Prevalence of Underweight , Stunting and Thinness Among Adolescent Girls in Kavre

Address for correspondence: Dr. Dil Islam Mansur Assistant Professor, Department of Anatomy Kathmandu University, School of Medical Sciences (KUSMS) Dhulikhel, Nepal E-mail: dillslam@kusms.edu.np Tel: 00977-9849678367 1Dr. Dil Islam Mansur, MBBS, MS, Assistant Professor, 2Dr. Mohammad Khurshidul Haque, MBBS, MS, Associate Professor and Head, 3Mrs. Kalpana Sharma, MSc, Lecturer, 4Mr. Dilip Kumar Mehta, MSc, Lecturer, 5Ms. Rojina Shakya, MSc, Lecturer. All from the Department of Anatomy, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal Abstract


Introduction
A dolescent is the developmental period between childhood and adulthood.The World health organiza on defi nes adolescents as young people between the ages of 9-19 years 1 .Out of es mated 27 million popula on 2 in Nepal around 23 percent are adolescents who form a crucial segment of the society 3 .Their current nutri onal status will decide the well-being of the present as well as the future genera ons.Adolescence is the second most cri cal period of physical growth a er the period of infancy 4,5 .It is a me of enormous physiological, cogni ve and psychosocial changes, largely dependent on hormonal and environmental infl uences 4,6 .
The girl child is considered to be a burden and discrimina on against her is rampant in all strata of society irrespec ve of class and economic condi ons.It is generally observed that girls and women par cularly in rural households suff er rela ve negligence with reference to nutri onal inputs 7 .
Anthropometric measurements remain the most prac cally useful means for the assessment of the nutri onal status of a popula on 8 .Generally, nutri onal status is assessed by low weight for age (underweight), low height for age (stun ng) and low BMI for age (thinness) following diff erent interna onally and regionally recommended standards 9 .
Studies on the assessment of nutri onal status of adolescents are less in number and a na onal database has not yet been developed.Hence, the present study was conducted to determine the prevalence of underweight, stunning and thinness among the adolescent girls using the recommended anthropometric indicators which allow the determina on of the nature and extent of under nutri on in the rural community in Kavre district of Nepal.

Material and Methods
A cross sec onal descrip ve study was conducted among adolescent girls a ending fi ve diff erent government schools in rural community of Kavre district, Nepal.A total number of sample sizes were 716 school going adolescent girls randomly selected within the age group of 9-16 years.The study was conducted during the period from 15 th March to 15 th September 2014.A er taking permission from the school authority, the class teachers of class were explained the purpose of the study and rapport was built up with the girl students and verbal consent was obtained from them.The students who were physically challenged were excluded from the study.Data was obtained from each interested par cipant.Height was recorded from heel (bare feet) to highest point of vertex in normal anatomical posi on by using measuring tape in cen metre and weight was measured using a standing weighing machine in kilogram.Body Mass Index (BMI) was derived by using the standard equa on: BMI = weight (kg)/ height (m 2 ).WHO anthropometric classifi ca on was used for the assessment of under nutri on.WHO has classifi ed the children using three categories: 'underweight' is defi ned as low weight for age and it refl ects present (acute) and past (chronic) under nutri on: children with Z-scores < -2.00 are said to be underweight, 'stun ng' is defi ned as a low height for age for children, and it measures the past (chronic) child under nutri on: children with Z-scores < -2.00 are said to be stunted and 'thinness' is defi ned as low BMI for age for children, and it is a measure of current or acute under nutri on: children with Z-scores < -2.00 are said to be thinned whereas children with Z-scores > 2 are said to be overweight.Adolescent girls were considered as having underweight, stun ng and thinness if their weight for age, height for age and BMI for age Z-scores were below -2.0 SD of the WHO reference 9

Results
The subjects for this study were 716 adolescent girls.Age wise distribu on of subjects, descrip ve sta s cs (mean ±SD) of height, weight and BMI among adolescent girls is men oned in Table 1.The overall mean ±SD of height, weight and BMI were 143.24 ±6.33 cm, 37.38 ±11.66 kg and 18.04 ±3.40 kg/m2 respec vely.The age specifi c mean height, weight and BMI were increased with age with an excep on, observed in 16 years (in height).
As shown in table 2; it has been concluded that the overall prevalence of underweight (low weight for age) was 31.98% with reference to WHO values.The adolescents with the age of 11 years had high percentage of underweight (49.5%) and the lowest (20.7%) was found in the age of 13 years.
The prevalence of stun ng (low height for age) was shown in Table 3.The overall prevalence of stun ng was 21.08% as compared to WHO values which was highest among the age group of 9 years (37.34%).The lowest prevalence of stun ng was 10.7% among the age group of 14 years of adolescent.
Similarly, 14.94% of the adolescent girls were found to be thin (low BMI for age) as described by WHO criteria.The highest (24.2%) prevalence of thinness was found among nine years and the lowest (11.0%) prevalence was found among 10 years adolescent girls.The highest prevalence of overweight was 4.6% in the age group of 13 years and was absent in the adolescent girls of 14 years.

Discussion
Most countries in Asia have high or very high prevalence of underweight, stun ng and thinness, the prevalence being far higher in Southern Asia.Southeastern Asia ranks second in the descending order of prevalence of underweight and third for stun ng and thinness 10 .The present study highlights the extent of nutri onal status in terms of underweight, stun ng, thinness and overweight among adolescent girls of rural community of Kavre district.Nutri onal status was evaluated using anthropometric indicators recommended by the WHO expert commi ee.Assessing the nutri onal status of groups of children is an essen al part of monitoring the health of a community 11 .The use of appropriate anthropometric indicators allows determina on of the nature and extent of nutri onal status in the rural community.
It has been found that under-nutri on during adolescence is a major health problem in most of the districts of Nepal including Kavre district.Many studies reported high prevalence of underweight in diff erent regions of the world especially in Asian countries.A study reported very high percentage of prevalence of underweight 51.7% among adolescents in Wardha, Maharashtra, India 12 .Ghosh et al. observed the overall underweight level was 46.09% among girls of aged 6-10 years in Kathmandu valley 13 .The high rate of underweight (41.33%) was reported among rural adolescent girls from Khagrachhari district in Chi agong hill region of Bangladesh 14 .In other context, low prevalence of underweight has also been reported 16.5% and 16.9% of girls with age group of 5-15 years in Mugu and Humla districts of far western region in Nepal 15 .
It is also apparent from the study that the overall prevalence of stun ng was 21.08% among studied subjects which was almost similar as compared with the fi nding (23.28%) reported in Bareilly district, (UP), India by Singh et al. with use of WHO reference 16 .However, use of Indian reference data, Mai et al. found 18.10% of stun ng among early adolescent school girls of Paschim Medinipur district, West Bengal, India 17 and Anand et al. reported 20% prevalence of stun ng at rural North India 18 which was consistent with the present result.In contrast to this, many studies reported high prevalence of stun ng among rural adolescent girls.The extent of stun ng was higher (50.3%) at rural area of Darjeeling district of West Bengal using WHO reference value 19 .
Bose et al. reported the frequency of stun ng to be 48.4% among pre-adolescent school girls 20 .Ghosh et al. reported high prevalence of stun ng (43.42%) among school going girls with age group of 6-10 years on Kathmandu valley, Nepal 13 .Mai et al. also no ced the prevalence of stun ng as 34.20% among rural early adolescent school girls based on WHO reference data 17 .In Bangladesh, a study conducted by Alam et al. found that the prevalence of stun ng was 32% of adolescent girls in rural areas 21 .In other context, low prevalence of stunted has also been reported 9.2% and 7.7% of girls with age group of 5-15 years in Humla and Mugu districts of far western region in Nepal 15 .The basic reason behind stun ng indicates the long term cumula ve inadequacies of health and nutri on and an insuffi cient intake of nutrients during the early stage of childhood 9 .
It is also apparent from the present study it was confi rmed that the overall prevalence of thinness and overweight was 14.94% and 3.22% among studied subjects.The thinness was found to be more common among nine years and overweight among 13 years.A noteworthy point is that both thinness and overweight were coexis ng among the girls in studied area.A similar fi nding (14.7%) also reported by Das et al. among adolescent girls in a rural area of North 24 Parganas district, West Bengal.India 22 .
In contrast, there was high prevalence of thinness reported in many studies in various regions of world.A community based cross sec onal study was carried out among adolescent girls (10-19 years) in selected villages of the Kolar district, Karnataka, India and reported the prevalence of thinness as 73.5% as per Indian standards 23 .Choudhary et al. have reported 68.52% of adolescents having a BMI less than 18.5 kg/ meter square in rural area of Varanasi 24 and studies overseas in developing country like Bangladesh have also reported higher rate of prevalence (67%) of thinness among girls in the south east region 25 .Thapa et al. no ced 21.13% girl child of Humla and 20.12% girl child of Mugu in the age group between 5 and 15 years were found to be thin 15 .This higher fi gure of thinness in their study may be a ributed to poor socioeconomic condi ons of mountain regions.The poor nutri onal status of adolescent girls has important implica ons in terms of physical work capacity and adverse reproduc ve outcomes.
However, low prevalence of thinness was also reported in the diff erent studies.Sood et al. reported a prevalence of thinness 5.1% adolescent girls in Bangalore City, Karnataka, India 26 .In another study done by Mushtaq et al. in Lahore, Pakistan, 10% children aged 5-12 years were found to be thin 27 .Sachan et al. also reported low prevalence of thinness (11.4%) among adolescent girls 28 .The prevalence of thinness was signifi cantly higher in the early age groups in most of the cases, but decreased with age.A similar trend has been reported by Sahabuddin et al. who opined that the prevalence of thinness decreased with age 25 .
In the present study, it was also observed that the overall overweight among adolescents was 3.22% which was same as compared to the data (3.6%) reported by Patanwar et al. among Kurmi adolescent girls from Raipur city, Chha sgarh, India 29 .A similar fi nding (3.9%) also reported by Sachan et al. from Lucknow, UP, India 28 .Low prevalence of overweight were also reported among rural adolescents from Assam (0.3%) 30 and rural Wardha (2.0%) 31 .While Subramanyam et al. 32 and Mehta et al. 33 in their study, reported a prevalence of overweight was 9.6% and 15.2% respec vely, which was higher than the present result and could be incriminated to the affl uent society.
The present study and other previous study has focused that under nutri on in terms of underweight, stun ng and thinness among adolescent girls is a major health problem at rural areas of Nepal.It is also men oned that under nutri on is an indicator of acute or chronic nutri on depriva on 9 .Further studies on larger sample are required to determine the most appropriate reference to measure the nutri onal status among adolescents.Hence, the special emphases are needed to formulate various developmental and healthcare programs for rural communi es to prevent under nutri on; and also need health educa on to improve the health and nutri onal status.There is an urgent need to intensify eff orts to improve the nutri onal profi le of children to op mize human resource development.

Conclusion
The present study concludes the high rate of prevalence of underweight; stun ng and thinness but low prevalence of overweight among adolescent girls in rural community of Kavre district and these refl ect major health problems among them.

Acknowledgements:
The authors would like to acknowledge the Principals of all schools providing permission to carry out the study.The authors are also acknowledged with deep gra tude for the coopera on and endurance of the students who par cipated in this study.The authors also thank to Mr. Binod Timalsina for his contribu on during the data interpreta on of this study.

Table 1 :
Mean, SD, Minimum and Maximum of Height, Weight and BMI according to age

Table 2 :
Prevalence of underweight (weight for age) among the adolescent girls

Table 3 :
Prevalence of stun ng (height for age) among the adolescent girls

Table 4 :
Prevalence of thinness (BMI for age) among the adolescent girls