Assessment of nutritional status of adolescent boys from public and private schools of Peshawar

INTRODUCTION

Adolescence, a transitional period between childhood and adulthood, covers the ages between 11-19 years¹. It is considered to be the most important and versatile period of life where growth and development are accompanied by physical, physiological, behavioral, and social changes. During this period of accelerated growth, the demand for nutrients increases posing a greater risk of nutritional deficiencies. Adolescents from developing countries are more vulnerable to nutritional deficiencies due to early childhood nutritional insults, which include underweight, stunting and low dietary intakes².

Pakistan is the 9th most populous country in the world with a population of about 140 million³. Adolescents constitute about one fourth of the population but haven't received much attention with respect to their nutritional needs and wellbeing⁴. Adolescence being a crucial period of human life is subjected to a variety of challenges that not only include diverse dietary and health care practices but also emotional, behavioural and peers controlled influences. These result in a complicated scenario which has to be dealt with individual support and counseling to avert long term functional and economic consequences. Before initiating any nutritional intervention for adolescents, it is important to have baseline nutritional data for the development of a proper and effective plan of action. In addition, socio-economic conditions of the families also play an important role in determining the quality of life, reflected by health and nutritional indicators of the country. Since very limited nutritional data on adolescents are available at the Purpose of study country level, the present study was undertaken to assess the nutritional status of adolescent boys studying in public and private schools of district Peshawar and to examine the relationship between the nutritional status and socio-economic factors of the families.

MATERIALS AND METHODS

Two public (Wazirbagh & Lakari Kaniza) and two private (Beaconhouse & Peshawar Model) schools of district Peshawar were selected to assess the nutritional status of boys by taking their anthropometric (weight, height, triceps skinfold, and mid arm circumference) measurements and dietary intake data. A total of 800 boys aged between 11-15 years, 200 from each school were selected randomly. Weight, height, triceps skinfold and mid-arm circumferences of the boys were taken by using the standard anthropometrics procedures⁵. Anthropometric values of the boys were compared with the National Centre for Health Statistics (NCHS) to generate Z-scores and to determine the nutritional standing of the boys⁶.

A semi-quantitative food frequency questionnaire was developed in which commonly consumed foods and drinks were listed and the respondents were asked for the frequency and portion size of the foods and drinks consumed. From the food frequency questionnaire, foods and drinks providing similar types of nutrients were grouped into cereals, meat, dairy and fruits groups. Energy, protein, and calcium intakes of the boys were determined from the portion size estimates by consulting food composition table⁷ and food analysis software⁸. The nutrient intakes of the boys were then compared with the recommended dietary allowances⁹. Demographic and socio-economic data were collected from the boys of public and private schools.

Data regarding anthropometry, dietary and demographic socio-economic characteristics were entered into the computer for statistical analysis using Epi-info¹⁰ and SAS¹¹. Descriptive statistics like frequency, range, stem and leaf were run to clean the data from errors and to check distribution of the data. Analysis of variance was run on anthropometric and socio-economic data to check for significant differences in Z-scores, family size and income of the boys families among the four age groups. Correlation analysis was performed on the anthropometric, dietary, and socio-economic variables to establish an association between different variables at 5% level of significance.

RESULTS

Anthropometric results of the boys from two public high school, Wazirbagh and Lakari Kaniza and two private high schools, Beaconhouse and Peshawar Model are presented in tables 1-4. As evident from table 1, there were no significant differences in the mean weight and mid arm circumference values of the boys between the public and private schools. But the mean height and triceps skinfolds values of the boys from the Beaconhouse and Peshawar Model schools were significantly higher than those from the Wazirbagh and Lakari Kaniza schools. The table also shows that 11-12 year-old boys from Beaconhouse and Peshawar Model schools had significantly higher mean weight-for-age Z-scores (WAZ), height-for-age Z-scores (HAZ) and mid arm circumference Z-scores (MACZ) than those of Wazirbagh and Lakarai Kaniza high schools. However, there was no significant differences (p > 0.05) in the mean WAZ, HAZ and MACZ between the Beaconhouse and Peshawar Model schools.

In the older group (12-15 years) of boys, the means WAZ, HAZ, WHZ, TSFZ, and MACZ of the boys from Beaconhouse and Peshawar Model schools were significantly (p <0.05) higher than those of Wazirbagh and Lakarai Kaniza high schools but these differences were not significant (p >0.05) between the boys from Beaconhouse and Peshawar Model schools. The prevalence of malnutrition assessed by applying the recommended cut-off (<-2 Z-score) on the anthropometric indicators revealed that the prevalence was highest amongst the boys of Lakarai Kaniza high school followed by Wazirbagh, Peshawar Model and Beaconhouse schools (table 5). The nutrient intakes by the 11-15 year-old boys from various schools of Peshawar district as shown in figure 1 indicate that 89% of the boys from the Beaconhouse school were meeting the recommended energy requirements as compared to 85% from the Peshawar Model school, 59% from the Wazirbagh and 57% from the Lakarai Kaniza high schools. The results on dairy products consumption revealed that only 13% and 11% of the boys from Beaconhouse and Peshawar Model School, respectively, were meeting the recommended calcium requirements while none from the Wazirbagh and Lakarai Kaniza high schools met the 100% requirement of calcium. Protein consumption by the boys from different schools demonstrated that only a very small percentage of boys from Beaconhouse and Peshawar Model schools received the 100% recommended requirement of protein while none from the Wazirbagh and Lakarai Kaniza high schools received the 100% recommended requirement of proteins. The demographic and socio-economic results of boys families indicate that the mean family sizes of the boys from Beaconhouse and Peshawar Model schools were significantly lower (p <0.05) than the family sizes of the boys from Wazirbagh and Lakarai Kaniza high schools (table 6). Similarly, the mean family income of the boys from Beaconhouse and Peshawar Model schools was significantly higher than the family incomes of the boys from Wazirbagh and Lakarai Kaniza high schools but there was no significant difference (p >0.05) in the mean income between the boys families from Beaconhouse and Peshawar Model schools.

Table 1. Anthropometric measurements of boys 11.0-12.0 years from public & private schools of Peshawar.

School

Weight Kg

Mean ±SD^*

Z-score

Mean ±SD^*

Height cm

Mean ±SD^*

Z-score

Mean ±SD^*

TSF mm

Mean ±SD^*

Z-score

Mean ±SD^*

MAC cm

Mean ±SD^*

Z-score

Mean ±SD^*

Wazir Bagh High School

32.77^a

±3.76

-0.68^a

± 0.63

138.7^a

±4.20

-0.97^a

±0.60

6.22^a

±2.74

-1.11^a

±0.74

19.87^a

±2.16

-0.95^b

±0.94

Lakarai Kaniza

High School

32.62^a

±4.19

-0.65^a

±0.71

138.1^a

±5.26

-0.92^a

±0.76

6.19^a

±2.89

-1.13^a

±0.77

19.84^a

±2.02

-0.89^c

±0.88

Beaconhouse School

33.90^a

±2.91

-0.50^b

±0.48

142.1^b

±3.91

-0.51^b

±0.56

8.31^b

±2.01

-0.55^b

±0.53

20.62^a

±1.28

-0.56^a

±0.55

Peshawar Model School

33.49^a

±3.55

-0.56^b

±0.60

140.5^b

±4.27

-0.72^c

±0.61

6.97^a

±2.48

-1.02^b

±0.66

20.38^a

±1.55

-0.65^d

±0.68

*Mean in columns with similar letters are not significantly different p >0.005

Table 2. Anthropometric measurements of Boys between 12.0-13.0 years from public & private schools of Peshawar.

School

Weight Kg

Mean ±SD^*

Z-score

Mean ±SD^*

Height cm

Mean ±SD^*

Z-score

Mean ±SD^*

TSF mm

Mean ±SD^*

Z-score

Mean ±SD^*

MAC cm

Mean ±SD^*

Z-score

Mean ±SD^*

Wazir Bagh High School

34.74^a

±2.56

-0.96^a

±0.42

143.8

±3.65

-1.02^a

±0.66

5.62^a

±3.10

-1.07^a

±0.42

19.78^a

±3.54

-1.30^a

±0.5

Lakarai Kaniza

High School

34.05^a

±3.01

-0.97^a

±0.23

142.9

±3.74

-1.10^a

±0.57

6.01^a

±4.35

-1.00^a

±0.45

19.24^a

±3.24

-1.20^a

±0.47

Beaconhouse School

36.64^b

±2.35

-0.68^b

±0.38

145.2

±3.58

-0.73^b

±0.52

7.72^b

±3.21

-0.71^b

±0.34

21.34^b

±3.50

-0.67^b

±0.80

Peshawar Model School

35.97^b

±2.95

-0.74^b

±0.36

144.7

±3.25

-0.80^b

±0.35

7.12^b

±3.58

-0.79^b

±0.38

20.84^b

±2.56

-0.91^c

±0.58

*Mean in columns with similar letters are not significantly different p >0.005

Table 3. Anthropometric measurements of boys between 13.0-14.0 years from public & private schools of Peshawar.

School

Weight Kg

Mean ±SD^*

Z-score

Mean ±SD^*

Height cm

Mean ±SD^*

Z-score

Mean ±SD^*

TSF mm

Mean ±SD^*

Z-score

Mean ±SD^*

MAC cm

Mean ±SD^*

Z-score

Mean ±SD^*

Wazir Bagh High School

40.82^a

±5.64

-0.72^a

±0.67

152.0^a

±6.01

-0.72^a

±0.65

6.30^a

±1.90

-0.82^a

±0.59

21.49^a

±2.53

-1.00^a

±0.96

Lakarai Kaniza

High School

39.02^a

±6.32

-0.88^b

±0.71

151.0^a

±6.64

-0.85^b

±0.74

5.45^a

±1.99

-1.08^b

±0.63

21.04^a

±2.78

-1.16^b

±1.07

Beacon house School

43.38^b

±3.48

-0.41^c

±0.40

155.7^b

±4.12

-0.34^c

±0.46

7.25^b

±1.42

-0.53^c

±0.44

23.12^b

±0.99

-0.37^c

±0.38

Peshawar Model School

41.78^c

±5.0

-0.59^d

±0.60

153.4^c

±6.40

-0.61^d

±0.72

6.93^b

±1.80

-0.62^d

±0.55

22.75^b

±2.05

-0.60^d

±0.81

*Mean in columns with similar letters are not significantly different p >0.005

Table 4. Anthropometric measurements of boys between 14.0-15.0 years from public & private schools of Peshawar.

School

Weight Kg

Mean ±SD^*

Z-score

Mean ±SD^*

Height cm

Mean ±SD^*

Z-score

Mean ±SD^*

TSF mm

Mean ±SD^*

Z-score

Mean ±SD^*

MAC cm

Mean ±SD^*

Z-score

Mean ±SD^*

Wazir Bagh High School

44.90

±5.01

-1.13^a

±0.59

158.6

±5.87

-1.06^a

±0.74

5.19

±1.88

-1.11^a

±0.63

22.86

±1.54

-1.09^a

±0.65

Lakarai Kaniza

High School

43.43

±5.11

-1.32^b

±0.59

157.3

±5.83

-1.25^b

±0.74

4.66

±1.76

-1.28^b

±0.60

22.01

±1.42

-1.45^b

±0.59

Beacon house School

49.620

±4.75

-0.58^c

±0.55

161.2

±4.25

-0.76^c

±0.54

6.28

±1.65

-0.75^c

±0.55

23.35

±1.19

-0.89^c

±0.50

Peshawar Model School

48.10

±5.02

-0.76^d

±0.59

159.8

±5.42

-0.92^d

±0.67

6.00

±1.55

-0.84^d

±0.52

23.19

±1.52

-0.95^d

±0.62

*Mean in columns with similar letters are not significantly different p >0.005

Table 5. Prevalence of Malnutrition -2 Z-score in boys from public & private schools of Peshawar.

Nutrition Status	Wazir bagh High School	Lakarai Kaniza High School	Beaconhouse School	Peshawar Model School
Underweight <-2WAZ (%)	26 .1	38.2	8.4	13.7
Stunted <-2HAZ (%)	27 .1	42..2	9.5	18.9
Impaired adiposity <-2TSFZ (%)	30 .2	44 .2	7.4	16.8
Impaired muscle mass <-2MACZ (%)	34.2	44 .2	10.5	14.7

Table 6. Socio-economic status of families of boys from public & private schools of Peshawar.

School	Family Size Mean ±SD^*	Family Income /month Mean ±SD^*
Wazir Bagh High School (n=200)	7.5 ± 4.77	Rs. 5000^a ± 3.58
Lakarai Kaniza High School (n=200)	9.6 ± 4.92	Rs. 4890^b ± 2.42
Beacon house School (n=200)	5..9 ± 3.52	Rs. 15000^c ± 4.97
Peshawar Modal School (n=200)	6..9 ± 3.30*	Rs. 13000^c ± 4.09

Figure 1. Percent of boys receiving 100% RDA of energy, protein, calcium, and vitamin-minerals from cereals, meat, dairy and fruits respectively.

Nutritional status which reflects the state of health influenced by environmental and dietary factors is important to be assessed for planning and implementing appropriate nutrition interventions to avert long term disabilities and economic losses. Nutritional status of the school boys assessed by anthropometric measurements and food frequency questionnaire showed that boys of the private schools (Beaconhouse and Peshawar Model) were better than those studying in the public schools (Wazirbagh and Lakarai Kaniza). The difference in the nutritional status of the boys between the public and private schools may partly be attributed to the socio-economic differences of the families. In Pakistan, the private schools offer English as a medium of instruction and charge a handsome tuition fee fetch children from middle to higher income families while the public schools offer Urdu (national language) as a medium of instruction charge a very nominal tuition fee get children from lower income families. Since the two public schools are situated in the remote areas, boys from under-privileged families are enrolled in these schools while the two private schools, which are situated in the heart of the city, boys from privileged families are enrolled.

Our findings that boys from the private schools had better nutritional status than those of public schools are in conformity with others^12-13 who reported that boys from well-to-do families had almost similar nutritional status to that of reference boys while nutritional status of underprivileged boys was inferior to that of well-to-do families. Similar findings were reported by other researchers¹⁴ for Pakistani children who found that the mean weight and height of the children from upper middle class were close to the reference US means and grew much better than the children of the underprivileged class from the same area and ethnic background.

The increased dietary intakes by the boys from private schools also indicate that due to higher income of their families they could have access to foods, which were superior in quality and quantity than those studying in public schools. In developing countries where a large segment of the population is involved in low income jobs with large family sizes can't afford to buy good quality food and their diets are mostly restricted to cereals and legumes. The caloric intake which has been used as a yardstick to define poverty in Pakistan has been recognizes as 33% i.e., about one-third of the households are living below the food poverty line¹⁵. These findings are also in line with others¹⁶ who reported that the diets of underweight boys mostly consist of cereals with very limited consumption of fruits, eggs and flesh foods.

The lower family size and higher family income of the boys from Beaconhouse and Peshawar Model schools showed that the socio-economic factor may partly be responsible for better nutritional status of boys which were substantiated by a positive correlation between anthropometric, dietary and socio-economic variables. These results are in fair agreement with those of other studies¹⁷ who conducted anthropometric and socioeconomic studies on Indian school boys and reported that the anthropometry of well to do families was significantly higher than that of under privileged Indian boys.

The present study concludes that adolescents boys from the private schools (Beaconhouse and Peshawar model) had better nutritional status as compared to the boys from the public (Wazirbagh and Lakarai Kaniza) high schools due to their higher nutrient intake, low family size and higher family income. The study suggests that nutritional intervention programmes in public schools are needed to improve the nutritional well being of the adolescents so that they may perform well their future responsibilities with vigor and zeal crucial for the economic development of the country.

1. WHO. Handbook of Human Nutritional Requirement. World Health Organization, Geneva,

2. Jacobson MS, Rees JM, Golden NH, Irwin CE. Adolescent nutritional disorders: Prevention and treatment.

3. UNICEF. Pakistan facts and figures 2003. United Nation's Children Fund, Pakistan Country Office,

4. NlPS. Pakistan Demographic and Health Survey. (1990-1991): National Institute of Population Studies,

5. WHO. Measuring change in nutritional status. World Health Organization, Geneva, 1983.

6. Frisancho AB. Anthropometric standards for the assessment of growth and nutritional status. Health

7. Hussain T. Food Composition Table. Department of Agricultural Chemistry and Human Nutrition, NWFP

8. FP-II. The Food Processor-II, Nutrition analysis System, Esha Research, Salem, Oregon,

9. NRC. Recommended Dietary Allowance, 10^th edition., National academy of Science,

10. Dean AD, Dean JA, Burton AH. Epi Info Version 6.02, A word processing data base and statistic

11. SAS. SAS User’s guide., Statistics version 6.12 Cary NC., SAS Institute Inc, USA, 1996.

12. Vijaya KR, Darshan S, Swaminathan MC. Heights and weights of well-nourished Indian school boys. Ind

13. Bishnoi IS, Parvati N. Prevalence of PEM in school boys of rural areas of Varanasi (India). Abstracts, pp

628-629, 15^th International Congress of Nutrition, Adelaide.1993, 26^th Sept.to 1^st Oct.

14. Karlberg J, Jalil F, Lam B, Yeung CY. Linear growth retardation in relation to the three phases of growth.

15. Qureshi SK, Arif GM. Profile of poverty in Pakistan: 1998-99. MIMAP Tech. PaP. Ser. Pakistan Institute of

16. Kapoor M, Joshi I. Dietary and nutrient assessment of rural boys, Rajasthan, India, Abstracts, pp

300-301.16^th International Congress of Nutrition, Montreal, Canada; 1997 27^th July to 1^st August.

17. Rao S, Joshi SB, Kanade AN. Pattern of under nutrition amongpre-school boys from an urban slum.

Abstracts, pp 603. 15^th International Congress of Nutrition, Adelaide; 1993: 26^th Sept. to 1^st Oct. Purpose