2.

REVIEW OF LITERATURE

The literature pertaining to the study on the Nutritional Awareness, Dietary Habits

and Health Status of College Girls is reviewed under the following headings:

1. Status of women in India

2. Gender Discrimination in Health and Nutrition

3. Health and Nutritional status of women in India

4. Determinants of Womens Health

5. Growth and Development of Humans

6. Dietary pattern of Adolescent girls

7. Assessment of Nutritional status

8. Nutrition Education

2.1 Status of women in India

India, in the millennium set goals to minimize women health problems after the ICPD

(International Conference on Population and Development, 1994, Cairo). As far as women health

is concerned, mainly in the developing countries, including India, the situation is very depressing

(Kalita et al., 2006).

Culturally, in India, women are expected to be subservient to the male members of the

household and work for the latters happiness and satisfaction. Further, society expects them to

play a very important role in providing informal health care, their health habits, prepare and

select the familys food, and care for the young, the sick, the aged and the disabled. Generally,

32
the term woman is used to refer to a female of at least fifteen years of age. But, health of a

woman, thus defined, is intertwined with her health related experiences in the early years of life.

According to the National Population Policy, (2000), The complex socio-cultural determinants

of womens health and nutrition have cumulative effects over a lifetime. Discriminatory

childcare leads to malnutrition and impaired physical development of the girl child. It also said

that nutrition in early adolescence is crucial to the womans well being and through her, to the

well being of children. Also in India, social, cultural and economic factors continue to inhibit

women from gaining adequate access to even the existing public health facilities. (Chatterjee and

Meera, 1990). This handicap does not just affect women as individuals; it also has an adverse

impact on the health, general well-being and development of the entire family, particularly

children. This statement shows the inherent nature of the society which stand in the way of

women getting adequate health care, the inadequacy of the available health care facilities and the

importance of womens health in deciding the health of other members of the family, particularly

children. Provision of health in the Indian families generally is along the lines of sex, age, status

and role in the family and women generally come at the end of the line. But India is a large

country which harbors a thoroughly heterogeneous group of people in terms of religion, caste,

language, ways of living, economic status, or levels of education. All these separate groups and

their sub-groups have their own cultural values and norms which will have an impact on their

attitude to life in general and health care in particular. Nevertheless, it is felt that womens

position is more or less the same across the board with only degrees of differences

(Mukhopadhyay, 1997).

During the last few decades, industrialization, urbanization, increasing level of education,

awareness of right, wider influence of media and westernization has changed the status and

33
position of women. The present sky rocketing prices resulting in economic tension have aroused

in her a desire to pool in her might in easing the financial and economic constraints of her life.

For this, she has to maintain an equilibrium and balance between home and career. This

changing status of women influences not only their role in society but also affects their

interaction with their children, today; the status of Indian women has totally changed. The

number of educated women including the number of working women is increasing. At present,

women are in a position to compete with men in all walks of life (Bamji, 2005).

2.2. Gender Discrimination in Health and Nutrition

Empirical research conducted by the International Food Policy Research Institute (IFPRI)

and others shows that the low status of women in South Asian countries, compared to other

countries and regions of similar economic development, is partly responsible for low birth

weight and the excessively high levels of childhood under nutrition in the region (P. Svedberg.

2007). The low social status of women deprives them of the ability and the resources needed to

make decisions regarding their childrens health, nutrition, and education, and prevents them

from accessing the services they need to protect their own health, nutrition, and survival. In order

to address the intergenerational transmission of poverty and poor nutrition, it is essential to

rapidly reduce under nutrition rates among the most vulnerable segments of the population-

infants, children, women of reproductive age, and adolescent girls.

Gender inequality is a well-known and still widespread reality in the developing

countries. One of its most noted manifestations is the unnaturally low Juvenile Female Male

Ratio (JFMR) in these areas (Anish Kumar, 2008).According to the FAO mostly women and

children experience hunger as a defining characteristic of their lives. Nearly 96 percentage of

34
those suffering from hunger live in the developing countries with Sub-Saharan Africa (SSA) and

South Asia (SA) the hardest hit (FAO, WFP, 2000).

It is now widely accepted that gender inequality dwells not only outside the household

but centrally within it (Agarwal, 2003). No wonder that the incidence of severe malnutrition is

greater among girls. Though women devote countless hours doing laborious work related to

household food security but at the end of the day that often go unrecognized. The empowerment

of women has a direct impact on the improvement of hunger and the provision of basic needs in

education, health, and income and numerous case studies elaborate on these issues. Extending

from this, female empowerment is especially important for the lives of the most vulnerable

segment of the population children (UNDP, 2003). Gender discrimination begins before birth

and spans the entire life of women the classic Womb to Domb scenario. Such action is

gender inequality in its most extreme form and is certainly not the case everywhere in the world

(Klasen& Wink, 2003). According to Scanlans (2004), Ramachandrans (2005) and Mehrotras

(2006) papers, Percentage of low birth weight infant is essentially an indicator of the nutritional

status of mothers. Small mothers give birth to small babies. Besides, if the weight that mothers

are supposed to put on during pregnancy is lower than what is required for the healthy growth of

the child then the probability of a new born to be of low birth weight infant becomes high.

Babys nutritional status is a direct outcome of the mothers nutritional status. South Asia has the

worst educational indicators relative to men compared to all other regions and it has been

observed that half of worlds malnourished children live in India, Pakistan and Bangladesh

(Mehrotra, 2006).

Recent literature (Marino et al., 2011) has highlighted that nutrition could differently

influence the health of male and female individuals. It is widely accepted that nutrition is not

35
only just a fuel but is the most significant part of the environment that we actually introduce

into our body and eating patterns are a relevant component of the cultural reference models.

The ill effects of food and nutritional insecurity can be linked to the life cycle of an

individual. When a child is weaned from mothers milk to other foods, very commonly the

protein and energy requirements are not met. Due to inappropriate complementary or

supplementary feeding practices, the energy gap widens. This is because for the proper growth

after 6 months of age, the requirement of the extra energy cannot be fulfilled by breast milk

alone. This is displayed as Protein Energy Malnutrition (PEM), which is very common form of

malnutrition. The onset of malnutrition starts from the period between 7-8 months of age and if

not mitigated then effects persist for the whole life. In the existing scenario where we see gender

disparity existing in families, the male child may make up for these nutritional losses while this

cannot be always the case with a girl child8. In rural areas, girls are mostly married off at a lower

age than prescribed by the law and hence also become mothers at a young age. With the

nutritional status of mother herself being inadequate, the birth of a child only adds to low

availability of nutrition for herself. This is a vicious cycle and further deteriorates the nutritional

status of the woman generation after generation (Balgir, 2007).

2.2.1. Gender Impact on Health

Change cannot be forced at personal level; therefore, laws are enacted in the society. All

we can do is to attempt to change the factors that dictate such a choice, by improving the

workable social status accorded to our daughters, through assured schooling, healthcare,

employment opportunities, and substantive legal equality. But even as we do this, we would need

to continue to monitor and punish medical personnel who seek to thrive on one of the most

36
pernicious forms of hate crimes known to modern Indian society - the hate crime called female

feticide. The child sex ratio shows a negative trend and causes serious concern to

anthropologists, population scientists, policy makers and planners. Low sex ratio trend in India is

due to large scale practice of female feticide. Female feticide or sex selective abortion is the

elimination of the female fetus in the womb itself. The decline in child sex ratio may be due to

different factors such as neglect of female children resulting in their higher mortality at younger

ages, female infanticide and female feticide. Female feticide refers to a practice where the female

fetuses are selectively eliminated after prenatal sex determination, thus, avoiding the birth of

girls. High incidence of induced abortion and the sharp decline in the child sex ratio clearly

proves the practice of female feticide (Philipose Pamela, 2006).

Factors Responsible for Female Feticide:

The obsession to have a son

The discrimination against the girl child

The socio-economic and physical insecurity of women

The evil of dowry prevalent in the society

The worry about getting girls married due to the stigma attached to being an unmarried

woman

Easily accessible and affordable procedure for sex determination during pregnancy

Failure of medical ethics

The two-child norm policy of the Government

37
Implications of Declining Sex Ratio in the Population:

Decreasing number of females in the society likely to increase sex related crimes against

women

Lead to increase in social problems like rape, abduction, bride selling, forced polyandry,

etc.

There will be increase of prostitution, sexual exploitation and increase in cases of STD

and HIV/AIDS

Growth in crime against women and cause various physical, physiological and

psychological disorders in women

Health of women is affected as she is forced to go for repeated pregnancies and abortions.

The basic principle is that every woman has a right to the highest attainable standard of

health, to safe reproductive choices, and to high-quality healthcare. We can concentrate on

preventing unsafe abortion, improving treatment related complications, and reducing its

consequences. We should strive to empower women by increasing access to services that

enhance their reproductive and sexual health in a conducive environment by introducing the new

technologies, training, research, and technical assistance:

Support the development of women-centered reproductive health policies,

Improve the quality and sustainability of services,

Ensure the long-term availability of reproductive health technologies, and

Promote womens active involvement in improving health care.

38
 Womens empowerment is the empowerment and development of the family and the

nation. Though data on the impact of environmental degradation and climate change on poor

women is scarce, the womens time burden will increase if drought, floods, erratic rainfall, and

deforestation undermine the supply and quality of natural resources. Many households lack

access to water in or near their premises, women spend as many as 40 billion hours each year

collecting water. The magnitude of wasted human efforts involved in this fetching of water can

be gauged from the fact that women spend so much time in securing such a basic necessity of life

that their efforts are equal to a years worth of labor by the entire Indian workforce (Balgir.R,

2008., Agarwal Anuja, 2008).

2.2.2. Food choice: A gender perspective

The choices people make among foods determine which nutrients enter the body.

However, in modern societies, food is more than mere sustenance. What people choose to eat is

not solely based on their biological needs; their choice also addresses many psychological and/or

emotional issues. After all, a person does not necessarily have to be hungry to eat, does not

always choose his/her most preferred food, and some of the influences in food choice might be

unconscious. Generally speaking, food choice is a complex human behaviour and consequently

is influenced by many interrelating factors ranging from biological

mechanism and genetic profiles to social and cultural factors. Many studies have explored

selected aspects of food choices from an ample variety of disciplines and perspectives (Booth,

1994; Shepherd, 1990, 2005; INRANI, 2012).

Anthropological and sociological work has emphasized the meaning of food and eating in

self and cultural definition (Berbesque, 2009; Counihan, 1999; Murcott, 1983; Vartaniana et al.,

39
2007). This literature indicates that, as mentioned above, the importance of food and eating

extends well beyond a the need of covering physiological needs, playing a role in identity

expression, communication, social interactions, as well as in delineating status and gender roles.

Eating behaviour is therefore likely to be vulnerable to various social influences, including the

desire to respond in a socially-desirable manner (Herman et al., 2003). Studies by Lindeman and

Colleagues (Lindeman &Sirelius, 2001; Lindeman & Stark, 1999, 2000) suggest that food choice

is a means by which one expresses ones own philosophy of life. In addition, the current

emphasis on dieting and slimness in Western cultures promotes norms describing what and

when one should eat, as well as what one should look like. Taken together, these considerations

suggest that what one eats has important implications for social judgments. In addition, social

changes such as the increased participation of women in the workforce lead to reduced time

available for food selection and meal preparation, which further complicates food choice.

Studies conducted in modern western societies report consistent associations between

gender and specific foods, where meat (especially red meat), alcohol, and healthy portion sizes

are associated with masculinity, while vegetables, fruit, fish and sour dairy products (e.g., yogurt,

cottage cheese) are associated with femininity (Jensen & Holm, 1999; Sobal, 2005). The result of

a study conducted on the Hazda, a tribe of human foragers living in Tanzania, also showed a sex

differences in food preferences, with males preferring meat more and females preferring berries

more (Berbesque, 2009).

International Health and Behaviour survey (IHBS) examined a range of health behaviours

in a total of 19298 university students from 23 different countries utilizing a study approach

40
based on a self-report questionnaire (Wardle et al, 2004). In almost all of the 23 countries a

higher percentage of women reported to avoid high fat-foods, to eat fiber-rich foods, to eat fruit

daily.

Studies conducted in Ireland reported that women were generally more prone to make

conscious efforts to try to eat a healthy diet 'most of the time', while men were three times more

likely to 'hardly ever' make such conscious efforts to eat a healthy diet (Kearney et al., 2001;

Hearty et al. 2007). Data from a representative sample of 98733 Canadians (Canadian

Community Health Survey) indicates that gender plays an important role in determining food

choices. Women are more likely than men to choose or avoid foods following to concerns about

health and, accordingly, choose or avoid foods due to their contents (Ree et al. 2008).

2.3. Health and Nutritional status of women in India

Health is regarded as the most crucial aspect of human wellbeing. The health status of a

population is an important indicator reflecting social and economic development as well as the

quality of human life. Improving the health of the general population as well as that of specific

groups (infants and women etc.,) has for long been an important concern for development. The

role of women in the developmental process assumes great significance, as they constitute a

substantial portion of the population. They play variety of roles both within the household as

well as outside the household, most of which often go unacknowledged. The womans ability to

perform these roles, as also her quality of life, is determined by the health status she enjoys.

41
 According to WHO (1992), the right to health is the most basic of all human rights.

The constitution of the WHO asserts that: The enjoyment of the highest attainable standard of

health is one of the fundamental rights of every human being without distinction of race,

religion, and political belief, economic or social condition. However, in developing nations as

well as in the developed world, many women are being denied this basic human right. Although

women generally live longer worldwide but they are more likely than men to experience poor

health (World Bank, 1996). Good health and well-being continue to elude most women. It is a

well-established truth that women face a host of problems throughout their life cycle which are

not only related to physiological changes, but also to their nature of work and working

conditions, their low status in the family and the society; and gender discrimination due to social,

cultural and economic factors operating inside and outside the home. But still, womens health is

probably one of the most inadequately researched areas in international public health. A major

flaw in past efforts has been an almost exclusive focus on women as mothers and child-care

givers rather than on women themselves as a target population of interest. In India also, the

health status of women is an area, which so far has received inadequate attention. In most of the

programs for women in India the underlying reason has always been demographic India has

made considerable progress in social and economic development in recent decades, as

improvements in indicators such as life expectancy, infant mortality, and literacy demonstrate

(Salomon, 2004). However, improvements in womens health have lagged behind gains in other

areas. The poor health of Indian women is a concern on both national and individual levels.

Poor health has repercussions not only for women but also for their infants and other

members of family. Women in poor health are more likely to give birth to low weight infants.

42
They also are less likely to capable to provide food and adequate care to their children. Finally, a

womens health affects the household economic well-being. As a result of poor health, women

will be less productive in the labour force. While women in India face many serious challenges

to their health, it is imperative to focus primarily on five key indices: reproductive health,

violence against women, nutritional status, unequal treatment of girls and boys, and HIV/AIDS

(Ellsberg, 2001).

In India the nutrition and health status of women is abysmally low. The National

Nutrition Monitoring Bureau (NNMB) survey (1990) had done in India shows the womens

calorie requirement after the age of 10 years is not adequately met. This itself indicates whether

women are victims or decision-makers. The poor health status of women in India is mainly due

to patriarchy and other socio-cultural constraints leading to her secondary status at home and

poor health. It is a bitter reality than in India womens health and nutrition is inextricably linked

to social, cultural and economic factors. Addressing the needs of girls and women throughout

their lives- the life cycle approach can improve womens nutritional status. Many nutritional

deficits experienced in infancy and childhood have irreversible consequences, so interventions to

support adequate nutrition from infancy onward directly benefit women later in life

2.4. Determinants of womens health

Health status in influenced by complex biological, social and cultural factors that are

highly interrelated (Figure 3). These factors affect men and women differently. Womens

reproductive biology, combined with their lower socioeconomic status, result in women bearing

the greater burden from unsafe sex-which included both infections and the complications of

unwanted pregnancy (Preker, 1999).

43
 Fig. 3 Determinants of Womens Health and Nutritional Status throughout the Life

Individual Behavior
and Psychological Factors

Biological Womens Health Social and Cultural

Factors and Nutritional Status Influences

Health and
Nutrition Services

Biological and social factors effect womens health throughout their lives and have

cumulative effects. Therefore, it is important to consider the entire life cycle when examining the

causes and consequences of womens poor health. For example, girls who are fed inadequately

during childhood may have stunted growth, leading to higher risks of complications during and

following childbirth. Similarly, sexual abuse during childhood increases the likelihood of mental

depression in later years, and repeated reproductive tract infections can lead to infertility.

2.4.1. Biological determinants

Unlike men, women are subject to risks related to pregnancy and childbearing. Where

fertility is high and basic maternity care is not available, women are particularly vulnerable.

Certain conditions, including hepatitis, anemia, malaria and tuberculosis, can be exacerbated by

pregnancy. For example, the incidence of viral hepatitis for pregnant women is twice as high as

for non-pregnant women and more likely to prove fatal. Complications of pregnancy can also

cause permanent damage, such as uterine prolapse and obstetric fistulae (Khan and Ayesha,

1999).

44
2.4.2. Socio Economic Factors

Poverty underlies the poor health status of developing country populations, and women

represent a disproportionate share of the poor. Furthermore, the cultural and socioeconomic

environment affects womens exposure to disease and injury, their diet, their access to and use of

health services, and the manifestations and consequences of disease. In all regions reproductive

health continues to be worst among the poor. Women in the poorest households have much

higher fertility rates than those in the wealthiest-and far fewer births in the presence of skilled

health professionals, contributing to higher maternal mortality ratios.

Womens disadvantaged social position, which is often related to the economic value

placed on familial roles, helps perpetuate poor health, inadequate diet, early and frequent

pregnancy, and a continued cycle of poverty. For example, women in many parts of the world

receive medical treatment less often when sick, and then only at a more advanced stage of

disease. In countries where women are less educated and have less control over decision-making

and family resources, they are also less apt to recognize health problems or to seek care.

Restrictions in some South Asian and Middle Eastern countries on women traveling alone, or

being treated by male health care providers, inhibit their use of health services.

Womens low socioeconomic status makes them more vulnerable to physical and sexual

abuse and mental depression. Unequal power in sexual relationships exposes women to

unwanted pregnancy as well as STIs. Their low social status has also led to more and more

women in forced prostitution (Leslie, 1991).

45
 Fig 4. Health and Nutrition problems affecting women exclusively or more severely

than men during the life cycle in developing countries

Source: World Bank, 2000. World Development Indicators.

In developing countries, womens health status is changing in response to several

emerging trends. Developing countries are now faced with an unfinished health agenda of

problems such as continuing high maternal mortality ratios and malnutrition, and the new

challenge of an increasing prevalence of chronic diseases such as cardiovascular disease

resulting from an aging population. Socio-medical problems, such as gender-based violence,

are also an increasing source of concern (Murray and Lopez, 1996). More than one-fifth of

the disease burden among women aged 15 to 44 results from reproductive health problems

which can be prevented or treated cost-effectively (Figure 5).

46
 Fig 5.Burden of diseases in females aged 15-44 in developing countries

Tuberculosis 4.9%

Source: Murray and Lopez eds. (1996). The Global Burden of Disease

An estimated 450 million adult women in developing countries are stunted as a result of

Protein-energy malnutrition during childhood and underweight is a common problem among

women in developing countries. More than 50 percent are anemic and about 250 million women

suffer the effects of iodine deficiency, and, although the exact numbers are unknown, millions

are probably blind due to vitamin A deficiency. The highest levels of malnutrition among women

are found in South Asia, where about 60 percent of women suffer from iron deficiency anemia.

This proportion rises to 80 percent among pregnant women in India (Agarwal et al., 2006).

47
 Fig 6. Intergenerational cycle of growth failure

Children of malnourished mother are born with low birth weight, are disadvantaged from

birth, fail to grow normally, and face a higher risk of disease and premature death (Figure 4).

Malnourished mothers also face a higher risk of complications and death during pregnancy and

childbirth. Malnutrition reduces womens productivity, increases their susceptibility to

infections, and contributes to numerous debilitating and fatal conditions (Jamison et al., 1993).

2.5. Growth and Development of Humans

In human being growth and development starts in the embryonic stage and lasts till the

life time. Each stage, it has unique potential. This may include both physical and psychological

development. Psychological development is also based on memory attention concentration etc.

2.5.1. Psychological Development

a. Memory

Memory has been defined as an individual capacity for reproducing or recalling, what has

been learnt and retained, as manifested in some special way or as associated with some bodily

48
process. It is the power of retaining in sub consciousness and of reviewing an impression or an

idea. It is mental power that enables one to retain and to recall through unconscious associative

process, previous experience, sensation impression ideas and concepts of all the information that

has been consciously learnt. If it is in fact the reservoir of all past experiences and knowledge

that may be recollected or received at will (Mosbys, 1993).

b. Types of Memory

Memory may be primary or secondary. Primary memory is the ability to recall facts. Words,

numbers, letters or other information for few seconds to a few minutes at a time are depending

upon individual. For example, it is the memory of the digits in a telephone number that remain

for a short period of time after being looked up in the telephone directory.

Secondary memory is the storage in the brain of information that can be recalled hours,

days, months or years letters. This type of memory has also been called long term, fixed or

permanent memory (Gayton 1987).

Primary, immediate or short term memory has a very short duration and is highly

vulnerable to distraction, requires attention and vigilance to maintain the content. It has duration

of about a minute and a very limited capacity of approximately 5 to 10 items. Whereas the long

term of secondary memory has duration of minutes to weeks and exhibits large storage capacity

than immediate memory (Brid et al, 2001).

c. Attention and Concentration

Although there are several concepts of attention, was defined in term of conscious

awareness and played crucial role in the great theories of consciousness. Wundt described

consciousness as consisting of a clear core or focus and a less clear periphery and considered

49
attention to be the process, by which the items in peripheral consciousness are brought into focus

of the consciousness. Attention transforms perception into the focus of consciousness, and

imparts clarity. William James describes attention as a process of selection among items not yet

in consciousness. James further stated that, attention is a necessary condition for conscious

clearness. He emphasized the importance of attention in the relationship between an organism

and his environment (Eysenck et at 1972).

While concentration is defined as a special form of attention, it is the disciplined

organization and fixation of subjective attention and shaping of matter containing meaning and

value. Concentration is a conscious restriction of the field of attention focusing motive forces by

determination and restricting or army for an excellent well planned performed and finding

functional links to develop ideas or thoughts. Concentration is dependent on physiological

factors such as fatigue, state of hormonal balance and sound functioning of nervous system, as

well as on mental and other factors, such as general outlook and condition. In Pavlov ion theory,

concentration refers to the limitation of certain neuronal process to a certain area of cortex.

Parlov speaks in this connection of law of concentration of excitation, the irradiated excitation

gathers along certain lines and towards certain foci (Eysenck et al 1972).

Cognitive testing assesses an individual thinking skills, specific area examined during

cognitive testing indicate Attention - Concentration, memory, Abstract thinking, problem

solving, Judgment, Language skills, Ability to interpret information fun senses such as hearing,

vision, touch, ability to control fine motor skills in the hands Intelligence, Academic skills and

emotional functioning.

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2.5.2. Physical Growth

Physical growth is no longer a process of increasing number of cells and body size.

Rather, it is the vital growing of new cells to replace old ones. Then at older ages, physical

declines gradually and individual vigor reflects the health status of following years.

The terms of adolescent has been defined by WHO as a period of life where a series of

varied rapid and extensive change occur. It is a clinical phase to catch up growth in life cycle of

girls after infancy. There are many physical changes that occur at the stage. These girls attain

menarche may develop iron deficiency anemia because of rapid growth and on set of

menstruation and under nutrition (Vijiyalakshmi et al 2000).

Adolescent is a period of profound and significant growth. During this period 35percent

of adult weight and 11-18percent of adult height is acquired, the growth spurt in girls occurs at

approximately 11 - 14 yrs. Less than 38 Kg of body weight is at risk for developing low birth

weight babies (Priti Tanya et al 1998).

Chronic under nutrition can also delay sexual maturity and adolescent growth spurt. This

delay can exaggerate differences in age of sexual maturation and growth spurt between under

nourished survey population and well-nourished reference population (Ahamed 1998).

Regular physical activity, fitness exercise is critically important for health and well being

of people of all adolescents. Research has demonstrated that virtually adolescents benefit from

regular physical activities, whether they participate in vigorous exercise or some type of

moderate health enhancing physical Activity. (Buller et al, 1998)

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2.5.3. Significance of Adolescence

Chatterjee (2005) pointed out that adolescence is often defined as a transient stage,

between childhood and adulthood and a formative period during which many life patterns are

learnt and established. it is a crucial and dynamic time for young people as they begin to develop

their capacity for empathy, abstract thinking and future time perspective.

Adolescence is the most crucial period of physical growth in the lifecycle. Adolescence is

particularly unique period in life because it is a period of dynamic changes physical, sexual,

psychological and cognitive development (Tatia et al., 2003). Adolescents are one of the most

important groups of any society because they have an influential effect on the future socio

economic and cultural status of the society.

The term adolescence comes from the Latin word Adolescere which means to grow to

maturity (Jaya and Rani, 2001). It is the period of transition from childhood to adulthood. This

transition involves biological, social and psychological changes. This is the formative period of

life when maximum amount of physical, psychological and behavioral changes take place

(Chaundhary&Khage, 2008 and Srilakshmi, 2006).

Adolescence means to emerge or achieve identity (Prabhakaran, 2003). Adolescence is

viewed as a transitional state, during which youths begin to separate themselves from their

parents but still lack a clearly defined role in society. It is generally regarded as an emotionally

intense and often stressful period (http//www.answers.com/ topic/ adolescence #xzzliekeuzzq).

Adolescent growth and development is closely linked to the diet they receive during

childhood and adolescence. They represent a window of opportunity to prepare nutritionally for a

52
healthy adult life. It may also be a time period to shape and consolidate a healthy eating and life

style behaviors, thereby preventing or postponing the onset of nutrition related to the chronic

diseases in the adulthood.

Hall described adolescence as a period of storm and stress. It is the unique dynamic

period in life because it is the second and last growth spurt in the life of human beings (Mahan

and Stump. 2004).

An adolescent is any person between the ages of 10 and 19 years. This is the phase of life

when important changes occur in which a person is no longer a child in different dimensions of

life, such as physical, biological, economic growth and maturity (WHO, 2007). According to

Debra and Krummel, (1996) & Stange and Story, (2005), adolescent period is divided into three

phase; early, middle, and late. Early adolescence (12-14 years) is characterized by major physical

changes. Middle adolescence (15-17 years) is the prime time for emotional development and

growth. Self-image issues are most relevant at this period. The last phase of adolescence (18-21

years) blends easily into young adulthood. This is the phase of life when important changes

occur in which a person is no longer a child in different dimensions of life, such as physical,

biological, economic growth and maturity.

According to Cole (1997) a long period of puberty was recognized as important from

early times. Adolescence starts from about 12 years of age and continues through 18 years. It

trends from sexual maturity until the age when independence from adult authority is legally

assured. Because there are such marked individual differences in the ages at which sexual

maturity occurs. It is difficult to do more than mark off the end of childhood and the beginning

of adolescence by using average ages. Society recognizes the individual as mature at the age of

53
18 /21 years as the legal age of maturity and gives her/ him at this age the right to vote and to be

responsible for her/his own behavior. Adjustment at the adolescent stage has an importance of

vast magnitude.

Adolescence is the period accelerated with physical, biochemical and emotional

development characterized by rapid increase in height, weight, hormonal change resulting in

sexual, maturation and causing wide swing of emotion (Guthrie, 1997).

Chatterjee (2000) pointed out that adolescence is a formative period during which many

life patterns are learnt and established. Owing to rapid growth, the demand for the nutrients

increases in the adolescents especially in girls. Unless there is a good eating habit during

Childhood, there is a change of getting into serious health problems in adolescence (Roth et al.,

2000).

Adolescence is one of the most challenging periods in human development (Spear, 2004).

It is a unique period in life because of dynamic changes in sexual, physical and cognitive

development (Tatia and Taneja, 2003). Adolescence stands seconds to infancy in the nutritional

requirements necessary for normal growth and development (Sizer and Whitney, 2000). Dietary

allowances of certain nutrients vitamins and minerals influence and predict an adolescents

behavior and growth. It is essential to consume a healthy diet.

During adolescence an individual total nutrient needs their highest point in their life

cycle. Healthy eating is important as this stage of life not only because of the nutritional needs

but also because habits formed early in ones life will most likely carry into adulthood (Latha,

2006).

54
 According to Rao (2006) adolescence is an important time for development of positive

health behaviors and sound nutritional practices because the individual is able to understand the

potential consequences of behavior and make choices accordingly. The food habits of

adolescence are important not only in ensuring an adequate diet to support growth and

development, but also in developing lifelong patterns for maintenance of health (Rao. 2006). In

the opinion of Espy, (2001), the food choices made by adolescents affect not only their growth

and development during puberty but also their reproductive capacity and susceptibility to

degenerative when they become adult.

Roberts and Williams, (2000) state that adolescence is the term applied to the period of

maturation of both mind and body. It is a crucial and dynamic time for young people as they

begin to develop their capacity for empathy, abstract thinking and future time perspective

(Chatterjee, 2005). This period is considered to be a nutritionally vulnerable period because of

the increase needs for all nutrition and the change in lifestyle and food habits that affect nutrient

intake (Parimalavalli and Sathiya, 2008).

The adolescence period is characterized by heavy demands of calories, proteins and other

nutrients. He/ She tend to consume more carbohydrate foods. Due to rapid growth and

maturation of new tissues and other widespread of developmental changes the nutritional needs

are more. The demand for nutrients like protein, energy, vitamins and minerals are increased

during this period (Baba et al., 2002).

Adolescence period is the second and last growth spurt in life of human beings. It

provides a chance to improve the nutritional status in case there had been a deficiency during

childhood (Food and Nutrition Board, 2003). Proper nutritional care during adolescence helps to

55
promote and maintain their overall development. The adolescents should be provided with good

nutrition and protected from deficiency disease and infections (Devi.T and Amirthagowari,

2007). Surveys of Nutrients intake have shown in females because of menstrual blood loss,

which averages about 20 mg of iron per mouth, but may be as high as 58 mg in some individuals.

In spite of increased iron needs many adolescents, particularly females, may have iron intakes of

only 10-11 mg/day of total iron, resulting in approximately 1 mg of absorbed iron. About three

fourths of adolescent females do not meet dietary iron requirements, compared to 17percent of

males says Beard (2001).

Shams et al., (2010) conducted study of the prevalence of iron deficiency and iron

deficiency anemia in 295 female students. It was reported that 40.9 percent were having iron

deficiency anemia.

Kotecha et al., (2004) conducted a study on anaemia prevalence and haemoglobin level

of the school girls. The sample consisted of 2,860 adolescent girls aged between 12-19 years.

The study revealed that 53.2 percent were found anaemic. Reduction of 20.5 percent in

prevalence anaemia was found after the initiation of the programme. The haemoglobin level was

raised and severe anaemia prevalence was reduced from 1.6 percent to 0.5 per cent. 32.7 percent

of the girls consumed vitamin C rich fruits along with snacks or food. They have proved that

the consumption of vitamin C rich foods improved among adolescent girls, yet greater effort

would be required promote consumption of iron rich foods for long-term gains in iron status of

the girls.

Bopape, et.al, (2008) conducted a study on the prevalence of anemia. The sample

consisted of 123 teenagers between the age group of 12 to 21 years. The study revealed that 57

56
percent were having iron deficiency anaemia. They have suggested that these teenagers need

nutrition so that they will be able to choose nutritious food, especially at a critical stage such as

pregnancy.

In a study to determine the prevalence of anemia among 209 adolescent Nepalese girls by

Shah and Gupta (2002) showed that there was prevalence of anemia found among 68.8 percent

of the adolescents.

Baral and Onta, (2009) conducted a study on the prevalence of anemia among 308

adolescents. The study indicated that the prevalence of anemia among adolescent population was

65.6 percent that adolescents are likely to obtain less vitamin A, vitamin B6, folate,

riboflavin, iron, calcium and zinc then recommended (Alimo, 1994). Gupta et al., (2001),

revealed that diet of Indian adolescent population is inadequate in iron, protein, calcium and in

overall calories. Adolescents may need more calcium. Calcium plays a vital role in the growth

and maintenance of strong bones, gums and teeth (Yasodhara and Pathak, 2001).

With profound growth, adolescents demand for energy, protein and micronutrient

increases. Protein, iron and calcium play important role in the adolescents diet. Iron has a

significant function of hemoglobin and myoglobin formation with protein (Ferrari et al., 2011).

The iron demands increase during adolescence due to the growth spurt with expanding blood

volume and increasing muscle mass. The onset of menstruation in adolescent girls adds to the

iron requirements (Eskeland et al., 1999). This indicated that the diet of adolescents, especially

of girls is deficient in micronutrients iron and calcium (Totega and Singh, 2002).

2.6. Dietary Pattern of Adolescent Girls

57
 Adolescent girls need more calories and nutrients that at any time because body mass

almost doubles. Adolescents are particularly vulnerable to even moderate levels of energy

restriction. Despite the availability of recommended age specific dietary guidelines for

adolescents, it can be difficult to estimate energy and nutrient needs (www.adolescentgirls.htm).

During adolescence, protein needs, like those for energy, correlates more loosely with the

growth pattern than with chronological age (Mahan et al., 2004). For most adolescence, eating to

satisfy appetite offers a reasonably sensitive indicator of energy needs. Protein needs represent

12 14 percent of energy intake. The protein intake usually exceeds 1 g / kg body weight

(Srilakshmi, 2006).

Adequate amounts nutrients such as calcium and iron are often not present in an

adolescent diet (www.nutrition.htm). Calcium intake is essential for development of strong dense

bones and teeth during the adolescence (www.teenshealth.com).

Yasodhara (2001) reported that adolescents may need more calcium than they get from

their diet. The teeth and the bones contain the majority of the body calcium about 99 percent

body tissues, blood and other body fluids contain the remaining calcium (1 percent). Inadequate

calcium intake during adolescence and young adulthood puts individuals at risk for developing

osteoporosis later in life.

In order to get the required 1,200 milligrams of calcium, teens are encouraged to

consume there to four serving of calcium rich foods each day. Good sources include milk,

yoghurt, cheese, calcium fortified juices and calcium fortified cereals (www.teenhealth.com).

58
 As adolescents gain muscle mass, more iron is needed to help their new muscle cells

obtain oxygen for energy. A deficiency of iron causes anemia, which leads to fatigue, confusion

and weakness (www.education.com).

Gupta (2001) revealed that diet of Indian adolescent population is inadequate in iron,

protein, calcium and in all over calories. The poor nutritional status of adolescents, especially

girls had important implications in terms of physical work capacity and adverse reproductive

outcomes.

Micronutrients play an important role in growth and health of adolescents. Inadequate

fruit and vegetable consumption has been linked to certain types of cancer and other diseases.

National recommendations support increased consumption of fruits and vegetables because of

their contributions of vitamins, minerals and phytonutrients. The recommendation is to eat five

servings of fruits and vegetables per day (Mahan et al., 2004)

Adolescents 16 to 18 years old are the least likely age group to meet the age 5 plus

level of fiber intake, 77 percent of boys and 89 percent of girls less than this amount (Lutz and

Przytulski, 1997).

2.6.1. Eating Behaviour of Adolescent Girls

Food behavior is an individuals response to stimuli related to the selection, procurement,

distribution, manipulation, storage, consumption and disposal of food (Bass et al., 1979).

a. Family

The adolescent may become unwilling to accept the parents world as a given,

particularly if the parents ideas are not logically founded. Parents may be in for a challenge and

59
an argument if they insist that their children need to eat breakfast daily if the parents themselves

do not (Steinberg, 1980).

Family eating practices are among the most important influences, both positive and

negative, on the food habits of adolescents. Family disorganization that leaves teens on their own

with respect to eating fosters poor eating habits. Families eat best when they eat together in a

relaxed and loving atmosphere and when mealtime conversation is pleasant (Haugen, 1981).

b. Peer Group

The family continues to have an impact during adolescence, there is a shift in orientation

and identification from parents to peers and peers become a pivotal force that may exert even

more influence over behavior than parents. It appears, however that the greater the antagonism

and the emotional distance from the parents, the greater the need to be part of the peer group.

Thus adolescents with poor parental relationships will be more susceptible to peer group control

and influence over behaviors. (Muuss,1980).

A study of adolescents found that adolescents gave these major reasons for not drinking

milk: It is a food for babies and children; it makes the (adolescent girls) fat and their peers do not

drink it because soft drinks were considered the appropriate social drink with the peers (John et

al., 1959).

c. Media

The role of mass media in influencing food beliefs, food attitudes, and eating patterns is

well acknowledged (Man off, 1973).

60
 In the last 15 years media, especially advertising has significantly influenced the

adolescents dietary pattern. Various forms of media especially television has had the greatest

impact on adolescents eating habits. It is estimated than children between the ages of 6 and 16

watch approximately 24 hours of television per week or an average of 3 hours every day.

Even they reach 17 and 18 years of age, adolescents still watch approximately 17 hours per

week or an average of 2 hours every day. During this time, they are exposed to both implicit

and explicit messages related to food, eating behavior, and ideal body image through not only

television commercials but also program content (Ruben, 1977).

Television presents viewers with two sets of conflicting messages. One suggests that we

eat in ways almost guaranteed to make us fat; the other suggests that we strive to remain slim

(Kaufman, 1980).

d. Food Preferences

Food preferences are formed as a result of the complex interaction of many factors in an

individuals environment. These preferences play a critical role in influencing food choices and

consumption.

Garton and Bass (1974) found foods preferred by deaf adolescents to be similar to those

preferred by hearing adolescents. This conformity reflects the influence of the mass media on

food habits. The national medias role in shaping and reinforcing the uniformity of food

preferences in our nations youth should not be underestimated.

e. Fast Foods

61
 The number of fast food restaurants has mushroomed in the last decade. Ten years ago

there were approximately 30,000 fast food outlets in the United States. Today there are almost

five times as many (Consumer Reports, 1979).

In 1978 fast food sales amounted to over $19 billion. The advent of fast food

restaurants and their rapidly continuing growth undoubtedly has had not only a great impact on

the American diet as a whole but also on the teenagers diet (Van dress, 1980).

f. Irregular Meals

Meal skipping and eating irregularly are common during adolescence and are especially

prevalent during middle and late adolescence. Numerous studies have documented the fact that

adolescents are chronic meal skippers (Greger et al., 1979)

The meals missed most often by adolescents are breakfast and lunch. Breakfast is

frequently neglected and is omitted more by teens and young adults than by any other age group

in the population (Brennan et al., 1981).

g. Snacking

There have been several noticeable changes in the food consumption, eating behaviors

and meal patterns of Americans since the beginning of the twentieth century. One such pattern

change that is characteristic of a different life style and reflects a more casual eating pattern is

increase snacking (Gifft et al., 1972).

Another study indicated that 12-16 year olds nutrient requirements exceed their RDA per

100 kcal for protein, riboflavin and vitamin C through between meal foods. But vitamin A,

calcium and iron levels were low.

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2.6.2. Nutritional status of Adolescence

A study on the nutritional status of adolescents in rural areas of Wardha, received that the

mean body mass index (BMI) for age was used for classifying the nutritional status with CDC

2000 reference overall 53.8percent of the adolescents were thin. 44percent were normal and

2.2percent were overweight. The mean body mass index for boys and girls was 16.88 and 15.54

respectively. The prevalence of thinness was significantly higher in early adolescent girls lower

education and lower economic status. Majority of the adolescents in this study area are thin and

only 2.2percent were overweight (Guptta et al., 2000).

A study on the seasonal variation in nutritional status of adolescent girls was carried in

between June 2001 to May 2002. 80 girls were selected from the rural areas of Dharwad

(Karnataka). The nutritional status of the subjects was assessed by anthropometry, Clinical and

biochemical method, and dietary intake. The frequency of consumption of foods rich in blood

forming nutrients by the subjects was higher during rainy and winter season compared to

summer. Irrespective of locality, the selected subjects recorded higher values for height, weight,

waist and hip circumference during winter followed by a lower value for rainy and summer

season. The adolescent had inadequate intake of energy and blood forming nutrients compared to

ICMR recommendations in all the seasons (Deepa et al., 2004). Irrespective of locality subjects

recorded higher mean hemoglobin level during winter and rainy season compared to summer

compared to summer (Bharati et. al., 2002).

A study on the diet and nutritional status of adolescent tribal population constitutes about

8 percent of the total population in India. They are particularly vulnerable to under nutrition,

because of their geographical isolation, socio-economic disadvantage and inadequate health

63
facilities. A total of 12,789 adolescents (10-17 yrs) were included for the analysis. About 63

percent of adolescent boys and 42 percent of girls were undernourished. A significant association

between under nutrition and socio-economic parameters like type of family, size of land holding

and occupation of head of household was observed (Laxmaiah et al., 1999).

A study on the nutritional status of 270 adolescent rural girls of Varanasi District showed

that the average hemoglobin of adolescent girls was 12.44 1.29 gm / d1. 30.74percent of the

study subjects were anemic. Average hemoglobin level of menstruating girls was significantly

more than that of non-menstruating girls (Choudhary et al., 2003).

A study on the current diet and nutritional status of rural adolescent girls in India

revealed that the major occupation of the heads of households surveyed was agriculture. The

prevalence of under nutrition is higher in boys than in girls. The extent of stunting was higher

among adolescents belonging to the schedule caste community. About 70 percent of adolescents

consumed more than 70 percent of RDA for energy. The intakes of micronutrients such as

vitamin A and riboflavin were usually inadequate (Venkaiah et al., 1997)

2.6.3. Nutritional Needs during Adolescence

Nutritional needs of adolescents correlate closely with biological maturation and are

extensively reviewed elsewhere in affluent countries. The age at physical maturation occurs in

determined primarily by genetics. Males mature two years later than females, although

differences of several years are seen among those of the same sex. Factors such as malnutrition

and disease may delay the onset of puberty (Carruth, 1990).

Nutritional needs of males and females of the same age differ little in childhood but

diverge after the onset of the pubertal growth spurt. After puberty, differences in nutrient needs

64
persist. The reasons for sex differences in nutrient recommendations after the age of 10 include

the earlier maturation of females, considerable variability in the age of puberty within each sex

and variations in the age of puberty within each sex and variations in physiological needs for

some nutrients by sex and biological age. These differences become particularly striking in later

adolescence because of sex related differences in body composition and functions (Gong et al.,

1988).

Appropriate weight for adolescents is more difficult to establish because sexual maturity

varies, especially early in adolescence. Therefore chronological age based standards are not a

good guide (Cachera, 1993).A better approach is to use body mass index (BMI), which is

calculated from weight in kilograms divided by height in meters squared. Such standards are

helpful for evaluating over and underweight in adolescents. BMI is well correlated with

subcutaneous and total body fat in adolescents. Individuals with a BMI > 95th percentile for age

and sex or whose BMI is > 30 are classified as overweight, and those < 5th percentile as

underweight (Dietz et al., 1991).

At adolescence, growth rates are greater than at any other time of life, except early

infancy. In most girls the growth spurt begins between the age 10 and 13, in boys between 12

and 15 years. In both cases rapid growth takes place over a period of 3 years. Girls gain lean

tissue, with increase of 30 cm in height and 30 kg in weight. In boys, there is loss of fat and gain

in lean tissue, with increases of 30 cm in height and 30 kg in weight (Arnold et al., 1997).

With the onset of adolescence, needs for all nutrients become greater than at any other

time of life except during pregnancy and lactation. The need during iron is especially great to

support menstruation in girls and to develop lean body mass in boys (Sizer et al.).Because of

65
their growing and developing bodies, adolescents need more energy, vitamins, and protein than

be school age child or the adult (Lutz and Przytulski, 1997).

2.6.4. Nutrition Related disorders Among Adolescent Girls

2.6.4.1. Eating Disorders among Adolescent Girls

Adolescent girls perceived their diets in the light of appearance and body shape while

boys are more concerned by fitness and general well being (Srilakshmi, 2005).Abnormal

behaviors related food and eating may include starving, vomiting, laxative abuse or excessive

exercise accompanied by unrealistic ideas about foods, a distorted body image, psychological

and developmental abnormalities (Kathleen et al., 2004).

2.6.4.2. Anorexia Nervosa

Anorexia nervosa is considered the flip side of the weight management coin. It usually

affects achievement oriented, affluent girls, although the problem now crosses socio economic

and sexual barriers (Srilakshmi, 2000).

This self induced starvation is often attributed to an obsession to attaining a slim figure

a desire that goes so far as to result in self starvation, emaciation and serious health problems,

including amenorrhoea. It is a state of emaciation that has been brought on by voluntary

starvation (Truswell et al., 1991).an extreme form of this starvation is called anorexia nervosa.

They use tremendous discipline to strictly avoid the intake of food and deny hunger. They

religiously follow exercise regimen to lose weight. Some even take laxative which hastens the

66
passage of food from their system if they feel they have taken more than that can be burnt with

exercise schedule (Udipi, 2003).

A moderate concern about weight is understandable and possibly even beneficial

provided it does not cause diets to be deficiency on essential nutrients or lead to anorexia nervosa

(Carolynn and Ruth, 1998).

Adolescents with anorexia usually experience amennorrhoea and sometimes fatal

electrolyte imbalances. Treatment for anorexia requires psychiatric as well as nutritional

management (Srilakshmi, 1993).

2.6.4.3. Bulimia

Eating disorder seen in adolescents who are in more fear of becoming fat is bulimia or

bulimia nervosa, characterized by recurring binge eating sometimes followed by self

inducing vomiting or purging (Udipi,2003).

A related phenomenon known as gorge and purge or bulimia is seen among

adolescents. These individuals consume enormous quantities of food and they immediately

induce vomiting or take laxatives to purge themselves of the food. Bulimia primarily is

psychological in origin and it has nutritional consequences (Srilakshmi, 1999).

2.6.4.4. Compulsive Eating

Eating disorder in which individuals consume large amount of food in shame and

depression after eating at one time vomit it was known as Compulsive Eating (Srilakshmi,

2000).

2.6.4.5. Obesity

67
 Studies have shown people who eat out more numbers times are susceptible for obesity.

Skipping meals at home and consuming foods that are junk also contribute to overweight.

Excessive intake of calories, it will be the less often the cause than lack of exercise. Concern

about personal appearance may take the adolescent more reluctant to participate in activities like

dance or sports that control weight. Other causes of obesity may be family habits, emotional

stress and hormonal imbalance (Srilakshmi, 2005).

A study on the prevalence of nutritional anemia among adolescent girls in rural Wardha

was carried out in four villages of Kasturba Rural Health Training Centre, Ranji. Relevant

information was collected with anthropometric measurements and hemoglobin estimation. The

prevalence of anemia was found to be 59.8percent in univariate analysis, low socio economic

status, low iron intake, vegetarian diet, history of worm infestation and history of excessive

menstrual bleeding showed significant association with anemia. Multivariate logistic regression

analysis suggested that strongest predictor of anemia was vegetarian diet followed by history of

excessive menstrual bleeding, where iron intake was <14 mg followed by 14-20 mg and history

of worm infestation. However, age, education, socio economic status, BMI and status of

menarche did not contribute significantly (Kaur et al., 2000).

In a study on the prevalence of anemia and serum ferritin status was studied among 1120

apparently healthy adolescents (12 to 18 years) sampled from 11 cities and 2 rural schools in

Chandigarh. All the boys and the girls were subjected to anthropometric measurements and

biochemical examination. The overall prevalence of anemia calculated as per WHO guidelines

was significantly higher among girls as compared to boys. Anemia was observed more in rural as

compared to urban adolescents. Iron stores estimated by serum ferritin in 183 subjects were

68
deficient in 81.7percent and 41.6percent of the adolescent girls and boys, respectively

(Basu et al., 2004).

A study was conducted on the prevalence of anemia among adolescents Egypt. Blood

samples were collected from 1980 adolescent for hemoglobin estimation. The overall prevalence

of anemia was 46.6percent most of which was mild or moderate with severe cases less than

1.0percent of the sample. A significant inverse relationship was observed between the level of

anemia and age, socioeconomic level, and educational level. Anemia was more prevalent in rural

areas and in upper (southern) Egypt. Anemia is a major public health problem among Egyptian

adolescents and wide scale public health education is warranted (Sallam et al., 2000).

A study on iron deficiency and cognitive achievement among school aged children and

adolescents in the United States 6 to 16 year old children was determined by the iron status

including transferring saturation, free erythrocyte protoporphyrin and serum ferritin. Children

were considered iron-deficient if any two of these values were abnormal for age and gender and

standard hemoglobin values were used to detect anemia. Among the 5398 children in the sample

3percent were iron deficient. The prevalence of iron deficiency was highest among adolescent

girls. Lower standards scores in mathematics was observed among iron deficient school aged

children and adolescents (Auinger et al., 2000).

A study on the prevalence and severity of micronutrient deficiencies among 945

adolescents of age 12-19percent years was performed. The prevalence of anemia was

49.5percent in males and 58.1percent in females. In anemic adolescents 30.2percent of males and

47.8percent females were iron deficient. Folate deficiency was found in 54.6percent and 52.55 of

boys and girls respectively whereas zinc deficiency occurred in 51.55 and 58.3percent anemic

69
boys and girls a 1.5percent and 1.6 fold for being stunted and underweight. The relative risks of

having 1.8percent of iron deficient subject had significant risk of being deficient in folate and

1.7percent of being deficient in zinc. Zinc deficient subject had a risk of 1.3 being iron deficient

subjects had a risk of 1.3 being iron deficient and 1.2 of being folate deficient. Micronutrient

deficiencies are prevalent in Srilankan adolescents (Steven et al., 2006).

A study on the prevalence of selected micronutrient deficiencies was done in anemic

adolescent girls in rural Bangladesh. Three hundred and ten adolescents aged 14-18 years from

eight schools participated in the study, parents were asked about their socio economic conditions.

Anthropometric data and blood sample were collected 28percent of the girls had depleted iron

stores, 89percent had vitamin B2 and 7percent had vitamins A and C deficiency was very low, a

significant proportion had low vitamin A and vitamin C status (Ahmed et al., 2007).

A study on the prevalence of vitamin D deficiency and to study associated factors in

adolescent girls in Beijing was conducted. A random sample of 1248 Beijing girls aged 12-14

years were assessed for their nutrient intakes, ultraviolet light exposure, anthropometric

characteristics, physical activity, signs and symptoms of rickets, and plasma concentrations of

25- hydroxyl vitamin D, 1,25-dihydroxyvitamin D and calcium. X-rays of the hand and wrist

were taken. The prevalence of vitamin D and calcium deficiency was 9.4percent in winter. The

prevalence of subclinical vitamin D deficiency was 45.2percent in winter and 6.7percent in

summer. Low plasma 25-hydroxyvitamin D concentration in winter was the main risk factor of

vitamin D deficiency in winter (Trube et al., 2001).

2.6.5. Iron Deficiency Disorder

70
 Nutritional anaemia due to iron deficiency is global problem and it affects more than a

billion people in the entire world. In the developing world alone, 370 million women suffer from

anaemia (Vijayaraghavan, 2007). Adolescents are vulnerable to iron deficiency because of

increased iron requirements related to rapid growth. After menarche, iron needs continue to be

remaining high. Sharma et al., (2000) in their study on 705 adolescent girls indicated that 61.9

percent of the adolescence had <12g/d1 Heamoglobin and were anaemic. Sidhu et al., (2005)

conducted a study on prevalence of anaemia among 265 adolescents Girls in Punjab. The sample

consisted of 265 adolescents girls. The study showed that 70.57 percent adolescents were

affected with various grades of anaemic condition. 30.57 percent girls being mildly anaemic and

27.17 percent moderately anaemic and 12.83 percent suffered from severe anaemia.

Kundu et al., (2001) conducted a survey on 811 adolescent girls with the age group of 10-

19 years, in Maharashtra to improve their iron status by enhancing the diet. The study revealed

that 58 were anemic (Hb<12gm/dl) and 1.3 percent severely anemic (Hb<7gm/dl). They have

suggested that the improvement in the dietary behaviors can improve iron status among the

adolescent girls.

Deegan et al., (2003) conducted a study on assessment on iron status of adolescents. The

sample consisted of 396 healthy adolescents. Study revealed that 6 ercent of females were having

iron deficiency anaemia. Shivaramakrishna et al., (2011) conducted a study on assessment on

nutritional status on 230 adolescents girls Kolar district. The result showed that 34.8 percent of

the adolescents were suffering from iron deficiency anaemia.

Trivedi and Palta, (2007) conducted a study on the prevalence of anaemia and impact of

iron supplementation on 360 anaemic adolescent school girls in Raipur City. The study revealed

71
that supplementation of iron improved the heamoglobin level of anaemic adolescent girls.Mary

and Selvi (2011) says in study on lotus stem to alleviate anaemia that the supplementation of

lotus stem powder along with vitamin C has reduced the levelof total iron binding capacity and

increased the hemoglobin level among the anaemic adolescent girls.

Siddharam et al., (2011) conducted a study on the prevalence of anemia among

adolescent girls. The sample consisted of 314 adolescent girls. The study showed that adolescent

girls were suffering from mild anemia (40.1percent), moderate anemia (54.92percent) and severe

anemia (4.92percent). A study on lotus stem to alleviate anaemia revealed that the

supplementation of lotus stem powder along with vitamin C has reduced total binding capacity

level and increased the hemoglobin level among the anaemic adolescent girls (Siddharam et al.,

2011).

Verma et al., (2004) conducted a study to assess the magnitude of anaemia in school

going, pre-adolescent and adolescent girls along with associated demographic variables. The

sample consisted of 1295 selected girls within the age group of 6-18 years. The study indicated

that the prevalence of anaemia (Hb<12gm/d1) was 81.8 percent.

Prkash et al., (2005) conducted a study on the nutritional anemia in a adolescents

students. The sample consisted of 1646 boys and girls with the age group of 11-8 years. Study

revealed that the overall prevalence of anemia was found to be 81.3 percent.

Gawarika et al., (2006) conducted a study on the prevalence of anaemia among 914

adolescent girls in M.P. the ages of the adolescent girls from 10.5-18 years. The prevalence of

anaemia was found in 96.5percent. They have suggested that higher prevalence in this age group

72
may be due to menstruation effect. Low intake of dietary pattern combined with continued blood

loss with each menstrual cycle may be the cause of higher prevalence in this age group.

Goyle and Prakash, (2004) designed an intervention study on iron status of 109

adolescent girls studying in a government school Jaipur city, India. The iron status of adolescent

girls was determined through haemoglobin, serum iron and serum ferritin levels. The results

revealed that 96.3 percent of the adolescent girls suffered from anaemia, about 75percent of the

subjects had low serum ferritin levels.

Patil et al., (2009) conducted a study on epidemiological correlates of nutritional anemia

among 630 adolescent girls within the age group of 13-16 years. The prevalence of anemia was

found to be 59.8percent. The total prevalence was categorized as severe, moderate and mild

cases of anemia 0.6percent, 20.8percent and 38.4percent respectively. The study provides an

indication to initiate the anemia prophylaxis measures for adolescent girls in India including

nutrition education in schools.

Devi and Amirthagowri, (2007) conducted a study on the effect of supplementation of

nutritional status of anemic adolescent girls. The sample consisted of 324 adolescent girls with

the age group of 1.83 cm and about weight was 1.32 kg. there was an appreciable reduction in

clinical signs. The consumption of supplements (red palm oil incorporated sweet ladoo) the

period over 90 days. The increase in hemoglobin level was seen in the biochemical estimation.

Vitamin A supplement promotes iron status of the subjects. They have suggested that the iron

and vitamin A in the body is to meet the nutritional needs for growth and development of

adolescent especially girls and also for the preparation of the future motherhood.

Anemia during pregnancy leads to

73
 About 4 million maternal deaths (Rao, 1997).

3 times greater risk of premature birth (Rao, 1997).

9 times higher risk of maternal morbidity and fetal wastage (Prema, 1981, 1982).

Increased rate of IUGR and LBW babies and possibly inferior neonatal health (Allen,

2000).

Anaemia during pregnancy is a good predictor of cardiovascular disease in later life of

the child (Baker, 1992).

Increased risk of maternal haemorrhage and prepartum blood loss can cause more

consequences to the mothers (Wolf, 1993).

About 1,624 babies die per day due to iron deficiency. About 20percent of prenatal

mortality (Combination of fetal death and deaths of infants in their first 28 days) in developing

countries is attributable to iron deficiency (WHO, 2002).

Anaemia in infants and children affects physical and intellectual growth, long-term or

permanent impairment of motor and mental development. They have a deficient of 5-IQ points

and 10percent reduction in learning capacity during school years (Ross and Horton, 1998).

Diminished platelet aggregation in patients with iron deficiency anaemia has been reported by

Caliskan et al. (1999). Iron deficiency hinders the immune systems ability to fight infection

(Stevens, 2000).

2.7. Assessment of Nutritional Status

Nutritional status refers to health of an individual and it is influenced by the intake and

utilization of nutrients. Nutritional assessment is the process whereby the state of nutritional

health of an individual is determined. It includes nutritional anthropometry, clinical examination,

biochemical assessment and dietary survey.

74
2.7.1. Nutritional anthropometry

Nutritional anthropometry is measurement of human body at various ages and level of

nutritional status. It is based on the concept that an appropriate measurement should reflect any

morphological variation occurring due to significant functional physiological changes (Mahtab

et al., 1996). The anthropometric measurement is a systematic quantitative representation of the

human body. Anthropometric techniques are used to measure the absolute and relative variability

in size and shape of the human body (Swaminathan, 2005).

Sivaramakrishna et al., (2011) conducted a study on assessment on nutritional status on

230 adolescent girls in Kolar district. Study showed the prevalence of washing and stunting was

54.79 percent.

Deshmukh et al., (2006) conducted a study on the nutritional status of adolescents in rural

area of Wardha (Maharashtra). The sample consisted of 764 adolescents. The study revealed that

the mean BMI was significantly higher among boys (16.38 3.09) as compared to girls (15.54

3.25) thinness was higher in early adolescence (57.0%) than in late adolescence (48.5percent).

The prevalence of thinness was significantly more in girls than boys.

According to National Nutrition Monitoring Bureau the percentage of under nutrition was

higher in boys than girls. Trends indicate better food intake by adolescent girls today. Yet it is

grossly unsatisfactory as 70 percent still consume food below RDAs. Family structure was

observed to have an effect on nutritional status of adolescent girls, as girls from extended

families were observed to be better nourished than those from joint families.

Venkaiah et al., (2002) conducted a study on diet and nutritional status of adolescents

during the year of 1996 1997. The study considered of 20 households from each selected

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villages and date obtained from 12,124 adolescents for anthropometric, 2,579 for 24 hour recall

method of dietary information. Information on demographic and socio-economic particulars,

nutritional assessment in all the 20 selected households were taken. This study revealed that

among married adolescent girls 24.1 percent was at risk due to short stature (<145 cms) and

18.6 percent were underweight (<38 kg.). Stunning in both the sexes boys for 39.5 percent and

girls for 39.1 percent under nutrition was more in males 53.1 percent as compared to females

39.5 percent.

Choudhary et al., (2003) reported that 68.52 percent of adolescents had BMI of less than

18.5 kg per sq.m. In rural area of Varanasi and also Shalabuddin et al., (2000) reported 67

percent prevalence of thinness in Bangladesh. Study conducted by Deshmukh et al., (2006) on

nutritional status of adolescents in rural Wardha showed that 53.8 percent of the adolescents

were thin, 44 percent were normal and 2.2 percent were overweight.

Zanvae et al., (2008) compared 500 adolescents (13-18 years) from urban, rural and tribal

areas of Marathwada region, found that urban adolescent girls had better height (152.26 8.6 cm)

than rural and tribal counterparts (150.197.11, 145.51 9.38 cm respectively). Similar trend was

observed in weight and body mass index, which ranged from 36.61 3.41 to 42.795.02 cm and

16.76 2.31 to 18.182.00 cm respectively.

A study conducted by Kowsalya et al., (2008) on the iron nutrition of 100 adolescents

(13-18 years) in Manipur found that the mean height and weight of the selected adolescent girls

were below the standard value.

Some studies given importance to the Community-based adolescent-friendly health and

nutrition education and services and economic development may improve the overall health and

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nutritional knowledge and status of adolescents. Alam et al., (2010) conducted a study on the

nutritional status and dietary intake and relevant knowledge of adolescent girls in rural

Bangladesh. The sample consisted of 4,999 adolescent girls aged between 13-18 years. The study

revealed that 26 percent of the girls were thin, with low body mass index (BMI) 0.3 percent

obese, 32 percent stunted.

Choudhary et al., (2003) conducted a study on the assessment of nutritional status of

adolescent girls of a rural area of Varanasi. The sample consisted of 270 adolescent girls. It was

found that 68.52 percent were undernourished (BMI<18.5). The average Weight, Height and Mid

Arm Circumference were 73.63 percent, 91.9 percent and 82.81 percent.

Shahid et al., (2006) conducted a study on assessment of nutritional status of adolescent

college girls at Rawalpindi. The sample consisted of 508 adolescent girls. Study revealed that 20

percent of girls were having BMI<18.5, 77 percent had normal BMI and 3 percent been obese.

Fifty eight percent of the girls had goiter out of which 52.96 percent had palpable goiter and 4.13

percent had visible goiter.

Goswanier al., (2008) conducted a study to assess the on nutritional status of adolescent

girls form high socio economic group at Punjab. The study contained samples of 302 students

under the age group of 13-15 years. The study showed that many had the habits of skipping the

meals (57.2%), mostly they skipped breakfast (36.1p%), fast foods was highly found (98.3%),

lower intake of intake of energy and iron may be attributed to the lower intake of cereals and

green leafy vegetables by the adolescent girls. Jude et al., (1991) conducted a study on the

objectives were to assess the nutritional status of rural adolescent girls. The sample consisted of

47 adolescent girls aged 13-18 years. The study revealed that the growth of 34.7 percent of the

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subjects was very poor, 51.2 percent had normal weight for their age group. The Hb levels of the

subjects (73.5%) were below 12 g/d1.

2.7.2. Clinical Examination

Clinical examinations assess levels of health of individuals or of population groups in

relation to the food they consume. It is the simplest and practical method. When two or more

clinical signs characteristic of deficiency diseases are present simultaneously, their diagnostic

significance is greatly enhanced (Srilakshmi, 2004).

Patil et al, (2009) conducted a study on health problems among adolescent girls in rural

areas Maharashtra. The sample consisted of 620 adolescent girls in the age group of 10-19 years.

The major problems related to menstruation cycle were dysmenorrheal (44.2%). The commonest

problems faced by adolescent girls were Irregular menses (16.9%), irritation (21.7%), Malaise

(9.5%), headache (14.2%), chest pain (8.2%), abdominal bloating (20.3%), constipation (11.3%)

tightness in chest (10.6%). and white discharge (38.3percent).

Hettiarachchi et al., (2003) conducted a study on the prevalence and severity of

micronutrient deficiency on 925 Sri Lankan adolescence students. The prevalence of anemia was

found in 54.8 percent of the subjects, 30.2 percent of males and 47.8 percent of females had iron

deficiency. Folate deficiency was found in 54.6 percent and 52.5 percent of boys and girls and

zinc deficiency occurred in 51.5 percent and 58.3 percent respectively. They have suggested that

the multiple micronutrient deficiencies are prevalent in Sri Lankan adolescents. Malnutrition is

not only a stigma for school children: it impairs the overall development of a country.

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 Choudhary et al., (2003) in a study of 270 adolescent girls that the vitamin A deficiency,

pallor, dental caries and iodine deficiency disorders were present in 13.70 percent, 25.90 percent,

13.33 percent and 4.44 percent adolescent girls respectively.

Kowsalya and Crassina, (2007) conducted a study on the impact of supplementation of

lotus stem on iron deficiency anemic adolescent girls. The sample consisted of 30 adolescent

girls with the age group of 13-18 years. The study revealed that the clinical signs of selected

moderately anemic girls decreased after supplementation. Hemoglobin level of subjects

increased. After 90 days supplementation there were improvement in the blood hemoglobin,

serum iron, PCV, MCV, MCH and MCHC levels and reduction in TIBC levels. The Clinical

signs and symptoms also reduced.

2.7.3. Biochemical Estimation

Hemoglobin assessment is an indicator of iron status in individuals by analyzing the level

of hemoglobin in blood, one can diagnose whether the individual is anaemic or not. The

hemoglobin content of the normal adolescent girls is 12 and more than 12 g/d1 is categorized as

non-anaemic and hemoglobin level less than 12g / d1 are anaemic based on the cut off points

given by WHO.

Jude et al., (1991) conducted a study on the nutritional assessment of adolescent girls in

the southern United States. The sample consisted of 550 black and 691 white adolescent girls.

The result indicated that the Specific nutritional problems of white and black girls included in the

regional study were with regard to folate, vitamin B-6, and zinc as indicated by biochemical

analyses. Shahid et al., (2006) conducted a study on assessment of nutritional status of

adolescent college girls at Rawalpindi. The sample consisted of 508 adolescent girls.

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Biochemical results indicated that 32.87 percent of the girls were suffering from Iron deficiency

anemia.

Choudhary et al., (2003) conducted a study on the assessment of nutritional status of

adolescent girls of a rural area of Varanasi. The sample consisted of 270 adolescent girls. The

overall 30.74 percent girls were anemic Hb<12g/d1 percent. Kotecha et al., (2009) conducted a

study on adolescent anaemia Control Programme in Vadodara district of Gujarat covering over

69000 girls in over 426 schools. This study revealed that 75 percent were anemic with low serum

ferritin. They were supplemented with the iron and folic acid, impact of intervention revealed

that reduction in anaemia prevalence was 21.5 percent that is from 74.7 percent to 53.2 percent.

Hb levels were improved among 80 percent girls. Pre- and post intervention also showed

improvement in serum ferritin value. Programme covered 10 lakh school girls. This was found to

be an effective intervention to reduce anaemia and was scalable within the system. The

experience to educate the girls on dietary behaviors has not been satisfactory and covering all out

of school girls is still a challenge to the success of anaemia control.

Zanvar et al., (2008) conducted a study on the supplementation of bio fortified biscuits to

selected adolescent girls at Marathwada region. The study sample consisted of 500 adolescent

girls with the age group of 13-18 years. The results showed that there was a 46.6 percent of

selected adolescent girls were suffering from moderate and mild anemia. From the observations

it was evident that biscuits were definitely helpful in improving Hb levels by 6.31 percent in the

absence of any tablets. The girls who received tablets as well as biscuits, the Hb level were

highest (17.7%). The acceptability scores of developed biscuits revealed that all adolescent girls

expressed highest acceptability for taste 84 percent, colour 81 percent and texture 80 percent.

The result indicated that the bio fortified biscuits are very useful as iron supplement in the

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absence of iron and folic acid tablets for improving the health and nutritional status of adolescent

girls.

Vasanthamani and Devi, (2009) conducted a study on supplementation of iron rich health

drink to selected anemic adolescent girls. The sample consisted of 25 adolescent girls with the

age range of 16 to 18 years. The study revealed that the serum iron and total iron binding

capacity had increased. No significant increase of serum ferritin after supplements. Blood protein

namely total protein, albumin and globulin had slightly increased. The health drink significantly

increased the blood hemoglobin and serum iron level of the subjects. They have suggested that

the health drink had significantly increased the hemoglobin and serum iron level of the subjects.

It was found that the supplementation of iron rich health drink was very effective in bringing up

the hemoglobin levels in anemic adolescent girls and was anemia among adolescent girls.

Agarwal et al., (2003) conducted a study on examine the benefits of anemia prophylaxis

in adolescent school girls. The sample size was 2,088 with the age group of 10 t0 17 years. The

study revealed that the daily intake of supplements for 100 days raised hemoglobin level.

Mittal et al., (2010) conducted an intervention study among 104 adolescent girls with an

objective to study the effect of change in dietary behaviors and iron supplementation for

reduction of iron deficiency anemia. The relevant information was collected with nutritional

assessment and biochemical estimation. The girls were administered iron and folate and calcium

supplementation whereas hemoglobin decreased slightly in girls in the control group. A

significant weight gain of 2.66 kg was seen in the intervention group, whereas girls in the control

group. A significant weight gain of 2.66 kg was seen in the intervention group,whereas girls in

the control group showed little weight gain. They have concluded that considering the biological

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feasibility and effectiveness of the intervention, supplementation of iron should be started and

dietary behaviors should be improved in adolescent girls for the control and prevention of

anemia and Iron Deficiency Anaemia (IDA) in this population.

2.7.4. Dietary Survey

Dietary studies are generally an integral part of most nutritional surveys. The main

objective of any dietary assessment is to discover what the person under investigation is in habit

of eating over the long range and in the short run. A dietary survey provides information about

dietary intakes patterns of specific foods consumed and estimated nutrient intakes. It indicates

relative dietary inadequacies, which is helpful in planning health education activities and

changes needed in the agriculture and food production industries (Srilakshmi, 2004).

Yoon et al., (2004) conducted a study on the survey about adolescent perception and

attitudes towards fast food. The study sample consisted of 1,050 students with the age group of

14-19 years. Most respondents answered that they consumed fast food once a month because it is

fast, easily accessible and tasty. Although they perceived fast as unhealthy and less nutritious,

they were less aware of its effect on their health and nutritional status. However, respondents

who had little or no knowledge about the nutritional factors of fast food accounted for 43.1

percent. Singh et al., (2006) conducted a study on the prevalence of lifestyle associated risk

factors in adolescents in Delhi. The sample consisted of 510 students (279 boys and 231 girls)

between the age group of 12-18 years. The study revealed that low consumption of fruits and

vegetables found among boys (31.5%) and (16.5%) girls 18.6percent boys and 16.5percent girls

were overweight.

2.8. Nutrition Education

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 Nutrition education has been defined as educational measure for inducing desirable

behavioral changes for the ultimate improvement in the nutritional status of individual and

family (Deshpande et al., 2003). All the above definitions suggest that nutrition education aims

at bringing in nutrition behaviors which promote health of an individual. According to UNESCO

(1983), nutrition education among adolescents can help to alleviate and even prevent the

incidence of nutritional deficiencies among vulnerable adolescents.

Nutrition education is the key element in promoting sustainable healthy eating behaviours

(Forester et al.,1997). Similarly, health promotion from early stages in life has a major impact on

health and well-being during childhood and later stages of life WHO; (2008).

The main objective of nutrition education is to create awareness regarding the health

requirements for promotion of growth and development of the body and mind (Pattanaik, 2004).

Nutrition education can serve as an effective tool to modify dietary habits of population groups

(Devadass, 2000).

Nutrition education is the planned effort to improve nutritional status by promoting

modification in behaviours. Nutrition education means individual or group sessions and the

provision of materials designed to improve health status that achieve positive changes in dietary

habits and emphasize relationship between nutrition and health, all the keeping with the

individuals, personal, cultural, any socioeconomic preferences (Swaminathan, 2000).

Nutrition education is essential one and all since it can help to prevent several diseases

(Srilakshmi, 2002). Varalakshmi and Jayashree, (2003) conducted a study on child to child

teaching technique in nutrition education. For the study 29 boys and 21 girls were selected using

triple random sampling technique. They were divided into two group as student communicators

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and student communicates on the basis of age and sex. The study showed that the mean

knowledge pre-tested scores of student communicators and communicates was 7.2. and 7.3

respectively. After the intervention, post-test scores were 14.9 and 13.6 in student

communicators and communicate respectively. The study showed that the child to child teaching,

method of teaching and learning process is more effective than the traditional method of

teaching.

Sucharitha et al., (2007) studied the impact of nutrition education through girl to girl

approach at Hyderabad. Adolescent girls aged 12-14 years and micronutrients, vitamin A, C,

Iron, calcium were selected as content for nutrition education. The results revealed that pretest

scores of girl leaders and student communicates in nutrition knowledge were 32.4 percent and

29.7 percent respectively. The post-test scores were 77.2 percent and 73.9 percent in nutritional

knowledge of girl leaders and student communicates. The consumption of micronutrient dense

foods also increased significantly. Intervention through girl to girl approach in gaining nutrition

knowledge was successful and the study also proved that the girls were more participatory,

active and efficient in sharing information.

2.8.1. Impact of Nutrition Education

Alaofe et al., (2009) conducted a study on the impact of a nutrition education program

combined with an increase in bioavailable dietary iron to treat iron-deficiency anemia has never

been studied in adolescent girls. The sample consisted of 34 control boarding-school girls aged

12 to 17 years from Benin. The study design consisting of 4 weeks of nutrition education

combined with an increase in the content and bioavailability of dietary iron for 22 weeks was

implemented in the intervention school. The study revealed that the nutrition knowledge and

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intakes of nutrients, including dietary iron, absorbable iron, and vitamin C, were significantly

higher after the intervention. Whereas the prevalence of anemia and iron-deficiency anemia was

significantly lower in the intervention period. They have suggested that a multidietary strategy

aiming to improve available dietary iron can reduce iron-deficiency anemia in adolescent girls.

Kaur et al., (2007) conducted a study on impact of nutrition education on nutrient

adequacy of adolescent girls. The sample of the study was 60 adolescent girls in the age group of

13-19 years. Nutrition education was imparted to the subjects after assessing their basic nutrition

knowledge. Nutrition education improved their mean nutrition knowledge scores significantly.

Significant increase in average daily intake of all the nutrients was found among all the

adolescent subjects. The study revealed that the nutrition education is an effective measure to

bring about the favorable and significant change in adolescent nutrient intake.

Hilary et al., (2003) conducted a formative research with 26 women and 16 adolescent

girls to develop an education intervention through community kitchens in Lima, to increase their

dietary iron intake and improve their dietary iron intake and improve their iron status. They have

suggested that the feasible ways of achieving a nutritious diet by promoting local heme iron

sources and the consumption of beans with a vitamin C source foods were amongst those

considered to be nutritious and were best buys for iron content. The use of animal source foods

in the community kitchen menus increased during the intervention.

Lanerolle, P. and Atukorala, S. (2006) conducted a study on the effect of nutrition

education on nutrition related knowledge, food consumption patterns and serum retinol

concentrations among 229 adolescent school girls, aged between 15-19 years. The study revealed

that educational intervention resulted in a significant increase in knowledge (P<0.001) and

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consumption of local vitamin A rich foods. The percentage of subjects with low serum retinol

concentrations (<20ug/dl) decreased from 17 to 4.8 percent. The effect of nutrition education on

serum retinol concentration was highly significant (P<0.001) in subjects with baseline serum

retinol concentrations below 20ug/L. They have suggested that the nutrition education was

effective in improving knowledge and food consumption patterns among these girls.

Gupta and Kochar, (2009) carried out a study to assess the nutritional awareness of 50

school going adolescent girls of 13-16 years age in rural area. After providing nutrition

education, a significant improvement in their nutritional knowledge was viewed and quantum of

improvement was 1.67 times. The study was successful in identifying certain gaps in their

knowledge, attitude and practices before imparting nutrition education and concluded that such

awareness programmes should be organized. It would not only improve the health of adolescent

girls, but future generation will also be influenced, as adolescent girls are would be mothers.

Saiyed et al., (2009) conducted a study on the impact intervention for the control of

anemia in adolescent girls. The sample consisted of 300,884 adolescent girls. The study showed

that prevalence of anaemia improved from 94 percent to 84 percent (11% reduction) and high

school performance rates improved from 16 percent to 24 percent.

Kumari, (2011) conducted a study on the impact of nutritional education on nutrient

adequacy of high school children. The sample consisted of 60 school children in the age group of

13-19 years. Nutritional education was imparted to subjects after assessing their basic nutritional

knowledge. The study indicated that there was significant increase in the nutritional knowledge

after imparting nutritional education.

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 Jyoti, (2008) conducted a study on the consumption pattern of green leafy vegetables and

impact of nutrition education on hemoglobin status of rural adolescent girls. The sample

consisted of 300 adolescent girls in the age group of 13-16 years. The study revealed that the

prevalence of anemia was found to be 100percent. Specific information on the consumption

pattern of green leafy vegetables indicated that the adequacy of green leafy vegetable was less

than ten percent. Nutrition education intervention resulted in significant increase in the

knowledge scores and also a significant increase in the hemoglobin level. They have suggested

that the nutrition education is one of the appropriate, effective and sustainable approaches to

combat iron deficiency anemia.

Rao et al., (2007) conducted a study on the assessment of dietary habits and nutrition

knowledge levels of the adolescent girls from different schools and to study the efficacy of two

different nutrition education tools in improving their nutrition knowledge in the classroom

setting. The sample consisted of 164 adolescent girls. The study showed that the consumption of

vegetables, green leafy vegetables and fruits was moderate; the improvement of nutrition

knowledge levels was observed. No significant difference in the improvement of nutrition

knowledge levels was observed with the second intervention over the first intervention as already

the children gained knowledge through print media.

Kaur et al., (2011) conducted a study on the impact of nutrition education in reducing

iron deficiency anemia in adolescent girls. The study was conducted on 50 girl student with the

age group of 17-19 years in Government Medical College, Amritsar. The study revealed that the

62 percent of girl students had mild anemia and 14 percent of them had anemia of moderate

degree. Hence the study was concluded that nutrition education is one of the appropriate,

effective and sustainable approaches to combat iron deficiency anemia.

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 Vijayapushpam et al., (2008) conducted a study on to assess the impact of a classroom

based nutrition and health education intervention among student community volunteers in

improving their knowledge on individual topics. The sample consisted of 687 student volunteers

under the age group of 19 years. The study revealed that the significant improvement was

observed in the overall nutrition and health knowledge scores of the student volunteers after the

education intervention.

Sharma et al., (2009) conducted a study to see the awareness of adolescent girls regarding

health aspects through an intervention study. A sample group of 112 adolescent girls of age 14 to

18 years were selected randomly from district Kangra of Himachal Pradesh. The result showed

that the knowledge of girls regarding health aspects improved significantly after intervention.

There was a considerable increase in the awareness levels of girls with regard to knowledge of

health problems, environmental health, nutritional awareness and reproductive and child health.

They have suggested that informative and educable intervention seen to have a positive effect on

awareness levels which would eventually encourage expansion of knowledge and positive health

habits.

Despande et al., (2003) studies the impact of nutrition education for a period of 3 days on

the inclusion of soybean products in 160 farm women of Madhya Pradesh. The study revealed

that nutrition knowledge of women before nutrition education was 3.2 and after nutrition

education increased to 7.3 out of total 10 scores, thereby indicating about 2-3 times increase in

nutrition awareness and knowledge exhibiting substantial impact of the nutrition education

programme.

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 A study on impact of nutrition education and carbohydrate supplementation on

performance of 30 boys of high school football players (14-15 years) in Dharwad district was

carried out by Meti and Saraswathi (2006). They study revealed that nutrition education and

carbohydrate supplementation for a period of 3 months improved their nutrition knowledge and

practice, physical and field performance during the competition. A significant different

(P<0.001) was observed in the scores of pre and post-test of nutrition education intervention.

Kaur (2007) conducted a study on impact of nutrition education on nutrient adequacy of

60 adolescent girls (13-19 years). Nutrition education for a period of 3 months was imparted to

the subjects after assessing their basic nutrition knowledge. Nutrition education improved their

mean nutrition knowledge scores significantly. The average contribution of carbohydrate,

protein, fat, vitamin and minerals increased significantly after imparting nutrition education.

Summary

As there is an increasing incidence rate of aggression with adolescent girls, there is a

need to develop a coherent research agenda with respect to this group. There is a small but

growing literature that supports useful directions in which to pursue a policy, assessment,

treatment and prevention frame work that is sensitive to the unique needs of adolescent girls who

now find themselves ever increasing numbers in the youth justice and social service delivery

system. Additionally some of the major contributors to the literature are coming forward with

findings that shed light on this at risk-group. Finally, now this research will generate a

knowledge and evidence base that can be used in multiple regions to help reduce gender

inequity, under nutrition and the importance of breakfast eating among adolescents.

89