The adolescent period, defined as the second decade of life (10–19 years), is characterized by the last major phase of human growth and development, including the pubertal growth spurt and significant changes in body composition [1, 2]. Nutritional status during this window critically influences adult health outcomes, chronic disease risk, and reproductive capacity, particularly in girls [3]. In low- and middle-income countries like India, the nutritional landscape is defined by a significant public health challenge often referred to as the "double burden of malnutrition," where high rates of stunting, underweight, and micronutrient deficiencies coexist with rapidly increasing rates of overweight and obesity [4, 5]. Anemia is perhaps the most pervasive nutritional deficiency globally, with a disproportionately high burden among adolescent girls due to menstrual blood loss coupled with poor dietary intake [6]. Iron deficiency anemia (IDA) compromises physical performance, cognitive function, and immune competence, all of which directly affect the severity and duration of any concurrent illness requiring hospitalization [7, 8]. Studies have consistently highlighted adolescent nutritional problems as priority pediatric issues, yet clinical data focusing specifically on the nutritional status of hospitalized adolescents aged 10–15 years, particularly in Eastern India, remain limited [9, 10]. Hospitalization itself can be a marker of underlying chronic poor health, and malnutrition often acts as an exacerbating factor, complicating recovery and prolonging the patient's stay [11]. This study aimed to conduct a rigorous cross-sectional assessment of the nutritional status and anemia prevalence among a consecutive series of hospitalized adolescents. The primary objectives were to estimate the prevalence of undernutrition (underweight), overnutrition (overweight and obesity), and anemia, utilizing standardized anthropometric and laboratory measures. Secondary objectives were to explore the association between these nutritional parameters and the primary admission diagnosis and the final length of hospital stay (LOS), while also gathering preliminary data on associated dietary practices and menstrual history in female patients. The findings from this study are essential for hospital management and policymakers to integrate targeted nutritional screening and intervention into the routine care pathway for this vulnerable patient group.

Study Design and Setting This was a hospital-based cross-sectional study. The study was conducted in the general pediatric wards of the Sriram Chandra Bhanja V.P.P.G. Institute of Pediatrics (SVPPGIP) and Sishu Bhaban in Cuttack, Odisha. Data were collected over a defined six-month period (January 2024 to June 2024). Study Population and Sampling The study population comprised adolescents aged 10.0 to 15.9 years who were admitted to the pediatric wards during the study period. A total of 500 consecutive eligible admissions were enrolled. Exclusion criteria included patients with conditions that acutely alter anthropometric measurements (e.g., severe edema, ascites, large masses), those in the intensive care unit, or those unable to provide reliable assent. Data Collection Procedure and Instruments Data were collected by trained research staff within 48 hours of admission. 1. Anthropometry: Weight was measured to the nearest 0.1 kg using a calibrated digital scale, and height was measured to the nearest 0.1 cm using a stadiometer (or knee-height measurement for non-ambulatory patients). 2. Laboratory Data: The most recent Hemoglobin (Hb) value, typically performed as part of the admission workup, was extracted from the patient’s medical chart. 3. Questionnaire: A brief, standardized questionnaire was administered to the adolescent and/or primary caregiver to collect demographic information (age, gender, diagnosis) and supplementary data on: o Dietary Patterns: Frequency of consumption of main food groups (e.g., iron-rich foods, protein sources) assessed as 'daily,' 'weekly,' or 'rarely.' o Menstrual History (for female patients): Age of menarche, regularity, and perceived heaviness of menstrual flow. Definitions and Classification 1. Nutritional Status: The Body Mass Index (BMI) was calculated as Weight(kg)/(Height(m))2. BMI-for-age z-scores were calculated using the WHO AnthroPlus software, based on the WHO 2007 reference standards for adolescents [12]. o Undernutrition (Underweight/Severe Thinness): BMI-for-age z-score <−2 standard deviations (SD). o Normal Weight: BMI-for-age z-score ≥−2 SD and ≤+1 SD. o Overweight: BMI-for-age z-score >+1 SD and ≤+2 SD. o Obesity: BMI-for-age z-score >+2 SD. o Overweight/Obesity: Combined category of z-score >+1 SD. 2. Anemia: Defined according to WHO and Indian consensus guidelines for age and sex, using the extracted Hb value [13, 14]. o Anemia: Hb <11.5 g/dL for 10–11-year-old children and 12–15-year-old males; Hb <12.0 g/dL for 12–15-year-old females. o Moderate Anemia: Hb ≥7.0 g/dL and < definition limit. o Severe Anemia: Hb <7.0 g/dL. Statistical Analysis Data were analyzed using SPSS version 26. Descriptive statistics (mean ± SD, frequencies, percentages) were calculated. The Chi-square test (χ2) was used to test for associations between categorical variables (e.g., nutritional status vs. diagnostic group; anemia vs. dietary pattern). Analysis of Variance (ANOVA) and Independent Samples t-tests were used to compare the mean Length of Stay (LOS) between different nutritional and anemia categories. Statistical significance was set at p<0.05.

The study enrolled a total of 500 adolescents, with 240 (48.0%) females and 260 (52.0%) males. The mean age was 12.9±1.2 years. The primary admission diagnoses were grouped into four major categories: Infectious Diseases (42.0%), Chronic Non-Communicable Diseases (NCDs) (28.0%), Acute Surgical Conditions (15.0%), and Other (including trauma, complex nutritional cases) (15.0%). The overall mean Length of Stay (LOS) for the cohort was 5.5±1.8 days. The prevalence of malnutrition was high and reflects the double burden of nutritional issues. Undernutrition was observed in 191 patients (38.2%). Conversely, 62 patients were classified as overweight (12.4%), including 31 who were obese (6.2%). The combined prevalence of overweight/obesity was 12.4%. The mean hemoglobin level for the entire cohort was 10.5±1.9 g/dL. The overall prevalence of anemia (Hb below age/sex thresholds) was 62.0% (n=310). Moderate anemia (7.0≤Hb< limit) was found in 56.4% of patients, and severe anemia (Hb<7.0 g/dL) was present in 5.6% of patients. The mean LOS showed significant variation based on anemia status: Anemic adolescents had a mean LOS of 6.1±2.0days, which was significantly longer than the mean LOS of 4.5±1.5 days for non-anemic adolescents (p<0.001).Table 1 details the relationship between the primary admission diagnosis, nutritional status, and anemia prevalence. Table 1: Nutritional Status and Anemia Prevalence by Primary Admission Diagnosis Primary Diagnostic Category (N=500) Undernutrition (z<−2 SD) (n) Undernutrition (%) Overweight/Obesity (z>+1 SD) (n) Overweight/Obesity (%) Anemia Prevalence (%) Infectious Diseases (n=210) 96 45.7% 15 7.1% 68.1% Chronic NCDs (n=140) 45 32.1% 25 17.9% 75.0% Acute Surgical (n=75) 21 28.0% 10 13.3% 45.3% Other Conditions (n=75) 29 38.7% 12 16.0% 58.7% χ2 (Diagnosis vs. Undernutrition): 18.90,p<0.001 χ2 (Diagnosis vs. Overweight/Obesity): 12.54,p=0.006 χ2 (Diagnosis vs. Anemia): 18.25,p<0.001 Patients admitted with Infectious Diseases exhibited the highest rate of undernutrition (45.7%) and a high anemia prevalence (68.1%). Patients with Chronic NCDs showed the highest prevalence of both overweight/obesity (17.9%) and anemia (75.0%). Table 2 shows the association between nutritional status, anemia, and the mean Length of Stay. Table 2: Length of Stay (LOS) by Nutritional Status and Anemia Nutritional Parameter Subgroup N Mean LOS (Days ± SD) p-value (vs. Reference Group) Nutritional Status (ANOVA) Undernutrition 191 6.4±2.2 p<0.001 (Reference: Normal Weight) Normal Weight 247 4.9±1.5 Overweight/Obesity 62 5.1±1.6 p=0.354 Anemia Status (t-test) Anemic 310 6.1±2.0 p<0.001 (Reference: Non-Anemic) Non-Anemic 190 4.5±1.5 Anemia Severity (ANOVA) Severe Anemia (Hb<7.0) 28 7.5±2.5 p<0.001 (Reference: Non-Anemic) Moderate Anemia (Hb≥7.0) 282 5.9±1.9 p<0.001 Patients classified as undernourished had a significantly prolonged mean LOS (6.4 days) compared to their normal weight counterparts (4.9 days) (p<0.001). Anemia, especially severe anemia (7.5 days), was strongly and significantly associated with a longer hospital stay compared to non-anemic patients (4.5 days). There was no significant difference in LOS between the overweight/obese and the normal weight groups. Regarding the supplementary data, among the 240 adolescent girls, 185 (77.1%) were anemic. Of these anemic girls, 71%reported consuming iron-rich foods (e.g., leafy greens, pulses) rarely (less than once a week). Only 25% of the adolescent girls reported using any iron-folic acid supplementation prior to admission.

This study confirms the alarming public health crisis of nutritional deficiencies among hospitalized adolescents in Cuttack, revealing a high prevalence of both undernutrition (38.2%) and anemia (62.0%). The dual burden of malnutrition is evident, with 12.4% of admissions attributed to overweight and obesity, though the immediate hospital morbidity is predominantly driven by undernutrition and anemia. The high prevalence of undernutrition, exceeding national averages for the general adolescent population [15], underscores the fact that hospitalization often selects for individuals with underlying chronic nutritional deficits, particularly those with infectious diseases. The significantly increased length of stay associated with undernutrition and anemia (6.4 days and 6.1 days, respectively) is a critical finding [16]. Malnutrition compromises immune function, impairs wound healing, and reduces overall physiological reserve, thus delaying recovery from the primary illness and increasing the risk of secondary infections, which directly translates into resource strain on the hospital and increased cost for the family [17]. The most severe cases of anemia (Hb<7.0 g/dL) had the longest LOS (7.5 days), emphasizing the need for aggressive screening and early blood transfusion or parenteral iron therapy where appropriate, immediately upon admission [18]. The strong association between anemia and chronic diseases (75.0% prevalence) is expected, as conditions such as chronic kidney disease, inflammatory bowel disease, and chronic infections are well-known causes of anemia of chronic disease [19]. However, the high prevalence of anemia in the infectious disease group (68.1%) likely reflects pre-existing iron deficiency worsened by the acute infection, poor dietary status, and parasitic infestations common in endemic areas [20]. The supplementary data regarding adolescent girls is particularly concerning. The high anemia rate (77.1%) combined with poor reported consumption of iron-rich foods and low prophylactic supplementation indicates that the state-run adolescent iron supplementation programs are either failing to achieve adequate coverage, or adherence among this group is poor [21]. Given the importance of iron status for pubertal development and future maternal health, this represents a major lost opportunity for intervention [22]. While overweight/obesity was less strongly associated with prolonged LOS in this acute care setting, the 17.9%prevalence in the Chronic NCD group suggests that these adolescents are managing underlying conditions (like asthma or endocrine disorders) in the context of poor lifestyle choices or side effects from treatments, signaling a necessary shift towards integrated lifestyle counseling in chronic disease management clinics [23]. This study's limitations include its cross-sectional design, which prevents causal inference; for instance, we cannot definitively say whether the LOS was prolonged because of anemia, or if the underlying severe illness causing the prolonged stay also caused the anemia. Furthermore, dietary recall is subject to social desirability bias and memory issues. However, the use of objective WHO standards for anthropometry and routine lab values provides a robust and replicable estimation of the true burden.

malnutrition and anemia are ubiquitous and detrimental co-morbidities among hospitalized adolescents at SVPPGIP and Sishu Bhaban. The findings mandate the integration of universal nutritional screening, coupled with immediate nutritional support and specific micronutrient correction protocols, as a fundamental component of the inpatient management pathway for all adolescents in this tertiary care setting.

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