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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 4  |  Page : 293-297  

Are our rural adolescents eating healthy?: Implications for redesigning school health interventions – A cross sectional study in rural Coimbatore


1 Assistant Professor, Department of Community Medicine, PSGIMSR, Coimbatore, Tamil Nadu, India
2 Dean Medical Education and Professor, Department of Community Medicine, Believers Church Medical College and Hospital, Kuttapuzha, Thiruvalla, Kerala, India
3 Associate Professor, Department of Community Medicine, PSGIMSR, Coimbatore, Tamil Nadu, India

Date of Web Publication18-Dec-2019

Correspondence Address:
Dr. Subhashini Ganesan
Department of Community Medicine, PSGIMSR, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_420_18

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   Abstract 


Background: Adolescence is a period of transition where independence in thinking and behavior is established and food choices that are made are followed for several years, and this can influence their health in adulthood. Hence, understanding the eating habits are necessary to plan effective nutritional interventions in adolescents. Objectives: The main objective of the study is to find out the extent of malnutrition among rural adolescents as well as evaluate their eating habits against recommended dietary food groups and to compare eating habits across gender and age groups. Methods: A cross-sectional study was done among 1425 adolescents from 13 rural schools from 2014 to 2015, and the variables considered in this study were age, sex, body mass index (BMI), and the eating habits of the adolescents. Results: Undernutrition was seen among 23% and overweight/obesity among 8% of adolescents. The habit of taking milk and milk products, fruits, and green leafy vegetables were very poor among the adolescents. Significant association was found between eating habits and BMI. Furthermore, late adolescents had better eating habits, and significant gender difference was seen in certain eating habits. Conclusions: The study shows that it is possible to understand the gaps in eating habits of adolescents, and this can be used to plan tailor-made nutritional interventions to adolescent groups as their eating habits are different and have long-term nutritional and health implications.

Keywords: Adolescent, dietary gap assessment, faulty diet, nutritional diagnosis, school health


How to cite this article:
Ganesan S, Chacko TV, Muhammad G M. Are our rural adolescents eating healthy?: Implications for redesigning school health interventions – A cross sectional study in rural Coimbatore. Indian J Public Health 2019;63:293-7

How to cite this URL:
Ganesan S, Chacko TV, Muhammad G M. Are our rural adolescents eating healthy?: Implications for redesigning school health interventions – A cross sectional study in rural Coimbatore. Indian J Public Health [serial online] 2019 [cited 2020 Jan 23];63:293-7. Available from: http://www.ijph.in/text.asp?2019/63/4/293/273365




   Introduction Top


Adolescence is a period of transition. The World Health Organization (WHO) defines the period of adolescents as 10–19 years of age.[1] It is a period of rapid growth and maturation in human development. It is a period where independence is established and adolescent makes choices of their own. The choices that are made are followed for several years and food habits are greatly established during this period, and this can influence their health in the adulthood.[2]

As global foods are widely marketed in low- and middle-income countries, it becomes important to understand the diet patterns and preferences.[3] In India, among adolescents, there is an increased consumption of fast foods contributing to overweight and obesity.[4] Furthermore, studies have shown that the food consumption pattern is poor among adolescents and have observed frequent consumption of energy-dense, nutrient-poor foods, and sugar-sweetened beverages, and the omission of a variety of healthy foods from their daily diet.[5]

In addition, cultural factors such as dietary practices and attitude toward food are evolving. These factors eventually influence the eating habits and today's adolescents lack proper knowledge on good eating habits and how those habits contribute toward their healthy nutritional status.

Hence, healthy eating behavior should be established in childhood and maintained during adolescence.[6] Adequate knowledge of healthy food choices and eating habits should be taught early to adolescents, as it can predispose them to lifestyle diseases in adulthood. Adolescents should be constantly motivated, and the need of the hour is bridging the knowledge gap on healthy eating.[7]

In India, there is a paucity of information about eating habits of adolescents, and limited information is available regarding various categories of food consumed by adolescents in relation to the food pyramid, which defines and identifies the balanced diet and corresponding nutritional status of an adolescent. Moreover, this type of nutritional data is even more difficult to find among rural population in India. Also, adolescents are the most important and vulnerable segment of population who have been largely ignored, and exclusive data pertaining to adolescent health are not widely available in Indian scenario.[8]

Hence, this study aimed to measure the extent of malnutrition among rural adolescents as well as evaluate their eating habits against recommended dietary food groups and to compare eating habits across gender and age groups.


   Materials and Methods Top


A cross-sectional study was done among adolescents from 13 schools in rural area within the Madukkarai block, Coimbatore District, in 2014–2015. Prior permission was obtained from the concerned school health authorities, and this study protocol was approved by the Institutional Human Ethics Committee. Data used in this study were collected as a part of the school health project. The variables considered in this study were age, sex, body mass index (BMI), and the various elements in the recommended food portions that constitute the eating habits of the adolescents.

This school health program was funded by Larsen and Toubro, under their corporate social responsibility scheme. The funders' interest was only on the services to the rural school children and did not have a role in the research component. The research on the data obtained was done after obtaining ethics committee clearance from our institution. All adolescents from 10 to 18 years were included in the study and students who were absent from school on the day of visit were excluded from the study.

Anthropometric measurements such as height and weight of all students were recorded. Instruments were calibrated, and the BMI was calculated based on the measured height and weight. The nutritional status of the adolescent was determined based on the WHO BMI charts available, separately for boys and girls, from 5 to 19 years.[9] The WHO chart classifies them as severe thinness, thinness, and normal, overweight, and obese based on their BMI for their particular age. A questionnaire/checklist was designed to record the daily eating habits of school children based on the recommended portions of various categories listed in the food pyramid, as recommended by the ICMR and National Institute of Nutrition (NIN).[10] Based on the above balanced diet recommendations, questionnaire was developed which assessed the daily eating habits of the adolescents.[11] The questionnaire was a simplified tool with ten items, to assess gaps in the recommended portions of food category intake, by directly asking question that checks in Yes/No terms the compliance with daily recommended intake of cereals in the three main meals, daily intake of vegetables and green leafy vegetable, daily intake of milk and milk products, habit of taking a fruit daily, and intake of protein-rich foods in daily diet. In the assessment of protein-rich food/pulses recommended, portions can also be replaced by egg or other nonvegetarian food as per recommendations.[10] Hence, this assessment includes the assessment of egg and nonvegetarian food also. Additional questions were added to assess other eating habits such as the habit of taking mid-day snacks and questions that captured certain faulty eating habits of students like habit of skipping meals, taking junk food, and eating from street shops. The scoring was also given for each student based on the Yes/No terms in the questionnaire. Each positive response had a score of 1. Total score was 10 and a score of <10 indicates the gap from the recommended portion of food, or they have a faulty eating habit. Lesser the score, more is the gap in the recommended dietary portion of food category. Each student was individually enquired about the eating habits based on the questionnaire, and individual nutrition counseling was given to students who had a faulty eating habit or not complying with the recommended dietary food group intake standards.

All quantitative values were expressed in proportions. Normality test (Shapiro–Wilk test) was done and the nutritional score followed a nonnormal distribution. The association between eating habits and gender, age, and the nutritional status was tested using Chi-square test and Kruskal–Wallis test. All statistical analysis was performed using IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp (24.0), P = 0.05 or less, were considered as statistically significant.


   Results Top


A total of 1425 adolescents between the ages, 10 and 18 years were included for this study, of which 53.1% belonged to early adolescents (10–13 years), 39.9% belonged to middle adolescents (14–16 years), and 6.9% belonged to late adolescents (17–18 years). The mean age was 13.38 ± 2.03 years. The study participants were 753 (47.2%) males and 672 (52.8) females.

[Table 1] shows that a majority (68.8%) of adolescents had a normal BMI. However, more than a quarter of them (23.2% of students who were undernourished including thin and severely thin and 8% were either overweight or obese) need dietary and other interventions.
Table 1: Nutritional status of adolescents based on the WHO body mass index charts

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The nutritional status of boys revealed 29.5% were either severely thin or thin, 4.2% were overweight, and 2.5% had obesity. Among girls, 17.6% were in severely thin or thinness category, 5.0% overweight, and 4.2% had obesity. This difference between boys and girls was statistically significant (P < 0.001).

[Figure 1] shows the percentage of adolescents taking the recommended food groups daily as per the ICMR/NIN recommendations and also certain faulty eating habits such as eating junk food, eating from street shops, and skipping meals. It shows that none of the adolescents had the habit of taking green leafy vegetables daily. Furthermore, the habit of taking fruits and milk was very poor among the adolescents, thereby putting them at risk of micronutrient and vitamin deficiency which are not picked up if we do anthropometry alone as done in most school health programs.
Figure 1: Pattern of eating habits among adolescents.

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[Table 2] shows that there is an association between eating habits and nutritional status of the adolescents. Chi-square test was used to find whether there was any significant difference in the eating habits among the adolescents of various nutritional statuses (based on BMI). Except for the habit of eating junk foods, others habits have significant association with BMI (P < 0.001).
Table 2: Association of eating habits and nutritional status of schoolchildren (n=1425)

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[Table 3] shows the difference in eating habits based on gender. Chi-square test was used to find whether there was any significant difference in the eating habits among the adolescent boys and girls. Odds ratio was also calculated. Habits of taking cereals, mid-day snacks, skipping meals, and eating from street shops showed significant difference between boys and girls.
Table 3: Association of eating habits and gender of the adolescents (n=1425)

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The mean score obtained by the students on the diet assessment was compared between the age groups. Kruskal–Wallis test was used to find the statistical significance among the various age groups. The mean scores of early, middle, and late adolescents were 4.3 ± 1.27, 4.2 ± 1.23, and 4.6 ± 1.02, respectively. Late adolescents had a better nutritional score compared to early and middle adolescents. The difference was found to be statistically significant (P = 0.006).


   Discussion Top


Our study shows that undernutrition or thinness among the rural school-going adolescents was a common problem (23.2%). Furthermore, 8% were overweight or obese and hence over a quarter of them need dietary and other interventions. The percentage of undernutrition and overweight was less in our study compared to a study done in Karnataka by Benazeera., where among school adolescents, 34% were belonging to the category of underweight, 21.33% were obese, and 10.67% were overweight.[12]

We also found that underweight was more common among boys and overweight and obesity were more among girls and hence targeted interventions for girls and boys are needed that address factors that could be different. This means further studies are needed to find out the reasons for the difference observed. A study done in Bangalore by Abraham and Anand showed similar findings among adolescent schoolchildren.[13] The study by Venkaiah et al. among rural adolescents in nine states also showed that underweight was more among boys than girls.[14]

Regarding eating habits, our study showed that the habit of taking green leafy vegetables daily was not there in any of the adolescents. Furthermore, the habit of taking fruits (2.5%) and milk and milk products (4.1%) was very poor. These habits were poor even in the normal BMI category. Thus, traditional school health programs that use anthropometry alone would not help identify vitamin and micronutrient deficiency unless anthropometry is combined with clinical screening for vitamin and micronutrient deficiency diseases and their contributing factors by doing a diet survey. A study done by Rathi et al. among adolescents in Kolkata also showed that 45% did not consume any fruit, 30% did not take vegetables, and 36% did not take milk and milk products. Our study showed that consumption was very less percentage maybe because it assessed daily habits, while the study in Kolkata showed the consumption based on the last 2 days.[5]

In our study, the eating habits of adolescents were found to have significant association with their nutritional status, except for habit of eating junk foods. Our study showed that habits like not consuming cereals for three main meals, not taking mid-day snacks, protein-rich food, and skipping meals were significantly associated with the underweight. In the overweight/obese category, factors such as milk and milk products, eating from street shops, and junk food were high, though junk food did not show any statistical significance. Similar findings were seen in a study by Amin et al. which showed that frequent consumption of sweets/candies and milk and milk products are associated with obesity.[15] However, even habits of eating vegetables and fruits were also high in the overweight/obese category. Since the study did not take into consideration the quantity of consumption and exact fruits and vegetables consumed, we could not comment on this. A study by Bhattacharjee et al. among adolescents showed that BMI correlated significantly with the dietary habits.[16] Another study by et al. showed that eating habits were a better predictor of BMI, especially among boys.[17]

In our study, association of gender with eating habits showed that habits such as consumption of cereals, having mid-day snacks, skipping meals, and eating from street shops showed significant differences. Habit of consuming cereals and having mid-day snacks were better among girls. A study by Rathi et al. also showed that females had better consumption of cereals.[5] However, higher percentage of girls had the habit of eating from street shops. This was again similar to a study which showed that significantly more mid-adolescent girls purchased from tuck shops than boys.[18] The habit of skipping meals was more common among boys than girls. Similarly, a study among Turkish Adolescents shows that one-third of the boys skip meals, while only one-sixth of the girls skip meals.[19] Furthermore, a systematic review done among young adults showed that men tend to skip breakfast more often than females, while skipping lunch and dinner was more common among females.[20]

Our study also showed that late adolescents had better eating habits as demonstrated by their higher nutritional scores compared to early and middle adolescents. The nutrition scores are least in the middle adolescents group. This might be because in early adolescents still parental influence is more as shown in a study which shows parental influences can influence the diet of the child.[21] In the late adolescence, the better scores might be because the adolescents become more aware about healthy eating, as shown in certain studies that late adolescents have better knowledge than the younger ones.[22] However, further studies are needed to establish the factors influencing their diet.

Limitations and strengths

Our study has several strengths; we have studied a large number of children in the study sample. A simple and effective questionnaire was used for identifying the gaps in the eating habits based on the standard ICMR/NIN recommendations for a balanced diet. In addition, standard methods like the WHO-developed BMI age charts were used to assess the nutritional status.

However, there were certain limitations, eating habits were assessed by self-reported data and quantitative measuring of the intake of the recommended portions of food groups was not done. We could not exclude the possibility of confounding effects by unmeasured variables such as physical activity and other comorbidities that influence the BMI. Furthermore, data did not include social factors known to affect BMI such as socioeconomic status, number of family members, and education of the mother. Although our study identified low intake of green leafy vegetables and fruits, we had not planned to look for clinical manifestations of vitamin and micronutrient deficiencies and then look for correlation between the two. Also, since we have found that underweight was more common among boys and overweight and obesity were more among girls and hence further studies are needed to find out the reasons for the difference observed.

Notwithstanding the above limitations, our study findings show that there is scope for doing further in-depth studies to prove the preliminary findings of this study.


   Conclusion Top


The study shows that it is possible to make a Nutritional Education Diagnosis by identifying the gaps in eating habits compared to the recommended one for school-going adolescents. This can then be used to plan tailor-made educational and nutritional programs for improving their eating habits. Using the rapid screening method used in the study, it would be relatively easy to conduct this exercise on a sample of schools in a district to capture gaps in diet at district level for conducting health education and awareness programs on nutrition for adolescents in schools at the district and using similar methods to scale it up for state-level as possibly a national-level initiative to extend school health nutritional interventions to adolescent groups, as their eating habits are different and have long-term nutritional and health implications for the population beyond adolescence.

Acknowledgments

We acknowledge the work of the entire PSGH school health project team and Larsen & Toubro Limited, Coimbatore, for its funding and support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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