Factors associated with adolescent malnutrition among Nigerian students

Original article Factors associated with adolescent malnutrition among Nigerian students Abdulkarim AA1, Otuneye AT2, Ahmed P3, Shattima DR4 Abstract: Objectives: The objective of this study was to determine the factors associated with malnutrition among adolescents. Design: This was a cross-sectional study conducted among adolescents (10-19 years) in secondary schools. A multistage sampling technique was employed. Setting: Senior secondary schools in The Abuja Municipal area council, Federal Capital Territory, Nigeria. Participants: A total of 1700 students from 8 selected schools. All schools in the Abuja Municipal Area council (AMAC) were stratified into urban and rural schools. Eight schools were selected by balloting from a list of schools obtained from the Education centre. A school was selected from each of the four major districts of AMAC and four schools were selected from the rural making a total of 8 schools. Although the consent of the school authorities was obtained, individual subject also consented to the study before being enrolled. Study: The study excluded those adolescents who were physically challenged thus limiting physical activity. Sociodemographic information was obtained using an interviewer administered questionnaire. Subject’s height and weight was taken using the floor-type height (H) and weight (W) measuring scale model ZT-120 using Massachusetts Department of Public Health Protocol. Main outcome measure: The nutritional status was determined using the formula: BMI= W/H2, where W=weight (in kilograms) and H=height (in meters). The age and sex specific height and BMI percentile for each subject was determined using the 2007 WHO Height and BMI growth charts for age 5-19 years. The students were then classified into one of the following categories using previously used standards: normal, stunted, wasted, overweight or obese. Data was analyzed using SPSS version 17 statistical package. A regression analysis of all investigated factors was done to determine those with significant association to malnutrition. Results: The mean age was 14.43±1.94 years; male 688, female 862, M:F ratio 1.1.3. Mean BMI, weight and height were 20.31±3.07kg/m2, 51.07±10.80 kg, and 157.88±9.33 cm. The prevalence of overweight, stunting, obesity and wasting was documented as 13.2% (205/1550), 11.3% (175/1550), 2.6% (41/1550) and 1.7% (27/1550) respectively. Low social class, male gender, hawking after school and rural setting were associated with stunting (p<0.05) and female gender and watching Television for more than 3 hours daily were associated with overweight (p<0.05). Obesity occurred more in urban areas.


Introduction:
Malnutrition has been reported in epidemic proportions among adolescents in developing and developed countries 1,2 .The prevalence and pattern of malnutrition-wasting, stunting, and overweight and obesity-however vary among countries and within regions in a country [3][4][5][6] .6][7][8] Furthermore, socioeconomic status, lifestyles including alcohol and tobacco consumption, eating habits and level of physical activity in an individual have been found to be associated with malnutrition among adolescents 5,[7][8][9][10] .Adolescent over-nutrition is associated with non-communicable diseases such as hypertension, diabetes mellitus and sleep apnoea among others.In adulthood, there is a higher burden of Type II Diabetes Mellitus (DM), hypertensive heart diseases, coronary heart diseases, colonic cancers and other disorders in obese and overweight individuals 11,12 .Under-nutrition affects the final physical height, body weight and cognitive ability of an adolescent 2,6,11,12 .Malnutrition in childhood through adolescence may progress to adult life.In addition, there may be factors that influence malnutrition that start in childhood or adolescence and persist into adulthood, thus the potential to increase the burden of non-communicable diseases (NCDs) among the population.The importance of understanding the factors associated with the epidemic of malnutrition in any population is important in order to institute measures to reduce and/or reverse the trend.Different countries and regions have a wide variation of factors associated with malnutrition.Also, there are many changing factors in our society.These include proliferation of fast food outlets, the technological advancements and increasing use of blackberry and video games by children and adolescent thus increasing sedentary lifestyles; the global economic recession, and the increasing number of families with working mothers which can affect the nutritional status of an adolescent.Few studies and data are available for Nigeria and many of these studies are in the Southern part of the country.This study explored some factors associated with malnutrition among Nigerian adolescents in secondary schools in the Federal capital territory.

Materials and methods:
This was a cross-sectional study conducted among adolescents in secondary schools in the Abuja Municipal area council in the Federal capital territory of Nigeria.A multistage sampling technique was employed.All schools in the Abuja Municipal Area council (AMAC) were stratified into urban and rural schools then eight schools were selected by balloting from a list.A school was selected from each of the four major districts of AMAC and four schools were selected from the rural area.Students' ages were verified (using school records and/or birth certificate) and only those between the ages of 10 and 19 years were selected.Informed consent was obtained from individual subject as well as the school authorities.The study excluded those adolescents who were physically challenged thus limiting physical activity.Sample size determination used the approach described by Araoye et al 13 , and assumed a prevalence of 50% among adolescents in the population.Eight hundred and fifty students were selected from the four urban schools and an equal number were selected from the rural schools.The total number subjects enrolled were 1,700.Random sampling was employed for the selection of students in each school.Information was obtained via the use of questionnaires that were administered by trained personnel.Subject's height and weight was taken in the presence of a chaperon assigned by the school.The floor-type height (H) and weight (W) measuring scale model ZT-120 was used for measurement using Massachusetts department of public health protocol.The nutritional status was determined using the formula: BMI= W/H 2 , where W =weight (in kilograms) and H= height (in meters).The age and sex specific height and BMI percentile for each subject was determined using the 2007 WHO Height and BMI growth charts for age 5-19years.The subjects were then classified into one of the following categories using previously used standards: normal, stunted, wasted, overweight or obese.The socioeconomic status of the students was determined as described by Olusanya et al 14 .
Data was analyzed using SPSS version 17 statistical package.The study was ethically approved by the ethical committee of University of Ilorin.

Results: Sociodemographic parameters
Only 1550 (91.2%) of the 1700 questionnaires were analyzed because of withdrawal of consent in 150 (8.8%).There were 688 (44.4%) males and 862 (55.6%) females and the Male: Female of 1:1.3.The mean age was 14.43±1.94years.Seven hundred and eighty (50.3%) were from urban schools while the 49.7% were selected from rural schools.The upper social class represented 708 (45.7%) of the study population; 542 (35.0%) were in the middle class and 300 (19.3%) in the lower class.In the urban area, 502 (64.4%) belong in the upper class and 68 (8.7%) in the lower class.In the rural area 206 (26.8%) and 232 (30.1%) belong in upper and lower class respectively (p<.05).The educational level of mothers was also documented thus: 615(39.7%)tertiary education; 654 (42.2%) secondary education; 188 (12.1%) primary education and 93 (6.0%) had no formal education.A total of 1515 adolescents volunteered information with respect to family size and number of children in the household.The mean family size of the study population was 6.86±2.5: Relationship between malnutrition and physical activity significant for obesity.School setting, sex and socioeconomic class as well as hawking after school hours were statistically significant for stunting.Discussion: Severe forms of malnutrition contribute significantly to a higher morbidity and mortality in childhood 2,15 .The association of over-nutrition with non-communicable diseases (NCDs) has long been established 11,12 .The effect of malnutrition in adolescents has been less studied compared to the effects in childhood, but reports from various parts of the world have started to emerge showing the association of overweight and obesity with noncommunicable diseases (NCDs) such as diabetes mellitus and hypertension 5,12,16 .Health promotion and prevention of malnutrition and related disorders rely on an understanding of factors associated with these disorders.These factors vary between and within regions of the world.This study therefore investigated some of the factors associated with adolescent malnutrition in the FCT of Nigeria.This study documented a higher prevalence of overweight and obesity among females when compared to males.This finding is consistent with earlier findings from other parts of Nigeria and elsewhere 3,6,[17][18][19] .These findings may be due to the fact that females are likely to lay down more fat due to the effect of oestrogens.In our culture, females also engage in cooking family meals and therefore have more access than males to larger portions though this was not investigated in this study.Also, females are less likely to engage in school sports compared to males but they engage more in household chores.It is however different from what has been found among adolescents in some developed countries particularly in USA and some developing countries where more males were documented to have overnutrition 4,5,[20][21][22] .The finding that fewer females are overweight or obese in USA and some other developed countries may be related to the societal and media promotion/ approval of thinness among females in such cultures.Perhaps, more females in the developed countries may also have eating disorders that leave them thin.Those from upper socioeconomic class and urban schools had higher prevalence of overweight and obesity.This agrees with the findings of other workers from Nigeria 3,8,18 .The socioeconomic class appears to reflect the access to food by the adolescents in our environment.The urban schools had more adolescents in the upper social class.In contrast, Gearhart et al found that those females from low socioeconomic class in the USA had a higher prevalence of obesity and overweight 22 .He attributed his findings to less opportunities being available for those in the lower class to make appropriate food choices and their exposure to high calorie cheap food.Furthermore, less opportunity for physical activity was also alluded to among those from low social class in USA 22 .This study also showed that those who engaged in sedentary activity-watch TV for long durationalso had higher prevalence of overweight.This is understandable as energy is not expended as it is consumed hence conversion to fat which then accumulates.Obesity was found to be significant among those who engaged in physical activity.This may be strategy for weight reduction in these adolescents rather than a routine.Stunting was more prevalent among males and this may reflect the effect of chronic malnutrition.Physiologically, males have a greater growth velocity and for a longer duration compared to female adolescents.Hence, the height of the male adolescent may suffer more from the effect of chronic malnutrition.Furthermore, the other factors associated with stunting in the study population namely rural setting, low social economic class and hawking could contribute to chronic under-nutrition.On the other hand wasting is associated with the male gender and watching TV.These findings are not thought to be significant as wasting reflects more of an acute malnutrition in the adolescent.Moreover, this study did not document episodes of illnesses that could be associated with wasting.Our findings suggest a rural-urban dichotomy in social class and malnutrition.The rural adolescents are affected by stunting while the urban adolescents have a high prevalence of overweight and obesity.It also showed that females are affected more by over-nutrition while males are affected more by under-nutrition.Limited data on physical activity was collected in this study-only related to school sports.There was no objective measurement of hours of activity or calories expended in the activities.The difficulties of obtaining information with respect to diet and the limited fund for this study precluded data collection on this aspect.This study has no doubt been able to document some factors associated with malnutrition among adolescents that can be used in planning health promotion and prevention programmes.It also shows the need for wider collection of data on factors associated with malnutrition in our environment as variations clearly occur.

Table 1 :
Distribution of mean weight, height and bmi for the study population

Table 2 :
Pattern of physical activities in the study population

Table 3 :
Types of malnutrition by school setting A regression analysis of the factors explored showed that gender, and watching TV for >3 hours/day remained significant factors with respect to overweight while school sport and setting were

Table 4 :
Types of malnutrition by socioeconomic status of the family