A comparison of the dietary pattern ofadolescent schoolgirls in two definedurban andrural settings.

*V Kumarapeli, *Athauda

Abstract

Objectives: To compare the dietary patternand somerelated factors among adolescentschoolgirls in two defined urban and ruralsettings.

Methodology: A —_crosi-sectionalcomparative study was carried out amongadolescent schoolgirls in year eleven classes,attending selected Grade 1AB schools intwo defined urban and rural settings. A self-administered questionnaire which included afood frequency questionnaire was used toassess the food habits and some relevantfactors such as independence of dietaryhabits, awareness on body size (bodyimage), dieting and exercise, foodpreferences, cultural ‘beliefs and attitudes(food taboos).

Results: Consumption of meat products,eggs, fish, vegetables, soft drinks, milkproducts and sweets was higher amongurban adolescent girls. Dried fish and darkgreen leaves was consumed more by ruraladolescent girls and the consumption offruits showed a mixed pattern, The studyshowed that the food habits of the subjectsare less independent even in the urbansetting. Although the concept of body imagewas a concern to some extent, especiallyamongurban adolescent girls, it was not soprevalent as in industrialized countries.

Introduction

WHOhasdefined an adolescentas a personbetween 10 and 19 years of age. During thisperiod eating habits ofthe child changeintothose typical of an adult. Very little is

' Department of Community Medicine,Faculty of Medicine, University of,Colombo.

?Senior Lecturer, Department of Community.Medicine, Faculty of Medicine, Universityof Colombo.

Journal ofthe Community Physician of Sri Lanka

known about young peoples’ food intake (1).Eating habits of adolescents are characterized byhigh energy intake, missed meals, unconventionalmeals, fast foods and frequent snacking, especiallyin urban societies. Adolescents like meats, sweets,

cakes and carbonated sugar drinks and are reluctantto eat green leafy vegetables and organ meat(2).Mostadolescents are more concerned about theirlooks than about any other aspects of themselves.Many are fearful of becoming obese (3). Foodchoices of many girls are influenced by theirpreoccupation with dieting and body weight (2, 4)

With urbanization, the food industry flourished,exacted substantial influence by promotingconsumption of soft drinks, meat products,confectioneries, snack foods etc. especially withfemale employment, use of processed food hasincreased However, these are expensive andrefined, rich in fat, salt and sugar, with artificialcolors and additives, calorie dense butdeficient indietary fibers and micronutrients, which are calledjunk foods (5) Manystudies have shown that thereis almost a universal increase in fat, animalproducts and free sugar consumption in urban areas,compared to rural communities, which usuallydepend on their staple crops of cereals, tubers,vegetables and fruits (6,7). Increases of urbanpopulation shown in national census from 10.6% in1891 to 21.5% in 1981might have shifted the foodconsumption pattern in Sri Lanka as well (8).

Data are limited on adolescent food habits in SriLanka, Hencethe study was under taken with theobjective of comparing the dietary pattern amongadolescent schoolgirls in defined rural and urbansettings

Methodology

A cross-sectional comparative study was carriedout to assess dietary pattern in two defined groupsofadolescentschoolgirls... The rural sub-populationconsisted of all girls in year eleven classes,attending the two Grade 1AB schools in MirigamaPradeshiya Sabha Division and who were residentsof the same area, The urban’ sub-populationconsisted of all girls in year eleven classes,attending three randomly selected Grade 1ABschools in the Colombo Municipality and who wereresidents of the samearea, 233 rural girls and 246urban girls participated in the study. The study wasconducted within a period of 6 weeks starting fromearly July 2001.

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‘A self-administered questionnaire (SAQ)which included a food frequencyquestionnaire) assessing the frequency offood intake during the previous one month.Thefrequency categories were continuous.But only the consumers of a given fooditem, who had a frequency “2 to 3 times aweek”or more were included in the finalcomparison as it was thought that theconsumption of food items onlyat thesefrequencies would have any effect on anindividual’s nutritional status (9). The SAQalso obtained information on some factorsrelevant to food habitssuch as independenceof dietary habits, knowledge on nutrition,awareness on body size (body image),dieting and exercise, food preferences,cultural beliefs and attitudes(food taboos).

Anthropometric measurements includedweight and height, The Body Mass Index(BMI) was calculated and the prevalencethinness (percentage below the 5"percentile) and over weight (percentage overthe 85" percentile) was calculated fromNCHSreference data for BMBfor age (10).

Results

The majority of girls in the ‘ural samplebelonged to families with a monthly incomeof Rs. 4001-10 000 while the majorityin theurban sample were from families withmonthly a income of over Rs. 10 000. Themajority of (p<0.0001) mothers in the urbansample had ‘Advanced Level education andabove’ while the majority of rural mothersbelonged to the ‘Grade6 to Ordinary Level’category. Significantly larger percentage(p<0.01) of girls (38.9%) in the urbansample had mothers who were employed.

Food habitsConsumption of all milk products wasgreater amongurban girls but a significantdifference was observed only for butter,cheese (p<0.0001) and yogurt (p<0.05)Among. fruits, consumption of plantains,apples, oranges and grapes was significantlyhigher (p<0.01) in urban girls while theconsumption of guava (p<0.00001) andavocado (p<0.05) was significanily high inrural girls. Consumption of all short-eatswith the exception of Chinese rolls wasgreater among urban girls with significant

Journal ofthe Community Physician ofSri Lanka

differences for patties and pastries, Consumption ofsweets was higher among urban girls but onlychocolate and ice cream showed a significantdifferent (p<0.0001). Soft drinks and fresh fruitjuices were consumed by a significantly largerpercentage of urban girls. (p <0.00001)Consumption of meat was compared using selectedfood items (chicken, sausages and meatballs) thatwere consumed by both groups at relatively highrates. Urban girls were foundto be eating meat at asignificantly higher rate (p<0.01) than rural girls.Consumption of dark green leaves was higheramong rural girls but the difference was notsignificant. Consumption of rice and bread wascompared at a frequency of ‘once daily or more’Rice consumption was 94.8% among rural and96.8% among urban girls at this frequencyConsumption of bread had a significance difference(p<0.00001) at the same frequency - 66.9% ruralgirls compared to 82.2% urban girls. Potatoes wasthe only tuber consumed at a high rate in bothsettings, consumption among rural girls (74.2%)was found to be significantly higher (p<0.01) thanamongurban girls (62.2%). Consumptionof othertubers was very low. Dhal was the only largelyconsumed pulse (rural 82.4%, urban 88.6%) whileconsumption ofother pulses was low (15-25% inboth settings)

Independence ofdiet

For a great majority of rural girls meals wereprepared almost daily by their mother (92.7%),which was significantly high (p<0.01) compared tourban girls; nevertheless the percentage for theurban girls was also high (84.1%). The majority in,both settings (82.8% in rural and 85.0% in urban)consumed dinner with their family almost daily. Agreat majority in both settings (98.2% rural and97.1% of urban) rarely or occasionally eat atrestaurants accompanied by family, friends oralone,

A significantly lager (p<0.01) percentage of urbangirls (45.5%) consumed a school meal which wasbrought from home. In both settings the majoritybought food from the school canteen in addition tothe meal brought from home, with a significantlyhigh percentage in the rural setting (p<0.01). Whenfoods brought from home were analyzed wasseen that rural girls brought mostly rice (93.1%)while only 46.3% of urban girls brought rice(p<0,000001). Bread was brought from home by asignificantly larger percentage of urban girls(66.3%) compared to rural girls (8.6%).

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Table! Distribution of the contents of the school meal boughtat the school canteen by rural and urbanadolescent girl

Rural Urban

No % No %Rice/bread/string hoppers 8 32 7 53Short eats 147 94.8 n 54.1*Sweets 0 0.0 34 25.6

Milk products 0 0.0 3 23Soft drinks 0 0.0 33 248 Multiple response question

‘When food bought from the canteen wasanalyzed a significantly larger number (p<0,00001) of rural girls bought short-eatscompared to urban girls, Sweets, milk

Difference betweentwoproportions *P<0.00001

products and soft drinks were bought exclusivelybyurban girls (Table 1).

Table 2. Assessment ofthe awareness of body image / body size amongrural andurban girls.

Rural UrbanNo % No %

Underweight @ 29.6 60 244Appropriate 123, 52.8 124 50.4

41 17.6 62 25.2"Overweightobese

Total 233 100.0 246 100.0

Difference between two proportions*P<0.05

Themajority of girls in both settings thoughtthat their weight was appropriate. Althoughthere was nosignificant difference betweenthose who thought themselves to be under-weight, significantly higher percentage of

Difference between two proportions*p<0,0001

urban girls thought themselves to be obese (Table2). The majority in both settings were concernedabout their parents’ commentson their body image.Fewergirls were concerned about their friends andrelatives commented.

‘Table 3. Distribution of the nature ofthe attempts at controlling weight amongrural andurban adolescentgirls.

“Attempted t matntain weightAttempted to reduce weightAttempiedto increase weightAll not relevantTotal

Rural

6140

2B109233,

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Urban% No62 «SR72 84

99 28468 761000 246

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%23634.1na3098

1000

15

The majority of rural girls had neverattempted to control weight while one thirdof urban girls had attempted to controlweight sometimein the past (Table 3).

Table 4. Distribution of being on a diet atthe time ofthe study and the reason amongrural and urban adolescentgirls.

Rural UnNo % No

Yes, to reduce 22 94 46 I87*Yes, to increase 13 56 18 73Yes, to maintain 38 163 46 18.7Not ona diet 160 68.7 136 55.3*total 233-100. 246 100.0

0

Difference between two proportion *p<0.01The majority of girls in both settings werenotcontrolling their diet at the time of thestudy.

Table 5. Distribution of BMI amonggirlswho thought they were over- weight orobese.

Rural Urbanned n-62No % No %

15" to 84" percentiles 32 78.0 44 709

285" percentile 8 195 17 274

Baseline knowledge on nutrition

Knowledge on nutrition was assessed usingthree sets of multiple-choice questions.When scores obtained were analyzed asignificantly higher (p<0.01) percentage ofurban girls (96.7%) had scored ‘three ormore’ out of five compared to rural girls(89.3%). In both settings the majority gotinformation on nutrition from elders/parents(rural 93.5% and urban 96.7%), schoolteachers were the second commonest sourceand radio was the least common. Nosignificant difference was observed withregard to the source of information on

Journal ofthe Community Physician ofSri Lanka

nutrition among the adolescent girls in the twosettings.Food taboosAlthough almostone third ofthe population ineach setting (rural 36.1%,urban 30.1%) avoidedcertain foods at menstruation no significantdifference was seen between rural and urbansettings. The majority in both settings wereadvised by parents to avoid certain foods duringmenstruation (rural 89.3% and urban 77.0%)relatives being the second highest but theinfluenceof other sources was very low.

Discussion

Significant differences existed between rural andurban settings in socio-economic status, whichcan have a great impact on dietary patterns andmayhave played a role in the differences noted inthe present study.

Adolescentfood habitsComparison ofthe dietary habits of the two settingscan beused to assess the degree of urbanization. Inthe present study consumption of meat products,eggs, fish, vegetables, soft drinks, milk products,cordial and sweets was higher among urbangirls.Significantly high consumption in urban settingscould beassociated with urbanization or indirectlyrelated to the better socio-economic status of urbandwellers, as these food items are relatively costly.Relatively low cost may contribute to thesignificantly higher consumption of dried fish bythe rural girls. Higher consumption ofcertain fruitsand dark green leaves by rural may bepossiblydetermined by the availability of home gardens. Asimilar situation has been reported elsewhere (7,11). Meat items, specially ready to eat meat itemslike sausages and meatballs are consumed at asignificantly higher rate (p<0.01) by urban whichcould again be due to urbanization, as well assignificantly larger percentage of mothers beingemployed in the urban setting. Percentage ofmothers being employed in the urban setting.

But it is important to note that the level ofconsumption of vegetables was higher the urbansetting unlike in industrialized countries. Breadwhich is consumed by a significantly largerpercentageof urban girls (p<0.00001) reflects busylife style and the higher rate of employment ofurban mothers. Consumption of short eats (snacks)was relatively low in both settings (less than onethird), a desirable trend when compared to otherurbanized societies.

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The present study used data from self-administered food frequency questionnaire(FFQ) which can be used most appropriatelyto compare patterns of intake betweendifferent groups and not to determineabsolute intakes ofindividuals. Errors mayarise in, individual variation in the accuracyof reporting. Errors due to variation of dietover a time was accounted for by using arelatively longrecall period but errors due toFFQitself could not be tested as it was notvalidated. Mostfindings are likely to be areflection ofdifferences in socio-economicstatus in the twosettings than an effect ofurbanization, Thefact that the present studyhas excluded adolescent girls attendingprivate schools in the urban area and thusdoes not representthe affluent society needto be considered in interpreting the results.Independence ofdietary habits

In the present study meals were prepared athome by the mother almost daily in asignificantly high (P<0.01) percentage ofgirls in the rural setting(92,7%) but the factthat the percentage in the urban setting toobeing fairly high (84.1%) shows lessindependenceof diet in both settings. Thefinding ofover 95% of girls in both settingsrarely or occasionally ate at restaurantsagain shows that the food habits of thesubjects are less independent even in theurban setting.

Almost all carried the school meal fromhomein both settings but over 50% in bothsettings, bought food from the schoolcanteen in addition to the food they broughtfrom home. This could be a reflection oftheir desire for frequent snacking (2) or acontinuation of their food habit persistedduring the growth spurt. However moreinformation on energy requirements areneeded to establish this and physical activitymust also be considered. Food bought fromthe canteen reflects more of theirindependent choice and of course dependson what was available in the canteen as well.A similar finding was reported by Rolls etal, that adolescents like sweets, cakes andcarbonated sugar drinks.

Awareness on body image

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The majority in both setting (rural 52.8% urban50.4%) thoughttheir weight as about right but asignificantly higher percentage of (p<0.05) urbangirls (25.2%) thoughtthemselves as over- weightand close to 25% in both settings thought‘themselves as under weight as well. This isdifferent from what has been reported by Chapmanetal, that less than half of adolescentgirls saw theirweight as appropriate and 51% saw themselves asover weight. Study finding shows that although theconcept of body image was a concern to someextent, especially among urban adolescent girls, itwas not so prevalent as in the industrializedcountries.

The level of knowledge with regard to nutrition inthe urban settings was higher. Information hadalready been provided to adolescent girls onnutrition through routine school teaching activitybut elders and parents who could provide correct aswell as incorrect information wereidentified by themajority of school girls in both settings as a sourceofinformation, Although nearly one third ofgirls inboth settings avoided certain foods duringmenstruation, no significance was seen in the habitor the typesoffoods avoided.

Acknowledgements

‘Wearegrateful to the students who participated inthestudy and thank them for their co-operation.

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3. Court JM. Nutrition in adolescents: anoverview of concerns in western societies,Medical Journal Of Australia, 1988; 148: 2-6,

4. Chapman G. Food practices and concerns ofteenage girls, National Institute of Nutrition,USA. 1988.

5. Gunarathna CD, Foodbased dietary guidelinesfor Sri Lanaka, Nutrition Division, Ministry ofHealth, Sri Lanka, 2002; 4-6.

6. Shetty P S, Diet and disease, Department ofPublic health and Policy planning, London

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