Introduction:
India is currently under going rapid technological advances, socioeconomic, demographic, nutrition and health transition. While the country is yet to overcome poverty, it is increasingly facing problems related to affluence due to industrialization, urbanization and better economy. With increasing affluence there are undesirable lifestyle alterations including consumption of diets rich in saturated fats and excess calories, decreased physical activity, addiction to tobacco and alcohol, and increase in psychosocial stress. As a result, overnutrition, heart disease and diabetes are emerging as newer public health problems. India has to gear itself up to prevent and combat the dual burden of under-nutrition and overnutrition and associated health problems.[1]
School age (5-18 yrs) spans the period between preschool years and adult life. This age group forms a very large proportion of the population. More than 20% of the total population of the country falls under this age group.[2] It is therefore essential that efforts be focused on improving health and nutritional status of school age children, irrespective of the fact whether they are studying in school or school dropouts so that they reach adult life with optimal nutrition and health status.
While the trend of increasing levels of obesity is seen among many affluent populations in developed countries, many countries in developing nations have both over nutrition as well as obesity. This can be attributed to many factors, but it seems economy is a very important factor in this regard.
Interstate differences of data from NNMB[3] showed that there are substantial interstate differences in underweight and stunting among rural girls and boys. In 1989 NFI carried out a study to assess growth patterns of girls in urban areas from affluent families in Delhi, Bombay, Calcutta, and Coimbatore. Mean weight and height of these affluent girls were lower than the mean weight and height of the NCHS standards. Delhi girls were taller and heavier than girls from Coimbatore and Calcutta (NFI).
According to Bogin [4], “growth may be defined as a quantitative increase in size or mass.” On the other hand, development refers to “progression of changes, either quantitative or qualitative, that lead from undifferentiated or immature state to a highly organized, specialized, and mature state.” The study of human growth and development has been a part of anthropology since the beginning of the twentieth century. The works of Franz Boas and his colleagues are well known in this respect. The interest of anthropologists in human growth and development is due to the fact that it reflects the bio-cultural nature and evolutionary processes of human species.[4] Moreover, according to Eveleth and Tanner [5], “a child growth rate reflects, perhaps better than any other single index, his state of health and nutrition, and often indeed his psychological situation also. Similarly the average values of children’s heights and weights reflect accurately the state of a nation’s public health and the average nutritional status of its citizens, when appropriate allowance is made for differences, if any in genetic potential.”
Therefore, a well-designed growth study is very important tool for assessing the health and nutritional status of a population. Besides its association with genetical factors, physical growth and development is subject to the influence of socio-environmental factors, including nutrition and socioeconomic conditions.[4-7]
Several growth studies have been carried out in different parts of India [8], but very few of them are concerned with specific children population like the Sainik schools where most of them are schooled to pursue a career in the Armed forces. Thus, it may be essential to conduct more researches on physical growth and development of children with a view to understanding the health and/or nutritional status of the different populations in different ecological conditions of this part of the country, and to understand the role of (SEC) socio-economic conditions in regulating the growth and nutritional status of children.
In this regard, the boys in the establishment mainly comprised of two dietary groups. To assess the dietary groups, questionnaire was employed with information asked on their dietary preference without asking them in detail about calorie nutritional values.
Vegetarianism encompasses a spectrum of eating patterns: from diets that leave out all animal meats and products (vegetarians) to diets that include eggs, milk, and milk products (lacto-ovo vegetarian) or even fish in addition to eggs, milk, and milk products (pesco- vegetarian) and non-vegetarian (those who eat animal meats, eggs, milk, milk products and fish). Vegetarian and lacto-ovo vegetarian were included in the vegetarian group and pesco- vegetarian in the non- vegetarian group. Dietary preference data are self-reported. Vegetarian status was defined purely on self-reported exclusion of red meat, poultry and fish.
Vegetarians are often a little leaner compared to non-vegetarians and suffer less from obesity and its associated complications than non-vegetarians; whether this is because of not eating meat specifically is unclear.[9] With regard to BMI and dietary habits, many studies have shown considerable differences in BMI and nutrient intakes between vegetarians and non-vegetarians.[10,11] Studies of western vegetarians have consistently reported that vegetarians have lower BMI than non-vegetarians and the reasons for this difference are not well understood, but may include differences in the composition of the diet such as a higher fibre intake and a lower protein intake.[12]
The present study was undertaken on 342 Sainik educated school boys in Bijapur, which includes vegetarians and non-vegetarians boys for understanding the difference in nutritional status between the two dietary groups based upon their dietary habits, anthropometry and body composition parameters.
Methods
Anthropometric data, body composition parameters like Fat percent (Fat%), Fat Mass (FM), Fat Free Mass (FFM) and Total Body Water (TBW) of 342 Sainik school boys were taken and descriptive statistics were used to characterize the participants. In the present study, participants were categorised into two main diet groups: 193 vegetarian (mean age (±SD), 15.1±1.11 years and 149 non vegetarian (mean age (±SD) 15.3±1.2 years.
Anthropometric assessment
Height of the subject was measured to the nearest mm, using SECA 767 electronic personal scale (Medical Scales and Measuring Systems, Germany). Weight was measured by the Tanita TBF-310 Body Composition Analyzer (Tanita Corporation, Tokyo, Japan). BMI was calculated by dividing the subject's weight in kilograms by height in metres squared kg/m2 and used the CDC reference values for assessing z-scores to see their nutritional status.
Body Composition assessment
Bioelectric impedance measurements were made using Tanita TBF-310 Body Composition Analyzer (Tanita Corporation, Tokyo, Japan). The Sainik boys were asked to stand without footwear and bare minimum clothing on the body composition analyser. This method uses a tetrapodal device with inbuilt scales for measuring body weight. Age, gender and height details were entered manually into the system. Impedance measurements allow assessment of the FFM and by difference with body weight, assessment of FM. BMI, Fat%, body weight and TBW were estimated using the standard built in prediction equation for the given age group and was displayed on the machine. The Tanita Body Composition Analyser has been found to provide estimates of %BF that are within 2% of body fat estimation by DXA [13] and is very reliable, with <1% variation within itself.[14] Bioelectrical impedance was the choice of measurement since it is used extensively in pediatric populations.[15,16]
BIA is based on the theoretical relationship between the volume of a conductor and its impedance. In biological systems, electrical conduction is related to water and ionic distribution in the conductor. Fat free mass (FFM) comprises of a protein matrix of adipose tissue, contains virtually all the water and conducting electrolytes in the body, hence conductivity is greater in fat free mass compared to fat mass (FM).[17] It has been shown to be accurate at predicting FFM and total body water in children.[15]
Mid upper arm circumference (MUAC): The MUAC was carried out to estimate skeletal muscle mass and fat stores using a flexible, non-elastic measuring tape. The measurement was taken in centimeters with nonelastic tape measure placed firmly on the left mid upper arm, at the mid-point between the acromion process of the scapular and the olecranon process of the ulna bone.[18]
The formula for SD or z-score is as follows:
Z = (Child’s measurement – Reference median)¸ Reference SD
where,
Child’s measurement = height or weight of a given child at age X
Reference median = mean or 50th percentile of the reference population at age X
Reference SD = standard deviation of the reference population at age X
Nutritional status of as indicated by z-scores of Karnataka Sainik School (13-18 years) as
Normal (£-2 to +2 Z-score) = 1
Moderate malnourished (<-2 to -3 Z-score) = 2
Severe malnourished (< -3 Z-score) = 3
Above normal (> +2 Z-score) = 4
Statistical analyses
The basic design of the study is to analyse and present comparative data between vegetarian and non- vegetarian boys. Beside descriptive statistics, to test the differences between the two dietary groups, t-test was done. All data was managed and analysed using SPSS/PC Software.
Results
Table 1 shows the Sainik boys nutritional status according to the three indices viz, weight-for-age, height-for-age and BMI-for-age based on NCHS references. Table 1 show that there is no statistical difference between vegetarian and non-vegetarian for weight- for- age, height-for-age and BMI-for-age. This means that dietary differences did not affect the nutritional status of the students as far as weight- for- age, height-for-age and BMI-for-age is concerned.
Table 1: Nutritional status according to WFA, HFA, BMIFA (based on NCHS references) |
Nutritional status |
Vegetarian (193) |
|
Non Vegetarian (149) |
|
Number |
Percent |
Number |
Percent |
Weight-for-age (13-18 years) |
Above normal (£ + 2 Z score) |
0.00 |
0.00 |
0.00 |
0.00 |
Normal (£ -2 to +2 Z-score) |
182.00 |
94.30 |
144.00 |
96.60 |
Moderate (-2 to -3 Z-score) |
11.00 |
5.70 |
5.00 |
3.4 |
Severe (< -3 Z-score) |
0.00 |
0.00 |
0.00 |
0.00 |
Total |
193.00 |
100.00 |
149.00 |
100.00 |
χ2 = 0.366 , D.F. = 1 , p >0.05 |
Height –for- age (13-18 years) |
Above normal (£ + 2 Z-score) |
0.00 |
0.00 |
0.00 |
0.00 |
Normal (£ -2 to +2 Z-score) |
169.00 |
87.60 |
132.00 |
88.60 |
Moderate (-2 to -3 Z-score) |
24.00 |
12.40 |
17.00 |
11.40 |
Severe (< -3 Z-score) |
0.00 |
0.00 |
0.00 |
0.00 |
Total |
193.00 |
100.00 |
149.00 |
100.00 |
χ2 = 0.084 , D.F. = 1 , p >0.05 |
BMI- for -age |
Above normal (£ + 2 Z-score) |
1.00 |
0.50 |
1.00 |
0.70 |
Normal (£ -2 to +2 Z-score) |
190.00 |
98.40 |
148.00 |
99.30 |
Moderate (-2 to -3 Z-score) |
2.00 |
1.00 |
0.00 |
0.00 |
Severe (< -3 Z-score) |
0.00 |
0.00 |
0.00 |
0.00 |
Total |
193.00 |
100.00 |
149.00 |
100.00 |
χ2 = 1.584 , D.F. = 1 , p >0.05 |
Table 2 shows the difference in weight of all six age groups. However, there was no statistically significant difference between vegetarian and non vegetarian in weight across all age groups.
Table 2: Statistical Constants Of Weight (Kg) Between Vegetarians and Non-Vegetarians |
Age
(yrs) |
Vegetarian (193) |
Non Vegetarian (149) |
t-value |
Mean |
SD |
Increment |
Mean |
SD |
Increment |
13 |
37.75 |
4.25 |
- |
43.50 |
3.82 |
- |
-1.602 |
14 |
42.65 |
5.98 |
4.9 |
43.05 |
7.61 |
-0.45 |
-0.307 |
15 |
47.02 |
7.00 |
4.37 |
47.09 |
5.46 |
4.04 |
-0.049 |
16 |
49.71 |
6.20 |
2.69 |
52.46 |
7.63 |
5.37 |
-1.776 |
17 |
54.48 |
7.14 |
4.77 |
58.30 |
7.46 |
5.84 |
-1.543 |
18 |
57.64 |
6.10 |
3.16 |
56.71 |
4.79 |
-1.59 |
0.295 |
Statistical constants of height (kg) between vegetarian and non vegetarian |
Age
(yrs) |
Vegetarian (193) |
Non Vegetarian (149) |
t-value |
13 |
155.75 |
7.09 |
- |
161 |
1.41 |
- |
-0.981 |
14 |
158.80 |
6.17 |
3.5 |
159.26 |
8.30 |
-1.74 |
-0.331 |
15 |
162.42 |
6.64 |
3.62 |
164.15 |
6.38 |
3.15 |
-1.295 |
16 |
166.33 |
6.17 |
3.91 |
168.22 |
6.34 |
4.07 |
-1.344 |
17 |
166.94 |
4.45 |
0.61 |
168.10 |
6.11 |
-0.12 |
-0.648 |
18 |
172.60 |
5.46 |
5.66 |
167.09 |
3.85 |
-1.01 |
2.063 |
Table 2 also shows the difference in height of all six age groups. Similarly, here too, there was no statistically significant difference between vegetarian and non vegetarian in height across all age groups.
Table 3 shows the mean z-score of weight-for-age of both the vegetarian and non vegetarian groups. For the 15 years age group (n=62) non vegetarian group had a lower wegiht-for-age value than the vegetarian group and siginficant at p< 0.045.
Table 3 also shows the mean z-score of height-for-age of both the vegetarian and non vegetarian groups. We did not see any significant difference between the two groups with regard to height-for-age.
Table 3: Mean Z-Scores for Weight-for-Age, Height-for-Age, BMI for Age of both Vegetarians and Non-vegetarians |
Mean Z-Scores for Weight-for-Age |
Age (yrs) |
Vegetarian (193) |
Non Vegetarian (149) |
t-value |
Number |
Mean |
SD |
Number |
Mean |
SD |
13 |
4 |
-1.140 |
0.40 |
4 |
-0.605 |
0.36 |
-1.58 |
14 |
60 |
-1.1060 |
0.53733 |
48 |
-1.0712 |
0.68423 |
-0.296 |
15 |
62 |
-1.0787 |
0.60656 |
39 |
-1.0736 |
0.47238 |
-0.045 |
16 |
43 |
-1.2505 |
0.51965 |
37 |
-1.0197 |
0.63932 |
-1.780 |
17 |
19 |
-1.0753 |
0.58488 |
16 |
-.7631 |
0.60907 |
-1.543 |
18 |
5 |
-1.0500 |
0.41467 |
7 |
-1.1114 |
0.32759 |
0.287 |
Mean Z-Scores for Height-for-Age |
13 |
4 |
-.3250 |
0.83819 |
2 |
.2950 |
.16263 |
-0.980 |
14 |
60 |
-.8593 |
0.72341 |
48 |
-.8063 |
0.97329 |
-0.325 |
15 |
62 |
-1.0666 |
0.86594 |
39 |
-.8408 |
0.83050 |
-1.296 |
16 |
43 |
-1.0291 |
0.90954 |
37 |
-.7519 |
0.93557 |
-1.341 |
17 |
19 |
-1.1168 |
0.56138 |
16 |
-.9700 |
0.77154 |
-0.651 |
18 |
5 |
-0.7160 |
0.79780 |
7 |
-1.5200 |
0.56003 |
2.064 |
Mean Z-Scores for BMI-for-Age |
13 |
4 |
-1.1425 |
0.11266 |
2 |
-.7500 |
0.38184 |
-2.114 |
14 |
60 |
-.9747 |
0.58711 |
48 |
-.9672 |
0.64737 |
-0.063 |
15 |
62 |
-.8199 |
0.79444 |
39 |
-.9722 |
0.56064 |
1.004 |
16 |
43 |
-1.0929 |
0.49091 |
37 |
-.9219 |
0.61576 |
-1.381 |
17 |
19 |
-.6764 |
0.66471 |
16 |
-.3476 |
0.76454 |
-1.361 |
18 |
5 |
-.9466 |
0.28637 |
7 |
-.7920 |
0.45752 |
-0.663 |
The mean z-score of BMI-for-age of both the vegetarian and non vegetarian groups is depicted in table 3 also shows similar trend, where we did not see any significant difference between the two groups with regard to BMI-for-age.
From table 4, it can be seen that the vegetarian had a lower mean values in all the age groups as compared to the non vegetarian. Except in the non vegetarian, there was a decrease in mean value between 13 and 14 years and also between 17 and 18 years. Instead of the normal increase in value, it is seen that the 14 years old had a lower value than the 13 years old. This is similar for the 17 years old whose mean is higher than the 18 years old. These differences could also be due to chance. For each age, there is no statistically significant difference between vegetarian and non vegetarian groups.
Table 4: Anthropometric and Body Composition Parameters(Mean ± SD) of vegetarian and Non-vegetarian Indian Boys. |
Variables |
Vegetarian (193) |
Non Vegetarian (149) |
F value |
p-value |
Mean ± SD |
SE |
Mean ± SD |
SE |
|
|
Age (years) |
15.1 ± 1.1 |
0.1 |
15.3 ± 1.2 |
0.1 |
0.775 |
0.379 |
Height (cm) |
162.7 ± 7.1 |
0.5 |
164.1±7.8 |
0.6 |
2.868 |
0.091 |
Weight (kg) |
47.1± 7.7 |
0.6 |
48.7±8.6 |
0.7 |
3.483 |
0.063 |
BMR |
1529.4 ± 380.7 |
27.4 |
1518.6±190.5 |
15.6 |
0.102 |
0.750 |
Fat (%) |
7.6± 3.6 |
0.3 |
8.4± 4.2 |
0.3 |
4.380 |
0.037* |
Fat Mass (kg) |
3.7± 2.2 |
0.2 |
4.3 ± 2.8 |
0.2 |
5.609 |
0.018* |
FFM (kg) |
43.4± 6.3 |
0.5 |
44.4± 6.8 |
0.6 |
1.934 |
0.165 |
TBW (kg) |
31.9± 5.0 |
0.4 |
32.7± 5.5 |
0.5 |
2.049 |
0.153 |
Triceps skinfold (mm) |
7.9± 3.1 |
0.2 |
8.6± 3.36 |
0.3 |
3.718 |
0.055 |
MUAC (cm) |
21.8± 2.3 |
0.2 |
22.1± 2.4 |
0.1 |
4.362 |
0.037* |
* p<0.05 |
Though there were no statistical difference in terms of vegetarian and non vegetarian for each age group, but looking at the mean of vegetarian and non vegetarian for each age, a clear difference (greater values in non vegetarian group) than the vegetarian weight can be seen.
A very interesting result was that Fat%, FM and MUAC all were statistically significant among non-vegetarian compared to vegetarian. From table 4, it was seen that fat (%), fat mass and MUAC all showed statistical significance difference between vegetarian and non vegetarians. Triceps skinfold even though not significant, was seen higher among the non vegetarian than vegetarian.
Non vegetarians had a larger MUAC (p =0.37, 22.1± 2.4), fat percent (p =0.37, 8.4± 4.2), fat mass (p =0.018, 4.3 ± 2.8), and higher triceps skinfold measurement (p= 0.05, 8.6 ± 3.36) than the vegetarians. There was no difference in the body composition of the two groups in relation to BMR, FFM and TBW measured using bioelectrical impedance analysis (Table 4).
Discussion
An attempt was made to follow as far as possible the standard techniques of taking the measurements as described in Weiner and Lourie.[19] For assessing the nutritional status of children, we have adopted three anthropometric indices – BMI-for-age, weight-for-age, height-for-age - which are considered as the indicators of nutritional status. These indices were derived as a standard deviation (SD) or z-score of a child’s measurement to the median weight of the international standard or reference, i.e., the growth reference of the WHO/U.S. National Centre for Health Statistics.[20,21] The z-score of -2 is generally considered as the cut-off point for screening the individuals who are likely to be malnourished.
Over the last six decades India has undergone a slow but sustained economic, social, demographic, agricultural, nutrition and health transition. While under-nutrition and micronutrient deficiencies continued to be major public health problems, over nutrition and obesity are also emerging as a major problem in many states.[1] It has been reported that in India there was a large shift from consumption of high fibre coarse grain such as barley, rye, maize and millet to consumption of low fibre rice and wheat among all income groups both in urban and rural areas.[4]
NFI carried out a cross sectional study in Delhi school children studying in government schools (predominantly low income group LIG) and public schools (predominantly high income group HIG) to assess prevalence of undernutrition and overnutrition. LIG children were shorter and weighed less as compared to HIG children and also the CDC standards. Dietary intake has remained essentially unaltered except among urban affluent segments of the population. Currently overnutrition rates are low in rural population and among poorer segments of population in urban areas. In the urban affluent segments an increase in energy intake of fats, refined cereals and sugar and simultaneous reduction in physical activity have contributed to the rapid increase in overnutrition in all age groups.[1]
In India, depending on the region or the strata of the population under study, we can get different percentages of obesity or malnutrition within the same ethnic group in the same state. This seems to be the case in the present study where the population were young boys grouped together in lieu of their schooling as they all belonged to a school in Bijapur, Karnataka.
Recent statistics on nutritional indicators showed that nearly 50% of Indian children were underweight and another 46% were stunted (low height for their age) in India. Considerable variations in the levels of under-nutrition were found both within and across six diverse Indian regions. For example, within the southern region, the proportion of underweight children varied between 4.7% in Kerala and 44% in Karnataka. Furthermore, the levels of under-nutrition were particularly high in the larger Indian states that are mostly caught in extreme poverty. As such, little is known about the underlying causes of child malnutrition in India especially at individual and national levels. The analysis considers height-for-age which is an indicator of nutritional stunting or dwarfing. Besides, BMI-for-age and also weight-for- age ere also calculated which is an indicator of underweight.
Although the present study did not assess the economic background of the students under study, it was seen that most of them came from the neighbouring areas of Bijapur and the districts lying near about and were from lower income family groups.
The present study tried to see also how body composition of Sainik school children were different among vegetarian and non vegetarian groups as the school mess clearly gives these two food preferences importance and approximately (56.4%) of them were vegetarians and (43.6%) non vegetarians. The study also wanted to see whether the vegetarians had higher value of FFM than the non vegetarians. Or, in other words, do non vegetarian have more fat mass than vegetarians? Do dietary preference results in one group having a better or higher BMI value?
National programmes for tackling anaemia, iodine deficiency disorders, Vitamin-A deficiency, ICDS programme, mid-day-meal programme, health infrastructure and manpower has all resulted in universal access to essential primary health care in India. As a result of all these interventions, there has been a substantial reduction in severe grades of under-nutrition in children and some improvement in the nutritional status of all the segments of population.[1]
In the present study we observed marginally better nutritional status in Non- vegetarian students based on their anthropometric measurements. Therefore while planning meals for school children, care should be taken in menu planning for vegetarian students to provide them quality protein diet, which can be achieved by judicious use of cereals, pulses, low fat milk, curd, paneer in the diet for vegetarians. The FSSAI recommends that at least 80% of available food items in the menu should include vegetables and legumes, fruits, grain (cereal/ pulses) foods; preferably wholegrain and/or high in fibre, lean meat, egg, fish, low fat milk, curd, paneer etc.[22]
Children are not the best judge of food choices as they are not aware of the importance of balanced diet and neither are they aware of the connection between various diseases to diet. They require special needs for growth, fighting infections, maturation, bone development and body building. Therefore food needs to be balanced as they play an important role in body composition , body mass index, reduced risk of diet related chronic diseases in later life. Burgers, pizzas, fries, chocolates, ice-creams, jams, etc. are not the right choice to meet neither the nutrient needs that is available in a balanced diet nor help children in their growth.
The present study was conducted in Sainik and Military schools which are residential schools and provide complete and wholesome meal to cadets at their mess. Besides, there is emphasis on regular physical activity in their activity schedule. These schools do not sell junk food in their campus through school canteen.
FSSAI has also recommended the development of a canteen policy to provide nutritional and healthy food in school. This should be done in combination with a focus on promoting physical activity habits that can impact the health of children.
Limitation:
Daily food intake was not assessed and therefore dietary habits were recorded using interview method. The frequency of taking non-vegetarian diet was also not known. On a weekly basis, boys took meat on weekends and on other days when there was no non vegetarian (meat/chicken) is not in the meal, eggs were consumed.
Conclusion:
As poverty and poor access to food are no longer the major barriers to through health and nutritional education; when coupled with improved access to health and nutrition services.
Indians are predisposed towards adiposity especially abdominal, insulin resistance and diabetes, hyper-triglyceridaemia and cardiovascular diseases.[23-25] This predisposition could be genetic or environmental and can manifest itself at birth, in childhood, during improvement in dietary intake, the country can achieve substantial improvement in dietary intake adolescence and in adult life. To prevent escalation of diseases and improve health of a nation, this has to be combated through efforts to ensure healthy dietary habits and lifestyle right from childhood in all segments of population.
Nutrition education that children, adolescents and adults should eat balanced diet with adequate energy intake and lots of vegetables and health education that exercise has to become a part of daily routine to promote muscle and bone health as well as prevent development of adiposity in all age groups have to be promoted throughout the country.
Acknowledgements:
The authors would like to thank the Bijapur Sainik school authorities and all staff members and the boys for their participation in the project.
Conflict of interest:
The authors declare that there are no competing financial interests in relation to the study.
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