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Year : 2022  |  Volume : 21  |  Issue : 3  |  Page : 185-192  

Role of dietary habits and personal hygiene on nutritional status of school-going adolescents: A cross-sectional study in selected schools located in slum areas of Nagpur City, Maharashtra

Department of Community Medicine, AIIMS, Nagpur, Maharashtra, India

Date of Submission04-Dec-2020
Date of Decision25-Apr-2021
Date of Acceptance06-Aug-2021
Date of Web Publication26-Sep-2022

Correspondence Address:
Mubashshera Firdous Khan
Department of Community Medicine, AIIMS, Nagpur, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_109_20

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Purpose: Adolescence is a nutritionally vulnerable time when rapid physical growth increases nutrient demand. Addressing the nutrition needs of adolescents could be an important step toward breaking the vicious cycle of intergenerational malnutrition. Under the healthy school initiative, a baseline assessment was carried out to assess the nutritional status, dietary habits, and personal hygiene of school-going adolescents to plan the future interventions at school level. Materials and Methods: A cross-sectional study was conducted in two government-aided schools for 6 months among 814 students of Class VI–IX to assess their dietary habits and personal hygiene by using the GSHS( Global School based student Health Survey) -2007(Indian version) tool. Anthropometric measurement was taken by standard technique. Results: The study found the proportion of thinness, stunting, and overweight/obesity as 40%, 20%, and 4.2%, respectively. Male students were found more thin (61.1% vs. 38.8%) and stunted (55.6% vs. 44.4%) as compared to female students. Less than one-fourth (13.7%) of the students reported <5 servings of fruits and vegetables. In multivariable analysis, male students, children of homemaker mother, skipping breakfast on all days of week, consumption of fast food ≥3 times/week, consumption of high sugary ready to use food, and infrequent handwashing after toilet were found to be predictors of thinness. Conclusion: Dietary habits and personnel hygiene were found to be important factors of undernutrition; promoting health behavior through school health policy with involvement of teachers, students, and parents is highly recommended to reduce the problem of undernutrition among adolescents.

   Abstract in French 

Objectif: L'adolescence est une période de vulnérabilité nutritionnelle pendant laquelle une croissance physique rapide augmente la demande en nutriments. Répondre aux besoins nutritionnels des adolescents pourrait constituer une étape importante vers la rupture du cercle vicieux de la malnutrition intergénérationnelle. Dans le cadre de l'initiative pour une école saine, une évaluation de base a été réalisée pour évaluer l'état nutritionnel, les habitudes alimentaires et l'hygiène personnelle des adolescents scolarisés afin de planifier les futures interventions au niveau de l'école. Matériels et Méthodes: Une étude transversale a été menée dans deux écoles subventionnées par le gouvernement pendant 6 mois auprès de 814 élèves des classes VI à IX pour évaluer leurs habitudes alimentaires et leur hygiène personnelle à l'aide du GSHS (Enquête mondiale sur la santé des élèves en milieu scolaire) -2007 (version indienne) outil. La mesure anthropométrique a été prise par la technique standard. Résultats: L'étude a révélé que la proportion de maigreur, de retard de croissance et de surpoids/obésité était de 40 %, 20 % et 4,2 %, respectivement. Les étudiants de sexe masculin se sont révélés plus minces (61,1 % contre 38,8 %) et rabougris (55,6 % contre 44,4 %) que les étudiantes. Moins d'un quart (13,7 %) des élèves ont déclaré <5 portions de fruits et légumes. Dans une analyse multivariée, les étudiants de sexe masculin, les enfants d'une mère au foyer, le fait de sauter le petit-déjeuner tous les jours de la semaine, la consommation de restauration rapide ≥ 3 fois/semaine, la consommation d'aliments prêts à l'emploi riches en sucre et le lavage peu fréquent des mains après la toilette se sont révélés être des prédicteurs de minceur. Conclusion : Les habitudes alimentaires et l'hygiène du personnel se sont révélées être des facteurs importants de dénutrition ; la promotion de comportements sains par le biais d'une politique de santé scolaire avec la participation des enseignants, des élèves et des parents est fortement recommandée pour réduire le problème de la dénutrition chez les adolescents
Mots-clés: Adolescent, habitudes alimentaires, hygiène personnelle, dénutrition

Keywords: Adolescents, dietary habit, personnel hygiene, undernutrition

How to cite this article:
Khan MF, Banerjee S, Bandyopadhyay K, Kalaiselvi S, Akkilgunata S, Tripathy J, Solanki R, Kushwaha AS, Deshmukh P. Role of dietary habits and personal hygiene on nutritional status of school-going adolescents: A cross-sectional study in selected schools located in slum areas of Nagpur City, Maharashtra. Ann Afr Med 2022;21:185-92

How to cite this URL:
Khan MF, Banerjee S, Bandyopadhyay K, Kalaiselvi S, Akkilgunata S, Tripathy J, Solanki R, Kushwaha AS, Deshmukh P. Role of dietary habits and personal hygiene on nutritional status of school-going adolescents: A cross-sectional study in selected schools located in slum areas of Nagpur City, Maharashtra. Ann Afr Med [serial online] 2022 [cited 2023 Sep 22];21:185-92. Available from:

   Introduction Top

In India, adolescents (10–19 years) constitute about 21% of total population (243 million).[1] Adolescence is a nutritionally vulnerable time when rapid physical growth increases nutrient demands. Dietary behaviors established in adolescence period contribute to nutrition-related problems that have consequences for long-term health.[2] Growths during this phase of life help overall development and provide adequate stores of energy for pregnancy and healthy adulthood. Addressing the nutrition needs of adolescents could be an important step toward breaking the vicious cycle of intergenerational malnutrition, chronic diseases, and poverty.[3] However, most of the nutrition-related initiatives in India have been centering on children and women of reproductive age and little focused on adolescent nutrition. Adolescent nutrition is influenced by several individual, household, and social factors. Studies on the role of these nutrition-sensitive factors among adolescents are not many.

Among many factors that influence the nutritional status of adolescents, dietary behavior and hygienic practices are important ones that affect the health of adolescents.[4],[5] The global commitment on sustainable development goals also acknowledges the contributory role of improved water, sanitation, and hygiene (WASH) practices to reduce the incidence on undernutrition. Dietary habits and choice of food influence nutrient and energy consumption and are developed over a period, especially during adolescence. Nutritional problems among adolescents can arise from the result of dietary inadequacies, principally from poor dietary choices. Some dietary patterns appear quite common among adolescents, snacking, usually on energy-dense foods; meal skipping, particularly breakfast, or irregular meals; wide use of fast food; and low consumption of fruits and vegetables.[6],[7]

Nutritional status of children in many developing countries is affected by hygiene status, such as lack of clean water, poor sanitation, poor hygiene practices, and lack of access to toilets.[8] The World Health Organization estimates that as much as 50% of childhood undernutrition is associated with poor WASH practices.[9] However, there is dearth of literature concerning impact of poor sanitation practices focused on anthropometric measurement of adolescents in India.

School setting provides an excellent opportunity for promoting sustainable behavior change, thereby enabling children to grow and mature into healthy adults. Several studies have stressed adolescents need to understand the importance of nutrition in this stage and have emphasized the importance of educational interventions.[10],[11]

With this background, the current study was planned to find out the nutritional status of school-going adolescents and assess the dietary and hygienic risk behaviors and their association with nutritional status to plan the future interventions at school level.

   Materials and Methods Top

Study setting

It was a cross-sectional study conducted in two government-aided secondary schools situated in catchment area of urban field practice area of a government medical college of Nagpur city, Maharashtra. These two selected schools are situated in slums of Nandanvan which is one of the largest slums in Nagpur, providing home to 27,000 slum dwellers. The survey was carried out for 6 months (from July 2019 to January 2020) as a part of baseline assessment in two schools which were purposively chosen for implementing healthy initiative in line with the World Health Organization (WHO) concept of “Health Promoting School.”[12] It is based on weekly peer-to-peer health education session with the involvement of teachers and parents under the direct guidance of trained staff from health sector.

Study population

All the students of Class VI–IX (10–19 years) who were present on the day of the visit were included in the study. Students of Vth standard were excluded as many of them were <10 years old. Students of Class X were excluded considering their examination schedule. Total students included in this study were 814.

Data collection

Data were collected from students in two phases; in the first phase, a predesigned self-administered questionnaire was administered in local language. Questionnaires consist of sociodemographic information, dietary pattern, food habits, and personal hygiene practices of participants. It was collected using 7-day recall method.

The inclusion of participants in the study was voluntary; confidentiality of students was ensured by omitting the name in a case record form. In each class, the purpose of the study and all individual questions were explained by one of the moderators from an investigating team. For ease of administration, at a time, one section of every class which caters to 30–50 students was assessed.

The dietary and personal hygiene risk behavior questionnaires were adopted from the Global School Health Survey Tool;[13] the English version of the structured questionnaires was translated into local language and then again back-translated to English to assure the consistency of the questions.

Pretest was done in 5% of the total sample before the actual survey to ensure clarity, ordering, consistency, and acceptance of the questionnaires. The participants included in pretesting were excluded from the main study.

In the second phase, anthropometric measurements were taken. Height and weight of the participants were measured by following standard technique and using calibrated instruments. Height was measured to the nearest of 0.1 cm using a wall-mounted standardized stadiometer (200 cm) and weight to the nearest of 0.1 kg using a portable weighing machine (seca electronic scale). Body mass index (BMI) was computed by using WHO AnthroPlus software.

Students who were either absent on the day of data collection or during subsequent visit to complete their anthropometric measurement were excluded from the study and also some were excluded due to incompleteness in a case record form. Thus, total 774 students were included in the present study out of 814 targeted students.

Definition of variables

In dietary behavior, inquiry was made about breakfast skipping, intake of fruits, vegetables, and ultra-processed food (UPF) items in the last 7 days. Low fruit and vegetable were defined as consuming less than minimum recommended five servings per day (fruit and vegetable together).[14],[15] We considered UPFs which are either packaged items or easily available road side ready to use foods which are high in sugar, salts, and trans fat. Data on different types of UPF consumption were recorded by using separate variables (carbonated beverage, fast food, and high sugar containing food from market). We considered the presence of risk behavior if participants are consuming them ≥3 times/week.

Regarding personal hygiene practices, handwashing practices were assessed in three categories: never, most of the times, and always. The first two categories were considered infrequent practice in analysis. Oral hygiene was assessed by recording the frequency of brushing teeth in a day in the last week. Children who are brushing their teeth at least once in a day were considered adequate.

Thinness, severe thinness, stunting, overweight, obesity, and normal were defined by age- and sex-specific BMI reference and height-for-age reference developed by the WHO (2007) for children aged 5–19 years.[16],[17]

Nutrition status of participants measured by the WHO standards was the outcome variable, and variables related to dietary habits, personal hygiene, and demographic factors were considered explanatory (independent) variables.

Statistical analysis

Data were entered into EpiData entry software (EpiData v3.1, Odense, Denmark). BMI and height-for-age Z score calculation and categorization were carried out by WHO AnthroPlus software and merged to the main database.

All variables including background characteristics and risk behaviors pertaining to dietary habits and personal hygiene having P < 0.2 in the univariate analysis were included in multivariable logistic regression model. In the multivariable analysis, variables with P < 0.05 were taken as significant predictors for thinness at a 95% confidence interval (CI).

Data were analyzed using IBM SPSS software 19.0 (Statistical Package for the Social Sciences Inc., Chicago, IL, USA).

Administrative approval was obtained from the head of the school and class teachers. In addition, consent from parents was obtained in a group. Assent also was obtained from the participating students. IEC was taken from the concerned institute.

   Results Top

The mean age of the students was 12.8 years. Nearly equal numbers of male and female students were found; about 22% of the participants' fathers and mothers had education beyond secondary school. Around 71% of the respondents' mothers were homemakers; very few mothers (6.2%) were belonging to professional and semiprofessional category. Almost half of the participants' fathers were unskilled workers [Table 1].
Table 1: Background characteristics of study participants

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Regarding dietary habits, 218 (28.2%) participants had never taken breakfast in the last week. 17.2% of the children reported less than once daily intake of vegetables and 13% reported no fruit intake in the last 1 week. Less than one-fourth (13.7%) of the students reported <5 servings of fruits and vegetables. High-risk behaviors pertaining to high intake of UPF items including fast food, high sugary ready-to-eat food, and carbonated drinks were found in 90.4%, 80.4%, and 67.2% of the students, respectively [Table 2].
Table 2: Risk behavior assessment of study participants (n=774)

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Regarding hygienic practices, brushing teeth at least once per day was always practiced by 93% of the students. 13% never wash their hands before eating; more than 40% never wash their hand with soap and water, but good numbers (88%) of students wash hands after coming from toilet [Table 2].

Thinness was found in around 40% of the students including 16% who had severe thinness. Overweight and obesity were found in 32 participants (4.1%). Both stunting and thinness were found more in males compared to females while the proportion of overweight/obesity was found slightly higher in females [Table 3] and [Table 4].
Table 3: Body mass index and height-for-age Z score

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Table 4: Anthropometric assessments of study participants

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The nutritional status of study participants was compared with the WHO 2007 reference population (5–19 years) curve; Z score curve of the present study was to the right of the WHO growth standard for chosen adolescent population [Figure 1] and [Figure 2].
Figure 1: Body mass index for age

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Figure 2: Height for age

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Stunting was found in 20% of the students. By using both BMI and height-for-age Z score criteria, 45% of the students were found to be in normal weight and height category. Three students had both stunting and underweight.

In univariate analysis, students at the age of 13, male, children of homemaker, unskilled and self-employed women, students who skipped breakfast on all days of week, consumption of fast food and sugary food more than 3 times/week, infrequent brushing of teeth, and infrequent handwashing before eating and after coming from toilet were found to independent predictors of thinness [Table 5].
Table 5: Association of undernutrition with background characteristics and selected risk factors (n=741)

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In multivariable logistic regression, after adjusting for all potential confounder, male students (adjusted odds ratio [AOR] [95% CI]: 1.89 [1.38–2]), children of homemaker mother (AOR [95% CI]: 2.12 [1.01–4.45]), students of unskilled mother (AOR [95% CI]: 5.38 [2.07–13.97]), skipping breakfast on all days of weeks (AOR [95% CI]: 1.66 [1.06–2.60]), consumption of fast food ≥3 times/week (AOR [95% CI]: 2.38 [1.27–4.43]), consumption of high sugary ready to use food (AOR [95% CI]: 1.81 [1.13–2.91]), and infrequent handwashing after toilet (AOR [95% CI]: 2.25 [1.37–3.70]) were remained significant predictors of thinness among study participants. The model was found good fit by nonsignificant Hosmer–Lemeshow test and significant Omnibus Chi-square statistics.

   Discussion Top

This study among school-going students from urban slum had identified the burden of thinness, stunting, and overweight/obesity as 40%, 20%, and 4.2%, respectively. Male students were found more thin (61.1% vs. 38.8%) and stunted (55.6% vs. 44.4%) as compared to female students. We found an alarming prevalence of undernutrition in adolescents with poor dietary and personal hygiene behavior along with a major inclination of adolescents toward consumption of UPF and poor intake of protective food (fruits and vegetables).

Thinness and stunting are indicators of chronic malnutrition. Many studies in India found a prevalence of undernutrition more than 50%.[18],[19],[20] However, National Nutrition Survey (CNNS) reported different proportion of under-nutrition at different adolescents age with prevalence of under-nutrition highest at the age of 10 years(26%), which is less than what the present study determine (40%), also observed low mean BMI among boys as compared to girls similar to our study. Furthermore, the prevalence of overweight was found higher (6.9%) as compared to our study in CNNS (2016–2018).

Finding related to prevalence of undernutrition more in adolescents' boys as compared to adolescent girls was reported in many other studies as well.[22],[23] The greater prevalence of thinness among boys than girls is indicative of “biological fragility” of males as compared to their female counterparts.[24] We found a proportion of undernutrition less among children of professional mothers as compared to homemakers and unskilled mothers. It could be related to adequate income, good knowledge, and availability and access to balanced food that comes as the educational status increased.

Breakfast is one of the most integral components of an individual's diet, despite that breakfast skipping is widely prevalent in children and adolescents including the present study.[25] Breakfasts play an important role in good health and well-being of an individual. A systematic analysis,[26] which included studies across the world, found an association of breakfast skipping with overweight and obesity; studies included were mostly conducted in developed countries; the present study was conducted in slums setting where food insecurity, poor hygiene, infection, lower socioeconomic status are common and compensating skipped breakfast with energy-dense foods may not be possible for them. This could have been the reason for higher proportion of undernutrition observed among breakfast skippers contrary to studies elsewhere.

We found around 60%–90% of the students had a habit of consuming UPF more than three times in a week; these Ultra Processed Foods are considered as empty calories and more consumption of these foods could pose a danger of acquiring micro-nutrients deficiency and later on risk of developing non communicable diseases. Furthermore, we observed that a very low proportion of students were taking fruits and vegetables as per the recommended amount.[15]

This shows a very serious picture of dietary behavior among adolescents with very less intake of protective food along with high consumption of UPF. A systematic review conducted by Keats et al. in 2018[27] to see the dietary practice of adolescent girls in low- and middle-income countries found 25 published articles showing low recommended intake of fruits and vegetables as high as 97% in Southeast Asian countries.

Furthermore, the Global School-Based Student Health Survey in Africa, Asia, Oceania, and Latin America conducted between 2008 and 2015 found infrequently consumption of fruits and vegetables and frequently consumption of carbonated soft drinks.[28]

The proportion of undernutrition was found more in those who consumed UPF with increased frequency; fast foods are usually associated with increased incidence of overweight and obesity; but the quantity, quality, and type of fast food are very important while searching the cause of under-nutrition in the present setting that is schools in slum setting and that need to be understood.

Personal hygiene plays an important role in nutrition, a widely accepted fact that unhygienic conditions lead to infections that in turn lead to undernutrition and the vicious cycle continues. Studies conducted in Indian setting reported an association between infrequent handwashing with undernutrition similar to the present study.[29],[30]

Adolescent age is the formative years of their life; Dietary habits and personal hygiene practices embraced during adolescents period play a vital role in their future health. Hence, promoting healthy behavior in school setting is an excellent opportunity to incorporate knowledge and skills in students along with health education. The government has taken many initiatives, but there should be health policy at school level with involvement of teachers, parents, and students. There is need to have regulation from administrative side to stop the selling of UPF items in and around school campus. Along with that policy is needed to promote availability of healthy food option at school to prevent malnutrition. It will help in promoting healthy behavior with reduction in undernutrition.

The limitation of the study includes self-reported nature of data collection which might affect the correct frequencies of risk behaviors and generalizability of findings to all students.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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