Nutritional Status of Adolescent School Children in Rural North India

K. Anand

S. Kant

S.K. Kapoor

From the Comprehensive Rural Health Services Project, Ballabgarh, All India Institute of Medical Sciences, New Delhi 110 029, India.

Reprint requests: Dr. K. Anand, Assistant Professor, Center for Community Medicine, All India Institute of Medical Sciences, New Delhi 110 029, India.

Manuscript received: November 5, 1998;

Initial review completed: December 9, 1998;

Revision accepted: March 1, 1999

 

Adolescence, a period of transition between childhood and adulthood, occupies a crucial position in the life of human beings. This period is characterized by an exceptionally rapid rate of growth. The peak rates of growth are exceeded only during the fetal life

and early infancy(1). However, in comparison to infancy, there is much more individual variation both in timing and in degree of growth. This has importance in terms of defining normality.

The United Nations' Sub Committee on Nutrition meeting held in Oslo in 1998 concluded that more data on health and nutrition of school age children are needed to assess their scale of problem(2). It also believed that the scale of nutritional problems may have been previously under estimated. Traditionally, the main health indicator used by health planners has been mortality rates. Adolescents have the lowest mortality among the different age groups and have therefore received low priority. However, recent studies have shown that the prevalence of malnutrition and anemia is high in these age groups(3-5). The present study was done with the objective of assessing the nutritional status of adolescent children attending a school in rural north India.

Methods

The study was conducted in the Government Senior Secondary School in village

Chandawli of District Faridabad in Haryana among students of Classes six to twelve. All children attending school at the time of the survey were included. Effort was made to examine the students who were absent on a particular day at the next visit. Medical under-graudates posted at the Rural Center of All India Institute of Medical Sciences, located at Ballabgarh, visited the school as a part of their practical exercise in epidemiology. The study was done in the month of September 1998. Throughout the visit, the students were guided by either a Senior Resident or a Post Graduate in Community Medicine posted at Ballabgarh. After explaining the purpose of visit, a verbal consent was obtained from the Principal of the school.

Measurements

Age: This was determined from the register of the school. The school insists on a birth certificate at the time of admission and thereafter the age is increased by one every year.Only those children who were listed in the register to be in the age group of 12 to 18 years were included.

Height: Height in centimeters was marked on a wall in the school with the help of a measuring tape. All children were measured against the wall. The children were asked to remove the foot wear, and stand with heels together and head positioned so that the line of vision was perpendicular to the body. A glass scale was brought down to the topmost point on the head. Height was recorded to the nearest 1 cm.

Weight: A bath room scale was used. It was calibrated against known weights regularly. Zero error was checked for and removed if present every day. Clothes were not removed as adequate privacy was not available. However, as the study period was in September, when the weather was warm, only light clothes were worn by the students. Weight was recorded to the nearest 500 grams.

Hemoglobin: This was estimated by cyan-methemoglobin method using a colorimeter. Known standards were run along with the test samples for maintaining quality control.

All the data was entered into computer in the Dbase package. Body Mass Index (BMI) was calculated from the measured height and weight by a self written computer programme. The analysis was performed using EPIINFO package.

The anthropometric indicators recommended for adolescents are stunting (height for age <3rd percentile) and thinness (BMI for age <5th Percentile). Weight for age has been found to be unreliable and therefore has not been included in this analysis(6). These were calculated separately for boys and girls for each year of age, as the WHO reference norms vary by age and sex(6-8). In areas where distributions of adolescent height and BMI are substantially below those of National Center for Health Statistics (NCHS), USA/WHO reference data, WHO has advised that locally defined cut offs should be used(6). Therefore, results are also presented according to Indian standards(9). Anemia was defined as per the WHO criteria for different ages(10).

Results

As per the registers available with the school, 534 children in the defined age group were enrolled. A total of 505 school children were present during the visit and full information was available for 494 students. Thus 92.5% of the enrolled school children were examined for height and weight. Almost 60% of the total children were from village Chandawli and rest from nearby villages. Blood was collected from 363 (72%) children for hemoglobin.

The prevalence of stunting (low height for age as per NCHS reference) is shown in

Table I. Among boys, prevalence of stunting shows a declining trend from 56% at 12 years of age to 25% at 17 years of age. If Indian norms are used, the prevalence of stunting comes down from 33% at 12 years to 20% at 18 years. The prevalence of stunting drops down sharply at 14 years of age. This is likely due to the pubertal growth which occurs at this age. The prevalence among girls is along similar lines, though the number of girls in each age group is smaller. The increase in mean height is about 8 cm per year among boys and 5 cm per year among girls in the age group below fifteen years.

Table I__Prevalence of Stunting.

Age(yrs)

Boys

Girls

  N            <3rd                            Mean SD
Percentile                                      height (cm)
Indian                         WHO**
                   (%)             (%)
  N            Mean SD                           <3rd
                 height (cm)                         Percentile
                                      WHO**            Indian*
                                          (%)                (%)
12

36

33.3

55.6

35.975.62

1 44

140.626.16

61.4

  29.5

13

50

28.0

52.0

143.868.90

27

145.446.32

70.4

29.6

14

36

16.7

38.9

152.617.68

22

149.094.18

22.7

13.6

15

62

14.5

27.4

160.378.28

24

154.836.93

25.0

20.8

16

73

13.7

37.0

165.667.73

20

155.057.02

30.0

10.0

17

52

19.2

25.0

168.276.29

11

156.547.62

27.3

9.1

18

29

20.7

31.0

168.487.30

8

158.253.33

_

0

Total

338

19.8

37.2

.

156

.

41.0

19.9

* Aggarwal et al.(10).
** NCHS standards(7).

The prevalence of thinness among the school going adolescent children is shown in Table II. As per the NCHS norms prevalence of thinness among boys varies between 31% to 52% without any clear trend. In girls, it varies between 4% to 59%. Though, the number of girls are less in each age group, it appears that prevalence of thinness in girls is lower than in boys.

Table II__Prevalence of Thinness.  

Age(yrs)

Boys

Girls

No.

<5thPercentile
(%)

Mean SD BMI

No.

Mean SD BMI

< 5th Percentile* (%)

13

36

50

15.311.25

44

14.951.63

59.1

13

50

36

15.991.67

27

16.932.29

18.5

14

36

41.7

16.491.18

22

17.391.73

18.2

15

62

43.5

16.831.60

24

19.192.47

4.0

16

73

39.7

17.271.65

20

18.752.41

20.0

17

52

30.8

18.351.92

11 

16.911.1

36.4

18

29

51.7

17.611.70

8

17.541.88

50.0

Total

338

.

43.8

156

.

30.1

* As recommended by WHO(8).

The prevalence of anemia as defined by WHO is shown in Table III. The prevalence of anemia was 27.8% in young boys (12 yrs-14 yrs; n = 79) compared to 41.3% in older boys (15 yrs-18 yrs; n = 92). Anemia was present in 51% of young girls (n = 68) compared to 38.5% (n = 39) in older girls. The mean hemoglobin was higher in boys as compared to girls in both the age groups. None of the subjects had hemoglobin level below 9 g/dl. Discussion This study was school based and about 92.5% of the enrolled school students were examined. Thus, the results of this survey are representative of school going children but not necessarily representative of all the children in this age group in the study area. Based on our data of village Chandawli and its surrounding areas, the school enrollment in this area is 77% in 11 yrs-15 yrs and 73.5% in 15-18 yrs. For boys, it is around 80% in all age group and among girls it is 73% in 11 yrs-15 yrs and 65% in 15 yrs-18 yrs.

Table III__Prevalence of Anemia. 

Age

Number

Definition of anemia(Hb in g/dl)

Prevalence (%)

Mean Hb( SD)

Boys 12-14 years

79

< 12

27.8

12.450.86

15-18 years

92

< 13

41.3

13.040.68

Girls 12-14 years

68

< 12

8.7

11.920.61

15-18 years

39

< 12

51.5

12.090.57

Total .

278

< 12

39.6

.
 

WHO recommends the use of vertical board with an attached metric rule and a horizontal head board for measurement of height and a levelled platform scale with a beam and movable weights for the measurement of weight in adults(6). In this study however, for logisitic reasons this protocol was not used. Sample size in many categories, especially that of girls, in this study were small. Therefore, the results in these categories should be interpreted with caution.

A high prevalence of stunting has been previously reported from India. The report on regional WHO Consultation on nutritional status of adolescent girls reported 45% prevalence of stunting among girls and 20% among boys with an average of 32% in both sexes(11). In our study the prevalence in the 12-18 year age group was 37.2% among girls and 41.0% among boys with an oveall prevalence of 38.5%. A similarity in the prevalence of stunting in boys and girls from developing countries has also been found by other workers(12). In our study, the mean height of the girls was more than the boys till 13 years, after which the boys were taller than the girls. This is probably because of the early onset of puberty in girls. A similar finding has been reported from Wardha district(4). However, at 14 yrs of age, the height of both girls and boys was about 10 cm more in Chandawli as compared to the children in Wardha.

Thinness as defined by a BMI <5th percentile was present in 43.8% of boys and 30.1% of girls. In a study among adolescent girls in Rajasthan, only 6.5% of the girls were found to have a BMI of more than 18.5(3). In another study in government and public schools of Delhi, the prevalence of stunting was 9.9% in upper socioeconomic class girls and 35.3% in lower middle class girls(13).

The overall prevalence of anemia in girls of this age group in our study was 48%. Vasanthi et al. assessed the iron nutritional status among 312 rural school girls of Delhi(5). the prevalence of anemia (Hb <12 g/dl) was 28% in girls who had attained menarche and 22% in girls who had not attained menarche. In another study among 1,500 rural girls

(10-19 yrs) from 10 villages in Gujarat, the prevalence of anemia (Hb <12 g/dl) was reported to be 60%(14). In another study in Delhi, anemia occurred in 46.6% of high socio-economic and 56% of lower middle socio-economic class girls(13).

The poor nutritional status of adolescents, specially girls, has important implications in terms of physical work capacity and adverse reproductive outcomes(6). The median age at marriage in the study area is around 18 years. Thus, the window period for intervention is quite short. School based mid day meal programme and iron supplementation should receive priority in rural areas. A beginning has been made by inclusion of adolescent girls as beneficiaries of iron tablets (once a week) under the Integrated Child Development Services (ICDS) scheme(15). Also in 1995, the Government of India launched the National Programme of Nutritional Support to Primary Education (NSPE)(2). Though the primary objective of this programme is to improve school attendance, it is likely to have a major impact on nutritional status of school children. However, much more needs to be done to address the issue of adolescent mal-nutrition at the national level.

Acknowledgements

The medical students involved in collection and analysis of data for this study were Anil Kumar, Arvind K. Singh, Himanshu Goel, Nikhil Kumar, Ramil Goel, Rajeev K. Singh, Shalimar, Sunil K. Singh, Subasit Acharjee and Utkarsh Kohli. We are thankful to Mr. A. Kaushik and R.P. Gupta for performing hemoglobin estimation of the students. We are also grateful to the Principal and students of the Rajkiya Varisht Madhyamik Vidyalaya of Chandawli for permission to conduct the study.

References

1. Tanner JM. Fetus into Man: Physical Growth From Conception to Maturity. Wells, Open Book Publishing Limited, 1978.

2. United Nations.Nutrition of the School Aged. Administrative Committee on Co-ordination-Subcommittee on Nutrition (ACC/SCN). July 1998; SCN News No. 16; pp 3-23.

3. Chaturvedi S, Kapil U, Gnanasekaran N, Sachdev HPS, Pandey RM, Bhanti T. Nutrient intake amongst girls belonging to poor socio-economic group of rural area of Rajasthan. Indian Pediatr 1996; 33: 197-202.

4. Rao NP, Singh D, Krishna TP, Nayar S. Health  and nutritional status of rural primary school children. Indian Pediatr 1984; 21: 777-783.

5. Vasanthi G, Pawashe AB, H Susie, T Sujatha, Raman L. Iron nutritional status of adolescent girls from rural area and urban slum. Indian Pediatr 1994; 31: 127-132.

6. World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. Technical Report Series 854. Geneva, World Health Organization, 1995; pp 263-308.

7. World Health Organization. Measuring Change in Nutritional Status. Geneva, World Health Organization 1983; pp 63-74.

8. Must A, Dallal GE, Dietz WH. Reference data for obesity: 85th and 95th percentiles for body mass index (wt/ht2) Am J Clinical Nutr 1991; 53: 839-846.

9. Agarwal DK, Agarwal KN, Upadhyaya SK, Mittal R, Prakash R, Sai R. Physical and sexual growth pattern of affluent Indian children from 5 to 18 years of age. Indian Pediatrics 1992; 29: 1203-1268.

10. Demayer EM. Preventing and Controlling Iron Deficiency Anemia Through Primary Health Care - A Guide for Health Administrators and

Programme Managers. Geneva, World Health Organization, 1989; p 26.

11. World Health Organization. Nutritional Status of Adolescents Girls and Women of Reproductive Age. Report of Regional Consultation Geneva, World Health Organization, SEA/NUT/141 1998; p 3.

12. Kurz KM, Johnson-Welch C. The Nutrition and Lives of Adolescents in Developing Countries: Findings From the Nutrition of Adolescent Girls research Program. Washington DC, International Center for Research on Women, 1994.

13. Kapoor G, Aneja S. Nutritional disorders in adolescent girls. Indian Pediatr 1992; 29: 969-973.

14. Sheshadri S. Nutritional Anemia in South Asia. In: Malnutrition in South Asia: A Regional Profile Ed. Gillespie S. Katmandu, UNICEF Regional Office for South Asia 1997; pp 75-124.

15. Integrated Child Development Services Scheme (ICDS). Department of Women and Child Development, Ministry of Human Resource Development, Government of India, Shastri Bhawan, New Delhi, 1995; pp 1-10.

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