CONSUMPTION PATTERN OF GREEN LEAFY VEGETABLES AND IMPACT OF NUTRITION EDUCATION ON HAEMOGLOBIN STATUS OF RURAL ADOLESCENT GIRLS

Transcription

1 CONSUMPTION PATTERN OF GREEN LEAFY VEGETABLES AND IMPACT OF NUTRITION EDUCATION ON HAEMOGLOBIN STATUS OF RURAL ADOLESCENT GIRLS Thesis submitted to the University of Agricultural Sciences, Dharwad in partial fulfillment of the requirement for the Degree of MASTER OF HOME SCIENCE In FOOD SCIENCE AND NUTRITION By JYOTI T. SAJJAN DEPARTMENT OF FOOD SCIENCE AND NUTRITION COLLEGE OF RURAL HOME SCIENCE, UNIVERSITY OF AGRICULTURAL SCIENCES, DHARWAD AUGUST, 2008

2 ADVISORY COMMITTEE DHARWAD August, 2008 (KASTURIBA, B.) MAJOR ADVISOR Approved by: Chairman: (KASTURIBA, B.) Members: 1. (RAMA K. NAIK) 2. (PUSHPA C. BHARTI) 3. (USHA MALAGI) 4. (A.R.S. BHAT)

3 CONTENTS Sl.No. Chapter particulars CERTIFICATE ACKNOWLEDGEMENT LIST OF TABLES LIST OF FIGURES LIST OF PLATES LIST OF APPENDICES 1 INTRODUCTION 2 REVIEW OF LITERATURE 2.1 Prevalence of iron deficiency anaemia 2.2 Assessment of nutritional status of the adolescent girls 2.3 Consumption of green leafy vegetables 2.4 Nutrition education 3 METHODOLOGY 3.1 Selection of the sample 3.2 General information 3.3 Assessment of nutritional status of the adolescent girls 3.4 Biochemical analysis 3.5 Nutrition education 3.6 Statistical Analysis 4 RESULTS 4.1 Demographic profile of selected adolescent girls 4.2 Nutritional status of the adolescent girls 4.3 Dietary survey 4.4 Clinical symptoms 4.5 Biochemical Analysis 4.6 Association between adequacy of energy and blood forming nutrients and other related factors 4.7 Nutrition education intervention study 5 DISCUSSION 5.1 Iron status of adolescent girls and other association factors 5.2 Consumption patter of green leafy vegetables and method of cooking of green leafy vegetables 5.3 Impact of nutrition education 6. SUMMARY AND CONCLUSION 7. REFERENCES

4 LIST OF TABLES Sl. No Title Demographic profile of selected adolescent Mean anthropometric measurements of adolescent girls Distribution of adolescent girls based on body mass of index (BMI) classification Classification of adolescent girls into different groups based on waist tohip ratio (WHR) Mean food intake of adolescent girls Mean intake of energy and blood forming nutrients Mean per cent adequacy (%) of energy and blood forming nutrients of dry and transitional zone adolescent girls Frequency of consumption of green leafy vegetables (GLVs) in dry zone adolescent girls Frequency of consumption of green leafy vegetables (GLVs) in transitional zone adolescent girls Methods of cooking used for green leafy vegetables Distribution of sample by possession of kitchen garden Prevalence of clinical symptoms of anemia in adolescent girls Hemoglobin status of selected adolescent girls Association between adequacy of energy and blood forming nutrients and locality Association between adequacy of energy and blood forming nutrients and family type in dry zone Association between adequacy of energy and blood forming nutrients and family type in transitional zone Association between adequacy of energy and blood forming nutrients and family size in dry zone Association between adequacy of energy and blood forming nutrients and family size in transitional zone Association between adequacy of energy and blood forming nutrients and Hemoglobin status Impact of nutrition education on nutrition knowledge of adolescent girls Impact of nutrition education on knowledge scores in experimental and control group Mean height and weight of adolescent girls before and after nutrition education Impact of nutrition education on hemoglobin level of adolescent girls Impact of nutrition education on hemoglobin level of experimental and control group

5 LIST OF FIGURES Sl.No Title Selection of sample Intervention study Per cent adequacy of energy and blood forming nutrients Hemoglobin status of adolescent girls Increment in nutrition knowledge of adolescent girls after intervention Increment in hemoglobin level of adolescent girls after intervention LIST OF PLATES Plate No. 1a 1b Title Nutrition education training by nutrition experts to communicators Nutrition education training by nutrition experts to communicators Demonstration conducted to communicators Nutrition education by communicators to communicates Group discussion between communicators and communicates Exhibition conducted in school LIST OF APPENDICES Appendix No Title Questionnaire I Questionnaire II Development of educational materials

6 1. INTRODUCTION The word adolescence comes from the Latin word adolescence which means to grow or to grow maturity. Adolescence is a period of transition when the individual changes physically and psychologically from a child into adult. Adolescence in contrast to puberty, is not a single stage but a range of 13 to 18 years. The period of adolescence is accomplished by its profound changes in growth rates, body compositions and marked physiological and endocrinal changes. The velocity of physical growth is second only to the rate of growth during infancy. The dramatic physical changes of body include increase in height and weight, deposition and redistribution of fat, increased lean body mass and enlargement of many organs including the sexual components. Adolescent girls are very important section of our society as they are our potential mothers and future home makers. Adolescents aged between years account for more than one fifth of the world s population. In India this age group forms 21.4 per cent of total population (Saroja Prabhakaran, 2003). Unfortunately adolescent girls are a neglected sector of the population of our country. They are poorly fed members of family under our present economic conditions. As a social custom and cultural practice, an adolescent girl enters married life and motherhood when she is neither matured enough to understand the meaning of motherhood nor is in good health to cope with the triple needs of growth, pregnancy and lactation. Several factors such as socio economic status, environment, attitude towards girl babies and adolescent girls, ignorance with regard to nutritional requirement, hygiene and illness are responsible for present nutritional status of adolescent girls. Anaemia is one of the problems of public health throughout the world, especially in developing countries. In India, it is an important public health problem affecting people from all walks of life. Iron deficiency anaemia (IDA) is most prevalent and severe in pregnant women, young children and adolescent girls. Seventy per cent of the adolescent girls are anaemic in India according to studies. IDA is a major threat to safe motherhood. It contributes to increased post perinatal maternal mortality, increased fetal growth retardation, pre and perinatal mortality and low birth weight. In general, IDA is a major contributory cause of lowered resistance to infection, poor cognitive development, fatigue, lowered physical activity, poor mental concentration and productivity. As per National Nutrition Monitoring Bureau (NNMB) though the habitual diet contain adequate iron (26 mg), iron deficiency anaemia is still widespread. Thus it is important to note that not only the quantity of iron consumed from diet but also its bioavailability plays unique role in combating anaemia. Nevertheless, the absorption of iron from Indian diet is only 1-5 per cent (Anon., 1995). Lack of haemopoitic factors such as ascorbic acid, folic acid, vitamin B 12, protein, β-carotene, vitamin B 6, copper and zinc may lead to nutritional anaemia. In addition, consumption of caffeinated beverages (only tea and coffee) along with food inhibits the iron absorption i.e., it makes iron unavailable to the body. Green leafy vegetables are the rich sources of pro-vitamin A, vitamin C, folic acid and minerals like calcium, iron, phosphorus, sodium and potassium. It has been estimated that 100 g of tropical leafy vegetables can provide mg of ascorbic acid, 100 µg of folic acid, 4-7 mg iron and mg of calcium (Saxena, 1999). India is endowed with an array of leafy vegetables suited for tropical, sub-tropical and temperate climates to be grown all the year round. Consumption of herbs is as old as human race itself. Green leafy vegetables represent an excellent component of the habitual diet in the tropical and temperate countries. Green leafy vegetables in our country are known to be the most inexpensive source of several vital nutrients. Leafy vegetables are appreciated because they not only supply the protective nutrients and add variety to a monotonous diet, but also have an alternative taste, pleasing appearance and aroma. Majority of the Indian population is vegetarian and daily intake of at least 100 g of fresh green leafy vegetable is recommended by the nutrition experts (Reddy, 1999). The commonly consumed tropical green leafy vegetable in India is Amaranthus. In addition to this, a great variety of less familiar green leafy vegetables like Basella, Chekkur manis, Alternanthera, Drumstick etc., are also used locally in different parts of the country. Similarly

7 leaves of large number of plants growing wild in the country side also prove to be good source of nutrients. Besides, cool season leafy vegetables like cabbage, Chinese cabbage, kale etc. are consumed by Indian people. In addition to all these, large number of minor vegetables are grown in India. Similarly leaves of other vegetables like, beetroot, pumpkin, radish etc. are also consumed by many. Green leafy vegetables are the cheapest of all the vegetables within the reach of poor man, being richest in their nutritional value. The problem of malnutrition is assuming seriousness in the vulnerable groups viz., adolescents, pregnancy, lactation and school children, not because of poverty but because of ignorance, illiteracy and callousness of the people. The lack of knowledge especially on the nutritive value of these green leafy vegetables among the public in general is the main drawback in their lower consumption. Nutrition education might be of the important strategies to combat iron deficiency anaemia in adolescent girls, stressing the importance of haemopoitic nutrients and consumption of green leafy vegetables which are excellent source of iron and micronutrients. Child-to-child education method is a new technique in nutrition education, where in a group of children will be trained by nutrition experts, who inturn will teach their fellow mates. This method can be especially beneficial in adolescent girls because of the reasons viz., they are open minded and friendly in their age groups and as a result they can communicate more freely with their fellow mates. Another advantage of this method is that, one can reach the large group in a short period. Hence, this study has been focussed on consumption of green leafy vegetables and impact of nutrition education on haemoglobin status of adolescent girls with following objectives. 1. To assess the nutritional status of rural adolescent girls 2. To determine the availability and consumption pattern of green leafy vegetables among the rural adolescent girls 3. To develop educational material for iron security 4. To determine the impact of nutrition education intervention on haemoglobin status.

8 2. REVIEW OF LITERATURE India is a country, which is blessed with different agro-climatic regions, which enables to grow different types of crops. With respect to vegetable production India is a second largest producer after China. Vegetables are cheap and rich source nutrients among them green leafy vegetables represent an excellent source of vital nutrients. Despite the abundant availability of vegetables, the present nutritional situation is alarming in the country because 70 per cent of adolescents are affected by iron deficiency anaemia (Vijayaraghavan, 2007). Adolescent period is the right time to invest in nutrition, health, education and social spheres of life as they are the citizens of tomorrow. Main etiological factors contributing to iron deficiency anaemia in adolescents is low dietary intake of iron and other blood forming nutrients. In India lack of awareness and ignorance is also another major factor, though iron rich foods are available in plenty and are inexpensive but their consumption is low. Hence, nutrition education may be rational approach to prevent iron deficiency anaemia. Nutrition education is the process of applying knowledge of nutrition related scientific information of social and behavioural sciences, in ways designed to influence individuals and groups to eat the kinds and amount of foods, that will make a maximum contribution to health and social satisfaction. The importance of nutrition education requires no special emphasis. It is relevant for all age groups at all levels. Hence, the literature in connection with prevalence of anaemia, nutritional status, haemoglobin level, consumption of green leafy vegetables, nutrition education and impact of nutrition education are presented in this chapter under the following headings. 2.1 Prevalence of iron deficiency anaemia Nutritional anaemia due to iron deficiency is a global problem and it affects more than a billion people in the entire world. In the developing world alone, 370 million women suffer from anaemia (Vijayaraghavan, 2007) Global prevalence To know the iron status of adolescent girls, Khan et al. (1996) selected 225 girls (12-15 years) of Bangladesh. It was reported that 22 per cent (46) of the subjects were found to be anaemic having haemoglobin level less than 12 g/dl. A study conducted by Adgeppa et al. (1997) in Indonesia including 805 adolescent girls showed that 21.1 per cent of the girls (170) were anaemic having haemoglobin level less than 12 g/dl. In Sri Lanka, a study was conducted on 690 adolescent girls to estimate the prevalence of anaemia (Jayatissa and Piyasena, 1999). Results indicated that 21.1 per cent (146) of girls were having haemoglobin less than 11.5 g/dl and thus were anaemic. Shahabuddin et al. (2000) conducted a study on nutritional status of adolescents in a rural community of Bangladesh. It was reported that 98 per cent (1453 out of 1483) of adolescent girls suffered from anaemia National level prevalence Jondhale et al. (1999) selected 300 school going adolescent girls (13-15 years) from Parbhani city to know the prevalence of anaemia. Haemoglobin level indicated that 12 to 15 year old girls had moderate anaemia with haemoglobin level of 9.92 g/dl whereas 14 year old girls were anaemic with haemoglobin level of g/dl. The prevalence of anaemia in 504 adolescent girls (10-18 years) representing 24 subcentres of village of Daurala block of Meerut was 34.4 per cent. The prevalence of mild, moderate and severe anaemia among adolescent girls was 19.0 per cent, 14.0 per cent and 1.4 per cent respectively. Majority (55.2%) were having mild anaemia and only 4.0 per cent had severe anaemia (Rawat, 2001). Gowrikar et al. (2002) carried out a study on prevalence of anaemia among 149 adolescent girls of Ujjain in western Madhya Pradesh. The study revealed that adolescent

9 girls belonging to weaker section of society was having very high prevalence of anaemia (97%). Eleven per cent of girls were suffering from severe anaemia, whereas moderate and mild anaemia were around 42.5 per cent. The prevalence of anaemia in 630 adolescent girls (13-16 years) of rural Wardha was found to be 59.8 per cent. The prevalence of severe, moderate and mild anaemia was 0.6, 20.8 and 38.4 per cent respectively (Kaur et al., 2006). A study was conducted by Kalpana et al. (2007) on 500 adolescens girls (13 to 15 years) of low income families in Coimbatore, which revealed that 76.4 per cent of adolescent girls were anaemic and only 23.6 per cent were non anaemic. Kowsalya et al. (2008) conducted a study on prevalence of anaemia in 100 adolescent girls (13-18 years) in Manipur. The results revealed that, among the total subjects, 30 were moderately anaemic (7-10 g/dl) and 25 girls were mildy anaemic (10-12 g/dl). Ten girls were severely anaemic (<7.0 g/dl) Regional level Akkamahadevi et al. (1998) studied the prevalence of anaemia in adolescent girls (12-18 years) of rural and urban areas of Dharwad taluka. Among 172 adolescents, per cent of the girls were severely anaemic, per cent moderately anaemic and per cent were having mild anaemia. The prevalence was higher in rural girls (57.8%) compared to urban counterparts (31.32%). Investigation focusing on seasonal variations on iron status of adolescent girls in Dharwad taluk was carried out. Deepa et al. (2004) studied the prevalence rate of anaemia. Nearly 32 per cent of the adolescent girls were having severe anaemia, per cent were having mild anaemia and about 35 per cent of them were moderately anaemic in the rural area. In the urban locality, nearly 17.5 per cent, 35 per cent and 32.5 per cent of the subjects were having severe, mild and moderate anaemia respectively Muthaya et al. (2007) studied the anaemia prevalence in school aged children (5-15 years) in Bangalore. The overall anaemia prevalence in this group was 13.6 per cent. Anemia prevalence was higher in girls than boys (15.3%, n = 993 Vs. 12.0%; n = 1037 respectively, P < 0.05). There was no significant difference in anemia prevalence between children in urban and rural locations (14.6 and 12.3% respectively). 2.2 Assessment of nutritional status of the adolescent girls Nutritional status refers to the health of an individual and it is influenced by the intake and utilization of nutrients. Nutritional assessment is the process where by the state of nutritional health of an individual is determined. It includes nutritional anthropometry, clinical examination, haemoglobin assessment and dietary survey Nutritional anthropometry Jelliffe (1966) defined nutritional anthropometry as that science which is concerned with the measurements of variations of the physical dimensions and gross composition of human body at different age levels and degree of malnutrition. Adolescence is a period of rapid growth and development. Nutritional requirement in relation to body size is more during adolescence. Majority of the girls do not achieve their full height and weight potential on account of their dietary insufficiencies (Chaturvedi et al., 1994). A study conducted by Rao et al. (1993) on adolescent girls belonging to well to do middle and lower middle class urban families in Hyderabad, revealed that the higher mean values of indices of weight/height was seen in adolescent girls of better socio-economic status than those of lower socio-economic status. Chaturvedi et al. (1994) compared the anthropometric measurements with that of ICMR s data in 941 married adolescent girls belonging to schedule caste in rural Rajasthan. The height and weight was significantly higher than those of ICMR data and lower compared to that of well to do group study data.

10 Adolescent girls of 13 to 18 years were selected from nearby villages of Pune to measure their heights and weights. Results exhibited, that the rural girls were shorter in comparison to NCHS standards by almost eight in cm at the age of 12 + years, but this deficit increased to 13 cm at the age of 17+ years. The respective figures for weight were even larger and increased from 5 kg at 12+ years to 16 kg at 17+ years, observed values were significantly lower at all ages for all measurements, showing that girls were shorter and lighter (Rao et al., 1998). To assess the nutritional status of adolescent girls in rural area of Dharwad taluk, 200 girls of 13 to 17 years were selected (Hanagi, 2001). The body mass index was computed using recorded heights and weights which revealed that maximum percentages of girls (34.5%) were belonging to CED grade III, followed by CED grade I (26.5%) and grade II (21%). Only 6.5 per cent of girls belonged to normal category, while none of them were in obese category of BMI. Deepa (2002) conducted a study on nutrition and health profile during menarche and testing seasonal variations for 80 adolescent girls aged between 13 to 15 years recorded higher values for height, weight, waist to hip circumferences during winter ( cm, kg, cm and cm respectively) followed by rainy ( cm, kg, cm and cm respectively) and summer ( cm, kg, cm and cm respectively). But all the girls were shorter and lighter compared to NCHS standard at 50 th percentile. Kumari and Singh (2003) conducted a study on nutritional status of 100 adolescents (13-18 years) belonging to schedule caste. Study revealed that, 26.6 per cent of male adolescents were severely malnourished with grade III chronic energy deficiency and 27.9 per cent female had grade II energy deficiency. Eleven per cent male and 8.5 per cent female adolescents were mildly malnourished. About 42.7 per cent male and 36.8 per cent female were in the normal category. A study was conducted by Saroja Prabhakaran (2003) to know the nutritional status of adolescent girls residing in a university hostel revealed that their mean height was cm while their mean weight was 50.6 kg against the NCHS reference standard of cm height and 56.6 kg weight respectively. Asma et al. (2003) assessed nutritional status of 340 under privileged children between the age group of 4 to 11 years residing in Ghousianagar, a densely populated area of Mysore city. The results revealed that 50 per cent were under weight and stunted. 10 per cent of them exhibited wasting and only 11 and 18 per cent of children had normal weight/age and height/age respectively. Choudary et al. (2003) reported that per cent of adolescents had BMI of less than 18.5 kg per sq.m. in rural area of Varanasi and also Shahabuddin et al. (2000) reported 67.0 per cent prevalence of thinness in Bangladesh. Study conducted by Deshmukh et al. (2006) on nutritional status of adolescents in rural Wardha showed that 53.8 per cent of the adolescents were thin, 44 per cent were normal and 2.2 per cent were over weight. Zanvar et al. (2007) compared 500 adolescents (13-18 years) from urban, rural and tribal areas of Marathwada region, found that urban adolescent girls had better height ( ± 8.6 cm) than rural and tribal counterparts ( ± 7.11, ± 9.38 cm respectively). Similar trend was observed in weight and body mass index, which ranged from ± 3.41 to ± 5.02 cm and ± 2.31 to ± 2.00 cm respectively. A study conducted by Kowsalya et al. (2008) on the iron nutriture of 100 adolescents (13-18 years) in Manipur found that the mean height and weight of the selected adolescent girls were below the standard value Clinical Examination Clinical examination is an important practical method for assessing the nutritional status of a community. The method is based on examination for changes, believed to be related to inadequate nutrition that can be seen or felt in superficial epithelial tissues.

11 Clinical examination has always been and remains an important practical method for assessing the nutritional status of a community (Jelliffe, 1966). Kumari and Singh (2003) conducted clinical examination of 100 schedule caste adolescents from deprived section of society in Pusa. Clinical symptoms were more prominent among female than male members. This might have been due to better nutritional status of males as compared to female adolescents. Devi and Uma (2005) studied the clinical symptoms of anaemia in 100-adolescent girls (14-16 years) from Sri. Avinashilingam higher secondary school for girls in Coimbatore. The results revealed that almost all the signs of iron deficiency anaemia were observed and none of them was affected by Koilonychia and Poor stamina. To assess the impact of iron, vitamin A and vitamin C supplementation on anaemic adolescent girls, clinical examination was carried out by Swarnalata and Yegmmai (2006) on 100 school adolescents girls (13-15 years) of Coimbatore. Prevalence of pale conjunctiva was greater (60%) in both experimental and control groups. After supplementation of iron, vitamin A and vitamin C, there was remarkable reduction observed in experimental group, while in control group, prevalence of pale conjunctive was greater. Kumar et al. (2006) studied the clinical examination of 80 adolescent girls from Allahabad and observed the various signs and symptoms of anaemia among adolescents like brethlessness, tiredness and pale nails Biochemical analysis Haemoglobin assessment is an indicator of iron status in individuals by analysing the level of haemoglobin in blood, one can diagnose whether the individual is anaemic or not Haemoglobin status The haemoglobin content of the normal adolescent girls is 12 and more than 12 g/dl is categorised as non-anaemic and haemoglobin level less than 12 g/dl are anaemic based on the cut off points given by WHO. Leela and Priya (2002) conducted a study on iron status and morbidity pattern among 120 school children in Coimbatore. The results revealed that mean haemoglobin level was 12.5, and 9.17 g/dl for the non-anaemic, mild and moderate anaemic respectively. Gowrikar et al. (2002) reported that the mean haemoglobin was 9.80 g/dl and overall prevalence of anaemic was 96.5 per cent in 459 girls of years of age in Ujjain. Saroja Prabhakaran (2003) conducted study on nutritional status of 300 adolescents (13-16 years) in four villages of sevagram. The results revealed that the prevalence of severe, moderate and mild anaemia was 0.6 per cent (<7 g/dl), 20.8 per cent (7.10 g/dl) and 38.4 per cent (10-12 g/dl) respectively. Shekar (2005) undertook a study on iron status of 150 adolescent girls to evaluate their physical fitness. Haemoglobin level estimation showed that 45 per cent of girls were non anaemic (<12 g/dl), 12.6 and 46 per cent were found to be moderately and mildly anaemic respectively. None of them were severely anaemic. A study conducted by Kaur et al. (2006) on 630 adolescent girls (13-16 years) in four villages of Sevagram, revealed that prevalence of severe, moderate and mild anaemia was 0.6 per cent (<7 g/dl), 20.8 per cent (7-10 g/dl) and 38.4 per cent (10-12 g/dl) respectively Dietary survey Dietary studies are generally an integral part of most nutritional surveys. The main objective of any dietary assessment is to discover what the person under investigaiotn is in habit of eating over the long range and in the short run. Tamilarasi and Mathew (1990) selected 20 obese adolescent girls from 200 residential adolescent girls of Avinashlingam Home Science College for Women, Coimbatore and observed that the energy intake was high as compared to RDA. Chaturvedi et al. (1994) studied the nutritional status of 941 married adolescent girls (10 to 18 years) belonging to schedule caste communities in rural Rajasthan. The girls of low

12 socio-economic group had inadequate diets. When the dietary intake was compared against ICMR RDA, it was found that the diets were deficit in calories by 30 to 40 per cent, protein by 25 to 37 per cent and iron by 39 to 55 per cent. While assessing the prevalence of anaemia and dietary intake of blood forming nutrients of 180 adolescent girls from rural and urban areas of Dharwad taluka, Akkamahadevi (1996) found that the mean intake of energy (1532 kcal), protein (38.77 g), ascorbic acid (23.28 mg), vitamin B12 (0.56 µg), folic acid (81.63 µg) and iron (14.7 mg) was lower than the ICMR recommendations. Intake of vitamin B 12 was significantly higher in urban girls (0.80 µg) compared to rural counterpart (0.32 µg/day). Assessment of food intake by Gowrikar et al. (2002) showed that the diet of adolescent girls of Ujjain city, Madhya Pradesh was basically cereal based with wheat as a staple food. Frequency of consumption of pulses, milk and milk products and fruit was low. Deepa (2002) showed that irrespective of the locality, the selected 80 adolescent girls had inadequate intake of energy and blood forming nutrients compared to ICMR recommendations, in all the seasons except folic acid (113.9 µg), ascorbic acid (55.9 mg) and copper (2.9 mg) during rainy season, which exceeded the recommendations. A study was conducted by Kumari and Singh (2003) on nutritional status of 100 adolescents (13-18 years) belonging to Schedule Caste. Intake of most of the foods and nutrients was lower than their respective RDAs. The intake of food and nutrients by the females was comparatively lower than males. `Tatia and Taneja (2003) studied the dietary intake of 256 tribal adolescent girls of Dhar district in Madhya Pradesh. Results revealed that consumption of cereals and pulses was 70 per cent and 25 per cent respectively of recommended dietary allowance. The intake of green leafy vegetable was very low, while fruit intake was almost negligible. Hence the intake of nutrient was deficient in almost all the nutrients. Kumar et al. (2006) conducted a study on influence of family s vegetable cultivation on prevalence of anaemia among 80 adolescent girls in Allahabad and results showed that intake of all the nutrients were comparatively less than the recommended dietary allowance except for fat. Inadequate consumption was noted for all food groups especially for green leafy vegetables, roots and tubers, fruits and milk among 500 adolescent girls (13-18 years) of Marathawada region (Zanvar et al., 2007). Kowsalya et al. (2008), while studying the impact of supplementation of lotus stem on the iron nutriture of 100 adolescents (13-18 years) in Manipur, found that the mean intake of green leafy vegetables, roots and tubers, fruits, meat, sugar and jaggery, fats and oils, fish and egg were deficient in both control and experimental groups compared with ICMR recommendations. 2.3 Consumption of green leafy vegetables Green leafy vegetables are good sources of iron and calcium, very good sources of pro-vitamin A and C. Iron content is high in amaranth, followed by spinach and chekkuramanis. Amaranth and spinach are easily available and are inexpensive sources of many nutrients other than iron. On drying, the iron content increases, so if dried leaves are consumed, it will be better source to overcome anaemia caused by iron deficiency. Adolescence is one of the nutritionally stress period of life. The requirement for iron increases during the adolescence for girls due to rapid growth and menstrual losses. Green leafy vegetables are the cheapest of all the vegetables within the reach of poor man, being richest in their nutritional value (Rao et al., 1980). The consumption level of green leafy vegetables was much below the recommended values in rural school children of Wardha district (Malhotra and Pralhad, 1984). A deficient intake of green leafy vegetables in selected 20 obese adolescent girls from Avinashilingam Home Science College for Women, Coimbatore was reported by Tamilarasi and Mathew (1990).

13 Kumar et al. (2006) studied the influence of family s cultivation on prevalence of anaemia, among forty adolescent girls from vegetable grower and forty from non vegetable grower families in Allahabad. The results indicated that, the food and nutrient consumption of adolescent girls diet did not differ significantly in the categories of families whether they cultivated or did not cultivate leafy vegetable. 2.4 Nutrition education Jelliffe (1966) stated that education which is geared to improve the local conditions and is based on local and free from the local cultural beliefs is most likely to be successful. He stressed that the most single aim of nutrition education is to persuade mothers in the tropics to make the best use of foods locally available for feeding children in the early years of life. Nutrition education is the foundation for any programme intended for nutritional improvements (Devdas et al., 1970). Albanese (1971) defines nutrition education as a means of translating nutritional requirements into food and adjusting the food choices to satisfy nutritional, cultural, psychological and economic needs. Nutrition education has been defined as educational measure for inducing desirable behavioural changes for the ultimate improvement in the nutritional status of individual and family (Deshpande et al., 2003). All the above definitions suggest that nutrition education aims at bringing in nutrition behaviours which promote health of an individual. According to UNESCO (1983), nutrition education in schools can help to alleviate and even prevent the incidence of nutritional deficiencies among vulnerable children. In this context, nutrition education intervention through child to child education was used. Varalakshmi and Jayashree (2003) conducted a study on child to child teaching technique in nutrition education. For the study 29 boys and 21 girls were selected using triple random sampling technique. They were divided into two group as student communicators and student communicatees on the basis of age and sex. The study showed that the mean knowledge pre-test scores of student communicators and communicatees were 7.2 and 7.3 respectively. After the intervention, post-test scores were 14.9 and 13.6 in student communicators and communicatees respectively. The study showed that the child to child teaching, method of teaching and learning process is more effective than the traditional method of teaching. Sucharitha et al. (2007) studied the impact of nutrition education through girl to girl approach at Hyderabad. Adolescent girls aged years and micronutrients vitamin A, C, Iron, calcium were selected as content for nutrition education. The results revealed that pretest scores of girl leaders and student communicatees in nutrition knowledge were 32.4 per cent and 29.7 per cent respectively. The post-test scores were 77.2 per cent and 73.9 per cent in nutritional knowledge of girl leaders and student communicatees. The consumption of micronutrient dense foods also increased significantly. Intervention through girl to girl approach in gaining nutrition knowledge was successful and the study also proved that the girls were more participatory, active and efficient in sharing information Impact of nutrition education Puri and Mehta (1994) studied the impact of nutrition and health education on 155 pre-school children (24-60 months) in villages around Chandigarh. Children received information on nutrition and health education relating to personal hygiene (PH), food hygiene (FH) and recognition of food (RF), it was observed that children s knowledge of PH, FH and RF increased significantly at the end of 12 months. An evaluation of impact of nutrition education on the knowledge and practices of soybean cultivators regarding soybean utilization was studied by Kamble (1997) in Dharwad district. The baseline information indicated that the knowledge as well as utilization of soybean by 90 rural women was nil. Further, nutrition education imparted to the rural women showed that utilization of soybean was 59 per cent during the first month evaluation and 42 per cent in second and 33 per cent in the third month of post education session.

14 Perry et al. (1997) reported that a life style education programme of six months period on dietary practices, exercise and metabolic measurements in 61 IDDM subjects resulted in decreased glycated haemoglobin level, total cholesterol (TC) and low density lipoprotein cholesterol (LDLC), increased the intake of carbohydrates and monounsaturated fatty acids and decreased the intake of total and saturated fat. Cox et al. (1998) studied the impact of education intervention for eight weeks to increase fruit and vegetable intake on commercial choice and nutrient intake in adult men and women (n = 170) eating less than five fruit and vegetable portion/day but contemplating increased intake. Intervention advice included the specific association of high fruit and vegetable intake with reduced risk of disease. Intervention of 8 weeks helped in bringing about significant increase in fruit and vegetables intake via conventional eating habit (rising from 324 to 557 g/day) with some desirable effect on micro and macro nutrients. Despande et al. (2003) studied the impact of nutrition education for a period of 3 days on the inclusion of soybean products in 160 farm women of Madhya Pradesh. The study revealed that nutrition knowledge of women before nutrition education was 3.2 and after nutrition education it increased to 7.3, out of total 10 scores, thereby indicating about 2-3 times increase in nutrition awareness and knowledge exhibiting substantial impact of the nutrition education programme. Sangha et al. (2006) conducted the study on impact of nutrition education on nutrition knowledge of parents of obese children. A group of 30 male and 30 female were selected from II, III and IV class studying in public school in Ludhiana city based on the criteria of 20 per cent above the normal weight for age. Based on the pre-test nutrition knowledge score of the parents of obese children, nutrition education intervention was carried out for one month. A significant difference (P < 0.01) was observed in the scores of pre and post-test of nutrition education intervention. A study on impact of nutrition education and carbohydrate supplementation on performance of 30 boys of high school football players (14-15 years) in Dharwad district was carried out by Meti and Saraswati (2006). The study revealed that nutrition education and carbohydrate supplementation for a period of 3 months improved their nutrition knowledge and practice, physical and field performance during the competition. Kaur (2007) conducted a study on impact of nutrition education on nutrient adequacy of 60 adolescent girls (13-19 years). Nutrition education for a period of 3 months was imparted to the subjects after assessing their basic nutrition knowledge. Nutrition education improved their mean nutrition knowledge scores significantly (P 0.01) from ± 1.42 to ± 1.8. The average contribution of carbohydrate, protein, fat, vitamin and minerals increased significantly after imparting nutrition education.

15 3. MATERIAL AND METHODS An investigation on Consumption pattern of green leafy vegetables and impact of nutrition education on haemoglobin status of rural adolescent girls of transitional and dry zone was carried out during The details of the present study are described here under. 3.1 Selection of the sample A sample of 300 school going adolescent girls were selected in the age group of 13 to 16 years from the transitional and dry zone. From each zone two villages were selected at random. Seventy five girls were selected from each village. Further a sub-sample of 60 anaemic adolescent girls were selected from total sample based on their haemoglobin level (<12 g/dl). These 60 adolescent girls were divided into two groups viz., experimental group and control group of 30 each for the nutrition education intervention. 3.2 General information General information such as name of the respondent, address, age, education, type of family, family size, occupation and family monthly income were collected by structured pre tested questionnaire through personal interview method. 3.3 Assessment of nutritional status of the adolescent girls Nutritional anthropometry Diet survey Clinical examination Haemoglobin assessment Nutritional anthropometry The anthropometric measurements viz., height, weight, and waist to hip ratio were measured as per the guidelines suggested by ICMR standards. The height was measured by using a height scale nearest to 0.1 cm. A portable personal weighing scale was used to measure the weight in kilograms nearest to 0.5 kg, with ordinary casual clothing and without shoes. Waist and hip circumference were measured by using a fibre glass measuring tape in centimeters Body mass index The anthropometric measurements of the adolescent girls were used for calculating the body mass index which was expressed as ratio of weight (kg) to height in metre square. Weight (kg) BMI = (Height) 2 (m) Further, the individuals were classified into different classes based on Anon., (2003) classification. BMI classification for adolescent girls BMI classes Presumptive diagnosis < 18.5 Under weight Ideal BMI >23.0 Over weight >25.0 Obese grade I >30 Obese grade II

16 Fig.1. Selection of subjects

17 Waist to hip ratio Waist to Hip ratio was computed using the waist and hip circumference. The abdominal obesity was judged by using the reference ratio given by Lean et al. (1995) for female. At risk No risk Dietary survey >0.85 < 0.80 The information on daily intake of food was collected by 24 hour recall method using a proforma (Appendix 1). To assist the subject to recall better, a set of standardized vessels were displayed to quantify identification and asked to indicate the vessel number. Further, information on, frequency of consumption of green leafy vegetables, methods of preparation of green leafy vegetables and storage of green leafy vegetables were also collected Dietary adequacy of blood forming nutrients To assess the adequacy of energy and blood forming nutrients, the cooked food was converted into raw ingredients. The commonly used recipes were prepared in the laboratory to computed the raw equivalents to compute the nutrients. The nutritive value of food consumed was computed using Annapurna VAR 3, a software developed by M.R. Chandrashekhar of Bangalore. The per cent adequacy of energy and blood forming nutrients like protein, iron, folic acid, vitamin A, Vitamin C copper and vitamin B12 was assessed by using recommended dietary allowances (RDA) given by ICMR (1989) with the help of formula Nutrient intake of subjects Per cent nutrient adequacy = x 100 RDA of nutrients Availability and consumption of green leafy vegetables Availability and consumption of green leafy vegetables was assessed by interviewing the subjects about the availability, pattern of frequency of consumption of green leafy vegetables, information on kitchen garden and common cooking methods used for green leafy vegetables Clinical examination To assess the prevalence of anemia, clinical features observed and experienced by the subjects were recorded. Further, the number of symptoms experienced by each individual were compiled and percentage was calculated. 3.4 Biochemical analysis Haemoglobin assessment The haemoglobin level in the blood was measured by cyanomethaemoglobin method (Anon, 2001). In this method 20 µl blood is mixed with 5 ml Drabkin s solution and vortexed in order to convert all haemoglobin into cyanmethaemoglobin. The concentration of haemoglobin was determined at 540 nm by comparison with a known standard in a colorimeter. The adolescent girls were classified into four groups based on the haemoglobin content (Anon, 2001). Classification (g/dl) Category >12 Normal Mild anaemic 7 10 Moderate anaemic <7 Severe anaemic

18 Fig.2. Intervention study

19 3.5 Nutrition education Nutrition education is defined as the process by which beliefs, attitudes, environmental influences and understanding about food lead to practice are scientifically sound, practical and consistent with individual needs and available food resources Development of educational material for iron security Educational materials used in this study were posters, charts, flip charts, messages and blow-ups. The above listed educational materials included information on food groups, RDA of iron, importance of iron and sources of iron, causes for iron deficiency anaemia, reasons and symptoms of anaemia Nutrition educational intervention Subjects Sixty anaemic adolescent girls out of 300 were taken for the study based on the haemoglobin level. The sample was divided into two groups viz., experimental and control of 30 each. Method Child-to-child education method was used for the intervention. The experimental group was divided into two groups as student communicators (n = 10) and student communicatees (n = 20). The student communicators were selected based on their involvement in various activities during class hours, while at play, during leisure and also by discussing with concerned teachers. A pre-test information of anaemia and consumption of green leafy vegetables was administered to assess the knowledge level of both experimental and control group through the structured questionnaire (Appendix II). The student communicators were given three days nutrition education training by the nutrition experts on the identified areas such as, functions of nutrients, blood forming nutrients, iron deficiency anaemia in adolescents, diet for iron deficiency anaemia, importance of green leafy vegetables and green leafy vegetable based recipes. Adolescent girls were also enlighted with importance of personal and environmental hygiene. Nutrition education was administered for the communicators in a formal classroom atmosphere and lectures were given by the nutrition experts. Demonstration method was employed to teach iron rich recipes. The visual aids used were black board, posters, charts, blow-ups, flip charts and power point presentations relevant to the topic. The student communicators were asked to convey these learnt messages to their fellow classmates or communicatees once a week. Each communicator taught at least two communicatees (i.e., 1:2 ratio) over a period of three months. The control group was not exposed to any formal nutrition education Impact of nutrition education After imparting nutrition education for a period of three months, the same structured questionnaire was used, for post testing their nutritional knowledge level. Impact of nutrition education was also assessed through change in anthropometry and haemoglobin level of the subjects of experimental and control group before and after nutrition education intervention. 3.6 Statistical Analysis The results obtained in the present investigation were analysed employing different statistical methods. a. The respondents were post classified into three income groups by using the formula : Mean ± x S.D.

20 Plate1a : Nutrition education training by nutrition experts to communicators

21 Plate 1b. Nutrition education training by nutrition experts to communicators

22 Plate 2. Demonstration conducted to communcators

23 Plate 3. Nutrition education by communicators to communicatees

24 Plate 4: Group discussion between communicators and ommunicates

25 Plate 5. Exhibition conducted in school

26 Transitional zone Group I Below Rs per month Group II Between Rs to Rs Group III Above Rs per month. Dry zone Group I Below Rs per month Group II Between Rs to Rs per month Group III Above Rs per month. b. The student t test was used to test the significance of mean difference between dry zone and transitional zone respondents with respect to mean anthropometric measurements, nutrient intake (protein, energy, vitamin C, vitamin B 12, folic acid and iron), mean per cent adequacy of nutrients (protein, energy, vitamin C, vitamin B 12, folic acid and iron) and mean haemoglobin levels. c. Contingency tables were constructed for various factors (locality, type of family, family size, haemoglobin level, all versus percentage adequacy of nutrients i.e., protein, energy, vitamin C, vitamin B 12, folic acid and iron) to test the significance of association between the attributes using the chi-square test. d. Student t test was used to determine the significance of mean difference in haemoglobin level and anthropometry before and after supplementation period.

27 4. EXPERIMENTAL RESULTS India is a tropical country, a wide range of green leafy vegetables are grown, which represent an excellent source of iron and other micronutrients. These green leafy vegetables are not only rich in iron content but are also available at low cost (Reddy et al., 1997). But still iron deficiency anaemia is public health problem in India. Specifically 70 per cent of adolescent girls are affected by iron deficiency anaemia. Though, the availability of green leafy vegetables being plenty, its consumption is less, due to illiteracy and lack of knowledge about green leafy vegetables. Hence, nutrition education for the adolescent girls is may be one of the important strategies to combat IDA. Results of the study on the consumption pattern of green leafy vegetables and impact of nutrition education on haemoglobin status of rural adolescent girls as revealed by structured education is presented in this chapter. 4.1 Demographic profile of selected adolescent girls 1. Distribution of study subjects based on the demographic profile is presented in Table Majority of the adolescent girls selected for the study belonged to age group of 13 to 14 years (75.33% in dry zone and 66.00% in transitional zone) followed by 15 to 16 years (28.00% dry zone and 24.66% transitional zone) and very few subjects (only in 6.00% dry zone) belonged to the age group of 12 years. About, per cent of the subjects from dry zone were studying in 8 th standard, followed by per cent who were in 9 th standard. While in the transitional zone, per cent of the subjects were studying in 9 th standard, followed by per cent from 8 th standard and only 8.66 per cent were from 10 th standard. Majority of the subjects (82.66% and 86.66% in dry and transitional zone respectively) were belong to nuclear family, 7.33 per cent of the subjects were from extended family and only 6 per cent of subjects were from joint family in transitional zone, while in the dry zone per cent of the subjects belonged to joint family and only 6.66 per cent of subjects were in extended family system. Most of the subjects were in the family size of 5 to 10 members (70.66 and 76.00% in dry and transitional zone, respectively) followed by 2 to 4 members group (23.33 and 18.66% in dry and transitional zone, respectively) and above 10 members group was 6.00 per cent in dry zone and 5.33 per cent in transitional zone. Majority of the subjects both in dry and transitional zone were Hindu (64.66 and 67.33% respectively) followed by Muslims (22.00 in dry and 12.00% in transitional zone), conversely per cent from dry and per cent from transitional zone belonged to category. Majority of the subjects expressed their family occupation as farming labour in both dry (48.00%) and transitional zone (65.33%) followed by business (20.66 and 14.00%, respectively). Ninteen and 16 per cent of the subjects were from employed group and rest of them (12.00 and 10.00%) were from skilled occupational group in dry and transitional zone, respectively. When adolescent girls were distributed based on family income, majority of the dry zone families (49.33%) had family income below Rs per month followed by per cent with a family income between Rs to Rs per month and only 16 per cent of them had family income above Rs per month. Similarly, in transitional zone, per cent of the families had income below Rs per month followed by per cent of the subjects had family income between Rs to per month and only 10 per cent of the subjects had family income above Rs per month. 4.2 Nutritional status of the adolescent girls Anthropometric measurements The mean anthropometric measurements of the selected adolescent girls are depicted in Table 2. The mean height of adolescent girls was cm and cm in dry

28 Table 1. Demographic profile of selected adolescent girls (n =30) Particulars Dry zone (N = 150) Transitional zone (N = 150) Total Age 12 years 9 (6.00) - 9 (3.00) years 99 (66.00) 113 (75.33) 212 (70.67) years 42 (28.00) 37 (24.66) 79 (26.33) Education 8 th standard 76 (50.66) 67 (44.66) 143 (47.66) 9 th standard 74 (49.33) 70 (46.66) 144 (48.00) 10 th standard - 13 (8.66) 13 (4.33) Type of family Nuclear 124 (82.66) 130 (86.66) 254 (84.66) Joint 16 (10.66) 9 (6.00) 25 (8.33) Extended 10 (6.66) 11 (7.33) 21 (7.00) Family size (members) (23.33) 28 (18.66) 63 (21.00) (70.66) 114 (76.00) 220 (73.33) >10 9 (6.00) 8 (5.33) 17 (5.66) Caste Hindu 97 (64.66) 101 (67.33) 198 (66.00) Muslim 33 (22.00) 18 (12.00) 51 (17.00) Any other 20 (13.33) 23 (15.33) 43 (14.33) Occupation Farming labour 72 (48.00) 98 (65.33) 170 (56.66) Skilled 18 (12.00) 16 (10.66) 34 (11.33) Employed 29 (19.33) 15 (16.00) 44 (14.66) Business 31 (20.66) 21 (14.00) 52 (17.33) Family income < /month 74 (49.33) /month 52 (34.66) - > /month 24 (16.00) - < /month 88 (58.66) /month 47 (31.33) > /month 15 (10.00) 162 (54.00) 99 (33.00) 39 (13.00) Table 2. Mean anthropometric measurements of adolescent girls (n = 300) Parameters NCHS standards* Dry zone (n = 150) Transitional zone (n= 150) t value Height to cm ± ± NS Weight 42.5 to 49.0 kg) ± ± NS * Vijayraghavan et al. (1971). NS Not significant

29 and transitional zone, respectively. The mean weight of adolescent girls was found to be almost same in dry and transitional zone (35.69 and kg, respectively). Thus it was apparent that all the anthropometric measurement between the subjects of dry and transitional zone were statistically not significant Body Mass Index The distribution of girls based on body mass index is presented in Table 3. In the present investigation only 14 per cent of the total population were found to be normal. It was alarming to note that majority of the adolescent girls (84.33%) were belonging to underweight category, while only 1 per cent of them were in over weight and only 0.66 per cent were obese grade I category. When dry zone sample was considered, only per cent were found to be normal. Maximum percentage (83.33%) of adolescent girls were underweight, while 2 per cent were over weight and only 1.33 per cent were in obese grade I category. In transitional zone, only per cent were in normal category and per cent belonged to under weight category. It indicates that majority of the adolescent girls were underweight in both the zones Waist to hip ratio Categorization of adolescent girls for abdominal obesity based on waist to hip ratio is presented in Table 4. Hundred and twelve girls (74.66%) were not having any risk and 38 girls (25.33%) were at risk of abdominal obesity with waist to hip ratio more than 0.80 in dry zone. Similarly in transitional zone, per cent were not having any risk and per cent were at risk. Thus indicating per cent of adolescent girls were in abdominally obese though majority of them are underweight. 4.3 Dietary survey Food intake of adolescent girls The results pertaining to food intake and adequacy by the dry and transitional zone adolescent subjects are presented in Table 5. The mean cereal intake of dry and transitional zone adolescent girls was and g, respectively, which met only 45 per cent of the Suggested Dietary Allowance. Student t test indicated that these differences in cereal intake were statistically significant at one per cent level. Irrespective of locality, the consumption of pulses was and g in dry and transitional zone respectively, which was two times (262%) higher than the recommendations. Pulse intake among dry and transitional zone was statistically significant over SDA for the target group. The per cent adequacy of green leafy vegetables (3.32 and 3.40 g), other vegetables (37.13 and g) and roots and tubers (4.54 and g) was less in both dry and transitional zone respectively. However, no significant difference was observed between the zones with respect to adequacy of vegetables. Surprisingly, consumption of fruits irrespective of locality was higher and could supply 100 per cent of the recommendation. In dry zone, the consumption was per cent and in transitional zone it was per cent. These differences in fruit intake were statistically significant in comparison with SDA. The average daily intake of oils and fats was higher in dry zone (43.43 g) over transitional zone (38.58 g) and these differences in comparison with SDA was less with an adequacy of per cent and per cent respectively. The oils and fat intake was significantly different between the zones. The daily consumption of fleshy foods, irrespective of locality was and per cent in dry and transitional zone respectively. These differences in intake of fleshy foods was statistically significant. The daily intake of milk and milk products could not meet the recommendation in both dry and transitional zone. It was higher in transitional zone (68.45) than dry zone (54.76)

30 Table 3. Distribution of adolescent girls based on body mass index (BMI) classification BMI Dry zone (n = 150) Transitional zone (n= 150) Total <18.5 (under weight) 125 (83.33) (ideal BMI) 20 (13.33) 128 (85.33) 22 (14.66) 253 (84.33) 42 (14.00) >23 (over weight) 3 (2.00) > 25 (obese grade I) 2 (1.33) - 3 (1.00) - 2 (0.66) Total Values in parentheses indicate percentage. None of the subjects belonged to obese grade II category (BMI >30). Table 4. Classification of adolescent girls into different groups based on waist to hip ratio (WHR) WHR Dry zone (n = 150) Transitional zone (n = 150) Total > 0.80 (obese) 38 (25.33) <0.80 (normal) 112 (74.66) Total 150 (100.00) 46 (30.66) 104 (69.33) 150 (100.00) 84 (28.00) 216 (72.00) 300 (100.00) Values in parentheses indicate percentage.

31 Table 5. Mean food intake of adolescent girls (N = 300) Food intake (g/day) SDA Dry zone (n = 150) Cereals (43.13) Pulses (244.42) Green leafy vegetables (3.32) Other vegetables (37.13) Roots and tubers (44.54) Fruits (466.30) Oils and fats (108.57) Fleshy foods (10.00) Milk and milk products (36.50) Sugar and jaggery (123.80) Transitional zone (n = 150) (47.30) (279.9) 5.10 (3.40) (37.36) (48.32) (637.76) (96.45) 8.45 (28.16) (45.63) (167.36) t value 2.52** 2.10* 0.20 NS 0.01 NS 0.70 NS 2.3* 2.1* 1.3* 4.2* 3.3* * Significant at 5% level, ** Significant 1% level, NS Not significant. Values in parentheses indicate per cent adequacy SDA Suggested dietary allowance (Zanvar et al., 2007). which could meet and per cent of adequacy in transitional and dry zone respectively. While in both the zones, the milk intake was significantly less than the SDA. Irrespective of locality, sugar and jaggery intake per day was more than the recommendation in both dry and transitional zone (123.8 and % respectively). The student t test indicated that the mean intake was significantly different between the zones Intake of energy and blood forming nutrients Mean intake of energy and blood forming nutrients in dry and transitional zone adolescent girls are given in Table 6. The mean intake of energy, protein and folic acid was significantly higher in transitional zone ( ± , ± and ± respectively) compared to dry zone ( ± , ± and ± respectively). Other blood forming nutrients like ascorbic acid (14.48 ± 29.08) and iron intake (14.04 ± 8.64) were though higher in transitional zone but were not significant. Even the intake of vitamin B 12 was found higher in the dry zone (0.15 ± 0.13) compared to transitional zone (0.13 ± 0.81) was not statistically significant Per cent adequacy of energy and blood forming nutrients The mean per cent adequacy of energy and blood forming nutrients in dry and transitional adolescent girls are depicted in Table 7 and Fig. 3. The mean per cent adequacy of energy, protein and folic acid was significantly higher in transitional zone (75.09, and %, respectively) compared to dry zone (71.03, and 93.49%, respectively). Other blood forming nutrients like ascorbic acid (37.68%) and iron (47.16%), were higher in transitional zone, but were significantly different from the dry zone. The adequacy of vitamin B 12 was higher in dry zone (47.53%) compared to transitional zone (44.83%), but significant differences was not there between the zones.

32 Table 6. Mean intake of energy and blood forming nutrients Nutrients Dry zone (n = 150) Transitional zone (n = 150) t value Energy (K.cal) ± ± * Protein (g/day) ± ± * Ascorbic acid (mg/day) ± ± NS Vitamin B 12 (µg/day) 0.15 ± ± NS Folic acid (µg/day) ± ± * Iron (mg/day) ± ± NS * Significant at 5% level, ** Significant 1% level, NS Not significant. Table 7. Mean per cent adequacy (%) of energy and blood forming nutrients of dry and transitional zone adolescent girls Nutrients Dry zone (n = 150) Transitional zone (n = 150) t value Energy * Protein * Ascorbic acid NS Vitamin B NS Folic acid * Iron NS * Significant at 5% level. NS Not significant.

33 140 Dry zone (n = 150) Transitional zone (n = 150) Per cent Energy Protein Ascorbic acid Vitamin B12 Folic acid Iron Nutrients Fig. 3. Mean per cent adequacy (%) of energy and blood forming nutrients of dry and transitional zone adolescent girls Fig.3. Mean per cent adequacy (%) of energy and blood forming nutrients of dry and transitional zone adolescent girls

34 4.3.4 Frequency of consumption of green leafy vegetables The Tables 8 and 9, reveal the frequency of consumption of green leafy vegetables in dry and transitional zones. The data on consumption of methi in the dry zone showed that majority of the adolescent girls consumed once a week (47.33%) followed by 26.66, 18.00, 3.33 and 1.33 per cent in twice a week, daily, occasionally and once in fortnight, respectively. Similarly in transitional zone, per cent of the subjects were consuming weekly once followed by 14.66, 5.33, 3.33, and 0.66 per cent of the subjects were consuming twice a week, once in fortnight, monthly, daily and occasionally respectively. In the dry zone, majority of the subjects (33.00%) expressed the frequency of consumption of palak as once in fortnight followed by weekly once (26.00%), twice a week (13.33%), occasionally (6.00%) and daily (3.33%). However, in the transitional zone most of the subjects (22.66%) consumed weekly once followed by occasionally (8.00%), twice a week (5.33%), once in fortnight (2.66%), monthly and daily (2.00% each). The data on consumption of Rajgira leaves in case of dry zone indicated that, 20 per cent of the subjects were consuming weekly once followed by once in fortnight (8.66%), twice a week (7.33%), monthly once (2.66%) and none of the subjects were consuming daily. However, about 18 per cent subjects were consuming rajgira weekly once followed by twice a week (8.66%), daily (2.66%), once in fortnight (2.00%) and only 1.33 per cent were consuming rajgira monthly once in transitional zone. The intake of shepu in case of transitional zone showed that, about 40 per cnet subjects consumed weekly once and least number of them consumed daily (4.00%). While in case of dry zone majority of them (66.00%) consumed fortnightly once and equal number of them consumed monthly and occasionally (4.66% each) respectively. Maximum per cent of the subjects consumed gogu monthly once (18.66%) followed by weekly once (15.33%), twice a week (14.66%, occasionally (12.66%), once in fortnight (2.66%) and daily (2.00%) in transitional zone. In dry zone, about 26 per cent of the subjects consumed gogu weekly once followed by daily (18.33%), occasionally (16.66%), fortnightly once (4.00%) and monthly (3.33%). Majority of girls consumed amaranth leaves weekly once (32.00%) and (32.66%) daily in transitional and dry zone respectively. Whereas 12 per cent, 4.66 per cent, 3.33 per cent and 2.66 per cent of the subjects were consuming twice a week, once in fortnight, daily and monthly respectively in transitional zone. While in dry zone per cent, per cent, 3.33 per cent, 2.00 per cent and 1.33 per cent were consuming twice a week, weekly once, occasionally, fortnightly once and monthly once respectively. Frequency of consumption of radish leaves in the dry zone indicates that, about 30 per cent subjects were consuming daily, followed by weekly once (18.00%), twice a week (16.00%), occasionally (8.66%), fortnightly (5.33%) and 0.66 per cent monthly. While in case of transitional zone majority of the subjects were consuming once a week (31.33%) followed by twice a week (15.33%), daily (12.00%), once in fortnight (3.33%), monthly once (1.33%) and occasionally (0.66%). The frequency of consumption of Hakkaraki green leafy vegetable revealed that, in dry zone, equal number of the subjects were consuming weekly once and daily (30% each) and less consumption was once in fortnight (5.33%). In the transitional zone majority of the subjects were consuming once a week (20.00%) and less consumption was observed once in fortnight (3.33%) group. In general, the commonly used green leafy vegetables in dry zone are methi, shepu, gogu, amaranth, radish leaves and hakkaraki and majority of subjects not consuming palak and rajgira in dry zone because they expressed that they were unaware about of these green leafy vegetables. Majority of the subjects consume radish leaves and hakkaraki daily but they expressed that the intake was only 2-3 leaves per day which was not sufficient to meet out the daily recommendation of green leafy vegetables. Whereas, in transitional majority of the subjects were not consuming most of the green leafy vegetables. Although in the transitional zone the cultivation of green leafy vegetables is more, the consumption level is very low, which indicates the higher degree of ignorance towards green leafy vegetables although it is

35 Table 8. Frequency of consumption of green leafy vegetables (GLVs) in dry zone adolescent girls Green leafy vegetables Daily Twice a week Weekly once Once in fortnight Monthly Occasionally None n % n % n % n % n % n % n % Methi Palak Rajgira Shepu Gogu Amaranth Radish leaves Hakkaraki

36 Table 9. Frequency of consumption of green leafy vegetables (GLVs) in transitional zone adolescent girls (N = 150) Green leafy vegetables Daily Twice a week Weekly once Once in fortnight Monthly Occasionally None n % n % n % n % n % n % n % Methi Palak Rajgira Shepu Gogu Amaranth Radish leaves Hakkaraki

37 available in plenty and at low cost. Hence there is an urgent need to educate the subjects in this regard Methods of cooking of the green leafy vegetables Methods of cooking used for green leafy vegetables presented in Table 10. In both dry and transitional zones, majority of the families were boiling the green leafy vegetables and discarding the water (72.63% and 83.52% respectively). Only and per cent of the families in dry and transitional zone respectively, seasoned and boiled the green leafy vegetables. Irrespective of the locality, majority of the subjects used short duration simmering for cooking green leafy vegetables (71.63% and 81.52%). Simmering of green leafy vegetables for long duration was carried out by per cent and per cent in dry and transitional zones respectively. In the method of frying for green leafy vegetables, shallow fat frying was mostly used in both dry and transitional zone (88.75% and 93.93%). Deep fat frying was done in very few subjects in both zones (11.25% and 6.06%) Possession of kitchen garden The distribution of study sample based on possession of kitchen garden is presented in Table 11. The maximum number of adolescent girls (77.66%) belonged to the families who had kitchen garden. Whereas, per cent of adolescent girls belonged to the families who did not possess the kitchen garden. When dry zone sample was considered per cent of the families had kitchen garden but it was observed that per cent of the families did not possess kitchen garden. Whereas in transitional zone, per cent of the families possessed kitchen garden and per cent of them had no kitchen garden. 4.4 Clinical symptoms Prevalence of clinical symptoms related to anaemia which were documented by using questionnaire is summarized in Table 12. When dry zone was considered majority of the subjects had fatigue and paleness (28% each), followed by giddiness and breathlessness (6.66 and 3.33% respectively), while 34 per cent of the girls were free of symptoms. About 23 per cent of subjects in transitional zone had fatigue followed by giddiness (8.00%), paleness (6.66%) and 4.66 per cent of the subjects had breathlessness, per cent of the subjects had no clinical symptoms. 4.5 Biochemical analysis Haemoglobin assessment Mean haemoglobin (Hb) percentage in dry and transitional zone adolescent girls and the classification according to WHO are presented in Table 13 and Fig. 4. Haemoglobin level was assessed in 300 adolescent girls. The mean Hb content was found to be 9.86 g/dl. The mean Hb content of dry zone girls was 9.54 g/dl, while that of transitional zone girls was g/dl. Maximum of the adolescent girls (72.00%) were moderately anaemic and per cent of them were mildly anaemic and neither of the subjects were normal nor severely anaemic. In dry zone group, majority of the subjects were in moderately anaemic group (74.66%) followed by mild anaemic category (25.33%). In transitional group also similar results were observed, majority (69.33%) were found to be in moderately anaemic group and per cent were in the mild anaemic category.

38 Table 10. Methods of cooking used for green leafy vegetables Methods Dry zone Transitional zone Boiling Seasoning and boiling without water 52 (27.36) 28 (16.47) Boiling and discarding water 138 (72.63) 142 (83.52) Simmering Long duration 48 (28.23) 31 (18.23) Short duration 122 (71.05) 139 (81.76) Frying Sautering 142 (88.75) 155 (93.93) Deep fat frying 18 (11.25) 10 (6.06) Values in parentheses indicate percentage. Table 11. Distribution of sample by possession of kitchen garden Locality Kitchen garden Total Yes No Dry zone 137 (91.33) 13 (20.00) 150 (100.00) Transitional zone 96 (64.00) 54 (33.33) 150 (100.00) Total 233 (77.66) 67 (22.33) 300 (100.00) Values in parentheses indicate percentage.

39 Table 12. Prevalence of clinical symptoms of anaemia in adolescent girls (N = 300) Symptoms Dry zone (n = 150) Transitional zone (n = 150) Total Fatigue 42 (28.00) Breathlessness 5 (3.33) Paleness 42 (28.00) Giddiness 10 (6.66) None 51 (34.00) Total 150 (100.00) 35 (23.33) 7 (4.66) 10 (6.66) 12 (8.00) 86 (57.33) 150 (100.00) 77 (25.66) 12 (4.00) 52 (17.33) 22 (7.33) 137 (45.66) 300 (100.00) Values in parentheses indicate percentage. Table 13. Haemoglobin status of selected adolescent girls (N = 300) Haemoglobin level Dry zone (n = 150) Mild anaemic (10-12 g/dl) 38 (25.33) Moderate anaemic (7-10 g/dl) 112 (74.66) Total 150 (100.00) Transitional zone (n = 150) 46 (30.66) 104 (69.33) 150 (100.00) Total 84 (28.00) 216 (72.00) 300 (100.00) Mean Haemoglobin level Values in parentheses indicate percentage. None of the subjects belonged to severe and non-anaemic category.

40 Mild anaemic (10-12 g/dl) 80 Moderate anaemic (7-10 g/dl) Per cent Dry zone Transitional zone Haemoglobin level Fig. 4. Haemoglobin status of selected adolescent girls Fig.4: Haemoglobin status of selected adolescent girls

41 Thus it indicated that all the adolescent girls were anaemic having haemoglobin less than 12 g/dl. 4.6 Association between adequacy of energy and blood forming nutrients and other related factors Chi-square test was applied to test the association between per cent adequacy of blood forming nutrients and locality, type of family, family size, and haemoglobin status. The results from the chi-square test are as follows. Per cent adequacy of energy and protein were found to be significantly associated with locality viz., transitional and dry zone, where as per cent adequacy of ascorbic acid, vitamin B 12, folic acid and iron were found to be independent of locality (Table 14). Per cent adequacy of energy and protein were found to be significantly associated with family type in both the dry and transitional zones. The other nutrients ascorbic acid, vitamin B 12, folic acid and iron were independent of family type (Table 15 and 16). The per cent adequacy of energy and blood forming nutrients were found to be independent of family size in both dry and transitional zones (Tables 17 and 18). The per cent adequacy of energy, protein, vitamin B 12 and iron were found to be independent of haemoglobin level, whereas per cent adequacy of ascorbic acid and folic acid was found to be significantly associated with haemoglobin level (Table 19). 4.7 Nutrition education intervention study Three months nutrition education to adolescent girls was planned and the results of the study are presented in this section Impact of nutrition on knowledge level Impact of nutrition education on knowledge scores of adolescent girls is depicted in Table 20. The mean pre-test scores of the experimental group was and it was increased to after intervention. A significant difference was observed between the pre and post test scores of experimental group at one per cent level. Whereas in control group pre-test score was 9.10 and post-test score was A non-significant difference was observed in the control group. Impact of nutrition education on knowledge scores of experimental and control group is presented in Table 21 and Fig. 5. Nutrition education showed a significant increase in the knowledge scores of experimental group, whereas control group also showed an increase in knowledge scores, but statistically not significant. The mean pre-test score of communicators was and post-test score was 29.10, which indicates that an increase of per cent over the pre-test scores. It was interesting to note that in the communicatees group also more than 100 per cent increase was seen in the knowledge scores after intervention. The mean pre-test score of communicatees group was and post-test score was In the control group only 11 per cent increase in the knowledge scores was seen. The student t test that no significant differences existed between the initial scores of all the three groups (Communicators Vs. Communicatees, communicator Vs. control, communicatees Vs. control). Whereas, highly significant differences were observed between the groups with regard to post-test scores. Thus, it indicates the effectiveness of Child-to- Child education method Impact of nutrition education on anthropometry Mean height and weight of adolescent girls before and after nutrition education is presented in Table 22.

42 Table 14. Association between adequacy of energy and blood forming nutrients and locality Locality Protein Energy <50% 50 to 80% 80 to 99.9% 100 and above Total χ 2 <50% 50 to 80% 80 to 99.9% 100 and above Dry zone Transitional zone * Total χ * Total Ascorbic acid Vitamin B 12 Dry zone Transitional zone NS NS Total Folic acid Iron Dry zone Transitional zone NS NS Total * Significant at 5% level NS Not significant.

43 Table 15. Association between adequacy of energy and blood forming nutrients and family type in dry zone Type of family <50% 50 to 80% 80 to 99.9% Protein 100 and above Total χ 2 <50% 50 to 80% 80 to 99.9% Energy 100 and above Nuclear Joint * Extended Total Total χ * Ascorbic acid Vitamin B 12 Nuclear Joint Extended NS Total Folic acid Iron Nuclear Joint Extended NS Total NS 6.41 NS * Significant at 5% level NS Not significant.

44 Table 16. Association between adequacy of energy and blood forming nutrients and family type in transitional zone Family type <50% 50 to 80% 80 to 99.9% Protein 100 and above Total χ 2 <50% 50 to 80% 80 to 99.9% Energy 100 and above Nuclear Joint * Extended Total Ascorbic acid Vitamin B 12 Total χ * Nuclear Joint Extended NS Total Folic acid Iron Nuclear Joint Extended NS Total NS 3.28 NS * Significant at 5% level NS Not significant.

45 Table 17. Association between adequacy of energy and blood forming nutrients and family size in dry zone Family size (members) <50% 50 to 80% 80 to 99.9% Protein 100 and above Total χ 2 <50% 50 to 80% 80 to 99.9% Energy 100 and above Above NS Total Total χ NS Ascorbic acid Vitamin B Above NS Total Folic acid Iron NS Above Total NS 7.27 NS * Significant at 5% level NS Not significant.

46 Table 18. Association between adequacy of energy and blood forming nutrients and family size in transitional zone Family size (members) <50% 50 to 80% 80 to 99.9% Protein 100 and above Total χ 2 <50% 50 to 80% 80 to 99.9% Energy 100 and above NS Above Total Ascorbic acid Vitamin B 12 Total χ NS Above NS Total Folic acid Iron Above NS Total NS 7.13 NS * Significant at 5% level NS Not significant.

47 Table 19. Association between adequacy of energy and blood forming nutrients and Haemoglobin status Protein Energy Haemoglobin <50% 50 to 80 to 100 and Total χ 2 <50% 50 to 80 to 100 and status 80% 99.9% above 80% 99.9% above Total χ 2 Non anaemic Mild anaemic Moderate anaemic NS * Severe anaemic Total Ascorbic acid Vitamin B 12 Non anaemic Mild anaemic Moderate anaemic * Severe anaemic Total Folic acid Iron Non anaemic Mild anaemic Moderate anaemic * Severe anaemic Total NS 2.28 NS * Significant at 5% level. NS Not significant.

48 Table 20. Impact of nutrition education on nutrition knowledge of adolescent girls Groups (n = 60) Mean t value Pre-test score Post-test score Experimental group ** Control group ns ** Significant at 1% level NS Not significant. Table 21. Impact of nutrition education on knowledge scores in experimental and control group Group Mean t value Pre-test Post-test Increment % increase Student communicator ** Student communicatees ** Control group ns Initial t value Between communicator ns and communicatees Between communicators and control Between communicatees and control Final t value Between communicator and communicatees Between communicator and control Between communicatees and control ** - Significant at 1% level NS Non significant ns ns ** ** **

49 Increment (%) Student communicator Student communicatees Control group Group Fig. 5. Increment in nutrition knowledge of adolescent girls after intervention Fig.5. Increment in nutrition knowledge of adolescent girls after intervention

50 Table 22. Mean height and weight of adolescent girls before and after nutrition education Parameters Experimental group (n = 30) Control group (n = 30) Communicators (n = 10) Communicatees (n = 20) Initial Final t value Initial Final t value Initial Final t value Height (cm) ± ± NS ± ± NS ± ± NS Weight (kg) 32.6 ± ± NS ± ± NS ± ± NS NS Not significant.

51 Table 23. Impact of nutrition education on haemoglobin level of adolescent girls Group (n = 60) Initial Final t value Experimental (n = 30) 9.76 ± ± * Control (n = 30) 9.52 ± ± ns * Significant at 5% level NS Not significant. After nutrition education mean weight was increased in all the groups. Weight increase in communicators was from kg to kg, indicating an increment of 0.70 kg after three months of nutrition education period. Similarly in the comunicatees the increase was from kg to kg, indicating an increment of 1 kg and in control group increase in weight was from kg to kg, indicating the increment of 0.43 kg after three month of intervention. The mean height of both experimental and control group showed a slight increase. The mean initial height of communicator, communicatees and control group was cm, cm and cm which increased to cm, cm and cm respectively. The student t test revealed that the increase in weight and height was not statistically significant in both the experimental and control groups Impact of nutrition education on haemoglobin level Impact of nutrition education on haemoglobin level of adolescent girls is depicted in Table 23. The mean initial level of haemoglobin in the experimental group was 9.76 g/dl which increased to g/dl after the three months of nutrition education. The increment of 0.78 g/dl was statistically significant at 5 per cent level. In the control group haemoglobin level was increased from 9.52 to 9.55 g/dl, this increment of 0.03 g/dl was statistically not significant. Impact of nutrition education on haemoglobin level of experimental and control group is depicted in Table 24 and Fig. 6. The initial haemoglobin level of communicators was 9.74 and final hemoglobin level was g/dl which indicated an increase of 7.70 per cent over the initial haemoglobin level which was statistically significant at 1 per cent level. However, in the communicatees group the initial haemoglobin level was 9.65 and final haemoglobin level was 9.76 g/dl, which indicated an increase of 1.13 per cent after the nutrition education period. In the control group, only 0.20 per cent increase in haemoglobin level was observed. The student t test indicated that significant differences existed between the groups (communicators Vs. Communicatees and communicator Vs. Control) and no significant difference existed between communicatees and control groups. In general, in the communicators group a significant increase in the mean heamoglobin level was observed. However, a marked increased in haemoglobin level was observed in communicatees group also which was statistically not significant but the change was towards increasing trend. Thus it indicated the effectiveness of child to child nutrition education technique.

52 Table 24. Impact of nutrition education on haemoglobin level of experimental and control group Group Mean Increment % increase t value Initial Final Student communicator 9.71 ± ± ± ** Student communicatees 9.65 ± 0.61 Control 9.78 ± 0.71 Initial t value 9.76 ± ± ± ± ns ns Between communicators Vs. Communicatees ns Between communicators Vs. control ns Between communicatees Vs. control Final t value Between communicator Vs. communicatees ** Between Vs. control communicator ** Between communicatees Vs. control ns ** - Significant at 1% level NS Non significant.

53 Per cent Student communicator Student communicatees Control Groups Fig. 6. Increment in haemoglobin level of adolescent girls after intervention Fig.6. Increment in haemoglobin in level of adolescent girls after intervention

54 5. DISCUSSION Adolescence growth and development is closely linked to the diet they receive during childhood and adolescence. Adolescents may represent a window of opportunity to prepare nutritionally for a healthy adult life. It may also be a timely period to shape and consolidate healthy eating and life style behaviour, there by preventing or postponing the onset of nutrition related chronic diseases in adulthood. However, eating patterns are frequently erratic in adolescents and this may be a common factor of nutritional risk. The problem of malnutrition in developing countries encompasses a spectrum of deficiencies, of which most devasting is that of micronutrients, especially iron deficiency anaemia. Anaemia is one of the glaring deficiencies in young adolescent girls probably due to low intake of haemopoetic nutrients since childhood, increased demand for nutrients coupled with menstrual loss. Anaemia affects more than a billion people in the entire world. Survey carried out by ICMR and NNMB reveal that 70 to 90 per cent of adolescent girls are anaemic in the country. In Karnataka 70 per cent of the adolescent girls are anaemic (Vijayaraghavan, 2007). India is a tropical country, where a wide range of green leafy vegetables are grown, which represents an excellent source of iron and micronutrients. These green leafy vegetables are not only rich in iron content but they are also available at low cost (Reddy et al., 1997). The leafy vegetables are the most important sources of essential minerals, vitamins and dietary fibre for the regulation of digestive tract and inexpensive when compared to other vegetables have they were within the reach of poor man. Being richest in micronutrients, green leafy vegetables are classified under protective foods. The lack of knowledge especially on the nutritive value of green leafy vegetables among public in general is the main drawback in their production and consumption. For this reason nutrition education may be one of the strategies to improve the knowledge and inturn combat iron deficiency anaemia. Hence, a study was taken on consumption pattern of green leafy vegetables and impact of nutrition education on haemoglobin status of rural adolescent girls. The salient results of the study are discussed in this chapter. 5.1 Iron status of adolescent girls and other associated factors Prevalence of anaemia among adolescent girls is a matter of great concern as they enter reproductive life soon after the attainment of menarche. Due to the fact that in rural areas, the girls are married at an early age, as social customs and cultural practices demands, adolescents need to have better status of haemoglobin. On the contrary, higher loss of iron may be expected in this age group due to the menstrual loss, worm infestation and imbalanced diet. Prevalence of anaemia in present study was found to be 100 per cent, with majority of girls having moderate to mild anaemia (Table 13). Majority of the adolescent girls (112) having haemoglobin level between 7-10 g/dl were more in dry zone compared to transitional zone. But number of adolescent girls (46) having haemoglobin level more than 10 g/dl was high in transitional zone compared to dry zone (Table 13), this difference was statistically significant, though all the adolescent girls were anaemic, but still the adolescent girls from transitional zone were in better iron status compared to dry zone adolescent girls. Similar results were observed in the study conducted by Jondhale et al. (1999). In the present study the prevalence of anaemia may be due to less than 50 per cent adequacy of blood forming nutrients viz., ascorbic acid, vitamin B 12, folic acid and iron (Table 7). All the anthropometric measurements of both dry and transitional zone girls were similar (Table 2), but significantly lower than the NCHS standards. The results of the present study were on par with that reported by Hanagi (2001). Majority of adolescent girls (84.33%) were in underweight group (Table 3). But it is alarming to note that about per cent of adolescent girls were having abdominal obesity, though they were underweight. Similar results were noticed in the study conducted by Jayashree (2002). Analysis of the diet survey (Table 6) from the present study revealed that, except for energy, protein and folic acid, significant differences did not exist in the intake of nutrients between dry and transitional zone. But the intake was significantly low in both the zones compared to ICMR recommendation for all the nutrients except for folic acid in transitional zone. This was due to the poor intake of green leafy vegetables, other vegetables, roots and tubers, cereals, fleshy foods and milk and milk products in both the zones. Intake of pulses,

55 sugar, jaggery, oils, fats and fruit was higher in consumption but these food groups mainly provides energy and protein and do not contribute to blood forming nutrients. The per cent adequacy of energy was less than 75 per cent (Table 7) compared to recommended dietary allowance in all the selected adolescent girls which may be due to inadequate consumption of food itself. Since 80 per cent of adolescents were from low and middle socio-economic group (Table 1). It was also documented by Akkamahadevi (1996) that the intake of energy (1532 kcal) was lower than the ICMR recommendations, by the adolescent girls of age group (12-18 years) belonging to Dharwad taluk. In general, higher protein adequacy than energy was found in the present study (Table 7). The cereal and pulses are staple foods, pulse consumption was higher in both dry (244.42) and transitional (279.9) zone and it may also be attributed to mid-day meal programme in the zones. Hence accounting for the higher protein adequacy. The adequacy was low for blood forming nutrients like ascorbic acid (mg), vitamin B 12 (µg) and iron (mg) but higher adequacy for folic acid was observed in transitional zone (Table 8). This can be attributed to low intake of green leafy vegetables, other vegetables, fleshy foods and milk and milk products which was clearly expressed by higher anaemic rate (Table 7). From the chi-square test, it was found that per cent adequacy of energy and protein were significantly associated with locality, family type and income but were independent with family size. It may be because of higher consumption of staple foods like cereals and pulses. From the clinical examination conducted it was found that majority of the adolescent girls did not show any clinical symptoms. Only few of the subjects exhibited clinical symptoms like fatigue, paleness, giddiness and breathlessness (Table 12). Similarly Kumar et al. (2006) also reported symptoms of anameia like breathlessness, tiredness and pale nails in 80 adolescent girls. Majority of the subjects (57.33%) from the transitional zone did not experience any clinical symptoms compared to dry zone (34.00%). This can be associated with slightly higher haemoglobin level (10.19 g/dl) of transitional zone adolescent girls compared to dry zone adolescent girls. The present study also revealed that mean per cent adequacy of energy, ascorbic acid and folic acid was found to be significantly associated with haemoglobin level. 5.2 Consumption pattern of green leafy vegetables and method of cooking of green leafy vegetables Vegetables occupy an important place especially in Indian vegetarian diets. Green leafy vegetables, in general are rich sources of iron, ascorbic acid, calcium, carotene and folic acid. These vegetables are also good sources of dietary fibre. Green leafy vegetables particularly the selected ones such as curry, colocasia, chekkurmanis, coriander, amaranthus and spinach are rich sources of beta carotene ranging from ,278 µg/100 g on fresh basis. Iron content ranges from 7-28 mg/100 g on fresh basis. In case of some vegetables like colocasia and carrot, the leaves are generally thrown away and some leaves are not consumed at all. These leaves which are not used, contain important nutrients that can be consumed. By doing so, the nutritional quality of diet can be improved considerably without incurring any additional expenditure. From this study, it is observed that commonly available green leafy vegetables in the dry and transitional zones are amaranth, radish leaves, gogu, shepu, methi, rajgira, hakkaraki, onion leaves, coriander leaves, curry leaves, palak and mint. These green leafy vegetables were available in plenty and they are available at low cost in both the zones. The commonly consumed green leafy vegetables in dry zone were methi, amaranth, radish leaves and hakkaraki (Table 8). Majority of the subjects in dry zone palak and rajgira are not using at all because they are unaware of these green leafy vegetables, and they are consuming radish leave and hakkaraki daily, but they expressed that they consume only 2-3 leaves per day, which was not sufficient to meet the daily recommendation of green leafy vegetable. It was surprising to note that majority of the subjects were not consuming most of the green leafy vegetable in transitional zone (Table 9). Although in the transitional zone the cultivation of green leafy vegetables is more the consumption level was very low, they are

56 available at low cost, which indicated the higher degree of ignorance towards green leafy vegetables. Hence there is an urgent need to educate people and specifically adolescent girls. Majority of the subjects though possessed kitchen garden (Table 11) in both the zones, prevalence of anaemia was high in these zones, may be because they were growing only vegetables like chillies, brinjal, cluster bean, ridge gourd and tomato, which are not good sources of iron. Hence, they should be encouraged to grow green leafy vegetables in kitchen garden and increase the consumption of green leafy vegetable in their daily diet through education. The commonly used method for cooking green leafy vegetables in dry and transitional zones were boiling, simmering and frying. In the boiling method majority of them boil the green leafy vegetables and discarded the water (Table 10). During boiling the nutrients are leached out into the water in turn leading to nutrient loss. Discarding the boiled water will incur heavy nutrient loss. Clyde et al. (1979) also reported that boiling coriander for 5 and 10 min in 4 volume of water caused losses of ascorbic acid 41 to 49 and 46 to 54 per cent respectively. Simmering is also one of the cooking method which was used for green leafy vegetables. From the present study it was evident that few of the families used long duration simmering which is not advisable because this may lead to nutrient loss. Among all the cooking methods of green leafy vegetables sautéing was most commonly used method among the families in both dry and transitional zone, which is one of the better method of cooking green leafy vegetables as cooking with fat retains nutrients in green leafy vegetables. Renquist et al. (1978) also reported that beta-carotene content did not change either during cooking for min or during stewing or frying in fat at C in five green leafy vegetables, cassava, Ceylon spinach, water leaf, taro and papaya. Hence, it is clear that, the method of cooking of green leafy vegetables employed by the families of both zones were appropriate, but the frequency of consumption of green leafy vegetable was very low in both the zones. Therefore, there is need to educate the people to increase the consumption of green leafy vegetables and help themselves in combating micronutrient deficiencies. 5.3 Impact of nutrition education Nutrition education is the foundation for any programme intended for nutritional improvement. The present study included child to child nutrition educational intervention for three months. The design of the child to child programme was first developed by the Institute of Education and Child Health of London University. In view of the fact that some 350 million children in the developing countries remain beyond the reach of even a minimum of essential services in the fields of health, nutrition and education, child to child approach should be considered a novel and bold initiative to provide nutritional education to children. Hence this approach was used in this investigation. The impact of nutrition education could be seen through the increased knowledge score of both the student communicators and the student communicatees in the post testing exercises. But the student communicators showed a higher increase in their knowledge compared to the student communicatees. This is because they were constantly teaching to the other group (communicatees). Thus, ideas were strongly imprinted in their mind and concepts were very strong and they were confident. But still knowledge score was almost double in the communicatees group also. Results of the present study on impact of nutrition education on anthropometry revealed that, height and weight of communicators, communicatees and control group were increased, increase was statistically not significant in all groups may be because of short duration of intervention. The mean haemoglobin of the experimental groups was comparatively higher than control group after education intervention. This may be due to educational intervention, which improved the consumption of green leafy vegetables and protective foods in their dietaries. But, when experimental group was considered, the hemoglobin level was significantly high in

57 communicator group and marked increase was also observed in communicatees group. Though the increase was statistically not significant in commuunicatees group but the change was towards positive side. The per cent increase in haemoglobin indicated that no change has been occurred in control group, but increase was high in both the experimental groups. This is also valuable factor which has to be considered in developing countries because by using child to child teaching method one can achieve the goal of reaching larger group. From the study it can be concluded that the height and weight of the adolescent girls of dry and transitional zone were similar but were shorter and lighter compared to NCHS standards and also diet of the adolescent girls was inadequate with regard to energy and blood forming nutrients. It was surprising to note that all the selected subjects (100%) were anaemic in both the zones. But, the mean haemoglobin level of adolescent girls was comparatively high in transitional zone than the dry zone. It was observed that frequency of consumption of green leafy vegetables was drastically low which was mainly because of lack of awareness about the importance of green leafy vegetables. Hence, in the present study nutrition education intervention was used to assess the impact of nutrition education on haemoglobin status adolescent girls for a period of three months by using child to child education method. The educational intervention showed significant increase in knowledge scores of both the communicators and communicatees group, but communicators showed higher increase in the knowledge score because they were constantly teaching to the other groups for three months, and as a result, ideas were strongly imprinted in their mind. The mean haemoglobin level was significantly increased in the communicators group. In the communicatees group significant increase was not observed, however the change observed was towards positive side. Hence, the nutrition education is one of the relevant, effective and sustainable strategy to combat anaemia.

58 6. SUMMARY AND CONCLUSIONS Nutritional anaemia is more common among the young adolescent girls, probably due to low intake of haemopoietic nutrients since childhood, increased demand for nutrients coupled with menstrual losses of iron. Green leafy vegetables are grown in a wide range in India and are excellent source of iron and micronutrients. Green leafy vegetables are inexpensive compared to other vegetables and hence, within the reach of poor man. The lack of knowledge especially on the nutritive value of green leafy vegetables among public in general is may be the main drawback for their lower consumption. For this reason nutrition education may be one of important strategies to combat iron deficiency anaemia. Hence an investigation on the consumption pattern of green leafy vegetables and impact of nutrition education on iron status of rural adolescent girls was carried out during A total sample of 300 adolescent girls was selected in the age group of 13 to 16 years from two villages each from dry and transitional zone. General information on type of family, family size, occupation, age, educational level and income of family was collected. Consumption pattern of the green leafy vegetables was assessed by interviewing subjects for the information on their frequency of consumption of green leafy vegetables, methods of cooking used and possession of kitchen garden. Nutritional status of adolescent girls was assessed by nutritional anthropometry, clinical examination, haemoglobin status and dietary survey. Sixty anaemic subjects from 300 adolescent girls based on the haemoglobin level i.e., less than 12 g/dl were further selected for the intervention study. Nutrition education intervention using child-to-child education method was conducted by dividing 60 children into two groups, viz., experimental and control groups. Each group consisted of 30 adolescent girls. Further experimental group was divided into two groups, viz., student communicators (n = 10) and student communicatees (n = 20). For the student communicators three days training was given by the nutrition experts. Then those communicators inturn gave the nutrition education to communicatees over a period of three months using educational materials like charts, posters, flip chart, messages and blow-ups and also demonstrations were given on iron rich recipes using green leafy vegetables. Conversely, the impact of nutrition education was assessed by the change in nutrition knowledge, anthropometry and haemoglobin status of the selected adolescent girls. The objectives of the study were : 1. To assess the nutritional status of rural adolescent girls 2. To determine the availability and consumption pattern of green leafy vegetables among the rural adolescent girls 3. To develop educational material for iron security 4. To determine the impact of nutrition education intervention on haemoglobin status. The salient findings of the study are summarized below The mean height of the dry and transitional zone adolescent girls was cm and cm respectively. The mean weight of the dry and transitional zone adolescent girls was kg and kg respectively. According to waist to hip ratio of the subjects, most of them had no risk (72%) and 28 per cent of them had a risk of abdominal obesity. Maximum percentage of subjects belonged to (84.33%) underweight, followed by ideal BMI (14.00%), over weight (1.00%) and obese grade I (0.66%). None of the subjects belonged to obese grade II category. The mean anthropometric measurements of height and weight showed no significant differences between the two zones.

59 Dry zone adolescent girls showed higher incidence of all the deficiency signs of anaemia than transitional zone girls. Mean haemoglobin level of dry zone adolescent girls was 9.54 g/dl and in transitional zone it was g/dl. The mean nutrient intake of protein (g), energy (kcal), ascorbic acid (mg), vitamin B 12 (µg), folic acid (µg) and iron (mg) was lower than the recommended dietary allowances in both dry and transitional zone adolescent girls. The intake of energy, protein, ascorbic acid, folic acid and iron was higher in transitional zone compared to dry zone. A significant difference was observed between the two groups with regard to intake of energy, protein and folic acid. Intake of other blood forming nutrients viz., ascorbic acid, vitamin B12 and iron were found to be similar difference in both dry and transitional zone. The per cent adequacy of energy and protein was found to be in positive association with locality. The per cent adequacy of energy and protein were found to be significantly associated with family type in both the dry and transitional zone. No significant difference was observed between per cent adequacy of energy and blood forming nutrients with respect to family size in both dry and transitional zone. The per cent adequacy of energy, ascorbic acid and folic acid were found to be in positive association with haemoglobin level. In both dry and transitional zones frequency of consumption of green leafy vegetables was mostly once in a week. Most of dry zone families possessed kitchen garden (91.33%) compared to transitional zone (64.00%). Among the cooking methods for green leafy vegetable, sauteing was mostly used in both dry (88.75%) and transitional zone (93.93%). Before nutrition education intervention mean knowledge of communicators, communicatees and control group was 13.40, and 9.10 respectively and after nutrition education mean knowledge increased to 29.10, and in communicators, communicatees and control group respectively. The mean height and weight of the adolescent girls were increased after nutrition education intervention, but the initial and final values were statistically not significant both in experimental and control group. The mean initial haemoglobin level of communicator, communicatees and control group was 9.75, 9.65 and 9.78 g/dl respectively which increased to 10.49, 9.76 and 9.80 g/dl respectively after nutrition education intervention. However, significant difference was observed only in communicators group (1% level). Hence, from the above findings it can be concluded that, nutrition education is one of the appropriate, effective and sustainable approach to combat iron deficiency anaemia.

60 7. REFERENCES Adgeppa, I.A., Werner, S., Sastroamidjojo, S., Gross, R. and Karyadi, D., 1997, Weekly micronutrient supplementation to build iron stores in female Indonesian adolescents. American J. Clinical Nutr., 66 : Akkamahadevi, K.H., 1996, Dietary iron intake and prevalence of anaemia in urban and rural adolescent girls of Dharwad taluk. M.H.Sc. Thesis, Univ. Agril. Sci., Dharwad (India). Akkamahadevi, K.H., Kasturiba, B. and Rao, M., 1998, Prevalence of anaemia in urban and rural adolescent girls. Maharashtra J. Agric. Sci. Albanese, N.G., 1971, A gain step in nutrition education. School Lunch J., 25 : 106. Anonymous, 1995, 25 years of national nutrition monitoring bureau of national institute of nutrition, ICMR, Hyderabad, p. 12. Anonymous, 2001, Iron deficiency anaemia : Assessment, prevention and control. A guide for programme Managers. World Health Organization, 2001, WHO / NHD/01, 3. Anonymous, 2003, World Health Organization, Technical Report Series, p Asma, K., Gayatri, G.N., Jyothilakshmi, P. and Jamuna, P., 2003, Growth pattern and nutritional status of children residing in slum areas of Mysore. Paper presented in IX Asian Congress of Nutrition, February 23-27, New Delhi, India p Chaturvedi, S., Kapil, U., Bhanthi, T., Gnanasekaran, N. and Panday, R.M., 1994, Nutritional status of married adolescent girls in rural Rajasthan, India. J. Pediatrics, 61 : Choudhary, S., Mishra, C.P., Shukla, K.P., 2003, Nutritional status of adolescent girls in rural area of Varanasi. Indian J. 34 (1) ; Clyde, D.D., Bertini, J., Dmochowski, R., 1979, The vitamin-a and C content of Coriandrum sativum and the variations in the loss of the latter with various methods of food preparation and preservation. Qualitas Plantarum, 28 (4) : Cox, N.D., Anderson, S.A., Reynolds, S.J., McKellar, S.E. and Lean, J., 1998, Take 5, a nutrition education intervention to increase fruit and vegetable intakes : Impact on consumer choice and nutrient intakes. British J. Nutr., 80 : Deepa, K.S., 2002, Nutrition and health profile during menarche and testing the seasonal variations. M.H.Sc. Thesis, Univ. Agril. Sci., Dharwad (India). Deepa, K.S., Pushpabharati and Kasturiba, B., 2004, Seasonal variation in iron status of adolescent girls in Dharwad taluk. J. Human Ecology, 15 (3) : Deshmukh, P.R., Gupta, S.S., Bharambe, A.R., Dongre, C., Maliye, S., Kaur and Garg, B.S., 2006, Nutritional status of adolescents in rural Wardha. Indian J. Pediatrics, 73 (2) : Deshpande, S.S., Mishra, A. and Mishra, M., 2003, Nutritional profile of farm women of Madhya Pradesh and impact of nutrition education on the inclusion of soybean products. Indian J. Nutr. And Dietetics, 40 : Devadas, R.P., Chandrasekhar, U., 1970, Nutrition education of illiterate people. J. Nutr. Edu., 1 : Devi, T.A. and Uma, K.R., 2005, Effect of supplementation of spirulina on anaemic adolescent girls. The Ind. J. Nutr. and Dietetics, 42 : Gowarikar, R.S,. Gawarikar, S.B. and Tripathi, B.C., 2002, Prevalence of anaemia in adolescent girls of Ujjain in western M.P. Indian J. Nutr. and Dietetics, 39 : Hanagi, C., 2001, Nutra-aceutical effect of protein concentrate in rural anaemic adolescent girls of Dharwad taluk. M.H.Sc. Thesis, Univ. Agril. Sci., Dharwad (India). Jayashree, S.P., 2002, Prevalence and assessment of obesity among high school children on Dharwad city. M.H.Sc. Thesis, Univ. Agric. Sci., Dharwad (India). Jayatissa, R. and Piyasena, C.,1999, Adolescent school girls : Daily or weekly iron supplementation. Food and Nutr. Bulletin, April, 1999.

61 Jellife, D.B., 1966, The assessment of nutritional status of community, WHO, Monograph series, WHO, Geneva. Jondhale, J.P., Reddy, S.N. and Nalwade, Y.M., 1999, Prevalence of anaemia among school going adolescent girls to Parbhani. The Indian J. Nutr. and Dietetics, 36 : Kalpana, C.A., Aruna Narayanan and Thangarathi, T., 2007, Effect of medicinal iron supplementation and nutrition education on anaemic adolescent girls of low income families. The Indian J. Nutr. and Dietet., 44 : Kamble, R.D., 1997, Promoting soybean utilization through nutrition education among families of soybean cutivators. M.H.Sc. Thesis, Univ. Agril. Sci., Dharwad (India). Kaur, S., Deshmukh, P.R. and Garg, B.S., 2006, Epidemiological correlates of nutritional anaemia in adolescent girls of rural Wardha. The Indian J. of Community Medicine, 31 (4) : Kaur, T.J., Kocher, G.K. and Agarwal, T., 2007, Impact of nutrition education on nutrition adequacy of adolescent girls. Student Home. Comm. Sci., 1 (1) : Khan, I. and Basser, A., 1996, Haemetologic effect of vitamin-a supplementation in anaemic Pakistani Children. J. Pakistani Medical Assoc., 46 (2) : Kowsalya, S. and Crassina, A., Shimaray, 2008, Impact of supplementation of lotus stem (Nelumbium nelumbo) on the iron nutriture of adolescent girls (13-18 years) in Manipur. The Indian J. Nutr. Dietet., 45 : Kumar, A.R., Yadav, N., Gupta, A.K., Parvin,., Tripathi, V. and Verma, V., 2006, Influence of family s vegetable cultivation on prevalence of anaemia among adolescent girls. The Indian J. Nutr. and Dietetics, 43 : Kumari, S. and Singh, S., 2003, Nutritional status of scheduled caste adolescents from deprived section of society. The Indian J. Nutr. and Dietetics, 40 : Lean, M.E., Han, T.S. and Morrison, C.E., 1995, Waist circumference as a measurement for indicating need for weight management. British Medical J., 42 (1) : Leela T. and Priya, S., 2002, Iron status and morbidity pattern among selected school children. The Indian J. Nutr. and Dietetics, 39 : Malhotra, A.K. and Rao, N.P., 1984, A study on anaemia and nutritive adequacies of the rural school children of district Wardha (Maharashtra). The Indian J. Nutr. and Dietetics, 21 : Meti, R. and Saraswathi, G., 2006, Impact of nutrition education and carbohydrate supplementation on performance of high school football players. The Ind. J. Nutr. Dietet., 43 : Mini, C. and Krishnakumary, K., 2004, Text book of leaf vegetables. Agrotech Publishing Academy Udaipur. Muthaya, S., Thankachan, P., Zimmermann, M.B., Anderson, M., Eilander, A., Misquith, D., Hurrell, R.F., Kurpad, A.V., 2007, Low anaemia prevalence in school-aged children in Bangalore, South India : Possible effect of school initiatives. European J. Clinical Nutri., 61 (7) : Perry, L.T., Mann, I.J., Lewis, B.J., Duncan, W.A., Waldron, A.M. and Thompson, C., 1997, Life style intervention in people with Insulin-dependent diabetes mellitus. European J. Clinical Nutr., 81 (11) : Puri, R. and Mehta, S., 1994, Impact of nutrition and health education on rural pre-school children. Indian J. Pediatrics, 31 (1) : Rajammal, P., Devadas, Usha Chandrashekar and Bhooma, N., 1972, Scope for nutrition education in the elementary school programme, 10 : Rao, G.P., Mallikarjun, K. and Gururaja Rao, G., 1980, Nutritional evaluation of some green leafy vegetables. The Indian J. Nutr. Dietet, 17 : 9-12.

62 Rao, S., Kanade, A. and Joshi, S., 1998, Height, weight and menarchael age of rural Indian girls. The Ind. J. Nutr. and Dietetics, Rao, V.K., Balakrishna, N., Shatrugna, V. and Thimmayamma, B.V.S., 1993, Relatives metrits of some anthropometric indices for use among school age children and adolescents. The Indian J. Nutr. and Dietetics, 30 : Rawat, C.M.S., Garg, S.K., Singh, J.V., Bhatnagar, M., Chopra, H., Bajpai, S.K., 2001, Prevalence of anaemia among adolescent girls in rural area of district Meerut, U.P., Indian J. Public Health, 45 (1) : Reddy, C.V.K., 1999, Greens for good health. Nutr., 33 (3) : 3-8. Renquist, U.H., Vreeze, A.C., De, Evenhuis, B., 1978, The effect of traditional cooking method on carotene content in tropical leafy vegetables. Ind. J. Nutr. and Dietetics, 15 (5) : Sangha, J., Pandher, A.K. and Navajot Kaur, 2006, Impact of nutrition education on nutrition knowledge of the parents of obese children. The Indian J. Nutr. and Dietetics, 43 : Saroja Prabhakaran, 2003, Nutritional status of adolescent girls residing in a university hostel. The Indian J. Nutr. and Dietetics, 40 : Saxena, R., 1999, How green is your diet? Nutr., 33 (3) : 9. Shahabuddin, A.K., Talukdar, K., Talukdar, M.K., Hassan, M., Seal, A., Rahman, Q., Mannan, A., Tomkins, A., Costello, A., 2000, Adolescent nutrition in a rural community in Bangladesh. Indian J. Pediatrics, 67 (2) : Shekhar, A., 2005, Iron status of adolescent girls and its effect on physical fitness. The Indian J. Nutr. And Dietetics, 42 : Sucharitha, k.v., Suneetha, E., Krishnapriya, A., 2007, Nutrition education through girl to girl approach. Paper presented at the 39 th National Conference, Hyderabad, November, p. 59. Swarnalatha, A. and Yegammai, C., 2006, Impact of iron, vitamin A and vitamin C supplementation on anaemic adolescent girls. The Ind. J. Nutr. Dietet., 43 : Tamilarasi, P. and Mathew, S., 1990, Body weight, diet and serum cholesterol level in selected obese adolescent girls. The Indian J. Nutr. and Dietetics, 27 : Tatia, R. and Taneja, P., 2003, Dietary intake of tribal adolescent girls of Dhar district in Madhya Pradesh. The Indian J. Nutr. and Dietetics, 40 : UNESCO, T.A., 1983, Nutrition Education : A case study experiences in Schools, UNESCO, Paris. Varalakshmi, R. and Jayashree, R., 2003, Child to child teaching technique in nutrition education. Health Education, pp Vijayaraghavan, K., 2007, Iron deficiency anaemia in India and its control. The Ind. J. Nutr. Dietetics, 44 : Zanvar, V., Roshini Devi, Arya, A. And Nerlekar, J.P., 2007, Prevalence of anaemia among selected adolescent girls of Marathwada region. The Ind. J. Nutr. Dietetics, 44 :

63 APPENDIX I Appendix I : Schedule to elicit the information on the consumption pattern of green leafy vegetables and iron status of rural adolescent girls I. General Information 1. Name : 2. Address : Ph. No. : 3. Age : 4. Education : 5. Family size : 6. Family type : Male : Female : Children : 7. Caste : Hindi/Muslim/Christian/Jain/ Any other 8. Total income of the family per month : 9. Occupation of parents : Father : Mother : II. Anthropometric measurement to assess the nutritional status of the respondent : Height (cm) Weight (kg) MUAC (cm) Waist circumference (cm) Hip circumference (cm) III. Biochemical assessment Hb level (g%) : IV. Clinical examination of anaemia : Fatigue Breathlessness Paleness Giddiness Information about menstrual cycle : - Severe bleeding - Duration of bleeding Any other

64 V. Dietary assessment (respondent) by 24 hour recall method : Meal pattern Menu Qty of food consumed (cooked) Qty of food consumed (row) Individual consumption Bed tea/coffee Breakfast Lunch Snacks Dinner Any other VI. Specific information 1. Information about the availability and consumption of green leafy vegetables : Sl. No. Seasonal Non-seasonal Approximate cost 2. Information on frequency of consumption of green leafy vegetables : Sl. No. Name Daily Twice a week Weekly once Once in fortnight Monthly Occasionally Not at all 1. Methi 2. Spinach 3. Rajgira 4. Shepu 5. Gogu 6. Amaranthus 7. Radish leaves

65 8. Hakkaraki 9. Drumstick leaves 10. Any other 3. Information on kitchen garden Sl. No. Name of crop grown Yield Quantity used for consumption Quantity used for selling 4. Methods of cooking used for green leafy vegetables Boiling a. Seasoning and boiling without water b. Boiling and discarding water Simmering a. Long duration b. Short duration Frying a. Shallow of frying (sautéing) b. Deep fat frying

66 APPENDIX II Appendix II : Questionnaire to elicit information about iron deficiency aneamia in adolescent girls 1. General information 1. Do you wash your hands before eating? a. Yes b. No 2. Do you cut finger nails regularly? a. Yes b. No 3. Do you take bath daily? a. Yes b. No 4. Do you walk barefooted outside the home? a. Yes b. No 5. Do you wash fruits and vegetables before consumption? a. Yes b. No 6. Vegetables and fruits are rich man foods? a. Yes b. No 7. Which colour of foods will keep eyes health? a. Yes b. No 8. A child who eats all vegetables and fruits is free from diseases? a. Yes b. No 9. Do you have kitchen garden? a. Yes b. No 10. Children love green leafy vegetables? a. Yes b. No 11. Inclusion of green leafy in the diet will lead to diarrhea during rainy season? a. Yes b. No 12. Consumption of yellow coloured fruits lead to glowing and healthy skin? a. Yes b. No 13. Night blindness is common in children? a. Yes b. No 14. Do you know anaemia is common in adolescence; pregnancy and lactating women? a. Yes b. No II. Specific information 15. Do you know about hemoglobin? a. Yes b. No 16. Do you know your hemoglobin level? a. Yes b. No 17. Do you know normal hemoglobin level of the individual?

67 a. Yes b. No 18. Do you know about Red Blood Cells? a. Yes b. No 19. Do you know about iron? a. Yes b. No 20. Do you know about importance of iron? a. Yes b. No 21. Do you know about functions of iron? a. Yes b. No 22. Do you know about anaemia? a. Yes b. No 23. Do you know causes of anameia? a. Yes b. No 24. Do you know about symptoms of anaemia? a. Yes b. No 25. Do you know efficiency of iron in foods leads to anaemia? a. Yes b. No 26. Do you know about sources of iron? a. Yes b. No 27. Do you know green leafy vegetables are sources of iron? a. Yes b. No 28. Do you know lack of green leafy vegetables in the diet will lead to efficiency disease? a. Yes b. No 29. Do you know iron and folic acid tablets prevent anaemia in adolescence? a. Yes b. No 30. Do you know vitamin C fruits help in absorption of iron? a. Yes b. No 31. Do you know tea and coffee drinking immediately after eating inhibit iron absorption? a. Yes b. No

68 Appendix III. Development of educational materials APPENDIX III

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