Get Permission Sinha, Patil, Halki, and Sharma: Assessment of nutritional status of school going adolescents in rural and urban area of north karnataka: A comparative study


Introduction

The word adolescence comes from the Latin word ‘adolescere’ meaning to grow and to mature. Adolescents are defined as the age group between 10-19 years according to WHO.1, 2 At present the population of adolescent is 1.2 billion globally forming 18% of the total population. Around 243 million are living in India and consists of about 21% of Indian population.3 Today, every 5th person in India is an adolescent.4 Adolescence may be divided into three developmental stages-early adolescence- 10 to 13 years, middle adolescence- 14 to 16 years, late adolescence- 17 to 19 years.4, 5, 6, 7

Adolescence is the transition period during which they gain up to 50% of their adult height and skeletal mass. Unmet nutritional needs lead to several public health problems such as stunted and retarded growth, impaired mental development, anaemia. In adolescent girls, short stature that carries on into adulthood is associated with many concurrent and future adverse health and pregnancy outcomes like obstructed labour, post-partum haemorrhage, genital infection etc. Global prevalence of underweight among children and adolescent is 8.4% in girls and 12.4% in boys according to worldwide pooled analysis of study published in Lancet in 2017.8 In India, it varies from 21.4% to 47.93% according to different studies conducted across the country.9 Poor nutrition can lead to underweight stunting and on the other hand increased risk of non-communicable diseases later in life. Most of the published literature focuses on nutritional status among adolescents, while there is a paucity of information of nutritional status of adolescents in both rural and urban area. Hence, the present study was designed to assess and compare the nutritional status and the factors affecting the nutritional status of school going adolescents in rural and urban area.

Material and Medhods

An observational study was conducted among the school going adolescents (10-19 years) studying in Government schools in rural and urban field practice area of Department of Community Medicine, BIMS, Belagavi during October 2019 to December 2019. There are 13 schools in Uchagoan and 9 schools in Kashbag. All the Government schools were included in the sampling frame. The calculated sample size was N=360 taking the prevalence of malnutrition 19.44% in a previous Indian study with absolute error 5%, 10% response failure and 95% confidence interval 10 A written permission from the authorities of all institutions was obtained prior to data collection. Students from standard six to ten were taken in the study and they were selected using simple random sampling technique.

Table 1

Classification of BMI according to IAP guidelines. 11

BMI

Categories

<18.5

Underweight

18.5-23

Normal

23-27

Overweight

>27

Obese

[i] Waist Hip ratio ≤1 for males was considered normal while waist-hip-ratio ≤0.85 in females.6, 12

Table 2

Socio-demographic distribution of the study participants. N=360

Socio-demographic characteristics

Rural N (%)

Urban N (%)

Total N (%)

Age (Adolescence phase)

Early

45(25.0%)

106 (58.89%)

151 (41.94%)

Middle

135(75.0%)

72(40.0%)

207(57.50%)

Late

0(0.00)

2(1.11%)

2(0.56%)

Total

180

180

360

Gender

Boys

73 (40.56%)

65 (36.11%)

138 (38.33%)

Girls

107 (59.44%)

115 (63.89%)

222 (61.67%)

Total

180

180

360

Standard (class)

6th

23 (12.78%)

48 (26.67%)

71(19.72%)

7th

22 (12.22%)

48 (26.67%)

70(19.44%)

8th

45 (25.0%)

42 (23.33%)

87(24.17%)

9th

45 (25.0%)

22 (12.22%)

67(18.61%)

10th

45 (25.0%)

20 (11.11%)

65(18.06%)

Total

180

180

360

Type of family

Nuclear

99 (55.0%)

111 (61.67%)

210(58.33%)

Joint

22 (12.22%)

26 (14.44%)

48(13.33%)

Three generation

59 (32.78%)

43 (23.89%)

102(28.33%)

Total

180

180

360

Religion

Hindu

172 (95.56%)

178 (98.89%)

350(97.22%)

Muslim

7 (3.89%)

1(0.56%)

8(2.22%)

Christian

1 (0.56%)

0(0.00)

1(0.28%)

Others

0(0.00)

1(0.56%)

1 (0.28%)

Total

180

180

360

Socio-Economic Status

Class I & II

6 (3.33%)

43 (23.89%)

49 (13.61%)

Class III

37 (20.56%)

40 (22.22%)

77 (21.39%)

Class IV

105 (58.33%)

71 (39.44%)

176 (48.89%)

Class V

32 (17.77%)

26 (14.44%)

58 (16.11%)

Total

180

180

360

Fathers Education

Illiterate

13 (7.22%)

9 (5.0%)

22 (6.11%)

Primary school

8(4.44%)

10 (5.56%)

18 (5.00%)

Middle school

46 (25.56%)

30 (16.67%)

76 (21.11%)

High school

80 (44.44%)

55 (30.56%)

135 (37.50%)

Pre-university

22 (12.22%)

40 (22.22%)

62 (17.22%)

Graduate and Higher

6(3.33%)

19 (10.56%)

25 (6.94%)

*Not Applicable

5 (2.78%)

17 (9.44%)

22 (6.11%)

Total

180

180

360

Mothers Education

Illiterate

13 (7.22%)

8 (4.44%)

21 (5.83%)

Primary school

2 (1.11%)

7 (3.89%)

9 (2.50%)

Middle school

51 (28.33%)

55 (30.56%)

106 (29.44%)

High school

95(52.78%)

68 (37.78%)

163 (45.28%)

Pre-university

19 (10.56%)

26 (14.44%)

45 (12.50%)

Graduate and Higher

0 (0.00)

13 (7.22%)

13 (3.61%)

*Not Applicable

0 (0.00)

3 (1.67%)

3 (0.83%)

Total

180

180

360

*Not Applicable: either not staying together or death

[i] Significant statistical difference was seen for built and nourishment (thin), hair (thin & sparse), ear discharge, pale tongue, spongy gums, enlarged thyroid gland, dry and scaly skin and flat nails. [Table 3]

Table 3

Distribution of adolescents according to clinical assessment. N=360

Category

Clinical Sign (General appearance)

Rural N, (%)

Urban N, (%)

Z-statistic & p-value

Total N, (%)

Built & nourishment

Thin

29 (16.11%)

59 (32.77%)

3.74901 &<0.01*

88 (24.44%)

Obese

12 (6.67%)

10 (5.56%)

0.439607 &>0.05

22 (6.11%)

Normal

139 (77.22%)

111 (61.67%)

--

250 (69.44%)

Hair

Thin & sparse

12 (6.67%)

03(1.67%)

2.391639 &<0.05*

15 (4.17%)

Lack of lustre

05 (2.78%)

11 (6.11%)

1.53789 &>0.05

16 (4.44%)

Dyspigmentation

01(0.56%)

01 (0.56%)

0 &>0.05

02 (0.56%)

Normal

162 (90.0%)

165 (91.67%)

--

327 (90.83%)

Eyes

Pallor present

49 (27.22%)

35 (19.44%)

1.752571 &>0.05

84 (23.33%)

Pallor absent

131 (72.78%)

145 (80.56%)

--

276 (76.67%)

Ears

Discharge

01 (0.56%)

09 (05.0%)

2.58583 &<0.05*

10 (2.78%)

Hearing aid

0 (0.00)

02 (1.11%)

1.42142 &>0.05

02 (0.56%)

Normal

179 (99.44%)

169 (93.88%)

--

348 (96.67%)

Teeth

Caries

79 (43.88%)

81 (45.0%)

0.21384 &>0.05

160 (44.44%)

Enamel attrition

7 (3.88%)

5 (2.78%)

0.581902 &>0.05

12 (3.33%)

Normal

94 (52.22%)

94 (52.22%)

--

188 (52.22%)

Tongue

Pale

16 (8.89%)

03 (1.67%)

3.103517 &<0.01*

19 (5.27%)

Fissured

10 (5.56%)

05 (2.78%)

1.322512 &>0.05

15 (4.17%)

Normal

154 (85.56%)

172 (95.56%)

--

326 (90.56%)

Lips

Stomatitis & cheilosis

15 (8.33%)

08 (4.44%)

1.514246 &>0.05

23 (6.39%)

Normal

165 (91.67%)

172 (95.56%)

--

337 (93.61%)

Gums

Spongy

07 (3.89%)

0 (0.00)

2.699148 &<0.05*

07 (1.94%)

Bleeding

06 (3.33%)

03 (1.67%)

1.010117 &>0.05

09 (2.5%)

Normal

167 (92.78%)

177 (98.33%)

--

344 (95.56%)

Thyroid gland

Enlarged

0 (0.00)

06 (3.33%)

2.49008 &<0.05*

06 (1.67%)

Normal

180 (100%)

174 (96.67%)

--

354 (98.33%)

Skin

Dry & scaly

42 (23.33%)

13 (7.22%)

4.359025 &<0.01*

55 (15.28%)

Normal

138 (76.67%)

167 (92.78%)

--

305 (84.72%)

Nails

Flat

12 (6.67%)

03 (1.67%)

2.391639 &<0.05*

15 (4.17%)

Normal

168 (93.33%)

177 (98.33%)

--

345 (95.83%)

Table 4

Comparison of mean weight, height, BMI and WHR of rural and urban adolescents (Mean ± SD). N=360

Parameters

Boys

Test statistic & p-value

Girls

Test statistic & p-value

Rural (73)

Urban (65)

Rural (107)

Urban (115)

Weight (kg) Mean ± SD Median IQR

37.74 ±7.98 37 8.5

34.15±9.11 32 11.5

Z=3.061 & 0.002*

39.33±7.66 151 7

38.60±9.2 149 12

Z=1.299 & P=0.194

Height (cm) Mean ± SD Median IQR

151.33±10.86

146.15±9.11

t= 2.92 & p=0.003*

149.66±8.49 151 7

149.43±8.69 149 12

Z= 0.66 & P=0.508

BMI (kg/m2) Mean ± SD Median IQR

16.33±2.16 15.82 2.92

15.81±3.15 14.88 3.45

Z= 2.09 & P= 0.037*

17.50±2.86 17.1 3.89

17.18±3.27 16.44 4.26

Z=1.096 & P= 0.273

WHR Mean ± SD

0.79 ± 0.05

0.83±0.06

t= 4.073 & p <0.001*

0.77±0.05

0.80±0.04

t= 5.287 & p =0.007*

Z= MW U test has been applied as the data was not normal. t= t test has been applied

[i] The weight of adolescent boys in rural was 37.74 ± 7.98 and of urban 34.15±9.11, weight of adolescent girls in rural 39.33±7.66 and urban38.60±9.2 and there was a significant statistical difference seen. Similarly, there was a significant difference in height, BMI and Waist-to-hip ratio of rural and urban boys. [Table 4]

Table 5

Overall prevalence of malnutrition according to IAP-BMI cut off among school adolescents. N=360

Nutritional status

Rural

Urban

Total

Normal weight

44 (24.44%)

32 (17.7%)

76(21.11%)

Under weight

132 (73.33%)

137 (76.11%)

269 (74.72%)

Overweight

3 (1.67%)

9 (5.0%)

12(3.33%)

Obese

1 (0.56%)

2(1.11%)

3 (0.83%)

[i] According to IAP guidelines BMI categories, overall prevalence of malnutrition among adolescents was 284 (78.89%) i.e., 75.56% in rural 82.22% in urban area in which prevalence ofunder-weight was 269 (74.72%) more in urban 137 (76.11%) compared to rural area 132 (73.33%). Over-weight 12 (3.33%) higher in urban area 5.0% compared to rural 1.67%. [Table 5]

Table 6

Distribution of adolescents according to IAP- BMI cut off. N=360

BMI Cut off (kg/m2)

Boys

Girls

Total

Rural N (%)

Urban N (%)

Total N (%)

Rural N (%)

Urban N (%)

Total N (%)

Rural N (%)

Urban N (%)

Total N (%)

<18.5 Under- Weight

61 (83.56%)

55 (84.62%)

132 (73.33%)

71 (66.36%)

82 (71.30%)

137 (76.11%)

132 (73.33%)

137 (76.11%)

269 (74.72%)

18.5-23 Normal

12 (16.44%)

7 (10.77%)

44 (24.44%)

32 (29.91%)

25 (21.74%)

32 (17.78%)

44 (24.44%)

32 (17.78%)

76 (21.11%)

23-27 Over- Weight

0 (0.0)

2 (3.08%)

3 (1.67%)

3 (2.80%)

7 (6.09%)

9 (5.0%)

3 (1.67%)

9 (5.00%)

12 (3.33%)

>27 Obese

0 (0.0)

1 (1.54%)

1 (0.56%)

1 (0.93%)

1 (0.87%)

2 (1.11%)

1 (0.56%)

2 (1.11%)

3 (0.83%)

Total

73

65

180

107

115

180

180

180

360

[i] Prevalence of stunting was 16 (4.44%) more among rural adolescents (5.0%) compared to urban (3.89%).Underweight was higher in urban adolescent boys and girls (84.62% and 71.30%) compared to rural (83.56% and 66.36%) respectively. [Table 6]

Table 7

Age wise distribution of malnutrition among adolescents. (IAP-BMI cut off). N=360

Age in years

Rural N (%)

Urban N (%)

Under weight

Over- weight

Obesity

Under Weight

Over-weight

Obesity

Early adolescence

30 (22.72%)

2 (66.67%)

1 (100%)

90 (65.69%)

5 (55.56%)

0

Middle adolescence

102 (77.27%)

1 (33.33%)

0

45 (32.85%)

4 (44.44%)

2 (100%)

Late adolescence

0

0

0

2 (1.46%)

0

0

Total

132

3

1

137

9

2

[i] Prevalence of underweight was more in middle adolescence phase 102 (77.27%) in rural compared to early adolescence phase 90 (65.69%) in urban area. [Table 7]

Table 8

Association of nutritional status according to IAP BMI cut off with socio-demographic profile of rural adolescents. N=360

Parameter

Rural

Urban

Under weight

Over- weight & Obesity

Normal

Total

Under weight

Over- weight & Obesity

Normal

Total

Sex

Boys

61 (83.6%)

0 (0.0)

12 (16.4%)

73 (100%)

55 (84.6%)

3 (4.6%)

7 (10.8%)

65 (100%)

Girls

71 (66.4%)

4 (3.7%)

32 (29.9%)

107 (100%)

82 (71.3%)

8 (7.0%)

25 (21.7%)

115 (100%)

Total

132 (73.3%)

4 (2.2%)

44 (24.4%)

180 (100%)

137 (76.1%)

11 (6.1%)

32 (17.8%)

180 (100%)

Chi-square & p-value

7.701 & 0.021*

0.448 & 0.126

Religion

Hindu

127 (73.8%)

4 (2.3%)

41 (23.8%)

172 (100%)

137 (77.0%)

11 (6.2%)

30 (16.9%)

178 (100%)

Muslim

4 (57.1%)

0 (0.0)

3 (42.9%)

7 (100%)

0 (0.0)

0 (0.0)

1 (100%)

1 (100%)

Christian

1 (100%)

0 (0.0)

0 (0.0)

1 (100%)

0 (0.0)

0 (0.0)

0 (0.0)

0 (0.0)

Others

0 (0.0)

0 (0.0)

0 (0.0)

0 (0.0)

0 (0.0)

0 (0.0)

1 (100%)

1 (100%)

Total

132 (73.3%)

4 (2.2%)

44 (24.4%)

180 (100%)

137 (76.1%)

8 (6.1%)

172 (95.6%)

180 (100%)

Chi-square & p-value

1.780 & 0.776

9.354 & 0.053*

Type of family Nuclear

78 (78.8%)

0 (0.0)

21 (21.2%)

99 (100%)

81 (73.0%)

8 (7.2%)

22 (19.8%)

111 (100%)

Joint

15 (68.2%)

2 (9.1%)

5 (22.7%)

22 (100%)

19 (73.1%)

2 (7.7%)

5 (19.2%)

26 (100%)

3- Gen

39 (66.1%)

2 (3.4%)

18 (30.5%)

59 (100%)

37 (86.0%)

1 (78.8%)

5 (11.6%)

43 (100%)

Total

132 (73.3%)

4 (2.2%

44 (24.4%)

180 (100%)

137 (76.1%)

11 (6.1%)

322 (17.8%)

180 (100%)

Chi-square & p-value

9.471 & 0.050*

3.272 & 0.513

Education of father

Illiterate

11 (84.6%)

0 (0.0)

2 (15.4%)

13 (100%)

7 (77.8%)

0 (0.0)

2 (22.2%)

9 (100%)

Primary

4 (50.0%)

2 (25.0%)

2 (25.0%)

8 (100%)

7 (70.0%)

1 (10.0%)

2 (20.0%)

10 (100%)

Middle

35 (76.1%)

0 (0.0)

11(23.9%)

46 (100%)

20 (66.7%)

5 (16.7%)

5 (16.7%)

30 (100%)

High

59(73.8%)

1(1.3%)

20(25.0%)

80 (100%)

41 (74.5%)

1 (1.8%)

13 (23.6%)

55 (100%)

Pre-university

17 (77.3%)

0(0.0)

5(22.7%)

22(100%)

32(80.0%)

2(5.0%)

6(15.0%)

40(100%)

≥Graduate

2(33.3%)

1(16.7%)

3(50%)

6(100%)

16(84.2%)

0(0.0)

3(15.8%)

19(100%)

NA

4(80.0%)

0(0.0)

1(20.0%)

5(100%)

14(82.4%)

2(11.8%)

1(5.9%)

17(100%)

Total

132(73.3%)

4(2.2%)

44(24.4%)

180(100%)

137(76.1%)

11(6.1%)

32(17.8%)

180(100%)

Chi-square & p-value

30.940 & 0.002*

13.588 & 0.328

Education of mother

Illiterate

10(76.9%)

1(7.7%)

2(15.4%)

13(100%)

5(62.5%)

0(0.0)

3(37.5%)

8(100%)

Primary

1(50.0%)

0(0.0)

1(50.0%)

2 (100%)

6(85.7%)

1(14.3%)

0(0.0)

7(100%)

Middle

41(80.4%)

2(3.9%)

8(15.7%)

51(100%)

39(70.9%)

4(7.3%)

12 (21.8%)

55(100%

High

69(72.6%)

0(0.0)

26(27.4%)

95(100%)

52(76.5%)

5(7.4%)

11(16.2%)

68(100%)

Pre-university

11(57.9%)

1(5.3%)

7 (36.8%)

19 (100%)

24(92.3%)

0(0.0)

2(7.7%)

26(100%)

≥Graduate

0(0.0)

0(0.0)

0(0.0)

0(0.0)

9(69.2%)

1(7.7%)

3(23.1%)

13(100%)

NA

0(0.0)

0(0.0)

0(0.0)

0(0.0)

2(66.7%)

0(0.0)

1(33.3%)

3(100%)

Total

132 (73.3%)

4(2.2%)

44 (24.4%)

180(100%)

137(76.1%)

11(6.1%)

32 (17.8%)

180(100%)

Chi-square & p-value

10.599 & 0.225

10.560 & 0.567

[i] In rural area there was a significant association between type of family and education of father with BMI. [Table 8]

A pre-designed semi-structured questionnaire was used to collect information regarding socio-demographic profile. Data was collected by using direct interview method. Detailed clinical examination including head to toe examination, anthropometry and systemic examination was done. Ethical clearance was obtained from institutional ethical committee of BIMS, Belagavi.

Inclusion criteria

  1. Students of both sexes between 10-19 years age group

  2. Willing to participate in the study

Exclusion criteria

Students who did not give informed written consent

Body weight of the study participants was measured to nearest 0.1 kilogram with portable machine with scale adjusted to zero before each session.Height was measuredwithout footwear using a stadiometerto nearest 0.5 centimetre. Hip and waist circumference was measured using non-stretchable tape to the nearest 0.1cm. Body Mass Index (BMI) classification is made according to IAP guidelines.

Statistical Analysis

Data entry was done in MS Excel and it was analysed using SPSS and MS Excel. Categorical variable was appropriately coded for data entry. Numerical data like age, weight, height, waist and hip circumference were entered as such. Statistical measures used were mean, median, standard deviation, percentage. Z-statistic, t-test, Mann Whitney U test and chi square test were applied as test of significance. The statistical significance was evaluated at 95% confidence level (p<0.05). Result was represented in tables.

Results

360 adolescents participated in the study i.e., 180 from rural and urban area respectively. Maximum participants 207(57.50%) were in middle adolescence phase (75.0%from rural and 40.0% from urban).55.0% from rural and 61.67% urban area belonged to nuclear family. As per modified B.G Prasad classification (January 2020) scale, majority of adolescents in rural area (58.33%) belonged to class IV compared to urban 39.44%. [Table 2 ]

Discussion

In Premkumar S et al. study in the rural area, the prevalence of overweight/obesity was 16.2% and 24%in the urban school going adolescents which was higher compared to our study.2 In our study, skin appeared dry and scaly in 23.33% rural compared to 7.22% urban which was significant (p-value <0.01) and was higher compared to Karak P et al. study (17% rural and 3% in urban).5 Prevalence underweight(74.72%) was higher in our study compared to Rahman F et al. in Kanpur (52.09%). Nearly 73.33% of rural and 76.11% urban adolescents were underweight whereas in Rahman F et al. 45.51% and 50.8% were undernourished in urban and rural areas respectively.8, 12 In Rajaretnam T et al. study in Karnataka weight among boys was 42.3±8.7 in rural 46.0±10.4 among urban whereas in girls 39.8±6.1 in rural and 42.3±7.7 in urban which was higher compared to our study.13 Eyes were pale in 25.4% and 11.8% had flat nails in Shivaprakash and Joseph study in urban area which was higher compared to our study where 19.44% of urban adolescent eyes were pale and 1.67% had flat nails.11, 10

Underweight finding inour study was similar to Deshmukh PR et al. (75.3%), less compared to Srinivasan K et al. (78.4%), whereas higher than Rao V G et (61.7%) and Pal A et al. (48.78%).14, 9, 15, 6

Conclusion

Prevalence of malnutrition (underweight, overweight and obesity) was more in urban area (76.11%) compared to rural area (73.33%) based on IAP-BMI criteria. Underweight was prevalent maximum in middle adolescence phase (77.27%) in rural and urban early adolescence phase (65.69%). Overweight (66.67%) was more in early adolescence phase in rural and compared to urban in middle adolescence phase (55.56%).

Recommendations

Adolescents must be educated at school level about the importance of regular intake of healthy nutritious food and harmful effects of non-nutritious food. Awareness campaigns in school highlighting nutritional status as a major risk factor that causes both physical and mental growth retardation.

Limitations

The present study included only government schools. The results whatever obtained cannot be generalized to entire adolescent population of Khasbag and Uchagaon.

Source of Funding

None.

Conflict of Interest

None.

Acknowledgements

Authors gratefully acknowledge the participants, coordinators and Dr R. G. Viveki, Head of the department of Community Medicine, BIMS, Belagavi for assistance and support.

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Received : 24-05-2022

Accepted : 02-06-2022


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https://doi.org/10.18231/j.jpmhh.2022.008


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