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II
D
DEED
DIIC
CAAT
TEED
DTTO
O
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
External Examiner
Internal Examiner
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 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 (computer-
based 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.
VII
TABLE OF CONTENTS
Chapter Title Page
1 INTRODUCTION
1.1 Adolescence 2
1.2 Nutritional status 3
1.3 Back ground on development of nutritional
assessment 5
1.4 Rationale of the study 6
1.5 Statement of the problem 7
1.6 Objectives of the study 8
1.7 Significance of the study 8
1.8 Limitations of the study 9
2 REVIEW OF LITERATURE
2.1 Nutritional status 12
2.2 Menarche 14
2.3 Iron deficiency anemia 16
2.4 Iodine deficiency disorders 20
2.5 Vitamin A deficiency 24
3 PROCEDURE OF THE STUDY
3.1 Locale 28
3.2 The study population 29
3.3 Sample and sampling techniques 29
3.4 Research design 30
3.5 Permission to visit the schools 30
3.6 School survey schedule 31
3.7 Sensitization of the study population 31
3.8 Consent of the girls for interview and examination 31
3.9 Research tools 31
3.10 Collection and coding of data 40
VIII
3.11 Statistical methods for data analysis 41
4 ANALYSIS OF THE DATA
4.1. Presentation and analysis of the data 42
4.2. Discussion 55
5 5.1. Summary of findings of the study 66
5.2. Conclusions 67
5.3. Recommendations 68
6 REFERENCES 71
7 APPENDICES
7.1. Physical signs indicative or suggestive of malnutrition 90
7.2. Letter to the EDO (Education) Rawalpindi and the
school Principals 92
7.3. School survey schedule 94
7.4. Introductory brochure for girls 95
7.5. Consent form 97
7.6. Questionnaire for assessment of nutritional status of
adolescence school girls at Rawalpindi 98
7.7. Coding of the data 100
7.8. Percentiles of BMI-for-age: female adolescents,
9-24 years 102
7.9. Recommended daily allowances for Pakistani
adolescent population of 10 – 19 years of age for
selected major nutrients 103
7.10. Recommended anthropometric cut-off values and
original sources of reference for adolescents 104
7.11.Normal age and gender related changes of
hemoglobin and hematocrit values for children and
adults 106
IX
LIST OF TABLES
No Description Page
4.1 Parent’s education 43
4.2 Parent’s profession 43
4.3 Malnutrition ( criteria BMI-for-age) in different adolescent age groups 47
4.4 Malnutrition (criteria BMI-for-age) and calorie consumption 47
4.5 Relationship of menstruation and nutritional status (criteria BMI-for-age) 48
4.6 Calories consumed by different adolescent age groups 50
4.7 Relationship between energy consumption and poverty 51
4.8 Anemia and socioeconomic status 54
X
LIST OF FIGURES
No Description Page
XI
LIST OF ABBREVIATIONS
Abbreviation Detailed description
µg Microgram
µmol Micromole
BC Beta carotene
bev Beverage
BMI Body Mass Index
COMSTECH Commission for Science and Technology
DGLV Dark Green Leafy Vegetables
DPS Divisional Public School
EDO Executive District Officer
EMR Eastern Mediterranean Region
FAO Food and Agriculture Organization
FFQ Food Frequency Questionnaire
g Gram
G&B Ghee and butter
g/dL Grams per deciliter
GCGHSS Government Comprehensive Girls Higher Secondary School
Hb Hemoglobin
ICNND Interdepartmental Committee on Nutrition for National Defense
ICRW International Center for Research on Women
IDA Iron Deficiency Anemia
IDD Iodine Deficiency Disorders
INAN Instituto Nacional de Almentacao e Nutricao
L Litter
M & m prd Meat and Meat Products
M prd Meat products
MCHC Mean corpuscular hemoglobin concentration
mg Milligram
XII
NCHS National Center for Health Statistics
NHANES National Health and Nutrition Examination Survey
NIH National Institute of Health
O& G Oil and Ghee
p Asymptotic Significance Value (2-sided)
PCV Packed Cell Volume
PEM Protein Energy Malnutrition
PGR Palpable Goiter Rate
PIDE Pakistan Institute of development Economics
PPM Parts Per Million
QAU Quaid-e-Azam University
RBCs Red Blood Cells
RDA Recommended Daily Allowance
SATMU Science and Technology in the Muslim Ummah
SD Standard Deviation
SES Socio Economic Status
SF Serum Feritin
TGR Total Goiter Rate
TIBC Total Iron Binding Capacity
UI Units International
UIC Urinary Iodine Excretion
UK United Kingdom
UNU United Nations University
USA United States of America
VA Vitamin A
VAD Vitamin A Deficiency
VGR Visible Goiter Rate
WHO World Health Organization
XIII
""Y Yoouu ccaannnnoott hhaam mm meerr aa ggiirrll iinnttoo aannyytthhiinngg.. SShhee
ggrroow wss aass aa fflloow weerr ddooeess -- sshhee w wiillll w
wiitthheerr w
wiitthhoouutt
ssuunn;; sshhee w wiillll ddeeccaayy iinn hheerr sshheeaatthh aass aa nnaarrcciissssuuss
wwiillll iiff yyoouu ddoo nnoott ggiivvee hheerr aaiirr eennoouugghh;; sshhee m maayy
ffaallll aanndd ddeeffiillee hheerr hheeaadd iinn dduusstt iiff yyoouu lleeaavvee hheerr
wwiitthhoouutt hheellpp aatt ssoom mee m moom meennttss ooff hheerr lliiffee;; bbuutt
yyoouu ccaannnnoott ffeetttteerr hheerr;; sshhee m muusstt ttaakkee hheerr oow wnn
ffaaiirr ffoorrm m aanndd w waayy iiff sshhee ttaakkeess aannyy.."" JJoohhnn
RRuusskkiinn,, ""SSeessaam mee aanndd L Liilliieess,,"" 11886655
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 later-
maturing 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
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 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.
4
CHAPTER 1 Introduction
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.
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.
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 hard-
to-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.
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.
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.
9
CHAPTER 1 Introduction
10
CHAPTER 2 Review of literature
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,
14
CHAPTER 2 Review of literature
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).
15
CHAPTER 2 Review of literature
Iranian school girls attain menarche at the age of 12.91 ± 1.23 years (95% CI: 12.84-
12.97). 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
16
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).
17
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).
18
CHAPTER 2 Review of literature
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 non-
vegetarians (17 v. 32%). Low Hb was present in 25% of girls who had tried to lose
19
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
20
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 deaf-
mutes 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).
21
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).
22
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
23
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).
24
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.
28
CHAPTER 3 Procedure of study
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 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
29
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 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
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.
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)
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: -
31
CHAPTER 3 Procedure of study
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: -
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.
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.
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.
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
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).
36
CHAPTER 3 Procedure of study
37
CHAPTER 3 Procedure of study
examined through palpation of the neck by moving to a position behind the patient.
Cricoid cartilage is identified with the fingers of both hands. By moving downward
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
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).
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.
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
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.
16 yrs 10 yrs
15 yrs 4.6% 3.5% 11 yrs
11.9% 15.2%
14 yrs 12 yrs
22.2% 18.4%
13 yrs
24.1%
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
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.
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
7
120
8
100
9
80
% 10
60
11
40 12
20 13
0 15
GCGHS School Rwp Div Public School Rwp
(p = 0.000)
44
CHAPTER 4 Presentation & analysis of data and discussion
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
120
100
97
90
80
%
60
40
SCHOOLS
20
GCGHSS Rwp
10 Div Public School Rwp
0
Stunted (Z-score <-2) Normal (Z-score ≥-2)
(p = 0.009)
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.
100
80
77 78
% 60
40 SCHOOLS
GCGHSS Rwp
20
19
16 DPS Rwp
0 6
Thin (<5) Overweight (≥85)
(p = 0.000) Normal (≥5 to <85)
46
CHAPTER 4 Presentation & analysis of data and discussion
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.
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.
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.
Edible oils
19.57% Milk Meat
4.89% 19.5%
50
CHAPTER 4 Presentation & analysis of data and discussion
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.
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
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.
Visible goiter
17.9%
No goiter
48%
Palpable goiter
34.1%
52
CHAPTER 4 Presentation & analysis of data and discussion
80
80
% 60
58
50 50
40 42
Use of iodized salt
20 Do not use
20
Use
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.
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
Mild to moderately
Anemic Not anemic
69.8% 29.1%
54
CHAPTER 4 Presentation & analysis of data and discussion
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).
41
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.
42
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.
43
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
44
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
45
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
46
CHAPTER 4 Presentation & analysis of data and discussion
times of famine (National plan of action for the SAARC decade of the girl child 1991-
2000 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
47
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 2001-
02). 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
48
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 38-
72% 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
49
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).
50
CHAPTER 5 Summary of findings of study, conclusions and recommendations 66
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.
66
CHAPTER 5 Summary of findings of study, conclusions and recommendations 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).
67
CHAPTER 5 Summary of findings of study, conclusions and recommendations 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: -
68
CHAPTER 5 Summary of findings of study, conclusions and recommendations 69
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APPENDICES
Appendix 1:
Clinical signs indicative or suggestive of malnutrition (Tierney et al. 2004; Jelliffe
1966)
Clinical signs Nutrient deficiency
Hair
1. Transverse depigmentation 1. Protein, copper
2. Easily pluckable 2. Protein
3. Sparse and thin 3. Protein, zinc, biotin
Skin
1. Dry scaling 1. Zinc, vit. A, essential fatty
2. Flaky paint dermatitis acids
3. Follicular hyperkeratosis 2. Protein, niacin, riboflavin
4. Perifollicular petechiae 3. Vitamin A and C
5. Petechiae, purpura 4. Vitamin C
6. Pigmentation, desquamation 5. Vitamin C and K
7. Nasolabial seborrhea 6. Niacin
8. Pallor 7. Niacin, riboflavin, pyridoxine
9. Scrotal/vulvar dermatoses 8. Fe, folate, vit B12, Cu
10. Subcutaneous fat loss 9. Riboflavin
10. Calories
Nails
1. Spooning (Koilonychia) 1. Fe
2. Transverse lines, ridging 2. Proteins, calories
Head
1. Temporal muscle wasting 1. Protein, calories
2. Parotid enlargement 2. Protein
Eyes
1. Night blindness (inability to see in low 1. Vitamin A, zinc
level of light)
2. Corneal vascularization 2. Riboflavin
3. Xerosis (excessive dryness of the 3. Vitamin A
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 4. Riboflavin
Mouth
1. Glossitis (scarlet, raw) 1. Niacin, pyridoxine, riboflavin,
B12, folate
2. Bleeding gums 2. Vit C, riboflavin
3. Cheilosis, angular stomatitis 3. Riboflavin
90
APPENDICES
Source:
91
APPENDICES
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
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
92
APPENDICES
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.
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.
93
APPENDICES
94
APPENDICES
Appendix 4:
Introductory brochure for girls
95
APPENDICES
96
APPENDICES
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.
Class: -
School: -
97
APPENDICES
Appendix 6: -
QUESTIONNAIRE FOR ASSESSMENT OF NUTRITIONAL
STATUS OF ADOLESCENT SCHOOL GIRLS AT RAWALPINDI
A. DEMOGRAPHIC PROFILE
S# Particulars Response
1 Name
2 Roll No
3 Class
4 Age in completed
years
5 Address
6 Father’s education
7 Father’s profession
8 Father’s income
9 Mother education
10 Mother’s profession
11 Mother’s income
12 Total income (6 + 9)
13 Family size
14 Brothers
16 Sisters
B. ANTHROPOMETRIC MEASUREMENTS
1 Height in cm
2 Weight in Kg
3 Are you menstruating
4 How old were you then
98
APPENDICES
99
APPENDICES
Appendix 7:
10
APPENDICES
3 Night blindness 2
4 Xerophthalmia 3
CLINICAL SIGNS OF IRON DEFICIENCY
1 No sign 0
2 Pallor 1
3 Koilonychia 2
10
APPENDICES
Appendix 8: -
Percentiles of BMI-for-age: female adolescents, 9-24 years*
Age Percentiles
(yrs) 5th 15th 50th 85th 95th
9 13.87 14.66 16.33 19.19 21.78
10 14.23 15.09 17.00 20.19 23.20
11 14.60 15.53 17.67 21.18 24.59
12 14.98 15.98 18.35 22.17 25.95
13 15.36 16.43 18.95 23.08 27.07
14 15.67 16.79 19.32 23.88 27.97
15 16.01 17.16 19.69 24.29 28.51
16 16.37 17.54 20.09 24.74 29.10
17 16.59 17.81 20.36 25.23 29.72
18 16.71 17.99 20.57 25.56 30.22
19 16.87 18.20 20.80 25.85 30.72
20-24 17.38 18.64 21.46 26.14 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).
10
APPENDICES
Appendix 9: -
Recommended daily allowances for Pakistani adolescent girls of 10 – 19 years of age
for selected major nutrients
Energy Protein Iron VA Iodine
Age (years) Weight (kg)
(kcal) (gm) (mg) (RE) (ug)
10-12 35.4 1925 52 30 500 120
12-14 44.2 2040 62 30 600 150
14-16 51.5 2135 69 20 550 150
16-19 54.6 2150 66 20 500 150
Total 185.7 8250 249 100 2150 570
Average 46.43 2062.5 62.25 25 537.5 142.5
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)
10
APPENDICES
Appendix 10: -
Recommended anthropometric cut-off values and original sources of reference for
adolescents
Indicator Anthropometric Cut-off values Original references
variable
Stunting or low Height-for-age < 3rd percentile or Hamill et al. 1979
height-for-age < -2 Z-scores
Thinness or low BMI-for-age < 5th percentile Must et al. 1991
BMI-for-age
At risk of BMI-for-age ≥85th percentile -do-
overweight
Obese BMI-for-age ≥85th percentile -do-
Triceps skin fold ≥90th percentile Owen 1982 and
thickness-for-age Johnson et al. 1981
Subscapular skin ≥90th percentile
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 Health
Statistics Series 11, No. 219; Department of Health and Human Services
Publication No. (PHS) 81-1669).
10
APPENDICES
10
APPENDICES
Appendix 11: -
10
RESUME
Qualifications:
Degree/ University/
Institution Subject Year
Diploma Country
1 FACP American College of Physicians Medicine USA 1999
and Surgeons New York
2 MCPS College of Physicians and Family Pakistan 1990
Surgeons, Pakistan Medicine
3 BSc Punjab University Medical Punjab 1989
4 MBBS Allama Iqbal Medical College, Medical Punjab 1981
Lahore
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.
4. Mahmood, A. 1994. Blood transfusion. Medical Review Vol. 6, No. 4. Apr 1994,
Karachi, Pakistan.
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.