Effectiveness of nutrition education on adolescent girl Eating habits and food choices Introduction:

Adolescence is a state or process of growing up from puberty to maturity. Adolescent account for 1/5 of the worlds population and in India they account for 22.8 per cent of the total population. Adolescents are tomorrows adult. Adolescent 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 behaviors, thereby preventing or postponing the onset of nutrition related chronic diseases in adulthood. Eating patterns are frequently erratic in adolescents, and this may be a common factor of nutritional risk. Eating disturbances and disorders have become a leading chronic illness among adolescent girls. Number of adolescent in India particularly girls live under suboptimal conditions marked by poor nutritional status and high level of morbidity and mortality. The next generation of our country will be effected if adolescent girls who are would be mothers would have ill health and nutritional status. Keeping in view, the importance of adolescent period in human life and nutritional problems of adolescent girls , the present study has been elucidated to see the impact of nutrition education on nutrient adequacy of adolescent girls.(Tarvinder Jeet Kaur ) Department of Home Science, Kurukshetra University, Kurukshetra) Adolescence is a period of rapid physical growth calling for adequate nutrient intake to meet body growth requirement. It is also a period of emotional and psychological changes during which there is a tendency to reject conventional dietary habits. Adolescent nutritional problem are common throughout the country. They have to encounter a series of serious nutritional challenges not only affecting their growth and development but also their livelihood as adults. Yet adolescents remain a largely neglected and hard to reach population especially girls. Thus it is not surprising that adolescent girl population who are mother to be is if considers as the most important section on which the future of nation depends.(Measham,A.R.,2000 and Rao,S.,1996)

Ad olescence is a critical period of growth and development. As adolescents go through the second growth spurt in this period, it is crucial that they receive the required nutrients. In the South East Asia Region, while a large number of adolescents suffer from chronic under nutrition; those belonging to the affluent segments of society may suffer from obesity. Both conditions however, compromise adolescents general health and performance. Chronic malnutrition, including anemia, aggravates risks during pregnancy, especially amongst adolescents. Regional data shows high prevalence of anemia in adolescent girls (up to 66%) and boys (up to 45%) in some areas. This high rate of anemia not only contributes to increased morbidity and mortality associated with pregnancy and delivery, but also to increased risk of producing low birth weight babies. In this way, poor nutritional status is passed on from generation to generation. Very little attention has been paid to adolescents so far, and adolescent nutrition has received inadequate attention in research as well as in programming for adolescent health. If adolescents are well nourished, they can make optimal use of their skills, energies and talents today, and be responsible parents of healthy babies tomorrow. To accomplish such a task, a special focus for overcoming malnutrition in adolescence is needed, in order to break the intergenerational cycle of malnutrition. (Report of the Regional Meeting Chandigarh, India 17-19 September 2002) Adolescents constitute nearly 22 per cent of the population of India [Registrar General and Census Commissioner, India 2001]. They are a vulnerable group, especially in terms of nutrition and health. Adolescent girls in particular have considerable unmet needs in terms of health, especially reproductive health, and nutrition. This is in large part due to the lack of targeted health services for adolescents, widespread gender discrimination and son-preference that prevail and limit adolescent girls access to health services as well as the practice of early marriage and childbearing that persists and puts adolescent girls and their children at increased risk of adverse outcomes.(Alka Barua,2007) Adolescence is a crucial period in a womans life. Health and nutritional status during this phase is critical for the physical maturity, which in turn influences the health of the offspring. It is seen that the rate of low birth weight, prematurity and neonatal and infant mortality is high among children born to malnourished adolescent girls. Adolescents
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constitute 21.2 per cent of the total population of India, where malnutrition is an important public health problem among children and adolescents. Adequacy of dietary intake in terms of calorie and protein are important in order to improve the chances of child survival and safe motherhood (Sharma A K, Shukla D, Kannan A T. Indian Journal of Community Medicine, Jan- March 2005;) . Adolescence is a crucial phase in the life of woman. At this stage, she stands at the threshold of adulthood. This stage is intermediary between childhood and womanhood and it is the most eventful for mental, emotional and psychological well being. The life-cycle approach for holistic child development remains unaddressed if adolescent girls are excluded from the developmental programmes aimed at human resource development.( GOVERNMENT OF INDIAMINISTRY OF HUMAN RESOURCE DEVELOPMENTDEPARTMENT OF WOMEN AND CHILD DEVELOPMENT Shastri Bhawan, New Delhi 2000) 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 10-19 years account for more than one fifth of the worlds 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
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towards girl babies and adolescent girls, ignorance with regard to nutritional requirement, hygiene and illness are responsible for present nutritional status of adolescent girls.(JYOTI T. SAJJAN AUGUST, 2008) Adolescent constitute over 21.4 % of the population in India. The onset of Adolescent is a major transition in an individual's life and has psychological and emotional implications. In the case of girls, the onset of menstruation further complicates their personal life. The psychosocial and emotional problems are of considerable magnitude and they may exert significant influence on their nutritional status. Unfortunately, assessment of nutritional status of adolescent girls has been the least explored area of research particularly in rural India.(Walawalkar Hospital 2006.) Adolescence is a time when the body prepares itself for the nutritional demands of pregnancy, lactation, and heavy workloads that girls will soon experience. Adolescent girls are, thus, particularly vulnerable to the effects of malnutrition. Underweight adolescent girls may not achieve their potential before their first pregnancy and are likely to give birth to a smaller baby than their counterparts aged more than twenty, due to poorer placental function and competition for nutrients between the growing adolescent and the growing fetus.( K. Prashant and Chandan Shaw1 Department of 1Pediatrics, Kamineni Institute of Medical Sciences) Childhood under nutrition, highly prevalent in South Asia continues to persist throughout adolescence but little attention has been given to under nutrition of adolescents perhaps for the belief that adolescents are a lowrisk group. Stunting in adolescence is 32% in India, 36% in Bangladesh, and 47% in Nepal, and low body mass index (BMI) is 53% in India, 50% in Bangladesh, and 36% in Nepal In Bangladesh, 2527% of adolescent girls are anemic (hemoglobin <12 g/dL)), and 30% in the age-group of 1418 years are iron-deficient (serum transferring saturation [TS] <15%) Half (4754%) of school going children are vitamin A-deficient). The level of zinc deficiency in adolescence is unknown. The average percapita energy intake by rural adolescent girls is 81% of the recommended dietary allowance (RDA) for age Protein, iron, and calcium are important for growth spurt and skeletal development in adolescence. More than 60% of schoolgirls aged 1016 years in Dhaka city consume protein, iron, and calcium less than 75% of the RDA for age The high prevalence of chronic energy and micronutrient deficiencies of today's adolescent girls is directly linked to the quality of the next generation. Without

addressing these deficiencies, the vicious cycle of inter-generational under nutrition, chronic diseases, and poverty perpetuates In developing countries, factors associated with under nutrition of adolescents are: poor household economic condition, periodic foodshortage, child-lab our (marker of household income-poverty), burden of disease, poor knowledge about long-term consequences of under nutrition of adolescents, quantity and quality of food, and access to health and nutrition services In Bangladesh, low family income, education, and periodic food-shortage were associated with inadequate dietary intake which might have led to under nutrition. Previous studies have either ignored the burden of disease or estimated the burden of disease ignoring reproductive morbidity of unmarried adolescent girls The present study estimates the burden of disease, consisting of general and reproductive morbidity and its nutritional consequences, in addition to other factors. Dietary knowledge and access to resources are critical to improve health and nutrition in a sustainable way. Adolescence is the time to learn and adopt healthy habits to avoid many health and nutritional problems later in life Adolescents have more easy access to health and nutrition information through schools, recreational activities, and mass media than they have later in their lives Particularly, health and nutrition knowledge and healthy habits of female adolescents will have critical roles to play in maintaining future family health and nutrition. No study has so far ever assessed dietary knowledge of adolescents, which this study has done for a number of factors. To combat the high prevalence of micronutrient deficiencies, the Government of Bangladesh recommends supplementation of micronutrients The National Nutrition Programme of the Bangladesh Government, through area-based Adolescent Girls Forum, provides health and nutrition education and iron supplements to unmarried adolescent girls The coverage of iron supplement in the programme and non-programme areas and its overall determinants are little known. This study also estimated the coverage for a number of factors to inform nutrition promoters to plan action. Nutrition promoters need information on levels and differentials in under nutrition of adolescents, burden of disease, dietary knowledge, and intake and coverage of iron supplement to meet the needs of those who need them most. The objectives of this study were to provide them with such information that would assist in planning for remedial actions to address health and nutrition needs of adolescent girls in Bangladesh.(Nurul Alam Public Health Sciences Division2010 February)

Malnutrition, defined as ill health caused by deficiencies of calories, protein, vitamins, and minerals interacting with infections and other poor health and social conditions, saps the strength and well-being of millions of women and adolescent girls around the world. [In this brief, the term malnutrition will refer to conditions of nutritional deficiency, including under nutrition and micronutrient deficiencies, though malnutrition actually also relates to problems of nutritional excess.] Although malnutrition's effects on this group have been recognized for decades, there has been little measurable progress in addressing the specific nutritional problems of women and adolescent girls. Ignorance about the symptoms of malnutrition, such as the lethargy and depression caused by iron deficiency, may be dismissed as "normal" or unimportant, further exacerbating the problem.1 Adequate nutrition, a fundamental cornerstone of any individual's health, is especially critical for women because inadequate nutrition wreaks havoc not only on women's own health but also on the health of their children. Children of malnourished women are more likely to face cognitive impairments, short stature, lower resistance to infections, and a higher risk of disease and death throughout their lives (Elizabeth I. Ransom and Leslie K. Elder July 2003)

Figure 1 Poor Nutrition Throughout the Life Cycle

Source: Adapted from the ACC/SCN-appointed Commission on the Nutrition Challenges of the 21st Century Adolescent is defined by WHO as a person between 10-19 years of age. There are about 1.2 billion adolescents worldwide and one in every
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five people in the world is an adolescent. Adolescents constitute 18-25% of the population in member countries of South East Asia Region(1). Adolescence involves: Rapid physical growth and development; Physical, social and psychological maturity, but not all at the same time; Sexual maturity and the start of sexual activity; Trying out experiences for the first time; A frequent lack of knowledge and skills to make healthy choices; Patterns of thinking in which immediate needs tend to have priority over long term implications; The start of behaviors that may become life-time habits that results in diseases many years later. One in every five people in the world is an adolescent, and 85% of them live in developing countries. Nearly two thirds of premature deaths and one third of the total disease burden in adults are associated with conditions or behaviors that began in youth, including tobacco use, a lack of physical activity, unprotected sex or exposure to violence. Promoting healthy practices during adolescence and efforts that better protect this age group from risks will ensure longer, more productive lives for many1. Total adolescent population of India is 209 148 (21% of the total population) adolescent health issues can be further complicated by factors associated with rapid social and economic development, increased urbanization, the widening gap between rich and poor, youth unemployment and rural poverty put adolescents at greater risk for sexually transmitted infections, pregnancy, under nutrition and over nutrition, and substance abuse. Adolescents should receive explicit attention with services that are sensitive to their increased vulnerabilities and designed to meet their needs. The present study was carried out to determine the nutritional status and high risk behavior of the adolescents. (Mital Prajapati1, Regional child Survival Officer) Poor nutritional status during adolescence is an important determinant of health outcomes. Short stature in adolescents resulting from chronic under nutrition is associated with reduced lean body mass and deficiencies in muscular strength and working capacity. In adolescent girls, short stature that persists into adulthood is associated with increased risk of adverse reproductive outcomes. As health systems have accepted life-cycle approach, the health issues of adolescents, like sexually transmitted diseases and reproductive health have been given due importance, but not on their nutritional status.(Deshmukh P R, Gupta S S,
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Bharambe M S, Dongre A R, Maliye C, Kaur S, Garg B S. Indian Journal of Pediatrics, February 2006;) Pubertal spurt leads to greater nutritional requirements among adolescent girls, but psychosocial and emotional problems too, may exert significant influence on their nutritional status. Unfortunately assessment of nutritional status of adolescent girls has been the least explored area of research, particularly in rural India. The findings of studies on school children/girls cannot be extrapolated to rural adolescent girls, as their school enrollment, as well as the sustenance levels are less than their urban counterparts. Girls not attending schools belonged to disadvantaged section of the society and contributed significantly to domestic and economic activities, which at times jeopardize their health.(Choudhary S, Mishra C P, Shukla K P. Indian Journal of Preventive and Social Medicine, 2003;) India is the second most populous country in the world with total population of over 1081 million. Adolescents form a large section of population, about 22.5 percent, that is, about 225 million. Adolescent has been defined by World Health Organization as the period of life spanning between 10-19 years. They are no longer children, but not yet adults. Adolescents have got disadvantages. They are developing rapidly and having an extreme degree of pressure from peers, from parents, from society, and self. They lack knowledge and skill to cope up with pressure. Adolescents are full of energy, have significant drive and new ideas. They are a positive force for a Nation and are responsible for its future productivity provided they develop in a healthy manner. Since death rate in this age group is relatively low the adolescents are considered to be healthy, however it is a misleading measure of adolescent health. In spite of definite health problems they may have, it is a common observation that adolescents do not access the existing services, especially adolescent girls. In India there are only few designated services (which are really making an impact) for adolescent girls so far, leading to substantial unmet service needs. Absence of friendly staff, lack of family concern regarding their health, working hours that are inconvenient to adolescents and lack of privacy and confidentiality have been identified as important barriers in accessing health services by adolescents girls The health sector needs to respond by offering services to adolescents girls in a more friendly manner and in a non-threatening environment. (Dr Arvind Dubey 2003)
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Nutrition during Adolescence Adolescence is a particularly unique period in life because it is a time of intense physical, psychosocial, and cognitive development. Growth is faster than at any other time in the individuals life except in the first year. Increased nutritional needs at this juncture relate to the fact that adolescents gain up to 50% of their adult weight, more than 20% of their adult height, and 50% of their adult skeletal mass during this period. Caloric and protein requirements are maximal. Requirement of other nutrients e.g., iron, calcium and vitamins also increase. In summary, the main nutrition problems affecting adolescents include: under nutrition in terms of stunting, thinness, catch-up growth, and intrauterine growth retardation in pregnant adolescent girls; iron deficiency and anemia; iodine, vitamin A and calcium deficiencies; other specific nutrient deficiencies, e.g. zinc, folate, and obesity. Under nutrition reduces work capacity, endurance and ability to concentrate, and over nutrition predisposes to chronic diseases, e.g.: diabetes, cardiovascular disease. (Dr. Rukhsana Haiders Report of the Regional Meeting Chandigarh, India 17-19 September 2002) Many scientific studies have documented the important role that nutrition plays in the promotion and maintenance of health, and in the prevention of disease. 8 of the 10 leading causes of death and disease in the United States in 1987 were directly linked to what we eat and drink. These 10 leading causes of death account for an estimated 2.125 million deaths (in the U.S.) in 1987, and the situation has changed little since then. Five of the 10 are directly related to the food we eat, and are caused by dietary imbalances and excesses. The Surgeon Generals Report on Nutrition and Health (U.S. Department of Health and Human Services, 1988) These 5 (heart disease, cancer, stroke, atherosclerosis, and diabetes) account for 68%, or 1.45 million of the 2.125 million annual deaths. Diet was also identified as a contributing factor to the development of other conditions, such as hypertension, osteoporosis, obesity, dental caries, and gastrointestinal diseases. As a result of this report, the U.S. dietary guidelines were redesigned in 1995 to urge consumers to change and improve their eating patterns. (Nutrition and Your Health: Dietary Guidelines for Americans, 4th ed., U.S. Department of Health and Human Services, 1995) Nutrition 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. the most single aim of nutrition education is to persuade mothers in the tropics to make the best use of foods locally available for
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feeding children in the early years of life. (Jelliffe (1966) Nutrition education is the foundation for any programme intended for nutritional improvements (Devdas et al., 1970). Nutrition education as a means of translating nutritional requirements into food and adjusting the food choices to satisfy nutritional, cultural, psychological and economic needs. Albanese (1971) Nutrition education has been defined as educational measure for inducing desirable behavioral 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 behaviors which promote health of an individual. Nutrition education in schools can help to alleviate and even prevent the incidence of nutritional deficiencies among vulnerable children. (UNESCO (1983) School-based nutrition education for children and adolescents is a very important issue today, as child growth, brain development, academic potential, and current and future health status all depend largely on the quality and quantity of food consumed. Adolescence is a particularly important time of rapid physical growth and development, and the enormous pubertal increases in height, weight, lean muscle mass, fat, organ size and bone density laid down in the teenage years require large nutritional intakes. In addition to the challenge of educating the population about optimum food and nutrient intakes in childhood and adolescence, another important issue in current nutrition education research and practice is childhood obesity prevention. (Jennifer A ODea Associate Professor in Health Education December 2010,) One of the keys to effective nutrition education and counseling of teenagers is a good understanding of normal adolescent psychosocial development. Adolescents are striving to achieve independence yet they are highly influenced by the beliefs and behaviors of peers. They are developing abstract reasoning skills, however they may revert to more concrete cognitive skills when faced with new challenges or perceived stressful situations. These aspects of adolescent development need to be integrated into all nutrition education and counseling efforts, whether
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they occur as classroom nutrition education presentations or individual counseling sessions. The capacity for more abstract thinking coupled with the changing psychosocial milieu of adolescence provides both challenges and opportunities for health professionals when providing nutrition education. Adolescence is an opportune time to train students to assess their own eating behaviors and set goals for dietary change. Nutrition education has generally not taken advantage of the social and cognitive shifts of adolescence that could be built upon to promote the adoption of More healthful behaviors.( Stang J, Story M (eds) Guidelines for Adolescent Nutrition Services (2005) GENERAL CONSIDERATIONS FOR NUTRITION EDUCATION Nutrition education involves teaching the client about the importance of nutrition, providing educational materials that reinforce messages about healthy eating, teaching adolescents skills essential for making dietary change, and providing information on how to sustain behavior change. Information gathered during nutrition screening or assessment will provide the necessary information on which nutrition issues need to be addressed during nutrition education and counseling sessions. Prior to beginning the education process, it is helpful to assess what the adolescent already knows about nutrition, how ready they are to adopt new eating behaviors, and if there are any language or learning barriers that may need to be addressed in order to facilitate the nutrition education process. Adolescents often enter nutrition education and counseling at the precontemplation stage. They are often not aware of the potential health risks associated with poor eating habits and have not thought about making dietary changes. The initial goal of nutrition education and counseling therefore, will be to increase the clients awareness of risks associated with current eating habits. In situations such as the diagnosis of diabetes mellitus, adolescents may be aware of the need to change dietary habits but may show resistance toward change. Identifying potential barriers to change and providing small, achievable goals along with concrete strategies to facilitate necessary dietary modifications are often the initial stages of nutrition education.( Stang J, Story M (eds) Guidelines for Adolescent Nutrition Services (2005)) Review of literature:

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Jennifer A ODea Associate Professor in Health Education and Nutrition Education Faculty of Education and Social Work University of Sydney Australia recent studies of body weight, obesity, body image and related health issues among Australian adolescents and the ways in which subsequent nutrition and physical activity programs in schools can interact with and complement each other, rather than contradicting or competing with each other. I briefly identify and discuss the commonalities between health promotion, obesity prevention, body image improvement, eating disorder prevention and promotion of physical activity. In this article I present for the first time the findings of a 2009 research study examining the recent barriers to participation in sport, physical education and physical activity from a study of 1000 Australian children and adolescents. These findings illustrate the complex interrelationships between various adolescent health issues and their prevention. Finally, I believe that preventing the co-existing problems of obesity, low physical activity, disordered eating and body image concerns among adolescents is very challenging and requires a thoughtful, careful community involvement strategy. I suggest that it would be a mistake to target any sort of weight loss or weight control message towards adolescent girls, many of whom clearly already have a fear of fatness, an apparent body image problem and low self-esteem. Similarly, I recommend that it would be culturally inappropriate to approach obesity prevention among ethnic groups of overweight or obese adolescents and their families without serious consideration of the potentially harmful, undesirable or culturally Inappropriate outcomes. Several facets of prevention need attention when focusing on school-based health promotion, nutrition education and body image improvement using a whole-school approach, including school curricula, school ethos, school policies and schoolcommunity links. School-based nutrition education for children and adolescents is a very important issue today, as child growth, brain development, academic potential, and current and future health status all depend largely on the quality and quantity of food consumed. Adolescence is a particularly important time of rapid physical growth and development, and the enormous pubertal increases in height, weight, lean muscle mass, fat, organ size and bone density laid down in the teenage years require large nutritional intakes.
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In addition to the challenge of educating the population about optimum food and nutrient intakes in childhood and adolescence, another important issue in current nutrition education research and practice is childhood obesity prevention. The importance of identifying cultural and ethnic issues in the management and prevention of weight-related disease has recently been recognized by Lawton and her colleagues (2006) who studied the cultural beliefs and attitudes of people with type 2 diabetes from ethnic minorities living in the United Kingdom. It is important to note that, whilst the imminent risk of any illness in obese children or teenagers is not considered high (Flegal, Tabak and Ogden 2006), the risk of developing insulin resistance and type 2 diabetes is considered more likely and Serious and some obese adolescents have already been diagnosed with these conditions (Fagot-Campagna et al. 2000). The vast majority of such cases, whilst small in actual number, have been diagnosed among adolescents who are both obese and sedentary (Drake et al. 2002), who have a strong family history of type 2 diabetes and who often come from Indian, Pakistani (Ehtisham, Barrett and Shaw 2000) or African-American or Native-American backgrounds. Similarly, about half of the 43 cases of type 2 diabetes and related conditions identified over the 12 years from 1990 to 2002 in children and adolescents in Western Australia were found among Aboriginal children (McMahon et al. 2004) A recent study of all medical register data on type 2 diabetes in children and adolescents aged 718 years in the state of New South Wales found 128 cases over the six years from 2001 to 2006. The authors reported that 90 per cent of cases were overweight or obese. (Craig et al. 2001) Aboriginal children were six times more likely to have type 2 diabetes than their non-Indigenous peers and 75 per cent of those with type 2 diabetes had a family history of the disease. Whilst ethnic and familial effects on type 2 diabetes risk are not always apparent they remain important risk factors (Wiegand et al. 2004),

K. Prashant and Chandan Shaw1 Department of 1Pediatrics, Kamineni Institute of Medical Sciences, Narketpally, Andhra Pradesh, India

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Adolescence is a time when the body prepares itself for the nutritional demands of pregnancy, lactation, and heavy workloads that girls will soon experience. Adolescent girls are, thus, particularly vulnerable to the effects of malnutrition. Underweight adolescent girls may not achieve their potential before their first pregnancy and are likely to give birth to a smaller baby than their counterparts aged more than twenty, due to poorer placental function and competition for nutrients between the growing adolescent and the growing fetus. The urban slum adolescent girl is subjected to more physical and mental challenges on a day-to-day basis due to ever increasing pressure of modernization as compared to the rural set up. They need to earn to cope with the future demands of life. Hence they have to work hard physically as well as mentally as compared to the rural adolescent girls. Thus we found it imperative to study the nutritional status of adolescent girls in an urban slum community. In the present study it was observed that prevalence of stunting as per NCHS and Indian standards was 47% and 28.3% respectively. This reflects the fact that average Indian build is probably poorer than that considered in the NCHS population. Nevertheless, the high prevalence of stunting is an indicator of chronic energy deficiency (CED). A recent study of adolescent worker in tea gardens of Assam revealed that prevalence of stunting was 47.4% and 51.9% among boys and girls respectively in relative to NCHS reference, which reduced to almost 30% while Indian reference data was used.3 In a study conducted in urban slum of Dhaka, 65% of the girls were short (<3rd percentile of NCHS reference values). Though the prevalence of short stature was higher when compared to the present study, a similar finding noted in both the studies was the prevalence of short stature was higher in the older girls. This may indicate that the same factors exist in both the populations but to different degrees as the racial and dietary confounders are similar in both populations. Other studies based on rural population of adolescent subjects reveal lesser proportions of CEDstudy by National Nutrition Monitoring Bureau from rural areas of nine Indian states in the south showed that 39% of the adolescents were stunted irrespective of sex,4 while another study in rural north India among school children recorded a prevalence of stunting as 41% and 19.9% as per NCHS and Indian standards respectively.5 Another study on adolescent nutrition in a rural community of Bangladesh, reported a prevalence of stunting of 48% according to NCHS standard6 which is comparable to the present study whereas Das DK et al7 reported a low prevalence of 37.8% when they carried out a study on nutritional status of adolescent girls in a rural area
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of West Bengal which happens to be a neighboring state of Bangladesh in India. The better socioeconomic conditions in West Bengal namely literacy, per capita income, and political stability may be responsible for the above observation. A case study from Congo also concluded that there is a parallel evolution during the period of economic adjustment between the increase of wasting of infants and the increase of CED among the mothers.8 Body Mass Index is an age independent anthropometric criteria. It is an indicator of acute under nutrition, the result of more recent food deprivation and/or illness.9 Prevalence of thinness in the index study was found to be 20.6%. The study of urban slum girls in Dhaka reported a similar prevalence of 17%.10 various authors have reported the prevalence of thinness among adolescent girls to be 14.7%, 10 30.1%, 8 41.3%, 5 and 59%.9 the heterogeneous population studied by the individual authors from different ethnic and geographical backgrounds may explain the variations in the result. A similar study conducted in an urban slum of Varanasi depicted 70.0% adolescent girls had BMI < 20%; 51.43% study subjects were suffering from CED while stunting (height for age < 90%) was present in 10% of adolescent girls.11 The differences observed may be attributable to the small sample size of 70 adolescent girls.12 In the present study prevalence of underweight was found to be 42.6% and 22.9% as per NCHS and Indian standards respectively. Underweight is used as a composite measure to reflect both acute and chronic under nutrition, although it cannot distinguish between them.4 In their diet and nutritional survey of rural adolescents in India Venkaiah K et al reported that the prevalence of underweight is higher (53.1%) in boys than in girls (39.5%).12 Also noteworthy is a review of literature by Srihari G et al13 on the health status of school children of affluent Indian class revealed that overweight and obesity were prevalent among 8.5 29.0%, 1.5 7.4% respectively among school children, as indicated by 11 studies which is in stark contrast to the observation by Medhi GK et al (2007)3 who found only 0.5% of their adolescent tea garden workers to be overweight.. A recent project by National Institute of Nutrition in India14 concluded that the prevalence of multiple subclinical micronutrient deficiencies is high in middle income Indian school children and that daily consumption of micronutrient enriched beverage had positive effects that were confined to those nutrients that were inadequate at baseline. Other authors have also reiterated the prevalence of micronutrient deficiencies in the adolescent girls both in India and other developing nations.11, 13, 15, 16 However; we noted a downward trend in all the anthropometric criteria with the advancing age of adolescence
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or age for that matter. All three criteria discussed in the study show an increase in the prevalence of stunting, thinness, and under nutrition by the age of 16 17 years. This probably puts the community at a greater risk as these adolescent girls were approaching the marriageable age and would be expected to bear children within a year or two. The poor nutritional status of the then mothers would definitely reflect on the health of their children

Deshmukh P R, Gupta S S, Bharambe M S, Dongre A R, Maliye C, Kaur S, Garg B S. Indian Journal of Pediatrics, February 2006; Poor nutritional status during adolescence is an important determinant of health outcomes. Short stature in adolescents resulting from chronic under nutrition is associated with reduced lean body mass and deficiencies in muscular strength and working capacity. In adolescent girls, short stature that persists into adulthood is associated with increased risk of adverse reproductive outcomes. As health systems have accepted life-cycle approach, the health issues of adolescents, like sexually transmitted diseases and reproductive health have been given due importance, but not on their nutritional status. The three different terminologies (thinness, chronic energy deficiency and wasting) and definitions/classifications used for assessing under nutrition provided three different proportions in the same population. This may at times be a bit confusing to health managers and planners, who are not always the subject matter specialists. Otherwise also, it is always better to follow one single criteria of assessment for comparison of priority areas in developmental planning and intervention. Hence, it is recommended that WHO criteria and terminology should be used to assess the nutritional status of adolescents to avoid the unnecessary confusion.

Choudhary S, Mishra C P, Shukla K P. Indian Journal of Preventive and Social Medicine, 2003 Pubertal spurt leads to greater nutritional requirements among adolescent
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girls, but psychosocial and emotional problems too, may exert significant influence on their nutritional status. Unfortunately assessment of nutritional status of adolescent girls has been the least explored area of research, particularly in rural India. The findings of studies on school children/girls cannot be extrapolated to rural adolescent girls, as their school enrollment, as well as the sustenance levels are less than their urban counterparts. Girls not attending schools belonged to disadvantaged section of the society and contributed significantly to domestic and economic activities, which attimes jeopardize their health. A considerable proportion of adolescent girls had clinical nutritional deficiency diseases. Two-third of study subjects were undernourished (BMI < 18.5 kg/m2), nearly one-third experiencing CED grade-III (BMI < 16 kg/m2). However, with varying parameters, the extent of under nutrition in adolescent girls also varied. Nearly one-third girls were anemic (Hb < 12 g/dl); anemia was significantly more in non menstruating girls and subjects not using footwear during defecation. Thus, there is a need to promote sound eating and personal hygienerelated habits in rural adolescent girls, besides improving intra-family food distribution and economic empowerment of rural households.

Pande Rohini, Kuz Kathleen, As many as 60-70 per cent of adolescent girls are anemic, and at risk of adverse pregnancy outcomes, including maternal deaths, reduced work productivity and impaired physical capabilities. Adolescence, as a period of growth and development, is considered the best time to intervene, to assist in physical and mental development, and to prevent maternal anemia. The Institute of Health Management- Pachod (IHMP), in collaboration with ICRW, had conducted an intervention study in Maharashtra to improve dietary behavior and reduce iron deficiency anemia among unmarried adolescent girls. Participatory nutrition education can influence adolescent girls anemia and dietary behavior. Key dietary behavior messages for girls include: eating more than 3 meals a day, eating with family so as to eat enough, Eating green vegetables daily and eating lemon or amla with meals. Iron supplementation programmes need to include nutrition education programmes to be effective. More effective methods need to be devised
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for community based hemoglobin testing. The governments anemia prevention and control programme should focus on adolescents.

Tarvinder Jeet Kaur Department of Home Science, Kurukshetra University, Adolescence is a state or process of growing from puberty to maturity. Adolescent account for 1/5 of the worlds population and in India they account for 22.8 per cent of the total population. Adolescents are tomorrows adult. Adolescent 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 behaviors, thereby 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. Eating disturbances and disorders have become a leading chronic illness among adolescent girls. Number of adolescent in India particularly girls live under suboptimal conditions marked by poor nutritional status and high level of morbidity and mortality. The next generation of our country will be effected if adolescent girls who are would be mothers would have ill health and nutritional status. Keeping in view, the importance of adolescent period inhuman life and nutritional problems of adolescent girls, the present study has been elucidated to see the impact of nutrition education on nutrient adequacy of adolescent girls. The results of the present investigation revealed that nutrition education was effective in increasing the level of nutrition knowledge as wellas nutrient intake. The diets consumed by the adolescent girls before as well as after imparting nutrition education were however, inadequate inmost of the nutrients when compared to ICMRrecommendations. Moreover, nutrient intake in terms of energy, protein, carbohydrate as well as all the vitamins except vitamin B12 and minerals increased significantly (P< 0.01).

Nurul Alam, 1 Swapan Kumar Roy,2 Tahmeed Ahmed,3 and A.M. Shamsir Ahmed3
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Public Health Sciences Division

nutritional status and dietary intake and relevant knowledge of adolescent girls in rural Bangladesh using data from the Baseline Survey 2004 of the National Nutrition Programme. A stratified two-stage random cluster-sampling was used for selecting 4,993 unmarried adolescent girls aged 1318 years in 708 rural clusters. Female interviewers visited girls at home to record their education, occupation, dietary knowledge, sevenday food-frequency, intake of iron and folic acid, morbidity, weight, and height. They inquired mothers about age of their daughters and possessions of durable assets to divide households into asset quintiles. Results revealed that 26% of the girls were thin, with body mass index (BMI)-for-age <15th percentile), 0.3% obese (BMI-for-age >95th percentile), and 32% stunted (height-for-age 2SD). Risks of being thin and stunted were higher if girls had general morbidity in the last fortnight and foul-smelling vaginal discharge than their peers. Consumptions of non-staple good-quality food items in the last week were less frequent and correlated well positively with the household asset quintile. Girls of the highest asset quintile ate fish/meat 2.1 (55%) days more and egg/milk two (91%) days more than the girls in the lowest asset quintile. The overall dietary knowledge was low. More than half could not name the main food sources of energy and protein, and 36% were not aware of the importance of taking extra nutrients during adolescence for growth spurt. The use of iron supplement was 21% in nutritionintervention areas compared to 8% in non-intervention areas. Factors associated with the increased use of iron supplements were related to awareness of the girls about extra nutrients and their access to mass

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media and education. Community-based adolescent-friendly health and nutrition education and services and economic development may improve the overall health and nutritional knowledge and status of Childhood under nutrition, highly prevalent in South Asia, continues to persist throughout adolescence but little attention has been given to under nutrition of adolescents perhaps for the belief that adolescents are a lowrisk group. Stunting in adolescence is 32% in India, 36% in Bangladesh, and 47% in Nepal, and low body mass index (BMI) is 53% in India, 50% in Bangladesh, and 36% in Nepal. In Bangladesh, 2527% of adolescent girls are anemic (hemoglobin <12 g/dL) and 30% in the age-group of 14 18 years are iron-deficient (serum transferring saturation [TS] <15%) Half (4754%) of school going children are vitamin A-deficient The level of zinc deficiency in adolescence is unknown. The average per-capita energy intake by rural adolescent girls is 81% of the recommended dietary allowance (RDA) for age). Protein, iron, and calcium are important for growth spurt and skeletal development in adolescence. More than 60% of schoolgirls aged 1016 years in Dhaka city consume protein, iron, and calcium less than 75% of the RDA for age The high prevalence of chronic energy and micronutrient deficiencies of today's adolescent girls is directly linked to the quality of the next generation. Without addressing these deficiencies, the vicious cycle of inter-generational under nutrition, chronic diseases, and poverty perpetuates Adolescence is a unique intervention point in the life-cycle for a number of reasons. Early adolescence after the first year of life is the second critical period of rapid physical growth and changes in body composition, physiology, and endocrine. Rapid growth and changes
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heighten their nutritional requirements and risks of under nutrition. Parents simply need to provide more nutrients and emotional support. Adolescence offers the last opportunity to intervene and recover growth faltered in childhood and also support growth spurt and skeletal development to break the vicious cycle of inter-generational under nutrition. In developing countries, factors associated with under nutrition of adolescents are: poor household economic condition, periodic foodshortage, child-labor (marker of household income-poverty), burden of disease, poor knowledge about long-term consequences of under nutrition of adolescents, quantity and quality of food, and access to health and nutrition services In Bangladesh, low family income, education, and periodic food-shortage were associated with inadequate dietary intake which might have led to under nutrition. Previous studies have either ignored the burden of disease or estimated the burden of disease ignoring reproductive morbidity of unmarried adolescent girls .The present study estimates the burden of disease, consisting of general and reproductive morbidity and its nutritional consequences, in addition to other factors. Dietary knowledge and access to resources are critical to improve health and nutrition in a sustainable way. Adolescence is the time to learn and adopt healthy habits to avoid many health and nutritional problems later in life Adolescents have more easy access to health and nutrition information through schools, recreational activities, and mass media than they have later in their lives Particularly, health and nutrition knowledge and healthy habits of female adolescents will have critical roles to play in maintaining future family health and nutrition. No study has so far ever assessed dietary knowledge of adolescents, which this study has done for a number of factors.
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To combat the high prevalence of micronutrient deficiencies, the Government of Bangladesh recommends supplementation of micronutrients). The National Nutrition Programme of the Bangladesh Government, through area-based Adolescent Girls Forum, provides health and nutrition education and iron supplements to unmarried adolescent girls the coverage of iron supplement in the programme and non-programme areas and its overall determinants are little known. This study also estimated the coverage for a number of factors to inform nutrition promoters to plan action. Nutrition promoters need information on levels and differentials in under nutrition of adolescents, burden of disease, dietary knowledge, and intake and coverage of iron supplement to meet the needs of those who need them most. The objectives of this study were to provide them with such information that would assist in planning for remedial actions to address health and nutrition needs of adolescent girls in Bangladesh. Hilary M. Creed-Kanashiro*,4, Rosario M. Bartolini*, Mary N. Fukumoto*, Tula G. Uribe*, Rebecca C. Robert and Margaret E. Bentley**Instituto de Investigacin Nutricional, Lima, Peru, Center for Human Nutrition, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Formative research was conducted with 26 women and 16 adolescent girls to develop an education intervention through community kitchens (CK) in Lima, to increase their dietary iron intake and improve their iron status. A combination of qualitative research methods was used to explore perceptions about foods, nutrition, health, anemia and body image. The women recognized that there was a close association among eating well, "alimentarse bien", their health and prevention and treatment of anemia. They perceived that the nutritive value of a meal is determined primarily by its content of "nutritious" foods and by its being "balanced".
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Using this information the conceptual model of the education intervention was developed. The vulnerability of women to anemia was presented with the relationship between anemia and diet as the central focus. Feasible ways of achieving a nutritious diet were introduced to the community kitchens through promoting local heme iron sources and the consumption of beans with a vitamin C source. Animal source foods were amongst those considered to be nutritious and were "best buys" for iron content. CK searched for ways of assuring accessibility to these foods. The use of animal source foods in the community kitchen menus increased during the intervention Iron deficiency anemia is the most prevalent nutritional problem worldwide, particularly affecting reproductive-aged women and children of developing countries. Numerous and severe consequences may result from iron deficiency including negative effects on health, fetal and child development, activity and well-being. In Peru, the prevalence of iron deficiency anemia in no pregnant women of fertile age is 35% at the national level and 70% in children aged 6 mo2 y In periurban populations of Lima, similar levels have been found (In addition, recent studies on adolescent girls in Lima have shown a prevalence ranging from 1014% Zinc deficiency has been reported both in pregnant women in Lima and in young children (. Increasing animal source food (ASF) intake has the potential to benefit the nutritional status of many vulnerable populations in developing countries, due primarily to the higher content and bioavailability of specific nutrients. Flesh foods are especially good sources of iron and zinc. Amongst the strategies for reducing iron deficiency anemia at the population level (supplementation, fortification of foods and dietary improvement), dietary modification, and specifically increasing animal source foods, will lead to improvement in the overall quality of the diet. Specific strategies to improve iron intake include increasing their consumption of the following: 1) total dietary iron; 2) low cost, high bioavailability heme iron (e.g., chicken offal, blood, fish); and 3) nonheme iron absorption enhancers (e.g., consuming a vitamin C food source with meals). In periurban Peru, community kitchens (CK) came into existence to provide a main meal at low cost to impoverished families. As reflected in the meals prepared in the CK and in the homes, typical Peruvian diets are low in bioavailability iron; yet in periurban populations, ASF are available throughout the year, providing a potential for dietary modifications to improve iron intake using locally available foods

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The presence and popular use of the community kitchens provided a unique opportunity to develop a nutrition education intervention designed to improve the iron content of the meals prepared. At the same time, the development of key nutrition communications targeted at women and adolescent girls, to improve awareness and knowledge about anemia and its prevention, was seen as central to improving dietary intake. Fundamental to designing the dietary modification education intervention is the need to understand the target population's perceptions and knowledge about diet, nutrition and health, as well as more specific aspects related to anemia and iron-rich foods. These concepts, and how they interrelate, provided insights into potential for change. Understanding the potential costs and benefits of dietary modification, and the expectations and aspirations of the women, provided motivational elements for the behavior change this article reports on the formative research conducted to understand perceptions of the women and adolescent girls participating in the CK, focusing specifically on the ability to increase iron-rich food intake, particularly animal food sources. The intervention was implemented based on the results of the formative research and its impact evaluated through a comparison between intervention and control CK. Neetu Gupta Doctoral Candidate Department of Home Science Kurukshetra University G.K. Kochar Professor, Foods and Nutrition cum Chairperson Department Of Home Science Kurukshetra University

Adolescent nutritional problem are common throughout the country. Some people lack adequate food while some people though have adequate amount of food yet make its poor choices. Because of these reasons, nutritional problems not only affect their growth and development but also in future would adversely affect their livelihood as adults. Occurrence of series of nutritional problems like underutrition, anemia, vitamin A deficiency, iodine deficiency and overweight or obesity may develop too in them. For prevention of these problems, WHO has emphasized that the mass information and awareness programmes should be organized to alert government and communities about the importance of health and nutrition. In view to this recommendation, a study was carried out to assess the nutritional awareness of 50 school going adolescent girls of 13-16 years age in rural area of district Kurukshetra before and after imparting nutrition education regarding healthy nutrition and dietary habits. To them, the nutrition

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education was imparted through lectures, audiovisual aids and demonstrations for three months. Before and after imparting nutrition education, the level of knowledge, attitude, beliefs and practices regarding good nutrition was adjudged by questionnaire cum interview method. To see the awareness level, scoring system consisting of scores between 1 to +1 depending on each question was developed. After providing nutrition education, a significant improvement in their nutritional knowledge was viewed and quantum of improvement was 1.67 times. The analysis of data also inferred that the students scoring more marks in science subject were found more attentive during the counseling sessions and had showed a rapid improvement in their score. The study was successful in identifying certain gaps in their knowledge, attitude and practices before imparting nutrition education and concluded that such awareness programmes should be organized. Adolescence is a period of rapid physical growth calling for adequate nutrient intake to meet body growth requirement. It is also a period of emotional and psychological changes during which there is a tendency to reject conventional dietary habits. Adolescent nutritional problem are common throughout the country. They have to encounter a series of serious nutritional challenges not only affecting their growth and development but also their livelihood as adults. Yet adolescents remain a largely neglected and hard to reach population especially girls. Thus it is not surprising that adolescent girl population who are mother to be is if considers as the most important section on which the future of nation depends.(Measham,A.R.,2000 and Rao,S.,1996) The poor nutritional status of girls has important implication in terms of physical work capacity and adverse reproductive outcome.(WHO 1998) Realizing the adversity of the problem several recommendations were made by WHO in order to bring down the nutrition related problems of adolescent population and one of these emphasizes, Mass information and awareness programmes are needed to alert government and communities about the importance of health and nutrition.

Importance of study: Nutrition education, as educational measure for inducing desirable behavioral changes for the ultimate improvement in the nutritional status of adolescent girl . Adequate nutrition, a fundamental cornerstone of any individual's health, is especially critical

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for adolescent girl because inadequate nutrition wreaks havoc not only on women's own health but also on the health of their children. The study provides an opportunity to assess the role of nutrition education among adolescent girl in rural area. Inadequate nutrition, poor dietary habits and lack of knowledge affect the future of adolescent girl. Nutrition educations play a critical role in maintaining future family health and nutrition of adolescent girl. The present study attempts to investigate this hypothesis ,for promoting good nutrition and healthy life for adolescent girl in rural area ,there appears to be a need for relevant attitude surrounding adolescent girl behavior need to be identified and addressed .The study is designated to meet this objective. Research objectives: To assess the nutritional status of adolescent girl. To assess the nutritional awareness of adolescent girl. To educate the adolescent girls about the benefits of balance diet, To assess the impact of nutrition education on selected group.

Method: Setting: The study will be conducted in a rural area of district Prathmik vidyalaya oyaa, vikas chetra amava, Raibareily. Area of study: Raibareily. Subject: School going adolescent girls, 13-16 age groups.

Sampling: This study will conducted on a representative group of 51 adolescent girls of age 13-16 years .The Samplings were selected by random sampling technique. from government school of district Prathmik vidyalaya

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oyaa, vikas chetra amava, Raibareily. Tools and technique: A KAPs questionnaire, nutritional assessment by anthropometric measurement , personel profile , socio-economic status, general hygiene body structure, nutritional intake Design: Intervention study design will be used for completion of study. In this intervention study, used Behaviorist approach theory. Firstly collect the information about age, qualification, caste and family pattern were collected through interview method. Nutrition Knowledge: For adjudging existing level of nutrition knowledge, a questionnaire containing list of questions pertaining to food beliefs, fads and fallacies; as well as constituents of balanced diet; functions and requirement of food, nutrients along with cooking practices to improve nutritive value of food through germination and fermentation; food hygiene and sanitation was supplied to each subjects for filling before imparting nutrition education.. Nutrition Education: After adjudging the level of nutrition knowledge of the subjects, nutrition education was imparted to all of the subjects in school classrooms once a week, for the period of three months through group contacts and lecture cum discussion method using charts, leaflets, posters and demonstrations. The topics covered for imparting nutrition education were functions of food; balanced diet; nutrient - their functions and requirements. In addition, cooking practices to improve nutritive value of food through germination and fermentation, food hygiene and sanitation etc were also covered. Data analysis: The nutritional status and impact of nutrition education will be assessed. Pearson correlation coefficient will be used to investigate the degree of association between variables .The data on food and nutrient intake will be analyzed statistically. Mean and standard error Of mean were calculated for each studied variable. Comparison of the nutrient intake before and after imparting nutrition education .
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References: Cinelli, RL and ODea, JA 2009, Body image and obesity among Australian adolescents from Indigenous and Anglo/European backgrounds: implications for health promotion and obesity prevention among Aboriginal youth, Health Education Research, vol. 24, no. 6, pp. 10591068. Egan, N, C. "Improving Teen-agers Health," Bulletin of Children's Bureau, October, 1960, Croll J, Neumark-Sztainer D, Story M. Healthy eating: what does it mean to adolescents? J Nutr Educ 2001;33:193-198. World Health Organization Regional Office for South-East Asia New Delhi December 2002 Chawla, S. 1992. Effect of Nutritional Status on Physical Work Capacity of School Going Girls. M. Sc. Thesis (unpublished) Ludhiana, PAU. Tarvinder Jeet Kaur, G.K.Kochar and Taru Agarwal Department of Home Science, Kurukshetra University, Kurukshetra 136 119, Haryana, India 2003

Ahmed T, Roy SK, Alam N, Ahmed AMS, Ara G, Bhuiya AU, et al. In: Baseline survey 2004 of the National Nutritional Programme: report. Shamsul Islam Khan M., Ahmed Tahmeed, Roy Dhaka S.K., editors. Bangladesh: International Centre for Diarrhoeal Disease Research; 2005. p. 319. (ICDDR,B special publication no. 124).

Elizabeth I. Ransom and Leslie K. Elder director of Food and Nutrition Technical Assistance at the Academy for Educational Development. SOHINI BANERJEE, AMIT DIAS, VIKRAM PATEL Goa Medical College, Goa AMIT DIAS Department of Preventive and

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Social Medicine Goa College of Home Science Sangath, 841/1 Alto Porvorim, Bardez, Goa 403521, Goa, India Mital Prajapati1, D.V.Bala2, Hemant Tiwari 31Regional child Survival Officer, Bhavnagar Region 2Professor and Head, 3 Assistant Professor in Bio-statistics, department of Community Medicine, NHL Municipal medical college, Ahmedabad N. Gupta & G. K. Kochar : Role Of Nutrition Education In Improving The Nutritional Awareness Among Adolescent Girls . The Internet Journal of Nutrition and Wellness. 2009 Volume 7 Number

Hilary M. Creed-Kanashiro*,4, Rosario M. Bartolini*, Mary N. Fukumoto*, Tula G. Uribe*, Rebecca C. Robert and Margaret E. Bentley** Instituto de Investigacin Nutricional, Lima, Peru, Center for Human Nutrition, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21205 and ** University of North Carolina Population Center, University of North Carolina, Chapel Hill, NC 27516

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