ASSESSMENT OF NUTRITIONAL STATUS OF ADOLESCENT SCHOOL GIRLS AT RAWALPINDI

DR. ARSHAD MAHMOOD UPPAL MBBS (Pb), MCPS (Pak), FACP (USA) Roll No. J-5917291: Registration No. OO PGT 2035

Dissertation submitted in partial fulfillment of the requirements for the MASTER OF SCIENCE IN COMMUNITY HEALTH AND NUTRITION At the faculty of SCIENCES Allama Iqbal Open University ISLAMABAD

Advisor: -

Dr. Riffat Ayesha Anis, PhD

Principal Scientific Officer Nutrition Division; National Institute of Health, Islamabad May 12, 2005

II

DEDICATED TO DEDICATED TO

My father late Muhammad Sadiq Uppal and my mother for leading me to live in this world of chaos. My wife for caring me well and my dears Ali Arshad Uppal, Aisha Arshad Uppal, Hafiz Usman Afzal Uppal for their innocent love.

II

ABSTRACT
The present study was undertaken to assess the nutritional status of the adolescent girls from the schools of Rawalpindi. Their dietary intake (in terms of calories & proteins), clinical signs of malnutrition with special emphasis to micronutrients i.e., vitamin A, iron & iodine and Hb levels were also studied. This study was conducted on 369 girls belonging to the age group of 10 – 16 years. The study subjects were selected from two schools of Rawalpindi i.e., Government Comprehensive Girls Higher Secondary School (GCGHSS) from public and Divisional Public School (DPS) from private sector, to afford an opportunity of comparison between two separate groups of adolescent population studying in these schools. Appropriate sampling methodology was undertaken. The approach adopted for the study was a cross sectional one. The tools for the study were pre-designed and pre-tested. A questionnaire, weighing scale, measuring tape, torch, autoscope and digital hemoglobinometer were used in the study. The techniques of study included interview method, clinical examination and anthropometry. The information on socio-demographic profile i.e. age, family income, education, occupation of the parents and family composition was collected. Information on dietary intake was gathered by using semi quantitative food frequency questionnaire. Anthropometric measurements for height & weight were done on all the girls. Their age and age at menarche was also noted. All the girls were subjected to clinical examination for detection of the signs of iron, iodine & vitamin A deficiencies and biochemical estimation of Hb levels. The outcome measures for nutritional status were proportion of thinness (wasted) (<5th percentile of BMI-for-age) and stunted (<-2 Z-score of NCHS standards of height-for-age). The calories & nutrients intake was compared with recommended daily allowances for Pakistan. To detect anemia the hemoglobin levels for different ages were compared with the WHO standards (8-11.99 years with Hb <11 g/dL, 12-14.99 years with Hb <11.5 g/dL, 15-19 years with Hb < 11.7 g/dL). Girls with Hb <7 g/dL were declared as severely anemic. Goiter was determined according to WHO classification (zero, grade I & II). Symptoms and signs for vitamin A & iron deficiency were also noted. The information/data collected was analyzed. The results indicated that 55% girls belonged to GCGHSS and 45% to DPS. Out of these girls 61.2% were from III

early (10-13 years) and 38.8% from middle (14-16 years) adolescent age group. Poverty level was 34.4%. Literacy rate of their fathers was 90.8% and mothers 72.6%. The average family composition was 7.15 ± 1.84. The mean age of the subjects was 13 ± 1.49 and age of menarche was 12.6 ± 0.842 years. Mainly these girls took three meals a day. On average 1523 calories were consumed per day, which was 74.47% of RDAs that was related to poverty (p=0.000). Main source of calories was wheat based food (35.52%). Consumption of milk, egg, meat and dark green leafy vegetables were also low. Micronutrients (Fe, I and vit A) were consumed less than RDA. 6.8% of the girls were stunted, 17.3% were wasted and 4.9% were overweight. Anemia was a common finding, 70.9% girls were anemic and 1.1% severely affected. Goiter was present in 52% and no signs of vitamin A deficiency were seen. Malnutrition is a major public health problem in the country and is prevalent in this study population. There was no vitamin A deficiency, however goiter and anemia was a significant finding of this study. These results correlate with the low intake of food in terms of calories and protein. The poor nutritional status of the adolescent girls can be improved by educating them about the important role of nutrients in their diet.

IV

Accepted by the faculty of SCIENCES Allama Iqbal Open University, Islamabad, in partial fulfillment of the requirements for the MASTER OF COMMUNITY HEALTH AND NUTRITION

Viva Voce Committee

Chairperson of the department of Home and Health Sciences

External Examiner

Internal Examiner

(May 12, 2005)

V

ACKNOWLEDGEMENTS
The author takes this opportunity to place on record his deep sense of gratitude to his advisor Dr. Riffat Ayesha Anis, Director Technical, National Institute of Health, Islamabad; who has helped him with her sagacious advice and has, in fact, been a source of inspiration to him, and without whose constant supervision and sincere encouragement this work would not have come in its present form. Her kind suggestions in the preparation of this thesis are respectfully acknowledged. The author extends cordial thanks to Dr Parveen Liaqat, Chairperson Department of Home and Health Sciences, Allama Iqbal Open University Islamabad, for her support and encouragement. Thanks are also due to Mrs. Hajra Ahmad, Assistant Professor and Syed Shahzad Hussain Shah for their help and cooperation during the course of this study. The author is highly indebted for the cooperation and help extended by Mr Muhammad Saleem (late), Ex-Chief Nutrition Division, NIH Islamabad. The author does not find words to express his sincerest thanks to Prof. Jaleel Ahmad, the Executive District Officer (Education) Rawalpindi; Mr. Muhammad Ayyaz, Principal, Divisional Public School, Rawalpindi and Mrs. Robina Tasneem, Principal, Govt, Comprehensive Girls Higher Secondary School, Rawalpindi, for allowing to conduct this study in their schools. Special thanks are extended for their hospitality. Thanks are also due to the focal persons of these schools Miss. Arjumand Azhar and Mrs. Mussarat Jabeen for their valuable help in gathering the data from their students. Thanks are due to Mrs. Nighat Kazmi & Miss Nusrat Nazia, Dieticians, Nutrition Division, NIH Islamabad for their valuable cooperation in interviewing the adolescent girls for their dietary history. Author’s thanks are also due to Dr. Nadeem Ikram & Mr. Ghulam Murtza Satti, Department of Pathology, and Mr. Muhammad Haleem, Blood Bank at DHQ Hospital Rawalpindi, for their suggestions & cooperation in biochemical estimations the girls. The author is also indebted to thank Dr Ali Abbas, Ophthalmologist at District Headquarters VI

Hospital Rawalpindi for his valuable help in doing the opthalmological examination of the adolescent girls. Also the author would be failing in his duty if he did not express his gratefulness to the adolescent girls under study for their patience; interest and cooperation in making this study a success. Without their participation this all would have not been possible .It was a wonderful experience working with the adolescence. Their optimism, innocence and adherence to the ritual formalities are really praiseworthy. The author is highly indebted to thank Dr. Zafar Moen Nasir, Chief of Research and Mr. Masood Azhar, Computer Programmer, Pakistan Institute of Development Economics (PIDE), Quaid-e-Azam University (QAU) Islamabad for their valuable guidance and suggestions in analyzing the data and making the author familiar with the Statistical Package for Social Sciences and Epinfo-2000, computer programs. The author cordially acknowledge the statistical assistance from Ch. Abdul Shakoor Head, Department of Statistics; University of Arid Agriculture Rawalpindi, who inculcated the statistical sense in him. The author is indebted to thank Mr. Abdul Hameed, Senior Librarian and his staff at NIH, Islamabad. Thanks are also extended to the officials of the libraries of Rawalpindi Medical College Rawalpindi and PIDE, QAU Islamabad, for making available the reading material relevant to this study. Thanks are also due to the Internet (computerbased global information system), which made available, the latest and relevant research data & informations from all over the globe in the shortest possible time. Last but not the least, author wishes his sincerest gratitude for his family members as they always remembered him in their prayers and of course this is the sweetest outcome of their blessings. The author is highly indebted to thank his wife Naheed Arshad Uppal; she really had a difficult time putting up with the mess he created at home.

Dr. Arshad Mahmood Uppal

VII

TABLE OF CONTENTS Chapter
1

Title
INTRODUCTION 1.1 1.2 1.3 Adolescence Nutritional status Back ground on development of nutritional

Page

2 3

assessment 1.4 1.5 1.6 1.7 1.8 2 Rationale of the study Statement of the problem Objectives of the study Significance of the study Limitations of the study

5 6 7 8 8 9

REVIEW OF LITERATURE 2.1 2.2 2.3 2.4 2.5 Nutritional status Menarche Iron deficiency anemia Iodine deficiency disorders Vitamin A deficiency 12 14 16 20 24

3

PROCEDURE OF THE STUDY 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Locale The study population Sample and sampling techniques Research design Permission to visit the schools School survey schedule Sensitization of the study population Consent of the girls for interview and examination Research tools 28 29 29 30 30 31 31 31 31 40

3.10 Collection and coding of data

VIII

3.11 Statistical methods for data analysis 4 ANALYSIS OF THE DATA 4.1. Presentation and analysis of the data 4.2. Discussion 5 5.1. Summary of findings of the study 5.2. Conclusions 5.3. Recommendations 6 7 REFERENCES APPENDICES 7.1. Physical signs indicative or suggestive of malnutrition 7.2. Letter to the EDO (Education) Rawalpindi and the school Principals 7.3. School survey schedule 7.4. Introductory brochure for girls 7.5. Consent form 7.6. Questionnaire for assessment of nutritional status of adolescence school girls at Rawalpindi 7.7. Coding of the data 7.8. Percentiles of BMI-for-age: female adolescents, 9-24 years 7.9. Recommended daily allowances for Pakistani adolescent population of 10 – 19 years of age for selected major nutrients 7.10. Recommended anthropometric cut-off values and original sources of reference for adolescents 7.11.Normal age and gender related changes of hemoglobin and hematocrit values for children and adults

41

42 55 66 67 68 71

90

92 94 95 97

98 100

102

103

104

106

IX

LIST OF TABLES No Description
4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Parent’s education Parent’s profession Malnutrition ( criteria BMI-for-age) in different adolescent age groups Malnutrition (criteria BMI-for-age) and calorie consumption Relationship of menstruation and nutritional status (criteria BMI-for-age) Calories consumed by different adolescent age groups Relationship between energy consumption and poverty Anemia and socioeconomic status

Page
43 43 47 47 48 50 51 54

X

LIST OF FIGURES No Description
2.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Global distribution of iodine deficiency disorders Location map of Rawalpindi Measuring Utensils Dietary interview Procedure of measuring height Measuring the height Measuring weight Night blindness Bitot’s spot Xerophthalmia

Page
24 28 34 34 36 36 37 38 38 38 38 38 38 38 38 39 42 44 45 46 50 52 53 54

3.10 Koilonychia 3.11 No goiter 3.12 Palpable goiter 3.13 Visible goiter 3.14 Visible goiter 3.15 Digital hemoglobinometer 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Age distribution in adolescent girls Household composition Prevalence of stunting Prevalence of malnutrition Share of different food groups in calories consumed by girls Prevalence of goiter Goiter and use of iodized salt Prevalence of anemia in adolescent school girls

XI

LIST OF ABBREVIATIONS Abbreviation Detailed description
µg µmol BC bev BMI COMSTECH DGLV DPS EDO EMR FAO FFQ g G&B g/dL GCGHSS Hb ICNND ICRW IDA IDD INAN L M & m prd M prd MCHC mg Microgram Micromole Beta carotene Beverage Body Mass Index Commission for Science and Technology Dark Green Leafy Vegetables Divisional Public School Executive District Officer Eastern Mediterranean Region Food and Agriculture Organization Food Frequency Questionnaire Gram Ghee and butter Grams per deciliter Government Comprehensive Girls Higher Secondary School Hemoglobin Interdepartmental Committee on Nutrition for National Defense International Center for Research on Women Iron Deficiency Anemia Iodine Deficiency Disorders Instituto Nacional de Almentacao e Nutricao Litter Meat and Meat Products Meat products Mean corpuscular hemoglobin concentration Milligram

XII

NCHS NHANES NIH O& G p PCV PEM PGR PIDE PPM QAU RBCs RDA SATMU SD SES SF TGR TIBC UI UIC UK UNU USA VA VAD VGR WHO

National Center for Health Statistics National Health and Nutrition Examination Survey National Institute of Health Oil and Ghee Asymptotic Significance Value (2-sided) Packed Cell Volume Protein Energy Malnutrition Palpable Goiter Rate Pakistan Institute of development Economics Parts Per Million Quaid-e-Azam University Red Blood Cells Recommended Daily Allowance Science and Technology in the Muslim Ummah Standard Deviation Socio Economic Status Serum Feritin Total Goiter Rate Total Iron Binding Capacity Units International Urinary Iodine Excretion United Kingdom United Nations University United States of America Vitamin A Vitamin A Deficiency Visible Goiter Rate World Health Organization

XIII

"You cannott hammer a giirll iintto anytthiing.. She "You canno hammer a g r n o any h ng She grows as a ffllower does -- she wiillll wiitther wiitthoutt grows as a ower does she w w her w hou sun;; she wiillll decay iin her sheatth as a narciissus sun she w decay n her shea h as a narc ssus wiillll iiff you do nott giive her aiir enough;; she may w you do no g ve her a r enough she may ffallll and deffiille her head iin dustt iiff you lleave her a and de e her head n dus you eave her wiitthoutt hellp att some momentts off her lliiffe;; butt w hou he p a some momen s o her e bu you cannott ffetttter her;; she mustt ttake her own you canno e er her she mus ake her own ffaiir fform and way iiff she ttakes any.." John a r orm and way she akes any " John Ruskiin,, "Sesame and Liilliies,," 1865 Rusk n "Sesame and L es " 1865
(Writes Shirley Landis-1996: at Blue Sky Farm, 1020 N. Manor Road, Honey Brook, PA 19344 USA)

XIV

CHAPTER 1 Introduction

ADOLESCENCE
The word adolescence is Latin in origin, derived from the verb adolescere, which means "to grow into adulthood" (Pipher and Mary 1994). It is often defined as a transient stage, between childhood and adulthood (Chilman and Nancy 1994), and a formative period during which many life patterns are learned and established. It is a crucial and dynamic time for young people as they begin to develop their capacity for empathy, abstract thinking and future-time perspective; a time when the close and dependent relationships with parents and older family members begin to give way to more intense relationships with peers and other adults. It is also a time when physiologically, adolescents begin to reach their adult size, their bodies become more sexually defined and reproductive capacity is established owning to the effects of growth and sex hormones, which is manifested by the onset of menstruation i.e. menarche, occurring around the age of 13 years. Physical changes seem to be related to psychological adjustment, studies suggest that earlier-maturing individuals are better adjusted in the society than their latermaturing contemporaries (Fenwick et al. 1994). Twenty five percent of a girl’s adult height and 35% of weight is achieved during adolescence, which typically marks the end of height gain. This all depends on adequate nutrition as determined by availability of sufficient quantity and quality of food, and the ability to digest & utilize it (Seidenfeld et al. 2004; Kurz and Welch 1994). The concept of adolescence itself is in fact relatively new. Until the 20th century, the passage from childhood to adulthood occurred relatively quickly, usually coinciding with puberty and subsequent childbearing. More recently, both biological and socioeconomic landmarks bracketing the transition to adulthood have moved in opposite directions. Menarche occurs earlier. Many societies' have adjusted the definition of socioeconomic maturing and independence upward in the teen years. As a result, adolescence can no longer be viewed merely as a stage between childhood and adulthood, but is now a unique and important developmental period requiring specific programming and policy attention. There is some variation in the age definition for adolescents, who are often defined as those having the age of 10-19 years (Kurz and Welch 1994). Currently the

2

CHAPTER 1 Introduction

adolescents are classified into three groups: a) the early adolescents having the age of 10 to 13 years, b) the middle adolescents with the age of 14 to 16 years and c) the late adolescents of the age of 17 to 19 years. This classification is based on biological, psychological and developmental basis (Hendee 1991). Adolescents form a crucial segment of population and constitute, as it were, the vital ‘bridge’ between the present and the next generation (Raman 1992). Adolescents are tomorrow's adults, and 85% of them live in developing countries (United Nations 1997). They are relatively healthy as compared to other lifecycle groups, and show roughly similar morbidity and mortality trends in developed and developing countries (Blum 1991).

NUTRITIONAL STATUS
According to Christakis (1973) nutritional status is condition of the health of an individual. The nutritional status of a country reflects the standard of living of the people. Although the body makeup is determined genetically, but besides heredity, nutrition plays an important role for the growth and maintenance of the body (Hels et al. 2003; Khongsdier 2003; Ali and Khan 1976). This is expressed as one being normal, stunted, thin, over weight and victim of micronutrient deficiencies. It depends on food availability, nutrition awareness, earning of the individuals, food prices, food imports, local food production, country environment, dietary intake, and food utilization, which depends on physiological status of the body, which in turn, is influenced by the environmental situation, accessibility to safe water, and the morbidity status that is the result of inadequacies in these situations (WHO 1989). Nutritional status is result of a complex interrelationship between environmental and social factors and the individual in a community. Therefore its medical assessment (clinical, dietary and biochemical), is of limited practical value if the other factors are ignored. So to have a comprehensive assessment of nutritional status we need to take full account of information on (Tierney et al. 2004; Scrimshaw and Gleason 1992; WHO 1963): -

3

CHAPTER 1 Introduction

o Agricultural data and food balance sheets. This gives us information on the gross estimates of agricultural production, agricultural methods, soil fertility, and predominance of cash crops, overproduction of staples and food import & exports. These factors determine the approximate availability of food supplies to a population. o Socioeconomic data, information on marketing, distribution and storage of food. This informs us about purchasing power of the people, distribution and storage of food stuffs. These factors determine the distribution of available foods between the socioeconomic groups in the community and within family. As low socioeconomic status is accompanied by low status in other factors in a person’s life. o Food consumption patterns, cultural and anthropological data. This tells us about the knowledge, erroneous beliefs, prejudices and indifferences about the foods. o Dietary surveys. This tells us about the food consumption by the individuals of the society, like low, excessive or unbalanced nutrient intake. o Special studies on foods. These inform us about the biological values of diets, presence of interfering factors (e.g., goitrogens) and effects of food processing. o Vital and health statistics. This like morbidity and mortality data informs us about the extent of risk to the community and identification of high risk groups. o Anthropometrics. With these informations we know about the physical development of an individual, which is outcome of his nutrition. o Clinical nutrition surveys. By observing the physical signs we know about deviation from health due to malnutrition (appendix 1). o Biochemical studies. By estimating the levels of nutrients, their metabolites and other components in the body, we know about the nutrient supplies in the body and impairment of biochemical functions.

4

CHAPTER 1 Introduction

o Additional medical informations. This homes us on the prevalent disease patterns including infections and infestations, which affect nutrition of an individual.

BACK

GROUND

ON

DEVELOPMENT

OF

NUTRITIONAL

ASSESSMENT
The need to assess the nutritional status was realized in 1932 under the flag of the League of Nations. The development on the subject progressed through the following years and finally Interdepartmental Committee on Nutrition in National Defense (ICNND) of USA succeeded in publishing a Manual for the Nutritional Surveys, which emphasized the need for establishing uniform methods, defining the responsibilities of team members, providing guidelines for the interpretation of dietary, biochemical, clinical & anthropometric data and training of the personnel (ICNND 1957 & 1963). World Health Organization took the task of coordinating the activities for assessing the nutritional status of the people and in 1966, WHO published detailed guidelines for the assessment of nutritional status of the community (Jelliffe 1966). Although nutritional surveys were underway throughout the world, with initial survey commencing in Pakistan in 1956, it was not until the late 1960s that the United States began to address its own nutrition problems. Two surveys were undertaken almost simultaneously to determine the extent of malnutrition, the Ten State Nutrition Survey, 1968-1970 and the Preschool Nutrition Survey, 1968-1970. In 1971 a third survey, the first Health and Nutrition Examination Survey (HANES), was begun, which was completed in 1974 (USDHEW 1972). These surveys provided with the basic informations and various cutoff points for biochemical and anthropometrical values, which are still serving as the references for the assessment of nutritional status of an individual and a community. The nutrition surveys are part of ongoing projects of all the governments of the world to keep themselves abreast to the latest nutritional situation of their people. This enables them to take corrective measures well in time because timely actions can be fruitful. In Pakistan serial nutrition surveys have been conducted for this purpose in 1956, 1965 and

5

CHAPTER 1 Introduction

2002 – 2003, but no attention has been given on the nutrition of the adolescent-a crucial segment of the population.

RATIONALE OF THE STUDY
Nutritional status of the girls in the SAARC region is the worst in the world and roots of malnutrition run deep into social soils, which count for higher maternal mortality rates in the member nations (Raheena 2001). Adolescents are especially affected by malnutrition as they are given little attention towards their health and nutrition (Senderowitz 1995). As a result in many developing countries one half of the children and adolescents fail to achieve their full genetic growth potential (Raheena 2001). The necessity of identifying malnutrition (stunting & thinness) in this group is very important as early adolescent girls can be benefited from improved nutrition or treatment of underlying problems (WHO Technical Report Series (854) 1995). The severity of the deficiency and length of time it takes to reverse the situation depends upon how long the child has been malnourished (Jenne and Greene 1976). To intervene at a proper time requires perpetual evaluation of the situation, by serial assessment of the nutritional status of the adolescence. During this period of rapid growth, caloric, nutrient and micronutrient-iodine, calcium, iron and vitamin needs are higher and their lack or excess leads to various diseases in them (WHO 1989). Thus, understanding and promoting nutritional health during adolescence warrants renewed attention, followed by the allocation of resources for nutritional advocacy, training, research, and care” (Rees et al. 1999). The adolescent girls are the future mothers of the nation. Well-nourished girls will grow into women facing fewer risks during pregnancy and childbearing. So they need to be kept watched as for their nutrition is concerned. History shows that societies that meet women’s nutritional needs also lift their capacities for greater social and economic progress. These facts led to choose the subject of assessment of the nutritional status of the adolescent girls, so that we know their nutritional problems and adopt early corrective

6

CHAPTER 1 Introduction

measures, when they can be benefited through nutrition intervention. Studies like this are need of the time.

STATEMENT OF THE PROBLEM
Role of food in maintenance of health had been recognized since the times of Hippocrates but it is only in recent years that that the role of nutrition in physical & mental development, productivity and of span of working years all of which influence socioeconomic development has been appreciated (Ali 1989). The price of nutritional inadequacy in the form of hunger and malnutrition is very high. About 800 million persons in developing countries are undernourished and an additional 300 million children are at risk of increased morbidity and mortality as a result of malnutrition (World Bank 1980 WHO 1983). Situation in Pakistan is also not so promising. The micronutrient survey from 1976 – 1977 revealed that 53.3% of the children < 5 years were underweight. The situation improved in 2001 – 2002 and only 37.4% were underweight. But the percentage of stunted children, which was 49% in 1965 and had improved to 36.3% in 1990 – 1994, has shot up to 40% in 2001 – 2002. Similarly and worryingly, the number of wasted children was 11% in 1965 increased to 14.9% in 2001 – 2002. However, the problem of malnutrition is worsening in Pakistan as it has gone from bad to worse (Mirza 2004; NNS 2001-02). The world’s adolescent population is around 1200 million (19%). Majority of them are of the view that they are in good health and hence show little concern for protecting their health “capital” for the future (Cordonnier 1995). Whereas the fact is that they suffer from multiple nutritional problems like malnutrition, micronutrient deficiencies, especially the iron & iodine deficiency, undernutrition or obesity and co-morbidity (Kurz and Welch 1994). Hence they remain a largely neglected, difficult-to-measure, and hardto-reach population, in which their needs are particularly ignored. These problems are prevalent in Asia and Africa. The data on adolescent growth between 14-18 years shows that girls of poor communities gain height & weight at much lower rates than in affluent ones (NNMB 1979). Other nutritional parameters are also affected e.g., among poorest

7

CHAPTER 1 Introduction

socioeconomic groups of India the mean age at menarche is around 14.5 years where as in higher income groups it is only 13.2 years (Raheena 2001). Malnutrition is a languishing state of the body, due to lack of food, and curable by adequate supply of food irrespective of its quality (Ali 1989). Its prevention in the face of a rapidly expanding population is indeed a task of staggering proportions. So it is necessary to assess the nutritional status of this important group to see the extent of malnutrition and micronutrient deficiencies in them and to intervene at a proper time to correct these.

OBJECTIVES OF THE STUDY
1. To assess the nutritional status of adolescent schoolgirls. 2. To assess the dietary intake in terms of carbohydrates, proteins, fats, vitamin A, iron and iodine. 3. To study the clinical signs of malnutrition with special emphasis to vitamin A, iron and iodine deficiency. 4. To estimate hemoglobin levels in the study group.

SIGNIFICANCE OF THE STUDY
At present there is so little data on adolescents' nutritional and health status and micronutrient nutrition, eating patterns and underlying influences, and on impact of nutrition intervention in adolescence, that research needs are immense. In order to develop appropriate anthropometric reference data, a multi-country study, with longitudinal and cross-sectional components, on adolescents’ somatic growth and maturation should be considered high priority. Such data are needed to define not only cut-off points, but also rates of too low or too high values that should trigger action at program or individual level. Schools provide a better environment for this sort of research as we can easy manipulate and monitor our nutritional interventions.

8

CHAPTER 1 Introduction

This study will enable us to know about the current nutritional status and nutrient deficiencies in this very important age group. No international reference data exists; the limited data available indicates that their nutritional status is considerably lower in developing than the industrialized world. Often, adolescents' health and nutritional status is a direct reflection of the cumulative effects of childhood health and nutrition. At the same time, like children, adolescents also have specific and increased nutritional needs due to rapid growth and development (Kurz and Welch 1994). Information related to nutrition is needed for a variety of purposes, such as: identifying chronic nutritional problems and causes; predicting and detecting short-term or acute nutritional problems; targeting population groups for both short-term relief efforts and longer-term policy and program development; monitoring changes and evaluating the impact of interventions and development programs (PREPCOM/ICN/92/lNF/5 1992.). This signifies the importance of the continued assessment of nutritional status and monitoring of the micro & macronutrient deficiencies in population. This is more important in women and particularly in the adolescent girls due to their special considerations like menarche. The studies like this will help in formulating national nutritional policy and provide the health professionals a frame work for counseling the individual adolescent.

LIMITATIONS OF THE STUDY
Though the study went smoothly and principals, teaching staff and school girls cooperated well, even then certain limitations were faced as: 1. Short time frame: Due to the time available total study population could not be approached. 2. Limited resources: The scarcity of resources made it difficult to address whole population. Moreover limited resources were not sufficient to study all biochemical parameters necessary for assessment of the nutritional status of these girls.

9

CHAPTER 1 Introduction

3. My being the male, it was not possible to conduct a complete physical examination of the girls under study.

10

CHAPTER 2 Review of literature

Nutritional status of adolescents measured in terms of weight-for-height and expressed as Body Mass Index (BMI), is a direct reflection of the cumulative effects of childhood health and nutrition. No international reference data exists, however the limited data available indicates that the average BMI among 11-18 year old girls is considerably lower in the developing than in developed world. This finding is based on studies conducted by the International Council for Research on Women (ICRW) across several countries in Africa, Asia, Latin America and the Caribbean region in 1994. Adolescence being a time of rapid growth and change requires increased supply of micronutrients (Kurz and Welch 1994). Stunting is a phenomenon of early childhood and a direct result of poor diet and infection (Martorell and Habicht 1986). It is the most easily measured and widespread effect of the malnutrition-infection complex, predicts generalized functional impairment on a wide range of biological, behavioral and social dimensions in children and adults from developing countries (Waterlow 1992; Pollitt 1990; Martorell et al. 1990; Martorell et al. 1992). Some of these functional correlates, such as poor school performance, even when socioeconomic status and other home and environmental factors are controlled for, stunting per se remains negatively correlated with cognitive & school performance, physical activity & reproductive outcome, and positively correlated with risk of infection. Stunting and underweight are highly prevalent in developing countries and are the most common forms of malnutrition (Jelliffe and Jelliffe 1989). In the last 10 years, interest in adolescence has increased worldwide. Much of the attention has been on adolescent health, but nutrition has aroused little interest. 11 studies on nutritional status of boys and girls have recently been conducted in Benin, Cameroon, Ecuador, India, Jamaica, Mexico, Nepal, Guatemala, and the Philippines. These differed in protocol, sample size and data collection methods. Anemia came out to be the commonest nutritional problem in 4 studies (55% in India, 42% in Nepal, 32% in Cameroon, and 48% in Guatemala) and significant in 2 others (17% in Ecuador and 16% in Jamaica). Slow growth was common in 9 studies (27-65%). Height in girls as well as in boys did not improve during adolescence. It approached the fifth percentile at age 10

12

CHAPTER 2 Review of literature

and 18. Low BMI was common (23-53%) in only 3 studies. Boys had lower BMI than the girls. In girls BMI improved with the advancing age. At age 18, the median BMI for girls and boys was well below the fifth percentile. However, in 3 countries where the median BMI at age 10 was low, the boys did not reach the 50th percentile and were still growing, while girls had reached the 50th percentile and stopped growing (Kurz 1996). In a cross sectional study to assess the nutritional status of adolescent girls from Indian slum community; 70.0% had BMI < 20%; 51.43% suffered from chronic energy deficiency and 10% were stunted. Their average weight, height and MAC were 83.45%, 93.08% and 82.05% of the reference values. Significant association of common parameters (viz. age, caste, type of family, income, working and literacy status) with nutritional status of study subjects was not observed. However, lesser under nutrition in large families (> 6) indicated role of familial support in prevention of under nutrition (Singh and Mishra 2001). In Delhi 454 adolescent girls (11-18 years) were screened for nutritional disorders by anthropometry, clinical examination and hemoglobin estimation. Of these, 56% belonged to upper socioeconomic status (SES) and the rest (44%) to lower & middle SES. A large number of girls from later group were undernourished (35.5% had BMI <5th percentile of reference standard) stressing the need for nutritional screening, nutrition and health education. Obesity was found in 3.1% of former group. Goiter grade I or more was prevalent in later group, stressing the need for using iodized salt. Anemia was a major health problem in both groups (47 & 56% respectively) stressing the need for iron supplementation along with health education (Kapoor and Aneja 1992). Raman (1992) used various parameters for assessing the nutritional status of the girls especially in terms of the extent of deficiency in different income groups. Even after attaining menarche a large percentage of girls in rural areas and urban slums remain weight deficient (<75% NCHS standard) compared to the upper middle income group in which only 20% showed deficiency in weight. Similarly height deficiency (<90%) is seen in almost 20% of girls in urban slums and rural areas as against 6% among upper class girls. The deficiency is of a much higher order in BMI or the index of fat fold thickness.

13

CHAPTER 2 Review of literature

Saudi Arabia adolescent girls were found to have heights below the 50th percentiles and their median weight between the 75th and 50th of the standards, indicating a trend towards obesity. Eleven percent of girls were underweight, 61% were normal and 28% were overweight or obese according to the BMI. The findings revealed that these girls are facing two contrasting nutrition situations, underweight and overweight. Similar findings were reported in other Arabian Gulf countries, indicating the need for intervention programs to promote better nutrition among and adolescents (Abahussain et al. 1999). Malhotra and Passi (2004) has reported a high prevalence of malnutrition in rural adolescent girls from Delhi and Rajasthan, wherein thinness is 35.9% and stunting 30.4%. In Bangladesh the rate of malnutrition is the highest in world, where almost half of the women suffer from chronic energy deficit that also include the adolescents (World Bank 2000). In rural Bangladesh 67% adolescents were thin with 75% boys and 59% girls. The percentage of thin adolescents fell from 95% at age 10 years to 12% at age 17 years. Stunting was seen in 48% of boys & girls, which rose from 34% at age 10 to 65% at age 17. Clinically 46% had stomatitis, 27% glossitis, 38% pallor, 11% dental caries, 3.2% goiter II and 2.1% had eye changes of vitamin A deficiency. Ninety four percent of the boys and 98% of the girls were anemic (Shahabuddin et al. 2000). In a study in Maputo, Mozambique stunting was found in 3.0% & 2.3%, thinness (wasting) in 21.9% & 10.0%, stunting & wasting in 3.0% & 0.8%, and 4.8% & 7.7% male & female adolescents were overweight (Prista 2003). The nutritional status of rural Nigerian girls is very poor, as in a survey of these girls 46% of them were stunted and thin (Glew et al. 2003). In a study in rural South Africa stunting was seen 7.3% and wasting 0.7% in school children (Jinabhai et al. 2001). Tanner (1981) has summarized the available data for average age at menarche in 19th century Europe for several groupings of countries. Average ages at menarche in the UK,

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Scandinavia, Germany and Russia were between 15.0 and 16.8 years in working women and between 14.3 and 15.0 years in middle class women. The range given for European samples (all social classes) collected since 1970 is 12.1 to 13.5 years, indicating a decline of several years with respect to 19th century data. In Oslo, where serial data are most complete, the mean age of menarche declined from 15.6 years in 1860 to 13.2 in 1960. Recent values for the US are 12.8 years for whites and 12.5 for blacks. Eveleth and Tanner (1990) also provide menarche data for various countries and regions of the world. For African samples since 1970, values range from 13.1 to 14.5 years, for India 12.5 to 14.6 years, while for Latin Americas they are 12.0 to 13.4 years, except in a sample of Oaxacan Indians from Mexico where mean age at menarche was 14.3. For purposes of this review, samples with mean ages at menarche of 15 years or higher are assumed to have had marked maturational delays, whereas those between 13.5 and 14.9 are assumed to have had mild to moderate delays. Garg S et al-2001 found the mean age at menarche for Indian women to be 13.5 they also found an association between physical maturity and the ability to marry and reproduce In Pakistan the reported age of menarche is 13.5 years (Sathar et al. 2002). In a study of Hong Kong Chinese girls the mean age at menarche was 11.67 years (Tang et al. 2003). The median menarcheal age calculated by probit analysis was significantly different in the two areas: 12.8 years (SD 0.9) in the urban area and 13.2 (SD 1.0) in the rural area (p < 0.001). Girls who reach menarche are significantly heavier and taller with higher BMI than those of the same age who are pre-menarcheal. After adjustment for BMI and other possible confounders, urban girls were still menstruating significantly earlier than rural ones in Peoples Republic of China (Hesketh et al. 2002). The secular trend in decline of the ages of menarche was observed in Bangkok girls. The median age was 11.2 years, whereas, the mean age was 12.1 years. Most girls reached near final adult height after 14 years of age (Mahachoklertwattana et al. 2002). In urban Bangladesh mean and median ages at menarche are 12.67 and 12.81 years, respectively, which is well ahead of rural girls (Haq 1984).

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CHAPTER 2 Review of literature

Iranian school girls attain menarche at the age of 12.91 ± 1.23 years (95% CI: 12.8412.97). Of all subjects 33.7% first menstruated in summer. The highest mean age at menarche was 13.01 years in winter. Stress, anxiety and discomfort were seen among 70.3% of subjects at menarche indicating total or partial ignorance of the menstruation phenomenon. Age at menarche decreased as SES improved. Menarcheal age was delayed for underweight subjects (Ayatollahi et al. 2002). Iron deficiency anemia (IDA) is the commonest feature in women (USDHHS 1998). Even today nearly 1.5 billion people all over the world are affected by IDA. It is generally recognized as the greatest nutritional problem among adolescents, especially the girls and diet is likely a major factor. In a review of 32 studies from developing countries (DeMaeyer and Adiels-Tegman 1985), the overall prevalence was 27%, and higher in boys in one study, where it is transient and subsides as the growth slows down (Raunklar and Sabio 1992). In the ICRW studies, rates ranged from 16% in Ecuador to 55% in India (Kurz and Welch 1994). Iron deficiency affects physical work capacity, in men and in women (Behrman 1992; Li et al. 1994) and is shown to be associated with impaired cognitive processes in adolescents as suggested by improved performance following supplementation in South-east Asia (Nelson 1996). Similarly, anemia was independently associated with lower school achievement in adolescent girls (Walker et al. 1996). Iron deficiency associated with poor intakes, or secondary to infections (Van den Broek et al. 1998), is likely the major cause of anemia in them, but other factors may be involved and need to be better documented, including multiple micronutrient deficiencies involving folate and vitamin A (VA). Furthermore, menorrhagia may be a contributing factor, as suggested by data in Nigerian girls (Barr et al. 1998), and vitamin A deficiency (VAD) may be implicated in this heavy menstrual blood loss observed in 12% of nulliparous under the age of 20. Vitamin A and iron deficiency are indeed interrelated. In Bangladesh school adolescents, it was found that low serum retinol was associated with low hemoglobin (Hb) and poor iron status (Ahmed et al. 1996). In India alone, depending on age and sex, IDA is reported to range from 38-72% (Choudhury and Vir 1994), majority of them being women and children. In girls IDA is

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CHAPTER 2 Review of literature

more prevalent beyond the age of 6 years (Rao et al. 1980), which could be due to menstruation, gender discrimination in intra-household food allocation and early marriage leading to early pregnancy. Adolescent girls form 22% of the population and about 25-50% is anemic by the time they reach menarche (Agarwal et al. 1987). In another study aanemia was found to be 44.8% with severe anemia being 2.1%, moderate 6.3% and mild anemia 36.5% in girls from Rural Tamalnadu, India. A decrease in IDA was observed with advancing age, which was not statistically significant. The prevalence of anemia was 40.7% in pre menarcheal girls as compared to 45.2% in post menarcheal girls. There was reduction in the mean Hb as the age increased. A similar decreasing trend was observed with increasing age at menarche of the girls and also earlier the age at menarche, the higher was mean Hb. The mean Hb of pre menarcheal girls was 11.63±1.5 g/dL and that of post menarcheal girls was 11.52±1.54 g/dL. A significant association was found between Hb and the girl’s education and her mother’s educational status. There were marginal differences in prevalence of anemia in relation to anthropometry. In the multiple regression analysis also girl’s education, mother’s education and the family type were identified as independent predictors for hemoglobin concentration. None of the other socio economic variables and nutritional status was picked up as independent significant predictors (Rajaratnam et al. 2000). In another study Vasanthi et al. (1994) found the prevalence of anemia in rural school girls of Delhi, India as high as 48%. He further observed that anemia was higher in post menarcheal (28%) than in pre menarcheal girls (22%). Malhotra and Passi (2004) have reported a very high rate of anemia in Indian adolescent girls from rural areas of Delhi and Rajasthan i.e. 93.2%. In a study in Bangladesh anemia (Hb<120 g/L) was found 27% while 17% had depleted iron stores (SF<12 µg/l). Of all anemic girls 32% had IDA. The girls with lower serum VA had significantly lower Hb and SF levels. Significant positive correlations were observed between Hb and serum iron, TS, SF and retinol, while there was a negative correlation with serum TIBC. Occupancy, frequency of consumption of large fish, serum iron, TIBC, TS, SF and serum VA were strongly related to Hb by multiple regression analysis (Ahmed et al. 2000).

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CHAPTER 2 Review of literature

High rates of anemia have been observed in other developing countries, such as 42% in Nepal and 32% in Cameroon (Kurz and Welch 1994). A study on adolescents in China revealed that 61.8% of girls were anemic (Cai and Yan 1990). Another study showed that iron deficiency was more prevalent in females than males, the highest rate being in teenage girls (Shaw 1996). Iron deficiency is a nutritional problem that affects 25% of school-age adolescent girls within the study population in Lima, Peru (Zavaleta et al. 1996). In national nutritional survey of Oman IDA was found one of the main nutritional problems among young children and adolescent girls i.e. 38% (Amine 1980). In the Eastern Mediterranean Region (EMR), a total of 149 million people are estimated to be anemic. In Egypt alone anemia was 46.6%, most of which was mild to moderate, with severe cases less than 1.0% of the sample. No gender difference was observed. A significant inverse relationship was observed between the level of anemia and age (especially among boys), socioeconomic level and educational level. Anemia was more prevalent in rural areas and in southern Egypt. It is a major public health problem in Egyptian adolescents (El-Sahn et al. 2000). In southern Malawi anemia is noted as a frequent finding among all the children and women and especially the pregnant adolescent girls up to 93.8% (Brabin et al. 2004). In a survey in Auckland iron deficiency and IDA was more common in girls (18.3% and 11.5%) than boys (1.5% and 1.4%). In females, iron deficiency was two to three times more common in Maori (25.6%), Pacific Islanders (20.9%) and Asians (15.4%) as compared with Europeans (8.3 %), while IDA was 3-4 times more common in Asians (15.9%), Pacific Islanders (12.1%) and Maori (11.2%) compared with Europeans (4.2%). Iron deficiency and IDA prevalence were inversely associated with aerobic fitness, but not with age or years since menarche (Schaaf 2000).

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CHAPTER 2 Review of literature

In US 9% of toddlers aged 1 to 2 years and 9% to 11% of adolescent girls and women of childbearing age were iron deficient; of these, IDA was found in 3% and 2% to 5%, respectively. This prevalence corresponds to approximately 700,000 toddlers and 7.8 million women with iron deficiency; of these, approximately 240,000 toddlers and 3.3 million women have IDA. Iron deficiency occurred in no more than 7% of older children or those older than 50 years, and in no more than 1% of teenage boys and young men. Among women of childbearing age, iron deficiency was more likely in those who are minority, low income, and multiparous (Looker 1997). In school-based clinic and health fair in an inner city of USA, predominantly African-American public high school the mean ± SD Hb level for girls was found 115 ± 15 g/L; 50% of the girls had Hb levels less than 120 g/L. The mean hemoglobin level for boys was 129 ± 13 g/L; 16.5% of boys had hemoglobin levels less than 120 g/L (Leshan 1995). In another report 20% of all women of childbearing age suffer from it as compared with only 2% of adult men (USDHHS 1998). In a study on 262 female teenagers living in the city of Taboao da Serra, Brazil, anemia was found to be 17.6% and its occurrence was inversely related to factors indicative of the economic-social level: income, schooling of parents and home's characteristics. Its prevalence was higher in the group that did not have reached menarche, and it showed no relation with the interval between menstrual cycles. The prevalence of iron-deficiency was of 29.4% and it was not verified correlation between the bloody Hb and the free erythrocyte protoporphyrin, except in severe cases of anemia (Fujimori 1996). In England 114 schoolgirls of 11-14 year from Wembley, Middlesex, were assessed for Fe status, Hb, PCV and MCHC, height, weight, eating habits, and ethnic origin, and subjected to a step test for assessment of physical performance. Overall, 20% of girls had Hb less than 120 g/L, ranging from 11% in White girls to 22-25% in girls of Asian origin. Prevalence of low Hb was 20% in vegetarians, higher in White vegetarians compared with non-vegetarians (23 v. 4%), but lower in the Indian vegetarians compared with nonvegetarians (17 v. 32%). Low Hb was present in 25% of girls who had tried to lose

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CHAPTER 2 Review of literature

weight in the previous year, and was more common in girls from manual (24%) social class backgrounds than non-manual (10%) (Nelson et al. 1994). In Japan a survey of 3,015 women showed the prevalence of IDA, latent iron deficiency, storage iron deficiency, normal and others were 8.5%, 8.0%, 33.4%, 43.6% and 6.5%, respectively. IDA increased with advancing age of the adolescent girls and decreased in elderly women (Uchida, et al.1992). In Pakistan anemia is found to be 44% in urban & 46% in rural girls whose mothers are illiterate and 37% and 44% respectively where mothers are at least matric. This shows a clear association of anemia with education of the mothers (Nutrition Country Paper 1992; WHO 1996). In NNS (2001-02) prevalence of anemia in children is 50.9% and 29.4% in women. Iodine is an essential trace element, present in a hormone of the thyroid gland that is involved in growth-controlling and other metabolic functions. Its deficiency is manifested as stunted growth and goiter (Microsoft® Encarta® Encyclopedia 2003), which is prevalent in hilly areas of the world. In a 120 nation survey Kelly and Snedden (1958) observed that goiter was found with varying intensity in almost every country, independent of race, color, climate, season or weather. Only a few were exempted. The most notorious goiter centers of the world are located in high mountain regions. Its main causes are a low concentration of iodine in soil and water due mainly, according to geochemists, to its removal during the last Ice Age by glaciations and flooding, which is reflected as low iodine contents of locally-grown foods. But factors other than iodine deficiency have been recognized or postulated. Goitrogenic substances present in certain foods, notably cabbage, may induce swelling of the thyroid even when there is no lack of iodine; this, as Clements (1954) has shown, has happened in Tasmania. In the world as a whole, however, deficiency of the iodine is the causative factor and prevention depends on the provision of additional iodine in the communities where goiter is endemic. There are as many as 200 million people with goiter in the world. Among the countries most wildly affected are Brazil, Indo-Pak, and

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CHAPTER 2 Review of literature

Mexico, where estimates of 11.5, 9.0 and 2 million suffers respectively have been made. Prevalence is high in the southern valleys and the foot hills of Himalayas from Afghanistan to Burma (Myanmar) and apparently a similar situation exists on the northern side of this great mountain massif, in the Russia. McCarrison (1917) recorded that in some Himalayan villages 60% of infants still at the breast were affected and that it was difficult to find a man, a woman or a child free from the disease. In such circumstances suffers from cretinism, deaf-mutism and idiocy are common; it has been stated that when the total goiter rate (TGR) rises above 50% mental defectives and deafmutes may constitute 4% or more of the population (WHO 1967). In a survey in Uttar Pradesh-a goiter area, Stott H et al in 1932 calculated that there were 25000 congenital deaf-mutes in this part of India; one village was called, “the abode of fools” because of the low mentality of its inhabitants. While there are areas of high endemicity else where in the world, notably in the Andean region of South America and in mainland China, it appears that the problem is more acute and extensive in the Himalayas than any where else. In USA and New Zealand cretinism and other developmental abnormalities were not part of the picture of endemic goiter existing before control measures were instituted, but this is not true of Switzerland, Italy and other countries in Europe. The cretin was familiar sight in some Swiss Alpine villages not very long ago. The adolescent being an integral of the world population is no exception from the above generalizations. These suffer from this disorder with the same frequency as others do. They have more prevalence due to puberty spurts in this age group. A study on high school girls in Shiraz, Iran, revealed a goiter rate of 25% with the range of 23.16% to 29%. Prevalence of goiter according to goiter grade 1A, 1B, 2 and 3 were 7.4%, 13.9% and 3.41% and 0.25% respectively. Grade 1B goiter was the most prevalent (13.9%). Age specific prevalence rate was highest (29%) at age 18 years and lowest (23.16%) at 17. Prevalence rates specific for school district were compared. Prevalence rate was higher in districts with lower SES. There was not a statistically significant difference between four districts. 97.75% of the subjects used iodized salt. Comparison of prevalence rate of goiter among high school girls in 1989 and present study in 1997 shows decrease in goiter rate, thanks to salt iodization (Ravanshad et al. 2003).

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CHAPTER 2 Review of literature

In a study in Netherlands school children it was found that thyroid volume increases with age, but a steep increase by 41% was observed in girls between 11 and 12 years, and by 55% in boys between 13 and 14 years, coinciding with peak height velocity. Girls have a larger thyroid volume at the ages of 12 and 13 years, but thyroid volume is larger in boys as of the age of 14 years (Wiersinga et al. 2001). In Dang district of Gujrat India it was found that females from both districts were affected more by iodine deficiency as evidenced by lower true urinary iodine and higher mean TSH levels. The interfering substances were significantly higher in Baroda boys and Dang girls as compared to their counterparts (< 0.001). Boys were more malnourished than girls as evidenced by lower BMI. Dang district was more severely affected by IDD as compared to Baroda. Drinking water in Dang district lacked in iodine. Iodine in salt varied at around 7 to 2000 PPM (Brahmbhatt et al. 2001). In another study in India the iodine status of 300 adolescent boys and girls was assessed by clinical examination and biochemical tests. TGR was 65.2% & 69.6% and visible goiter rate (VGR) 17.7% & 21.1% in boys and girls respectively. They had poor nutritional status. Using discriminate analysis it was found that age, height and weight of the adolescents were significantly related to goiter grade (p < 0.001).among these 38% were found to be suffering from mild (average UIE between 50-100 µg iodine/g creatinine) and 12.4% moderate iodine deficiency (UIE< 50 µg iodine/g creatinine) The results of this study indicate a high prevalence of mild to moderate IDD among them (Dodd and Godhia 1992). In Bosnia Herzegovina and in its some areas the goiter is endemic. These facts confirm that its soil bas been iodine deficient and that necessity for iodine prophylaxis is obvious here. A study conducted on 5,523 schoolchildren of 7-14 years of age from both sexes. They were randomly selected. Inspection and palpation methods were used for detection of goiter in them. The prevalence of goiter was 27.6% in Federation of Bosnia Herzegovina. The highest prevalence of goiter was 51.20% in Bosnia Podrinje Canton while the lowest 12.90% was in West Herzegovina Canton (Tahirovic et al. 2000).

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CHAPTER 2 Review of literature

An extensive IDD survey was conducted in Bangladesh in 1993 to assess the latest iodine status of the country. The clinical variables of the survey were goiter and cretinism, and the biochemical variable was urinary iodine. The study population consisted of boys and girls, aged 5-11 years, and men and women, aged 15-44 years, in about equal populations. The total number of respondents was 30,072. The current TGR (grade 1 + grade 2) in Bangladesh is 47.1% (hilly, 44.4%; flood-prone, 50.7%; and plains, 45.6%). The prevalence of cretinism in the country is 0.5% (hilly, 0.8%; flood-prone, 0.5%; and plains, 0.3%). Nearly 69% of Bangladeshi population have biochemical iodine deficiency (UIE < 10 mg/dL) (hilly, 84.4; flood-prone, 67.1%; and plains 60.4%). Women and children are more affected than men, in terms of both goiter prevalence and UIE. The widespread severe iodine deficiency in all ecological zones indicates that the country as a whole is an iodine-deficient region (Yusuf et a. 1996). Sikkim is a small state in the eastern Himalayas. A survey was conducted to determine the prevalence of IDD. A total of 17,837 subjects were studied from 3,197 households of 249 villages. Overall prevalence of goiter and cretinism in the community as a whole, were 54.03% and 3.46% respectively. Of the population studied, 5939 were children in the age group of 5 to 16 years (3,005 boys and 2,934 girls). Goiter was detected in 3,381 (56.9%). Goiter prevalence in the boys was 55.4% and in girls it was 58.5% (p = < 0.05). Grade I goiter was seen in 2,472 (73.1%), grade II in 888 (26.3%) and grade III in 21 (0.6%). The study shows the existence of severe iodine deficiency in the school-aged children of Sikkim (Sankar et al. 1994). Fuse and Igari et al. (2003) has reported the goiter rate of 43.3% in schoolchildren from Ulaan Baatar of Mongolia, wherein goiter is endemic in most of its parts. Luboshitzky and Dgani et al. (1995) have noted a progressive increase in goiter prevalence and size of thyroid with age, with peak occurrence around puberty i.e. 72.2%, in Ethiopian adolescent girls migrated to Israel. Pakistan is recognized as a country with a severe iodine deficiency in the school children (ICCIDD 1995). This fact is reflected in very a few studies done in this part of the world

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CHAPTER 2 Review of literature

Fig. 2.1

like one in done in the Swat district from NWFP Pakistan, which confirms high prevalence of IDD in school children. Here goiter is found 52% in male and 45% in female school children (Akhtar and Ullah 2003). Another study indicated that 40% of the population in Pakistan was at risk of IDD (Khavin and Nikolayer 1962). Vitamin A deficiency (VAD) affects the formation and maintenance of skin, mucous membranes, bones, teeth, vision, reproduction and immune system, leading to excessive skin dryness, dry mucous membranes, night blindness and susceptibility to bacterial invasion. VAD is cause by a) diet deficient in vitamin A, b) rapid growth as in adolescents and c) recurrent infection (Kinney and Follis 1958; Oomen et al. 1961 & 1964; McLaren 1966). Its deficiency is wide spread. There is evidence for the antiquity of night-blindness caused by lack of visual purple in retina, which requires VA for its formation. Its treatment is by liver (the richest natural source of VA) is mentioned by Hippocrates and in an Egyptian medical papyrus of 1500 BC. This visual abnormality commonly precedes and accompanies xerophthalmia, but may be difficult to detect in children. Its existence becomes especially apparent when occupation requires the adjustment of vision in a dim light e.g., sailors (Aykroyd 1970).

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CHAPTER 2 Review of literature

In 1961 Oomen et al., undertook a “global survey of xerophthalmia” in three broad areas of South & East Asia, the Near East & Northern Africa and Central & South America. It was a common finding in 1-3 years old children and was often related to weaning. With respect to geographical incidence, the condition occurs in most of the developing countries but is especially common in large urban areas in South and East Asia; with high prevalence Indonesia. Its intensity is less urban areas in the EMR, North Africa and Africa south of Sahara and Latin America. In West Africa it is rare owning to the use of red palm oil a rich source of carotene. For years it has been said that at least 50% of permanent blindness in south India was due to VAD (Venkataswami 1966). The current situation is also not so promising. In a study it is found that clinical VAD affects at least 2.80 million preschool children in over 60 countries, and sub clinical VAD is considered a problem for at least 251 millions schoolchildren and pregnant women (Stephenson et al. 2000) and it is associated with excess maternal mortality (West et al. 1999). Sub-clinical VAD is also widespread among adolescents. In Malawi, low serum retinol was observed in 27% of rural adolescent girls and 74% of the pregnant ones (Fazio-Tirrozzo et al. 1998). A study was conducted to asses the vitamin A (VA) status of pre-school (0-6 yrs) and schoolchildren (6-12 yrs) of lower SES from slums of Bombay and its suburbs. The VA, protein, calories and iron from the rice and pulse based diet was found to be below RDA. Among the 1956 children surveyed 20% showed low (< 20 µg/dL) serum VA levels. 4.8% of the children were suffering from one or the other signs of VAD. Mild conjunctival xerosis observed was correlated with serum VA levels (Aspatwar and Bapat 1995). A survey conducted for the evaluation of nutritional status of the population of pre-school and schoolchildren (n = 2357) of Jequitinhonha Valley from Brazil, with regards to VAD and IDA; revealed a) Hb: 23.9% & 20% in urban and 34.6% & 18.2% in rural area, b) Hematocrit: 1.5% & 2.2% in urban and 17.3% & 5.5% in rural c) VA: 8.9% & 4.4% in urban and 5.8% & 0% in rural area, had deficient values (< 10 µg/dL); 26.9% & 31.1% in urban and 26.9% and 23.6% in the rural area, had low values (10-20 µg/dL). These

25

CHAPTER 2 Review of literature

results are suggestive of IDA & VAD in these children. Conjunctival xerosis was seen in 3.16% & 6.04% in the urban and 7.7% & 12.6% in rural areas. Conjunctival xerosis with Bitot spot in 0.2%, corneal xerosis in 0.08% and kerotomalacia in 0.04% were observed. The therapeutic effect of 200,000 UI of oral VA was more efficient in preschool children (90.3%) than in schoolchildren (25.9%) (Araujo et al. 1986). In Pakistan the situation is not so different from other parts of the developing world. On the basis of prevalence and severity of VAD in Pakistan, WHO has classified Pakistan as one with sub-clinical VAD, which is considered to be a significant public health problem. Clinical evidence of VAD in Pakistan is rare but cross sectional studies conducted in different parts of the country suggest that sub-clinical VAD does exist in pre-school children at a significant level and the schoolchildren are no exception to it. Various studies carried out in Pakistan during 1961-1998 have proved that VAD a public health problem. Malik et al. (1968) have noted 2-3% incidence of Bitot’s spot in 5-12 years old school children in a survey from 1961 to 1963 at Lahore. The nutrition survey of West Pakistan in 1965-1966 revealed that the dietary intake of vitamin A containing foods was low in all income groups. In micronutrient survey of Pakistan (1977-1978) VA status was determined through dietary intake from 24 hours recall method and bio-chemical assay, vitamin A deficiency was found in 12.6% of the sample with plasma retinol levels < 0.7 µmol/L. A study conducted in the healthy population of Karachi revealed eye changes attributable to vitamin A deficiency to be 2.7% of 0-3 years of age and 26% among 4-15 years of age group (Ibrahim et al. 1997). A community based study in Peshawar revealed serum retinol levels in children < 0.7 µmol/L in 59% and less than 3.5 µmol/L in 7% (Paracha et al. 1998). In Colombian adolescence Medellin VAD is 3.6% regardless of the gender (Avarez Uribe 2004)

26

CHAPTER 3 Procedure of study

LOCALE
This research was carried out in the three girls’ schools of Rawalpindi city-the adobe of Rawals. This is in the northern region of Punjab province of Pakistan beside the federal capital-Islamabad. It lies at the outskirts of Himalayas, 520 meters above the mean sea level having particularly good climate with all four seasons. This is an industrial, trade & military center serving the northern Pakistan and Kashmir. This is gateway to Afghanistan. It was founded by Rawal a Ghakkar chief 500 years ago around the remains of Gajipur, the capital of Bhatti tribes. Farmers in the nearby countryside cultivate barley, maize, millet, mustard and wheat, and trade these products through Rawalpindi. The city’s water supply is provided by the Rawal Dam-which harnesses the flow of the Kurang River, Khanpur Dam on river Harro and deep tube wells. The Liaqat Gardens, Safari Park & Zoo, Public Park Murree Road and the beautifully landscaped Ayub National Park attract tourists and area residents alike. Its population is 1,406,214 (1998). Worm infestation is common especially the tape worm (Microsoft® Encarta® Encyclopedia 2004; Gazetteer of Rawalpindi 1893-4; Adamson and Shaw 1981). Its population is unique mixture of all the races of Pakistan as people come here to serve in the Federal Capital of Pakistan in various Government Departments.

Fig: 3.1. Location map of Rawalpindi

The schools under study are located in the Shamsabad, off Murree Road-Divisional Public School (DPS) and Dhoke Kashmirian-Government Comprehensive Girls Higher Secondary School (GCGHSS).

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CHAPTER 3 Procedure of study

THE STUDY POPULATION
All the individuals, who possess some common characteristics and we are interested to study some of their properties constitute a population. Each individual is a study unit. Size of population is denoted by the letter N (Kiani and Akhtar 2003). As nutritional status of the adolescent school girls at Rawalpindi is under study, the adolescent school girls from 10 – 16 years of age from Rawalpindi city constitute our study population. The reason for selecting this area is that population of Rawalpindi apart from locals consists of immigrants from nearby areas like Murree and other parts of the Punjab and small numbers from other provinces of Pakistan. So the adolescent girls from here are a mixture of rural and urban population. These also belong to various socioeconomic classes. The GCGHSS students mainly come from the lower income group & only a few from middle, as the education here is free and majority is from rural areas. The DPS is a public school and education here is costly. The girls studying here are mainly from the middle and a few from upper SES. So the samples taken from these schools are true representative of majority of the adolescent girls.

SAMPLE AND SAMPLING TECHNIQUES
Sample is a definite part of a statistical population whose properties are studied to gain information about the whole (Webster 1985) and its size is denoted by letter “n” (Kiani and Akhtar 2003). Sampling is the process of selecting a representative part of the population for the purpose of determining parameters or characteristics of the whole population (Margetts and Nelson 2000, pp 64-68). We obtain a sample rather than a complete enumeration (a census) of the population for being cheaper and are prepared to cope with its dangers. It helps in understanding and quantifying mathematical probabilities, trends, or relationships within a group. Sample for research study should be 5-10% of the population in size to be the true representative (WHO 1995). Two stage sampling technique was used (Steel 1980). In first stage two schools were randomly selected, one from private and other from government sector to afford a

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CHAPTER 3 Procedure of study

comparison of the girls from lower and middle income groups and in second stage 369 girls were selected through systematic random sampling technique (WHO 1995); 203 from GCGHSS and 166 from DPS. These girls were split into 2 groups i.e. early (10-13) and middle (14-16) adolescents. Inclusion or exclusion criteria were the specific age group.

RESEARCH DESIGN
This observational, cross-sectional study was aimed at the assessment of the nutritional status of the adolescent school girls at Rawalpindi. It also aimed at the assessment of VAD, IDD and IDA in this specific age group. The sample consisted of 369 girls. These were 166 from DPS and 203 from GCGHSS; selected through systematic random sampling technique. The first girl from each school was selected through balloting and subsequently every tenth girl from each section was taken to make the sample 10%. Their socio-demographic profile (education & profession of father & mother, family income and family size), anthropometric measurements (height, weight, age and age at menarche), dietary history (through semi quantitative food frequency questionnaire, noting the weekly, daily and one time consumption of cereal, meat, milk, egg, pulses, oils, DGLV and fruits groups in food), clinical examination (for micronutrient deficiency) and hemoglobin estimation (by cynmethemoglobin method) was done. For hemoglobin estimation a field laboratory was established at school under study. The survey for this study was done from 1st June 2003 to 12th June 2003. The data thus collected was analyzed on computer with the help of Statistical Package for Social Sciences (SPSS) and Epinfo-2000. Chi-square test was used to determine whether the results of the study sample were applicable to the population or not. The study was concluded by making recommendations for the target group.

PERMISSION TO VISIT THE SCHOOLS
Permission was obtained from the EDO (Education) Rawalpindi and the Principals of the schools (appendix 2). The later were personally approached and briefed about the study.

30

CHAPTER 3 Procedure of study

SCHOOL SURVEY SCHEDULE
Schools were visited according to the schedule attached as appendix 3. This survey schedule was discussed with principals of all the schools before the commencement of the study. The focal persons appointed by the school principals were homed at the study and its procedures. Their suggestions were well taken care of.

SENSITIZATION OF THE STUDY POPULATION
Before the study was launched the subject population was educated on the subject. The students were briefed on the subject of balanced diet and all the procedures to be done on them were explained in simple, understandable language. They were given a brochure on the diet, which explained the diet, balanced diet and study procedures (appendix 4)

CONSENT OF THE GIRLS FOR INTERVIEW AND EXAMINATION
Written consent of the girls was obtained on a form before interview and examination (see appendix 5)

RESEARCH TOOLS
These are the instruments of the research by which information is collected, observations are made and various tests are done. The tools and techniques used in this study were the questionnaire, clinical examination and laboratory tests.

1. Questionnaire: This was especially designed for the study and following
informations were collected: A.

Socio-demographic informations: In most forms of epidemiology the
populations of interest are described in terms of socio-demographic characteristics. The socio-demographic variables like age, gender and social class are also called face sheet variables as these are written on the front sheet

31

CHAPTER 3 Procedure of study

of the case (Margetts and Nelson 2000, pp 273-288). Following information were collected: I. Age is an important variable, which may be an indicator of biological states & processes (growth, development, maturation, metabolism and repair); of historical processes & contexts (Pakistan Independence Day); and of psychological & social processes (as adolescent girls have no obligation to cook & serve food to the family). This was measured in completed years (NNS 2001-02). II. Social class is a strong predictor of life chances and a key variable in nutritional epidemiology (Mcloone 1994). It is measured in a number of ways, lacks a gold standard against which to assess the accuracy and is subject to conceptual clarities. Usually these combine informations about education, occupation and income (Liberators et al. 1988). For this information about family income (income of father & mother in Pak rupees per month, from all the sources like salary and property etc), father & mother education & occupation was collected. III. Family composition is defined for census purposes as being persons who usually live and eat together, and having obvious relevance for nutritional epidemiology (Bradby 1996). This is important both as a predictor in its own right of nutritional exposures or outcomes, and as a control for other variables (Department of Social Security 1993 and 1994). B.

Dietary informations: Dietary data was obtained for all the adolescent
girls. There are many methods in use for the measurement of diet in cohort, cross-sectional and the interventional studies, where the aim is to assess contemporaneous diet (Cameron and van Staveren 1988; Bingham 1987; Black 1982). These methods generally consist either of the collation of observations from a number of separate days’ investigations, as in records, check lists and 24 hour recalls, or attempts to obtain average intake by asking

32

CHAPTER 3 Procedure of study

about the usual frequency of food consumption, as in diet history and food frequency questionnaires (FFQ). In all methods of dietary assessment, some estimates of the weight of food consumed is required and for the determination of nutrient or other food component intake, either an appropriate description for use with food tables or an aliquot for chemical analysis is necessary (Margetts and Nelson 2000, pp 134-6). Following methods were used: I. Food frequency questionnaires (FFQ): This is the most commonly used method in nutritional epidemiology, where evidence is sought for an association of diet in general, rather than with specific nutrients in a chronic disease (Morgan et al, 1978). These are designed to assess usual eating habits, over recent months or years, and comprise a list of foods most informative about the nutrients of foods of interest. These generally have been of the frequency and amount type (FAQ) in which the subjects are asked to say how often they usually consume an item of food or drink and how much they typically have on the days they consume it (Cu et al. 1984). For this a questionnaire to assess the semi quantitative food frequency intake was designed (appendix 6). II. Food groups: As all the food items cannot be included in the questionnaire, the most commonly used foods in our society can be categorized into groups, based on biological characteristics, function in meals or the dietary food pattern, or based on their nutrient value (Tierney et al. 2004; Margetts and Nelson 2000, pp 118 & 126). A very good agreement (75-100%) for the food groups i) pulses, ii) green leafy vegetables, iii) fruits, iv) milk products, v) eggs, and vi) flesh foods exits (Kapil et al. 2003). The food items were grouped in to following 12 groups: a) Roti, b) Rice, c) Meat & its products, d) Eggs, e) Pulses, f) Milk & its products, g) Oil/ghee, h) Desi ghee/butter, i) Carrot, j) DGLV, k) Fruits and l) Beverages (appendix 6).

33

CHAPTER 3 Procedure of study

III.

Portion size of the foods consumed: Various methods to assess portion sizes are used, for example fitting average portion weights derived from other data to the respondents’ chosen food and frequency selection (Thomas 1994) or asking subjects to describe amount in terms of household measures or standard portions. In this study measures as shown in the figure 3.2 were used. The respondents were asked in which bowl their food portion consumed fitted 50, 80, 100 or 200 gram size utensil.

Fig: 3.2. Measuring utensils

IV.

Technique: Each girl was interviewed by lady dietician or school teachers (especially trained to conduct a dietary interview) or the researcher himself. The girls were asked how many days in a week they took a particular food group. Then they were questioned how many times in a day they took this food. Thirdly they were questioned how much food they take at one time.

Fig: 3.3. Dietary interview

34

CHAPTER 3 Procedure of study

They were asked to use the bowls lying on the table. About the fruits and vegetables consumed raw, they were asked if the certain food is cut in to pieces which size utensil it will fill, the size/weight of the indicated utensil was noted as portion of the food standardized in grams. V. Calculating the calories and nutrient intake: For this purpose Food Composition Table for Pakistan (2001) and The Concise New Zealand Food Tables 3rd Edition, were used. Values for each group were calculated by taking the average of the component foods of each group.

2. Anthropometry: It is especially important during adolescence because it allows
the monitoring and evaluation of the hormone-mediated changes in growth and maturation during this period. Moreover, because growth may be sensitive to nutritional deficit and surfeit, adolescence anthropometry provides indicators of nutritional status and health risk, and may be diagnostic of obesity. The study and understanding of this period of rapid changes are, at once, important and difficult (WHO Technical Report Series (854) 1995). Published studies have identified important determinants and consequences of anthropometric variations and generated or confirmed important etiological hypotheses regarding adolescent body dimensions. Much less work has been done to extract from these data the specific information required for using adolescent anthropometric dimensions as indicators of health and nutritional status (WHO Technical Report Series (593) 1976). Nutritional status was determined as stunting (height-for-age Z-score < -2), thinness (BMI-for-age < 5th percentile), normally nourished (BMI-for-age > 5th & < 85th percentile) and at the risk of overweight (BMI-for-age ≥ 85th percentile) refer to appendix 8 & 10.. For this following anthropometric information about the respondents were collected: A. Height: The measurement of height was done against a vertical wall with an attached measuring tape and a horizontal head board that could be brought into contact with the upper most point on the head. The girls’ height was measured barefoot or in thin socks while they were wearing little

35

CHAPTER 3 Procedure of study

clothing so that the position of the body was seen. Each girl was asked to stand on the flat surface, with weight distributed evenly on both feet, heels together against the wall and the head positioned so that the line of vision was perpendicular to the body. The arms hanging freely to the sides, and the head, back, buttocks and heels were in contact to the wall. The girls were asked to inhale deeply and to maintain a fully erect position. The moveable

Fig: 3.4. Procedure of measuring height

Fig: 3.5. Measuring height

headboard was brought on to the topmost point on the head with sufficient pressure to compress the hairs. The height was measured in meters and recorded to the nearest 0.1 cm (Lohman et al. 1988). B. Weight: - The well calibrated bath room scale was used to weigh the girls. The weighing scale was calibrated with the help of 10 kg weight. This calibration was done after weighing 10 girls. The weight was measured with little clothing and bare feet. Weight was recorded to nearest 100 g (Lohman et al. 1988). C.

Menarche: The timing of the adolescent spurt and associated changes in
anthropometric dimensions are maturational phenomena. Maturational status must therefore be used to interpret the meaning of anthropometric

36

CHAPTER 3 Procedure of study

indicators of nutritional and health status based on chronological age. Breast development and attainment of menarche are used in girls (WHO technical report series (854) 1995). As the breast examination was not possible, the age at menarche was determined by questioning a) are they menstruating and b) what was their age at that time with the help of school teachers.

Fig: 3.6. Measuring weight

3. Clinical examination: - Clinical deficiency signs (or physiological
abnormalities e.g. dark adaptation decline) usually represent the extreme lower end of status and intake ranges. Although clinical investigations are very important in assessing the nutritional status, they frequently have the disadvantage of poor specificity (Margetts and Nelson 2000, pp 182) as these are rarely seen in ambulatory population. WHO have published guide lines for this (Jelliffe 1966). The clinical signs of VAD, IDD and IDA like Night blindness, Bitot’s spots, Xerophthalmia, Koilonychia and goiter (figures 3.7 – 3.14) were looked in these girls. Goiter was recognized through the examination of the neck of the girls. A swelling seen in the thyroid region of the neck from the front or from the lateral view of the neck, which moved on deglutition was read as visible goiter grade II, the other girls were

37

CHAPTER 3 Procedure of study

examined through palpation of the neck by moving to a position behind the patient.

Fig: 3.7. Night blindness

Fig: 3.8.Bitot’s spot

Fig: 3.9. Xerophthalmia

Fig: 3.10. Koilonychia

Cricoid cartilage is identified with the fingers of both hands. By moving downward

Fig. 3.11. No goiter

Fig. 3.12. Palpable goiter

Fig. 3.13. Visible goiter

Fig. 3.14. Visible goiter

and laterally below the second or third tracheal ring isthmus and lateral lobes of the thyroid gland are palpated. Their size, symmetry, and position are noted along with presence of any nodule. The normal gland is often not palpable (Swash 1989).

4. Biochemical estimation: - Laboratory methods of nutritional assessment are
considered to provide a more objective and precise approach to nutritional status, that is, when compared with community assessment, dietary methodology, or clinical assessment methods. They principally consist of biochemical tests performed in a laboratory (Liaqat 1997). In this study only hemoglobin (Hb) level of all the girls was measured by cynmethemoglobin method (Sir Decie and Lewis 1991). Following technique was used: -

38

CHAPTER 3 Procedure of study

A.

A field lab was established in the school being surveyed for the estimation of Hb by above selected method. All the equipment like, digital

Fig. 3.15. Digital hemoglobinometer

hemoglobinometer, Drabkin’s solution, blood lancets for finger pricks, methylated spirit for sterilization of the finger tips of the girls, test tubes, test tube racks, micropipettes, yellow tips and markers were supplied. Estimation was done by the trained laboratory technician hired from the hospital lab. B. The girls whose Hb was to be estimated was briefed about the procedure, so that she does not fear and cooperates with the laboratory staff. Her finger tip was sterilized with spirit, was pricked with sterile disposable lancet and 20 micro liter of blood was taken with the help of micro pipette. C. This blood was poured in the test tube containing 4 ml of Drabkin’s solution. It was thoroughly mixed and given a number for identification to avoid misinterpretation. This was allowed to stand for few minutes to allow the reaction to complete. D. Small amount of the solution is transferred in the cuvette, which is placed in the special hole in the photometer to measure absorbance of solution through a suitable filter. Hb is read in g/dL. E. Girls were declared anemic according to the WHO standards (8-11.99 years of age with Hb <11 g/dL, 12-14.99 years of age with Hb <11.5 g/dL and 15-

39

CHAPTER 3 Procedure of study

19 years of age with Hb < 11.7 g/dL) (WHO 2001), refer appendix 11; and those having Hb >7 g/dL were taken as severely anemic (WHO Technical Report Series (3) 1972).

COLLECTION AND CODING OF DATA
After taking the permission of school authorities and the girls, data for each subject was collected on separate questionnaires, as shown in appendix 6. All the respondents were given an identity number, by which they can be traced. Their name, age, their father & mother education, occupation and income were noted. Their family size was taken into account. Their anthropometric measurements and dietary history was taken. Their clinical examination was conducted by the physician, for ophthalmic examination the services of an ophthalmologist were obtained and in the end their hemoglobin level was checked. Occupation & education level of father & mother, clinical signs of VAD, IDD and IDA was coded (appendix 7) to facilitate entry of data into the computer.

STATISTICAL METHODS FOR DATA ANALYSIS
Data analysis is the art of putting the numbers together into meaningful expressions, which may lead to valid conclusions. Data was entered and cleaned using the SPSS version 11. The data was analyzed by SPSS and Epinfo-2000 and subjected to Chi-square test, to find out whether the results of this sample study are applicable to the population or not.

40

CHAPTER 4 Presentation & analysis of data and discussion

PRESENTATION AND ANALYSIS OF DATA
The data was collected for the adolescent girls from the two schools of Rawalpindi. The sample size (n) of this study was 369. Two sub samples were collected, one from each school i.e. 203 (55%) girls are from GCGHSS and 166 (45%) from the DPS. The data thus collected is presented, analyzed and the results are discussed in the following pages.

DEMOGRAPHIC PROFILE
1. AGE OF THE ADOLESCENT GIRLS: The mean age of the adolescent girls was 13.00 ± 1.49 years. Maximum number 89 (24.1%) of girls were 13 years old. Distribution of different ages is shown in figure 4.1. Two hundred and twenty six 61.2% were from early adolescent age group and 143 (38.8%) were from the middle.

Fig: 4.1. Age distribution in adolescent girls (n = 369)
15 yrs 11.9% 14 yrs 22.2% 13 yrs 24.1% 16 yrs 4.6% 10 yrs 3.5% 11 yrs 15.2% 12 yrs 18.4%

2. EDUCATION: The girls were studying in classes from 6 – 10th. Literacy rate of their fathers was 90.8% and mothers 72.6%. Only 18.7% parents had higher qualification and 60.74% mothers were above the primary level. Illiteracy was more prevalent in poor (p = 0.000), where 79.4% illiterate fathers and 73.3% mothers were poor. Literacy rate of parents was poor in GCGHSS (fathers 83.7% & mothers 55.2%) as compared to DPS (fathers 99.4% & mothers 94%).

42

CHAPTER 4 Presentation & analysis of data and discussion

Table 4.1: Parent’s education Education level Illiterate Primary Middle Matriculate Intermediate Graduate Postgraduate Professional Total Fathers Frequency Percent 34 09.2 19 05.1 23 06.2 90 24.4 48 13.0 86 23.3 40 10.8 29 07.9 369 100.0 Mothers Percent Frequency 27.4 101 11.9 44 05.1 19 22.5 83 13.3 49 14.6 54 04.3 16 00.8 03 369 100.0

3. PROFESSION: Profession truly affects one’s income which is the prime factor influencing the health and nutritional status of the family. The fathers of these girls belonged to different professions,1.1% were laborers, 36.7% government servants and 51.9% were self employed (private service and business). Mothers were mainly were housewives i.e. 90.8%, 6.5% government servants and rest in other professions. Table 4.2: Parent’s profession Profession Labor House wife Govt servant Private job Business Professional Technical Deceased Total Missing system Total Fathers Frequency Percent 04 01.1 135 36.6 86 23.3 105 28.5 10 02.7 14 03.8 14 03.8 368 99.7 01 00.3 369 100.0 Mothers Percent Frequency 90.8 335 06.5 24 01.1 04 00.5 02 00.5 02 00.3 01 00.3 01 100.0 369 -

43

CHAPTER 4 Presentation & analysis of data and discussion

4. HOUSEHOLD COMPOSITION: The mean household size was 7.15 ± 1.84 persons per family and mode of 6, which is 22.5%. The detailed breakdown of the various sizes in these schools is shown in figure 4.2. Larger sizes were more prevalent in the families of the adolescent girls from GCGHSS and poor SES (p = 0.000). Family size had no significant relationship with father education (p = 0.084), but had strong relationship with mother’s education (p = 0.000), as illiterate mothers had larger families. 5. SOCIOECONOMIC STATUS: The mean monthly income of these families was Rs. 12078/- and per capita income Rs. 1930 ± 1845/-. These figures revealed that 34.4% of the girls were living below the poverty line (Economic Survey of Pakistan 2002-03) and 65.6% above this line. Poverty was seen only in GCGHSS (p = 0.000) where 62.6% were

Fig: 4.2. Household composition (n = 369)

3 4 5 6

120 100

7 8 9

%

80 60 40 20 0 GCGHS School Rwp Div Public School Rwp

10 11 12 13 15

(p = 0.000)

44

CHAPTER 4 Presentation & analysis of data and discussion

living below poverty (n = 203).

ANTHROPOMETRICS
The mean age of these adolescent girls was 13 ± 1.49 years. Majority of the girls i.e. 24.1% were in the 13th years of their age. Their mean height was 1.512 ± 0.081 meters. Their mean weight was 41.4 ± 9.73 kg. They had the mean BMI of 17.95 ± 3.16 kg/m2, ranging from 12.33 to 35.82 kg/m2. Different indices were used to declare their nutritional status as stunted, thin, overweight or normal: 1. STUNTING: Out of the adolescent girls under study 6.8% were stunted. It was more prevalent in girls from GCGHSS (p = 0.009) 80% of the stunted belonged to this school and stunting was found in 20% of the girls from DPS see figure 4.3. No correlation could be established between stunting and poverty level, as 52% of the stunted girls lived above that level. 88% of the stunted girls consumed energy < RDA and in contrast 83.1% of the

Fig: 4.3. Prevalence of stunting (n = 369)
120 100 80 90 97

%
60 40 20 0 (p = 0.009) 10 Stunted (Z-score <-2) Normal (Z-score ≥-2)

SCHOOLS
GCGHSS Rwp Div Public School Rwp

Nutritional status (Height-for-age Z-score)

45

CHAPTER 4 Presentation & analysis of data and discussion

normally nourished girls also consumed energy < RDA. Only 7.1% of the girls who consumed calories ≥ RDA were stunted. Hence no relationship could be established between stunting and energy consumption. 2. THINNESS: The results indicate that 17.3% girls were thin, 77.8% normal and only 4.9% were at the risk of being overweight. Thinness had no significant relationship with school (p = 0.518) as shown in fig 4.4 and parent education. Thinness was more significant in early adolescents (p = 0.004) as shown in table 4.3, where 79.7% of 64 thin were from that age group. No relationship could be established between thinness, poverty and energy consumption by these girls.

Fig: 4.4. Prevalence of malnutrition (n = 369)
100

80 77

78

%

60 40

SCHOOLS
GCGHSS Rwp 19 16 DPS Rwp

20 0 (p = 0.000)

6 Thin (<5) Overweight (≥85) Normal (≥5 to <85)

Nutritional status (BM-for-age percentile)

46

CHAPTER 4 Presentation & analysis of data and discussion

Table 4.3: Malnutrition (criteria BMI-for-age) in different adolescent age groups Nutritional status according to BMIfor-age n Thin Normal Overweight Total p = 0.004 Table 4.4: Malnutrition (criteria BMI-for-age) and calorie consumption Calorie consumption by the girls Nutritional status according to BMI-for-age Thin Normal Overweight Total p = 0.419 Consuming calories < RDA n 54 241 13 308 % 14.6 65.3 03.5 83.5 Consuming calories ≥ RDA n 10 46 05 61 % 02.7 12.5 01.4 16.5 n 64 18 369 % 17.3 04.9 100 Total 51 165 10 226 % 13.8 44.7 02.7 61.2 Adolescent age groups (age in years) Early (10-13) Middle (14-16) n 13 122 08 143 % 03.5 33.1 02.2 38.8 n 64 18 369 % 17.3 04.9 100 Total

287 77.8

287 77.8

3. OVERWEIGHT: Obesity was very low in the girls under study, where only 4.9% were at risk of being overweight. 4. MENARCHE: Out of the total girls 69.4% were menstruating at the time of study. The mean age of menarche was 12.6 ± 0.84 years and range of 10 to 15 years. Among the menstruating girls 82.8% were well nourished, 6.3% were overweight and 10.9% were thin, which clearly indicates that there is a strong relationship between nutritional status

47

CHAPTER 4 Presentation & analysis of data and discussion

(BMI for age percentile) and the age of menstruation (p = 0.000) see table 4.5. No relationship could be found between age of menarche and stunting. Table 4.5: Relationship of menstruation and nutritional status (criteria BMI-forage) Menstrual status at the time of study Not menstruating Menstruating Total p = 0.000 n 36 28 64 Nutritional status (BMI-for-age) Thin % 09.8 07.6 17.3 Normal N 75 212 287 % 20.3 57.5 77.8 Overweight n 02 16 18 % 0.5 04.3 04.9 Total n 113 256 369 % 30.6 69.4 100

DIETARY SURVEY
1. MEAL PATTERN Three meals were taken per day i.e. break fast, mid-day meal and evening meal. The morning meal usually consisted of roti or paratha made from wheat flour and taken with Tea or Salan. Mid-day meal consists of roti with vegetable, pulse or meat curry. Evening meal was same as the mid-day. Rice was taken as meal sparingly, at the most twice a week. Snacks were infrequent between the meals. 2. INTAKE OF FOOD BY FOOD GROUPS A. Roti: This is made from wheat flour. Out of the adolescent girls under study 43.9% took roti through out the week. Roti was eaten twice daily by 55.8%. Its mean daily consumption was 176.3 ± 79.6 gm per head. This was the main source of energy in food of the girls. B. Rice: It is taken sparingly in this part of the country, maximum frequency was 2 times per week taken by 34.1% girls and 1.4% did not eat rice at all. Mean daily per head consumption of rice was 94.6 gm.

48

CHAPTER 4 Presentation & analysis of data and discussion

C. Meat and meat products: These are the main source of animal proteins but are eaten sparingly being costly. At the most it was taken 2 times per week only by 37.7% and 7.6% did not eat meat at all. Mean per head per day consumption of meat was 55.7 gm. D. Eggs: Consumption of eggs was also poor as 36.9% girls did not eat eggs. Maximum consumption of eggs was once per week by 16.3% girls. Mean daily consumption of eggs was 15.1 gm/person. E. Pulses: It was eaten 2 times per week by 44.7% of the girls and 3% did not take at all. The mean daily consumption of pulses was 49.6 gm/person. F. Milk: It was not consumed by 45% of the girls and 30.9% girls drank milk daily. The mean daily consumption of milk was 104.5 ml/person. G. Edible oils: This was taken by all the subjects through out the week and all times a day, as all the meals were prepared in oil or ghee. The mean daily consumption was 33.6 gm/person. H. Dark green leafy vegetables: These were consumed once a week by 37.7% girls and 12.7% did not eat DGLV. Mean daily consumption was 35 gm/person. I. Fruit: Consumption of fruit was relatively good and 44.4% of the girls eat fruit daily and only 4.6% did not take fruit at all. Mean daily consumption was 113.5 gm/person. 3. ENERGY CONSUMED Results indicate that mean daily caloric intake by these girls was 1524 ± 525. This came to be the 74.47% of the average RDA of 2033 calories for these girls. The main energy contributor was roti (wheat) i.e. 35.52% followed by oil/ghee as shown in fig 4.5. The calories consumption was low as 83.5% of the girls were consuming less than RDA (refer appendix 9) and only 16.5% of the girls consumed ≥ RDAs of the calories for their age; details are shown in table 4.6 & 4.7. A strong relationship existed between poverty level

49

CHAPTER 4 Presentation & analysis of data and discussion

and calories consumed by the girls (p = 0.000), as poor consumed less. Education of parents had a strong relationship with the calorie consumption by these girls (p = 0.000), more so in mothers, where 95% of illiterate mothers had daughters who consumed calories less than the RDA, where as this ratio was 79.1% in literate mothers.

Fig: 4.5. Share of different food groups in calories consumed by the girls (n = 369)
Fruit, DGLV, pulses, etc 20.52%

Roti 35.52%

Edible oils 19.57%

Milk 4.89%

Meat 19.5%

Table 4.6: Calories consumed by different adolescent age groups Adolescent age groups Calories consumed by the girls Early (10-13 yrs) n Consuming calories < RDA Consuming calories ≥ RDA Total p = 0.448 186 40 226 % 50.4 10.8 61.2 n 122 21 143 Middle (14-16 yrs) % 33.1 05.7 38.8 n 308 61 369 % 83.5 16.5 100 Total

50

CHAPTER 4 Presentation & analysis of data and discussion

Table 4.7: Relationship between energy consumption and poverty Poverty Calories consumed by the girls n Consuming calories < RDA Consuming calories ≥ RDA Total p = 0.000 4. PROTEINS The mean consumption of proteins was 43.84 ± 20.07 gm/person. That was 71.9% of the mean RDA. The consumption of proteins was considerably low in the adolescent girls as 85.6% of them were consuming proteins < RDA and only 14.4% consumed proteins according to RDA. Protein consumption was not related to poverty. 5. CONSUMPTION OF MICRONUTRIENTS IN THE FOOD These were determined by using food tables for Pakistan 2001. A. Iron: Consumption of iron in the food was generally low. The mean consumption was 17.21 ± 6.88 mg/day, which was 64.53% of the RDA; 78.05% girls were consuming iron less than RDA and 21.95% were taking iron according to RDA (refer appendix 9). B. Iodine and use of iodized salt: Iodine consumption was very poor in these girls. All the girls consumed less than the RDA. The mean daily consumption of iodine from the food was 27.66 ± 19.72 µg, which is 26.6% of the RDA. The girls using iodized salt were 56.4% of the adolescent girls under study. Iodized salt consumption was related with the literacy level of mothers (p = 0.000), as mothers of 79.8% girls using iodized salt were literate and 40.4% mothers of the girls not using this salt were illiterate. A strong relationship was 123 04 127 Poor % 33.3 01.1 34.4 Not poor n 185 57 242 % 50.1 15.4 65.6 n 308 61 369 Total % 83.5 16.5 100

51

CHAPTER 4 Presentation & analysis of data and discussion

observed between use of iodized salt and poverty (p = 0.000) as 58.9% of the girls not using iodized salt were poor and 80.8% using iodized salt were living above the poverty line. The lesser use of iodine was well mad up through the use of iodized salt. C. Vitamin A and β-carotene: The mean daily consumption of vit-A was 517.23 ± 403.01 RE, which is 94.04% of the RDA. The girls consuming vit-A less than RDA were 63.7% (refer appendix 9). The encouraging point is that vitamin A deficiency is covered by the conversion of dietary β-carotene to vit-A. The mean daily consumption of β-carotene by these girls was 2014.72 ± 1694.44 µg.

CLINICAL EXAMINATION FOR MICRONUTRIENT DEFICIENCY
1. Iodine: Clinical manifestation of iodine deficiency is observed as enlargement of the thyroid gland, which is denoted as goiter. The goiter prevalence in the adolescent girls under study was considerably high; total goiter rate was 52%. Break down of goiter grading is shown in figure 4.6. Goiter had no association with the school (p = 0.144) and age (p = 0.641). It was related to the consumption of iodized salt (p = 0.017), as 57.5% of the girls not using iodized salt had goiter; where as 50.5% of the girls using iodized salt were seen with goiter as shown in figure 4.7. Goiter was comparatively more prevalent in early adolescent age group i.e. 53.98% than the middle i.e. 48.95%.

Fig: 4.6. Prevalence of goiter (n = 369)

Visible goiter No goiter 48% Palpable goiter 34.1% 17.9%

52

CHAPTER 4 Presentation & analysis of data and discussion

Fig: 4.7. Goiter and use of iodized salt (n = 369)
100

80

80

%

60 58 50 40 42 50

Use of iodized salt
20 Do not use 20 Use 0 No goiter Goiter present Does not know

(p = 0.000)

2. Iron: Clinically iron deficiency is manifested as conjuntival pallor, which was seen only in 0.8% of the girls. 2. Vitamin A: No clinical signs of vitamin A deficiency were seen in the adolescent girls under study.

BIOCHEMICAL ASSESSMENT OF MICRONUTRIENT DEFICIENCIES
1. Hemoglobin (Hb) level: The mean Hb level of these schoolgirls was 10.5 ± 1.68 g/dL. Prevalence of anemia among these girls was very high i.e. 70.9% as shown in figure 4.8. Out of the adolescent girls under study 1.4% girls refused for finger prick and hence their Hb level could not be estimated. Anemia had no relationship with age group, stunting, thinness and energy consumption. 58.3% of the anemic girls belonged to poor socioeconomic status see table 4.8. Anemia was also related to parent education.

53

CHAPTER 4 Presentation & analysis of data and discussion

Fig: 4.8. Prevalence of anemia in adolescent school girls (n = 369)
Severely anemic 1.1%

Mild to moderately Anemic 69.8%

Not anemic 29.1%

Table 4.8: Anemia and socioeconomic status Socioeconomic status Anemia status N Anemic Not anemic Total p = 0.000 74 53 127 Poor % 20.3 14.6 34.9 n 184 53 237 Not poor % 50.5 14.6 65.1 n 258 106 364 Total % 70.9 29.2 100

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DISCUSSION
Pakistan is a third world country situated in the SAARC region, which is adversely affected by malnutrition, infectious and deficiency diseases (Raheena 2001). The prime factors leading to this bad situation are poverty, illiteracy, deteriorating socioeconomic situation, lack of health facilities, poor sanitation, lesser availability of food and larger household sizes (Choudhary 2003; Reifen 2003; Hesketh 2003; Kennedy and Garcia 1992; Leslie 1992). The adolescent group of population is also affected by these factors. Nutritional status of the adolescent girls under study is poor and is similar to the girls from other developing nations (Raheena 2001). Adolescent girls from developing and developed world behave similarly in certain respects i.e. food consumption, eating habits and food taboos (hot, cold etc.), where in certain foods are withheld from their diet (Gittelsohn 1991) and these factors lead to deficiency diseases in them. With this background the important findings of the study are discussed with reference to geographic, socioeconomic and cultural similarities and judged against the status of adolescence from the developed world accepting them as the standard. The study population was the adolescent girls of schools. The schools in Pakistan are from class one to the 10th. The adolescent age starts from the 10th year of the life and extends up to the 19th. The usual age of the last class of the school is 16 years. So the study sample was from the age of 10 to 16 years. For convenience the adolescent girls were divided into 3 groups i.e. early, middle and late adolescents. Our sample consisted of 61.2% early (10-13 years) and 38.8% middle (14-16 years). The earlier period is more important as puberty starts in this age group. Adequate nutrition is essential during this age because growth and development during this period plays a key role in attaining normal adult size and establishing reproductive capacity (Seidenfeld 2004). The education is a prime factor in maintaining health, nutrition and socioeconomic wellbeing of and individual and his dependents (Reifen et al. 2003; Hosegood and Campbel 2003). The education of these girls does not matter as for their nutritional status is concerned, what affects is the education of their parents, especially the mother. Parent

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CHAPTER 4 Presentation & analysis of data and discussion

education is the key component in determining the socioeconomic status (SES) of the family (Reifen et al. 2003), which is a main factor in choosing a school for the children and affecting their nutritional status. The parents had the literacy rate of 81.7% and 60.7% mothers were above the primary level. This literacy rate is much higher than the national literacy rate of 51.6% (Economic Survey of Pakistan 2002-03). The reason is that this segment of population is urban and the majority is in government services, who are usually an educated lot. Generally they are better caring towards their family in respect of education, health and nutrition. The post primary education for mothers is important because here they are taught the subject of Home Economics (Akhtar and Mashkoor 2003), which improves their home care, health and nutrition sense thus affecting their nutritional status. Hundred percent household heads (fathers) were employed, 1.1% laborers, 36.7% government servants (better educated from the whole lot) and others are self employed, undertaking various jobs/businesses. The mothers are mainly housewives i.e. 90.8%. Profession of the household head is a key factor in determining the socioeconomic status of the family. Urban areas offer plenty of job opportunities as compared to the rural ones. The hard fact is that majority are low paid, even the government servants are from the lower ranks. Household composition verily affects the nutritional status of an individual (Ramos de Marins 2004). The mean household size of 7.15 ± 1.84 was much higher and reflects the higher annual population growth rate i.e. 2.1% in Pakistan. The average Pakistani household size is 6.8. In Punjab it is 6.9, FATA 9.3 and in Islamabad it is 6.2 (Economic Survey of Pakistan 2002-03). In India it is 5.1 (Raheena 2001). Larger sizes are more prevalent in GCGHSS, in poor and illiterate mothers. Poor and illiterate mothers cannot be easily persuaded for the family planning measures and also have lower access to such facilities and hence they rear larger families. Household composition determines the per capita income and large sizes decrease it, thus increasing the poverty level and decreasing the availability of the food, good sanitation and health facilities to these girls, which affects their nutritional status.

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CHAPTER 4 Presentation & analysis of data and discussion

Socioeconomic status (SES) is the final outcome of the education, profession and income of the household. All these factors influence the SES and without improving the SES, nutritional status and education can’t be improved (Reifen et al. 2003). In the past it used to be measured as lower, middle and upper SES on the basis of household income only, which does not reflect the true picture. Now the household size is also taken into account and per capita monthly income is calculated, which is compared with the poverty line to declare one poor or non poor. According to the Economic Survey of Pakistan 2002-03 a person with per capita income below Rs. 748.52 per month is poor. This gives us the poverty level of a population, which is the true indicator of the socioeconomic status of an individual. The mean per capita income in this study was Rs. 1930 ± 1845. The poverty level in these girls was 34.4%, which is in line with the national poverty level of 31.8% (Economic Survey of Pakistan 2002-03) and Indian poverty level of 36.1% (Microsoft Encarta Encyclopedia 2004). Both the countries have similar socioeconomic and political conditions. Poverty in Pakistan is on increase, as it has increased from 29.1% in 1987 to 31.8% in 2003 (Economic Survey of Pakistan 2002-03). The contributing factors are decreasing job opportunities (unemployment rate has increased from 5.37% in 1993 to 7.82% in 2003) (Economic Survey of Pakistan 2002-03), slow industrial growth, political unrest and hostile international scenario. Poverty has many dimensions, as the poor has not only low income but they also lack access to basic needs such as food, education, healthcare, clean drinking water and proper sanitation. These factors further deteriorate the health and nutritional status of the people. Anthropometrics is used during adolescence in various contexts related to nutritional and health status. There are no well defined criteria or cut-off values that relate to specific risks or aspects of health in individuals. Available data are insufficient and it is quite likely that best cut-offs for one purpose are far from ideal for another. Better definitions await the results of further research. The reference values used for these indicators are derived from the data collected by NCHS in United States. In some cases local reference data may be required or other local factors must be considered. In the absence of such references WHO advocates the use of afore said data for this purpose, (WHO 1983; WHO Technical Report Series 854-1995) refer appendix 10.

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CHAPTER 4 Presentation & analysis of data and discussion

The malnutrition is expressed as stunting and thinness (wasting). Though one’s physical development is genetically determined, the availability of good diet, good sanitation and better health care facilities do play a role in the final outcome of genetic potentials of an individual (Garnier and Simondon et al. 2003; Khongsdier and Mukherjee 2003; Akhtar 1976). Stunting is a phenomenon of early childhood and a direct result of poor diets and infection (Martorell and Habicht 1986) and thinness or wasting a recent one. Stunting was 6.8% in this study and thinness 17.3%; it had no relationship with poverty, calorie consumption and age of the girls. Stunting is a frequent seen in GCGHSS where 100% of poor girls are studying and there are chances that they are chronically under nourished. Thinness is more prevalent in early adolescents i.e. 79.7%, who show a casual attitude towards feeding and are preoccupied with playing. Thinness may be related with calorie consumption as 84.4% of thin girls consumed calories less than RDA; in contrast 84% of the normally nourished consumed calories less than RDA. This shows no statistically significant relationship between calorie consumption and thinness. This may be due to fact that calories consumption was not properly calculated. This status is much better than the Indian, where 51.43%, 35.5% & 20% adolescent girls are reported to be suffering from chronic protein energy malnutrition (PEM), (Singh and Mishra 2001; Kapoor and Aneja 1992; Raman 1992), 46% in rural Nigeria (Glew et al. 2003) and Bangladeshi where 59% girls are malnourished (Shahabuddin et al. 2000). In Maputo, Mozambique stunting is 2.3% and wasting 10% (Prista 2003). In Saudi Arabian and other Gulf countries 11% adolescents are under weight (Abahussain et al. 1999). In US and other developed countries overnutrition is a problem rather than the undernutrition. In rural South Africa stunting was seen 7.3% and wasting 0.7% in school children (Jinabhai, et al. 2001). In a study in Peshawar Pakistan stunting and thinness is found to be 4.5% & 4% and 21% & 19% in adolescents from well off families and poor families respectively (Din and Paracha 2003). So the findings of this study are inline with the other studies conducted in other parts of the world apart from Pakistan. A strong relationship has been observed with the maturation and nutritional status of these girls as menarche occurs earlier in the girls with good nutritional status (Vitalle 2003). By the end of 15 years all the girls had started menstruating. The mean age of

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CHAPTER 4 Presentation & analysis of data and discussion

menarche in this study population was 12.6 ± 0.842 years. This age is at power with the US whites, US black and Bangladeshi girls’ i.e. 12.8, 12.5 & 12.67 respectively and less than the Indian and Iranian girls whose mean age at menarche is 13.5 & 13.01 respectively. Thai girls in Bangkok attain menarche at an early age i.e. 12.1 years (Mahachoklertwattana et al. 2002). Age at menarche reflects numerous health aspects of a population including the timing of sexual maturation, growth, nutritional status and environmental conditions (Chumlea et al. 2003). Age at menarche decreases as the SES improves; this is why the age of menarche has considerably lowered from the previous century (Tanner 1981). Menarcheal age is delayed for underweight subjects (Ayatollahi et al. 2002). This is due to the fact that wastage of Fe in the menstruation is delayed to make good the nutritional deficiency, which is a frequent finding in girls with a lower nutritional status. There was no correlation between stunting and the age of menarche, but larger number of thins were not menstruating. In the girls who are living above the poverty level better living conditions, better nutrition, increased social interaction and media all may play a role in maturing them at an early age (Tanner 1981). The same trend is seen in the girls living below the poverty level. This shows that there is no relationship between poverty and the maturational status (p = 0.355). This signifies the need for further research to explore other factors responsible for the early maturing trends. Meal pattern of these girls is typically of oriental style i.e. breakfast, lunch and dinner. Meat & meat products, milk & milk products, eggs and vegetables are taken sparingly by these girls like the US girls (USDA 1997). Daily roti consumption of 176.3 ± 79.6 gm per head is even lower than the national consumption of 322 gm, but is better than the Pakistani children i.e. 165 gm. Daily milk consumption of 104.5 ml by these girls is slightly better than the national value of 90 ml. Meat consumption of 57.7 gm is less than the mothers i.e. 72, but certainly better than the children i.e. 50 gm (NNS 2001-02). These figures are not ideal and may be a part of overall less consumption of food. Cost is the major insinuation in the lesser use of meat, milk and eggs, as these items are usually costly as compared to the other food items. This is due to the higher prevalence of poverty in this group, which is on the increase in Pakistan (Economic Survey of Pakistan

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CHAPTER 4 Presentation & analysis of data and discussion

2002-03). Vegetable consumption is low, which may be because of the personal likening of the girls. These factors render their food imbalanced. Calories provided from various food groups is not according to standard share of the food groups, as their 35.52% calories come from roti (carbohydrates-cereal group), 24.4% from milk & meat (protein group), 19.57% from oil/ghee (fat group) and 20.52% from other sources. Ideally it should have been 55-60% from carbohydrate group, 15-20% from protein group and 20-30% from fat group. This picture is suggestive of the fact that their diet is not balanced, which is reflected by increased presence of malnutrition and deficiency diseases (anemia & goiter). Calorie consumption in this study is 1523.6 ± 525.3, which is considerably low i.e. 74.7% of the RDA. This when compared with the national calorie consumption of mothers i.e. 2099, it is considerably low. More than 50% of the Pakistani women consume calories less than their RDA (NNS 2001-02), which include the adolescent girls. It is even lower than the Indian adolescent girl’s calorie consumption of 1609.19 ± 528.87 (Choudhary et al. 2003) and US girls, who consume 1809 calories per day (USDA 1997). Indian and US girl’s calorie consumption is also lower than the RDA. When we look for the reasons, poor socioeconomic status (Garnier and Ndiaye 2003; Garnier and Simondon 2003) is strongly associated with the calorie consumption by these girls (p = 0.000), lack of education is another reason; especially the mother education (p = 0.000). These factors do not explain the poor calorie consumption by the girls living above the poverty level and the girls from affluent nations like US. There may be other factors, which are responsible for this trend, e.g. dieting is mentioned in the literature to attain the appropriate body figures and avoid the social stigma of obesity (Barszez and Kolarzyk 2003; Story et al. 1998; Chapman et al. 1992; Lynam 1982). These girls have reduced physical activity with the increasing age as they are not encouraged by the parents to participate in the games and are kept busy in the kitchen or they are busy in studying, which reduce their appetite leading to lesser consumption of food. Lesser supply of calories to the girls may be a function of gender biases in access to food and health care, as compared to the boys, girls are fed with the mothers at the end of the main meal and hence fewer calories are made available to them, which is evident from the fact that malnutrition does not affect all members of the family equally, except in

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CHAPTER 4 Presentation & analysis of data and discussion

times of famine (National plan of action for the SAARC decade of the girl child 19912000 AD 1991; Gittelsohn 1991; Chatterjee and Lambert 1989; Batliwala 1987). Senior household members are served food before the children and especially the girls who are served in the end. Another important factor is that adolescent girls usually under report their calorie consumption (Bandini et al. 2003). Moreover the girls are permitted lesser outing as compared to the boys in this society and hence less chances of eating foods out side. This all is well supported by the finding that after marriage these girls gain weight rapidly when they are not that concerned with their body figures and have free access to food with lesser checks. It has been cited in the literature that certain foods are withheld from the diet of adolescent girls for being harmful, which appear to have an overall negative effect on their dietary diversity and intake (Gittelsohn 1991). Lower consumption of meat and eggs by the girls under study supports this fact. Chronic calorie deficiencies decrease the BMR as an attempt to conserve what ever is taken in the body (Ferro-Luzzi 1990) leading to anorexia and further malnutrition. Protein consumption of 43.84 gm per day is lower in the study population as compared to the consumption of 58 gm (NNS 2001-02). Up to 85.6% are taking proteins less than RDA. Poverty, lack of nutrition education, increasing cost of foods due to increasing inflation, large household sizes and lower food intake play a part in less protein availability and consumption. This may be due to certain taboos where in some protein rich foods are prohibited for female adolescents, for being hot, like meat, chicken, fish, eggs and dry fruit. Also there are flaws in estimating the consumption through food intake analysis (Hels et al. 2003). Pakistan is an area severely affected by iodine deficiency (ICCIDD 1995). The city of Rawalpindi is lying at the foot hills of Himalayas (a goiter prone region) (Kelly and Snedden 1958) and hence a place where goiter is frequently seen. The soil is deficient in iodine, which reduce its contents in the foods. Approximately 5% of the world population have goiter. Of these 75% are in the persons dwelling in geographic regions characterized by significant iodine deficiency, which are found in 115 countries, mostly in developing areas. In certain highly endemic areas up to 50% of population may have goiters (Tierney

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CHAPTER 4 Presentation & analysis of data and discussion

et al. 1998). In the light of these facts 52% total goiter rate in this study group is not a rare finding. In Iran it is 25% (Ravanshad et al. 2003), 72.2% in Ethiopian adolescent girls migrated to Israel, India 65.2% (Dodd and Godhia 1992), Netherlands 41% (Wiersinga et al. 2001), Bosnia 27.6% (Tahirovic et al. 2000), Bangladesh 47.1% (Yusuf et al. 1996) and Mongolia 43.3% (Fuse and Igari et al. 2003). In a study in Swat district of NWFP province of Pakistan goiter was seen in 45% of school girls (Akhtar and Ullah 2003). So the results of present study are very much in line with the studies conducted in developing/underdeveloped countries. Moreover the increased incidence of goiter in this age group is due to puberty spurts as its prevalence is more in early adolescents girls (53.98%) than in middle (48.95%), where pubertal changes occur around the age of menarche and this is more prominent in girls than in the boys (Fleury et al. 2001; Wiersinga et al. 2001; Luboshitzky and Dgani et al. 1995) and the study population is from early and middle adolescent age group. This is because physiological thyroid growth during puberty is mainly influenced by growth factors involved in somatic development and further modulated by sex steroid secretion profiles. The thyroid growth spurt coinciding with menarche in girls may contribute to a higher incidence of goiter during mid- to late puberty (Fleury et al. 2001) i.e. early and middle adolescent age group. Goiter is related to the use of iodized salt as 57.5% 146 not using it have goiter, and 50.5% of 208 using iodized salt have goiter. Use of iodized salt is poor (56.4%) in this study which needs to be improved, but it is certainly better than the national level of 17% (NNS 200102). This wide difference may be due to the fact that this study is undertaken in an urban area, where the people are more literate and better informed about the benefits of the iodized salt than the rural ones. But certainly it is lower than the developed and many underdeveloped countries; in Iran 97.75% of the adolescent girls use iodized salt. Clinical signs of vitamin A deficiency are not seen in the study population because it may be supplemented with the availability of the β-carotene vegetable based diets. Anemia is a global health problem and nearly 1.5 billion people all over the world are affected by iron deficiency anemia (IDA). It is generally recognized as the greatest nutritional problem among women as 52% of the pregnant and 35-40% non pregnant

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CHAPTER 4 Presentation & analysis of data and discussion

suffer from anemia (WHO 1992) and adolescents (DeMaeyer and Adiels-Tegman 1985). Diet is likely to be a major factor in its causation, as 80% of the adolescent girls consume less iron in their diet (Muratee 1990). In this study the prevalence of anemia is 70.9%, which is very high, but the third world countries have the same picture. In India it is 3872% depending on the age & sex (Chaudhary and Virs 1994) and 93.2% (Malhotra, and Passi 2004), in China 61.8% (Cai and Yan 1990), 68.8% in Nepal (Shah and Gupta 2002) and in Egypt 46.6% (el-Sahn et al. 2000). This shows that anemia is more prevalent in the developing and underdeveloped countries (Leenstra et al. 2004); Pakistan is also a developing country hence the findings of our study are in line with other third world studies and national Pakistani figures of 46% (Nutrition Country Paper 1992; WHO 1996), 50.9% (NNS 2001-02). But definitely our adolescence is far behind the developed world, like US where anemia is 9-11% (Leshan 1995), Auckland 11.5% (Schaaf 2000), Basque country 2.3% (Arenceta Bartrina et al. 1998), Brazil 17.6% (Fujimori et al. 1996) and UK 20.0% (Nelson et al. 1994). Though it is a third world dilemma, the adolescents from the developed countries also suffer from this problem as 20% in UK is quite a high figure. The main reason for the anemia in these adolescent girls is nutritional one. It is further strengthened when we look at the eating habits and consumption of different food groups by these girls. The iron rich foods like meat & its products are consumed sparingly i.e. at the most 2 times per week by only 37.7% girls and 7.6% don’t eat meat; the DGLV are consumed once weekly only by 37.7% and 12.7% don’t eat DGLV at all. Hence there is scarcity of blood forming micronutrients (Fe, vitamins & proteins) in their diet, which leads to anemia. The main source of iron for these girls is the cereal (wheat), but surprisingly this Fe is not made bio-available to the body because of their high contents of inhibitors i.e. phytate, tennate and oxalate and less contents of enhancers of iron absorption i.e. meat, fish, poultry and vitamin C (Hashizume et al. 2004; WHO/UNICEF/UNU 1994). Iron in the cereals can be made bio-available by fermenting the wheat flour or using citrus foods, which contain excess of ascorbic acid. No relation between anemia and malnutrition, SES and poverty level was found in this study. Anemia in this study is related to the education and social development (Hadden 2003). Lesser availability of food is third world problem and increased rate of anemia suggests that

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CHAPTER 4 Presentation & analysis of data and discussion

other factors also contribute towards it, which are intestinal parasites, 39-58% adolescent school girls suffer from it (WHO 1987), blood loss during menstruation (Senderowitz 1998) and infections. Age and menarcheal status did not affect the prevalence of anemia in this study. However, Dallman e t al. (1980) found the prevalence to be highest in 15 to 17 year old girls, who were menstruating. Our findings suggest that dietary factors superimposed by physical growth spurt in the study age group may be playing a larger role in causation of anemia than menstrual losses. However, a detailed dietary survey is required to address these issues (Shah et al. 2002).

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CHAPTER 5 Summary of findings of study, conclusions and recommendations

66

SUMMARY OF FINDINGS OF STUDY
This study provides an insight into the nutritional status and eating pattern of the adolescent girls. The data indicates that their dietary habits are less than ideal and so is their nutritional status. Anemia and goiter are prevalent in these girls. Clinical signs of vitamin A deficiency are not seen. Very interesting findings are noted in this study. A total of 369 adolescent girls from two schools of the Rawalpindi city were included in this study from the age 10 – 16 years. Among these 61.2% belonged to early and 38.8% to middle adolescent age groups. These girls were studying in classes 6 – 10th. Literacy rate of their fathers was 90.8% and mothers 72.6%. The mean household size was 7.15 ± 1.84 persons per family. Poverty level in these girls was 34.4%. Mean age of menarche was 12.6 ± 0.842 years. The girls mainly took three meals a day. Consumption of milk, egg, meat and DGLV in their diet was very low. Mean daily calorie consumption was 1532 ± 525 per head, which is 74.47% of the RDA (average for this age group is 2033). Main source of calories was roti made from wheat flour, which contributed 35.52%. Protein consumption was low i.e. 43.84 ± 20.07 gm/day, which is 71.9% of RDA. Micronutrients (iron, iodine and vitamin A) were consumed less than RDA. Stunting was seen in 6.8% girls, 17.3% were thin and only 4.9% were overweight. Anemia was very common i.e. 70.9%. Total goiter rate was 52%. No signs of vitamin A deficiency disease were seen in these girls.

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67

CONCLUSIONS
Nutritional status of these adolescent girls is not ideal as it is below the standard. Pakistan is a third world country and lacks for behind the developed nations in this respect, but the scenario is not so bad, when we compare these findings with the underdeveloped and developing countries. In fact we are much better than many of the later nations. Malnutrition is a significant problem. Anemia and goiter rates are high, which have a definite nutritional & social background, as these girls have low calorie and micronutrients consumption. Moreover their diet is not balanced. The major culprits are poverty, large family sizes, scarce health care facilities, lack of nutrition education and certain food taboos in adolescent girls. There is dearth of data both anthropometric and dietary, on adolescents' nutrition and health, to determine and confirm the prevalence of malnutrition (stunting, thinness and obesity), eating disorders and other micronutrient deficiencies (iron, iodine and vitamins) among adolescents in developing countries; whether catch-up growth is possible during adolescence and if so to what extent and how; if adolescent undernutrition is transferred into adulthood and reasons for gender differentials in adolescent nutritional status (Kurz and Welch 1994; Senderowitz 1998; Baldwin 1995). Extensive research is needed in nutrient consumption, eating patterns and impact of nutrition intervention (supplementation) in them. In order to develop appropriate anthropometric reference data, a multi-country study, with longitudinal and crosssectional components, on adolescents’ somatic growth and maturation should be considered a high priority. Such data is required to serve as cut-off points and an instrument to trigger action at program or individual level. Schools are ideal targets for food-based approaches to improving micronutrient status, in particular vitamin A and iron. The influence of school goes beyond the classroom and includes normative messages from peers and adults regarding foods and eating patterns.

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68

RECOMMENDATIONS
The nutritional status of the adolescent girls is strongly related with the future productivity of a nation and its economic growth. Realizing the importance of the nutritional status as the key indicator in the development process efforts should be made to help the vulnerable groups through different ways and means for its improvement. Their nutritional status can be improved by:1. Improving the knowledge of adolescents, parents, school teachers and other community members about nutrition, balanced diet and deficiency diseases. 2. Improving their dietary intake through locally available food resources by family involvement. 3. Supplementing their diet where dietary intake alone is not enough to fulfill certain nutrient requirements, such as Fe, initiate supplementation and/or food fortification programs. 4. Encouraging the use of iodized salt at household level for prevention of iodine deficiency disorders. 5. Short term feeding programs started by the government as a pilot project should be extended in all the schools of the country as the nutritional status of the girls is poor. 6. Providing health care facilities to prevent and treat infections & worm infestations for anemia alleviation and maintenance of good health. This segment of the adolescence being in schools can be best approached through school-based nutrition education programs. These programs should be part of comprehensive school health programs and reach students from preschool through secondary school. School leaders, community leaders, government functionaries, media and parents must commit to implementing and sustaining nutrition education programs within the schools. Such support is crucial to promoting healthy eating behaviors. Following recommendations are made: 1. Policy: Adopt a coordinated school nutrition policy that promotes healthy eating through classroom lessons and a supportive school environment, which can powerfully influence students' attitudes, preferences, and behaviors related to food.

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69

2. Curriculum for nutrition education: Implement nutrition education as part of a sequential, comprehensive school health education curriculum designed to help students adopt healthy eating behaviors. 3. Instruction for students: Provide nutrition education through developmentally appropriate, culturally relevant, fun, participatory activities that involve social learning strategies. 4. Integration of school food service and nutrition education: Coordinate school food service with nutrition education and with other components of the comprehensive school health program to reinforce messages on healthy eating. School cafeteria is a place for this. In its absence school cafeteria or the tuck shop should have a close liaison with nutrition people and promote healthy eating behavior. 5. Training for school staff: Provide staff involved in nutrition education with adequate pre-service and ongoing in-service training that focuses on teaching strategies for behavioral change. 6. Family and community involvement: Involve family members and the community in supporting and reinforcing nutrition education. Their attitude directly influences adolescents' choice of foods (Johnson CC-1994). Parents control most of the food choices available at home, so changing parents' eating behaviors may be one of the most effective ways to change their children's eating behaviors. 7. Involve media: Both print (newspapers, magazine) and electronic media (TV, radio and internet) can play a pivotal role in modifying the public behavior. 8. Regularly evaluate the effectiveness of the school health program in promoting healthy eating, and change the program as appropriate to increase its effectiveness.

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APPENDICES

Appendix 1:
Clinical signs indicative or suggestive of malnutrition (Tierney et al. 2004; Jelliffe 1966) Clinical signs Hair
1. 2. 3.

Nutrient deficiency
1. 2. 3. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1. 2. 1. 2. 1. 2. 3.

Transverse depigmentation Easily pluckable Sparse and thin Dry scaling Flaky paint dermatitis Follicular hyperkeratosis Perifollicular petechiae Petechiae, purpura Pigmentation, desquamation Nasolabial seborrhea Pallor Scrotal/vulvar dermatoses Subcutaneous fat loss Spooning (Koilonychia) Transverse lines, ridging Temporal muscle wasting Parotid enlargement

Protein, copper Protein Protein, zinc, biotin Zinc, vit. A, essential fatty acids Protein, niacin, riboflavin Vitamin A and C Vitamin C Vitamin C and K Niacin Niacin, riboflavin, pyridoxine Fe, folate, vit B12, Cu Riboflavin Calories Fe Proteins, calories Protein, calories Protein Vitamin A, zinc Riboflavin Vitamin A

Skin
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Nails
1. 2.

Head
1. 2.

Eyes Night blindness (inability to see in low level of light) 2. Corneal vascularization 3. Xerosis (excessive dryness of the cornea & conjunctiva), Bitot’s spots (small circumscribed, lusterless, grayish white, foamy, greasy triangular deposits on the bulbar conjunctiva adjacent to cornea in the palpebral fissure), keratomalacia 4. Conjunctival inflammation Mouth 1. Glossitis (scarlet, raw)
1. 2. 3.

4. 1.

Riboflavin

Bleeding gums Cheilosis, angular stomatitis

Niacin, pyridoxine, riboflavin, B12, folate 2. Vit C, riboflavin 3. Riboflavin

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4. 5. 6.

Atrophic lingual papillae Hypogeusia Tongue fissuring Goiter Thoracic rosary

Niacin, Fe, riboflavin, folate, B12 5. Zinc, Vit A 6. Niacin
4. 1. 1. 1. 2. 1. 2. 3. 1. 2. 3. 4. 1. 2. 3. 4. 5. 6. 7. 1.

Neck
1.

Iodine Vitamin D Thiamin Protein,-calorie Protein-calorie Protein-calorie Niacin, folate, B12 Thiamin, vit C Protein-calorie Protein, thiamin Vitamin C & D, Ca, P Thiamin Vitamin B12, thiamin Vit. B12, thiamin, niacin Thiamin Niacin Thiamin, P Ca, Mg Zinc, protein-calorie, Vit. C

Chest
1.

Heart High-output failure Decreased output Abdomen 1. Hepatosplenomegaly 2. Distension 3. Diarrhea Extremities 1. Muscle tenderness, pain 2. Muscle wasting 3. Edema 4. Bone tenderness Neurologic 1. Hyporeflexia 2. Decreased position and vibratory sense 3. Paresthesia 4. Confabulation, disorientation 5. Dementia 6. Ophthalmoplegia 7. Tetany Others 1. Delayed wound healing
1. 2.

Source: 1. Tierney, L. M., S. J. McPhee, and M. A. Papadakis, 2004. Assessment of nutritional status: Current Medical Diagnosis and Treatment. Lange Medical Books/McGraw Hill, New York. Pp 1210-3. 2. Jelliffe, D. B. 1966. The assessment of the nutritional status of a community. WHO monograph Series No 53, 194, 221-228.

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Appendix 2: Letter to the Executive District Officer (Education) Rawalpindi and
school Principals. To 1. Executive District Officer (Education) Rawalpindi 2. Mr. Muhammad Ayyaz Principal, Divisional Public School Rawalpindi 3. Mrs. Robina Tasneem Principal, Govt. Comprehensive Girls Higher Secondary School Rawalpindi

Subject: - STUDY FOR ASSESSMENT OF NUTRITIONAL STATUS OF ADOLESCENT SCHOOL GIRLS Respected Sir/Madam, Adolescence is the age (10 – 19), between childhood & adulthood, and a formative period during which many life patterns are learned and established. It a crucial and dynamic time for young people as they begin to develop their capacity for empathy, abstract thinking and future-time perspective; a time when the close and dependent relationships with parents and older family members begin to give way to more intense relationships with peers and other adults. It is also a time when physiologically, adolescents begin to reach their adult size, their bodies become more sexually defined and reproductive capacity is established. The concept of adolescence itself is in fact relatively new. Until the 20th century, the passage from childhood to adulthood occurred relatively quickly, usually coinciding with puberty and subsequent childbearing. More recently, both

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biological and socioeconomic landmarks bracketing the transition to adulthood have moved in opposite directions. Menarche occurs earlier and many societies' adjusted definition of social and economic maturing and independence has moved upward in the teen years. As a result, adolescence can no longer be viewed merely as a stage between childhood and adulthood. It is now a unique and important developmental period requiring specific programming and policy attention. As in this age rapid physiological, biological and mental changes occur, which require an increased supply of food rich in vitamins and energy. This requirement is not sufficiently met and adolescent girls are prone to develop nutritional deficiencies. About 27% of adolescents are estimated to be anemic in developing countries, compared to 6% in developed ones. Girls are often expected to have higher rates of anemia than boys because of iron lost during menstruation and pregnancy. Under-nutrition, seen as stunting and micronutrient (vitamin A. B, & D, iron, iodine, calcium and others) deficiency is a frequent seen in South Asia. This affects growth and reproductive health especially in the girls, thus limiting school achievement and work productivity. Preventing under nutrition is of special importance for adolescent girls because it can result in poor pregnancy outcomes, in particular low birth weight and consequently increased risk of infant mortality. For prevention of these nutritional deficiencies we need to know about the present status of this group. No research to explore it has yet been carried out in Pakistan and in fact very limited data is available even in developed world. I plan to undertake subject study for the completion of my thesis leading me to the degree of MSc (Community Health & Nutrition) from Allama Iqbal University Islamabad. You are please requested to cooperate in this regard by letting me to interview and examine the students from your schools.

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Dr. Arshad Mahmood Uppal

Appendix 3: SCHOOL SURVEY SCHEDULE
Particulars Name Location Date of visit Time Focal person School- 1 Higher Secondary School Dhoke Rawalpindi June 04 – 06, 2004 0900 Mrs. Mussarat Jabeen June 01 – 03, 2004 0900 Miss. Arjumand Azhar Kashmerian Shams Abad off Murree Road, Rawalpindi School- 2

Govt. Comprehensive Girls Divisional Public School

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Appendix 4:
Introductory brochure for girls

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Appendix 5: CONSENT FORM
I am a student of Allama Iqbal Open University Islamabad. I am conducting a research study for my MSc thesis. Your schools are selected for this survey. In this context I will be measuring your height and weight. You will be clinically examined for assessment of micronutrient deficiency. For biochemical estimation your Hb will be checked by taking a drop of blood from your finger tip through a prick by sterile disposable lancet. To carry out the dietary survey few questions regarding your dietary intake will also be asked. I hope you are willing to participate in this study. If you are willing please sign below. Signature of the student: Name of the student: Class: School: Signature of the witness (class teacher): -

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Appendix 6: QUESTIONNAIRE FOR ASSESSMENT OF NUTRITIONAL STATUS OF ADOLESCENT SCHOOL GIRLS AT RAWALPINDI

A. DEMOGRAPHIC PROFILE
S# 1 2 3 4 5 6 7 8 9 10 11 12 13 14 16 Name Roll No Class Age in completed years Address Father’s education Father’s profession Father’s income Mother education Mother’s profession Mother’s income Total income (6 + 9) Family size Brothers Sisters Particulars Response

B. ANTHROPOMETRIC MEASUREMENTS
1 2 3 4 Height in cm Weight in Kg Are you menstruating How old were you then

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C. SEMI QUANTITAITVE FOOD FREQUENCY INTAKE
Ser # 1 2 3 4 5 6 7 8 9 10 11 12 13 Roti Rice Meat & its products Eggs Pulses Milk & its products Oil/ghee Desi ghee/butter Carrot DGLV Fruits Beverages Use iodized salt Yes No Food items No of No of One time portion size standardized (gm) days/week times/day

D. CLINICAL EXAMINATION
Ser No 1 2 3 4 5 6 Clinical feature Night blindness (known cases only) Bitot’s spots in eyes Xerophthalmia Conjuntival pallor Koilonychia Goiter 0 = Non I = Palpable II = Visible Present Absent

E. HEMOGLOBIN ESTIMATION
Test Hemoglobin mg/dl (BMS digital Hb meter Cynox-1 USA) Observed value

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Appendix 7: CODING OF THE DATA
Ser No 1 2 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8 1 2 Feature SCHOOLS Government Comprehensive Girls Higher Secondary School 1 Rawalpindi Divisional Public School Rawalpindi EDUCATION Illiterate Primary Middle Matric Intermediate Graduate Post graduate Professional PROFESSIONS Laborer in fathers House wife in mothers Government servant Private job Business Professionals (doctors, engineers, lawyers, MBAs etc) Technical Deceased CLINICAL SIGNS OF VITAMIN A DEFICIENCY No sign Bitot’s spots 0 1 1 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 2 Code

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3 4 1 2 3

Night blindness Xerophthalmia CLINICAL SIGNS OF IRON DEFICIENCY No sign Pallor Koilonychia

2 3 0 1 2

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Appendix 8: Percentiles of BMI-for-age: female adolescents, 9-24 years* Age (yrs) 9 10 11 12 13 14 15 16 17 18 19 20-24 5th 13.87 14.23 14.60 14.98 15.36 15.67 16.01 16.37 16.59 16.71 16.87 17.38 15th 14.66 15.09 15.53 15.98 16.43 16.79 17.16 17.54 17.81 17.99 18.20 18.64 Percentiles 50th 16.33 17.00 17.67 18.35 18.95 19.32 19.69 20.09 20.36 20.57 20.80 21.46 85th 19.19 20.19 21.18 22.17 23.08 23.88 24.29 24.74 25.23 25.56 25.85 26.14 95th 21.78 23.20 24.59 25.95 27.07 27.97 28.51 29.10 29.72 30.22 30.72 31.20

*Reference data based on the first National Health and Nutrition Examination Survey (NHANES-1) in the United States of America (Must, Dallal and Dietz 1991. Reference data for obesity; 85th and 95th percentiles of body mass index (wt/ht2) – a correction. American Journal of Clinical Nutrition, 54: 773).

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Appendix 9: Recommended daily allowances for Pakistani adolescent girls of 10 – 19 years of age for selected major nutrients Age (years) Weight (kg) 10-12 12-14 14-16 16-19 Total Average 35.4 44.2 51.5 54.6 185.7 46.43 Energy (kcal) 1925 2040 2135 2150 8250 2062.5 Protein (gm) 52 62 69 66 249 62.25 Iron (mg) 30 30 20 20 100 25 VA (RE) 500 600 550 500 2150 537.5 Iodine (ug) 120 150 150 150 570 142.5

Adopted from Food Composition Table for Pakistan (revised 2001); prepared by Department of Agricultural Chemistry, NWFP University, Peshawar for Ministry of Planning and Development Government of Pakistan and UNICEF Islamabad page iii (their source is Nutrition in Growth and Health by Mushtaq Khan & Mushtaq Khan 1980, Islamabad, Pakistan)

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Appendix 10: Recommended anthropometric cut-off values and original sources of reference for adolescents Indicator Stunting or low height-for-age Thinness or low BMI-for-age At risk of overweight Obese BMI-for-age Triceps skin fold thickness-for-age Subscapular skin fold thickness Sources: 1. Hamill, P. V. V., et al. 1979. Physical growth. National Center for Health Statistics percentiles. American Journal of Clinical Nutrition, 32: 607-629. 2. Must, A., G. E. Dallal, and W. H. Dietz, 1991. Reference data for obesity; 85th and 95th percentiles of body mass index (wt/ht2) – a correction. American Journal of Clinical Nutrition, 54: 773 3. Johnson, C. L., et al. 1981. Basic data on anthropometric measurements and angular measurements of the hip and knee joints for selected age groups 1-74 years of age. Washington DC, National Center for Health Statistics, (Vital and Publication No. (PHS) 81-1669). Health Statistics Series 11, No. 219; Department of Health and Human Services ≥90th percentile ≥85th percentile ≥90th percentile -doOwen 1982 and Johnson et al. 1981 BMI-for-age ≥85th percentile -doBMI-for-age Anthropometric variable Height-for-age < 3rd percentile or < -2 Z-scores < 5th percentile Must et al. 1991 Hamill et al. 1979 Cut-off values Original references

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APPENDICES

4. Owen, G. M. 1982. Measurement, recording and assessment of skin fold thickness in childhood and adolescence: report of a small meeting. American Journal of Clinical Nutrition, 35: 629-638.

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Appendix 11: -

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RESUME
Title of the thesis: Assessment of nutritional status of adolescent school girls at Rawalpindi Major department: Name: Place and date of birth: Home and Health Sciences Dr. Arshad Mahmood Uppal Gujrat (Punjab) June 01, 1954

Qualifications:
Degree/ Diploma 1 FACP 2 MCPS 3 BSc 4 MBBS Institution American College of Physicians and Surgeons New York College of Physicians and Surgeons, Pakistan Punjab University Allama Iqbal Medical College, Lahore Subject Medicine Family Medicine Medical Medical University/ Year Country USA 1999 Pakistan Punjab Punjab 1990 1989 1981

Membership in learned or honorary societies:
1. District Red Crescent Society, Rawalpindi 2. Pakistan Medical Association, Rawalpindi/Islamabad 3. Pakistan Society of Family Physicians, Lahore 4. All Pakistan China Friendship Association, Islamabad 5. Public Relations Association of Pakistan, Islamabad 6. Holy Quran Research Foundation, Islamabad

Publications: Professional;
1. Mahmood, A. 1992. Indications of blood transfusion in surgical practice & ABO groups in blood donors at blood bank DHQ Hospital Rawalpindi. Rawal Medical Journal Vol. 20 (1), Pakistan Medical Association, Rawalpindi/Islamabad. 2. Mahmood, A. 1992. Practice of blood transfusion at DHQ Hospital Rawalpindi & prevalence of various blood groups in admitted cases. DOCTOR fortnightly International Vol. 14, No. 2, May 15 – 31:1992, Karachi – 74400, Pakistan.

3. Mahmood, A. 1993. Indications of transfusion of blood & prevalence of ABO & Rh D blood groups in emergency cases presenting at DHQ Hospital Rawalpindi. Specialist quarterly: Pakistan’s J. Medi. Sci. Jul – Sep 1993, Vol.9, No. 4, 377 – 382, ISSN 1017 – 4699 Karachi – 74400, Pakistan. 4. Mahmood, A. 1994. Blood transfusion. Medical Review Vol. 6, No. 4. Apr 1994, Karachi, Pakistan. 5. Mahmood, A. 1994. Blood transfusion in Gynae/OB cases admitted in DHQ Hospital Rawalpindi. Specialist quarterly Pak. J. Med. Sci. Oct – Dec Vol. 2, No.1, ISSN 1017 – 4699, Karachi – 74400. 6. Mahmood, A. 1996. Can we afford to operate on patients without HBsAg screening? CPSP Journal Vol. 6, No. 2, Mar – Apr. Pp. 98 – 100. Karachi – 75500, Pakistan. 7. Mahmood, A. 1998. Safe blood transfusion. DOCTOR fortnightly International, Vol. 18, No 1, 1 – 14 may.. Karachi – 74000, Pakistan. 8. Mahmood, A. 1998. Blood transfusion. Specialist quarterly Pakistan’s J. Med. Vol. 14, No. 3, 275 – 276, ISSN 1017 – 4699. Karachi – 74400, Pakistan. 9. Uppal, A. M. 2000. Safe blood transfusion-an outline. Neghaban Press, 12 AlKarim Market, Gordon College Road, Rawalpindi.

Publications: Miscellaneous:
1. Uppal, A. M. 1995. Qanoon-e-Shahadat aur Khawateen. a) Weekly Kashmir International Vol. 4, No. 48 – 49, 7 Dec. 1995, Rawalpindi, b) Daily Assas, Rawalpindi, Pakistan, 31 Dec. 1995, c) Monthly Media Times International, Islamabad. 2. Uppal, A. M. 1997. Castes and Uppals a socio–cultural study. Monthly Media Times International. Vol.1, No. 10, Oct 1997, 19. Saleem Plaza, Blue Area, Islamabad. 3. Uppal, A. M. 1999. Iddat–The waiting period (A scientific review). Monthly Tuloo-e-Mehr. Vol. 1, No. 8, Mar. 1999. 19 Saleem Plaza, Blue Area, Islamabad. 4. Uppal, A. M. 2000. Khoon is ka Istimal, banking, is say phailnay wali bemarian (AIDS, hepatitis B&C) aur Thalassaemia. (motivation literature in Urdu). With the courtesy of Siraj Flour & General Mills Fateh Jang Distt. Attock.

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