Nutritional Status of Adolescent School Girls

II

ASSESSMENT OF NUTRITIONAL STATUS OF ADOLESCENT

SCHOOL GIRLS AT RAWALPINDI

DR. ARSHAD MAHMOOD UPPAL MBBS (Pb), MCPS (Pak), FACP (USA)

Roll No. J-5917291: Registration No. OO PGT 2035

Dissertation submitted in partial fulfillment of the requirements for the

MASTER OF SCIENCE IN COMMUNITY HEALTH AND NUTRITION

At the faculty of SCIENCES Allama Iqbal Open University

ISLAMABAD

Advisor: - Dr. Riffat Ayesha Anis, PhD

Principal Scientific Officer

Nutrition Division; National Institute of Health, Islamabad

May 12, 2005

DDDEEEDDDIIICCCAAATTTEEEDDD TTTOOO

My father late Muhammad

Sadiq Uppal and my mother for

leading me to live in this world of

chaos. My wife for caring me well

and my dears Ali Arshad Uppal,

Aisha Arshad Uppal, Hafiz

Usman Afzal Uppal for their

innocent love.

II

ABSTRACT

The present study was undertaken to assess the nutritional status of the adolescent girls

from the schools of Rawalpindi. Their dietary intake (in terms of calories & proteins),

clinical signs of malnutrition with special emphasis to micronutrients i.e., vitamin A, iron

& iodine and Hb levels were also studied. This study was conducted on 369 girls

belonging to the age group of 10 – 16 years. The study subjects were selected from two

schools of Rawalpindi i.e., Government Comprehensive Girls Higher Secondary School

(GCGHSS) from public and Divisional Public School (DPS) from private sector, to

afford an opportunity of comparison between two separate groups of adolescent

population studying in these schools. Appropriate sampling methodology was

undertaken. The approach adopted for the study was a cross sectional one. The tools for

the study were pre-designed and pre-tested. A questionnaire, weighing scale, measuring

tape, torch, autoscope and digital hemoglobinometer were used in the study. The

techniques of study included interview method, clinical examination and anthropometry.

The information on socio-demographic profile i.e. age, family income, education,

occupation of the parents and family composition was collected. Information on dietary

intake was gathered by using semi quantitative food frequency questionnaire.

Anthropometric measurements for height & weight were done on all the girls. Their age

and age at menarche was also noted. All the girls were subjected to clinical examination

for detection of the signs of iron, iodine & vitamin A deficiencies and biochemical

estimation of Hb levels. The outcome measures for nutritional status were proportion of

thinness (wasted) (<5th percentile of BMI-for-age) and stunted (<-2 Z-score of NCHS

standards of height-for-age). The calories & nutrients intake was compared with

recommended daily allowances for Pakistan. To detect anemia the hemoglobin levels for

different ages were compared with the WHO standards (8-11.99 years with Hb <11 g/dL,

12-14.99 years with Hb <11.5 g/dL, 15-19 years with Hb < 11.7 g/dL). Girls with Hb <7

g/dL were declared as severely anemic. Goiter was determined according to WHO

classification (zero, grade I & II). Symptoms and signs for vitamin A & iron deficiency

were also noted. The information/data collected was analyzed. The results indicated that

55% girls belonged to GCGHSS and 45% to DPS. Out of these girls 61.2% were from

III

early (10-13 years) and 38.8% from middle (14-16 years) adolescent age group. Poverty

level was 34.4%. Literacy rate of their fathers was 90.8% and mothers 72.6%. The

average family composition was 7.15 ± 1.84. The mean age of the subjects was 13 ± 1.49

and age of menarche was 12.6 ± 0.842 years. Mainly these girls took three meals a day.

On average 1523 calories were consumed per day, which was 74.47% of RDAs that was

related to poverty (p=0.000). Main source of calories was wheat based food (35.52%).

Consumption of milk, egg, meat and dark green leafy vegetables were also low.

Micronutrients (Fe, I and vit A) were consumed less than RDA. 6.8% of the girls were

stunted, 17.3% were wasted and 4.9% were overweight. Anemia was a common finding,

70.9% girls were anemic and 1.1% severely affected. Goiter was present in 52% and no

signs of vitamin A deficiency were seen. Malnutrition is a major public health problem in

the country and is prevalent in this study population. There was no vitamin A deficiency,

however goiter and anemia was a significant finding of this study. These results correlate

with the low intake of food in terms of calories and protein. The poor nutritional status of

the adolescent girls can be improved by educating them about the important role of

nutrients in their diet.

IV

Accepted by the faculty of SCIENCES Allama Iqbal Open University, Islamabad, in

partial fulfillment of the requirements for the MASTER OF COMMUNITY HEALTH

AND NUTRITION

Viva Voce Committee

Chairperson of the department of

Home and Health Sciences

External Examiner

Internal Examiner

(May 12, 2005)

V

ACKNOWLEDGEMENTS

The author takes this opportunity to place on record his deep sense of gratitude to his

advisor Dr. Riffat Ayesha Anis, Director Technical, National Institute of Health,

Islamabad; who has helped him with her sagacious advice and has, in fact, been a source

of inspiration to him, and without whose constant supervision and sincere encouragement

this work would not have come in its present form. Her kind suggestions in the

preparation of this thesis are respectfully acknowledged.

The author extends cordial thanks to Dr Parveen Liaqat, Chairperson Department of

Home and Health Sciences, Allama Iqbal Open University Islamabad, for her support and

encouragement. Thanks are also due to Mrs. Hajra Ahmad, Assistant Professor and Syed

Shahzad Hussain Shah for their help and cooperation during the course of this study.

The author is highly indebted for the cooperation and help extended by Mr Muhammad

Saleem (late), Ex-Chief Nutrition Division, NIH Islamabad.

The author does not find words to express his sincerest thanks to Prof. Jaleel Ahmad, the

Executive District Officer (Education) Rawalpindi; Mr. Muhammad Ayyaz, Principal,

Divisional Public School, Rawalpindi and Mrs. Robina Tasneem, Principal, Govt,

Comprehensive Girls Higher Secondary School, Rawalpindi, for allowing to conduct this

study in their schools. Special thanks are extended for their hospitality. Thanks are also

due to the focal persons of these schools Miss. Arjumand Azhar and Mrs. Mussarat

Jabeen for their valuable help in gathering the data from their students.

Thanks are due to Mrs. Nighat Kazmi & Miss Nusrat Nazia, Dieticians, Nutrition

Division, NIH Islamabad for their valuable cooperation in interviewing the adolescent

girls for their dietary history.

Author’s thanks are also due to Dr. Nadeem Ikram & Mr. Ghulam Murtza Satti,

Department of Pathology, and Mr. Muhammad Haleem, Blood Bank at DHQ Hospital

Rawalpindi, for their suggestions & cooperation in biochemical estimations the girls. The

author is also indebted to thank Dr Ali Abbas, Ophthalmologist at District Headquarters

VI

Hospital Rawalpindi for his valuable help in doing the opthalmological examination of

the adolescent girls.

Also the author would be failing in his duty if he did not express his gratefulness to the

adolescent girls under study for their patience; interest and cooperation in making this

study a success. Without their participation this all would have not been possible .It was a

wonderful experience working with the adolescence. Their optimism, innocence and

adherence to the ritual formalities are really praiseworthy.

The author is highly indebted to thank Dr. Zafar Moen Nasir, Chief of Research and Mr.

Masood Azhar, Computer Programmer, Pakistan Institute of Development Economics

(PIDE), Quaid-e-Azam University (QAU) Islamabad for their valuable guidance and

suggestions in analyzing the data and making the author familiar with the Statistical

Package for Social Sciences and Epinfo-2000, computer programs.

The author cordially acknowledge the statistical assistance from Ch. Abdul Shakoor

Head, Department of Statistics; University of Arid Agriculture Rawalpindi, who

inculcated the statistical sense in him.

The author is indebted to thank Mr. Abdul Hameed, Senior Librarian and his staff at NIH,

Islamabad. Thanks are also extended to the officials of the libraries of Rawalpindi

Medical College Rawalpindi and PIDE, QAU Islamabad, for making available the

reading material relevant to this study. Thanks are also due to the Internet (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.

Dr. Arshad Mahmood Uppal

VII

TABLE OF CONTENTS

Chapter Title Page

1

INTRODUCTION

1.1 Adolescence

1.2 Nutritional status

1.3 Back ground on development of nutritional

assessment

1.4 Rationale of the study

1.5 Statement of the problem

1.6 Objectives of the study

1.7 Significance of the study

1.8 Limitations of the study

2

3

5

6

7

8

8

9

2 REVIEW OF LITERATURE

2.1 Nutritional status

2.2 Menarche

2.3 Iron deficiency anemia

2.4 Iodine deficiency disorders

2.5 Vitamin A deficiency

12

14

16

20

24

3 PROCEDURE OF THE STUDY

3.1 Locale

3.2 The study population

3.3 Sample and sampling techniques

3.4 Research design

3.5 Permission to visit the schools

3.6 School survey schedule

3.7 Sensitization of the study population

3.8 Consent of the girls for interview and examination

3.9 Research tools

3.10 Collection and coding of data

28

29

29

30

30

31

31

31

31

40

VIII

3.11 Statistical methods for data analysis 41

4 ANALYSIS OF THE DATA

4.1. Presentation and analysis of the data

4.2. Discussion

42

55

5 5.1. Summary of findings of the study

5.2. Conclusions

5.3. Recommendations

66

67

68

6 REFERENCES 71

7 APPENDICES

7.1. Physical signs indicative or suggestive of malnutrition

7.2. Letter to the EDO (Education) Rawalpindi and the

school Principals

7.3. School survey schedule

7.4. Introductory brochure for girls

7.5. Consent form

7.6. Questionnaire for assessment of nutritional status of

adolescence school girls at Rawalpindi

7.7. Coding of the data

7.8. Percentiles of BMI-for-age: female adolescents,

9-24 years

7.9. Recommended daily allowances for Pakistani

adolescent population of 10 – 19 years of age for

selected major nutrients

7.10. Recommended anthropometric cut-off values and

original sources of reference for adolescents

7.11.Normal age and gender related changes of

hemoglobin and hematocrit values for children and

adults

90

92

94

95

97

98

100

102

103

104

106

IX

LIST OF TABLES

No Description Page4.1 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

2.1 Global distribution of iodine deficiency disorders 24

3.1 Location map of Rawalpindi 28

3.2 Measuring Utensils 34

3.3 Dietary interview 34

3.4 Procedure of measuring height 36

3.5 Measuring the height 36

3.6 Measuring weight 37

3.7 Night blindness 38

3.8 Bitot’s spot 38

3.9 Xerophthalmia 38

3.10 Koilonychia 38

3.11 No goiter 38

3.12 Palpable goiter 38

3.13 Visible goiter 38

3.14 Visible goiter 38

3.15 Digital hemoglobinometer 39

4.1 Age distribution in adolescent girls 42

4.2 Household composition 44

4.3 Prevalence of stunting 45

4.4 Prevalence of malnutrition 46

4.5 Share of different food groups in calories consumed by girls 50

4.6 Prevalence of goiter 52

4.7 Goiter and use of iodized salt 53

4.8 Prevalence of anemia in adolescent school girls 54

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

XIV

"""YYYooouuu cccaaannnnnnooottt hhhaaammmmmmeeerrr aaa gggiiirrrlll iiinnntttooo aaannnyyyttthhhiiinnnggg... SSShhheee gggrrrooowwwsss aaasss aaa ffflllooowwweeerrr dddoooeeesss --- ssshhheee wwwiiillllll wwwiiittthhheeerrr wwwiiittthhhooouuuttt sssuuunnn;;; ssshhheee wwwiiillllll dddeeecccaaayyy iiinnn hhheeerrr ssshhheeeaaattthhh aaasss aaa nnnaaarrrccciiissssssuuusss wwwiiillllll iiifff yyyooouuu dddooo nnnooottt gggiiivvveee hhheeerrr aaaiiirrr eeennnooouuuggghhh;;; ssshhheee mmmaaayyy fffaaallllll aaannnddd dddeeefffiiillleee hhheeerrr hhheeeaaaddd iiinnn ddduuusssttt iiifff yyyooouuu llleeeaaavvveee hhheeerrr wwwiiittthhhooouuuttt hhheeelllppp aaattt sssooommmeee mmmooommmeeennntttsss ooofff hhheeerrr llliiifffeee;;; bbbuuuttt yyyooouuu cccaaannnnnnooottt fffeeetttttteeerrr hhheeerrr;;; ssshhheee mmmuuusssttt tttaaakkkeee hhheeerrr ooowwwnnn fffaaaiiirrr fffooorrrmmm aaannnddd wwwaaayyy iiifff ssshhheee tttaaakkkeeesss aaannnyyy...""" JJJooohhhnnn RRRuuussskkkiiinnn,,, """SSSeeesssaaammmeee aaannnddd LLLiiillliiieeesss,,,""" 111888666555

(Writes Shirley Landis-1996: at Blue Sky Farm, 1020 N. Manor Road, Honey Brook, PA 19344 USA)

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


adolescents are classified into three groups: a) the early adolescents having the age of 10

to 13 years, b) the middle adolescents with the age of 14 to 16 years and c) the late

adolescents of the age of 17 to 19 years. This classification is based on biological,

psychological and developmental basis (Hendee 1991).

Adolescents form a crucial segment of population and constitute, as it were, the vital

‘bridge’ between the present and the next generation (Raman 1992). Adolescents are

tomorrow's adults, and 85% of them live in developing countries (United Nations 1997).

They are relatively healthy as compared to other lifecycle groups, and show roughly

similar morbidity and mortality trends in developed and developing countries (Blum

1991).

NUTRITIONAL STATUS

According to Christakis (1973) nutritional status is condition of the health of an

individual. The nutritional status of a country reflects the standard of living of the people.

Although the body makeup is determined genetically, but besides heredity, nutrition

plays an important role for the growth and maintenance of the body (Hels et al. 2003;

Khongsdier 2003; Ali and Khan 1976). This is expressed as one being normal, stunted,

thin, over weight and victim of micronutrient deficiencies. It depends on food

availability, nutrition awareness, earning of the individuals, food prices, food imports,

local food production, country environment, dietary intake, and food utilization, which

depends on physiological status of the body, which in turn, is influenced by the

environmental situation, accessibility to safe water, and the morbidity status that is the

result of inadequacies in these situations (WHO 1989).

Nutritional status is result of a complex interrelationship between environmental and

social factors and the individual in a community. Therefore its medical assessment

(clinical, dietary and biochemical), is of limited practical value if the other factors are

ignored. So to have a comprehensive assessment of nutritional status we need to take full

account of information on (Tierney et al. 2004; Scrimshaw and Gleason 1992; WHO

1963): -

3


o Agricultural data and food balance sheets. This gives us information on the gross

estimates of agricultural production, agricultural methods, soil fertility, and

predominance of cash crops, overproduction of staples and food import &

exports. These factors determine the approximate availability of food supplies to a

population.

o Socioeconomic data, information on marketing, distribution and storage of food.

This informs us about purchasing power of the people, distribution and storage of

food stuffs. These factors determine the distribution of available foods between

the socioeconomic groups in the community and within family. As low

socioeconomic status is accompanied by low status in other factors in a person’s

life.

o Food consumption patterns, cultural and anthropological data. This tells us about

the knowledge, erroneous beliefs, prejudices and indifferences about the foods.

o Dietary surveys. This tells us about the food consumption by the individuals of

the society, like low, excessive or unbalanced nutrient intake.

o Special studies on foods. These inform us about the biological values of diets,

presence of interfering factors (e.g., goitrogens) and effects of food processing.

o Vital and health statistics. This like morbidity and mortality data informs us about

the extent of risk to the community and identification of high risk groups.

o Anthropometrics. With these informations we know about the physical

development of an individual, which is outcome of his nutrition.

o Clinical nutrition surveys. By observing the physical signs we know about

deviation from health due to malnutrition (appendix 1).

4

o Biochemical studies. By estimating the levels of nutrients, their metabolites and

other components in the body, we know about the nutrient supplies in the body

and impairment of biochemical functions.


o Additional medical informations. This homes us on the prevalent disease patterns

including infections and infestations, which affect nutrition of an individual.

BACK GROUND ON DEVELOPMENT OF NUTRITIONAL

ASSESSMENT

The need to assess the nutritional status was realized in 1932 under the flag of the League

of Nations. The development on the subject progressed through the following years and

finally Interdepartmental Committee on Nutrition in National Defense (ICNND) of USA

succeeded in publishing a Manual for the Nutritional Surveys, which emphasized the

need for establishing uniform methods, defining the responsibilities of team members,

providing guidelines for the interpretation of dietary, biochemical, clinical &

anthropometric data and training of the personnel (ICNND 1957 & 1963). World Health

Organization took the task of coordinating the activities for assessing the nutritional

status of the people and in 1966, WHO published detailed guidelines for the assessment

of nutritional status of the community (Jelliffe 1966).

Although nutritional surveys were underway throughout the world, with initial survey

commencing in Pakistan in 1956, it was not until the late 1960s that the United States

began to address its own nutrition problems. Two surveys were undertaken almost

simultaneously to determine the extent of malnutrition, the Ten State Nutrition Survey,

1968-1970 and the Preschool Nutrition Survey, 1968-1970. In 1971 a third survey, the

first Health and Nutrition Examination Survey (HANES), was begun, which was

completed in 1974 (USDHEW 1972). These surveys provided with the basic

informations and various cutoff points for biochemical and anthropometrical values,

which are still serving as the references for the assessment of nutritional status of an

individual and a community.

5

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


6

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

segment of the population.

RATIONALE OF THE STUDY

Nutritional status of the girls in the SAARC region is the worst in the world and roots of

malnutrition run deep into social soils, which count for higher maternal mortality rates in

the member nations (Raheena 2001). Adolescents are especially affected by malnutrition

as they are given little attention towards their health and nutrition (Senderowitz 1995). As

a result in many developing countries one half of the children and adolescents fail to

achieve their full genetic growth potential (Raheena 2001). The necessity of identifying

malnutrition (stunting & thinness) in this group is very important as early adolescent girls

can be benefited from improved nutrition or treatment of underlying problems (WHO

Technical Report Series (854) 1995). The severity of the deficiency and length of time it

takes to reverse the situation depends upon how long the child has been malnourished

(Jenne and Greene 1976). To intervene at a proper time requires perpetual evaluation of

the situation, by serial assessment of the nutritional status of the adolescence. During this

period of rapid growth, caloric, nutrient and micronutrient-iodine, calcium, iron and

vitamin needs are higher and their lack or excess leads to various diseases in them (WHO

1989). Thus, understanding and promoting nutritional health during adolescence warrants

renewed attention, followed by the allocation of resources for nutritional advocacy,

training, research, and care” (Rees et al. 1999).

The adolescent girls are the future mothers of the nation. Well-nourished girls will grow

into women facing fewer risks during pregnancy and childbearing. So they need to be

kept watched as for their nutrition is concerned. History shows that societies that meet

women’s nutritional needs also lift their capacities for greater social and economic

progress.

These facts led to choose the subject of assessment of the nutritional status of the

adolescent girls, so that we know their nutritional problems and adopt early corrective


measures, when they can be benefited through nutrition intervention. Studies like this are

need of the time.

STATEMENT OF THE PROBLEM

Role of food in maintenance of health had been recognized since the times of Hippocrates

but it is only in recent years that that the role of nutrition in physical & mental

development, productivity and of span of working years all of which influence

socioeconomic development has been appreciated (Ali 1989). The price of nutritional

inadequacy in the form of hunger and malnutrition is very high. About 800 million

persons in developing countries are undernourished and an additional 300 million

children are at risk of increased morbidity and mortality as a result of malnutrition

(World Bank 1980 WHO 1983). Situation in Pakistan is also not so promising. The

micronutrient survey from 1976 – 1977 revealed that 53.3% of the children < 5 years

were underweight. The situation improved in 2001 – 2002 and only 37.4% were

underweight. But the percentage of stunted children, which was 49% in 1965 and had

improved to 36.3% in 1990 – 1994, has shot up to 40% in 2001 – 2002. Similarly and

worryingly, the number of wasted children was 11% in 1965 increased to 14.9% in 2001

– 2002. However, the problem of malnutrition is worsening in Pakistan as it has gone

from bad to worse (Mirza 2004; NNS 2001-02).

The world’s adolescent population is around 1200 million (19%). Majority of them are of

the view that they are in good health and hence show little concern for protecting their

health “capital” for the future (Cordonnier 1995). Whereas the fact is that they suffer

from multiple nutritional problems like malnutrition, micronutrient deficiencies,

especially the iron & iodine deficiency, undernutrition or obesity and co-morbidity (Kurz

and Welch 1994). Hence they remain a largely neglected, difficult-to-measure, and 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


socioeconomic groups of India the mean age at menarche is around 14.5 years where as

in higher income groups it is only 13.2 years (Raheena 2001).

Malnutrition is a languishing state of the body, due to lack of food, and curable by

adequate supply of food irrespective of its quality (Ali 1989). Its prevention in the face of

a rapidly expanding population is indeed a task of staggering proportions. So it is

necessary to assess the nutritional status of this important group to see the extent of

malnutrition and micronutrient deficiencies in them and to intervene at a proper time to

correct these.

OBJECTIVES OF THE STUDY

1. To assess the nutritional status of adolescent schoolgirls.

2. To assess the dietary intake in terms of carbohydrates, proteins, fats, vitamin A,

iron and iodine.

3. To study the clinical signs of malnutrition with special emphasis to vitamin A,

iron and iodine deficiency.

4. To estimate hemoglobin levels in the study group.

SIGNIFICANCE OF THE STUDY

At present there is so little data on adolescents' nutritional and health status and

micronutrient nutrition, eating patterns and underlying influences, and on impact of

nutrition intervention in adolescence, that research needs are immense. In order to

develop appropriate anthropometric reference data, a multi-country study, with

longitudinal and cross-sectional components, on adolescents’ somatic growth and

maturation should be considered high priority. Such data are needed to define not only

cut-off points, but also rates of too low or too high values that should trigger action at

program or individual level. Schools provide a better environment for this sort of research

as we can easy manipulate and monitor our nutritional interventions.

8


This study will enable us to know about the current nutritional status and nutrient

deficiencies in this very important age group. No international reference data exists; the

limited data available indicates that their nutritional status is considerably lower in

developing than the industrialized world. Often, adolescents' health and nutritional status

is a direct reflection of the cumulative effects of childhood health and nutrition. At the

same time, like children, adolescents also have specific and increased nutritional needs

due to rapid growth and development (Kurz and Welch 1994). Information related to

nutrition is needed for a variety of purposes, such as: identifying chronic nutritional

problems and causes; predicting and detecting short-term or acute nutritional problems;

targeting population groups for both short-term relief efforts and longer-term policy and

program development; monitoring changes and evaluating the impact of interventions

and development programs (PREPCOM/ICN/92/lNF/5 1992.).

This signifies the importance of the continued assessment of nutritional status and

monitoring of the micro & macronutrient deficiencies in population. This is more

important in women and particularly in the adolescent girls due to their special

considerations like menarche. The studies like this will help in formulating national

nutritional policy and provide the health professionals a frame work for counseling the

individual adolescent.

LIMITATIONS OF THE STUDY

Though the study went smoothly and principals, teaching staff and school girls

cooperated well, even then certain limitations were faced as: -

1. Short time frame: Due to the time available total study population could not be

approached.

2. Limited resources: The scarcity of resources made it difficult to address whole

population. Moreover limited resources were not sufficient to study all bio-

chemical parameters necessary for assessment of the nutritional status of these

girls.

9


10

3. My being the male, it was not possible to conduct a complete physical

examination of the girls under study.

CHAPTER 2 Review of literature

Nutritional status of adolescents measured in terms of weight-for-height and expressed

as Body Mass Index (BMI), is a direct reflection of the cumulative effects of childhood

health and nutrition. No international reference data exists, however the limited data

available indicates that the average BMI among 11-18 year old girls is considerably

lower in the developing than in developed world. This finding is based on studies

conducted by the International Council for Research on Women (ICRW) across several

countries in Africa, Asia, Latin America and the Caribbean region in 1994. Adolescence

being a time of rapid growth and change requires increased supply of micronutrients

(Kurz and Welch 1994).

Stunting is a phenomenon of early childhood and a direct result of poor diet and infection

(Martorell and Habicht 1986). It is the most easily measured and widespread effect of the

malnutrition-infection complex, predicts generalized functional impairment on a wide

range of biological, behavioral and social dimensions in children and adults from

developing countries (Waterlow 1992; Pollitt 1990; Martorell et al. 1990; Martorell et al.

1992). Some of these functional correlates, such as poor school performance, even when

socioeconomic status and other home and environmental factors are controlled for,

stunting per se remains negatively correlated with cognitive & school performance,

physical activity & reproductive outcome, and positively correlated with risk of infection.

Stunting and underweight are highly prevalent in developing countries and are the most

common forms of malnutrition (Jelliffe and Jelliffe 1989).

In the last 10 years, interest in adolescence has increased worldwide. Much of the

attention has been on adolescent health, but nutrition has aroused little interest. 11 studies

on nutritional status of boys and girls have recently been conducted in Benin, Cameroon,

Ecuador, India, Jamaica, Mexico, Nepal, Guatemala, and the Philippines. These differed

in protocol, sample size and data collection methods. Anemia came out to be the

commonest nutritional problem in 4 studies (55% in India, 42% in Nepal, 32% in

Cameroon, and 48% in Guatemala) and significant in 2 others (17% in Ecuador and 16%

in Jamaica). Slow growth was common in 9 studies (27-65%). Height in girls as well as

in boys did not improve during adolescence. It approached the fifth percentile at age 10

12


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


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).

14

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,


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).

15

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).


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).

16

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


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


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


In US 9% of toddlers aged 1 to 2 years and 9% to 11% of adolescent girls and women of

childbearing age were iron deficient; of these, IDA was found in 3% and 2% to 5%,

respectively. This prevalence corresponds to approximately 700,000 toddlers and 7.8

million women with iron deficiency; of these, approximately 240,000 toddlers and 3.3

million women have IDA. Iron deficiency occurred in no more than 7% of older children

or those older than 50 years, and in no more than 1% of teenage boys and young men.

Among women of childbearing age, iron deficiency was more likely in those who are

minority, low income, and multiparous (Looker 1997). In school-based clinic and health

fair in an inner city of USA, predominantly African-American public high school the

mean ± SD Hb level for girls was found 115 ± 15 g/L; 50% of the girls had Hb levels less

than 120 g/L. The mean hemoglobin level for boys was 129 ± 13 g/L; 16.5% of boys had

hemoglobin levels less than 120 g/L (Leshan 1995). In another report 20% of all women

of childbearing age suffer from it as compared with only 2% of adult men (USDHHS

1998).

In a study on 262 female teenagers living in the city of Taboao da Serra, Brazil, anemia

was found to be 17.6% and its occurrence was inversely related to factors indicative of

the economic-social level: income, schooling of parents and home's characteristics. Its

prevalence was higher in the group that did not have reached menarche, and it showed no

relation with the interval between menstrual cycles. The prevalence of iron-deficiency

was of 29.4% and it was not verified correlation between the bloody Hb and the free

erythrocyte protoporphyrin, except in severe cases of anemia (Fujimori 1996).

In England 114 schoolgirls of 11-14 year from Wembley, Middlesex, were assessed for

Fe status, Hb, PCV and MCHC, height, weight, eating habits, and ethnic origin, and

subjected to a step test for assessment of physical performance. Overall, 20% of girls had

Hb less than 120 g/L, ranging from 11% in White girls to 22-25% in girls of Asian origin.

Prevalence of low Hb was 20% in vegetarians, higher in White vegetarians compared

with non-vegetarians (23 v. 4%), but lower in the Indian vegetarians compared with non-

vegetarians (17 v. 32%). Low Hb was present in 25% of girls who had tried to lose

19


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


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


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


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.

23

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


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


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


26

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)

CHAPTER 3 Procedure of study

LOCALE

This research was carried out in the three girls’ schools of Rawalpindi city-the adobe of

Rawals. This is in the northern region of Punjab province of Pakistan beside the federal

capital-Islamabad. It lies at the outskirts of Himalayas, 520 meters above the mean sea

level having particularly good climate with all four seasons. This is an industrial, trade &

military center serving the northern Pakistan and Kashmir. This is gateway to

Afghanistan. It was founded by Rawal a Ghakkar chief 500 years ago around the remains

of Gajipur, the capital of Bhatti tribes. Farmers in the nearby countryside cultivate barley,

maize, millet, mustard and wheat, and trade these products through Rawalpindi. The

city’s water supply is provided by the Rawal Dam-which harnesses the flow of the

Kurang River, Khanpur Dam on river Harro and deep tube wells. The Liaqat Gardens,

Safari Park & Zoo, Public Park Murree Road and the beautifully landscaped Ayub

National Park attract tourists and area residents alike. Its population is 1,406,214 (1998).

Worm infestation is common especially the tape worm (Microsoft® Encarta®

Encyclopedia 2004; Gazetteer of Rawalpindi 1893-4; Adamson and Shaw 1981). Its

population is unique mixture of all the races of Pakistan as people come here to serve in

the Federal Capital of Pakistan in various Government Departments.

Fig: 3.1. Location map of Rawalpindi

The schools under study are located in the Shamsabad, off Murree Road-Divisional

Public School (DPS) and Dhoke Kashmirian-Government Comprehensive Girls Higher

Secondary School (GCGHSS).

28


THE STUDY POPULATION

All the individuals, who possess some common characteristics and we are interested to

study some of their properties constitute a population. Each individual is a study unit.

Size of population is denoted by the letter N (Kiani and Akhtar 2003). As nutritional

status of the adolescent school girls at Rawalpindi is under study, the adolescent school

girls from 10 – 16 years of age from Rawalpindi city constitute our study population.

The reason for selecting this area is that population of Rawalpindi apart from locals

consists of immigrants from nearby areas like Murree and other parts of the Punjab and

small numbers from other provinces of Pakistan. So the adolescent girls from here are a

mixture of rural and urban population. These also belong to various socioeconomic

classes. The GCGHSS students mainly come from the lower income group & only a few

from middle, as the education here is free and majority is from rural areas. The DPS is a

public school and education here is costly. The girls studying here are mainly from the

middle and a few from upper SES. So the samples taken from these schools are true

representative of majority of the adolescent girls.

SAMPLE AND SAMPLING TECHNIQUES

Sample is a definite part of a statistical population whose properties are studied to gain

information about the whole (Webster 1985) and its size is denoted by letter “n” (Kiani

and Akhtar 2003). Sampling is the process of selecting a representative part of the

population for the purpose of determining parameters or characteristics of the whole

population (Margetts and Nelson 2000, pp 64-68). We obtain a sample rather than a

complete enumeration (a census) of the population for being cheaper and are prepared to

cope with its dangers. It helps in understanding and quantifying mathematical

probabilities, trends, or relationships within a group. Sample for research study should be

5-10% of the population in size to be the true representative (WHO 1995).

29

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


comparison of the girls from lower and middle income groups and in second stage 369

girls were selected through systematic random sampling technique (WHO 1995); 203

from GCGHSS and 166 from DPS. These girls were split into 2 groups i.e. early (10-13)

and middle (14-16) adolescents. Inclusion or exclusion criteria were the specific age

group.

RESEARCH DESIGN

This observational, cross-sectional study was aimed at the assessment of the nutritional

status of the adolescent school girls at Rawalpindi. It also aimed at the assessment of

VAD, IDD and IDA in this specific age group. The sample consisted of 369 girls. These

were 166 from DPS and 203 from GCGHSS; selected through systematic random

sampling technique. The first girl from each school was selected through balloting and

subsequently every tenth girl from each section was taken to make the sample 10%. Their

socio-demographic profile (education & profession of father & mother, family income

and family size), anthropometric measurements (height, weight, age and age at

menarche), dietary history (through semi quantitative food frequency questionnaire,

noting the weekly, daily and one time consumption of cereal, meat, milk, egg, pulses,

oils, DGLV and fruits groups in food), clinical examination (for micronutrient

deficiency) and hemoglobin estimation (by cynmethemoglobin method) was done. For

hemoglobin estimation a field laboratory was established at school under study. The

survey for this study was done from 1st June 2003 to 12th June 2003. The data thus

collected was analyzed on computer with the help of Statistical Package for Social

Sciences (SPSS) and Epinfo-2000. Chi-square test was used to determine whether the

results of the study sample were applicable to the population or not. The study was

concluded by making recommendations for the target group.

PERMISSION TO VISIT THE SCHOOLS

30

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.


SCHOOL SURVEY SCHEDULE

Schools were visited according to the schedule attached as appendix 3. This survey

schedule was discussed with principals of all the schools before the commencement of

the study. The focal persons appointed by the school principals were homed at the study

and its procedures. Their suggestions were well taken care of.

SENSITIZATION OF THE STUDY POPULATION

Before the study was launched the subject population was educated on the subject. The

students were briefed on the subject of balanced diet and all the procedures to be done on

them were explained in simple, understandable language. They were given a brochure on

the diet, which explained the diet, balanced diet and study procedures (appendix 4)

CONSENT OF THE GIRLS FOR INTERVIEW AND

EXAMINATION

Written consent of the girls was obtained on a form before interview and examination

(see appendix 5)

RESEARCH TOOLS

These are the instruments of the research by which information is collected, observations

are made and various tests are done. The tools and techniques used in this study were the

questionnaire, clinical examination and laboratory tests.

1. Questionnaire: This was especially designed for the study and following

informations were collected: -

A. Socio-demographic informations: In most forms of epidemiology the

populations of interest are described in terms of socio-demographic

characteristics. The socio-demographic variables like age, gender and social

class are also called face sheet variables as these are written on the front sheet

31


of the case (Margetts and Nelson 2000, pp 273-288). Following information

were collected: -

I. Age is an important variable, which may be an indicator of biological states

& processes (growth, development, maturation, metabolism and repair); of

historical processes & contexts (Pakistan Independence Day); and of

psychological & social processes (as adolescent girls have no obligation to

cook & serve food to the family). This was measured in completed years

(NNS 2001-02).

II. Social class is a strong predictor of life chances and a key variable in

nutritional epidemiology (Mcloone 1994). It is measured in a number of

ways, lacks a gold standard against which to assess the accuracy and is

subject to conceptual clarities. Usually these combine informations about

education, occupation and income (Liberators et al. 1988). For this

information about family income (income of father & mother in Pak rupees

per month, from all the sources like salary and property etc), father &

mother education & occupation was collected.

III. Family composition is defined for census purposes as being persons who

usually live and eat together, and having obvious relevance for nutritional

epidemiology (Bradby 1996). This is important both as a predictor in its

own right of nutritional exposures or outcomes, and as a control for other

variables (Department of Social Security 1993 and 1994).

B. Dietary informations: Dietary data was obtained for all the adolescent

girls. There are many methods in use for the measurement of diet in cohort,

cross-sectional and the interventional studies, where the aim is to assess

contemporaneous diet (Cameron and van Staveren 1988; Bingham 1987;

Black 1982). These methods generally consist either of the collation of

observations from a number of separate days’ investigations, as in records,

check lists and 24 hour recalls, or attempts to obtain average intake by asking

32


about the usual frequency of food consumption, as in diet history and food

frequency questionnaires (FFQ). In all methods of dietary assessment, some

estimates of the weight of food consumed is required and for the

determination of nutrient or other food component intake, either an

appropriate description for use with food tables or an aliquot for chemical

analysis is necessary (Margetts and Nelson 2000, pp 134-6). Following

methods were used: -

I. Food frequency questionnaires (FFQ): This is the most commonly used

method in nutritional epidemiology, where evidence is sought for an

association of diet in general, rather than with specific nutrients in a chronic

disease (Morgan et al, 1978). These are designed to assess usual eating

habits, over recent months or years, and comprise a list of foods most

informative about the nutrients of foods of interest. These generally have

been of the frequency and amount type (FAQ) in which the subjects are

asked to say how often they usually consume an item of food or drink and

how much they typically have on the days they consume it (Cu et al. 1984).

For this a questionnaire to assess the semi quantitative food frequency

intake was designed (appendix 6).

II. Food groups: As all the food items cannot be included in the questionnaire,

the most commonly used foods in our society can be categorized into

groups, based on biological characteristics, function in meals or the dietary

food pattern, or based on their nutrient value (Tierney et al. 2004; Margetts

and Nelson 2000, pp 118 & 126). A very good agreement (75-100%) for the

food groups i) pulses, ii) green leafy vegetables, iii) fruits, iv) milk products,

v) eggs, and vi) flesh foods exits (Kapil et al. 2003). The food items were

grouped in to following 12 groups: a) Roti, b) Rice, c) Meat & its products,

d) Eggs, e) Pulses, f) Milk & its products, g) Oil/ghee, h) Desi ghee/butter,

i) Carrot, j) DGLV, k) Fruits and l) Beverages (appendix 6).

33


III. Portion size of the foods consumed: Various methods to assess portion

sizes are used, for example fitting average portion weights derived from

other data to the respondents’ chosen food and frequency selection (Thomas

1994) or asking subjects to describe amount in terms of household measures

or standard portions. In this study measures as shown in the figure 3.2 were

used. The respondents were asked in which bowl their food portion

consumed fitted 50, 80, 100 or 200 gram size utensil.

Fig: 3.2. Measuring utensils

IV. Technique: Each girl was interviewed by lady dietician or school teachers

(especially trained to conduct a dietary interview) or the researcher himself.

The girls were asked how many days in a week they took a particular food

group. Then they were questioned how many times in a day they took this

food. Thirdly they were questioned how much food they take at one time.

Fig: 3.3. Dietary interview

34


They were asked to use the bowls lying on the table. About the fruits and

vegetables consumed raw, they were asked if the certain food is cut in to

pieces which size utensil it will fill, the size/weight of the indicated utensil

was noted as portion of the food standardized in grams.

V. Calculating the calories and nutrient intake: For this purpose Food

Composition Table for Pakistan (2001) and The Concise New Zealand Food

Tables 3rd Edition, were used. Values for each group were calculated by

taking the average of the component foods of each group.

2. Anthropometry: It is especially important during adolescence because it allows

the monitoring and evaluation of the hormone-mediated changes in growth and

maturation during this period. Moreover, because growth may be sensitive to

nutritional deficit and surfeit, adolescence anthropometry provides indicators of

nutritional status and health risk, and may be diagnostic of obesity. The study and

understanding of this period of rapid changes are, at once, important and difficult

(WHO Technical Report Series (854) 1995). Published studies have identified

important determinants and consequences of anthropometric variations and generated

or confirmed important etiological hypotheses regarding adolescent body dimensions.

Much less work has been done to extract from these data the specific information

required for using adolescent anthropometric dimensions as indicators of health and

nutritional status (WHO Technical Report Series (593) 1976). Nutritional status was

determined as stunting (height-for-age Z-score < -2), thinness (BMI-for-age < 5th

percentile), normally nourished (BMI-for-age > 5th & < 85th percentile) and at the

risk of overweight (BMI-for-age ≥ 85th percentile) refer to appendix 8 & 10.. For this

following anthropometric information about the respondents were collected: -

A. Height: The measurement of height was done against a vertical wall with

an attached measuring tape and a horizontal head board that could be

brought into contact with the upper most point on the head. The girls’ height

was measured barefoot or in thin socks while they were wearing little

35


36

Fig: 3.4. Procedure of measuring height

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

headboard was brought on to the topmost point on the head with sufficient

pressure to compress the hairs. The height was measured in meters and

recorded to the nearest 0.1 cm (Lohman et al. 1988).

Fig: 3.5. Measuring height

B. Weight: - The well calibrated bath room scale was used to weigh the girls.

The weighing scale was calibrated with the help of 10 kg weight. This

calibration was done after weighing 10 girls. The weight was measured

with little clothing and bare feet. Weight was recorded to nearest 100 g

(Lohman et al. 1988).

C. Menarche: The timing of the adolescent spurt and associated changes in

anthropometric dimensions are maturational phenomena. Maturational

status must therefore be used to interpret the meaning of anthropometric


indicators of nutritional and health status based on chronological age.

Breast development and attainment of menarche are used in girls (WHO

technical report series (854) 1995). As the breast examination was not

possible, the age at menarche was determined by questioning a) are they

menstruating and b) what was their age at that time with the help of school

teachers.

Fig: 3.6. Measuring weight

3. Clinical examination: - Clinical deficiency signs (or physiological

abnormalities e.g. dark adaptation decline) usually represent the extreme lower end of

status and intake ranges. Although clinical investigations are very important in

assessing the nutritional status, they frequently have the disadvantage of poor

specificity (Margetts and Nelson 2000, pp 182) as these are rarely seen in ambulatory

population. WHO have published guide lines for this (Jelliffe 1966). The clinical

signs of VAD, IDD and IDA like Night blindness, Bitot’s spots, Xerophthalmia,

Koilonychia and goiter (figures 3.7 – 3.14) were looked in these girls. Goiter was

recognized through the examination of the neck of the girls. A swelling seen in the

thyroid region of the neck from the front or from the lateral view of the neck, which

moved on deglutition was read as visible goiter grade II, the other girls were

37


Fig: 3.7. Night blindness

Fig: 3.8.Bitot’s spot

Fig: 3.9. Xerophthalmia

Fig: 3.10. Koilonychia

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

and laterally below the second or third tracheal ring isthmus and lateral lobes of the

thyroid gland are palpated. Their size, symmetry, and position are noted along with

presence of any nodule. The normal gland is often not palpable (Swash 1989).

Fig. 3.13. Visible goiter

Fig. 3.14.

Visible goiter

Fig. 3.12. Palpable goiter

Fig. 3.11. No goiter

4. Biochemical estimation: - Laboratory methods of nutritional assessment are

considered to provide a more objective and precise approach to nutritional status, that is,

when compared with community assessment, dietary methodology, or clinical

assessment methods. They principally consist of biochemical tests performed in a

laboratory (Liaqat 1997). In this study only hemoglobin (Hb) level of all the girls was

measured by cynmethemoglobin method (Sir Decie and Lewis 1991). Following

technique was used: -

38


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

hemoglobinometer, Drabkin’s solution, blood lancets for finger pricks,

methylated spirit for sterilization of the finger tips of the girls, test tubes,

test tube racks, micropipettes, yellow tips and markers were supplied.

Estimation was done by the trained laboratory technician hired from the

hospital lab.

Fig. 3.15. Digital hemoglobinometer

B. The girls whose Hb was to be estimated was briefed about the procedure, so

that she does not fear and cooperates with the laboratory staff. Her finger tip

was sterilized with spirit, was pricked with sterile disposable lancet and 20

micro liter of blood was taken with the help of micro pipette.

C. This blood was poured in the test tube containing 4 ml of Drabkin’s

solution. It was thoroughly mixed and given a number for identification to

avoid misinterpretation. This was allowed to stand for few minutes to allow

the reaction to complete.

D. Small amount of the solution is transferred in the cuvette, which is placed in

the special hole in the photometer to measure absorbance of solution

through a suitable filter. Hb is read in g/dL.

39

E. Girls were declared anemic according to the WHO standards (8-11.99 years

of age with Hb <11 g/dL, 12-14.99 years of age with Hb <11.5 g/dL and 15-


40

19 years of age with Hb < 11.7 g/dL) (WHO 2001), refer appendix 11; and

those having Hb >7 g/dL were taken as severely anemic (WHO Technical

Report Series (3) 1972).

COLLECTION AND CODING OF DATA

After taking the permission of school authorities and the girls, data for each subject was

collected on separate questionnaires, as shown in appendix 6. All the respondents were

given an identity number, by which they can be traced. Their name, age, their father &

mother education, occupation and income were noted. Their family size was taken into

account. Their anthropometric measurements and dietary history was taken. Their

clinical examination was conducted by the physician, for ophthalmic examination the

services of an ophthalmologist were obtained and in the end their hemoglobin level was

checked. Occupation & education level of father & mother, clinical signs of VAD, IDD

and IDA was coded (appendix 7) to facilitate entry of data into the computer.

STATISTICAL METHODS FOR DATA ANALYSIS

Data analysis is the art of putting the numbers together into meaningful expressions,

which may lead to valid conclusions.

Data was entered and cleaned using the SPSS version 11. The data was analyzed by

SPSS and Epinfo-2000 and subjected to Chi-square test, to find out whether the results of

this sample study are applicable to the population or not.

CHAPTER 4 Presentation & analysis of data and discussion

PRESENTATION AND ANALYSIS OF DATA

The data was collected for the adolescent girls from the two schools of Rawalpindi. The

sample size (n) of this study was 369. Two sub samples were collected, one from each

school i.e. 203 (55%) girls are from GCGHSS and 166 (45%) from the DPS. The data

thus collected is presented, analyzed and the results are discussed in the following pages.

DEMOGRAPHIC PROFILE

1. AGE OF THE ADOLESCENT GIRLS: The mean age of the adolescent girls was

13.00 ± 1.49 years. Maximum number 89 (24.1%) of girls were 13 years old.

Distribution of different ages is shown in figure 4.1. Two hundred and twenty six 61.2%

were from early adolescent age group and 143 (38.8%) were from the middle.

Fig: 4.1. Age distribution in adolescent girls (n = 369)

11 yrs15.2%

12 yrs18.4%

13 yrs24.1%

14 yrs 22.2%

15 yrs11.9%

16 yrs4.6%

10 yrs3.5%

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


Table 4.1: Parent’s education

Education level Fathers Mothers Frequency Percent Frequency Percent

Illiterate 34 09.2 101 27.4 Primary 19 05.1 44 11.9 Middle 23 06.2 19 05.1

Matriculate 90 24.4 83 22.5 Intermediate 48 13.0 49 13.3

Graduate 86 23.3 54 14.6 Postgraduate 40 10.8 16 04.3 Professional 29 07.9 03 00.8

Total 369 100.0 369 100.0

3. PROFESSION: Profession truly affects one’s income which is the prime factor

influencing the health and nutritional status of the family. The fathers of these girls

belonged to different professions,1.1% were laborers, 36.7% government servants and

51.9% were self employed (private service and business). Mothers were mainly were

housewives i.e. 90.8%, 6.5% government servants and rest in other professions.

Table 4.2: Parent’s profession

Profession Fathers Mothers Frequency Percent Frequency Percent

Labor 04 01.1 - - House wife - - 335 90.8

Govt servant 135 36.6 24 06.5 Private job 86 23.3 04 01.1 Business 105 28.5 02 00.5

Professional 10 02.7 02 00.5 Technical 14 03.8 01 00.3 Deceased 14 03.8 01 00.3

Total 368 99.7 369 100.0 Missing system 01 00.3 - -

Total 369 100.0 - -

43


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

44

3

15

13

12

11

10

9

8

7

6

5

4

%

(p = 0.000)

Fig: 4.2. Household composition (n = 369)

Div Public School Rwp GCGHS School Rwp

120

100

80

60

40

20

0


living below poverty (n = 203).

ANTHROPOMETRICS

The mean age of these adolescent girls was 13 ± 1.49 years. Majority of the girls i.e.

24.1% were in the 13th years of their age. Their mean height was 1.512 ± 0.081 meters.

Their mean weight was 41.4 ± 9.73 kg. They had the mean BMI of 17.95 ± 3.16 kg/m2,

ranging from 12.33 to 35.82 kg/m2. Different indices were used to declare their nutritional

status as stunted, thin, overweight or normal:

1. STUNTING: Out of the adolescent girls under study 6.8% were stunted. It was more

prevalent in girls from GCGHSS (p = 0.009) 80% of the stunted belonged to this school

and stunting was found in 20% of the girls from DPS see figure 4.3. No correlation could

be established between stunting and poverty level, as 52% of the stunted girls lived above

that level. 88% of the stunted girls consumed energy < RDA and in contrast 83.1% of the

SCHOOLS

Div Public School Rwp

GCGHSS Rwp

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

Normal (Z-score ≥-2) Stunted (Z-score <-2)

%

120

100

80

60

40

20

0

9790

10

(p = 0.009)

Fig: 4.3. Prevalence of stunting (n = 369)

45


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.

(p = 0.000)

DPS Rwp

SCHOOLS

GCGHSS Rwp

Overweight (≥85) Normal (≥5 to <85)

Thin (<5)

%

100

80

60

40

20

0 6

78

16

77

19

Nutritional status (BM-for-age percentile)

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

46


Table 4.3: Malnutrition (criteria BMI-for-age) in different adolescent age groups

Nutritional status according to BMI-

for-age

Adolescent age groups (age in

years)

Total

Early (10-13) Middle (14-16)

n % n % n %

Thin 51 13.8 13 03.5 64 17.3

Normal 165 44.7 122 33.1 287 77.8

Overweight 10 02.7 08 02.2 18 04.9

Total 226 61.2 143 38.8 369 100

p = 0.004

Table 4.4: Malnutrition (criteria BMI-for-age) and calorie consumption

Nutritional status according

to BMI-for-age

Calorie consumption by the girls

Total Consuming

calories < RDA

Consuming

calories ≥ RDA

n % n % n %

Thin 54 14.6 10 02.7 64 17.3

Normal 241 65.3 46 12.5 287 77.8

Overweight 13 03.5 05 01.4 18 04.9

Total 308 83.5 61 16.5 369 100

p = 0.419

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


(BMI for age percentile) and the age of menstruation (p = 0.000) see table 4.5. No

relationship could be found between age of menarche and stunting.

Table 4.5: Relationship of menstruation and nutritional status (criteria BMI-for-

age)

Menstrual status at the

time of study

Nutritional status (BMI-for-age) Total

Thin Normal Overweight

n % N % n % n %

Not menstruating 36 09.8 75 20.3 02 0.5 113 30.6

Menstruating 28 07.6 212 57.5 16 04.3 256 69.4

Total 64 17.3 287 77.8 18 04.9 369 100

p = 0.000

DIETARY SURVEY

1. MEAL PATTERN

Three meals were taken per day i.e. break fast, mid-day meal and evening meal. The

morning meal usually consisted of roti or paratha made from wheat flour and taken with

Tea or Salan. Mid-day meal consists of roti with vegetable, pulse or meat curry. Evening

meal was same as the mid-day. Rice was taken as meal sparingly, at the most twice a

week. Snacks were infrequent between the meals.

2. INTAKE OF FOOD BY FOOD GROUPS

A. Roti: This is made from wheat flour. Out of the adolescent girls under study

43.9% took roti through out the week. Roti was eaten twice daily by 55.8%. Its

mean daily consumption was 176.3 ± 79.6 gm per head. This was the main source

of energy in food of the girls.

B. Rice: It is taken sparingly in this part of the country, maximum frequency was 2

times per week taken by 34.1% girls and 1.4% did not eat rice at all. Mean daily

per head consumption of rice was 94.6 gm.

48


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


and calories consumed by the girls (p = 0.000), as poor consumed less. Education of

parents had a strong relationship with the calorie consumption by these girls (p = 0.000),

more so in mothers, where 95% of illiterate mothers had daughters who consumed

calories less than the RDA, where as this ratio was 79.1% in literate mothers.

Fig: 4.5. Share of different food groups in calories consumed by the girls (n = 369)

Fruit, DGLV, pulses, etc20.52%

Milk4.89%

Roti 35.52%

Edible oils19.57% Meat

19.5%

Table 4.6: Calories consumed by different adolescent age groups

Calories consumed by the girls

Adolescent age groups

Total Early

(10-13 yrs)

Middle

(14-16 yrs)

n % n % n %

Consuming calories < RDA 186 50.4 122 33.1 308 83.5

Consuming calories ≥ RDA 40 10.8 21 05.7 61 16.5

Total 226 61.2 143 38.8 369 100

p = 0.448

50


Table 4.7: Relationship between energy consumption and poverty

Calories consumed by the girls

Poverty Total

Poor Not poor

n % n % n %

Consuming calories < RDA 123 33.3 185 50.1 308 83.5

Consuming calories ≥ RDA 04 01.1 57 15.4 61 16.5

Total 127 34.4 242 65.6 369 100

p = 0.000

4. PROTEINS

The mean consumption of proteins was 43.84 ± 20.07 gm/person. That was 71.9% of the

mean RDA. The consumption of proteins was considerably low in the adolescent girls as

85.6% of them were consuming proteins < RDA and only 14.4% consumed proteins

according to RDA. Protein consumption was not related to poverty.

5. CONSUMPTION OF MICRONUTRIENTS IN THE FOOD

These were determined by using food tables for Pakistan 2001.

A. Iron: Consumption of iron in the food was generally low. The mean consumption

was 17.21 ± 6.88 mg/day, which was 64.53% of the RDA; 78.05% girls were

consuming iron less than RDA and 21.95% were taking iron according to RDA

(refer appendix 9).

B. Iodine and use of iodized salt: Iodine consumption was very poor in these girls.

All the girls consumed less than the RDA. The mean daily consumption of iodine

from the food was 27.66 ± 19.72 µg, which is 26.6% of the RDA.

The girls using iodized salt were 56.4% of the adolescent girls under study.

Iodized salt consumption was related with the literacy level of mothers (p =

0.000), as mothers of 79.8% girls using iodized salt were literate and 40.4%

mothers of the girls not using this salt were illiterate. A strong relationship was

51


observed between use of iodized salt and poverty (p = 0.000) as 58.9% of the girls

not using iodized salt were poor and 80.8% using iodized salt were living above

the poverty line. The lesser use of iodine was well mad up through the use of

iodized salt.

C. Vitamin A and β-carotene: The mean daily consumption of vit-A was 517.23 ±

403.01 RE, which is 94.04% of the RDA. The girls consuming vit-A less than

RDA were 63.7% (refer appendix 9). The encouraging point is that vitamin A

deficiency is covered by the conversion of dietary β-carotene to vit-A. The mean

daily consumption of β-carotene by these girls was 2014.72 ± 1694.44 µg.

CLINICAL EXAMINATION FOR MICRONUTRIENT DEFICIENCY

1. Iodine: Clinical manifestation of iodine deficiency is observed as enlargement of the

thyroid gland, which is denoted as goiter. The goiter prevalence in the adolescent girls

under study was considerably high; total goiter rate was 52%. Break down of goiter

grading is shown in figure 4.6. Goiter had no association with the school (p = 0.144) and

age (p = 0.641). It was related to the consumption of iodized salt (p = 0.017), as 57.5% of

the girls not using iodized salt had goiter; where as 50.5% of the girls using iodized salt

were seen with goiter as shown in figure 4.7. Goiter was comparatively more prevalent in

early adolescent age group i.e. 53.98% than the middle i.e. 48.95%.

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

No goiter

48%

Visible goiter

17.9%

Palpable goiter

34.1%

52


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

(p = 0.000)

Does not know

Use

Do not use

Use of iodized salt

%

Goiter presentNo goiter

100

20

80

5050

58

42

0

20

40

60

80

2. Iron: Clinically iron deficiency is manifested as conjuntival pallor, which was seen

only in 0.8% of the girls.

2. Vitamin A: No clinical signs of vitamin A deficiency were seen in the adolescent girls

under study.

BIOCHEMICAL ASSESSMENT OF MICRONUTRIENT

DEFICIENCIES

1. Hemoglobin (Hb) level: The mean Hb level of these schoolgirls was 10.5 ± 1.68 g/dL.

Prevalence of anemia among these girls was very high i.e. 70.9% as shown in figure 4.8.

Out of the adolescent girls under study 1.4% girls refused for finger prick and hence their

Hb level could not be estimated. Anemia had no relationship with age group, stunting,

thinness and energy consumption. 58.3% of the anemic girls belonged to poor

socioeconomic status see table 4.8. Anemia was also related to parent education.

53


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

Severely anemic1.1%

Not anemicMild to moderately

Anemic 69.8% 29.1%

Table 4.8: Anemia and socioeconomic status

Anemia status

Socioeconomic status Total

Poor Not poor

N % n % n %

Anemic 74 20.3 184 50.5 258 70.9

Not anemic 53 14.6 53 14.6 106 29.2

Total 127 34.9 237 65.1 364 100

p = 0.000

54


DISCUSSION

Pakistan is a third world country situated in the SAARC region, which is adversely

affected by malnutrition, infectious and deficiency diseases (Raheena 2001). The prime

factors leading to this bad situation are poverty, illiteracy, deteriorating socioeconomic

situation, lack of health facilities, poor sanitation, lesser availability of food and larger

household sizes (Choudhary 2003; Reifen 2003; Hesketh 2003; Kennedy and Garcia

1992; Leslie 1992). The adolescent group of population is also affected by these factors.

Nutritional status of the adolescent girls under study is poor and is similar to the girls

from other developing nations (Raheena 2001). Adolescent girls from developing and

developed world behave similarly in certain respects i.e. food consumption, eating habits

and food taboos (hot, cold etc.), where in certain foods are withheld from their diet

(Gittelsohn 1991) and these factors lead to deficiency diseases in them. With this

background the important findings of the study are discussed with reference to

geographic, socioeconomic and cultural similarities and judged against the status of

adolescence from the developed world accepting them as the standard.

The study population was the adolescent girls of schools. The schools in Pakistan are

from class one to the 10th. The adolescent age starts from the 10th year of the life and

extends up to the 19th. The usual age of the last class of the school is 16 years. So the

study sample was from the age of 10 to 16 years. For convenience the adolescent girls

were divided into 3 groups i.e. early, middle and late adolescents. Our sample consisted

of 61.2% early (10-13 years) and 38.8% middle (14-16 years). The earlier period is more

important as puberty starts in this age group. Adequate nutrition is essential during this

age because growth and development during this period plays a key role in attaining

normal adult size and establishing reproductive capacity (Seidenfeld 2004).

The education is a prime factor in maintaining health, nutrition and socioeconomic

wellbeing of and individual and his dependents (Reifen et al. 2003; Hosegood and

Campbel 2003). The education of these girls does not matter as for their nutritional status

is concerned, what affects is the education of their parents, especially the mother. Parent

41


education is the key component in determining the socioeconomic status (SES) of the

family (Reifen et al. 2003), which is a main factor in choosing a school for the children

and affecting their nutritional status. The parents had the literacy rate of 81.7% and 60.7%

mothers were above the primary level. This literacy rate is much higher than the national

literacy rate of 51.6% (Economic Survey of Pakistan 2002-03). The reason is that this

segment of population is urban and the majority is in government services, who are

usually an educated lot. Generally they are better caring towards their family in respect of

education, health and nutrition. The post primary education for mothers is important

because here they are taught the subject of Home Economics (Akhtar and Mashkoor

2003), which improves their home care, health and nutrition sense thus affecting their

nutritional status.

Hundred percent household heads (fathers) were employed, 1.1% laborers, 36.7%

government servants (better educated from the whole lot) and others are self employed,

undertaking various jobs/businesses. The mothers are mainly housewives i.e. 90.8%.

Profession of the household head is a key factor in determining the socioeconomic status

of the family. Urban areas offer plenty of job opportunities as compared to the rural ones.

The hard fact is that majority are low paid, even the government servants are from the

lower ranks.

Household composition verily affects the nutritional status of an individual (Ramos de

Marins 2004). The mean household size of 7.15 ± 1.84 was much higher and reflects the

higher annual population growth rate i.e. 2.1% in Pakistan. The average Pakistani

household size is 6.8. In Punjab it is 6.9, FATA 9.3 and in Islamabad it is 6.2 (Economic

Survey of Pakistan 2002-03). In India it is 5.1 (Raheena 2001). Larger sizes are more

prevalent in GCGHSS, in poor and illiterate mothers. Poor and illiterate mothers cannot

be easily persuaded for the family planning measures and also have lower access to such

facilities and hence they rear larger families. Household composition determines the per

capita income and large sizes decrease it, thus increasing the poverty level and decreasing

the availability of the food, good sanitation and health facilities to these girls, which

affects their nutritional status.

42


Socioeconomic status (SES) is the final outcome of the education, profession and income

of the household. All these factors influence the SES and without improving the SES,

nutritional status and education can’t be improved (Reifen et al. 2003). In the past it used

to be measured as lower, middle and upper SES on the basis of household income only,

which does not reflect the true picture. Now the household size is also taken into account

and per capita monthly income is calculated, which is compared with the poverty line to

declare one poor or non poor. According to the Economic Survey of Pakistan 2002-03 a

person with per capita income below Rs. 748.52 per month is poor. This gives us the

poverty level of a population, which is the true indicator of the socioeconomic status of an

individual. The mean per capita income in this study was Rs. 1930 ± 1845. The poverty

level in these girls was 34.4%, which is in line with the national poverty level of 31.8%

(Economic Survey of Pakistan 2002-03) and Indian poverty level of 36.1% (Microsoft

Encarta Encyclopedia 2004). Both the countries have similar socioeconomic and political

conditions. Poverty in Pakistan is on increase, as it has increased from 29.1% in 1987 to

31.8% in 2003 (Economic Survey of Pakistan 2002-03). The contributing factors are

decreasing job opportunities (unemployment rate has increased from 5.37% in 1993 to

7.82% in 2003) (Economic Survey of Pakistan 2002-03), slow industrial growth, political

unrest and hostile international scenario. Poverty has many dimensions, as the poor has

not only low income but they also lack access to basic needs such as food, education,

healthcare, clean drinking water and proper sanitation. These factors further deteriorate

the health and nutritional status of the people.

Anthropometrics is used during adolescence in various contexts related to nutritional

and health status. There are no well defined criteria or cut-off values that relate to specific

risks or aspects of health in individuals. Available data are insufficient and it is quite

likely that best cut-offs for one purpose are far from ideal for another. Better definitions

await the results of further research. The reference values used for these indicators are

derived from the data collected by NCHS in United States. In some cases local reference

data may be required or other local factors must be considered. In the absence of such

references WHO advocates the use of afore said data for this purpose, (WHO 1983; WHO

Technical Report Series 854-1995) refer appendix 10.

43


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.

44

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


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


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


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


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


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


50

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).

CHAPTER 5 Summary of findings of study, conclusions and recommendations 66

SUMMARY OF FINDINGS OF STUDY

This study provides an insight into the nutritional status and eating pattern of the

adolescent girls. The data indicates that their dietary habits are less than ideal and so

is their nutritional status. Anemia and goiter are prevalent in these girls. Clinical signs

of vitamin A deficiency are not seen. Very interesting findings are noted in this study.

A total of 369 adolescent girls from two schools of the Rawalpindi city were included

in this study from the age 10 – 16 years. Among these 61.2% belonged to early and

38.8% to middle adolescent age groups. These girls were studying in classes 6 – 10th.

Literacy rate of their fathers was 90.8% and mothers 72.6%. The mean household size

was 7.15 ± 1.84 persons per family. Poverty level in these girls was 34.4%. Mean age

of menarche was 12.6 ± 0.842 years. The girls mainly took three meals a day.

Consumption of milk, egg, meat and DGLV in their diet was very low. Mean daily

calorie consumption was 1532 ± 525 per head, which is 74.47% of the RDA (average

for this age group is 2033). Main source of calories was roti made from wheat flour,

which contributed 35.52%. Protein consumption was low i.e. 43.84 ± 20.07 gm/day,

which is 71.9% of RDA. Micronutrients (iron, iodine and vitamin A) were consumed

less than RDA. Stunting was seen in 6.8% girls, 17.3% were thin and only 4.9% were

overweight. Anemia was very common i.e. 70.9%. Total goiter rate was 52%. No

signs of vitamin A deficiency disease were seen in these girls.

66


CONCLUSIONS

Nutritional status of these adolescent girls is not ideal as it is below the standard.

Pakistan is a third world country and lacks for behind the developed nations in this

respect, but the scenario is not so bad, when we compare these findings with the

underdeveloped and developing countries. In fact we are much better than many of

the later nations. Malnutrition is a significant problem. Anemia and goiter rates are

high, which have a definite nutritional & social background, as these girls have low

calorie and micronutrients consumption. Moreover their diet is not balanced. The

major culprits are poverty, large family sizes, scarce health care facilities, lack of

nutrition education and certain food taboos in adolescent girls.

There is dearth of data both anthropometric and dietary, on adolescents' nutrition and

health, to determine and confirm the prevalence of malnutrition (stunting, thinness

and obesity), eating disorders and other micronutrient deficiencies (iron, iodine and

vitamins) among adolescents in developing countries; whether catch-up growth is

possible during adolescence and if so to what extent and how; if adolescent

undernutrition is transferred into adulthood and reasons for gender differentials in

adolescent nutritional status (Kurz and Welch 1994; Senderowitz 1998; Baldwin

1995).

Extensive research is needed in nutrient consumption, eating patterns and impact of

nutrition intervention (supplementation) in them. In order to develop appropriate

anthropometric reference data, a multi-country study, with longitudinal and cross-

sectional components, on adolescents’ somatic growth and maturation should be

considered a high priority. Such data is required to serve as cut-off points and an

instrument to trigger action at program or individual level. Schools are ideal targets

for food-based approaches to improving micronutrient status, in particular vitamin A

and iron. The influence of school goes beyond the classroom and includes normative

messages from peers and adults regarding foods and eating patterns.

67


RECOMMENDATIONS

The nutritional status of the adolescent girls is strongly related with the future

productivity of a nation and its economic growth. Realizing the importance of the

nutritional status as the key indicator in the development process efforts should be

made to help the vulnerable groups through different ways and means for its

improvement. Their nutritional status can be improved by:-

1. Improving the knowledge of adolescents, parents, school teachers and other

community members about nutrition, balanced diet and deficiency diseases.

2. Improving their dietary intake through locally available food resources by

family involvement.

3. Supplementing their diet where dietary intake alone is not enough to fulfill

certain nutrient requirements, such as Fe, initiate supplementation and/or food

fortification programs.

4. Encouraging the use of iodized salt at household level for prevention of iodine

deficiency disorders.

5. Short term feeding programs started by the government as a pilot project

should be extended in all the schools of the country as the nutritional status of

the girls is poor.

6. Providing health care facilities to prevent and treat infections & worm

infestations for anemia alleviation and maintenance of good health.

This segment of the adolescence being in schools can be best approached through

school-based nutrition education programs. These programs should be part of

comprehensive school health programs and reach students from preschool through

secondary school. School leaders, community leaders, government functionaries,

media and parents must commit to implementing and sustaining nutrition education

programs within the schools. Such support is crucial to promoting healthy eating

behaviors. Following recommendations are made: -

1. Policy: Adopt a coordinated school nutrition policy that promotes healthy

eating through classroom lessons and a supportive school environment, which

can powerfully influence students' attitudes, preferences, and behaviors related

to food.

68

CHAPTER 5 Summary of findings of study, conclusions and recommendations

69

69

2. Curriculum for nutrition education: Implement nutrition education as part of a

sequential, comprehensive school health education curriculum designed to

help students adopt healthy eating behaviors.

3. Instruction for students: Provide nutrition education through developmentally

appropriate, culturally relevant, fun, participatory activities that involve social

learning strategies.

4. Integration of school food service and nutrition education: Coordinate school

food service with nutrition education and with other components of the

comprehensive school health program to reinforce messages on healthy eating.

School cafeteria is a place for this. In its absence school cafeteria or the tuck

shop should have a close liaison with nutrition people and promote healthy

eating behavior.

5. Training for school staff: Provide staff involved in nutrition education with

adequate pre-service and ongoing in-service training that focuses on teaching

strategies for behavioral change.

6. Family and community involvement: Involve family members and the

community in supporting and reinforcing nutrition education. Their attitude

directly influences adolescents' choice of foods (Johnson CC-1994). Parents

control most of the food choices available at home, so changing parents' eating

behaviors may be one of the most effective ways to change their children's

eating behaviors.

7. Involve media: Both print (newspapers, magazine) and electronic media (TV,

radio and internet) can play a pivotal role in modifying the public behavior.

8. Regularly evaluate the effectiveness of the school health program in

promoting healthy eating, and change the program as appropriate to increase

its effectiveness.

REFERENCES

Abahussain, N. A., A. O. Musaiger, and P. J. Nicholls, et al. 1999. Nutritional status of

adolescent girls in the eastern province of Saudi Arabia. Nutr Health. 13(3):171-7

Adamson, H., and I. Shaw, 1981. A Traveler’s Guide to Pakistan, Asian Study Group, PO

Box No 1552, Islamabad, Pakistan. Pp 39.

Agarwal, D. K., S. K. Upadhyay, and A. M. Tripathy, et al. 1987. Nutritional Status,

Physical Work Capacity and Mental Function in School Children. Nutrition

Foundation of India, New Delhi, Scientific Report No. 6. Pp 16-23.

Ahmed, F., M. R. Khan, and M. Islam, et al. 2000. Anemia and iron deficiency among

adolescent schoolgirls in peri-urban Bangladesh. Eur J Clin Nutr Sep; 54(9): 678-

83.

Ahmed, F., M. R. Khan, and R. Karim, et al. 1996. Serum retinol and biochemical

measures of iron status in adolescent schoolgirls in urban Bangladesh. Eur J

Clin Nutr; 50: 346-51.

Akhtar, A. and Z. Mashkoor, 2003. Home Economics for class 7. Punjab Text Book

Board Lahore.

Akhtar, R. A. 1976. Nutritional status of college girls (thesis). Department of Nutrition,

Faculty of Animal Husbandry, University of Agriculture, Faisalabad. Pp 1.

Akhtar, T., and Z. Ullah, 2003. Goiter in district Swat NWFP-Pakistan, Current situation.

Pakistan J Med Res Jun: 42(2): 74-6.

Ali, S. M. 1989. Nutritional problems of the Muslim Ummah: Food & Nutritional

problems of the Muslim Ummah. Pakistan Science Foundation & Pakistan

Academy of Sciences. Project foe SATMU c/o Pakistan Academy of

Sciences, Islamabad.

Ali, S.M., And M.A. Khan 1976. Nutritional Status Of Students Of Deeni Madaris. M.Sc.

71

REFERENCES

Thesis. University of Agriculture, Faisalabad.

Alvarez Uribe, M.C., R. M. Uscategui Penuela, and C. Lopez Bedoya, et al. 2004. Plasma

retinol concentration according to pubertal maturation in school children and

adolescents of Medellin, Colombia. Eur J Clin Nutr. 2004 Mar; 58(3): 456-61.

Amine, E. K. 1980. Oman Nutritional Status survey. UNICEF, Gulf Area Office, Abu

Dhabi

Aranceta Bartrina, J., C. Perez Rodrigo, I, Marzana Sanz, et al. 1998. Prevalence of iron

deficiency anemia in the Basque Country. Aten Primaria Oct 15;22(6): 353-61

Araujo, R. L., M. B. Araujo, and R. O. Sieiro, et al. 1986. Diagnosis of hypovitaminosis

A and nutritional anemia status in the population of Vale do Jequitinhonha,

Minas Gerais, Brazil. Arch Latinoam Nutr. Dec; 36(4): 642-53.

Aspatwar, A. P., and M. M. Bapat, 1995. Vitamin A status of socio-economically

backward children. Indian J Pediatr. Jul-Aug; 62(4): 427-32.

Ayatollahi, S. M., E. Dowlatabadi, and A. S. Ayatollahi, 2002. Age at menarche in Iran.

Ann Hum Biol. Jul-Aug; 29(4): 355-62.

Aykroyd, W. R. 1970. Conquest of deficiency diseases, achievements and prospects.

WHO Basic Study No 24. Geneva.

Baldwin, J. 1995. A Picture of Health. A Review and Annotated Bibliography of

theHealth of Young People in Developing Countries. New York and Geneva:

UNICEF and WHO.

Bandini, L. G., et al. 2003. Longitudinal changes in the accuracy of reported energy

intake in adolescent girls 10 – 15 years of age. American Journal of Clinical

Nutrition. Vol. 77 No. 4, 962-959.

Barr, F., L. Brabin, and S. Agbaje, et al. 1998. Reducing iron deficiency anemia due to

72

REFERENCES

heavy menstrual blood loss in Nigerian rural adolescents. Public Health Nut. 1:

249-57.

Barszez, B., and E. Kolarzyk, 2003. Dietary habits and nutritional status of secondary

school pupils. Pzegl Lek. 60 Suppl 6: 36-9.

Batliwala, S. 1987. Women’s access to food. Indian Journal of Social Work, 48(3):

255B271.

Behrman, J. R. 1992. The economic rationale for investing in nutrition in developing

countries. USAID, Office of Nutrition, Washington DC.

Bingham, S. A., 1987. The dietary assessment of individuals; methods, accuracy, new

techniques and recommendations. Nutr. Abs. Rev. 57: 705-42.

Black, A. E. 1982. The logistics of dietary surveys. Hum. Nutr: Appl. Nutr. 36A: 85-94.

Blum, R. W. 1991. Global trends in adolescent health. JAMA. 265: 2711-9

Brabin, B. J., P. D. Prinsen-Geerligs, F. H. Verhoeff, et al. 2004. Hematological profiles

of the people of rural southern Malawi: an overview. Ann Trop Med Parasitol.

Jan; 98(1): 71-83.

Bradby, H., 1996. Cultural strategies of young women of South Asian origin in

Glasgow [dissertation]. University of Glasgow UK.

Brahmbhatt, S. R., R. A. Fearnley, and R. M. Brahmbhatt, et al. 2001. Biochemical

assessment of iodine deficiency disorders in Baroda and Dang districts of

Gujarat. Indian Pediatr Mar; 38(3): 247-55.

Cai, M. Q., and W.Y. Yan, 1990. Study on iron nutritional status in adolescene. Biomed

Environ Sci; 3: 113-119.

Cameron, M. E. and W. A. van Staveren, 1988. Manual on methodology for food

73

REFERENCES

consumption studies. Oxford University Press, Oxford.

Chapman, G. E. 1992. Perspectives on Adolescent Women and Food (dissertation).

University of Toronto.

Chatterjee, M., and J. Lambert, 1989. Women and nutrition; reflections from India and

Pakistan. Food and Nutrition Bulletin, 4: 13B28.

Chilman, S. M., and M. C. Nancy, 1994. Nutrition during childhood and adolescence and

the later years. Hounghton Hiffin Company, London.

Choudhary, S., C. P. Mishra, and K. P. Shukla, 2003. Energy balance of adolescent girls

in rural area of Varanasi. Indian J Public Health. 2003 Jul-Sep; 47(3): 21-8.

Choudhury, P., and S. Vir, 1994. Prevention and strategies for control of iron deficiency

anemia. In: Nutrition in children – Developing Country Concerns. Eds.

Sachdev HPS, Choudhury P. Cambridge Press, New Delhi. Pp 492-524.

Christakis, G. 1973. Nutritional assessment in health problems. Am. J. Public Health, 63

(suppl): 1.

Chumlea, W. C., C. M. Schubert, and A. F. Roche, et al. 2003. Age at menarche and

racial comparisons in US girls. Pediatrics; Jan; 111(1): 110-3.

Clement, F. W. 1954. Endemic goiter in Australia, New Zealand and Melanesia. Bull.

WHO, 10, 105.

Cordonnier, D. 1995. Événements quotidiens et bien-être à l’adolescence. Vers de

nouvelles stratégies d’éducation pour la santé. Genève. Éd Méd Hyg,

Cu, S. Y., L. N. Kolonel, J. H. Hankin, and J. Lee, 1984. A comparison of frequency and

quantitative dietary methods for epidemiologic studies of diet and diseases. Am.

J. Epid. 119: 323-34.

Dallman, P. R., M. A. Siimes, and A. Stekel, 1980. Iron deficiency in infancy and

74

REFERENCES

childhood. Am J Clin Nut. 33: 86-118.

DeMaeyer, E., and M. Adiels-Tegman, 1985. The prevalence of anemia in the world.

World Health Stats Q; 38:302-16.

Department of Social Security, 1993. Household below average income 1979-

1990/91. HMSO London, UK.

Din, Z. U., and P. I. Paracha, 2003. Assessment of nutritional status of adolescent boys

from public and private schools of Peshawar. Pakistan J Med Res Sep; 42(3): 129-

33

Dodd, N. S., and M. L. Godhia, 1992. Prevalence of iodine deficiency disorders in

adolescents. Indian J Pediatr Sep-Oct; 59(5): 585-91.

Economic Survey of Pakistan, 2002-03. Planning and Development Division,

Ministry of Finance, Islamabad.

El-Sahn, F., S. Sallam, and A. Mandil, et al. 2000. Anemia among Egyptian adolescents:

prevalence and determinants. East Mediterr Health J Sep-Nov; 6(5-6):1017-25.

Eveleth, P. B., and J. M. Tanner, 1990. Worldwide variation in human growth, 2nd edn.

Cambridge University Press.

Fazio-Tirrozzo G, Brabin L and Brabin B, et al-1998. A community based study of

vitamin A and vitamin E status of adolescent girls living in Shire Valley,

Malawi. Eur J Clin Nutr; 52: 637-42.

Fenwick, Elizabeth, and Richard Walker, 1994. How Sex Works: A Clear,

Comprehensive Guide for Teenagers to Emotional, Physical, and Sexual

Maturity. Dorling Kindersley

Ferro-Luzzi, A. 1990. Seasonal energy stress in marginally nourished rural

women; interpretation and integrated conclusions of a multicenter study in

75

http://www.pakmedinet.com/journal.php?id=PJMR

REFERENCES

three developing countries. European Journal of Clinical Nutrition. 44(Suppl.1):

41B46.

Fluery, Y., G. Van Melle, and V. Woringer, et al. 2001. Sex dependent variations and

timing of thyroid growth during puberty. J Clin Endocrinol Metab. Feb; 86(2):

750-4.

Food Composition Table for Pakistan Revised, 2001. Department of Agriculture

Chemistry, NWFP Agriculture University, Peshawar. Ministry of Planning and

Development, Government of Pakistan.

Fujimori, E., S. Szarfarc, and I. M. de Oliveira, 1996. Prevalence of iron deficiency

anemia in female adolescents in Taboaoa da Serro, SP. Brazil. Rev Lat Am

Enfermagem. Dec; 4(3):49-63.

Fuse, Y., T. Igari, and C. Yamada, et al. 2003. Epidemiological survey of thyroid volume

and iodine intake in schoolchildren, postpartum women and neonates living in

Ulaan Baatar. Clin Endocrinol (Oxf). Sep; 59(3): 298-306.

Garg, S., N. Sharma, and R. Sahay, 2001. Socio-cultural aspects of menstruation in an

urban slum in Delhi, India. Reprod Health Matters. May; 9(17): 16-25.

Garnier, D., G. Ndiaye, and E. Benefice, 2003. Influence of urban migration on physical

activity, nutritional status and growth of Senegalese adolescents of rural origin.

Bull Soc Pathol Exot. 2003 Aug; 96(3): 223-7.

Garnier, D., K. B. Simondon, et al. 2003. Impact of the health and living conditions of

migrant and non migrant Senegalese adolescent girls on their nutritional status

and growth. Public Health Nutr. 2003 Sep; 6(6):535-47.

Gazetteer of Rawalpindi, 1893-4. Sang-e-Meal Publications, Lahore. Pp 1, 15, 16 & 19.

Gittelsohn, J. 1991. Opening the box: Intrahousehold food allocation in rural Nepal.

76

REFERENCES

Social Science and medicine, 33(10): 1141B1154.

Glew, R. H., C. A. Conn, R. Bhanji, et al. 2003. Survey of the growth characteristics and

body composition of Fulani children in a rural hamlet in northern Nigeria. J Trop

Pediatr. 2003 Oct; 49(5): 313-22.

Hadden, W. C., G. Pappas, and A. Q. Khan, 2003. Social stratification, development and

health in Pakistan: an empirical exploration of relationships in population-based

national health examination survey data. Soc Sci Med. Nov; 57(10):1863-74.

Hamill, P. V. V., et al. 1979. Physical growth. National Center for Health Statistics

percentiles. American Journal of Clinical Nutrition, 32: 607-629.

Haq, M. N. 1984. Age at menarche and the related issue: a pilot study on urban school

girls. J Youth Adolesc. 1984 Dec; 13(6): 559-67.

Hashizume, M., T. Shimoda, S. Sasaki, et al. 2004. Anemia in relation to low

bioavailability of dietary iron among school aged children in Aral Sea region,

Kzakhstan. Int J Food Sci Nut. Feb; 55(1): 37-43.

Hels, O., N. Hassan, I. Tetens, et al. 2003. Food consumption, energy and nutrient intake

and nutritional status in rural Bangladesh: changes from 1981-1982 to 1995-96.

Eur J Clin Nutr. 2003 Apr; 57(4): 586-94.

Hels, O., U. Kidmose, T. Larsen, et al. 2003. Estimated nutrient intakes and adequacies in

Bangladesh change when newer values for vitamin A, iron and calcium in

commonly consumed foods are applied. Int J Food Sci Nutr. 2003 Nov; 54(6):

457-65.

Hendee, W. R. 1991. Sociodemographic trends and projections in the adolescent

population. The health of adolescents. A publication of American Medical

association. Jossey-Bass Publishers, San Francisco 94104, USA. Pp 2.

Hesketh, T., J. D. Qu, and A. Tamkins, 2003. Health effect of family size: cross sectional

77

REFERENCES

survey in Chinese adolescents. Arch Dis Child. Jun; 88(6): 467-71.

Hesketh, T., Q. J. Ding, A. Tomkins, 2002. Growth status and menarche in urban and

rural China. Ann Hum Biol. May-Jun; 29(3): 348-52.

Hosegood, V., and O. M. Campbell, 2003. Body mass index, height, weight, arm

circumference, and mortality in rural Bangladeshi women: a 19-y longitudinal

study. Am J Clin Nutr. 2003 Feb; 77(2): 341-7.

Ibrahim, et al. 1997. Urban Study on children of Karachi. JPMA 1997.

ICCIDD, 1995. Global distribution of iodine deficiency disorders; based on total goiter

prevalence in school age children. Data from CIDDS database. Updated January

1995. ICCIDD communication focal point: International Communication

Enhancement Center; Tulane University School of Public Health. 1501 Canal

Street, Suite 1300, New Orleans LA 70112 USA

ICNND, 1957, 1963. Manual of Nutrition Surveys. Interdepartmental Committee on

Nutrition for National Defense. Government Printing Office. Washington, D. C.

Jelliffe, D. B. 1966. The assessment of the nutritional status of a community. WHO

monograph Series No 53, 194, 221-228.

Jelliffe, D. B., and E. F. P. Jelliffe, 1989. Community nutrition assessment. Oxford

University Press, London.

Jenne, F. H., and W. H. Greene 1976. School Health and Health Education. 7th ed. St.

Louis, Mo.; C.V. Mosby.

Jinabhai, C. C., M. Taylor, and A. Coutsoudis, et al. 2001. A health and nutritional

profile of rural school children in KwaZulu-Natal, South Africa. Ann Trop

Paediatr. Mar, 21(1): 50-8.

Johnson, C. L., et al. 1981. Basic data on anthropometric measurements and angular

78

REFERENCES

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).

Kapil, U., P. Pathak, P. Singh, and S. N. Dwivedi1, 2003. Reproducibility and

Validity of the Food Frequency Questionnaire Methodology in an Urban Middle

Income Group Community of Delhi, India. Pakistan; Journal of Nutrition 2 (1):

33-35. Asian Network for Scientific Information.

Kapoor, G., and S. Aneja, 1992. Nutritional disorders in adolescent girls. Indian

Pediatr, 29(8): 969-73.

Kelly, F. C., and W. W. Snedden, 1958. Prevalence and ecological distribution of

endemic goiter. In: Endemic goiter, Geneva (WHO: Monograph Series, No. 44). P

27.

Kennedy, E., and M. Garcia, 1993. Effects of selected policies and programs on

women’s health and nutritional status. International Food Policy Research

Institute, Washington, DC.

Khavin, I., and O. Nikolayer, 1962. Diseases of the thyroid gland. Peace Publishers

Moscow.

Khongsdier, R., and N. Mukherjee, 2003. Effects of heterosis on growth in height and its

segments: a cross-sectional study of the Khasi girls in Northeast India. Ann Hum

Biol. 2003 Sep-Oct; 30(5): 605-21.

Kiani, G. H. and M. H. Akhtar, 2003: Basic Statistics for Intermediate Classes part I;

Majeed Book Depot, Lahore pp 3.

Kinney, T. D., and R. H. Follis, 1958. Proceedings of a conference on beriberi, endemic

goiter and hypovitaninosdis A. Princeton N J. June 1-5 (Fed Proc, 17, No 3 part

79

REFERENCES

II, Suppl No 2 Nutritional diseases).

Kurz, K. M. 1996. Adolescent nutritional status in developing countries. Proc Nutr

Soc. Mar; 55(1B): 321-31.

Kurz, K. M., and J. C. Welch, 1994. The nutrition and lives of adolescents in developing

countries. Findings from the nutrition of adolescent girls research program.

ICRW.

Leenstra, T., S. K. Kariuki, J. D. Kurtis, 2004. Prevalence and severity of anemia and

iron deficiency: cross-sectional studies in adolescent schoolgirls in western

Kenya. Eur J Clin Nutr. 2004 Apr; 58(4): 681-91.

Leshan, L., M. Gottlieb, and D. Mark, 1995. Anemia is prevalent in an urban,

African – American adolescent population. Arch Fam Med May; 4(5): 433-7.

Leslie, J. 1992. Women’s lives and women’s health: using social science research to

promote better health for women. J Wom Health, 1(4): 307-18.

Li, R., X. Chen, and H. Yan, et al. 1994. Functional consequences of iron

supplementation in iron-deficient female cotton mill workers inn Beijing, China.

Am J Clin Nutr; 59: 908-13.

Liaqat, P. 1997. Biochemical assessment a tool of nutritional assessment: Community

Nutrition. Code # 862. Department of Home and Health Sciences. AIOU

Islamabad, pp 112.

Liberators, P., B. G. Link, and J, L, Kelsey, 1988. The measurement of social class in

epidemiology. Epid. Rev. 10: 87-121.

Lohman, T. G., A. F. Roche, and R. Martorell, eds. 1988. Anthropometric

Standardization Reference Manual. Champaign, IL, Human Kinetics Books.

Looker, A. C., P. R. Dallman, and M. D. Carroll, et al. 1997. Prevalence of iron

80

REFERENCES

deficiency in the United States. JAMA, Mar 26; 277(12): 973-6.

Luboshitzky, R., Y. Dgani, and S. Atar, et al. 1995. Goiter prevalence in children

immigrating from an endemic goiter ares in Ethiopia to Israel. J Pediatr

Endocrinol Metab. Apr-Jun; 8(2): 123-5.

Lynam, M. J. 1982. Adolescents Perception of Food and Food Behaviors: An

Interpretive Study (dissertation). University of British Columbia, Canada.

Mahachoklertwattana, P., U. Suthutvoravut, and S. Charoenkiatkul, et al. 2002. Earlier

onset of pubertal maturation in Thai girls. J Med Assoc Thai. Nov; 85 Suppl 4:

S1127- 34.

Malhotra, A., ans S. J. PAssi, 2004. Nutrition and health status of rural adolescent girls in

selected ICDS blocks of Delhi and Rajasthan. Asia Pac J Clin Nutr. 13(Suppl):

S134.

Malik, F. R., et al. 1968. Survey of school children. PJMR, 124-33, 7.

Margetts, B. M., and M. Nelson, 2000: Design Concepts in Nutritional Epidemiology. 2nd

edition. National Book Foundation. Code # TBRP/727/2000, Islamabad,

Pakistan.

Martorell, R., and J. P. Habicht, 1986. Growth in early childhood in developing

countries. In Human growth: A comprehensive treatise, Vol. 3. Methodology:

Ecological, genetic, and nutritional effects on growth. 2nd edn, eds F Falkner &

JM Tanner. Pp. 241-262. Plenum Press, London.

Martorell, R., J. Rivera, and H. Kaplowitz, 1990. Consequences of stunting in early

childhood for adult body size in rural Guatemala. Ann. Nestlé 48, No. 2, 85-92.

Martorell, R., J. Rivera, H. Kaplowitz, and E. Pollitt, 1992. Long-term consequences

of growth retardation during early childhood. In Human growth: basic and clinical

aspects, eds M. Hernandez & J Argente. Pp. 143-149. Amsterdam, The Netherlands:

81

REFERENCES

Elsevier Science Publishers B.V.

McCarrison, R. 1917. The thyroid gland in health and disease. London, Bailliere, Tindall

& Cox.

McLaren, D. S. 1966. Present knowledge of the role of vitamin A in health and

disease. Trans Roy Soc Trop Med Hyg, 60, 436.

Mcloone, P. 1994. Carstairs scores for Scottish postcode sectors for the 1991 census.

Public Health Research Unit, University of Glasgow, UK.

Microsoft® Encarta® Encyclopedia 2003. © 1993-2002 Microsoft Corporation.

Mirza, Z. 2004. Pakistan a dismal nutritional scenario (cover story). The Network’s Drug

Bulletin, ISSN 1022, 257X, Vol. 13, No.1

MNS, 1977-78. Micro Nutrient Survey of Pakistan, Islamabad.

Morgan, R. W., A. B. M. Jain, and N. W. Miller, et al. 1978: A comparison of dietary

methods in epidemiological studies. Am. J. Epidemiol. 107: 488-497.

Mukudi, E. 2003. Nutrition status, education participation, and school achievements

among Kenyan middle school children. Nutrition. Jul-Aug; 19(7-8): 612-6.

Muratee, S. 1990. About anemia. Nutrition, 24(2). Pp 3-12.

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.

National plan of action for the SAARC decade of the girl child 1991-2000 AD, 1991.

Situational analysis. New Delhi. Government of India. Department of Women and

Child Development. Ministry of Human Resource Development.

Nelson, M. 1996. Anaemia in adolescent girls: effects on cognitive function and

82

REFERENCES

activity. Proc Nutr Soc; 55:359-67.

Nelson, M., F. Bakaliou, and A. Trivedi, 1994. Iron-deficiency anemia and physical

performance in adolescent girls from different ethnic backgrounds. Br J Nutr.

Sep; 72(3): 427-33.

NNMB, 1979. Special publication Series 5. Nutrition Foundation of India. Pp 45.

NNS, 2001-02. National nutrition survey by Pakistan Institute of Development

Economics. Sponsored by Nutrition Section Planning and Development

Division, Government of Pakistan & UNICEF, Islamabad.

NNS, 2001-02. National Nutrition Survey, 2001-02. Nutrition Section, Planning and

Development Division. Government of Pakistan, Islamabad and UNICEF.

Nutrition Country Paper, 1992. Joint FAO/WHO Conference on Nutrition.

Nutrition Section, Planning and Development Division; Government of Pakistan,

Islamabad.

Nutritional survey, 1965-1966. Government of Pakistan on the people of West

Pakistan.

Oomen, H. A. P. C. 1961. An outline of xerophthalmia. Int Rev Trop Med. 1, 131.

Oomen, H. A. P. C., D. S. McLaren, and H. Escapini, 1964. A global survey of

xerophthalmia. Trop Geogr Med, 16, 271.

Owen, G. M. 1982. Measurement, recording and assessment of skin fold thickness

in childhood and adolescence: report of a small meeting. American Journal of

Clinical Nutrition, 35: 629-638.

Paracha, P., et al. 1998. Community based study in children of Peshawar. UNICEF

1997.

83

REFERENCES

Pipher, and Mary, 1994. Reviving Ophelia. Ballantine Books. New York.

Pollitt, E. 1990. Malnutrition and infection in the classroom. Belgium: UNESCO.

PREPCOM/ICN/92/lNF/5, 1992. International Conference On Nutrition: Major issues

for nutrition strategies, Summary. FAO/UN/WHO.

Prista, A., J. A. Maia, A. Damasceno, and G. Beunen, 2003. Anthropometric indicators of

nutritional status: implications for fitness, activity, and health in school-age

children and adolescents from Maputo, Mozambique. Am J Clin Nutr. Apr;

77(4): 952-9.

Raheena, M. B. 2001. Prevalence of malnutrition among adolescent girls, A case study in

Kalliyoor panchayat Thiruvananthapuram. Kerala Research Program on Local

Development. Center for Development Studies Thiruvananthapuram India. ISBN

No: 81-87621-37-0. Pp 5.

Rajaratnam J, Rajaratnam A, Asokan SJ and Jonathum P-2000. Prevalence of anemia

among adolescent girls of rural Tamilnadu; Indian Pediatrics’ 37:532-536.

Raman, L. 1992. Health and nutritional problems of adolescent girls. Nutrition, 10,

(5), National Institute of Nutrition, Hyderabad, India. Pp 8-12.

Ramos de Marins, V. M., R. M. Almeida, R. A. Pereira, et al. 2004. The relationship

between parental nutritional status and overweight children/adolescents in Rio de

Janeiro, Brazil. Public Health. Jan; 118(1): 43-9.

Rao, V. K., G. Radhaiaha, and S. V. S. Raju, 1980. Association of growth status and the

prevalence of anemia in preschool children. India J Med Res; 71: 237-246.

Raunklar, R. A., and H. Sabio, 1992. Anemia in the adolescent athlete. Am J Dis Child;

146:1201-5.

Ravanshad, S. E., S. Maram, F. Nader, and H. Mostafavy, 2003. Prevalence study of

84

REFERENCES

iodine deficiency disorders among high school girls in Shiraz, Islamic Republic

of Iran, 1996–1997. Pak J Med Sci. 2003, 19(2) 70-74.

Rees, J. M., and D. N. Sztainer, et al. 1999. Improving the Nutritional Health of

Adolescents: A Position Statement of the Society for Adolescent Medicine.

Journal of Adolescent Health: 24: 461-462

Reifen, R., L. Haftel, and G. Manor, et al. 2003. Ethiopian-born and native Israeli school

children have different growth patterns. Nutrition. 2003 May; 19(5): 427-31.

Sankar, R., T. Pulger, and T. B. Rai, et al. 1994. Iodine deficiency disorders in school

children of Sikkim. Indian J Pediatr Jul-Aug; 61(4): 407-14.

Sathar, Z. A., M. Sultana, and C. B. Lloyd, et al. 2002. Adolescents and Youth in

Pakistan 2001- 2002. A nationally representative survey. Population Council,

Islamabad, Pakistan and UNICEF Pakistan. Pp 83.

Schaaf, D., R. Scragg, and P. Metcalf, et al. 2000. Prevalence of iron deficiency in

Auckland high school students. N Z Med J Aug 25; 113(1116): 347-50.

Scrimshaw, N. S., and G. R. Gleason, eds. 1992. RAP - rapid assessment procedures.

Qualitative methodologies for planning and evaluation of health related

programs. Boston, Massachusetts, USA, International Nutrition Foundation for

Developing Countries.

Seidenfeld, M. E., E. Sosin, and V. I. Rickert, 2004. Nutrition and eating disorders in

adolescents. Mt Sinai J Med. 2004 May; 71(3):155-61.

Senderowitz, J. 1995. Adolescent health: reassessing the passage to adulthood. World

Bank Discussion Paper No. 272, Washington, D.C.

Senderowitz, J. 1998. Young People and Anemia: Focus on Young Adults. Pathfinder

International. Washington, DC.

85

REFERENCES

Shah, B. K. and P. Gupta, 2002. Anemia in adolescent girls: a preliminary report from

semi-urban Nepal. Indian Pediatr. Dec; 39(12): 1126-30.

Shahabuddin, A. K., K. Talukder, and M. K. Talukder, et al. 2000. Adolescent nutrition

in a rural community in Bangladesh. Indian J Pediatr. Feb; 67(2): 93-8.

Shaw, N. S. 1996. Iron deficiency and anemia in school children and adolescents. J

Formos Med Assoc; 95: 692-698.

Singh, N., and C. P. Mishra, 2001. Nutritional status of adolescent girls of a slum

community of Varanasi. Indian J Public Health. Oct-Dec; 45(4): 128-34.

Sir Decie, J. V., and S. M. Lewis, 1991. Basic hematological techniques: Practical

Hematology. Churchill Livingstone, London. Pp 37-40.

Steel, R. G. D. and J. H. Torrie, 1980. Principles and procedures of statistics. McGraw

Hill Book Co, Inc. New York.

Stephenson, L. S., M. C. Latham, and E. A. Ottesen, 2000. Global malnutrition.

Parasitology. 121 Suppl: S5-22

Story, M., D. Newmark-Sztainer, N. Sherwood, et al. 1998. Dieting status and its

relationship to eating and physical activity behaviors in a representative sample of

US adolescents. Journal of American Dietetic Association, 98(10), 1127.

Stott, H., B. B. Bhatia, R. C. Lal, and K. C. Rai, 1932. The distribution and causes of

endemic goiter in Uttar Pradesh. Indian J. med. Res., 20, 139.

Swash, M. 1989. The thyroid gland; Hutchison’s Clinical Methods. 19th ed. ELBS

with Bailliere Tindal, 24-28 Oval Road, London, pp 34-35.

Tahirovic, H., A. Toromanovic, and N. Hadzibegic, et al. 2000. Iodine deficiency in the

Federation of Bosnia and Herzegovina. Med Arh; 54(3):153-8.

Tang, C. S., D. Y. Yeung, and A. M. Lee, 2003. Psychosocial correlates of emotional

86

REFERENCES

responses to menarche among Chinese adolescent girls. J Adolesc Health. Sep;

33(3):193-201.

Tanner, J. M. 1981. A history of the study of human growth. Cambridge University

Press.

The Concise New Zealand Food Tables 3rd Edition. New Zealand Institute for Crop &

Food Research Limited-A Crown Research Institute & Ministry of Health, New

Zealand.

Thomas, B. 1994. Manual of dietetic practice. Blackwell Scientific, Oxford.

Tierney, L. M., S. J. McPhee, and M. A. Papadakis, 1998. Iodine deficiency disorders:

Current Medical Diagnosis and Treatment. Appleton & Lange, Stamford CT. Pp

1048.

Tierney, L. M., S. J. McPhee, and M. A. Papadakis, 2004. Assessment of nutritional

status: Current Medical Diagnosis and Treatment. Lange Medical Books/McGraw

Hill, New York. Pp 1210-3.

Uchida, T., Y. Kawachi, and Y. Sakamoto, et al. 1992. Prevalence and pathogenesis of

iron deficiency in Japanese women (1981-1991). Rinsho Ketsueki. Nov;

33(11):1661-5

United Nations, 1997. The sex and age distribution of the world populations. The 1996

revision. United Nations, New York.

USDA, 1997. US Department of Agriculture, Agricultural Research Service, Pyramid

Serving Data: Results from USDA’s 1995 and 1996 Continuing Survey of Food

Intakes by Individuals, December 1997.

USDHEW, 1972. Ten State Nutrition Survey in United States 1968-1970. US

Department of Health, Education and Welfare, Washington DC. Publication no

87

REFERENCES

(HSM) 72-8134. Government Printing Office.

USDHHS, 1998. The National Women’s Health Information Cen the Office on

Women’s Health. US Department of Health and Human Services

Van den Broek, N. R., and E. A. Letsky, et al. 1998. Iron status in pregnant women:

which measurements are valid? Br J Haematol; 103: 817-24.

Vasanthi, G., A. B. Pawashe, and H. Suie, et al. 1994. Iron nutritional status of

adolescence girls from rural area and urban slum. Indian Pediatr 31: 127-132.

Venkataswami, G. 1966. Malnutrition blindness in India. J Indian Med Association, 47,

67-74.

Vitalle, M. S., C. Y. Tomioka, Y. Juliano, and O. M. Amacio, 3002. Body mass index,

pubertal development and their relationship with menarche. Rev Assoc Med Bras.

Oct-Dec; 49(4): 429-33. Epub 2004 Feb 04.

Walker, S. P., S. Grantham-McGregor, J. H. Himes, and S. Williams, 1996. Adolescent

Kingston girls’ school achievement: nutrition, health and social factors. Proc Nutr

Soc; 55:333-43.

Waterlow, J. C. 1992. Protein energy malnutrition. London: Edward Arnold.

Webster, M. 1985. Webster’s ninth new collegiate dictionary. Meriam-Webster Inc.

West, K., J. Katz, and S. K. Khatry, et al. 1999. Double blind cluster Randomized trial of

low dose supplementation with vitamin A or carotene on mortality related to

pregnancy in Nepal. Brit Med J. 318:570-5.

WHO Technical Report Series (3), 1972. Nutritional Anemia. WHO, Geneva.

WHO Technical Report Series (593), 1976. Methodology of nutritional Surveillance.

Report of a Joint FAO/UNICEF/WHO Expert Committee, WHO.

88

REFERENCES

WHO Technical Report Series (854), 1995. Physical Status: The Use and Interpretation

of Anthropometry; WHO, Geneva.

WHO, 1963. Technical Report Series No. 258. WHO, Geneva.

WHO, 1967. Report of a seminar on goiter control. Regional Office for South Asia New

Delhi (Document SEA/Nut/22).

WHO, 1983. Infant and Young Child Nutrition. A report by the Director General of

WHO, Geneva.

WHO, 1983. Measuring change in nutritional status: Guidelines for assessing the

nutritional impact of supplementary feeding programs. WHO, Geneva.

WHO, 1987. Prevention and control of intestinal parasitic infections. WHO, Geneva.

WHO, 1989. WHO EMRO Technical Publication No 13. Guidelines for the

development of a food and nutrition surveillance system for the countries in the

Eastern Mediterranean Region Based on the deliberations of a WHO/FAO Inter

Country Meeting on Nutrition Surveillance Islamabad, Pakistan, October 1988.

WHO, 1992. Report on prevalence of IDD among school children in Egypt. Cairo,

Egypt, Nutrition Institute/WHO.

WHO, 1995. Selecting the sample: Field Guide on Rapid Nutritional Assessment in

Emergencies. WHO Regional Office Eastern Mediterranean. ISBN 92-9021-

1998-9. Pp 9-16.

WHO, 1996. WHO Indicators and strategies for iron deficiency and anemia

programs. WHO/UNICEF/UNU, Geneva.

WHO, 2001. Iron Deficiency Anemia Assessment, Prevention, and Control: A guide for

program managers. WHO/NHD/01.3, WHO Geneva.

WHO/UNICEF/UNU, 1994. Consultation on Indicators and Strategies for Iron

89

REFERENCES

90

Deficiency and Anemia Program. A report of WHO, Geneva.

Wiersinga, W. M., J. Podoba, and M. Srbecky, et al. 2001. A survey of iodine intake and

thyroid volume in Dutch schoolchildren: reference values in an iodine-sufficient

area and the effect of puberty. Eur J Endocrinol Jun; 144(6): 595-603.

World Bank, 1980. World Bank Staff Working paper No 374. World Bank,

Washington DC.

World Bank, 2000. News Release No 2000/367/SAS, I. South Asia Region. Washington

DC 204333; 2000.

Yusuf, H. K., S. Quazi, and M. R. Kahn, et al. 1996. Iodine deficiency disorders in

Bangladesh. Indian J Pediatr Jan-Feb; 63(1): 105-10.

Zavaleta, N., G. Respicio, and T. Garcia, 1996. Efficacy and Acceptability of Two Iron

Supplementation Schedules in Adolescent School Girls in Lima, Peru. J. Nutr.

130: 462S-464S. IIN website http://www.iin.sld.pe

http://www.iin.sld.pe/

APPENDICES

Appendix 1: Clinical signs indicative or suggestive of malnutrition (Tierney et al. 2004; Jelliffe

1966)

Clinical signs Nutrient deficiency Hair

1. Transverse depigmentation 2. Easily pluckable 3. Sparse and thin

1. Protein, copper 2. Protein 3. Protein, zinc, biotin

Skin 1. Dry scaling 2. Flaky paint dermatitis 3. Follicular hyperkeratosis 4. Perifollicular petechiae 5. Petechiae, purpura 6. Pigmentation, desquamation 7. Nasolabial seborrhea 8. Pallor 9. Scrotal/vulvar dermatoses 10. Subcutaneous fat loss

1. Zinc, vit. A, essential fatty

acids 2. Protein, niacin, riboflavin 3. Vitamin A and C 4. Vitamin C 5. Vitamin C and K 6. Niacin 7. Niacin, riboflavin, pyridoxine 8. Fe, folate, vit B12, Cu 9. Riboflavin 10. Calories

Nails 1. Spooning (Koilonychia) 2. Transverse lines, ridging

1. Fe 2. Proteins, calories

Head 1. Temporal muscle wasting 2. Parotid enlargement

1. Protein, calories 2. Protein

Eyes 1. Night blindness (inability to see in low

level of light) 2. Corneal vascularization 3. Xerosis (excessive dryness of the

cornea & conjunctiva), Bitot’s spots (small circumscribed, lusterless, grayish white, foamy, greasy triangular deposits on the bulbar conjunctiva adjacent to cornea in the palpebral fissure), keratomalacia

4. Conjunctival inflammation

1. Vitamin A, zinc 2. Riboflavin 3. Vitamin A 4. Riboflavin

Mouth 1. Glossitis (scarlet, raw) 2. Bleeding gums 3. Cheilosis, angular stomatitis

1. Niacin, pyridoxine, riboflavin,

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

90

APPENDICES

4. Atrophic lingual papillae 5. Hypogeusia 6. Tongue fissuring

4. Niacin, Fe, riboflavin, folate, B12

5. Zinc, Vit A 6. Niacin

Neck 1. Goiter

1. Iodine

Chest 1. Thoracic rosary

1. Vitamin D

Heart 1. High-output failure 2. Decreased output

1. Thiamin 2. Protein,-calorie

Abdomen 1. Hepatosplenomegaly 2. Distension 3. Diarrhea

1. Protein-calorie 2. Protein-calorie 3. Niacin, folate, B12

Extremities 1. Muscle tenderness, pain 2. Muscle wasting 3. Edema 4. Bone tenderness

1. Thiamin, vit C 2. Protein-calorie 3. Protein, thiamin 4. Vitamin C & D, Ca, P

Neurologic 1. Hyporeflexia 2. Decreased position and vibratory sense 3. Paresthesia 4. Confabulation, disorientation 5. Dementia 6. Ophthalmoplegia 7. Tetany

1. Thiamin 2. Vitamin B12, thiamin 3. Vit. B12, thiamin, niacin 4. Thiamin 5. Niacin 6. Thiamin, P 7. Ca, Mg

Others 1. Delayed wound healing

1. Zinc, protein-calorie, Vit. C

Source:

1. Tierney, L. M., S. J. McPhee, and M. A. Papadakis, 2004. Assessment of nutritional

status: Current Medical Diagnosis and Treatment. Lange Medical Books/McGraw

Hill, New York. Pp 1210-3.

2. Jelliffe, D. B. 1966. The assessment of the nutritional status of a community. WHO

monograph Series No 53, 194, 221-228.

91

APPENDICES

Appendix 2: Letter to the Executive District Officer (Education) Rawalpindi and

school Principals.

To

1. Executive District Officer (Education)

Rawalpindi

2. Mr. Muhammad Ayyaz

Principal, Divisional Public School

Rawalpindi

3. Mrs. Robina Tasneem

Principal, Govt. Comprehensive Girls Higher Secondary School

Rawalpindi

Subject: - STUDY FOR ASSESSMENT OF NUTRITIONAL STATUS OF

ADOLESCENT SCHOOL GIRLS

Respected Sir/Madam,

Adolescence is the age (10 – 19), between childhood & adulthood, and a formative period

during which many life patterns are learned and established. It a crucial and dynamic

time for young people as they begin to develop their capacity for empathy, abstract

thinking and future-time perspective; a time when the close and dependent relationships

with parents and older family members begin to give way to more intense relationships

with peers and other adults. It is also a time when physiologically, adolescents begin to

reach their adult size, their bodies become more sexually defined and reproductive

capacity is established. The concept of adolescence itself is in fact relatively new. Until

the 20th century, the passage from childhood to adulthood occurred relatively quickly,

usually coinciding with puberty and subsequent childbearing. More recently, both

92

APPENDICES

biological and socioeconomic landmarks bracketing the transition to adulthood have

moved in opposite directions. Menarche occurs earlier and many societies' adjusted

definition of social and economic maturing and independence has moved upward in the

teen years. As a result, adolescence can no longer be viewed merely as a stage between

childhood and adulthood. It is now a unique and important developmental period

requiring specific programming and policy attention.

As in this age rapid physiological, biological and mental changes occur, which require an

increased supply of food rich in vitamins and energy. This requirement is not sufficiently

met and adolescent girls are prone to develop nutritional deficiencies. About 27% of

adolescents are estimated to be anemic in developing countries, compared to 6% in

developed ones. Girls are often expected to have higher rates of anemia than boys

because of iron lost during menstruation and pregnancy.

Under-nutrition, seen as stunting and micronutrient (vitamin A. B, & D, iron, iodine,

calcium and others) deficiency is a frequent seen in South Asia. This affects growth and

reproductive health especially in the girls, thus limiting school achievement and work

productivity.

Preventing under nutrition is of special importance for adolescent girls because it can

result in poor pregnancy outcomes, in particular low birth weight and consequently

increased risk of infant mortality.

For prevention of these nutritional deficiencies we need to know about the present status

of this group. No research to explore it has yet been carried out in Pakistan and in fact

very limited data is available even in developed world.

I plan to undertake subject study for the completion of my thesis leading me to the degree

of MSc (Community Health & Nutrition) from Allama Iqbal University Islamabad.

93

You are please requested to cooperate in this regard by letting me to interview and

examine the students from your schools.

APPENDICES

Dr. Arshad Mahmood Uppal

Appendix 3:

SCHOOL SURVEY SCHEDULE

Particulars School- 1 School- 2

Name Govt. Comprehensive Girls

Higher Secondary School

Divisional Public School

Location Dhoke Kashmerian

Rawalpindi

Shams Abad off Murree Road, Rawalpindi

Date of visit June 04 – 06, 2004 June 01 – 03, 2004

Time 0900 0900

Focal

person

Mrs. Mussarat Jabeen Miss. Arjumand Azhar

94

APPENDICES

95

Appendix 4: Introductory brochure for girls

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.

Signature of the student: -

Name of the student: -

Class: -

School: -

Signature of the witness (class teacher): -

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

C. SEMI QUANTITAITVE FOOD FREQUENCY INTAKE Ser

#

Food items No of

days/week

No of

times/day

One time portion size

standardized (gm)

1 Roti

2 Rice

3 Meat & its products

4 Eggs

5 Pulses

6 Milk & its products

7 Oil/ghee

8 Desi ghee/butter

9 Carrot

10 DGLV

11 Fruits

12 Beverages

13 Use iodized salt Yes No

D. CLINICAL EXAMINATION Ser No Clinical feature Present Absent

1 Night blindness (known cases only)

2 Bitot’s spots in eyes

3 Xerophthalmia

4 Conjuntival pallor

5 Koilonychia

6 Goiter 0 = Non I = Palpable II = Visible

E. HEMOGLOBIN ESTIMATION Test Observed value

Hemoglobin mg/dl (BMS digital Hb meter Cynox-1 USA)

99

APPENDICES

Appendix 7:

CODING OF THE DATA

Ser No Feature Code

SCHOOLS

1 Government Comprehensive Girls Higher Secondary School

Rawalpindi

1

2 Divisional Public School Rawalpindi 2

EDUCATION

1 Illiterate 0

2 Primary 1

3 Middle 2

4 Matric 3

5 Intermediate 4

6 Graduate 5

7 Post graduate 6

8 Professional 7

PROFESSIONS

1 Laborer in fathers 1

2 House wife in mothers 1

3 Government servant 2

4 Private job 3

5 Business 4

6 Professionals (doctors, engineers, lawyers, MBAs etc) 5

7 Technical 6

8 Deceased 7

CLINICAL SIGNS OF VITAMIN A DEFICIENCY

1 No sign 0

2 Bitot’s spots 1

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

(yrs)

Percentiles

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

Age (years) Weight (kg) Energy

(kcal)

Protein

(gm)

Iron

(mg)

VA

(RE)

Iodine

(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

variable

Cut-off values Original references

Stunting or low

height-for-age

Height-for-age < 3rd percentile or

< -2 Z-scores

Hamill et al. 1979

Thinness or low

BMI-for-age

BMI-for-age < 5th percentile Must et al. 1991

At risk of

overweight

BMI-for-age ≥85th percentile -do-

Obese BMI-for-age ≥85th percentile -do-

Triceps skin fold

thickness-for-age

≥90th percentile Owen 1982 and

Johnson et al. 1981

Subscapular skin

fold thickness

≥90th percentile

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

4. Owen, G. M. 1982. Measurement, recording and assessment of skin fold thickness

in childhood and adolescence: report of a small meeting. American Journal of

Clinical Nutrition, 35: 629-638.

10

APPENDICES

Appendix 11: -

10

RESUME

Title of the thesis: Assessment of nutritional status of adolescent school girls at

Rawalpindi

Major department: Home and Health Sciences

Name: Dr. Arshad Mahmood Uppal

Place and date of birth: Gujrat (Punjab) June 01, 1954

Qualifications:

Degree/ Diploma Institution Subject University/

Country Year

1 FACP American College of Physicians and Surgeons New York

Medicine USA 1999

2 MCPS College of Physicians and Surgeons, Pakistan

Family Medicine

Pakistan 1990

3 BSc Punjab University Medical Punjab 19894 MBBS Allama Iqbal Medical College,

Lahore Medical Punjab 1981

Membership in learned or honorary societies: 1. District Red Crescent Society, Rawalpindi

2. Pakistan Medical Association, Rawalpindi/Islamabad

3. Pakistan Society of Family Physicians, Lahore

4. All Pakistan China Friendship Association, Islamabad

5. Public Relations Association of Pakistan, Islamabad

6. Holy Quran Research Foundation, Islamabad

Publications: Professional;

1. Mahmood, A. 1992. Indications of blood transfusion in surgical practice & ABO groups in blood donors at blood bank DHQ Hospital Rawalpindi. Rawal Medical Journal Vol. 20 (1), Pakistan Medical Association, Rawalpindi/Islamabad.

2. Mahmood, A. 1992. Practice of blood transfusion at DHQ Hospital Rawalpindi & prevalence of various blood groups in admitted cases. DOCTOR fortnightly International Vol. 14, No. 2, May 15 – 31:1992, Karachi – 74400, Pakistan.

3. Mahmood, A. 1993. Indications of transfusion of blood & prevalence of ABO & Rh D blood groups in emergency cases presenting at DHQ Hospital Rawalpindi. Specialist quarterly: Pakistan’s J. Medi. Sci. Jul – Sep 1993, Vol.9, No. 4, 377 – 382, ISSN 1017 – 4699 Karachi – 74400, Pakistan.

4. Mahmood, A. 1994. Blood transfusion. Medical Review Vol. 6, No. 4. Apr 1994, Karachi, Pakistan.

5. Mahmood, A. 1994. Blood transfusion in Gynae/OB cases admitted in DHQ Hospital Rawalpindi. Specialist quarterly Pak. J. Med. Sci. Oct – Dec Vol. 2, No.1, ISSN 1017 – 4699, Karachi – 74400.

6. Mahmood, A. 1996. Can we afford to operate on patients without HBsAg screening? CPSP Journal Vol. 6, No. 2, Mar – Apr. Pp. 98 – 100. Karachi – 75500, Pakistan.

7. Mahmood, A. 1998. Safe blood transfusion. DOCTOR fortnightly International, Vol. 18, No 1, 1 – 14 may.. Karachi – 74000, Pakistan.

8. Mahmood, A. 1998. Blood transfusion. Specialist quarterly Pakistan’s J. Med. Vol. 14, No. 3, 275 – 276, ISSN 1017 – 4699. Karachi – 74400, Pakistan.

9. Uppal, A. M. 2000. Safe blood transfusion-an outline. Neghaban Press, 12 Al-Karim Market, Gordon College Road, Rawalpindi.

Publications: Miscellaneous:

1. Uppal, A. M. 1995. Qanoon-e-Shahadat aur Khawateen. a) Weekly Kashmir International Vol. 4, No. 48 – 49, 7 Dec. 1995, Rawalpindi, b) Daily Assas, Rawalpindi, Pakistan, 31 Dec. 1995, c) Monthly Media Times International, Islamabad.

2. Uppal, A. M. 1997. Castes and Uppals a socio–cultural study. Monthly Media Times International. Vol.1, No. 10, Oct 1997, 19. Saleem Plaza, Blue Area, Islamabad.

3. Uppal, A. M. 1999. Iddat–The waiting period (A scientific review). Monthly Tuloo-e-Mehr. Vol. 1, No. 8, Mar. 1999. 19 Saleem Plaza, Blue Area, Islamabad.

4. Uppal, A. M. 2000. Khoon is ka Istimal, banking, is say phailnay wali bemarian (AIDS, hepatitis B&C) aur Thalassaemia. (motivation literature in Urdu). With the courtesy of Siraj Flour & General Mills Fateh Jang Distt. Attock.

Nutritional Status of Adolescent School Girls

Documents

Transcript of Nutritional Status of Adolescent School Girls