Dietary Habits and their Impact on the Physical Status of School Going Adolescents in Delhi: A Cross-sectional Study

1. PhD Scholar, Department of Community Medicine, Santosh Deemed to be University, Ghaziabad, Uttar Predesh, India. 2. Professor and Head, Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India. 3. Professor, Department of Community Medicine, Santosh Deemed to be University, Ghaziabad, Uttar Predesh, India. 4. Professor and Head, Department of Community Medicine, Santosh Deemed to be University, Ghaziabad, Uttar Predesh, India. 5. Professor, Department of Community Medicine, Santosh Deemed to be University, Ghaziabad, Uttar Predesh, India. 6. Professor, Department of Biochemistry, Santosh Deemed to be University, Ghaziabad, Uttar Predesh, India.

Abstract

Introduction: The dietary habits and food preferences in the adolescent age group can influence their physical growth. The importance of healthy eating habits cannot be ignored. Faulty eating habits among adolescents contribute towards undernutrition, overnutrition and micronutrient deficiency.

Aim: To evaluate the dietary habits and nutritional status of school-going, urban adolescents.

Materials and Methods: A questionnaire based cross-sectional observational study was conducted among 1600 adolescents from 10 government schools in Delhi between April 2018 and March 2019. The socio-demographic profile, anthropometric measurements and dietary habits using simplified dietary gap assessment tool was recorded. The nutritional status of the participants was categorised as per World Health Organisation- Body Mass Index (WHO-BMI) Z-score for adolescents. The data collected was analysed using the statistical analysis software Graph Pad version 5. Chi-square test was applied to assess the association between dietary habits and BMI status.

Results: A total of 855 males (mean age 13±2 years) and 745 females (mean age 13.4±2 years) with age range between 10 and 19 years participated in the study. A total of 955 (59%) adolescents consumed milk or milk products, 655 (41%) consumed fruits, and 838 (52%) consumed green leafy vegetables in their daily dietary habits along with their staple diets. 1089 (68%) of adolescents were undernourished, out of which 328 (30%) skipped their regular meals. The Chi-square analysis revealed that consuming junk food (p=0.005) and buying eatables from street shops (p=0.0025) were significantly associated in adoloscents from the age group of 15-19 years. It was observed that male participants consumed milk and milk products more often than female participants (p<0.0001). Faulty dietary habits of skipping meals or eating junk food or buying eatables from street shop was associated with more number of participants under the obese/overweight category (p<0.0001).

Conclusion: The poor choice of dietary habits significantly affects the physical development among school-going adolescents. Study participants who belonged to the late adolescent age group had more tendencies to develop faulty dietary habits. The study will help to plan for nutritional supplementation and create awareness to develop healthy food choices among adolescents.

Body mass index, Food preferences, Junk food, Undernutrition

The WHO defines the individuals in the age group between 10 to 19 years as adolescents. Adolescents undergo several physical, emotional, cognitive and social changes which bring anticipation and anxiety (1). These changes also contribute towards faulty dietary habits emphasising the role of parents in promoting healthy eating behaviour among adolescents (2).

The dietary habits of adolescents are important factors to understand their present and future health. High consumption of nutrient-poor dietary items and inadequate consumption of protein and vitamin-rich diet can contribute to various health problems like malnourishment, metabolic disorders and obesity (3),(4). In one of the prospective cohort studies, poor breakfast habits were the predictors of obesity in adulthood (5). Consumption of energy dense snacks was most common among Indian adolescents (6).

Due to the rapid urbanisation, there is a change in dietary pattern which contributes to chronic diseases and obesity in the urban areas (7). The habit of skipping meals and preference for eating junk food is present among the dietary behaviour of adolescents (8). There also exist gender differences in food preferences and dietary habits among early and late adolescents age groups (9). In one of the prospective cohort studies with a follow-up period of 27 years, it was predicted that irregular eating habits at the age of 16 years had a higher prevalence of metabolic syndrome at 43 years (5). It was found, in another longitudinal study that if early intervention of adolescent health behaviour is tracked then healthy eating habits can be inculcated in the food preferences of adolescents (10). The intervention to promote healthy eating habits through a nutrition education program was found effective in motivating adolescents to make healthy food choices (11).

In one of the studies conducted in northern India, the burden of undernutrition and overnutrition was found among the rural and urban population of adolescent girls (12). The consumption of fast food and food items rich in sugar/fat/salt content is found to be high among the adolescents (8).

Among urban adolescents in India, some dietary patterns and preferences are likely to be similar but little information is available about the school going adolescents studying in the government schools of Delhi. The current study was designed to evaluate the nutritional status of adolescents and assess their dietary patterns. This study will help to design intervention strategies to improve nutritional status and dietary habits among adolescents.

Material and Methods

A questionnaire based cross-sectional, observational study was conducted in 10 government co-educational schools of the South Delhi area between April 2018 to March 2019. The study was approved by the Institutional Ethics Committee (IEC/555/9/dated 22/11/2017) and the Directorate of Education, Government of Delhi (No. HQ Br./2018/Project/22 dated 09/04/2018).

Sample size calculation: The sample size was calculated based on the formula of n=z² pq/e² where ‘p’ prevalence of thinness, q=1-p, and ‘e’ is the allowable error (13). The sample size estimated was 1580 adolescents, assuming prevalence (p) of thinness among adolescent as 20.2% (14) and with an allowable error of 10% and rounded to 1600 residing in the urban area of Delhi.

Inclusion criteria: A total of 1600 participants between 10-19 years of age whose parents gave informed consent were included in the study.

Exclusion criteria: Participants on any long-term medication and those who were absent on the day of visit were excluded from the study.

Data Collection

The study was permitted to be conducted in 101 government schools with a population size of 7,58,611 students. A total of 23 co-educational government schools fell under the permitted area and 10 school principals gave consent to be a part of the study. The permission was sought from the Directorate of Education, Delhi. Since the permitted population was large, a sample of 1600 students was selected to participate in the study. Confidentiality and anonymity of participants were maintained.

The consent forms were distributed from class 6^th to class 12^th standard of each school. A total of 180 students from each school were randomised to ensure data from 160 students considering the dropout due to absence from each school on the particular day of data collection.

The complete information about the study was shared with the study participants. A predesigned, pretested, self-administered questionnaire in English and Hindi (local languages) was given to the participants according to their preference. All the questions included in the socio-demographic profile and simplified dietary gap assessment tool (15) based on the dietary recommendation by the Indian Council of Medical Research (ICMR) and the National Institute of Nutrition (NIN) (16) were discussed by the investigator with each participant and ample time was given to fill the questionnaire. The study participant’s age was reverified from their school records.

A portable stadiometer was used to measure the height of participants. Each participant was made to stand without shoes with the head held comfortably upright. The horizontal headpiece of the stadiometer was made to have firm contact with the top of the head of the participant.

The calibrated weight machine was used to record the weight of the subjects. Participants were instructed to stand on the weight machine without shoes, with feet apart and looking straight.

Criteria for adolescent stage: As per WHO, the adolescence period is divided into early, middle and late periods, which is 14, 15-17 and 18-19-year age groups, respectively (17).

Criteria for the assessment of obesity, overweight and thin: The WHO-BMI for age and gender-specific standards for adolescents (5-19 years) was used. BMI was categorised by using Z score tables (18). The normal BMI range was based on the age and gender specific standards. The obesity, overweight and thin were assessed with the criteria of obesity: >+2 SD (equivalent to BMI 30 kg/m² at 19 years), overweight: >+1 SD (equivalent to BMI 25 kg/m² at 19 years) and thin: <-2 SD.

Criteria for socio-economic status: The socio-economic status was assessed using the Modified BG Prasad socioeconomic scale 2017 (19).

Statistical Analysis

The data obtained from the study participants were subjected to statistical analysis using Graph pad Version 5 statistical software. The descriptive analysis was done to calculate the frequency of dietary consumption pattern in students. Cross-tabulation and Chi-square test was used to investigate the association between dietary intake and BMI levels.

Results

There were 1600 students out of which 53.4% (855) were males and 46.5% (745) were females. The mean age of the male participants was 13±2 years and female participants was 13.4±2 years. The majority of the study subjects 1107 (69.1%) were from the age group of 10-14 years. The socio-demographic profile of the study participants is shown in (Table/Fig 1).

A total of 457 (28.5%) of the participants had normal BMI as per the WHO-BMI chart while 1089 (68%) participants were thin and 54 (3.3%) participants were obese/overweight. The (Table/Fig 2) shows the nutritional status of the participants as per the WHO-BMI chart.

The nutritional status of male participants revealed 71% were thin, 3.9% were overweight/obese. Among female participants, 64.5% were thin and only 2.6% were overweight/obese. This difference between male and female participants was statistically significant (p<0.001). A 75.9% of participants belonged to early adolescent age were thin while 50% of participants from late adolescent age were thin which was also statistically significant (p<0.0001).

(Table/Fig 3) shows the distribution and pattern of the eating habits among adolescents as the simplified dietary gap questionnaire. The habit of taking milk, milk products and fruits were low among the males and early adolescent age group.

In (Table/Fig 4), Chi-square test was applied to find whether there was any significant difference in the eating habits between the age group and gender of adolescents. Except for the eating habit of consuming three main meals of cereal or intake of milk or milk products rest other food habits were found to be significant between the age group. There is no significant difference associated with faulty dietary habits of skipping meals/eating junk food/buying eatables from street shop between male and female participants. The habit of taking milk and milk products was significantly more common among the male participants (p<0.0001).

In (Table/Fig 5), the χ² test was applied to measure the association between the pattern of food habits and the BMI status of adolescents. The habit of taking pulses or non vegetarian food items in the daily diet was not found significant whereas all other food habit patterns were significantly associated with BMI levels among adolescent school students. It was observed that faulty dietary habits of skipping meals or eating junk food or buying eatables from street shop were associated with more participants under the obese/overweight category. The habit of non consumption of healthy mid-morning and mid-evening snack/milk or milk products/green leafy vegetables/other vegetables/fruit in daily diet was significantly associated with participants under the thin category.

Discussion

The present study shows that 608 (55.8%) boys and 481 (44.1%) girls were thin. These findings of undernutrition are similar to the survey conducted by the National Family Health Survey 2015-16 where the prevalence of thinness in boys and girls was estimated as 58.1% and 46.8%, respectively (20).

The proportion of thin students 1089 (68%) in the current study is much higher as compared to the study conducted in the urban adolescent population of West Bengal where the prevalence of underweight students was 27.9% (14). In the current study, there were only 54 (3%) students who fell under the obese/overweight category whereas the prevalence of overweight was 5.9% and obesity was 2.7% in a study covered under field practice of north India (12). The summary of current and previous studies are tabulated in (Table/Fig 6) to understand the key aspects on each study (21),(22),(23),(24).

In the present findings, 1422 (89%) participants consumed three main meals a day. It is observed that girls had significantly less tendency to have three main meals in a day as compared to boys (p=0.0004*). The behaviour behind not taking the main meals among adolescent girls is their desire to be thin and the unhappy feeling about their weight (25),(26). The other reason associated with skipping main meals can be the lack of appetite or time or interest in the diet (25).

It is observed in the current study that 530 (30%) students tend to skip their meals and get themselves trapped under faulty dietary pattern. Nearly 30% from the thin category and 41% from the overweight/obese category tends to skip one of their daily meals. This behaviour among adolescents pushes them towards the double burden of malnutrition where the prevalence of underweight and prevalence of obesity/overweight among the adolescent population is increasing rapidly in India (27).

A study done by Rodrigues P et al., also revealed that skipping a meal is often associated with a low-quality diet and high intake of low nutritious food items. It also suggested that regular meal habits among adolescents can help them to improve the quality and pattern of diet intake (28).

The study population belongs to the students studying in the Government schools of Delhi where the mid-day meal facility is provided. It has been observed that 94% (434) students from the normal BMI category had developed the habit of consuming midmorning snack daily. Though the students belonging to mid and late adolescent age were bringing their lunch and taking meals while the early adolescents were skipping their mid-morning meals (Table/Fig 4). There was a significant gender difference between the intake of mid-morning snack in the present study (p<0.0002). It is evident in the current study that mid-morning and mid-evening healthy snack bridged the nutritional gap. Benton D and Jarvis M, also noted that the adverse effects of low quantity and quality breakfast were reversed by mid-morning snack intake (29).

According to the Comprehension National nutrition survey in 2016-18 by the Ministry of Health and Family Welfare of India on 11,00,000 pre-schooler, school-age children and adolescents suggested that more than 80% of the study population consumed pulses in their weekly diet chart though the intake of meat/fish/egg consumption was less frequent (30). In the current study, also we have found that 1502 (94%) study participants consumed pulses/non vegetarian items in their daily diet. In the present study, the intake of pulses or non vegetarian food in their daily diet was taken by most of the study participant irrespective of their gender, adolescent stage and BMI levels.

In the current study, 955 (59%) participants had the habit of taking milk and milk products daily. The habit of taking milk and milk products were significantly higher among the boys than the girls (p<0.0001). However, there is no remarkable change in the habit of taking milk or milk products between 10-14 years and 15-19 years of adolescent age groups. The study results are also aligned with the study done by Rathi N et al., where two-fifth of the participants did not consume milk products (6).

The BMI levels of the individuals who are dependent on the habit of consuming milk products can be compared in the current study (Table/Fig 5). Milk is a rich source of calcium which has an impact on the growth during the adolescent phase. In this line, one more study conducted in Baroda, Western India revealed that nearly one fourth of the participants did not take milk/milk products in their daily diet (8).

In the present study, 838 (52%) consumed green leafy vegetables and only 655 (41%) participants consumed fruits in their dietary pattern. A study done by Kotecha PV et al., revealed that green vegetables were consumed by 75% and fruits by 63% in the past 24 hours (8). (Table/Fig 5) shows that one quarter (32%) of participants under the thin category of BMI consumed green leafy vegetables and one-fourth quarter (23%) fruits in their daily diet. In our study, the quantitative analysis of micronutrients was not done however, the poor consumption gives indirect evidence of micronutrient malnutrition among adolescents.

A study done by Meenakshi J, also claimed that low intake of fruits and vegetable lead to micronutrient deficiencies in Indian population. It is a kind of triple burden of malnutrition among adolescents where the hidden hunger of micronutrient deficiency also exists (31). Our study showed no significant gender difference in the eating habit of junk food and buying eatables from street vendors. Mid and late adolescents had more frequent habit of eating junk food (p=0.005) and buying eatables from street vendors (p=0.0025) than the early adolescents. This behavioural change among early adolescents might be related to the parental influence in their diet (32).

The percentage of obese/overweight students was only 3% (54) in the current study and out of them 65% (35) students were consuming junk foods and bought eatables from street vendors. Likewise, it is also evident from another study done in Maharashtra, that BMI was higher in the subjects who consumed junk food item (30.9%) more frequently (33). The survey data from 1,999 secondary school students also found that 81.2% of students who drank sweetened carbonated were overweight/obese (34).

In schools, the awareness about healthy eating habits among adolescents should be encouraged to reduce the gap of nutrition in the daily diet. This kind of approach can be inculcated to increase the consumption of milk, green vegetables and fruits to minimise the micronutrient deficiency among the adolescents.

Limitation(s)

This study was conducted among adolescents only in government schools, therefore the findings cannot be generalised to private schools. The data on dietary habits was based on recall memory of the students, so there may be recall bias. The quantitative measurements of the recommended portions of food groups were not recorded.

Conclusion

The dietary gap was more pronounced in female participants and participants in the early adolescent age group. The gap in the diet of adolescents influences their nutritional status and BMI. The poor choice of dietary habits significantly affects the physical development among school-going adolescents. Therefore, awareness about the consequences of faulty dietary habits must start during childhood and nutritional interventional programs should be designed based on the gap in the diet of adolescents.

It has been identified in the current study that intake of milk/milk products, green leafy vegetables and fruits is low among adolescents. Low consumption of milk/milk products, green leafy vegetables and fruits among adolescents may lead to micronutrient deficiency. Further studies can be designed to detect the clinical manifestation of micronutrient deficiency and socioeconomic status and its correlation with the consumption pattern of food items.

Acknowledgement

The authors are thankful to the Directorate of Education, Delhi for permitting us to conduct the study. The authors sincerely acknowledge the Principal and teachers of the selected schools in Delhi for consenting to this study; and the students for their cooperation.

DOI and Others

10.7860/JCDR/2021/48202.15158

Date of Submission: Dec 20, 2020
Date of Peer Review: Jan 19, 2021
Date of Acceptance: Apr 07, 2021
Date of Publishing: Jul 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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