Exploring Gender Disparity in Nutritional Status and Dietary Intake of Adolescents in Uttarkashi

Abstract

Adolescence is considered to be a nutritionally vulnerable period of life. The current cross-sectional study attempts to assess gender-based differences in nutritional status and dietary intake of a sample of 240 adolescents from Uttarkashi district in the state of Uttarakhand. The data were collected across two schools (Kendriya Vidyalaya, Manera, and Alpine Public School) of Uttarkashi. The nutritional status of each subject was evaluated by using two anthropometric indices, that is, weight-for-age and height-for-age, and derived indices expressed as z-scores by using the National Center for Health Statistics (NCHS) reference data. Dietary intake was ascertained by employing 24-h dietary intake for 3 consecutive days. The results show an increasing trend of mean height and weight of adolescent boys and girls with advancing age. Gender wise, however, boys had higher prevalence of underweight than girls, whereas girls were slightly more stunted compared to boys. The dietary intake of energy, iron, calcium and protein was significantly higher in boys than their female counterparts. Despite an advantage in terms of dietary intake, an enhanced prevalence of underweight among boys may be attributed to difference in physical activity between both sexes, owing to gendered cultural setting.

Keywords

Adolescence nutritional status recommended dietary allowance underweight

Introduction

Nutritional status is an important indicator of the country’s overall development. Nutritional factor is one of the primary environmental factors that is associated with delayed physical growth, decreased cognitive function, behavioural problems, low immunity and high susceptibility to diseases. Adolescence is a transitional period between childhood and adulthood, which is characterized by marked acceleration in growth (Anand et al.,1999). There is a growing consensus that poor nutritional status during childhood can have lifelong adverse consequences during adulthood, in terms of both health and mortality, as well as schooling and productivity (Behrman et al., 2006; Glewwe and Miguel, 2007; Maluccio et al., 2005).

During the past two decades, a significant change in the nutritional status of adolescents has been observed worldwide, which may be attributed to global technological advancement and modernization. From a nutritional point of view, adolescents are susceptible due to their modern lifestyle and dietary habits, as well as high energy and nutritional requirements (Anderson, 1991; Duyer, 1981). Lack of diversification in diets is particularly a serious concern among poor populations in developing countries, where diets are predominantly based on starchy food and often include only seasonal fruits and vegetables and few or no non-vegetarian items (Guidetti & Cavazza, 2008). Undernourished children are at a higher risk of poor health outcomes because of the synergism between malnutrition and infections. The marked increase in physical growth and development during adolescence exerts significant burden on the requirement for nutrients (Brasel, 1982). There may be sociocultural determinants or change of lifestyle and food habits of adolescents that can interfere with both their nutrient intake and needs (Spear, 2002). Growth is an uneven process whose rate is controlled by a maturational clock (Tanner, 1963); disturbing factors can be induced by either delay in the maturation process (timing effect) or directly limiting the exploitation of the full genetic potential (intensity effect). It was highlighted by Gopalan et al. (1989), that under favourable circumstances, from a nutritional point of view, the adolescence period offers a second possibility to catch up on physical growth.

Anthropometry is a reliable, non-evasive and relatively inexpensive tool for the assessment of nutritional status, particularly among children (Johnston, 1981). To determine the nutritional status of children, the World Health Organization (WHO) has recommended the use of z-score indicators (Waterlow et al., 1977), which helps in assessing the severity of under-nutrition. In India, there are 190 million estimated adolescents who comprise over one-fifth of the entire population (Kotecha et al., 2013). Various studies have been conducted in India on children (Kaur & Talwar, 2000; Maken & Varte, 2012; Waly, 2014), women in reproductive age (Manjunath et al., 2017; Mastiholi et al., 2018; Rao et al., 2010) as well as on elderly women (Agarwalla et al., 2015; Arlappa et al., 2003; Khole and Soletti, 2017), but there still exists limited work that looks specifically on adolescents. It was observed by Chaturvedi et al. (1996) that adolescents are generally overlooked with respect to nutritional, status considering they demonstrate low death rates. It has been highlighted by previous studies (Jha et al., 2011; Subramanian & Corsi, 2011) that despite significant efforts made by governmental and non-governmental agencies, females continue to experience gender inequality throughout their lifespan. Therefore, the focus of this cross-sectional study is to primarily assess the gender-based differences among adolescents through the following objectives: (a) to assess and compare the growth trend of adolescent, (b) to determine the nutritional status using z-score of adolescent and (c) to evaluate the dietary intake among the adolescents of Uttarkashi district and their comparison with recommended dietary allowance.

Land and People

The data of the present study were collected from the Uttarkashi area of District Uttarakhand, North India. Uttarakhand is divided into two regions, Kumaon and Garhwal. Uttarkashi belongs to Garhwal divisions with six tehsils named Badkot, Bhatwadi, Chiniyalisaud, Dunda, Purola and Mori. The religious composition of the population of this area are Hinduism (82.97%), Islam (13.95%), Sikhism (2.34%), Christianity (0.37%), Buddhism (0.15%), Jainism (0.09%) and other or not religious groups (0.13%) (Population Census, 2011). The staple food in this region consists of dal bhat (rice-lentils); they also eat chapatti, vegetables, dal, rice, fruits, etc. A significant proportion of boys (77%) and girls (49%) were non-vegetarian, while 16.5 per cent boys and 39 per cent girls were vegetarian and remaining were ovatarian, that is, 5.7 per cent boys and 12 per cent girls. A considerable percentage of mothers (47%) and fathers (34%) of the subjects were illiterate and were mostly employed in petty business or farming, or government services.

Material and Methods

The present cross-sectional study was conducted on the sample of 240 adolescents (boys: 140, girls: 100), ranging from 9 to 13 years of age. The data were collected between 25th October 2017 and 2nd November 2017 from two schools—Kendriya Vidyalaya, Manera, and Alpine Public School, Uttarkashi. Inclusion criteria involved only healthy adolescent subjects who were not suffering from any long-term disease or physical deformity. The age of the subjects was obtained from the school records and their chronological ages were converted into decimal ages, following the decimal age calendar of Tanner et al. (1966). Accordingly, the 9-year-old age group included all the boys and girls from 8.500 years to 9.499 years and 10-year-old age group included students who were above 9.500 and below 10.499 years, etc. The data thus gathered were categorized into five age levels, each with a magnitude of 1 year. Age- and sex-wise distribution of adolescents of Uttarkashi is presented in Figure 1.

All subjects were selected randomly from the schools after getting necessary permission from the school authorities. They were informed about the nature and objective of the study prior to data collection. The data collection involved basic information from the school registers, and interview schedules were used to get other information like caste; father’s and mother’s occupation; and education of the parents. All the anthropometric measurements were taken by following standard protocol recommended by Weiner and Lourie (1981). Height (in cm) was taken to the nearest 0.1 cm with an anthropometric rod, and weight was measured with the upright position with nearest 0.1 kg with a weighing machine.

Figure 1.

Source: The authors.

Body mass index was computed as weight in kg divided by height squared (height was measured in metres). The nutritional status of each subject was evaluated by using 2 anthropometric indices, that is, weight-for-age, height-for-age and derived indices were denoted as z-scores by using National Center for Health Statistics (NCHS) reference data (WHO, 1995). The cut-off points for mild, moderate and severe malnutrition for z-score of these indices were from –1.1 to –2.0 S.D., –2.1 to –3.0 S.D. and –3.1 to –4.0 S.D, respectively. The formula for z-score is as follows: z = (subject’s measurement – reference median) ÷ reference SD Where, subject’s measurement = height or weight of a given child at age X, reference median = mean or 50th percentile of the reference population at age X, reference SD = standard deviation of the reference population at age X.

The approximate amount of dietary intake was evaluated by using the 24-h recall method for consecutive 3 days. Additional information on frequency (ate two times/day or three times/day) and kind of food consumption (vegetarian or non-vegetarian, intake of fruits) was also recorded. Nutritive value tables for Indian foods were employed to gauge nutrient intake (Gopalan et al., 1990).

Statistical Analysis

All statistical computations were performed using Statistical Package for Social Sciences (SPSS) version 20.0 computer software. Descriptive statistics were calculated for all anthropometric measurements, z-scores and dietary intake. One-way analysis of variance (ANOVA) was employed to study the age variation for each dimension for both boys and girls at each level. Gender disparity in anthropometric parameters, z-scores and dietary intake was obtained by using the student t-test, wherein the statistical significance was set at p < 0.05.

Results

Descriptive statistics for the various anthropometric variables of the adolescent boys and girls of Uttarkashi is summarized in Table 1. An increasing trend in the mean values of height and weight with advancing age has been noticed in both the groups in the entire range taken under consideration. It is apparent from the Table 1 that boys were taller (139.6 ± 10.4 vs. 137.89 ± 11.7) and slightly heavier (32.26 ± 7.4 vs. 32.10 ± 7.8) than their female counterparts in the similar age group. The girls (16.68 ± 2.3) revealed higher body mass index as compared to their boy counterparts (16.38 ± 2.1) at all the age levels except at 12 years, but the sex differences were not statistically significant. Results of the one-way ANOVA demonstrated significant age differences in height (F = boys 29.23, girls 48.35) and weight (F = boys 18.68, girls 22.27), while, for body mass index, only boys presented significant F-value (3.44*).

Table 1.

Descriptive Statistics for Various Anthropometric Variables of Adolescent Boys and Girls of Uttarkashi

Parameters	9 Years Mean ± S.D	10 Years Mean ± S.D	11 Years Mean ± S.D	12 Years Mean ± S.D	13 Years Mean ± S.D	Total Mean ± S.D.	ANOVA
Height B G	128.08 ± 7. 124.25 ± 7.1	134.57 ± 7.4 130.72 ± 4.8	137.99 ± 7.1 136.25 ± 7.2	140.73 ± 8.2 146.37 ± 8.3	148.95 ± 8.1 149.65 ± 6.0	139.6 ± 10.4 137.89 ± 11.7	29.23 48.35
Weight B G	25.16 ± 4.7 24.77 ± 3.1	29.02 ± 8.8 27.61 ± 4.1	31.03 ± 4.2 31.31 ± 7.2	33.16 ± 4.3 35.70 ± 6.9	38.13 ± 6.7 39.70 ± 5.8	32.26 ± 7.4 32.10 ± 7.8	18.68 22.27
MUAC B G	16.54 ± 1.7 16.39 ± 1.1	17.43 ± 2.8 17.62 ± 1.3	17.67 ± 1.7 18.04 ± 2.4	18.07 ± 2.0 18.53 ± 1.5	19.2 ± 2.33 20.07 ± 2.5	17.97 ± 2.3 18.18 ± 2.2	5.89 10.00
BMI B G	15.29 ± 1.9 16.06 ± 1.5	15.74 ± 2.7 16.11 ± 1.8	16.34 ± 1.7 16.72 ± 2.6	16.76 ± 2.0 16.59 ± 2.5	17.08 ± 1.8 17.74 ± 2.5	16.38 ± 2.1 16.68 ± 2.3	3.44** 1.76

Source: Data from the present study.

Note: Level of significance *p < 0.05, **p < 0.01 and p < 0.001.

MUAC: Mid upper arm circumference, BMI: body mass index, B: boys, G: girls.

Descriptive statistics of the z-score of weight for age and height for age of adolescent boys and girls of Uttarkashi are presented in Table 2. The overall mean z-score for height for age (–0.75 ± 1.9 vs –0.83 ± 1.1) of girls was recorded higher as compared to boys, whereas a reverse trend was recorded for weight for age (–0.45 ± 0.7 vs –0.54 ± 0.7). Statistically significant sex differences were noticed only for weight for height from age level 9–11 years.

Table 3 demonstrated prevalence of malnutrition in adolescent boys and girls of Uttarkashi. For weight for age, about 18 per cent girls and 27 per cent boys demonstrated mild undernutrition (–1 S.D. to –2 S.D.). The weight-for-age z-score presented statistically non-significant sex difference. Girls (18%) were mildly underweight than boys (27.14%), that is, fall under –1 S.D to –2 S.D. scores, whereas remaining was in normal category. Approximately 47.86 per cent boys and 49 per cent girls were found to be in different categories of stunting. In the current cross-sectional study, dietary intake of energy, protein, iron and calcium demonstrated an age-related increment in their mean values in both boys and girls with some minor fluctuation (Table 4). Results of ANOVA demonstrated significant age differences for all the variables except for calcium in both the sexes and protein in girls as it is apparent from their F-ratio. In comparative term, dietary intake of energy (boys: 2,366.84 Kcal vs. girls: 1,957.39 Kcal), Iron (boys: 42.81 mg/d vs. girls: 35.65mg/d), calcium (boys 0.98 mg/d vs. 0.79 mg/d) and protein (boys: 75.84g/d vs. girls: 62.56 g/d) was significantly higher in boys than their female counterparts in the similar age categories.

Table 2.

Mean and Standard Deviation Value of z-score for Height-for-Age and Weight-for-Age of Adolescent Boys and Girls of Uttarkashi

Age (in years)	Sex	Height-for-Age (stunting)		Weight-for-Age (underweight)
Age (in years)	Sex	Mean ± S.D	t-Value	Mean ± S.D	t-Value
9	Girls	0.38 ± 3.53	–1.18	–0.12 ± 0.77	–1.30
	Boys	–0.58 ± 1.24		–0.44 ± 0.8
10	Girls	–1.0 ± 0.74	1.79	–0.54 ± 0.5	0.76
	Boys	–0.41 ± 1.2		–0.31 ± 1.18
11	Girls	–1.01 ± 1.12	1.12	–0.47 ± 0.81	0.14
	Boys	–0.66 ± 1.02		–0.44 ± 0.5
12	Girls	–0.75 ± 1.24	0.16	–0.46 ± 0.66	–0.86
	Boys	–1.13 ± 1.09		–0.63 ± 0.47
13	Girls	–1.34 ± 0.99	0.74	–0.64 ± 0.53	–0.86
	Boys	–0.83 ± 1.08		–0.75 ± 0.5
Total	Girls	–0.75 ± 1.9	–0.42	–0.45 ± 0.68	–1.03
	Boys	–0.83 ± 1.08		–0.54 ± 0.71

Source: Data from the present study.

Note: Level of significance *p < 0.05, **p < 0.01 and p < 0.001.

Table 3.

Prevalence (%) of Malnutrition in Uttarkashi Adolescent Boys and Girls

Anthropometric Index	Girls N (%)	Boys N (%)
Weight-for-age (underweight)
Normal > –1 S.D. scores	82 (82%)	102 (72.85%)
Mild –1 to –2 S.D. scores	18 (18%)	38 (27.14%)
Moderate –2 to –3 S.D. scores	–	–
Severe < –3 S.D. scores	–	–
Height-for-age (stunting)
Normal > –1 S.D. scores	51 (51%)	73 (52.14%)
Mild –1 to –2 S.D. scores	31 (31%)	52 (37.14%)
Moderate –2 to –3 S.D. scores	16 (16%)	13 (9.28%)
Severe < –3 S.D. scores	2 (2%)	2 (1.42%)

Source: Data from the present study.

Table 4.

Descriptive Statistics for Dietary Intake According to Age in Adolescent Boys and Girls of Uttarkashi

Parameters	9 years Mean ± S.D.	10 years Mean ± S.D.	11 years Mean ± S.D.	12 years Mean ± S.D.	13 years Mean ± S.D.	Total Mean ± S.D.	ANOVA
Energy B G	1909.34 ± 399.4 1779.12 ± 489.42	2232.64 ± 654.6 1862.44 ± 616.2	2411.1 ± 651.0 1904.29 ± 337.7	2470.00 ± 467.9 1979.92 ± 541.76	2579.74 ± 681.50 2223.01 ± 658.6	2366.84 ± 632.1 1957.39 ± 550.5	4.862** 2.075*
Calcium B G	0.71 ± 0.2 0.62 ± 0.1	0.74 ± 0.2 0.67 ± 0.2	0.77 ± 0.2 0.73 ± 0.2	0.83 ± 0.2 0.70 ± 0.2	0.98 ± 1.8 0.79 ± 0.3	0.83 ± 1.0 0.70 ± 0.2	0.350 1.148
Protein B G	67.09 ± 15.9 58.58 ± 18.9	68.78 ± 15.8 59.19 ± 20.5	75.49* ± 19.9 61.67 ± 13.4	76.98 ± 8.6 64.98 ± 19.3	83.81 ± 17.4 67.44 ± 18.7	75.84** ± 17.2 62.56 ± 18.2	5.097** 0.874
Iron B G	37.03* ± 7.4 32.55 ± 7.2	40.66* ± 12.9 33.74 ± 7.1	45.61* ± 14.4 34.97 ± 5.7	43.39* ± 7.3 38.10 ± 9.2	44.63* ± 9.9 38.37 ± 8.7	42.81* ± 11.1 35.65 ± 7.9	2.492* 2.268*

Source: Data from the present study.

Note: Level of significance *p < 0.05, **p < 0.01 and p < 0.001.

B: Boys; G: girls.

Discussion

In the present study, mean height and weight of adolescent boys and girls exhibited an increase in trend with advancing age. The boys were taller and heavier than girls at age levels 9–11 years, thereafter a growth spurt in height and weight of the girls was observed. A study conducted by Tanner (1971) also noticed a similar trend that boys were slightly taller as compared to their age-matched female counterparts until female adolescent spurt occurs. During this period, girls were found to be taller than boys, and in boys, adolescent spurt was yet to begin. A study conducted by Agarwal et al. (1992) of affluent Indians showed that mean and percentile values for height and weight of boys and girls exhibited an increasing trend with age. During 11–12.5 years, girls have higher mean height (approximately 2 cm) as compared to boys of the same age, and this may be due to a spurt in adolescent growth earlier in girls than boys. Our results are in concordance with previous studies (Bhasin & Jain, 2007; Gaur & Singh, 1995; Gautam & Thakur, 2017), which also exhibited that adolescence triggers bodily changes in girls, on an average, two years prior to their opposite sex. In this cross-sectional study, girls had a higher mean value of bodily mass index—BMI (16.68 vs 16.38, p > 0.05) as compared to boys. In divergence with this study, Deshmukh et al. (2006), assessed the nutritional status of adolescents in rural Wardha and found that BMI was higher among boys (16.88 vs 15.54) as compared to their female counterparts. Findings of Medhi et. al. (2007), among tea garden adolescent boys and girls of Assam, described that mean BMI of girls was higher than boys at all ages. Mean BMI of adolescents in the present study was found to be far below the NCHS median. In comparison to most of the other Indian studies as well as international findings (Agarwal et al., 1992; CDC, 2000; Kumaravel et al., 2014; WHO, 2006), Uttarkashi girls and boys were lagging far behind.

To ascertain the population differences, heights and weights of the adolescent boys and girls of present the study have been compared with NCHS percentiles (Figures 2a–3b) .The mean height of adolescent girls of Uttarkashi lay on the 5th percentiles up till 11 years, and at age 12 and 13, it lay on the 10th percentiles. On the other hand, among the adolescent boys, mean height of Uttarkashi boys lay between the 10th and 25th percentiles from 9 to 11 years, and thereafter from 12 years onwards, it lay between 5th and 10th percentile. Thakur and Gautam (2015) examined the adolescents of both the sexes from Sagar city and compared them with NCHS reference data. They revealed that Indian girls and boys were lagging behind from international standards. The results of previous studies (Agarwal et al., 1992; Venkaiah et al., 2002) highlighted that the adolescents were shorter and lighter than their American counterparts (NCHS standards) at all ages. These differences in height may be attributed to the genetic factors as well as to various demographic, economic, sociocultural and other physical environment (altitude) factors (Cossio-Bolaños et al., 2015). The available literature shows that populations living at a higher altitude demonstrated comparatively lesser mean height as compared to the population residing in the plains (Frisancho et al., 1969; Singh, 2002).

Figure 2a.

Source: Present study and NCHS percentiles.

Figure 2b.

Source: Present study and NCHS percentiles.

Figure 3a.

Source: Present study and NCHS percentiles.

Figure 3b.

Source: Present study and NCHS percentiles.

Table 3 demonstrates the prevalence of the malnutrition in adolescent boys and girls of Uttarkashi. It shows that 47.86 per cent boys and 49 per cent girls were stunted. A study of sexual dimorphism illustrates that boys had higher prevalence of underweight (27.14% vs. 18%) than their female counterparts, while girls exhibited more stunting as compared to boys (49% vs. 47.86%). In convergence to the findings of present study, Dey et al. (2011) also witnessed that 33 per cent boys and 19 per cent girls of school-going adolescents in a rural Block of Darjeeling were suffering from underweight. Venkaiah et al. (2002) examined that the prevalence of undernutrition in rural adolescents from nine states ( < median –2 S.D. of NCHS weight for age) and undernutrition was found to be higher (53.1%) in boys than their age-matched girl counterparts (39.5%). The extent of undernutrition increased from 41.6 per cent to 68.6 per cent in boys with increasing age. A similar study of Medhi et al. (2007) found that the prevalence of stunting was more among girls (51.9%) than boys (47.4%) and thinness was higher among males (59.5%) than females (41.3%). Similar results were noticed by various other cross-sectional studies (Anand et al., 1999; Das et al., 2007; Shaikh et al., 2003). A report of WHO (1998) also recorded higher stunting among girls (45% vs. 20%) as compared to their counterparts from opposite sex.

The dietary intake of energy (boys: 2366.84 kcal vs. girls: 1957.39 kcal), iron (boys: 42.81 mg/d vs. girls: 35.65 mg/d), calcium (boys 0.98 mg/d vs. 0.79 mg/d) and protein (boys: 75.84 g/d vs. girls: 62.56 g/d) was significantly higher in boys than their female counterparts in the present study. Dietary intake was adequate among adolescent boys and girls of Uttarkashi, when compared with recommended dietary allowances for Indians (RDA) (Table 5). Finding of Venkaiah et al. (2002) also showed that intake of all the nutrients were higher among the boys than in girls. The staple food of adolescents of Uttarkashi was dal-bhat (rice and lentils). According to Malhotra and Passi (2007), diet quality and nutritional status of rural adolescent girls in Northern India followed a two-meal pattern, and their diets were monotonous and cereal-based. The consumption of milk and milk products, pulses, green leafy vegetables, other vegetables, and fruits were grossly insufficient. Hence, the findings of the present study demonstrate that although the dietary intake of boys was more than girls, the prevalence of wasting and underweight was higher in boys. The prevalence of stunting was marginally higher among females, which can be attributed to the cultural stigmas and pressures associated with their growth which the boys do not encounter (Eveleth, 1975; Stini, 1985). Moreover, females are considered biologically stronger because of a pair of “X” Chromosome, which protects them against chromosome-linked recessive disorders and also makes them less susceptible to infectious diseases (Ramana, 1990). Boys were engaged in more strenuous physical activity due to rough terrain as well as due to the nature of subsistence of the region; largely, males and females had differential physical activity, owing to their cultural setting. Despite various government schemes, boys were found to be less regular in their schools, than girls, and instead were found to be more engaged in agricultural work.

Table 5.

Nutrient Intake of Uttarkashi Adolescent Boys and Girls with Reference to Recommended Dietary Allowances (RDA)

Nutrients	Age	RDA	Boys (present study)	RDA	Girls (present study)
Energy (kcal)	7–9 10–12 13–15	1925 2150 2400	1909.30 2371.25 2579.74	1925 1950 2050	1779.12 1915.55 2223.01
Protein (g/d)	7–9 10–12 13–15	41 53 71	67.09 73.75 83.81	41 55 67	58.58 61.95 67.44
Calcium (mg/d)	7–9 10–12 13–15	400 600 600	710 780 980	400 600 600	620 700 790
Iron (mg/d)	7–9 10–12 13–15	25 28 43	37.03 43.22 44.63	25 20 28	32.55 35.60 38.37

Source: Data from the present study.

In conclusion, the present study found that girls are more stunted than boys, whereas boys are more underweight than girls despite having significantly higher dietary intake than girls (40%). The dietary intake among both boys and girls is adequate when compared with Recommended Dietary Allowance (RDA); however, in comparison to the NCHS data standards, this study shows that Uttarkashi boys and girls are lagging behind international standards. Hence, there is a need for better nutrition intervention programmes, in order to reduce health risks among adolescents and to promote healthy adolescent period.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research of this article: Authors are thankful to UGC Center of Advanced study-II (CAS-II) and PURSE GRANT awarded to Department of Anthropology, Panjab University, Chandigarh, India, for supporting.

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