Page mackup-Final.qxd Original Article Assessment of Nutritional Status among Adolescent Garo in Sherpur District, Bangladesh Tamanna S1, Rana MM2, Ferdoushi A3, Ishtiyaq Ahmad SA4, Rahman M5, Rahman A6 Abstract: Background: Garo is one of the largest indigenous communities of Bangladesh. Adolescence is a gold- en period of time for nutritional promotion. Adolescent nutrition did not receive adequate attention in Bangladesh. Tribal people like the Garo are even more unaware about the importance of adolescent nutrition. Objectives: To find out physical growth as well as nutritional status among adolescent Garo children in Sherpur district on the basis of anthropometric indices. Methods and materials: This cross sectional descriptive study was conducted among 384 adolescent Garo children (boys and girls) aged 10- 18 years. A structured pre-tested questionnaire and a checklist were used to collect data through inter- view. Anthropometric survey of randomly selected adolescent was carried out and compared against the NCHS/WHO reference indicators such as BMI-for-age, Height-for-age and Weight-for-age. Standard methods were applied to measure the height and weight of the adolescent and BMI was calculated. Associations of nutritional status with socio-economic status, maternal working status, family type and family size were determined. Results: In most of the age groups it is notable that the mean height and weight of both boys and girls were lower than the WHO/NCHS standards. The prevalence of thinness, stunting and underweighting was 49.74%, 15.1% and 7.29% respectively. Conclusions: Significant association between malnutrition and socio-economic parameters was observed. So socio-economic sta- tus, maternal working status, family type and family size are important determinants of nutritional sta- tus of adolescent. Therefore, comprehensive programmes are required to be undertaken for the overall nutritional development of the Garo population with special focus on the adolescents. Kew words: Nutritional status, Adolescence, Anthropometry, Garo, Bangladesh. Introduction: Adolescents constitute a core resource of a nation for national rejuvenation and augmentation. They are a large and growing segment of the global pop- ulation. Adolescence is a period in life when tran- sition from childhood to adulthood takes place and behaviours and life styles are shaped 1 . According to the World Health Organization people aged between 10-19 years are considered as adoles- cence 2 . They form a distinct group in the society, which is clearly different from children and the adults. They need a special support, care and require special health services 3 . Proper nutrition during adolescence period can be an important link in nutrition throughout lifespan. To invest in the health and development of the adolescents is to invest in the greater well-being of the country. United Nations estimated that about 1/5th of the total population of the world are adolescents 4 . Again, among the total adolescents of the world, about one-fifth (19%) live in Asia 5 . Bangladesh is one of the world's most densely populated coun- Corresponds to: Aysha Ferdoushi, Lecturer, Department of Biotechnology and Genetic Engineering, Mawlana Bhashani Science and Technology University, Bangladesh. E-mail: nupur_bmb@yahoo.com 1. Sonia Tamanna, Department of Biochemistry and Molecular Biology, University of Dhaka, Bangladesh. 2. Md. Masud Rana, Department of Biotechnology and Genetic Engineering, Mawlana Bhashani Science and Technology University, Bangladesh. 3. Aysha Ferdoushi, Department of Biotechnology and Genetic Engineering, Mawlana Bhashani Science and Technology University, Bangladesh. 4. Shah Adil Ishtiyaq Ahmad, Department of Biotechnology and Genetic Engineering, Mawlana Bhashani Science and Technology University, Bangladesh. 5. Mustafizur Rahman , Department of Biochemistry and Molecular Biology, University of Dhaka, Bangladesh. 6. Atiqur Rahman, Department of Biochemistry and Molecular Biology, University of Dhaka, Bangladesh. Bangladesh Journal of Medical Science Vol. 12 No. 03 July’13 269 tries facing major health and economic challenges. Rates of malnutrition in Bangladesh are among the highest in the world 6 . Malnourished children are more probable to grow into malnourished adults who face heightened risks of diseases and death 7 . Dr Sohail Ally reported that the adolescent popu- lation in Bangladesh is 29.5 million 8 . Adolescent growth spurt is delayed, extended, and less intense in the Bangladeshi females than in their western counterparts 8. Chronic energy deficiency, protein energy malnutrition, low birth weight, micronutri- ent deficiency are all serious problems in Bangladesh. Although it affects people of all ages, the children, women and the female adolescents are mostly affected 9 . Again chronic under-nutrition is considered to be the primary cause of ill health and premature mortality among children in devel- oping countries 10 . In Bangladesh there are indigenous groups, approx- imately 1.2 million and 1.13% of the total popula- tion 9, 11 . Among them the Garo is one of the largest indigenous communities. According to the histori- ans of this continent, the Garo tribe colonized Bangladesh in the first century. They were refugees from Mongolia and came to this region through Tibet. Recent estimates suggest that in total there are 97,695 Garo people. They live in the north-eastern parts of the country especially in Gajipur, Mymensingh, Netrakona, Tangail, Sherpur, Jamalpur and some in Syllet districts close to the Indian border 12 . The Garo tribe, like every other indigenous community has its own cul- ture. Their dresses, food habits and celebration styles can be easily distinguished from the native people and other tribes. Compared to the other tribal groups, the Garo tribe is little advanced in education and social activities. The problem of food security is common in all the ethnic groups. Being part of a developing country, the Garo com- munity also suffers from poverty. Children belong- ing to socially rearward groups like scheduled castes 13 and tribes 14 are very much prone to malnu- trition. In general, the tribal population is at a higher risk of malnutrition, because of the socio- cultural, socio-economic and environmental factors influencing the food intake and health seeking behaviour 15 . However, nutrition-related data of adolescents in the Region is very scarce 16 . This area obviously needs more focus. To protect Garo adolescents from health risks and make healthy choices, complete and disaggregated data (by age and sex) must be collected. The objective of the present study is to evaluate the nutritional status of the Garo children aged 10-18 years using anthro- pometric indices. The subjects for the present cross-sectional study were selected from Jhenaigati Upazila in Sherpur District, a hilly district of Bangladesh that has a significant number (about 16232) of tribal people. Methods and materials: This cross sectional study was conducted among 384 adolescent Garo children in Sherpur district, Dhaka, Bangladesh. Among the 384 adolescent children 209 (54.43%) were males and 175 (45.57%) were females. The study subject was chosen following simple random sampling method. Samples were collected from the place of residence and schools. The sample size (n) was calculated by the follow- ing formula17:- N=z 2 pq/d 2 =384 Where, N= desired sample size Z=normal standard deviation confidence level of set will be 95%, which corresponds to 1.96 P=the estimated prevalence (assume 0.5 or 0.05) Q= 1-p=1-0.5=0.5 D=degree of accuracy desired usually set at 5 % (0.05) A well structured questionnaire was developed to obtain relevant information on anthropometric and socioeconomic condition of the Garo adolescents. All questions were customized and resettled to obtain and record information easily. Nutritional status was assessed by anthropometric measure- ments such as height, weight, BMI using standard- ized methodology 18 . Age of the subjects under study was determined by interrogation and confirmed through probing if the birth certificate were unavail- able. The weight was measured by using digital scale to the nearest 0.1 kg and height was measured using anthropometer to the nearest of 0.1cm. BMI was computed using the standard equation: BMI = Weight (kg) / height (m2). Two nutritional indices such as “weight for age z score” (WAZ), “height forage z score” (HAZ) were calculated using World Health Organization (WHO) standard (WHO, 2000). Z- Scores <-2 SD of the above indices were Assessment of Nutritional Status among Adolescent Garo in Sherpur District, Bangladesh 270 considered as underweight (WAZ) and stunting (HAZ). Data were analyzed by using SPSS Version 14.0. P-values of less than 0.05 were considered to Local ethical approval was taken before study. Results and Discussions: Malnutrition continues to be a serious public health problem in Bangladesh. Consecutive national nutri- tion surveys reported high prevalence of malnutri- tion in our country 19, 20. The nutritional status of adolescent contributes significantly to the nutrition- al status of the community. As adolescent is a crit- ical period of growth and development, any pro- gramme for a long-term effect on health should have a focus on this period of life. The present study was carried out among the Garo children aged 10-18 years in Sherpur district to find out their physical growth as well as nutritional status on the basis of anthropometric indices. Anthropometry is widely recognized as one of the useful techniques for nutritional assessment because it is highly sensitive to detect under-nutri- tion 21 . It can be used to verify the existence of nutritional problem in a population and to assess its magnitude. These types of measurements are non- expensive, need minimal training and readings are reproducible. Table I: Detail age and sex wise distribution of the study sample The age and sex distribution of the studied children are given in Table I. A total of 384 adolescent were studied. Among them 209 (54.43%) were male and 175 (45.57%) were female. Of them 11.19%, 8.07%, 25%, 11.46%, 14.58%, 16.14%, 7.55%, 2.86% and 3.12% children were in age group 10, 11, 12, 13, 14, 15, 16, 17 and 18 years respectively. Tamanna S, Rana MM, Ferdoushi A, Ishtiyaq Ahmad SA, Rahman M, Rahman A 271 Frequency Age in Years Male Female Total 10 21(48.8) 22(51.2) 43(100) 11 17(54.83) 14(45.17) 31(100) 12 48(50) 48(50) 96(100) 13 23(52.27) 21(47.73) 44(100) 14 29(51.79) 27(48.21) 56(100) 15 39(62.9) 23(37.1) 62(100) 16 21(72.41) 8(27.59) 29(100) 17 5(45.46) 6(54.54) 11(100) 18 6(50) 6(50) 12(100) Total 209(54.43) 175(45.57) 384(100) Boys Girls Number examined Mean weight (kg) SD WHO/NCHS standard weight (kg) Number examined Mean weight (kg) SD WHO/NCHS standard weight (kg) p- value 21 27.36 3.37 31.4 22 28.18 4.21 32.5 0.481 17 29.70 6.07 32.2 14 30.71 6.37 33.7 0.658 48 36.12 6.78 37.0 48 37.06 6.69 38.7 0.519 23 46.0 7.05 40.9 21 42.81 5.06 44.0 0.091 29 46.24 5.53 47.0 27 43.26 5.53 48.0 0.049 39 50.74 6.34 52.6 23 47.43 3.75 51.5 0.027 21 53.19 7.18 58.0 8 45.13 5.35 53.0 0.008 5 57.4 6.06 62.7 6 45.00 3.16 54.0 0.002 6 57.84 4.66 65.0 6 45.5 2.66 54.4 0.000 Table II: Comparison of mean weight of boys and girls SD= Standard Deviation Table II focused the mean weights of boys and girls of the study group. The mean weight of girls was more than the boys till twelve years of age, there after the boys weighed more. In age group 16 to 18 there was statistically significant difference in the mean weight of the boys and girls. On comparison with the WHO/NCHS standard the mean weight of boys and girls was found to be lower in most of the age groups. Only thirteen years old boys weighted more than the standard value. It is noticeable that the mean weight of girls was found to be much lower compared to WHO/NCHS standard. Table III: Comparison of mean height of the study population Height may be considered most representative characteristic of overall growth and development. Table III represents the mean height of boys and girls. No significant mean height difference was found in 10, 11 and 12 aged adolescents but thereafter the boys were taller than the girls. In most of the age groups it was notable that the mean height of both boys and girls was lower than the WHO/NCHS standards. Only the boys aged thirteen years were taller than the standard height. Table IV: Nutritional Status of Study population according to WHO International Classification of underweight, overweight and obesity based on BMI In the current study (presented in table IV) according to WHO reference standard 49.47% adolescents were normal (BMI 18.5-24.99), 49.74% adolescents were undernourished (BMI<18.5) and rest 0.79% were overweight and none of the adolescent was found to be obese. Boys suffering from chronic energy deficiency grade I, II and III were 25.36%, 17.22% and 7.65 % respectively and for girls it was 71%, 16% and 7.03 % respectively. So girls were more undernourished than boys. Table V: Prevalence of stunting and underweight in study group according to WHO/NCHS standards According to WHO/NCHS standards, 58 (15.1%) out of 384 adolescent were stunted, with 9 (2.34%) adolescent showing severe grade of stunting (Table V). Among them girls (17.71%) were more stunted compared to boys (12.91 %). However 28 (7.29%) adolescent were underweight with 1.56% showing severe grade of underweight. Among them girls (10.86%) were more underweight than boys (4.3%). Assessment of Nutritional Status among Adolescent Garo in Sherpur District, Bangladesh 272 Boys Girls Number examined Mean height (cm) SD WHO/NCHS standard height (cm) Number examined Mean height (cm) SD WHO/NCHS standard height (cm) p- value 21 132.14 7.82 137.5 22 132.32 6.05 138.3 0.79 17 135.24 9.56 140.0 14 137.29 6.71 142.0 0.49 48 143.94 8.87 147.0 48 140.16 6.68 148.0 0.64 23 155.57 8.08 153.0 21 148.61 5.74 150.0 0.002 29 154.62 5.77 160.0 27 149.19 5.91 155.0 0.001 39 158.05 6.36 166.0 23 152.17 4.83 161.0 0.000 21 161.76 5.88 171.0 8 149.13 4.73 162.0 0.000 5 164.20 2.58 175.0 6 151.5 4.13 163.0 0.000 6 163.67 1.96 177.0 6 149.67 3.07 164.0 0.000 Age 10 11 12 13 14 15 16 17 18 Grade of Under nutrition BMI Cut off Value Kg/m2 No. of adolescent boys (%) No. of adolescent girls (%) No. of total adolescent (%) Grade 3 Thinness < 16 16(7.65) 27(7.03) 43(11.20) Grade 2 Thinness 16.0-16.99 36(17.22) 28(16) 64(16.67) Grade 1 Thinness 17-18.49 53(25.36) 31(17.71) 84(21.87) Normal 18.5-24.99 103(49.28) 87(49.71) 190(49.47) Overweight 25-29.99 1(0.47) 2(1.14) 3(0.79) Obese >30 0 0 0 Stunted Underweight Severe (%) Moderate (%) Total (%) Severe (%) Moderate (%) Total (%) Boys (n=209) 3(1.43) 24(11.48) 27(12.91) 1(0.47) 8(3.83) 9(4.3) Girls (n=175) 6(3.42) 25(14.28) 31(17.71) 5(2.85) 14(8) 19(10.86) Total (n=384) 9(2.34) 49(12.76) 58(15.1) 6(1.56) 22(5.73) 28(7.29) Table VI: Prevalence of stunting and underweight in study group according to mothers’ working status Table VI executed that the prevalence of stunting and underweight was higher among adolescent whose mothers were housewives than those who are involved in different types of working. Similar study car- ried out by Mukherjee et. al also found the parallel result. Table VII: Prevalence of stunting and underweight with respect to socioeconomic status Table VII represents that out of 384 study population 244 (63.54%) belongs to the family of farmer, 61 (15.89%) belong to day labourer, 47 (12.24%) belong to employee, 7 (1.82%) belong to small busi- nessman and rest 25 (6.51%) from other category. Majority of the mothers 331(86.2%) were housewives and most of them were illiterate. From this table it is revealed that of the 384 adolescent whose father are day labour were more stunted (24.59%) and underweighted (21.31%) than those whose father are employee, while the lowest prevalence of stunning(4.25%) and underweight (2.13%) were observed in the adolescents whose father are employee. So, these figures suggest that socioeconomic conditions are closely associated with nutritional status of the adolescents. Table VIII: Prevalence of stunting and underweight in study group according to family type Significant association was also observed between stunting, underweight and socio economic indicators such as type of family (Table VIII). Prevalance of stunning and underweight was observed to be much higher in the joint families compared to the nuclear families. Table IX: Prevalence of stunting and underweight with respect to family size Table IX represents that 114 (29.68%) adolescent children came from families consisting three-four mem- bers, 199 (51.82%) were from families of five-six members and 71 (18.49%) were from families consist- ing more than six members. Higher prevalence of stunning and underweight was observed in the families having more than six members whereas lowest prevalence of stunning and underweight was seen in those families having three-four members. Thus the present study implies that family size is significantly associ- ated with nutritional status. Similar results have been reported by Gopaldas et al and Mukherjee et al. 22,23 Tamanna S, Rana MM, Ferdoushi A, Ishtiyaq Ahmad SA, Rahman M, Rahman A 273 thgiewrednU detnutSMaternal working status N (%) Stunted (%) Normal (%) Underweight (%) Normal (%) Working 53(100) 6(11.32) 47(88.68) 3(5.67) 50(94.33) Housewives 331(100) 52(15.71) 279(84.29) 25(7.55) 306(92.45) Total 384 58(15.10) 326 (84.9) 28(7.29) 356(92.71) thgiewrednU detnutSSocioeconomic Status N Stunted (%) Normal (%) Underweight (%) Normal (%) Farmer 244 36(14.75) 208(85.25) 10(4.09) 234(95.91) Day labour 61 15(24.59) 46(75.41) 13(21.31) 48(78.69) Employee 47 2(4.25) 45(95.75) 1(2.13) 46(97.87) Business 7 1(14.28) (85.72) 1(14.28) 6(85.72) Other 25 4(16) 21(84) 3(12) 22(88) Total 384 58(15.10) 326(84.9) 28(7.29) 356(92.71) thgiewrednU detnutS Type of family N (%) Stunted (%) Normal (%) Underweight (%) Normal (%) Nuclear family 347(100) 39(11.24) 308(88.76) 17(5.67) 330(94.33) Joint family 37(100) 14(51.35) 23(48.65) 11(29.72) 26(70.28) Total 384 58(15.10) 326 (84.9) 28(7.29) 356(92.71) Stunted Underweight Family size (members) N Stunted (%) Normal (%) Underweight (%) Normal (%) 3-4 members 114 13(11.4) 101(88.6) 5(4.38) 109(95.62) 5-6 members 199 21(10.55) 178(89.45) 12(6.03) 187(93.97) Aove-6 members 71 24(33.81) 47(66.19) 11(15.49) 60(84.51) Total 384 58(15.1) 326(84.9) 28(7.29) 356(92.71) Figure I: Prevalence of stunted (a) and under- weight (b) children with respect to different socioeconomic parameters. a. b. In Figure I, we have tried to summarize the find- ings of the study with respect to the association of different socioeconomic parameters with adoles- cent nutrition of the subjected Garo tribe. From the figure, we can see that the joint families, families with more than 6 members and families of day labourers are the worst in maintaining adolescent nutrition. So, in order to improve the adolescent health status we must give emphasis on these three types of families. Conclusion: Adolescence is a golden period of time for nutri- tional promotion as it is a vital phase of physical growth and development in the lifespan. Another proposition of adolescence in human life cycle lies in its immediacy to later life. Thus, health and nutritional status of adolescent children may have great impact on the quality of the next generations. According to UNICEF report there are 27.7 mil- lion adolescents aged 10-19 years in Bangladesh – 13.7 million girls and 14 million boys – making up about one fifth of the total population. Regardless of all these important considerations, adolescent nutrition did not receive adequate attention in Bangladesh. Tribal people like the Garo are even more unaware about the importance of adolescent nutrition. The aim of this study was to prepare an adolescent health profile for the adolescent Garo of Jhenaigati upazila. The results of the present study indicate that nutritional status of these children is not satisfactory as more than half of the adoles- cents are malnourished. This study also focuses on some other contributing factors which may affect adolescent nutrition like socio-economic status, maternal working status, family type and family size etc. There is much scope for the improvement of their nutritional status. The economic status of the parents must first be improved. 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