School-based study to assess the nutritional status (BMI based) School-based study to assess the nutritional status (BMI based) of adolescents of Gojra city of district Toba Tek Singh, Punjab, of adolescents of Gojra city of district Toba Tek Singh, Punjab, Pakistan Pakistan

and balanced nutrition is a vital requirement to support this phase. Adolescents living in developing and low-income countries are more likely to face nutritional challenges. Poor nutritional status during adolescence is an important determinant of health outcomes. Objective: To analyze the nutritional status (BMI based) of school-going adolescents in Gojra city, Punjab, Pakistan. Methods: A school-based cross-sectional survey was carried out covering 635 (6-8 grade) school-going adolescents (boys and girls) from public schools in Gojra city. Data were collected through anthropometric measures taken. Symptoms of malnutrition were also assessed. Mean and frequencies were reported for demographic variables and symptoms of malnutrition while two sample Independent T-test was used to compare the means of groups under study using SPSS version-23. Results: The overall prevalence of underweight in boys was found (33.9%) as compared to adolescent girls (32.3%). It was also found that malnutrition and related health complications were higher in adolescents with lower BMI values. Conclusions: Adolescent boys and girls were found with a high prevalence of malnutrition along with other symptoms.


Original Article
Healthy Nutrition results in better growth and development during infancy and adolescence.However, nutritional requirements keep changing through the period of adolescence [1].In Pakistan, the nutritional status of early adolescents is extremely poor [2].The adolescence period is one of the crucial periods in human life that greatly impact individuals' health and well-being in the later phases of their lives.According to World Health Organization (WHO), adolescents can be de ned as individuals aged 10 to 19 years [3].The years of adolescence period are generally divided mainly into three stages that are early adolescence (9-14 years), middle adolescence (15-17 years), and late adolescence (18-21 years) [4].The phase of adolescence constitutes the development of human beings from the

M E T H O D S
getting an adequate amount of required nutrition [8].Adolescents having proper dietary intake and better nutritional status are likely to show good performance in schools, have better physical performance, and overall good health status.Poor nutritional status in the adolescent phase can cause retarded physical, hormonal, cognitive, and sexual development among individuals.As found by Arage et al., poor nutritional status among adolescent girls can lead to a cycle of low nutritional status in their coming generations leading to low birth weight of infants and higher child mortality rates [7].It is also found that adolescent facing nutritional challenges have poor sexual development and reproductive cycle maturation [9].Over-nutrition and under-nutrition contribute to the increase in the burden of global health challenges for low and middle-income countries like Pakistan.Greater intake of processed foods, high-calorie foods, and drinks causes greater BMI in children, weak bones and teeth, and increased risk of type 2 diabetes and iron de ciency among young children and adolescents [10,11].According to two out of three death globally are caused by noncommunicable results that are mainly the consequences of poor nutritional status in individuals.High prevalence of vitamin A and B de ciency, anemia, dental caries, and stomatitis were also found in adolescent girls in a schoolbased study in India [12,13].found that bad eating habits in early and middle adolescence lead to obesity and depression issues in later phases of life.The assessment of the nutritional status of adolescents in developing and lowincome countries is frequently neglected in clinical programs and research4.It causes a problem in analyzing the nutritional status of adolescents.Recent studies also suggest severe consequences of poor nutritional status on the development and growth of adolescents, mainly in developing countries [14].Most recent health intervention programs also focused on improving health and nutrition for children below the age of 5 years, and less focus is given to adolescents' nutritional status and health consequences in developing countries [15].According to Baye et al., improving nutrition status is the second in Sustainable Development Goals.However, using different policies and strategies, less priority is given to elevating adolescents' nutritional status in developing countries [13].Due to the gap in research on this subject, it is important to assess the nutritional de ciencies and over-nutrition status in adolescents between the ages of 10 to 19 years and to provide valuable ndings that offer the nutrition status of these individuals and the factors that affect the nutrition status of these individuals.This study aims to assess and analyze the nutritional status of adolescents in Gojra city in the province of Punjab, Pakistan.
A quantitative cross-sectional research design was adopted to analyze the nutritional status of adolescents.A pre-tested survey questionnaire was used for data collection.The study was conducted in four (two boys and two girls) different public schools in Gojra city from August 2021 to December 2021.A strati ed random sample of size of n=635 school-going adolescent boys and girls from schools in Gojra city, Punjab, Pakistan.

Equation
The sample size was calculated on the basis of a 42 % prevalence of undernutrition among adolescents.with a 95% con dence level by using the open-epi formula.The data were collected from 635 (boys and girls) adolescents from public schools.Among them, 375 were adolescent girls, and 260 were adolescent boys.About 81.3 % of adolescents were between the age of 10-14 years.The mean age of girls was 12.77 ± 1.52, and 12.64 ± 1.53 of boys, which showed that there was no such variation in the agegender distribution.The age data were also grouped into three such as early adolescents, mid and late adolescents (Table 2).By birth category, most of them are ≤ 2 and by the sibling of adolescents, it was found > 5.By category of father occupation, most of them were daily laborers (Table 3).Participants' mean weight, showed that the boys were more underweight than the girls.The mean height of the respondents was also calculated in which the boys were found with a greater height than girls.The mean BMI of the girls (18.50 ± 3.63) and boys (16.51 ± 2.74) showed that girls possess a normal BMI, but the boys had slightly lower BMI than the normal range (Table 4).Malnutrition according to the BMI category found that 33.9 % of adolescent boys and 32. 3 % of girls were underweight.Only 3.3 % of girls were overweight and 0.6 % were obese.The prevalence of being underweight was found very much similar in both genders.According to the age group, most of the underweight adolescents were found between 10-14 years of age (Table 5).As per the data collected and calculated from the symptoms of malnutrition in the underweight and healthy adolescents, it was observed that in the last two weeks at the time of data collection diseases like diarrhea, fever, body aches common cold, etc., were reported in which the ratio of underweight adolescents, was higher as compared to the healthy adolescents.In addition, the percentage of having diseases was almost equal in the ratio of boys and girls (Table 6).the participants were male, 61.9% were between the ages of 13 and 15, and 87.1% attended public schools [16,17].In another previous study, a comparable total of 655 adolescents attending school took part, with males outnumbering females at 340 (51.9%).In terms of respondents' age, con icting ndings emerged, with the majority (532 (81.2%) falling within the 15-19-year-old range.
The median age of the respondents was 17 years, with an interquartile range (IQR) of 3 years.Additionally, in contrast, approximately half (333 (50.8%)) of the respondents had fathers employed in the government sector [18].In this current study, about 33.9 % of adolescent boys and 32.3% girls were found underweight.Only 3.3 % of girls were overweight and 0.6 % girls were obese.The prevalence of being underweight was found very much similar in both genders.According to the age group, most of the underweight adolescents were found between 10-14 years of age.A previous study by Nithya and Bhavani discovered consistent ndings, revealing that the average BMI Zscores of teenage boys were lower than the designated threshold (< -2SD), indicating that a majority (51%) of them were experiencing under-nutrition in both locations.The BMI Z-scores of teenage girls were also at the edge of the designated limits, suggesting a heightened risk of undernutrition, with 27% of girls being affected.Contrasting results were observed in terms of age and gender, as the average height-for-age Z-scores fell within the speci ed limits for both boys and girls.Additionally, it was noted that a higher percentage of adolescent boys (50.7%) experienced stunting compared to girls (27.3%) [19].The study has signi cantly helped determine malnutrition symptoms among both genders, including male and female students.The study included body mass index and sociodemographic characteristics of students between 10 to 19 years of age.The results interpretation indicates the underweight and overweight characteristics among different age groups.The results indicated within the study showed a high prevalence of illness among underweight girls and boys as compared to healthy ones.Similarly, the study results also indicated low BMI issues among boys as compared to girls.Moreover, the challenges of malnutrition were found to be more dominating among underweight adolescents as compared to healthy ones.The risk of increased malnutrition among underweight adolescent students was greater, indicating poor diet quality and socioeconomic factors in uence their growth and development [20].Moreover, the increase in malnutrition symptoms among adolescents increases healthcare costs and adversely impacts their cognitive potential.The aim of the study has been signi cantly achieved by analysing biodata, nutritional status, and clinical assessment of adolescents among 635 sample sizes of the targeted

D I S C U S S I O N
In the current study, the data were collected from 635 (boys and girls) adolescents from public schools in the present study.Among them, 375 were adolescent girls, and 260 were adolescent boys.About 81.3 % of adolescents were between the ages of 10-14 years.The mean age of girls was 12.77 ± 1.52, and 12.64 ± 1.53 of boys, which showed that there was no such variation in the age-gender distribution.By birth category, most of them are ≤ 2 and by the sibling of adolescents, it was found > 5.By category of father occupation, most of them were daily laborers.A previous study yielded comparable results, revealing that 50.3% of population.The distribution of students among girls and boys about their mean age helped determine the nutritional needs of adolescents.Moreover, it is reported that adolescents usually have a higher basal metabolic rate compared to old people, indicating more nutrient intake needs.Furthermore, based on the metabolism, the assimilation of power varies from person to person.The signi cance of using body mass index supported in determining the degree of under-nutrition and overnutrition values among adolescents, including both male and female gender.Also, it increased the monitoring aspects value of nutrition trends among school-based adolescents.Overweight adolescents showed the prevalence of unhealthy lifestyles or poor diets, having increased levels of fat and sugar adolescents [20].
Similarly, the study by Ahmad et al.,indicated an 11.1% prevalence of underweight school-going children and 11.5% of stunted students [21].The factor of stunting among adolescents causes severe cognitive challenges along with motor and social-emotional development problems.The BMI assessment among school-based adolescents thus promotes identifying the risk of underweight and overweight issues, which adversely impacts the cognitive learning process.

Table 1 :
Sample Size for Frequency in a Population

Table 2 :
Weight was measured in kilograms, and the participant stood at the center of the scale, not holding anything, adjusting the scale to zero with minimum clothing and no footwear.Distribution of adolescents, boys, and girls according to age group The required sample was 636 adolescents.The school-going adolescents of both genders studying in 6,7 and 8 grades in the age group of 10-18 years and willing to participate in the study were included.Exclude those students who were below 10 years of age and above 19 years of age group and Students who were on leave, or at home due to any sickness.All elementary boys' and girls' public schools in the city were invited for the study.There were 7 boys and 6 girls' public elementary schools.Out of these Willing schools, two boys (260 boys) and two girls (375) schools were randomly selected to reach calculated sample size.All participants enrolled in the study were from 6-8 grade and who themselves and whose parents gave consent.The participants were briefed about the nature of the study and expected outcomes.The pre-tested questionnaire was used for interview and adolescents were clinically examined for anthropometric measurement by the researcher.Age was estimated by asking for date of birth, and veri ed with school admission record.For s o c i o d e m o g r a p h i c i n fo r m a t i o n , a s t r u c t u r e d questionnaire was used.The BMI of each participant was calculated using age, height, weight, and age.

Table 3 :
Socio-demographic characteristics of participants

Table 4 :
Mean of Age, Weight, Height and BMI

Table 5 :
Nutritional status of adolescents (BMI Percentile)

Table 6 :
Diseases reported in the last two weeks by under-weight and healthy-weight adolescents

Table 7 :
Symptoms of Malnutrition in Underweight and Healthy Weight Respondents