients. A fully balanced diet is also required for good health, including foods with iron.

In addition, the province gave us their full support to test whether one egg is enough below our givens.


Goals

This study conducted by REAP seeks to:

  • Improve the nutrition and health of poor rural elementary school students, specifically in context of iron deficiency anemia, and to improve their educational performance.
  • Provide policymakers with objective study results that elucidate the impacts from the current initiative.
  • Evaluate the effects of additional policy-relevant options.

Specific objectives of this project are to assess effective means of improving health status (iron deficiency) and educational achievement of school-aged children, by comparing the effects from:

  • Consuming eggs on a daily basis without any other intervention. 
  • Supplementing meals with a nutritious fortified meal (Vitameal) in addition to consuming eggs.
  • Receiving iron supplements in multivitamin form, in addition to consuming eggs.
  • Providing information to students, parents and principals regarding the importance of balanced nutrition, in addition to consuming eggs. 
Vitameal infused meals to be distributed in schools.

Approach

Baseline: Month 1

Chosen from ten poverty counties in three prefectures of Shaanxi (these three prefectures only give eggs to boarding students in implementing the egg/milk initiative)-- Baoji, Hanzhong and Ankang (a total population of over 3.3 million) – 70 sample schools were randomly selected by REAP. From an initial canvas survey, enumerators first identified all rural elementary schools satisfying three requirements: a.) including six grades (complete schools or in Chinese—wanxiao); b.) having boarding facilities; c.) enrolling a minimum of 150 students, including at least 50 boarding students. In order for these schools to be comparable (“identical” in terms of the factors that we are controlling for), a balance test was conducted between the four sets of schools (three interventions and one control) using the information from the canvas survey.

To establish a baseline of health and learning abilities, our specific data collection instruments include: cognitive tests (math and Chinese); psychological tests; anthropometrics measurements; behavioral records; 24-hour food (nutrition) intake recalls; student surveys; household surveys; teacher surveys; and school surveys. Additionally, hemoglobin levels will be measured by a finger-prick Hemocue 201+ blood test, which will be administered by certified professional nurses from Xi’an Jiaotong University, School of Medicine. Only fourth grade students are included in this study.

Intervention: Months 2-7

Within our sample of 70 schools, 15 will receive the Vitameal intervention; 15 will receive the vitamin intervention; 15 will receive the information treatment (for principals, canteen managers and parents); and 25 schools will be our control group.

Vitameal Treatment: In the first subset of treatment schools, Vitameal (a fortified porridge-like mixture of rice and lentils containing essential nutrients provided by NuSkin Enterprises’ Nourish the Children Initiative) will be supplied to all schools. School canteen managers will be given clear instructions on how to prepare one serving of Vitameal as a meal for each boarding student every school day. REAP will provide a subsidy (2.5 RMB/30 servings of Vitameal) for costs from cooking Vitameal.

Vitamin Treatment: In fifteen schools, all fourth grade students will receive a vitamin with minerals or 21 SUPER-VITA (in tablet form) daily, administered by their homeroom teachers who will receive instructions and training. Students who return home on weekends will receive two multivitamins to take on their own, with clear directions.

Information Treatment: The third “food and nutrition information” treatment will provide dietetic and balanced nutrition knowledge to key stakeholders.

  • Families and students will receive an intensive training course on preparing nutritious and cost-effective home meals (and meals at school or away from home), hygiene, food purchasing, the relationship of these with health and education.
  • School staff (principals, cafeteria managers, and teachers) will receive an intensive training course on preparing nutritious and cost-effective school meals, hygiene, food purchasing, and the relationship of these with health and education. 

Control Group: The remaining 25 schools in our 70 school sample receive no intervention. However, it is important to note that all boarding students in all 70 schools will be consuming an egg every school day. Their baseline and evaluation health status and performance will be monitored by REAP, compared to the schools who receive an intervention.

This study design allows us to compare the impacts of egg consumption alone, egg consumption in conjunction with additional treatments (receiving Vitameal, vitamins, information) using boarding students, and also the impacts of receiving Vitameal, vitamins, information using the non-boarding students.


Evaluation

After the implementation of the intervention, REAP will conduct a final evaluation at Month 8. Evaluation surveys will test the effects of different interventions on the cognitive, psychological, behavior and physical development of primary school students.


Results

On-going study


Funding

Ford Foundation, Nu-Skin Enterprises’ Nourish the Children Initiative, Minsheng Pharma

Research Materials

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