|Year : 2021 | Volume
| Issue : 4 | Page : 285-290
Prevalence of malnutrition and its associated sociodemographic and clinical factors among adolescents in selected schools of Urban Puducherry, India
Sneha Anil Wangaskar, Swaroop Kumar Sahu, Marie Gilbert Majella, Sathish Rajaa
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||29-Sep-2021|
|Date of Decision||21-Oct-2021|
|Date of Acceptance||26-Oct-2021|
|Date of Web Publication||29-Nov-2021|
Dr. Swaroop Kumar Sahu
Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Background: In India, adolescents constitute 21% of the total population. Majority of boys and girls in developing countries enter adolescence as undernourished, making them more vulnerable to several diseases. Objective: Among adolescents in selected schools of urban Puducherry, we determined the prevalence of malnutrition and also assessed the sociodemographic and clinical factors associated with undernutrition. Materials and Methods: A cross-sectional analytical study was conducted among adolescents (10–18 years) in selected public schools of Urban Puducherry. Data were collected using semi-structured and pre-tested questionnaires. The data collection period was between September and October 2019. Malnutrition was assessed by the World Health Organisation recommended Height-for-age and body mass index-for-age cut-offs using AnthroPlus software. Results: A total of 144 (28.9%) boys and 355 (71.1%) girls were included in the study (N = 499). The prevalence of malnutrition was 46.8% (95% confidence interval [CI]: 42.5–51.3). The prevalence of undernutrition was 33.3% (Stunting [21.6%] and Thinness [15%]). The prevalence of overweight and obesity were 10.2% and 5.8%, respectively. Male gender was found to be an independent risk factor of undernutrition (annual percentage rate = 1.4; 95% CI: 1.0–1.9); and known risk factors such as socio-economic status, parental education were not significantly associated with undernutrition. Conclusions: One in every two school-going adolescents was malnourished. Despite the high prevalence of undernourishment, over nourishment was also commonly observed. Educating parents and students about growth monitoring and dietary habits might help in bringing down the burden of malnutrition.
Keywords: Adolescent, malnutrition, obesity, overweight, schools, undernutrition
|How to cite this article:|
Wangaskar SA, Sahu SK, Majella MG, Rajaa S. Prevalence of malnutrition and its associated sociodemographic and clinical factors among adolescents in selected schools of Urban Puducherry, India. Niger Postgrad Med J 2021;28:285-90
|How to cite this URL:|
Wangaskar SA, Sahu SK, Majella MG, Rajaa S. Prevalence of malnutrition and its associated sociodemographic and clinical factors among adolescents in selected schools of Urban Puducherry, India. Niger Postgrad Med J [serial online] 2021 [cited 2022 May 20];28:285-90. Available from: https://www.npmj.org/text.asp?2021/28/4/285/331537
| Introduction|| |
Adolescence is a period of transition between childhood to adulthood and occupies a very pivotal role in human life. In a developing country like India, adolescents (10–19 years) constitute around 21% of the whole population. Usually, in this phase, the requirement for the macro and micronutrients increases, thereby leading to malnutrition. Majority of the mortality and morbidity occurring in adolescents are mainly due to preventable causes.,
According to the World Health Organisation (WHO), the term 'malnutrition' refers to 'A deficiency, imbalance or excesses in a person's intake of energy and/or nutrients'. As per Sustainable development goals, India has set a target of eliminating all forms of malnutrition by 2030. Meanwhile, WHO elimination of malnutrition is defined as 'Reduction to zero incidences of all form of malnutrition in a defined geographic area'.
The high rate of malnutrition among adolescent girls not only affects their present life but, is also associated with their future health problems related to pregnancy and low birth weight babies. The intergenerational cycle plays an important role in the prevalence of malnutrition among adolescents. According to the National Family Health Survey (NFHS)-3, the proportion of thinness among adolescent girls and boys was 47% and 58%, respectively. NFHS-3 also reported that 2.7% of girls and 31.7% of boys were overweight. According to the Comprehensive National Nutrition Survey conducted in India, (CNNS 2016–18) the prevalence of stunting, thinness and overweight among adolescents was 26.4%, 24.1% and 4.1%, respectively.
In India, there are many barriers that influence adolescent health. In 2014, Rashtriya Kishor Swasthya Karyakram (RKSK) was started with an objective to provide continuous care for adolescents and meet their developmental needs. To enhance nutritional support to adolescents, the Mid-day meal scheme, a centrally sponsored scheme, has been extended to cover adolescents in 2007. Schools have always been an efficient platform for early detection and prevention of health issues among adolescents. The government of India has started a new initiative Rashtriya Bal Swasthya Karyakram (RBSK) to address the health issues among children from birth to 18 years encompassing the spectrum of 4Ds-Deficiencies, Disease, Development Delays and Disability. In 2018, the National nutrition mission, also known as POSHAN Abhiyan, was launched which mainly focus on undernutrition, stunting and low birth weight babies among young child, women and adolescent girls.
Although efforts have been taken through various national programs to address malnutrition among adolescents in the past two decades, still a number of challenges are faced in addressing the same and malnutrition has continued to be a common health problem among adolescents. Hence, the objective of our study was to find the prevalence of malnutrition among the school-going adolescents in selected schools of urban Puducherry and also to assess the socio-demographic and clinical factors associated with undernutrition.
| Materials and Methods|| |
A school-based cross-sectional analytical study was carried out among adolescents studying in all the eligible government schools present in the service area of the urban health and training centre of a tertiary medical college. In the service area, there are four government schools that provide education to the 6th to 12th class and one private nursery school. All government schools that are giving education to students from 6th to 12th class were included in our study. The health center provided health services to 4 wards (Kurusukuppam, Vazhaikkulam, Vaithikuppam and Chinnayapuram) comprising 13 anganwadis functioning under it. The centre runs Adolescent friendly health clinic weekly on every Saturday as per RKSK guidelines. Iron-folic Acid supplementation is given to adolescents studying in selected schools through the WIFS program and are also covered under the RBSK programme.
Assuming 95% confidence level (CI), 4% absolute precision and the proportion of undernutrition and overnutrition among the school-going adolescents as 19.8% and 16.9%, respectively, based on a previous study; the sample size was calculated to be 382 and 338, respectively, using OpenEpi v. 3.03. This research involved evaluating a routine package of services as prescribed in the program. We enrolled all the students present during the day of the visit to the school (499) from all the four existing government schools present in the area. The sample size required was more than two-thirds of the total children enrolled; we thus preferred to include them all.
The study protocol was reviewed and approved by Institutional Ethics Committee for observational studies, JIPMER (JIP/IEC/2019/296 on July 26, 2019). Written permission was obtained from the Directorate of school education, Puducherry, the head of the institution and parents. Verbal assent was taken from the students aged 10–12 years and written assent was obtained from the school students aged 13–18 years, after briefing them about the study. Before obtaining permission, a copy of the questionnaire and study protocol was shared with the school authorities.
Separate questionnaires were administered to both students and parents. A semi-structured and pretested questionnaire which was self-administered, except for certain clinical parameters like height and weight was used for data collection. Almost 93% of parents could self administer the questionnaire and the information was collected on socio-demographic characteristics of the adolescent's family, i.e. parent's education, occupation, monthly income, and source of drinking water. Those parents who were not able to fill the questionnaire (around 17%), their information were obtained from school records through the student's class teachers. Data were collected from the students in their respective classes during school hours. The questionnaire included sociodemographic characteristics, dietary habits, personal hygiene, physical activity and details of vitamin deficiencies (adopted from RBSK questionnaire). Self-reported morbidities were collected for the past 1 month. Clinical assessment was performed by a team of researchers and Master in public health postgraduate students for nutrition status, vitamin deficiencies, oral health and skin conditions.
For anthropometric measurement standard procedure was followed. Height was recorded using a validated stadiometer with a precision of 0.1 cm. Weight was measured using a validated digital weighing machine with a precision of 0.1 kg. Nutrition status was assessed using WHO body mass index (BMI)-for-age and Height-for-age growth charts. The Z scores for BMI-for-age and height-for-age were plotted using WHO AnthroPlus software which uses WHO Reference 2007 for children aged 5–19 years.,,
Stunting-According to WHO standards adolescents with height for age z–score below-2 standard deviation (SD) of the median of a reference standard, below-3 SD is severe stunting.
Thinness-According to WHO standards adolescents with BMI for age z–score below-2 SD of the median of a reference standard, below-3SD is severe thinness.
Overweight and obesity-According to WHO standards adolescents with BMI for age z–score more than 1 SD of the median of a reference standard, more than 2 SD is obesity.
Undernutrition-Either stunting and thinness or both.
Malnutrition-Undernutrition and/or, overweight and/or obesity.
Data was entered in EpiData Manager Software (version 126.96.36.199, The EpiData Association, Odense Denmark) and analysis was done using SPSS (version 22, IBM Corp, Armonk, NY, USA) and OpenEpi (2008 Andrew G. Dean and Kevin M. Sullivan, Atlanta, GA, USA). Continuous variables were summarised as mean (SD) or median (interquartile range) based on the distribution of the data. The categorical variables were summarised as frequency and proportion. The prevalence of malnutrition was reported as proportions with 95% confidence interval (CI). Association between sociodemographic factors and clinical factors with undernutrition was assessed using Chi-square test and prevalence ratio with 95% CI. Multivariable (logistic binomial regression analysis) was done to adjust for confounders taking variables with P < 0.20 into the model.
| Results|| |
Of the total 550 students enrolled in the four selected schools, 499 students were included in the study. The remaining 51 students could not be contacted despite two visits and hence were excluded from the study.
[Table 1] show that 59.9% of the study participants belonged to the age group of 15–18 years and a majority of them were females (71.1%). The mean age of the adolescents was 14.7 (SD 1.9). About 51% of the mothers of the study participants were employed, whereas 91% of the participant's fathers were engaged in some occupation. More than three-fourth of the participant's belonged to the lower socioeconomic class. Majority of the adolescents (95.6) were taking nonvegetarian diet and 72.1% used tap water for drinking. More than half of the adolescents (58.9%) were not engaged in regular physical activity. About 454 (91%) adolescents washed their hands before having meal and 491 (98.4%) adolescents washed their hands after defecation.
|Table 1: Socio-demographic and other characteristics of adolescents in selected schools of urban Puducherry (n=499)|
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The distribution of nutritional-related morbidities (assessed using RBSK guidelines) among the school-going adolescents is depicted in [Table 2]. About one-fourth of the adolescents had dental caries. About 34.3% of the participants had palmar pallor. Of the total, 99 (19.8%) reported of suffering from some illness in the last month, the most common being fever (11.8%).
|Table 2: Clinical profile of adolescents in selected schools of urban Puducherry (n=499)|
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The prevalence of malnutrition (undernutrition and overnutrition) among the study participants was 46.8% (95% CI 42.5–51.3) [Table 3].
|Table 3: Nutrition status among the adolescents in selected schools of urban Puducherry (n=499)|
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As shown in [Figure 1], the proportion of adolescents with thinness or severe thinness was found to be 15% by using the WHO BMI-for-age growth chart. The proportion of children with stunting or severe stunting was found to be 21.6%, using the Height-for-age growth chart. The prevalence of undernutrition (either stunting, thinness or both) using two growth charts was found to be (166 out of 499) was found to be 33.3% (95% CI 29.3–37.5).
|Figure 1: Distribution of undernourished adolescents identified using World Health Organisation growth charts among adolescents in selected schools of urban Puducherry (n = 499)|
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Among the undernourished adolescents, as shown in [Figure 1], almost 17 (3.4%) suffered from both stunting and thinness.
On bivariate analysis, factors such as gender and mother's education were found to be significantly associated with undernutrition as shown in [Table 4]. While in multivariable logistic regression analysis, only gender, i.e., Males had 1.4 (1.0–1.9) times more risk of having undernutrition as compared to females and was found to be statistically significant with P value of 0.04.
|Table 4: Association of socio-demographic factors and clinical factors with Under-nutrition among the adolescents in selected schools of urban Puducherry (n=499)|
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| Discussion|| |
The overall prevalence of malnutrition in this study was found to be 46.8% (95% CI 42.5–51.3) while the prevalence of undernutrition, stunting and thinness were found to be 33.3% (95% CI 29.27–37.51), 18.2% (95% CI 15.03–21.81) and 10.4% (95% CI 7.96–13.34) respectively; similar results were reported by Selvaraj et al. in a study conducted in semi-urban area of Chennai, where they found the prevalence of stunting and thinness to be 19.2% and 13% respectively. In our study, the overall prevalence of overweight and obesity was found to be 16% (95% CI 12.9–19.6) which was in line with the findings of a similar study from the same study setting but in contrast to the studies from Northern India. Likewise, the proportion of thinness among the adolescents in this study was less compared to the study carried out by Rashmi et al., among school-going students (34%) in Bangalore. This disparity could be due to differences in the study setting and differences in the availability and accessibility of health care services. Compared to a study from Africa, our study had a better undernutrition status among the adolescents, while it was poorer than the estimates from the neighboring country Nepal. This disparity might be due to differences in health-care systems, dietary habits and cultural variations among the study participants. Moreover, students reading in public schools in our study setting were mostly from lower socio-economic status families.
Around one-fourth of the adolescents in the present study had dental caries, palmer pallor (34.3%) and history of worm infestation (8%). Similar findings were observed in studies conducted in Puducherry.,, In contrary to our findings, a higher prevalence was found in a study conducted in West Bengal. Regular screening camps for children through outreach activities by the health centre, health education activities in school and the availability of better health facilities in Puducherry might have contributed to lower morbidities among the participants in the current study.
In our study, the male gender was found to be an independent risk factor associated with undernutrition, in contrast to usual expectation; but this finding was similar to the results of another study from West Bengal. According to CNNS (2016–2018), 29.4% of boys and 18.9% of girls aged between 10 and 19 years were undernourished. In the present study, children of the nonworking mother showed better nutritional status than working mothers but was not statistically significant. Similar findings were observed in a study by Srivastava et al.
The study had certain strengths; we included all the adolescents from all the existing government schools present in the area to estimate the burden of malnutrition. Standard WHO growth charts were used to assess the nutritional status among adolescents. Questions from RBSK guidelines were selected for assessing nutritional deficiencies and other common co-morbidities.
We had a few limitations in our study like being a study conducted among government schools in our study setting alone; the findings of the present study may not be generalisable to adolescents from private schools or to other study settings. Recall bias and social desirability bias while administrating the questionnaire may not be completely eliminated. Assessment of self-reported co-morbidities might has been subjected to reporting bias. Almost 17% of the parents were not having formal education enough to self-administer the questionnaire. Due to practical difficulty in meeting the parents for an interview, data regarding these children were collected from school records. Despite this care has been taken to record the latest and authentic data to reduce any bias.
| Conclusion|| |
One in every two adolescents was malnourished and one-third of adolescents were undernourished. One fourth of the adolescents had dental caries. Adolescent males need to be given special focus to tackle undernutrition among them as they are usually missed in routine interventions. Inclusion of advices related to healthy diet and healthy lifestyle needs to be given focused attention in the school curriculum. Periodic growth monitoring of school going students needs to be emphasised for the early identification of malnutrition.
Special thanks to the Directorate of School education Puducherry for giving permission to conduct the study. We would like to thank the school authorities, adolescents who participated in this study and urban health centre staff. We would also like to express our gratitude to JIPMER Intramural grand Committee for supporting us financially.
Financial support and sponsorship
Grants received from Intra-Mural fund.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Selvaraj V, Sangareddi S, Velmurugan L, Muniyappan U, Anitha FS. Nutritional status of adolescent school children in a semi-urban area based on anthropometry. Int J Contemp Pediatr 2016;3:468-72.
Sivagurunathan C, Umadevi R, Rama R, Gopalakrishnan S. Adolescent health: Present status and its related programmes in India. Are we in the right direction? J Clin Diagn Res 2015;9:E01-6.
Lassi Z, Moin A, Bhutta Z. Nutrition in Middle Childhood and Adolescence. In: Bundy DAP, Silva ND, Horton S, Jamison DT, Patton GC, editors. Child and Adolescent Health and Development. 3rd
ed. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2017 Nov 20. Chapter 11. PMID: 30212127.
Pal A, Pari AK, Sinha A, Dhara PC. Prevalence of undernutrition and associated factors: A cross-sectional study among rural adolescents in West Bengal, India. Int J Pediatr Adolesc Med 2017;4:9-18.
Sunitha S, Gururaj G. Health behaviours & problems among young people in India: Cause for concern and call for action. Indian J Med Res 2014;140:185-208.
] [Full text]
Webb P, Stordalen GA, Singh S, Wijesinha-Bettoni R, Shetty P, Lartey A. Hunger and malnutrition in the 21st
century. BMJ 2018;361:k2238.
Anand D. Malnutrition status of adolescent girls in India: A need for the hour. Int J Sci Res 2016;5:642-6.
Aguayo VM, Paintal K. Nutrition in adolescent girls in South Asia. BMJ 2017;357:j1309.
Chetana M, Garg BS. Adolescent health and adolescent health programs in India. J Mahatma Gandhi Inst Med Sci 2017;22:78-82.
Joice S, Velavan A, Natesan M, Singh Z, Purty AJ, Hector H. Assessment of nutritional status and morbidity pattern among school children of rural Puducherry. Acad Med J 2013;1:32-25.
Dhikale P, Suguna E, Thamizharasi A, Dongre A. Evaluation of weekly iron and folic acid supplementation program for adolescents in rural Pondicherry, India. Int J Med Sci Public Health 2015;4:1-5.
Ramesh Masthi NR, Madhusudan M, Gangaboraiah B. Nutritional status of school age children (6 15 years) using the new WHO growth reference in a rural area of Bengaluru, South India. Natl J Res Community Med 2017;6:144-50.
Prasad RV, Bazroy J, Singh Z. Prevalence of overweight and obesity among adolescent students in Pondicherry, South India. Int J Nutr Pharmacol Neurol Dis 2016;6:72-5. [Full text]
Rashmi MR, Shweta BM, Fathima FN, Agrawal T, Shah M, Sequeira R. Prevalence of malnutrition and relationship with scholastic performance among primary and secondary school children in two select private schools in Bangalore rural district (India). Indian J Community Med 2015;40:97-102.
] [Full text]
Mohamed F. Comparative study of nutritional status of urban and rural school girls children Khartoum State, Sudan. J Sci Technol 2011;12:60-8.
Bhattarai S, Bhusal CK. Prevalence and associated factors of malnutrition among school going adolescents of Dang district, Nepal. AIMS Public Health 2019;6:291-306.
Abraham S, Chauhan R, Rajesh M, Purty AJ, Singh Z. Nutritional status and various morbidities among school children of a coastal area in South India. Int J Res Med Sci 2015;3:718-22.
Rajaa S, Sahu SK, Thulasingam M. Contribution of community health volunteers in facilitating mobilization for nutritional screening among adolescents (10-19 years) residing in urban Puducherry, India – An operational research study. Int J Community Med Public Health 2021;8:4506-12.
Bhattacharya A, Basu M, Chatterjee S, Misra RN, Chowdhury G. Nutritional status and morbidity profile of school-going adolescents in a district of West Bengal. Muller J Med Sci Res 2015;6:10-5. [Full text]
Srivastava A, Mahmood SE, Srivastava PM, Shrotriya VP, Kumar B. Nutritional status of school-age children – A scenario of urban slums in India. Arch Public Health 2012;70:8.
[Table 1], [Table 2], [Table 3], [Table 4]