NUTRITIONAL STATUS OF ADOLESCENT GIRLS IN

RURAL AREA OF VARANASI

Seema Choudhary1, C.P. Mishra2, K.P. Shukla3

1. Resident, 2. Senior Lecturer, 3. Ex. Professor, Department of Preventive and Social Medicine, Institute of
Medical Sciences, Banaras Hindu University, Varanasi- 221005
Seema Choudhary et al. Nutritional Status of Adolescent Girls

INTRODUCTION
At the time of independence maternal and childhood mortality was at peak. Country was
confounded with illiteracy, poverty and resources were meagre. During first developmental plan
priority was accorded to MCH services and inspite of all odds, success has been achieved in bringing
down mortality indicators. Emphasis had been put on raiding nutritional status of under five children
through a number of initiatives including Integrated Child Development Scheme. However, benefits of
various nutrition programmes have not been so profound particularly in case of girl child. It is now
realized that nutritional insult at earlier ages leaves their mark during adolescence. Besides this, this
is a period of great turbulence. Because of puberty spurt, rapid physical growth do take place during
this period and therefore nutritional requirements are quite different. In adolescent girls psychosocial
and emotional problems are of considerable magnitude and they may exert significant influence on
their nutritional status. Although genetic codes set the upper limit of optimum growth, the environment
in which they thrive can help or hinder realization of that goal. During adolescence, gender based
discrimination prevails in various ways viz. selective nutritional neglect of girls, differential investment
or expenditure on health care, educational opportunities and work force participation.

Unfortunately assessment of nutritional status of adolescent girls has been the least explored
1,2
area of research particularly in rural India. The findings of studies on school children (girls) can not
be extrapolated to adolescent girls, as their school enrollment as well as sustenance are less than
that of boys. It is likely that girls not attending schools belonged to disadvantaged section of society
and contribute significantly in domestic and peridomestic activities, there by jeopardizing their health.
With this background this community-based study was undertaken to assess the nutritional status of
adolescent rural girls of Varanasi district.

MATERIAL AND METHODS

The approach adopted for this community based study was cross sectional one.
Sample size estimation was based on the extent of under nutrition in adolescent girls. As per literature
1-4
search and a pilot study conducted in Chiraigaon block, prevalence of malnutrition in rural
adolescent girls ranged from 50-72% and thus taking a middle course a prevalence rate of 60% was

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Seema Choudhary et al. Nutritional Status of Adolescent Girls

assumed. By taking this prevalence and permissible level of error as 10%, sample size was computed
as 267. In all, 270 adolescents were enrolled for the study.

Following steps were involved in the selection of study subjects: [a] one Community
Development Block (i.e. Chiraigaon) was selected from eight CD Block of the Varanasi District by
simple random sampling; [b] Villages of Chiraigaon were stratified into 3 strata according to distance
(Viz. < 7 Km, 7-14 Km and > 14 Km) from Block headquarter and from each stratum one village was
selected by simple random sampling; [c] In the selected villages, total enumeration of adolescent girls
was done. This served as the sampling frame. The required study subjects were selected adopting
probability proportion to size (PPS) sampling technique.

The primary tools in this study were predesigned and pretested interview and examination
schedules for recording of family as well as individual informations. Libra weighing machine, steel
anthropometric rod with parallel bar and measuring tape were utilized for weight, height and mid arm
circumference (MAC) recording, respectively. Hemoglobin estimation was done with the help of
5
Sahli's Hemoglobinometer. Each study subject was subjected to weight, height, MAC measurement
6
and Hemoglobin estimation following standard techniques.

Data, thus generated, were analyzed with the help of personal computer using SPSS
package. Nutritional status of study subjects was assessed by using various parameters viz. weight
for age, height for age, weight for height MAC for age and Body Mass Index (BMI). Relevance of
th 7
these parameters were examined against available reference values viz. 50 Centile of NCHS for
7
weight for age and height for age, Frisancho for mid arm circumference for age, Baldwin and Wood
5 8
table for weight for height and First National Health and Nutrient Examination Survey (NHANES I)
for BMI for age. BMI of each study subject was computed by using the formula weight (kg)/ height
2
(m ). Study subjects were graded in different grades of nutritional status according to previous WHO
9
and proposed criteria for Asians . Their anthropometric parameters (viz weight, height and MAC) at
5
different age points were compared with the corresponding reference value .

RESULTS

Nutritional status of study subjects was assessed by employing direct methods viz. clinical
examination, anthropometry and hemoglobin estimation. On clinical examination 53.33% adolescent
girls were of normal build. Vitamin A, B, C and D deficiencies were present in 13.70%, 4.07%, 15.92%
and 0.00% study subjects, respectively. Subjects with Bitots spot were 3.33%. As much as 25.90%

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Seema Choudhary et al. Nutritional Status of Adolescent Girls

and 13.33% study subjects had anaemia and dental caries; correspondingly value for iodine deficiency
disorders (IDD) was 4.44% (Table 1).

TABLE-1: Clinical manifestations in adolescent girls (n=270)

Various anthropometric indices were used to pinpoint nutritional status of adolescent girls
(Table 2). In 55.56% subjects BMI for age was ≤ 90% of BMIs at different age points . BMI for age of
8

17.41% adolescent girls was > 100% of their reference values. As per Proposed Asian and Previous
WHO criterias, 68.52% adolescent girls were under weight (BMI < 18.5). According to Proposed
Asian criteria subjects with normal nutritional status were 28.52%; corresponding value by Previous
WHO criteria was 30.74%. Adolescent girls who were categorized as overweight by Proposed Asian
2 2
(23 to 24.9 kg/m ) and Previous WHO (25-29.9 kg/m ) criterias were 2.22% and 0.74% respectively.
None of the study subjects were labeled as obese as per Previous WHO criteria; however 0.74%
subjects belonged to this category according to Proposed Asian criteria. As much as 19.63%
adolescent girls suffered from chronic energy deficiency (CED) grade I; corresponding value for
grade II and grade III was 17.78% and 31.11%, respectively.

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Seema Choudhary et al. Nutritional Status of Adolescent Girls

TABLE- 2: Nutritional status of study subjects (n=270)

Adolescent girls with weight for age ≤

7
80% of the reference value were 71.45%;
corresponding value for subjects with weight
for age ≤ 60% was 12.56%. As much as
32.59% of study subjects were stunted
(height for age ≤ 90% of the 50
th
Centile
NCHS value ). Wasting (weight for height ≤
7

9
90% of reference ) was present in 54.44%
adolescent girls; 3.70% were severely
wasted. In 80.37% subjects MAC was ≤ 80%
7
of the reference (Table 2).

Average weight, height and MAC of study

subjects have been examined against
reference value at different age points. The
average weight (37.31 ± 8.05 kg), height
(146.25 ± 8.75 cm) and MAC (20.58 + 2.58
cm) of study subjects were 73.63, 91.98 and
82.81%, of their estimated references,
respectively (Table 3).
7
In comparison to reference values ,
weight and MAC of adolescent girls were
m i ni m u m i .e . 6 4 . 20 % and 77 . 93 % ,
respectively at. 12 years, while corresponding
value for height (87.56%) was between 15 to 17
years of age (Table 3).

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Seema Choudhary et al. Nutritional Status of Adolescent Girls

TABLE- 3: Anthropometric parameters of adolescent girls according to their age

th 5
* 50 centile of NCHS values were taken as reference value .
5
** Reference values for MAC were based on Frisancho .

Average hemoglobin of adolescent girls was 12.44 ± 1.29 gm/dl. As much as 30.74% study
10
subjects were anaemic (Hb < 12 gm%). As per WHO guidelines 2.22% adolescent girls had marked
anaemia/i.e.Hb <10 gm /dl (Fig. 1). Average hemoglobin of menstruating girls (12.65 ±1.3 g/dl) was

significantly (p<0.001) more than that of non-menstruating girls(12.10 ± 1.21 g/dl).

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Seema Choudhary et al. Nutritional Status of Adolescent Girls

Mean Hb of adolescent girls using foot wear during defecation (12.6 ± 1 . 2 g%) was
significantly (p<0.001) higher than that of subjects without footwears (12.2 ± 1.4 gm %). Extent of
anaemia (Hb < 12 gm/dl) in this group (20.00%) was significantly less (p< 0.001) than that in subjects
(42.30%) not using foot wear (Table 4).

[
TABLE- 4:Association of footwear used during defecation with haemoglobin status of adolescent girls

DISCUSSION
Clinical examination has always been, and remains an important practical method for
assessing the nutritional status of a community. Nutritional anaemia has been considered as an
important problem in adolescent girls. Clinically one out of four adolescent girls suffered from
11
anaemia. This figure is less than the figure reported elsewhere . Adverse nutritional status of study
subjects is also substantiated by existence of signs of vitamin deficiencies. Vitamin A deficiency has
11
been higher than the figure reported by other researcher , while vitamin B complex deficiency has
12
been comparatively much lower than the figure reported in a study of rural Rajasthan . For IDDs and
11,13
dental caries the findings of study have been in conformity with other studies .

Nutritional anthropometry predominates over the other methods of nutritional assessment.

14,15
Several workers have emphasized the importance of Body Mass Index (BMI) as an index of
13,16,17
nutritional assessment. As reported elsewhere high prevalence of undernutrition (BMI<18.5)
was observed in adolescent girls of rural Varanasi on the basis of this index. One third of the study
subjects suffered from chronic energy deficiency grade III which reflects high degree of nutritional
insult in adolescent girls. In contrast to the observation of present study lower figures of under
13,16
nutrition have been reported in other studies . Weight for age and weight for height represent

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Seema Choudhary et al. Nutritional Status of Adolescent Girls

current nutritional status. This situation is serious with respect to the findings of present study.
17
However, comparatively low figure has been reported by other researcher . The maximum under
nutrition observed on the basis of mid arm circumference and weight for age at different age points is
in close agreement at early adolescent age. Which indicates that adolescent girls are the worst
sufferers of the ravages of various forms of malnutrition since the beginning of adolescent period. This
phenomenon remains uninterrupted through out their life. This is substantiated by the fact that in this
study stunting which is considered as index of chronic or long duration of malnutrition was maximally
present during middle and late adolescence. However, comparatively lower figures of stunting have
11,18,19
been reported by some researchers . Variations in the extent of under-nutrition among
adolescent girls could be attributed to differences in socio-cultural practices, level of socio-economic
development, value attached to girl child and prevailing dietary practices in different settings.

Besides clinical examination and nutritional anthropometry, hemoglobin (Hb) estimation is an

important component of nutritional assessment. Nutritional anaemia even if it is prevalent in
adolescent girls its proper assessment needs Hb estimation and study of biochemical parameters.
Perceptible difference has not been observed in the extent of anaemia by clinical observation and
hemoglobin estimation, thereby indicating applicability of clinical examination for detecting anaemia in
13,20
adolescent girls. In contrast to reports elsewhere low prevalence of anaemia was observed in
adolescent girls of study area. It is interesting to note that menstruating girls had higher hemoglobin
level than that of non-menstruating girls. Findings of the study (Table 4) also supports the view that
use of footwear during defecation particularly in situations where open field defecations is in practice
may be helpful in reducing anaemia in a given community. Thus the nutritional status of adolescent
girls has been far from satisfactory which calls for urgent interventions at individual, family as well as
community level.

CONCLUSION
A considerable proportion of adolescent girls had clinically obvious nutritional deficiency
2
diseases. Two third of study subjects were undernourished (BMI <18.5 kg/m ); nearly one third
experiencing CED grade III (BMI < 16). However* with varying parameters extent of under-nutrition in
adolescent girls also varied. Nearly one third girls were anaemic (Hb<12 gm/dl); anaemia was
significantly more in non-menstruating girls and subjects not using footwear during defecation.

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Seema Choudhary et al. Nutritional Status of Adolescent Girls

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