S Choudhary, C Mishra, K Shukla
adolescent girls, body mass index, energy balance, nutritional status, under nutrition
S Choudhary, C Mishra, K Shukla. Correlates Of Nutritional Status Of Adolescent Girls In The Rural Area Of Varanasi. The Internet Journal of Nutrition and Wellness. 2008 Volume 7 Number 2.
In spite of impressive gain in the field of health and nutrition, significant proportion of young people in developing countries are under-nourished. The effect of earlier insult is visible in the adolescent age particularly in girls.
Often health and nutritional status of adolescent girls are direct reflection of the cumulative effects of physical growth, the onset of menarche and increase in fat and muscle mass which place extra nutrition requirements on them. Physical growth of adolescent girls integrately related to their dietary intake which is determined by availability of food in terms of quality and quantity and the ability to digest, absorb and utilize food. Food availability is influenced by dietary practices, cultural traditions, family structure, birth intervals, meal patterns, and food allocation. At the same time, digestion and absorption can be impeded by infection as a result of lack of environmental sanitation. In general adolescent girls are the worst sufferers of the ravages of various forms of malnutrition because of their increased nutritional needs and low social power. Further low literacy levels, lack of awareness about nutrition & health and poverty aggravate this dismal situation. The cycle of poor nutrition perpetuates itself across generations particularly in girls.
Apart from this among rural adolescent girls an increased risk of low energy intake but high energy expenditure due to enhanced multiplicity of physical activities in terms of domestic, peri-domestic, low paid occupations and social activities forced them towards the negative energy balance. Which has profound adverse effect on their nutritional status. Various studies report that majority of rural adolescent girls suffer from chronic energy deficiency which jeopardize their nutritional status1.
This is the situation of the adolescent girls especially in rural areas when she is the foundation stone of the family in particular and society in general. It is very much true that the growth and prosperity of a nation depends heavily on the status and development of adolescent girls as they not only constitute one tenth of its population but also influence the growth of the remaining population. Hence the problems related to adolescent girls deserve special attention. But unfortunately correlates of under-nutrition of adolescent girls residing in rural areas, have been the least explored area. The present research is an attempt towards this direction.
Materials And Methods
The approach adopted for this community based study was cross sectional one. Sample size estimation was based on the extent of under nutrition in adolescent girls. As per literature search and a pilot study conducted in Chiragaon block, prevalence of malnutrition in rural adolescent girls ranged from 50-72% and thus taking a middle course a prevalence rate of 60% was assumed. By taking this prevalence and permissible level of error as 10%, sample size was computed as 267.In all, 270 adolescents were enrolled for the study.
Following steps were involved in selection of study subjects: [a] One Community Development Block (i.e. Chiraigaon) was selected from eight CD Block of the Varanasi District by simple random sampling; Villages of Chiraigaon were stratified into 3 strata according to distance (Viz < 7 Km, 7-14 Km and > 14 Km) from Block headquarter and from each stratum one village was selected by simple random sampling;[c] In the selected villages, total enumeration of adolescent girls was done. This was served as the sampling frame. The required study subjects were selected adopting probability proportion to size (PPS) sampling technique.
The primary tools in this study were predesigned and pretested interview and examination schedule for recording of family as well as individual information. Weighing machine (Libra) and steel anthropometric rod with parallel bars were utilized for weight and height recording respectively.
A composite indicator for socio-economic status was developed on the basis of expert opinion taking into consideration monthly per-capita income, highest education in the family, type of house including number of rooms in the house, family amenities and possession of prestigious durable goods and use/consumption pattern of various food items.
Each study subject was subjected to anthropometry (weight & height recording ) following standard technique2. Nutritional status of study subjects, was assessed by body mass index. BMI of each study subject was computed by using the formula weight (kg)/ height (m2). Study subjects were graded in different grades of nutritional status according to proposed criteria for Asians3.
Dietary intake of the study subjects was assessed by 24 hours recall oral questionnaire method. Standardised utensils were used for measuring the approximate intake of different food items, Dilution factor of liquid food was also noted. Diet survey was not conducted on day after any festival or any other special occasion. Their energy intakes were computed by referring to “Nutritive Value of Indian Foods”4 & “Nutritive Value of Common Indian Food”5 Calculations.
Physical activity was noted by 24 hours activity recall questionnaires method. This served as basis for computation of energy expenditure. Energy expenditure of each study subjects was determined by multiplying their Basal Metabolic Rate (BMR) and rate of energy expenditure. BMR of study subjects was computed by taking into consideration of their body weight and using the formulae suggested by FAO/WHO/UNU6 consultation group. Utilizing the data on time spent on various activities (in minutes) and the corresponding multipliers78, the rate of energy expenditure in terms of BMR units was found out mathematically.
Where, ti is time spent (in minutes) for ith activity and mi is the corresponding multiplier.
Energy balance of each subject was obtained by subtracting energy expenditure from energy intake.
Initially associates of under nutrition were analysed by applying univariate analysis, X2 test was applied. In order to identify absolute contribution of influencing factors logistic regression was also applied.
As per Proposed Asian Criteria, 68.52% adolescent girls were under weight (BMI<18.5).In all 31.11% subjects suffered from chronic energy deficiency (CED) grade III (BMI<16). Only 28.52% study subjects had normal nutritional status; corresponding values for overweight (BMI 23-24.9) & obese (BMI
In subjects, with highest education in the family as graduate and above under nutrition was 55.17%; corresponding value for educational categories up to standard V and VI to XII were 82.93% and 72.54%, respectively. With increasing level of highest education in the family significant (p<0.01) decline in under-nutrition was noticed among study subjects. Under-nutrition was to the extent of 86.10% in subjects either illiterate or just literate; corresponding value for subjects with education primary and middle, and high school and above were 64.04% and 45.0% (p<0.001).There existed significant (p<0.001) difference in nutritional status of adolescent girls with varying level of father’s education. As much as 66.67% and 41.67% subjects with father’s education high school plus intermediate, and graduate and above, respectively were under-nourished; corresponding values for subjects with father’s education as illiterate plus just literate and high school plus intermediate were 73.3% and 78.08%, respectively. Educational status of either mother or husband showed no significant(p> 0.05) association with nutritional status of adolescent girls. Extent of under-nutrition in subjects with main occupation of the family as agriculture, service and labour was 64.52%, 73.68% and 79.45%, respectively; being least 53.19% in subjects with main occupation of the family as business. (p<0.05).Maximum (82.54%) under nutrition was observed in subjects belonging to lower SES, followed in middle (69.92%) and then in high (54.05%) SES categories. There was significant (P<0.01) association between SES and nutritional status of study subjects. Neither per capita income nor working status of study subjects was significantly (p>0.05) associated with their nutritional status. Chronic energy deficiency grade III was least in high school plus intermediate subjects (15.0%) and in subjects with highest education in the family as graduate and above (21.84%) and belonging to high SES (22.97%)(Table 2).
Under-nutrition was significantly (p<0.05) more in unmarried subjects (72.02%) than married subjects (53.85%).As much as 54.82% menstruating and 90.38% non-menstruating adolescent girls were under-nourished (p<0.01).Neither addiction nor nature of diet was significantly (p>0.05) associated with nutritional status of study subjects. Under-nutrition was to the extent of 78.79% and 62.57% with and without history of passage of worms, respectively (p<0.01). CED grade III was more in unmarried (35.32%), non menstruating (56.73%) and subjects with history of passage of worms (40.41%)(Table 3).
Neither the type of house nor the main source of drinking water was significantly (P>0.05) associated with the nutritional status of study subjects. Under-nutrition was 60.0% and 70.22% in subject with and without latrine facility, respectively (p>0.05)(Table 4).
Under-nutrition was 70.21% and 64.63% in subjects with negative and positive energy balance, respectively (p>0.05)(Table 5). As much as 70.95% and 73.42% subjects, with protein intake 80% and 80.1-100% were undernourished; corresponding value (56.90%) for subjects with protein intake more than 100% was not statistically (p>0.05) different(Table 6).
Under-nutrition was not significantly (p> 0.05) different in subjects ill (76.19%) and not ill (65.05%) at the time of survey. Dietary modification during illness did not exert significant (p>0.05) influence on nutritional status of study subjects .As much as 66.67% and 68.72% subjects with and without past history of illness were under-nourished (P> 0.05)(Table 7).
Out of 9 parameters shown in the table of logistic regression analysis only menstrual status, occupation of the family and literacy status of father contributed significantly to the nutritional status of adolescent girls. Compared to menstruating adolescents non-menstruating girls had 3.59 (CI = 1.44-8.93) times higher risk of being under-nourished. Adolescent girls belonging to labour class had 3.39 times higher risk (CI=1.29 -8.90) of being under–nourished when compared with the business class, where as adolescents of service and agriculture class the risk of under-nutrition was statistically similar to business class. The risk of under-nutrition (odds ratios) in adolescents with their father’s literacy status primary to middle and high school to intermediate were 3.66 (CI = 1.12-11.89) and 3.05 (CI= 1.05-8.81), when compared with adolescents, with their father’s education graduate and above. However, risk of under-nutrition was insignificant in subjects having illiterate and just literate father (odds ratio 3.15 CI=0.94-10.60)(Table 8).
Only 52 girls were married & father of 8 girls were not alive.
Note : For computation of X, BMI has been grouped into 2 categories i.e. < 18.5 and 18.5 kg/m2, as also main source of drinking water (well and others).
Adolescence is a period which includes puberty spurt during which maximum growth in terms of weight and height takes place9. According to some studies101 high under-nutrition at earlier age of adolescence has been reported. Similar finding has been observed in this study also. Adolescent girls belonging to 10-12 years were suffering from under-nutrition / chronic energy deficiency grade III maximally . Factors which may contribute to this phenomenon may be the earlier nutritional insult during preschool period as well as adverse dietary practices during 5-9 years age period. Although in this study religion, caste, type and size of family did not exert significant effect on the nutritional status of adolescent girls by taking cut off BMI 18.5 kg/m2, chronic energy deficiency grade III has been maximum in Hindu and schedule caste subjects. (Table 1).
One of the important parameter that determines nutritional status of an individual is level of education in the family11. In this study when the nutritional status of adolescent girls was examined against highest education in the family it was evident that with increasing level of education decline in under-nutrition was noticed among subjects. Nutritional status of study subjects had been significantly influenced by their educational status and literacy status of their father. Chronic energy deficiency grade III was least in high school plus intermediate subjects and in subjects with highest education in the family as graduate and above . Importance of parental education in raising the nutritional status of children is well known12. Mothers education has profound effect on preschool children whereas fathers education seems greater importance in the care of adolescent girls13.In the present observation variables such as literacy status of mother and husband, per capita income and main occupation (working status) of subjects did not exert significant effect on their nutritional status .Besides education one of the major factors determining nutritional status of an individual is socio-economic status .In this study SES has been computed by taking other parameters (viz. highest education in the family, per capita income, housing, family assets etc.). Under nutrition has been significantly less in subjects belonging to high SES ,having main occupation of the family as business .They may affect income of the family as well as energy expenditure and thereby energy balance & nutritional status of the study subjects(Table 2).
Adolescent girls who were married still residing with their parents may enjoy different status than unmarried girls. It is possible that they are cared better and if it is so then nutritional status of married girls will be better than the unmarried girls. This situation prevailed in the study area also. Establishment of menarche is closely associated with the age & nutritional status of adolescent girls14, in the present study under nutrition was significantly more in non menstruating girls than in menstruating girls .Besides this poor personal hygiene may predispose to worm infestations which may contribute to the phenomenon of under-nutrition; in the present observation under-nutrition was significantly more in subjects with positive history of passage of worms. These factors were also associated with occurrence of CED grade III (Table 3).
In rural areas environmental conditions may not be very conducive for optimum health. Unfavourable environment may predispose to nutritional diseases15. Generally mixed patterns of dwellings prevail and in such situations role of specific variable may not be clear cut in causation of under-nutrition. This is evident in the study area also. Neither the type of house nor the main source of drinking water was significantly associated with nutritional status of study subjects. Similar pattern has been observed in subjects with and without latrine facility (Table 4).
Association of energy balance and nutritional status has been explored by some workers although161718under-nutrition was higher in subjects with negative energy balance than those with positive balance . However association was statistically not significant (Table 5). With increase in protein consumption their has been declined in the under-nutrition in adolescent girls (Table 6). Also presence of illness at the times of survey as well as history of past illness and dietary modifications during illness did not significantly affect nutritional status of subjects (Table 7). Nutritional status is primarily determined by energy balance and morbidities. However, role of morbidities in causation of PEM in preschool children is well documented, this area needs to be explored in a longitudinal manner.
Several factors (age, highest education in the family, literacy status of study subjects, literacy status of father, main occupation of the family, socio-economic status, menstrual status and history of passage of worms) were found to be significantly associated with the nutritional status of the study subjects.
In order to identify influencing factors, logistic regression analysis (multinomial) was applied. The risk of under-nutrition in adolescent girls was more in non-menstruating girls, from families with main occupation as labour and fathers education from primary to intermediate level . Higher under-nutrition in adolescent girls from labour class may be attributed to their more work participation(Table 8). The ability of the model to detect under-nutrition of adolescent girls by including above significant factors is 41.5%, which is otherwise we can say that sensitivity of model is 41.5%.. However specificity of the model to detect normals is 85.0%. The accuracy of the model for classification of normals and under-nourished is 71.4%. in this light the results of the study should be interpreted.
On univariate analysis age, highest education in the family, literacy status of study subjects, literacy status of father, main occupation of the family, SES, menstrual status and history of passage of worms were significantly associated with nutritional status of adolescent girls. However, on logistic regression analysis, out of these nine parameters only literacy status of father, main occupation of the family and menstrual status of subjects significantly influenced the nutritional status of adolescent girls. The risk of under-nutrition was more in non menstruating girls and subjects with main occupation of the family as labour, service and agriculture. Under-nutrition was least in adolescent girls having fathers with education status as graduate and above. Other factors viz. religion, caste, family size, literacy status of mother and husband, working status, addiction, nature of diet, social behaviour, environmental variables, energy balance, protein intake and presence of illness were not significantly associated with nutritional status of adolescent girls.
Dr. Seema Choudhary Associate Professor, Deptt. Of Community Medicine Maharaja Agrasen Medical College, Agroha (HISAR), HARYANA-125047 E-mail: firstname.lastname@example.org