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A Low Pulse Food Intake May Contribute to the Poor Nutritional Status and Low Dietary Intakes of Adolescent Girls in Rural Southern Ethiopia a
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Alemzewed C. Roba , Kebebush Gabriel-Micheal , Gordon A. Zello , c
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Joann Jaffe , Susan J. Whiting & Carol J. Henry a
School of Nutrition and Food Science, Hawassa University, Awassa, Ethiopia b
Department of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada c
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Department of Sociology and Social Studies, University of Regina, Regina, Canada Published online: 20 Jan 2015.
To cite this article: Alemzewed C. Roba, Kebebush Gabriel-Micheal, Gordon A. Zello, Joann Jaffe, Susan J. Whiting & Carol J. Henry (2015) A Low Pulse Food Intake May Contribute to the Poor Nutritional Status and Low Dietary Intakes of Adolescent Girls in Rural Southern Ethiopia, Ecology of Food and Nutrition, 54:3, 240-254, DOI: 10.1080/03670244.2014.974593 To link to this article: http://dx.doi.org/10.1080/03670244.2014.974593
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Ecology of Food and Nutrition, 54:240–254, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2014.974593
A Low Pulse Food Intake May Contribute to the Poor Nutritional Status and Low Dietary Intakes of Adolescent Girls in Rural Southern Ethiopia ALEMZEWED C. ROBA and KEBEBUSH GABRIEL-MICHEAL Downloaded by [University of Sydney] at 02:56 04 May 2015
School of Nutrition and Food Science, Hawassa University, Awassa, Ethiopia
GORDON A. ZELLO Department of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
JOANN JAFFE Department of Sociology and Social Studies, University of Regina, Regina, Canada
SUSAN J. WHITING and CAROL J. HENRY Department of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Poor nutrition in adolescent girls poses critical health risks on future pregnancy and birth outcomes especially in developing countries. Our purpose was to assess nutritional status and dietary intake of rural adolescent girls and determine pulse and food intake patterns associated with poor nutritional status. A cross– sectional community-based study was conducted in a traditional pulse growing region of southern Ethiopia on 188 girls between 15 to 19 years of age, with 70% being from food insecure families. Prevalence of stunting (30.9%) and underweight (13.3%) were associated with low food and nutrient intake. Diets were cereal-based, with both animal source foods and pulses rarely consumed. Improving dietary intakes of female adolescents with nutrient dense foods would ensure better health for themselves and for the next generation. KEYWORDS adolescent girls, dietary intakes, Ethiopia, pulses, stunting, underweight Address correspondence to Susan J. Whiting, PhD, Department of Pharmacy and Nutrition, University of Saskatchewan, 110 Science Pl., Saskatoon, Saskatchewan, S7N 5C9, Canada. E-mail: [email protected] 240
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Adolescence is characterized by intense physical and psychosocial developments that bridge childhood and early youth with adulthood. This period also provides a second chance for catch-up growth for children who had nutritional deficiencies in early life and prepares them for a healthy productive and reproductive adult life (Omran and Al-Hafez 2006). Linear growth seen during this period is faster than in any other period of human growth after birth, with the exception of first year of life (Belachew, Lindstrom, Hadley et al. 2013). Thus, the growth spurt together with maturation of reproductive capacity and physiological preparedness for optimal childbearing puts a high nutrient demand on adolescent girls (Jee et al. 2009; Rees et al. 1999). Increased nutritional needs during this period translate to adolescent gains up to 50% of their adult weight, more than 20% of their adult height, and 50% of their adult skeletal mass (WHO 2013). Adolescent nutritional needs, however, remain a largely neglected area, and the needs of adolescent girls in particular are often ignored (Jackson, Samms-Vaughan, and Ashley 2002). In Ethiopia, a country currently populated with a very young age demographic, adolescent girls between the ages of 15–19 years receive minimal attention in research and programs designed to improve nutritional status of the population (CSA 2012). The baseline study for the national nutrition program conducted by the Ethiopian Health and Nutrition Research Institute documented 23% stunting and 14% wasting among adolescent girls between 13–19 years of age (EHNRI 2010). Other studies report similar or even higher stunting rates in this age group (Belachew, Lindstrom, Hadley, et al. 2013; Mulugeta et al. 2009). Underweight has been reported as a concern in Ethiopian adolescents, as high as 27% in one region (Yetubie et al. 2010). Adolescents in Ethiopia, particularly girls, have been reported to have poor dietary diversity (Belachew, Lindstrom, Gebremariam, et al. 2013). While low intakes of animal source foods (ASF) are implicated in poor dietary intakes, awareness is growing as to the use pulse crops as a source of protein and some micronutrients in places where cereal grain intake is predominant and ASF intake is low (Kebebu et al. 2013). Pulses (e.g., chickpeas, lentils, peas, fava beans, mung beans) can provide an important source of protein, fiber, complex carbohydrates, iron, and zinc in the diet (Ofuya and Akhidue 2005). As a protein source, pulses are more affordable than ASF such as meat, fish, and dairy products and when combined with cereal proteins, they can supply the amino acids necessary for growth and development, although ASF are required for vital nutrients such as vitamin B12. In Ethiopia pulse crops can play an important role in improving household food security, by providing not only an affordable, highly dense nutrient food to the family diet, but also as a crop that increases food diversification and as a source of income because it yields a higher gross margin than cereals (Shahidur et al. 2010).
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The purpose of this study was to assess the nutritional status and dietary intakes of adolescent girls between the ages of 15–19 years old in a rural and traditionally pulse-growing community of southern Ethiopia. Furthermore, we hypothesized that the continued rates of wasting and stunting in rural adolescent girls were related to current poor dietary choices, especially the lack of pulse foods in the diet.
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METHODS A cross-sectional study was carried out to determine the nutritional status and dietary intake of adolescent girls, with the age range of 15–19 years Data for this study were generated from a randomly selected sample of adolescent girls from Huletegna-Choroko kebele (i.e., district of ∼500 families), in Halaba special woreda, in Southern Nations, Nationalities and Peoples Regional State (SNNPR) of Ethiopia. Of 271,000 people inhabiting Halaba, women constituted 49.5% of the population, and the majority of the population (89%) lived in rural areas (CSA 2008). Halaba was purposely selected for the project “Improving food security in the highlands of Ethiopia through improved and sustainable agricultural productivity and human nutrition” (International Development Research Center of Canada funded project) on the basis of it being a traditionally pulse growing region and its pulse crop production potential. Within the Halaba region, Huletegna-Choroko kebele was randomly chosen as the site for this study. The study was conducted February–March 2011. Participants were identified through a house-to-house survey at the beginning of the study and households with all adolescent girls that met the criteria were included in the study. One girl was selected randomly using the lottery method in the case of households having more than one adolescent girl. Adolescent girls with severe physical abnormality or history of chronic illness were excluded. The number of eligible adolescent girls in the area was 188 and all of them were included in the study. All participants were interviewed by trained data collectors and nurses who were fluent in the local language, Halabigna. Participants’ anthropometric measurements (i.e., height and weight) were measured by the principal researcher (KGM) to eliminate inter-examiner error whereas weighed food intake was measured by trained female nurse. All data collectors and nurses were given three days’ training by the principal researcher, who instructed them in the collection of dietary data and the administration of questionnaires. The study was approved by the Hawassa University Ethical Review Committee. Permission was sought from local authorities and community leaders before contacting participants. Individual assent and parental consent were also obtained from each participant and their anonymity has been preserved.
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Socio-demographic variables were collected via a pre-tested questionnaire adapted from the Ethiopian Demographic and Health Survey Report (CSA 2006). To conduct a pre-test, we chose 10 adolescent girls from outside the study area, at a nearby kebele. That pretest indicated questionnaires were understood. It also aided in training of assistants. During the study, daily supervision (i.e., spot checks, re-interviewing, and thorough inspection of filled-in questionnaires) was performed by field nurses. At the end of every data collection day, a meeting was held between data collectors, nurses and the researcher to discuss practical problems and issues of major concern. Anthropometric measurements were all taken by same female researcher (KGM) with participants minimally clothed and barefoot. Height was measured to the nearest 0.1 cm using a stadiometer (Shorr Productions, LLC) and weight to the nearest 0.1 kg using a solar powered digital scale (UNICEF scale, SECA Ltd, Birmingham, UK). The scales were regularly calibrated against known weights and all measurements were taken in duplicate. Body mass index (BMI, kg/m2 ) was calculated. Using growth reference charts (WHO 2006), anthropometric measurements were converted into height-forage z scores (HAZ), and BMI-for-age z scores (BAZ) using WHO AnthroPlus. Stunting (≤ 2 SD of HAZ), underweight (≤ 2 SD of weight-for-age z score), thinness/wasting (≤ 2 SD of BAZ), overweight (≥ 1 SD BAZ), and obesity (≥ 2 SD BAZ) were calculated (WHO 2006). Usual dietary intake was determined using a semi-quantitative food frequency questionnaire (FFQ) in all participants. This FFQ underwent face validity testing prior to its use. The FFQ consisted of a list of foods with standard serving size for each. Participants were asked to report their frequency of consumption of a given serving of each food item during the previous year on a daily, weekly or monthly basis. A one-day weighed food record was used to assess dietary intakes of a subsample (n = 75) of participants. Weekdays, weekend days and market days were proportionately represented (25 for each) in the final survey to account for day of the week effects on food and nutrient intake. The trained female nurses stayed in each girl’s home for one day, starting from 7:30 a.m. until the last meal of the day, weighing portions of all foods and beverages consumed and any left over at completion of each meal. Uneaten portion of the foods and beverages were deducted from the weight of the original meal served. Foods and beverages consumed by the girls were weighed to the nearest 0.1 g using digital scales (2 kg maximum weight, Model CS 2000, Ohaus Corporation). Foods and beverages were initially classified into eight major food groups that comprise diet diversity as listed in the FFQ. However, intakes of ASFs were low, so individual ASFs were grouped under a single heading of Animal Source Foods. Detailed weighed recipe data were also collected for all composite dishes consumed on the survey day and used to calculate the amount of nutrients consumed by the respondents (Gibson and Ferguson
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1999). Each food and beverage was coded for analysis of energy and other nutrients of interest using the Diet Analysis program (ESHA Oregon USA) modified to include data on the food composition tables developed for use in Ethiopia (Abebe et al. 2007; EHNRI 1998). Median (25th and 75th percentile) intakes and major food sources of energy and selected nutrients of interest were calculated. The median energy intakes were compared with the energy requirement recommended for adolescent girls (FAO/WHO/UNU 2004). Intakes of selective nutrients of interest were also compared with respective recommendations on nutrient requirements in adolescent girls (FAO/WHO/UNU 2004, 2007). Food insecurity status was measured using a household food insecurity access scale by focusing on items that pertained to adolescents (FANTA 2007). Each question was asked with a recall period in the last four weeks (30 days). Responses were tallied for occurrence and frequency of occurrence which produced score for each household. These scores were classified into the categories of food secure, mildly food insecure, moderately food insecure and severely food insecure. Statistical analyses were carried out using SPSS software, Version 16.0 (SPSS Inc. Chicago IL, USA). Variables were tested for normality using the Kolmogorov–Smirnov Test. Dietary results are expressed in terms of median (25th and 75th percentiles) to account for intakes not being normally distributed. Vitamin A percentiles could not be calculated. Frequencies were compiled for some variables and expressed in percentages. Chi-square test and logistic regression analyses were carried out to determine relationship between nutritional status and age, family size, educational status, and food security status. Associations were determined between the nutritional status of the adolescent girls and their socio-demographic, anthropometric and dietary variables using bivariate logistic regression analysis. An odds ratio with 95% confidence interval (CI) was used to determine strength of association and a p value of < .05 was considered statistically significant.
RESULTS Demographics of Participants Participant characteristics and demographics are found in table 1. The mean (SD) age of the adolescent girls (n = 188) was 17 (1.4) years and 70.2% of those participating were between the ages of 15 and 17 years. Most girls were unmarried (89.9%), and were students (93.1%) with a large proportion (46.8%) having reached junior high school, followed by girls (45.2%) who had elementary school level education. Few had no schooling. The average family size was 6.9 with nearly all (97.9%) belonging to the Muslim religion. Average monthly income of the girls’ families was 270 birr (approximately $14 USD). More than half (57%) of the girls lived with families, that had
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TABLE 1 Selected Participant and Socio-demographic Characteristics, Food-security Status, and Nutritional Status of Adolescent Girls (n = 188) from a Rural Kebele in Halaba, Ethiopia
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Characteristics and variables Age (y) 15 16 17 18 19 Schooling No school Elementary Junior high High school Marital status Unmarried Married Have children Yes No Heavy workload Yes No Own radio Yes No Own mobile telephone Yes No Food security status Food secure Mild insecure Moderate insecure Severely insecure Nutritional status Stunting (HAZ < –2) Underweight (BAZ < –2) Acute underweight (BMI < 18.5) Overweight (BMI > 24.9)
n
%
55 40 38 39 20
29.3 21.3 20.2 19.2 19.6
5 85 88 10
2.7 45.2 46.8 5.3
169 19
89.9 10.1
9 179
4.8 95.2
185 3
98.4 1.6
80 108
42.6 57.4
54 134
28.7 71.3
25 32 101 30
13.3 17 53.7 16
58 3 25 26
30.9 1.6 13.3 13.8
Note. n = number in variable category; HAZ = Height-for-age z score; BAZ = Body Mass Index-for-age z score; BMI = Body Mass Index = kg/m2 .
no radio and nearly three quarters (71.3%) of the girls had no mobile telephone. The percentage of girls living in households with some degree of food insecurity was 86.7%.
Nutritional Status of Adolescent Girls The mean (SD) height, weight, BMI, HAZ, and BAZ were 151.9 (6.4) cm, 50.8 (7.4) kg, 22.0 (2.8) kg/m2 , –1.57 (0.9), and 0.27 (0.9), respectively. As shown in table 1, 30.9% were stunted, 1.6% were wasted, 13.3% had underweight,
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and 13.8% were overweight. Age and educational status were significantly associated with stunting (p < .05) using bivariate analysis (i.e., younger girls and less education showed greater stunting). However, only age was significantly associated with stunting using multivariate logistic regression with middle-age adolescent girls (15–17 y), who were three times more likely to be stunted than late age adolescent girls (18–19 y); odds ratio OR (95% CI) of 3.2 (1.45–7.21). Age and educational status of adolescent girls were associated with BMI in bivariate logistic regression, but only educational status retained an association as a predictor in multivariate logistic regression model (p < .01); adolescents who attained grade 6 and below were 62% less likely to have normal BMI as compared with education > 6 grade level, with OR (95% CI) 0.38 (0.15–0.99).
Dietary Intake and Food Consumption Frequency Based on one-day weighed food records, the girls’ diets were predominately plant based with very low intakes of animal source foods and no intake of fruit (table 2). Kitta prepared from unleavened corn flour, enjera made from sorghum-maize mixed flour, kale stew, and coffee constituted the majority of the foods consumed by these participants. Girls ate either three (78.7%) or two (21.3%) meals per days, with 87.2%, 84.6%, and 94.1% eating breakfast, lunch, and dinner, respectively, on the recorded day. Almost all (96.3%) reported cereal as sole source of energy and protein, while a few (3.7%) had pulse and cereal mixes. Food frequency determination of different items by the total sample (table 2) indicated that maize (99.5%) and sorghum (85.6%) were consumed more than once a day. However, pulses were not as frequently consumed (range 0% to 15.4%). Although pulses were generally part of a weekly intake—specifically, lentils (84.6%), haricot beans (59%), peas (51%), fava beans (35.6%), and chick pea (28.7%)—the weekly frequency of intake (highest for lentil) was still below that of the “more than once per day” for the cereals maize and sorghum. Animal source foods were consumed less than once a month except cheese which was eaten with a greater frequency, as high as once a week for 40.4% of the sample. Kale was the most frequent vegetable consumed. Intakes of selected nutrients (table 3) show that the median intake of energy, protein, and key micronutrients, with the exception of iron (in older girls only) and fiber (in younger girls), were below the respective daily requirements (i.e., median intakes less than 100% of DRI). As recommendations vary by age, girls were placed into two groups—one for girls aged 15–18 years, and the other for those 19 years of age. Table 4 shows how nutrient intakes were obtained according to foods eaten. While cereals provided most of the girls’ protein (75.9%), protein intake did not meet requirements. Pulses were the major source of zinc, yet intake of this food group was low and zinc intake remained inadequate.
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TABLE 2 Consumption Frequency and Percentage Distribution of Different Food Items by Adolescent Girls (n = 188) Frequency (%) of consumption
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Variable Cereals Maize Sorghum Teff Wheat Millet Pulses Lentils Haricot beans Peas Fava beans Chick peas Animal products Meat Poultry Eggs Cow’s milk Yogurt Cheese Vegetables and fruit Kale Cabbage Pepper Tomato Carrot Potato Sweet potato Pumpkin Papaya Avocado Banana Mango Orange Fats and oils Oil Butter
More than once per day
1–7 times per week
Once per month
Less than once per month or never
99.5 85.6 3.7 6.9 26.1
0.5 11.2 50.0 44.1 18.6
0 1.6 34.0 32.4 11.2
0 1.6 12.3 16.5 44.1
0.5 3.2 15.4 0 0
84.6 59.0 51.1 35.6 28.7
13.8 25.5 22.3 33.5 34.6
1.1 12.2 11.2 30.8 37.2
0 0 0 1.1 0 0
0.5 0.5 31.4 3.7 3.2 40.4
3.7 12.8 57.4 2.7 6.4 48.9
95.7 86.7 11.2 92.6 90.4 10.6
90.4 0.5 31.4 1.6 2.7 2.7 0 1.1 2.7 0 0.5 0 0
5.3 34.6 41 10.1 4.8 68.6 26.6 32.4 52.7 41.5 66.5 8.5 7.4
2.7 33.5 6.9 18.1 12.8 25.5 29.8 22.9 28.7 29.8 25.5 16.5 21.8
1.6 31.4 20.7 70.3 79.7 3.2 43.6 69.2 15.9 28.8 7.4 75.0 70.7
95.2 3.2
3.7 59.6
0.5 30.9
0.5 6.4
DISCUSSION Regardless of the high prevalence of undernutrition documented in many developing countries, adolescence is considered a low-risk group for health and nutrition intervention programs (Jackson et al. 2002). This study determined and provided data on cross-sectional nutritional status and dietary intake of 15–19 year-old adolescent girls in the traditionally pulse-growing rural community of Halaba in southern Ethiopia. Despite the availability of
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TABLE 3 Median Energy and Other Key Nutrient Intakes of Adolescent Girls Divided into Younger and Older Groups to Account for Differences in Dietary Reference Intake Recommendations (n = 75) 15–18 y (n = 55)
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Nutrients
DRI 15–18 y/19 y
Energy (kcal) 2,200 Protein (g) 46 Calcium (mg) 1,300/1,000 Iron (mg) 62/59 Zinc (mg) 19/10 Vitamin A (RE µg) 600/500 Vitamin C (mg) 40/45 Thiamin (mg) 1.1 Riboflavin (mg) 1 Niacin (mg) 16/14 Fiber (g) 15 Phytate (g) N/A
19 y (n = 20)
Median intake (25th–75th)
% DRI
Median intake (25th–75th)
% DRI
1,548 (1,345–1,820) 40 (35–46) 162 (124–221) 53 (22–193) 10 (8–7) 285 2 (1–3) 0.4 (0.2–0.5) 0.4 (0.3–0.5) 6 (5–8) 16 (11–19) 1.50
70 87 13 85 53 47 5 36 40 39 106 N/A
1,483 (1,282–1,768) 38 (32–46) 161 (106–198) 107 (33–148) 9 (7–11) 300 3 (1–4) 0.3 (0.2–0.5) 0.3 (0.3–0.5) 3 (1–5) 12 (9–14) 1.81
67 82 16 180 90 60 8 27 27 24 81 N/A
Note. A median intake less than 100% of the DRI is considered inadequate. DRI = Dietary Reference Intake recommended intake; N/A = not applicable; RE = retinol equivalent.
TABLE 4 Percentages of Nutrient Intake from Different Food Groups by the Adolescent Girls (n = 75) Food groups Cereals Pulses Roots and tubers Leafy vegetables Dairy product Beverages
Protein (%)
Iron (%)
Zinc (%)
75.9 14.2 0.2 5.7 3.6 0.4
89.8 8.9 0.3 0.8 0 0.2
16.9 81.9 0 0 1.2 0
pulse foods from household farms or local markets, pulse use is very low in these girls, starting with childhood and now into adolescence. Stunting and underweight have important implications for the reproductive health of adolescent girls (Konje and Ladipo 2000) and underweight can result in poor pregnancy outcomes, especially in terms of low birth weight and increased risk of infant mortality (Osrin and Costello 2000). Our findings show that poor nutritional status among adolescent girls was a concern. Of the girls, about one-third (31%) were stunted and nearly one in eight (13.3%) were underweight. This could be attributed to the girls’ inadequate food intake as we also have documented. Reasons may include lack of access to sufficient food and inequities in food allocation as a majority of the girls belonged to poor families. The lack of access to sufficient food and inequities in intra-household food allocation are the key causes for malnutrition in poor households of southern Ethiopia (Regassa and Stoeker
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2007). This prevalence of stunting is comparable to the national survey data of 30% (EHNRI 2010). The percentage of girls who were underweight in our study (13.3%) did not exceed the number defined by WHO (1995) as serious (i.e., 20%–30%). In Ethiopia, nationally it is 20% (EHNRI 2010), and in a study from the north of the country (i.e., Tigray region), it was reported as 58.3% (Mulugeta et al. 2009). We also report a significant prevalence of overweight in our sample, 13.8%. However, few were obese. This finding needs further investigation as excess carbohydrates in the absence of dietary protein can lead to overweight and obesity (Liu et al. 2003). Dietary intake among adolescent girls was found to be poor in quality and below required dietary reference intakes (FAO/WHO/UNU 2004, 2007). This could be due to priority given for boys and younger children over adolescent girls in terms of intra-household food distribution (EHNRI 2010). While meal frequencies per day of two and three were reported by 21.3% and 78.7% of the adolescent girls, respectively, nutrient quality was low. More than half (64.4%) of the girls reported variety of foods in the FFQ at some time during the week before the data collection. However, foods consumed by those girls were predominately cereals and the intake was particularly low with respect to animal source foods and fruits. Low intake of protein sources by adolescents has been reported by Belachew and colleagues (2013) in Jimma, Ethiopia, wherein food insecurity worsened the intake pattern. In our sample, the ASF was primarily diary which would be low in iron; other ASF provide highly available zinc and iron in contrast to plant-based foods. When closely examined as observed 24-hour intakes, nutrient intakes were found to be low in quantity and quality. There was an overreliance on cereals, as noted in the dietary records of the subsample of girls who participated (n = 75). In terms of use of pulse foods, there was, in the FFQ, indication that many of the girls consumed pulses weekly, including lentils (84.6%), haricot beans (59%), peas (51%), fava beans (35.6%), and chick peas (28.7%). Yet in the food records, little evidence of pulse consumption was seen. While food records are not indicative of the usual intakes of individual, they can be useful to characterize a group, and one would expect to see some pulse use by the girls in the subset. Furthermore, with cereal crops being the prominent sources of daily protein, and the lack of cereal-pulse mixed meals (3%), the quality of protein consumed (i.e., inadequate mix of indispensable amino acids) is also of concern. Consumption of proteins of low quality without a sufficient of intake of complementary proteins (i.e., pulses) results in an increase in protein needs above that of requirement and could contribute to the overall wasting and stunting in the adolescent girls. If more pulses were consumed, protein and micronutrient intakes would be improved. In addition to being a protein source, pulses also provide an important dietary source of iron and zinc, supplanting meat, especially for low income, food insecure households, which were prevalent in our study. Due to their importance in the diet, they are a valuable crop to farm families both for
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home consumption and as a commodity sold in the market (Adler 2008). Pulses can play a significant role in improving their food security, by providing an affordable source of protein. In our study the contribution as a protein source of 14% was second to that of cereals at 76% (table 4). This low percentage was unexpected as the region of Halaba is traditionally a pulse growing region. However in one study (Tadesse 2009), calorie consumption of pulses and oilseeds in rural communities was reported to be 9% of dietary intake which was almost half that of urban communities at 14% in Ethiopia. The reasons for low pulse intakes in our participants are speculative without further research, but may include; less pulse crops being planted (e.g., perception as being a “poor” person’s food), the time year our study was carried out (e.g., pulse not being harvested, or being stored for future use), pulses available were being provided to other members of the family for consumption and/or harvested pulses being sold for income. In an ongoing study by our group (Kabeta 2013), we have found that family size, cultural taboos, household processing, formation of intestinal flatulence and educational level of households are main reasons for less consumption of pulses in a rural community in southern Ethiopia. Therefore, the results of our study suggest a need for nutrition education interventions be undertaken to improve knowledge and practice of pulse processing and increase pulse consumption pattern in households by focusing on the perceived barriers within the community. Animal source food intake was nearly negligible among the girls, likely due to high cost. The majority of the girls did not consume milk and yogurt at all, a finding also reported in a study conducted in Ambo Town, although their data revealed a greater animal source food consumption, wherein nearly half of the adolescent girls consumed meat once a week (Yetubie 2008). Cheese was consumed, but more as a condiment, as dietary calcium levels remained low overall. The requirement for calcium in adolescence is higher because of the acceleration of skeleton development (Vatanparast et al. 2010). Inadequate calcium intake during adolescence and young adulthood puts individuals at risk for developing osteoporosis later in life. Fruit also was not part of the daily diet in our study, and as a result, vitamin C and vitamin A (from carotenes) were below nutrition recommendations. It was found in the one day food records that coffee was the predominant accessory to the girls’ meals and not fruit. In Ethiopia, to end a meal with coffee rather than with fruit is common (Amare et al. 2010). Iron intakes were not as poor as some other micronutrients, and could be attributed to the reliance on whole grain cereal consumption (table 4). However, the bioavailable iron is likely low being as their consumption of iron was from a plant source with low bioavailability due to high phytate content. Also to consider is a high consumption of coffee by girls at each meal. Coffee decreases the absorption of non-heme iron due to its tannin content and thus could contribute to increased iron deficiency
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anemia (Mascitelli, Pezzeta, and Sullivan 2007). Further, iron bioavailability is improved with consumption of vitamin C–rich foods, yet fruit intake was practically nil in our study. Zinc absorption is also affected by phytate. Limited intake or uptake of zinc may affect physical growth as well as development of secondary sexual characteristics (Salgueiro et al. 2004). Zinc intake by our participants did not meet requirements even without consideration of phytate. Limitations to our study include the reliance on two dietary assessment methods. The FFQ did not have quantities specified. The one day record cannot be used to assess the usual intake of an individual, however, one would expect a reasonable assessment of the group’s intake, and thus we use it as the more reliable tool as it was done objectively. As we assessed the girls’ dietary patterns during only one season, it may be that at other times of the year, intakes of foods such as fruit would improve. Another limitation of this study is its cross-sectional nature, thus one cannot assume a cause and effect of diet on nutritional status. In conclusion, the present study provides data on nutritional inadequacy along with poor nutritional status among 15–19 year-old adolescent girls in a rural pulse growing region of southern Ethiopia. Our results show dietary patterns that are low in animal source foods, due to high cost, yet also low in pulses for reasons that need to be studied further. More emphasis should be made on planning and implementing nutritional programs aimed at preventing or correcting nutrient deficiencies among adolescent girls. The recently announced National Nutrition Program places emphasis on adolescent girls ages 10–19, and specifies that they should be “nutritionally fit” in order to become mothers (Government of the Federal Democratic Republic of Ethiopia 2013). In this regard, health institutions should provide skill based nutrition education for adolescent girls regarding consumption of diverse foods, including pulses, rich in macro- and micronutrients.
FUNDING This study was financially supported by The Canadian Department of Foreign Affairs, Trade and Development/International Development Research Center—Canadian International Food Security Research Fund (IDRC-CIFSRF) project and in part by Hawassa University and the University of Saskatchewan. We would like to thank the study participants without whom this study could not have been completed.
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Kebebu, A., S. J. Whiting, W. J. Dahl, and C. J. Henry. 2013. Formulation and acceptability testing of a complementary food with added broad bean (Vicia faba) in southern Ethiopia. African Journal of Food Agriculture Nutrition and Development 13:3. Konje, J. C., and O. A. Ladipo. 2000. Nutrition and obstructed labor. American Journal of Clinical Nutrition 72:S291–S297. Liu, S., W. C. Willett, J. E. Manson, F. B. Hu, B. Rosner, and G. Colditz. 2003. Relation between changes in intakes of dietary fiber and grain products and changes in weight and development of obesity among middle-aged women. American Journal of Clinical Nutrition 78:920–927. Mascitelli, L., F. Pezzetta, and J. L. Sullivan. 2007. Inhibition of iron absorption by coffee and the reduced risk of type 2 diabetes mellitus. Archives of Internal Medicine 167:204–205. Mulugeta, A., F. Hagos, B. Stoecker, G. Kruseman, L. Vincent, Z. Abraha, M. Yohannes, and G. Girmay. 2009. Nutritional status of adolescent girls from rural communities of Tigray, Northern Ethiopia. Ethiopian Journal of Health and Development 23:5–11. Ofuya, Z. M., and V. Akhidue. 2005. The role of pulses in human nutrition: A review. Journal of Applied Science and Environmental Management 9:99–104. Omran, A. R., and G. Al-Hafez. 2006. Health education for adolescent girls. Cairo, Egypt: World Health Organization, Regional Office for the Eastern Mediterranean. Osrin, D., and A. M. Costello. 2000. Maternal nutrition and fetal growth: Practical issues in international health. Seminars in Neonatology 5:209–219. Population Census Commission. 2008. Census Summary and Statistical Report of the 2007 Population and Housing Census. Addis Ababa, Ethiopia: Population Census Commission, Federal Democratic Republic of Ethiopia. Rees, J. M., D. Neumark-Sztainer, M. Kohn, and M. Jacobson. 1999. Improving the nutritional health of adolescents: Position statement, Society of Adolescent Medicine. Journal of Adolescent Health 24:461–462. Regassa, N., and B. J. Stoecker. 2012. Household food insecurity and hunger among households in Sidama district, southern Ethiopia. Public Health Nutrition 15:1276–1283. Salgueiro, M. J., R. Weill, M. Zubillaga, A. Lysionek, R. Caro, C. Goldman, D. Barrado, M. M. Sarrasague, A. Ridolfi, and J. Boccio. 2004. Zinc deficiency and growth: Current concepts in relationship to two important points: Intellectual and sexual development. Biology of Trace Element Research 99:49–69. Shahidur R, Y. Chilot, B. Befekadu, and L. Solomon. 2010. Pulses value chain in Ethiopia: Constraints and opportunities for enhancing exports. Working paper. Washington, DC: International Food Policy Research Institute. Tadesse, K. W. 2009. Analysis of changes in food consumption pattern in urban Ethiopia. Proceedings of the Seventh International Conference on the Ethiopian Economy, June 25–27, Addis Ababa. Vatanparast, H., A. Baxter-Jones, D. A. Bailey, and S. J. Whiting. 2010. Calcium accrual during growth: Using data from a cohort of Canadian adolescents to determine calcium requirements. British Journal of Nutrition 103:575–580
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A Low Pulse Food Intake May Contribute to the Poor Nutritional Status and Low Dietary Intakes of Adolescent Girls in Rural Southern Ethiopia a
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Alemzewed C. Roba , Kebebush Gabriel-Micheal , Gordon A. Zello , c
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Joann Jaffe , Susan J. Whiting & Carol J. Henry a
School of Nutrition and Food Science, Hawassa University, Awassa, Ethiopia b
Department of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada c
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Department of Sociology and Social Studies, University of Regina, Regina, Canada Published online: 20 Jan 2015.
To cite this article: Alemzewed C. Roba, Kebebush Gabriel-Micheal, Gordon A. Zello, Joann Jaffe, Susan J. Whiting & Carol J. Henry (2015) A Low Pulse Food Intake May Contribute to the Poor Nutritional Status and Low Dietary Intakes of Adolescent Girls in Rural Southern Ethiopia, Ecology of Food and Nutrition, 54:3, 240-254, DOI: 10.1080/03670244.2014.974593 To link to this article: http://dx.doi.org/10.1080/03670244.2014.974593
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Ecology of Food and Nutrition, 54:240–254, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0367-0244 print/1543-5237 online DOI: 10.1080/03670244.2014.974593
A Low Pulse Food Intake May Contribute to the Poor Nutritional Status and Low Dietary Intakes of Adolescent Girls in Rural Southern Ethiopia ALEMZEWED C. ROBA and KEBEBUSH GABRIEL-MICHEAL Downloaded by [University of Sydney] at 02:56 04 May 2015
School of Nutrition and Food Science, Hawassa University, Awassa, Ethiopia
GORDON A. ZELLO Department of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
JOANN JAFFE Department of Sociology and Social Studies, University of Regina, Regina, Canada
SUSAN J. WHITING and CAROL J. HENRY Department of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Poor nutrition in adolescent girls poses critical health risks on future pregnancy and birth outcomes especially in developing countries. Our purpose was to assess nutritional status and dietary intake of rural adolescent girls and determine pulse and food intake patterns associated with poor nutritional status. A cross– sectional community-based study was conducted in a traditional pulse growing region of southern Ethiopia on 188 girls between 15 to 19 years of age, with 70% being from food insecure families. Prevalence of stunting (30.9%) and underweight (13.3%) were associated with low food and nutrient intake. Diets were cereal-based, with both animal source foods and pulses rarely consumed. Improving dietary intakes of female adolescents with nutrient dense foods would ensure better health for themselves and for the next generation. KEYWORDS adolescent girls, dietary intakes, Ethiopia, pulses, stunting, underweight Address correspondence to Susan J. Whiting, PhD, Department of Pharmacy and Nutrition, University of Saskatchewan, 110 Science Pl., Saskatoon, Saskatchewan, S7N 5C9, Canada. E-mail: [email protected] 240
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Adolescence is characterized by intense physical and psychosocial developments that bridge childhood and early youth with adulthood. This period also provides a second chance for catch-up growth for children who had nutritional deficiencies in early life and prepares them for a healthy productive and reproductive adult life (Omran and Al-Hafez 2006). Linear growth seen during this period is faster than in any other period of human growth after birth, with the exception of first year of life (Belachew, Lindstrom, Hadley et al. 2013). Thus, the growth spurt together with maturation of reproductive capacity and physiological preparedness for optimal childbearing puts a high nutrient demand on adolescent girls (Jee et al. 2009; Rees et al. 1999). Increased nutritional needs during this period translate to adolescent gains up to 50% of their adult weight, more than 20% of their adult height, and 50% of their adult skeletal mass (WHO 2013). Adolescent nutritional needs, however, remain a largely neglected area, and the needs of adolescent girls in particular are often ignored (Jackson, Samms-Vaughan, and Ashley 2002). In Ethiopia, a country currently populated with a very young age demographic, adolescent girls between the ages of 15–19 years receive minimal attention in research and programs designed to improve nutritional status of the population (CSA 2012). The baseline study for the national nutrition program conducted by the Ethiopian Health and Nutrition Research Institute documented 23% stunting and 14% wasting among adolescent girls between 13–19 years of age (EHNRI 2010). Other studies report similar or even higher stunting rates in this age group (Belachew, Lindstrom, Hadley, et al. 2013; Mulugeta et al. 2009). Underweight has been reported as a concern in Ethiopian adolescents, as high as 27% in one region (Yetubie et al. 2010). Adolescents in Ethiopia, particularly girls, have been reported to have poor dietary diversity (Belachew, Lindstrom, Gebremariam, et al. 2013). While low intakes of animal source foods (ASF) are implicated in poor dietary intakes, awareness is growing as to the use pulse crops as a source of protein and some micronutrients in places where cereal grain intake is predominant and ASF intake is low (Kebebu et al. 2013). Pulses (e.g., chickpeas, lentils, peas, fava beans, mung beans) can provide an important source of protein, fiber, complex carbohydrates, iron, and zinc in the diet (Ofuya and Akhidue 2005). As a protein source, pulses are more affordable than ASF such as meat, fish, and dairy products and when combined with cereal proteins, they can supply the amino acids necessary for growth and development, although ASF are required for vital nutrients such as vitamin B12. In Ethiopia pulse crops can play an important role in improving household food security, by providing not only an affordable, highly dense nutrient food to the family diet, but also as a crop that increases food diversification and as a source of income because it yields a higher gross margin than cereals (Shahidur et al. 2010).
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The purpose of this study was to assess the nutritional status and dietary intakes of adolescent girls between the ages of 15–19 years old in a rural and traditionally pulse-growing community of southern Ethiopia. Furthermore, we hypothesized that the continued rates of wasting and stunting in rural adolescent girls were related to current poor dietary choices, especially the lack of pulse foods in the diet.
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METHODS A cross-sectional study was carried out to determine the nutritional status and dietary intake of adolescent girls, with the age range of 15–19 years Data for this study were generated from a randomly selected sample of adolescent girls from Huletegna-Choroko kebele (i.e., district of ∼500 families), in Halaba special woreda, in Southern Nations, Nationalities and Peoples Regional State (SNNPR) of Ethiopia. Of 271,000 people inhabiting Halaba, women constituted 49.5% of the population, and the majority of the population (89%) lived in rural areas (CSA 2008). Halaba was purposely selected for the project “Improving food security in the highlands of Ethiopia through improved and sustainable agricultural productivity and human nutrition” (International Development Research Center of Canada funded project) on the basis of it being a traditionally pulse growing region and its pulse crop production potential. Within the Halaba region, Huletegna-Choroko kebele was randomly chosen as the site for this study. The study was conducted February–March 2011. Participants were identified through a house-to-house survey at the beginning of the study and households with all adolescent girls that met the criteria were included in the study. One girl was selected randomly using the lottery method in the case of households having more than one adolescent girl. Adolescent girls with severe physical abnormality or history of chronic illness were excluded. The number of eligible adolescent girls in the area was 188 and all of them were included in the study. All participants were interviewed by trained data collectors and nurses who were fluent in the local language, Halabigna. Participants’ anthropometric measurements (i.e., height and weight) were measured by the principal researcher (KGM) to eliminate inter-examiner error whereas weighed food intake was measured by trained female nurse. All data collectors and nurses were given three days’ training by the principal researcher, who instructed them in the collection of dietary data and the administration of questionnaires. The study was approved by the Hawassa University Ethical Review Committee. Permission was sought from local authorities and community leaders before contacting participants. Individual assent and parental consent were also obtained from each participant and their anonymity has been preserved.
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Socio-demographic variables were collected via a pre-tested questionnaire adapted from the Ethiopian Demographic and Health Survey Report (CSA 2006). To conduct a pre-test, we chose 10 adolescent girls from outside the study area, at a nearby kebele. That pretest indicated questionnaires were understood. It also aided in training of assistants. During the study, daily supervision (i.e., spot checks, re-interviewing, and thorough inspection of filled-in questionnaires) was performed by field nurses. At the end of every data collection day, a meeting was held between data collectors, nurses and the researcher to discuss practical problems and issues of major concern. Anthropometric measurements were all taken by same female researcher (KGM) with participants minimally clothed and barefoot. Height was measured to the nearest 0.1 cm using a stadiometer (Shorr Productions, LLC) and weight to the nearest 0.1 kg using a solar powered digital scale (UNICEF scale, SECA Ltd, Birmingham, UK). The scales were regularly calibrated against known weights and all measurements were taken in duplicate. Body mass index (BMI, kg/m2 ) was calculated. Using growth reference charts (WHO 2006), anthropometric measurements were converted into height-forage z scores (HAZ), and BMI-for-age z scores (BAZ) using WHO AnthroPlus. Stunting (≤ 2 SD of HAZ), underweight (≤ 2 SD of weight-for-age z score), thinness/wasting (≤ 2 SD of BAZ), overweight (≥ 1 SD BAZ), and obesity (≥ 2 SD BAZ) were calculated (WHO 2006). Usual dietary intake was determined using a semi-quantitative food frequency questionnaire (FFQ) in all participants. This FFQ underwent face validity testing prior to its use. The FFQ consisted of a list of foods with standard serving size for each. Participants were asked to report their frequency of consumption of a given serving of each food item during the previous year on a daily, weekly or monthly basis. A one-day weighed food record was used to assess dietary intakes of a subsample (n = 75) of participants. Weekdays, weekend days and market days were proportionately represented (25 for each) in the final survey to account for day of the week effects on food and nutrient intake. The trained female nurses stayed in each girl’s home for one day, starting from 7:30 a.m. until the last meal of the day, weighing portions of all foods and beverages consumed and any left over at completion of each meal. Uneaten portion of the foods and beverages were deducted from the weight of the original meal served. Foods and beverages consumed by the girls were weighed to the nearest 0.1 g using digital scales (2 kg maximum weight, Model CS 2000, Ohaus Corporation). Foods and beverages were initially classified into eight major food groups that comprise diet diversity as listed in the FFQ. However, intakes of ASFs were low, so individual ASFs were grouped under a single heading of Animal Source Foods. Detailed weighed recipe data were also collected for all composite dishes consumed on the survey day and used to calculate the amount of nutrients consumed by the respondents (Gibson and Ferguson
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1999). Each food and beverage was coded for analysis of energy and other nutrients of interest using the Diet Analysis program (ESHA Oregon USA) modified to include data on the food composition tables developed for use in Ethiopia (Abebe et al. 2007; EHNRI 1998). Median (25th and 75th percentile) intakes and major food sources of energy and selected nutrients of interest were calculated. The median energy intakes were compared with the energy requirement recommended for adolescent girls (FAO/WHO/UNU 2004). Intakes of selective nutrients of interest were also compared with respective recommendations on nutrient requirements in adolescent girls (FAO/WHO/UNU 2004, 2007). Food insecurity status was measured using a household food insecurity access scale by focusing on items that pertained to adolescents (FANTA 2007). Each question was asked with a recall period in the last four weeks (30 days). Responses were tallied for occurrence and frequency of occurrence which produced score for each household. These scores were classified into the categories of food secure, mildly food insecure, moderately food insecure and severely food insecure. Statistical analyses were carried out using SPSS software, Version 16.0 (SPSS Inc. Chicago IL, USA). Variables were tested for normality using the Kolmogorov–Smirnov Test. Dietary results are expressed in terms of median (25th and 75th percentiles) to account for intakes not being normally distributed. Vitamin A percentiles could not be calculated. Frequencies were compiled for some variables and expressed in percentages. Chi-square test and logistic regression analyses were carried out to determine relationship between nutritional status and age, family size, educational status, and food security status. Associations were determined between the nutritional status of the adolescent girls and their socio-demographic, anthropometric and dietary variables using bivariate logistic regression analysis. An odds ratio with 95% confidence interval (CI) was used to determine strength of association and a p value of < .05 was considered statistically significant.
RESULTS Demographics of Participants Participant characteristics and demographics are found in table 1. The mean (SD) age of the adolescent girls (n = 188) was 17 (1.4) years and 70.2% of those participating were between the ages of 15 and 17 years. Most girls were unmarried (89.9%), and were students (93.1%) with a large proportion (46.8%) having reached junior high school, followed by girls (45.2%) who had elementary school level education. Few had no schooling. The average family size was 6.9 with nearly all (97.9%) belonging to the Muslim religion. Average monthly income of the girls’ families was 270 birr (approximately $14 USD). More than half (57%) of the girls lived with families, that had
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TABLE 1 Selected Participant and Socio-demographic Characteristics, Food-security Status, and Nutritional Status of Adolescent Girls (n = 188) from a Rural Kebele in Halaba, Ethiopia
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Characteristics and variables Age (y) 15 16 17 18 19 Schooling No school Elementary Junior high High school Marital status Unmarried Married Have children Yes No Heavy workload Yes No Own radio Yes No Own mobile telephone Yes No Food security status Food secure Mild insecure Moderate insecure Severely insecure Nutritional status Stunting (HAZ < –2) Underweight (BAZ < –2) Acute underweight (BMI < 18.5) Overweight (BMI > 24.9)
n
%
55 40 38 39 20
29.3 21.3 20.2 19.2 19.6
5 85 88 10
2.7 45.2 46.8 5.3
169 19
89.9 10.1
9 179
4.8 95.2
185 3
98.4 1.6
80 108
42.6 57.4
54 134
28.7 71.3
25 32 101 30
13.3 17 53.7 16
58 3 25 26
30.9 1.6 13.3 13.8
Note. n = number in variable category; HAZ = Height-for-age z score; BAZ = Body Mass Index-for-age z score; BMI = Body Mass Index = kg/m2 .
no radio and nearly three quarters (71.3%) of the girls had no mobile telephone. The percentage of girls living in households with some degree of food insecurity was 86.7%.
Nutritional Status of Adolescent Girls The mean (SD) height, weight, BMI, HAZ, and BAZ were 151.9 (6.4) cm, 50.8 (7.4) kg, 22.0 (2.8) kg/m2 , –1.57 (0.9), and 0.27 (0.9), respectively. As shown in table 1, 30.9% were stunted, 1.6% were wasted, 13.3% had underweight,
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and 13.8% were overweight. Age and educational status were significantly associated with stunting (p < .05) using bivariate analysis (i.e., younger girls and less education showed greater stunting). However, only age was significantly associated with stunting using multivariate logistic regression with middle-age adolescent girls (15–17 y), who were three times more likely to be stunted than late age adolescent girls (18–19 y); odds ratio OR (95% CI) of 3.2 (1.45–7.21). Age and educational status of adolescent girls were associated with BMI in bivariate logistic regression, but only educational status retained an association as a predictor in multivariate logistic regression model (p < .01); adolescents who attained grade 6 and below were 62% less likely to have normal BMI as compared with education > 6 grade level, with OR (95% CI) 0.38 (0.15–0.99).
Dietary Intake and Food Consumption Frequency Based on one-day weighed food records, the girls’ diets were predominately plant based with very low intakes of animal source foods and no intake of fruit (table 2). Kitta prepared from unleavened corn flour, enjera made from sorghum-maize mixed flour, kale stew, and coffee constituted the majority of the foods consumed by these participants. Girls ate either three (78.7%) or two (21.3%) meals per days, with 87.2%, 84.6%, and 94.1% eating breakfast, lunch, and dinner, respectively, on the recorded day. Almost all (96.3%) reported cereal as sole source of energy and protein, while a few (3.7%) had pulse and cereal mixes. Food frequency determination of different items by the total sample (table 2) indicated that maize (99.5%) and sorghum (85.6%) were consumed more than once a day. However, pulses were not as frequently consumed (range 0% to 15.4%). Although pulses were generally part of a weekly intake—specifically, lentils (84.6%), haricot beans (59%), peas (51%), fava beans (35.6%), and chick pea (28.7%)—the weekly frequency of intake (highest for lentil) was still below that of the “more than once per day” for the cereals maize and sorghum. Animal source foods were consumed less than once a month except cheese which was eaten with a greater frequency, as high as once a week for 40.4% of the sample. Kale was the most frequent vegetable consumed. Intakes of selected nutrients (table 3) show that the median intake of energy, protein, and key micronutrients, with the exception of iron (in older girls only) and fiber (in younger girls), were below the respective daily requirements (i.e., median intakes less than 100% of DRI). As recommendations vary by age, girls were placed into two groups—one for girls aged 15–18 years, and the other for those 19 years of age. Table 4 shows how nutrient intakes were obtained according to foods eaten. While cereals provided most of the girls’ protein (75.9%), protein intake did not meet requirements. Pulses were the major source of zinc, yet intake of this food group was low and zinc intake remained inadequate.
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TABLE 2 Consumption Frequency and Percentage Distribution of Different Food Items by Adolescent Girls (n = 188) Frequency (%) of consumption
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Variable Cereals Maize Sorghum Teff Wheat Millet Pulses Lentils Haricot beans Peas Fava beans Chick peas Animal products Meat Poultry Eggs Cow’s milk Yogurt Cheese Vegetables and fruit Kale Cabbage Pepper Tomato Carrot Potato Sweet potato Pumpkin Papaya Avocado Banana Mango Orange Fats and oils Oil Butter
More than once per day
1–7 times per week
Once per month
Less than once per month or never
99.5 85.6 3.7 6.9 26.1
0.5 11.2 50.0 44.1 18.6
0 1.6 34.0 32.4 11.2
0 1.6 12.3 16.5 44.1
0.5 3.2 15.4 0 0
84.6 59.0 51.1 35.6 28.7
13.8 25.5 22.3 33.5 34.6
1.1 12.2 11.2 30.8 37.2
0 0 0 1.1 0 0
0.5 0.5 31.4 3.7 3.2 40.4
3.7 12.8 57.4 2.7 6.4 48.9
95.7 86.7 11.2 92.6 90.4 10.6
90.4 0.5 31.4 1.6 2.7 2.7 0 1.1 2.7 0 0.5 0 0
5.3 34.6 41 10.1 4.8 68.6 26.6 32.4 52.7 41.5 66.5 8.5 7.4
2.7 33.5 6.9 18.1 12.8 25.5 29.8 22.9 28.7 29.8 25.5 16.5 21.8
1.6 31.4 20.7 70.3 79.7 3.2 43.6 69.2 15.9 28.8 7.4 75.0 70.7
95.2 3.2
3.7 59.6
0.5 30.9
0.5 6.4
DISCUSSION Regardless of the high prevalence of undernutrition documented in many developing countries, adolescence is considered a low-risk group for health and nutrition intervention programs (Jackson et al. 2002). This study determined and provided data on cross-sectional nutritional status and dietary intake of 15–19 year-old adolescent girls in the traditionally pulse-growing rural community of Halaba in southern Ethiopia. Despite the availability of
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TABLE 3 Median Energy and Other Key Nutrient Intakes of Adolescent Girls Divided into Younger and Older Groups to Account for Differences in Dietary Reference Intake Recommendations (n = 75) 15–18 y (n = 55)
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Nutrients
DRI 15–18 y/19 y
Energy (kcal) 2,200 Protein (g) 46 Calcium (mg) 1,300/1,000 Iron (mg) 62/59 Zinc (mg) 19/10 Vitamin A (RE µg) 600/500 Vitamin C (mg) 40/45 Thiamin (mg) 1.1 Riboflavin (mg) 1 Niacin (mg) 16/14 Fiber (g) 15 Phytate (g) N/A
19 y (n = 20)
Median intake (25th–75th)
% DRI
Median intake (25th–75th)
% DRI
1,548 (1,345–1,820) 40 (35–46) 162 (124–221) 53 (22–193) 10 (8–7) 285 2 (1–3) 0.4 (0.2–0.5) 0.4 (0.3–0.5) 6 (5–8) 16 (11–19) 1.50
70 87 13 85 53 47 5 36 40 39 106 N/A
1,483 (1,282–1,768) 38 (32–46) 161 (106–198) 107 (33–148) 9 (7–11) 300 3 (1–4) 0.3 (0.2–0.5) 0.3 (0.3–0.5) 3 (1–5) 12 (9–14) 1.81
67 82 16 180 90 60 8 27 27 24 81 N/A
Note. A median intake less than 100% of the DRI is considered inadequate. DRI = Dietary Reference Intake recommended intake; N/A = not applicable; RE = retinol equivalent.
TABLE 4 Percentages of Nutrient Intake from Different Food Groups by the Adolescent Girls (n = 75) Food groups Cereals Pulses Roots and tubers Leafy vegetables Dairy product Beverages
Protein (%)
Iron (%)
Zinc (%)
75.9 14.2 0.2 5.7 3.6 0.4
89.8 8.9 0.3 0.8 0 0.2
16.9 81.9 0 0 1.2 0
pulse foods from household farms or local markets, pulse use is very low in these girls, starting with childhood and now into adolescence. Stunting and underweight have important implications for the reproductive health of adolescent girls (Konje and Ladipo 2000) and underweight can result in poor pregnancy outcomes, especially in terms of low birth weight and increased risk of infant mortality (Osrin and Costello 2000). Our findings show that poor nutritional status among adolescent girls was a concern. Of the girls, about one-third (31%) were stunted and nearly one in eight (13.3%) were underweight. This could be attributed to the girls’ inadequate food intake as we also have documented. Reasons may include lack of access to sufficient food and inequities in food allocation as a majority of the girls belonged to poor families. The lack of access to sufficient food and inequities in intra-household food allocation are the key causes for malnutrition in poor households of southern Ethiopia (Regassa and Stoeker
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2007). This prevalence of stunting is comparable to the national survey data of 30% (EHNRI 2010). The percentage of girls who were underweight in our study (13.3%) did not exceed the number defined by WHO (1995) as serious (i.e., 20%–30%). In Ethiopia, nationally it is 20% (EHNRI 2010), and in a study from the north of the country (i.e., Tigray region), it was reported as 58.3% (Mulugeta et al. 2009). We also report a significant prevalence of overweight in our sample, 13.8%. However, few were obese. This finding needs further investigation as excess carbohydrates in the absence of dietary protein can lead to overweight and obesity (Liu et al. 2003). Dietary intake among adolescent girls was found to be poor in quality and below required dietary reference intakes (FAO/WHO/UNU 2004, 2007). This could be due to priority given for boys and younger children over adolescent girls in terms of intra-household food distribution (EHNRI 2010). While meal frequencies per day of two and three were reported by 21.3% and 78.7% of the adolescent girls, respectively, nutrient quality was low. More than half (64.4%) of the girls reported variety of foods in the FFQ at some time during the week before the data collection. However, foods consumed by those girls were predominately cereals and the intake was particularly low with respect to animal source foods and fruits. Low intake of protein sources by adolescents has been reported by Belachew and colleagues (2013) in Jimma, Ethiopia, wherein food insecurity worsened the intake pattern. In our sample, the ASF was primarily diary which would be low in iron; other ASF provide highly available zinc and iron in contrast to plant-based foods. When closely examined as observed 24-hour intakes, nutrient intakes were found to be low in quantity and quality. There was an overreliance on cereals, as noted in the dietary records of the subsample of girls who participated (n = 75). In terms of use of pulse foods, there was, in the FFQ, indication that many of the girls consumed pulses weekly, including lentils (84.6%), haricot beans (59%), peas (51%), fava beans (35.6%), and chick peas (28.7%). Yet in the food records, little evidence of pulse consumption was seen. While food records are not indicative of the usual intakes of individual, they can be useful to characterize a group, and one would expect to see some pulse use by the girls in the subset. Furthermore, with cereal crops being the prominent sources of daily protein, and the lack of cereal-pulse mixed meals (3%), the quality of protein consumed (i.e., inadequate mix of indispensable amino acids) is also of concern. Consumption of proteins of low quality without a sufficient of intake of complementary proteins (i.e., pulses) results in an increase in protein needs above that of requirement and could contribute to the overall wasting and stunting in the adolescent girls. If more pulses were consumed, protein and micronutrient intakes would be improved. In addition to being a protein source, pulses also provide an important dietary source of iron and zinc, supplanting meat, especially for low income, food insecure households, which were prevalent in our study. Due to their importance in the diet, they are a valuable crop to farm families both for
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home consumption and as a commodity sold in the market (Adler 2008). Pulses can play a significant role in improving their food security, by providing an affordable source of protein. In our study the contribution as a protein source of 14% was second to that of cereals at 76% (table 4). This low percentage was unexpected as the region of Halaba is traditionally a pulse growing region. However in one study (Tadesse 2009), calorie consumption of pulses and oilseeds in rural communities was reported to be 9% of dietary intake which was almost half that of urban communities at 14% in Ethiopia. The reasons for low pulse intakes in our participants are speculative without further research, but may include; less pulse crops being planted (e.g., perception as being a “poor” person’s food), the time year our study was carried out (e.g., pulse not being harvested, or being stored for future use), pulses available were being provided to other members of the family for consumption and/or harvested pulses being sold for income. In an ongoing study by our group (Kabeta 2013), we have found that family size, cultural taboos, household processing, formation of intestinal flatulence and educational level of households are main reasons for less consumption of pulses in a rural community in southern Ethiopia. Therefore, the results of our study suggest a need for nutrition education interventions be undertaken to improve knowledge and practice of pulse processing and increase pulse consumption pattern in households by focusing on the perceived barriers within the community. Animal source food intake was nearly negligible among the girls, likely due to high cost. The majority of the girls did not consume milk and yogurt at all, a finding also reported in a study conducted in Ambo Town, although their data revealed a greater animal source food consumption, wherein nearly half of the adolescent girls consumed meat once a week (Yetubie 2008). Cheese was consumed, but more as a condiment, as dietary calcium levels remained low overall. The requirement for calcium in adolescence is higher because of the acceleration of skeleton development (Vatanparast et al. 2010). Inadequate calcium intake during adolescence and young adulthood puts individuals at risk for developing osteoporosis later in life. Fruit also was not part of the daily diet in our study, and as a result, vitamin C and vitamin A (from carotenes) were below nutrition recommendations. It was found in the one day food records that coffee was the predominant accessory to the girls’ meals and not fruit. In Ethiopia, to end a meal with coffee rather than with fruit is common (Amare et al. 2010). Iron intakes were not as poor as some other micronutrients, and could be attributed to the reliance on whole grain cereal consumption (table 4). However, the bioavailable iron is likely low being as their consumption of iron was from a plant source with low bioavailability due to high phytate content. Also to consider is a high consumption of coffee by girls at each meal. Coffee decreases the absorption of non-heme iron due to its tannin content and thus could contribute to increased iron deficiency
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anemia (Mascitelli, Pezzeta, and Sullivan 2007). Further, iron bioavailability is improved with consumption of vitamin C–rich foods, yet fruit intake was practically nil in our study. Zinc absorption is also affected by phytate. Limited intake or uptake of zinc may affect physical growth as well as development of secondary sexual characteristics (Salgueiro et al. 2004). Zinc intake by our participants did not meet requirements even without consideration of phytate. Limitations to our study include the reliance on two dietary assessment methods. The FFQ did not have quantities specified. The one day record cannot be used to assess the usual intake of an individual, however, one would expect a reasonable assessment of the group’s intake, and thus we use it as the more reliable tool as it was done objectively. As we assessed the girls’ dietary patterns during only one season, it may be that at other times of the year, intakes of foods such as fruit would improve. Another limitation of this study is its cross-sectional nature, thus one cannot assume a cause and effect of diet on nutritional status. In conclusion, the present study provides data on nutritional inadequacy along with poor nutritional status among 15–19 year-old adolescent girls in a rural pulse growing region of southern Ethiopia. Our results show dietary patterns that are low in animal source foods, due to high cost, yet also low in pulses for reasons that need to be studied further. More emphasis should be made on planning and implementing nutritional programs aimed at preventing or correcting nutrient deficiencies among adolescent girls. The recently announced National Nutrition Program places emphasis on adolescent girls ages 10–19, and specifies that they should be “nutritionally fit” in order to become mothers (Government of the Federal Democratic Republic of Ethiopia 2013). In this regard, health institutions should provide skill based nutrition education for adolescent girls regarding consumption of diverse foods, including pulses, rich in macro- and micronutrients.
FUNDING This study was financially supported by The Canadian Department of Foreign Affairs, Trade and Development/International Development Research Center—Canadian International Food Security Research Fund (IDRC-CIFSRF) project and in part by Hawassa University and the University of Saskatchewan. We would like to thank the study participants without whom this study could not have been completed.
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