Prevalence of Double Nutrition Burden Among Adolescent Girls of Assam , Northeast India

Address for correspondence: Dr. Nitish Mondal, Assistant Professor, Department of Anthropology, Assam University: Diphu Campus, Karbi Anglong 782 462, Assam, India, E-mail: nitishanth@gmail.com Tel: +91-9613712613 1Jyotismita Sharma, MA, Research Scholar, 2Dr. Nitish Mondal M.Sc, Ph.D, Assistant Professor. Both from the Department of Anthropology, Assam University: Diphu Campus, Karbi Anglong 782 462, Assam, India. Abstract


Introduction
P revalence of the malnutri on is a very common phenomenon in the developing countries leads to high mortality, morbidity and long-las ng physiological eff ects 1 .The South Asian countries have par cularly shown dras c changes in the nutri onal status in the past few decades, primarily due to the changes in the socioeconomic status, dietary and lifestyle habits.Recent trends of popula on transi on in the economic, demographic, epidemiological, nutri onal and sociological fronts have decreased undernutri on with accelera on in overweight and obesity, [2][3][4][5] but the highest propor on (463 million) of undernourished people is living in Asia 3 .Current trend shows the prevalence of overweight and obesity are epidemic is an ever-growing concern in developed countries and also frequent in urban areas in developing countries including India 3,4 .Therefore, the prevalence of double burden of nutri on is simultaneously more prevalent in the socio-economically deprived segments and overweightobesity among more affl uent were well recognized, but recent changes tend to result in the opposite manifesta on causes double nutri onal burden [2][3][4][5] .It is therefore important to assess overweight-obesity and be able to classify its severity in the popula on.The non-invasive and inexpensive, prac cal technique of anthropometry has become a widely used in assessing nutri onal status, especially in clinical and epidemiological studies 2,6 .The Body Mass Index (BMI) classifi ca on is the most widely used surrogate anthropometric measures for assessing both undernutri on (e.g., thinness) and overweightobesity 4,6,7,8,9,10,11 .
Due to its immense popula on size, socioeconomic dispari es, illiteracy and inadequate access to the healthcare facili es, the assessment of nutri onal status have the poten al to play a signifi cant role in implemen ng development strategies in Indian popula ons 3,5,12 .It is evident that the na onal policy response to reduce the magnitude of malnutri on in India is s ll restricted to the undernutri on 3,5 .Several researchers have primarily focused on the magnitude of undernutri on in diff erent Indian children and adolescents 9,10,11,12,13,14,15,16,17,18 .Therefore, assessment of nutri onal status is considered to be the prime indicator of the health situa on which interacts with the demographic and socioeconomic variables in important ways 10,12,13,16,17 .Currently, it is es mated that adolescents contributes to 1.20 billion of the total world popula on and belonging to the largest popula on of adolescent cohort of 243 million (20.00%) in India 18 .Researchers have already reported that the prevalence of thinness (low BMI-for-age) is the major nutri onal problem among adolescents in India 9,10,13,14,15,18,19 .Recent studies have also reported a signifi cant propor on of the popula on residing in urban areas are being aff ected by overweight and obesity 3,4,20,21,22,23 , as a manifesta on these popula ons experienced double nutri onal burden.Furthermore, the use of BMI in rela on to age was recommended as the best surrogate anthropometric measure of thinness and overweight during adolescents 6,7,8 .Given above, the present study was conducted among adolescent girls popula on residing in rural areas with an aim to determine the prevalence of double nutri onal burden (e.g., thinness and overweight) of Assam, Northeast India.

Materials and Methods
The present cross-sec onal study was conducted among the adolescent girls in Diphu, Karbi-Anglong, Assam, Northeast India.The district Karbi-Anglong (25 0 33ʹ N to 26 0 35ʹ N la tude and 92 0 10ʹ E to 93 0 50ʹ E longitude) is the largest district among the 27 districts of Assam and covers an area of 10,434 km 2 .According the Na onal Census, 2011 the district had a popula on of 9,56,280 individuals (4,93,482 male; 4,71,798 female) with an average literacy rate of 59.52% (56.82% male; 43.18% female).A total of 6 schools in the adjacent areas of Diphu were covered and total student strength of the schools was iden cal.The community area has a habitat of the major tribal popula on, predominantly Karbi and other ethnic group includes Dimasa, Bodo, Tiwas, Khasi and Rengma Naga tribal ethnic groups.A total of 1306 subjects belonging to heterogeneous ethnic groups were iden fi ed and adolescents belonging to the age group 10-16 years were approached.A total of 1228 adolescent girls aged 10-16 years were included using simple random sampling method.The age of the subjects was recorded from the school records and was subsequently verifi ed from birth cer fi cates.The anthropometric data was collected during the period of January-December, 2013.The necessary study approvals and clearance were obtained from the school authori es and local community leaders prior to the commencement of study.All the subjects were free from any physical deformi es, systema c diseases, nutri onal defi ciencies and previous surgical episodes.The inves ga on was conducted in accordance with the ethical guidelines of the human experiments as laid down in the Helsinki Declara on 24 .

Collection of the anthropometric data
The anthropometric measurement of height and weight of the subject was recorded using the standard procedure 25 .Height of the subject was recorded to the nearest 0.10 cm with the help of an anthropometer rod (GPM type, Galaxy Informa cs, New Delhi) with the head held in the Frankfort horizontal plane.The weight of the subjects, wearing minimum clothing and with bare feet was taken using a portable weighing scale (Libra®, Edryl-India, Tiswadi, Goa) to the nearest 100 gm.The anthropometric instruments were also checked in regular interval to reduce the systema c errors during measurement collec ons.The BMI was calculated by using the standard equa on: BMI= weight /height 2 , kg/ m 2 ).The diff erence in anthropometric measurements was calculated for tes ng the co-effi cient of reliability [R= {1− (TEM) 2 /SD 2 }, the SD= standard devia on of all measurements] using the technical error measurement {TEM=√ (ΣD 2 /2N), D=diff erence between the measurements, N= number of individuals measured} following the method of Ulijaszek and Kerr 26 .A total of 50 subjects were iden fi ed using simple random sampling method for calcula on of TEM analysis.Very high values of R (>0.98) were obtained for height and weight using TEM analysis and values were found within  26 .Hence, the anthropometric measurements were obtained in this study are free from observer bias, reproducible.The TEM values were not considered for further sta s cal considera on, and all the measurements were subsequently recorded by the author JS.

Assessment of nutritional status
The prevalence of thinness 7 and overweight 8 were assessed using recently proposed age-sex specifi c interna onal reference and cut-off s.The prevalence of thinness was proposed similar to the cut-off s of adult chronic energy defi ciency (CEC) (BMI<18.50kg/ m 2 ) and overweight (BMI>25.00kg/m 2 ) 6,7,8 .These references and cut-off points are already u lized to assess and document such prevalence among Indian adolescents 9,13,14,22 .

Statistical analysis
Sta s cal analyses were done using the Sta s cal Package for Social Science (SPSS, version 17.0).Normality was tested using the Shapiro-Wilk test for each of the anthropometric variable age groups-wise, and p-values observed were sta s cally not signifi cant in most of the categories (p>0.05).The data were analysed in terms of descrip ve sta s cs of mean and standard devia on (SD).One way analysis of variance (ANOVA) was done to assess the age specifi c mean diff erence in anthropometric variables.The chi-square analysis was u lized to assess diff erences in nutri onal indices between diff erent Indian ethnic groups.The p-values of <0.05 were considered to be sta s cally signifi cant.

Results
Age specifi c subject distribu on, descrip ve sta s cs (mean ±SD) of height, weight and BMI among adolescent girls is depicted in Table 1.The overall mean ±SD of height, weight and BMI were 147.76 ±7.69 cm, 40.51±8.14kg and 18.40 ±2.64 kg/m 2 respec vely.The age specifi c mean height and weight was increased with age with an excep on, observed in 16 years (in height).However, age-specifi c trend was found to be absent in mean BMI but there was a posi ve increase when approached to higher ages with an excep on observed in 14 years and 16 years.The age specifi c mean BMI was ranged from 16.36 ±1.94 kg/ m 2 (in 10 years) to 19.56 ±2.57kg/m 2 (in 16 years).Using ANOVA, the age specifi c mean diff erences were observed to sta s cally signifi cant (p<0.01) in weight (F-value= 125.23; d.f.6; 1227), height (F-value= 119.23; d.f.6; 1227) and BMI (F-value= 60.98; d.f.6;1227).The overall prevalence of overweight and thinness using BMI classifi ca on proposed by Cole et al. 7,8 was found to be 8.31% and 19.14%, respec vely (Figure 1).The age specifi c prevalence of thinness and overweight was found to be higher among 16 years (31.13%) and 11 years (12.00%)respec vely.The age-specifi c lower prevalence of thinness and overweight was observed among 15 year (9.03%) and 14 years (3.23%).However, age-specifi c trend in the prevalence of thinness and overweight was found to be absent among adolescent girls, but the prevalence of thinness was observed to be greater (>20.00%) in early and higher age groups (e.g., 10-12 and 16 years) (Figure 1).

Discussion
The prevalence of malnutri on is con nuing to be the major nutri onal problem, especially in rural popula on of India due to widespread poverty, socioeconomic dispari es and the scarcity of basic healthcare ameni es problem mostly refl ec ng among vulnerable segments [9][10][11][12][13][14][15] .The prevalence of the thinness due to chronologically poor condi ons are very common in much of the developing countries like India 9,18 .Therefore, the present study emphasized the importance of iden fying the magnitude of undernutri on (e.g., thinness) and overweight to provide an insight into the public health condi on and establish the need of appropriate interven on strategies in a heterogeneous rural adolescent popula on of Northeast India.Several studies have already advocated that the prevalence of undernutri on is be er assessed as thinness rather than was ng (low weight-for-height) 6,7,14,15 .The present study assesses the prevalence of thinness and overweight using newly proposed reference 7,8 .These references were suggested to encourage direct comparison of global trends in thinness and overweight prevalence and to provide a classifi ca on for the public health purpose.
Several studies have reported that the problem of thinness is persistent transversely among diff erent Indian popula ons with consistent propor ons, especially among Indian children and adolescents 9,10,12,13,14,17,19 .When the prevalence of the thinness of the present study was compared with Indian popula on, it has been observed that tribal Sonowal Kachari 15 (23.92%) and Indian adolescent girls 16 (41.30%)were signifi cantly (p<0.05)aff ected in Assam.Venkaiah et al. 17 also reported that the prevalence of thinness to be signifi cantly higher among rural adolescent girls (39.50%) (p<0.05).Recently, lower prevalence of thinness was reported among tribal Karbi adolescent popula on of Assam (14.90%) 19 (p>0.05).A signifi cantly greater prevalence of thinness among adolescent girls (30.61%) has also been reported from North India 27 (30.61%)and Darjeeling, West Bengal 14 (46.89%)(p<0.05).It is, however, now generally reported that there is a very high prevalence of thinness among the Indian communi es with more than 50.0% of adolescents being aff ected 11,13 .The majority of the popula ons in India are generally poverty stricken and belonging to the poor socioeconomic background, agriculture-based strategies are important for improving household food security and exis ng nutri onal condi on in rural adolescents.Moreover, the poor nutri onal status among adolescent girls will apparent as an adverse eff ect on their physical work capacity, health status and poor reproduc ve outcomes in adulthood 6,14,18 .
It can be summarized that in the present study, the rural adolescents are facing a great risk in terms of double nutri onal stress.The prevalence of overweight (BMI ≥25 kg/m 2 ) in the present study is 8.13%.The results of Na onal Family Health Survey showed that the prevalence of overweight in children did not increase much in the last decade from 1.60% (in 1998-1999) to 1.50% (in 2005-2006) 18 .A signifi cantly lower prevalence of overweight has been reported among rural adolescent from Assam (0.30%) 13 (p<0.01)andrural Wardha (2.00%) 11 (p<0.01)andrural Darjeeling of West Bengal (0.30%) 10 (p<0.01).Recent studies have reported the prevalence of overweight has increased in Indian children and adolescent of Delhi (22.00%) 20 (p<0.05),Punjab (14.31%) 21(p<0.05),Andhra Pradesh (7.22%) (p>0.05) 22and Pune (19.9%) 23 (p<0.05).Furthermore, the prevalence of overweight and obesity had increased slightly over the past decade in India, but in some urban and higher socioeconomic groups, it reached rela vely greater propor ons 4 .The appearance of overweight among the adolescents residing in especially urban popula ons generally a ributed due to the changes in the socioeconomic status, physical ac vity and lifestyle 4,21,22 .Current data suggested that the similar occurrence has also started small segments of the adolescents residing in rural regions in India 10,11,13 .The results of the present study will be useful for the policy makers in their endeavour to formulate various developmental strategies and healthcare programmes the popula on concern to reduce the double burden of nutri on in Indian popula on.

Conclusion
Moreover, the nutri onal status is considered to be an integral component of the overall health of an individual and/or popula ons.The present study showed that the rural adolescent girls are facing great risks in terms of the double burden of nutri on as thinness which is more pronounced than the overweight.Therefore, the magnitude of thinness is considered to be s ll a major problem than overweight in rural adolescents in India.The results of the present study would be helpful to reveal the enhanced eff ec veness of the ongoing nutri onal interven on at targeted popula on.Since, the ul mate objec ve of such nutri on assessment studies is to improve human health condi ons, therefore there is an urgent need for appropriate nutri onal interven on program becomes a priority to reduce malnutri on related health problems especially in adolescents residing in rural areas in India.

Fig 1 :
Fig 1: Age specifi c and overall prevalence (in percentages) of thinness and overweight amongst adolescent girls of Karbi-Anglong, Assam

Table 1 :
Age specifi c subject distribu on, descrip ve sta s cs (mean ±SD) of weight, height and BMI among adolescent girls of Karbi-Anglong Assam