A COMPARATIVE STUDY OF ANTHROPOMETRIC STATUS AND FEEDING PATTERN OF CHILDREN AGED 6-12YEARS ATTENDING PUBLIC AND PRIVATE SCHOOLS IN UMUAHIA NORTH LOCAL GOVERNMENT AREA, ABIA STATE NIGERIA

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ABSTRACT

Adequate assessment of anthropometry and feeding pattern is of critical importance in children so as to identify those with poor diet who are at increased risk of becoming stunted, underweight, wasted, overweight or obese. This study was conducted to determine the anthropometric status and feeding pattern of children aged 6-12years and compare between children attending public and private schools in Umuahia North Local Government Area, Abia State. A cross sectional comparative study was conducted among 356 children who were randomly selected from four public schools and four private schools in Umuahia North LGA, Abia State. A well structured and validated questionnaire was used to collect information on the socioeconomic data, anthropometric data and feeding pattern of the children. Descriptive statistics was used to sort the anthropometric characteristics and WHO anthropometry software was used to evaluate the height for age z-score (HAZ), weight for age z-score (WAZ), weight for height z-score (WHZ) and basal metabolic index for age z-score (BAZ). The study revealed that equal percentage (1.7%) of children had height for age (stunted) in both public and private schools. About 5.1% of the children in public schools had weight for height (wasted) while 9.6% of the children in private schools had weight for height (wasted). BMI for age (overweight/obese) was seen to be higher in private (7.9%) schools than in public schools (1.7%). BMI for age (overweight/obese) was also found to be higher among children aged 6-9years in both public and private schools. The p value for BMI for age showed a significant association (p=0.002) with the age of the children in public schools. In private schools, the mother’s educational level was significantly associated with stunting (p=0.000) and underweight (p=0.000). None of the high income earners had a stunted, wasted, underweight and overweight child but in private schools, high income earners had 25.0% wasted and 28.6% overweight children. The implication of this study is that children are the most vulnerable members of the society in Nigeria and the nutritional status of these children should be a primary indicator of socioeconomic development. The existence of malnutrition among school age children which is affected by poor feeding pattern will hinder the socioeconomic development of the society and also lead to waste in human potential.

 

 





TABLE OF CONTENTS

Title Page                                                                                                      i

Certification page                                                                                               ii

Declaration                                                                                             iii

Dedication                                                                                             iv

Acknowledgement                                                                                  v

Table of Content                                                                                    vi

List of Tables                                                                                         x                                                                       

Abstract                                                                                                 xi

 

CHAPTER 1

INTRODUCTION                                                                              1

1.1       Background of the Study                                                                        1

1.2       Statement of the Problem                                                                        6

1.3       Objectives of the Study                                                                           9

1.3.1    General objective of the Study                                                               9

1.3.2    Specific objectives of the Study                                                             9

1.4       Significance of the Study                                                                     10

 

            CHAPTER 2                                                                                                                 

            REVIEW OF RELATED LITERATURE                                       11

2.1       Malnutrition in Nigeria                                                              11

2.1.1    Wasting                                                                                                12

2.1.2    Causes of wasting                                                                             13

2.1.3    Underweight                                                                                     13

2.1.4    Treatment of underweight                                                                14

2.1.4.1 Diet                                                                                               14

2.1.4.2 Exercise                                                                                            15

2.1.4.3 Appetite stimulants                                                                           15

2.1.5    Childhood obesity                                                                              16

2.1.5.1 Attitudes toward obesity in different periods of life                      16

2.1.5.2 Obesity and stunting                                                               17

2.1.5.3.1The effect of obesity on motor performance at different ages             19

2.1.5.2             Cause of obesity                                                                 21                                                                  

2.1.5.2.1          Behavioural and social factors                                                     22

2.1.5.2.1.1       Diet                                                                                          22

2.1.5.2.1.2       Calorie intake                                                                           23

2.1.5.2.1.3       Fat intake                                                                                24

2.1.5.2.1.4       Other dietary factors                                                               24   

2.1.5.2.2          Physical activity                                                                      25             

2.1.5.3             Prevention of obesity                                                                  26

2.1.5.4.1          What age group is the priority for starting prevention?              26

2.1.5.4.2          Build a healthy environment                                                        27

2.1.5.4.3          Increase physical activity                                                         27

2.1.5.4.4          Restriction on TV watching                                                  28

2.1.5.4.5          Improve the food sector                                                             29

2.1.5.5             Effectiveness of the prevention methods                                  29

2.1.5.6             Alterations due to obesity                                                      30

2.2                   Feeding Pattern                                                                      34

2.2.1                Problems of feeding pattern                                                  36

2.3                   Assessment of Nutritional Status                                             38

2.3.1               Anthropometric assessment                                                       39

2.3.1.1             Height                                                                                 39

2.3.1.2             Weight                                                                                     41

2.3.1.3             Weight status                                                                            42

2.3.1.4             Importance of nutrition and weight status                               43

2.3.1.5             Body mass index (BMI)                                                       43

2.4                   Biochemical Assessment                                                     44

2.5                   Clinical Assessment                                                              45

2.6                   Dietary Assessment                                                                 45

2.6.1                Food frequency                                                                         46

 

CHAPTER 3

            MATERIALS AND METHODS                                                  54

3.1       Area of Study                                                                             54

3.2       Study Design                                                                                   54

3.3       Study Population                                                                           54

3.4       Sample Size and Sample Size Calculation                                           55

3.5       Sampling Technique                                                                       56

3.6       Preliminary Activities                                                                     56

3.6.1    Preliminary visits                                                                               56

3.6.2    Training of research assistants                                                           56

3.6.3    Informed consent                                                                                 57

3.7       Data Collection and Instrumentation                                                       57

3.7.1    Questionnaire                                                                                        57

3.7.2    Anthropometric measurement                                                                   57

3.7.2.1 Height measurement                                                                                57

3.7.2.2 Weight measurement                                                                                      58

3.7.3    Assessment of feeding pattern                                                                      58

3.8       Statistical Analysis                                                                              58

 

            CHAPTER 4

            RESULTS AND DISCUSSION                                                      59

4.1       Characteristics of the Children in Public and Private Schools                  59

4.2       Economic Characteristics of Parents of Children                                  61

4.3       Income of Parents and Demographic Characteristics of the Children           64

4.4       Feeding Pattern of the School Children                                              66

4.5       Snack Consumption Pattern of the Children                                       69

4.6       Feeding Pattern of the School Children using Food Frequency Questionnaire     71

4.7       Consumption of Meat and Meat Products, Legumes of the Children      74

4.8       Consumption Pattern of Cocoa, Milk and Milk Products                    77

4.9       Consumption Pattern of Fruits and Vegetables                                   79

4.10     Anthropometric Characteristics of the Respondents                             82

4.11     Prevalence of Stunting, Wasting, Underweight and BMI-for-age in Children in

             Public and Private Schools                                                      84

4.12     Prevalence of Stunting, BMI-for-age, Wasting and Underweight by Age

             Categorized in Public and Private Schools                                      86

4.13     Prevalence of Stunting, Wasting, Underweight and BMI-for-Age among

            Males and Females in Public and Private Schools                      88

4.14     Effect of Parents Level of Education on the Anthropometric Status of Children

             in Public and Private Schools                                                       91

4.15     Effect of Mothers Level of Education on Anthropometric Status of Children      92

4.16     Effect of Parents Occupation on the Anthropometric Status of Children

             in Public and Private Schools                                                   95

4.17     Effect of Mothers Occupation on the Anthropometric Status of Children   97

4.18     Effect of Family Income on the Anthropometric Status of the Children in

            Public and Private Schools                                                      99

           

CHAPTER 5

CONCLUSION AND RECOMMENDATIONS                          101

5.1       Conclusion                                                                                  101

5.2       Recommendations                                                                     103

 

            REFERENCES                                                                         104

 

 

 

 

 

 

 

LIST OF TABLES

Table 4.1         Characteristics of the Children in Public and Private Schools                        60

Table 4.2         Level of Education and Occupation of Parents of the Children in Public and

                        Private Schools                                                                                                 63

Table 4.3         Income and Household Characteristics of Parents                                          65  

Table 4.4         Food Consumption Pattern of the Children Studied by School Type             68

Table 4.5         Snack Consumption Pattern of the Children Studied by School Type           70

Table 4.6        Consumption Pattern of Cereal, Roots and Tubers, Fats and Oil of the

Children                                                                                                          73

Table 4.7        Consumption Pattern of Meat and Meat Product, Legumes of the Children   76

Table 4.8         Consumption Cattern of Cocoa, Milk and Milk Products of the Children      78

Table 4.9         Consumption Pattern of Fruits and Vegetables of the Children                       81

Table 4.10       Anthropometric Status of the Children                                                            83

Table 4.11       Prevalence of Stunting, Wasting, Underweight and BMI-for-Age in Children  

                        in Public and Private Schools                                                                           85

Table 4.12       Prevalence of Stunting, BMI-for-Age, Wasting and Underweight by Age     87

Table 4.13       Prevalence of Stunting, Wasting, Underweight and BMI-for-Age among

                        Males and Females in Public and Private Schools                                           89

Table 4.14       Effect of Father’s Level of Education on the Anthropometric Status of Children in Public and Private Schools                                                            91

Table 4.15       Effect of mother’s level of education on the anthropometric status of children

                        in public and private schools                                                                            94

Table 4.16       Effect of father’s occupation on the anthropometric status of children in

                        public and private schools                                                                                96

Table 4.17       Effect of mother’s occupation on the anthropometric status of children in

                        public and private schools                                                                                98

Table 4.18       Effect of family income on the anthropometric status of the children in

public and private schools                                                                              100

                  


 

 

 

 

 

 

 

 

 

CHAPTER 1

          INTRODUCTION

1.1       BACKGROUND OF THE STUDY

Many years ago, the focus of international nutritionists was on childhood malnutrition and the related problem of how to feed the worlds’ expanding population, especially the children (Prentice, 2006). Today, the World Health Organization finds the need to deal with the new pandemic of obesity and its accompanying non-communicable diseases, while the challenge of childhood malnutrition is still far from being over (Prentice, 2006). Deficiency in macro and micronutrients has been the major problem among children in low-income countries for many years (Jafar et al., 2008; Chatterjee, 2002; Bamidele et al., 2011). Nevertheless, owing to progressive urbanization, economic growth and the associated changes in lifestyle, the energy balance is shifting (Goran and Sun, 1998).

Childhood overweight and obesity is becoming equally challenging, yet under-recognized, problem in many emerging countries (Jafar et al., 2008; Wang et al., 2002; de Onis and Blossner, 2000; Samuelson, 2000). Childhood overweight/obesity was previously a health problem for developed countries because of their high calorie foods, labor-saving devices and dwindling levels of physical activity, but it is now spreading to developing countries. These countries are now reporting unprecedented levels of childhood obesity with substantially rising trends every year (Agarwal, 2008). The problem of obesity exists alongside the problem of undernutrition in many developing countries which creates a double burden of nutrition-related ill health among children (Senbanjo and Oshikoya, 2010; Popkin et al., 2001) and this has been referred to as the "double burden of malnutrition (DBM) (FAO, 2006).

Childhood obesity has been increasing over the past few decades and is now a public health concern in developed and developing countries (Karnik, 2012). Global estimates indicate that 43 million children were overweight and obese in the year 2010 (Blossner, 2000). Over one-fifth of overweight and obese children were from developing countries.

Globally, the prevalence of overweight is expected to rise from 6.7% in 2010 to more than 9% in 2020 compared to the increase from 8.5% to 12.7% in Africa within the same span of time (Blossner, 2000). Additionally, The International Obesity Task Force (IOTF) report showed that one in ten children worldwide is overweight; a total of 155 million children and adolescents are overweight and around 30–45 million are classified as obese. In children, obesity has serious implications for health such as cardiomyopathy, pancreatitis orthopaedic disorders and respiratory disorders (NIH, 2007; WHO, 2003). After a while, obesity has psycho-social effects on children such as social isolation and low self-esteem of obese children which can lead to overwhelming feelings of hopelessness, which in turn lead to depression (Joseph et al., 1996; Bowman and Russell, 2001). Obese children do less well in schools because of stress and anxiety, which interfere with learning and create a vicious cycle in which the over-growing worry increases the declining academic performance (Joseph et al., 1996; Bowman and Russell, 2001).

Excessive weight gain is a precursor to different physiological aberrations that ultimately predispose the subject to morbidity and mortality later in life. Studies have shown that, large number of adult chronic non-communicable diseases have their origin during childhood (Gill et al., 2000; Pierre et al., 2003). Obesity has deleterious effects not only to adults but also to school age children. It impairs concentration in school activities and affects hygiene in general. Obese children are victims and perpetrators of bullying in school (Janssen et al., 2004). In addition they have increased health risks like diabetes mellitus, bronchial asthma, increased risk of cardiovascular problems and being more prone to developing fracture. They are also prone to further weight gain after a life changing event like pregnancy. There is a link between untreated pre-pubertal obesity and obesity in adulthood (Dietz, 1998; Guillaume and Lissau, 2002). Some would argue that because there are a lot of children in the world who are hungry and starving, why should we care too much about obesity, the health problem of affluence and a poor lifestyle? One never sees an obese child from a poor Asian or African village, however, when the economic situation in such countries improves, the prevalence of obesity increases, as is the case in India, Brazil, Paraguay, Venezuela, South Africa, and so forth (Jimenez-Cruz, Bacardi-Gascon, and Spindler, 2003). In most of these countries, including Mexico, obesity and malnutrition coexist (Jimenez-Cruz, Bacardi-Gascon, and Spindler, 2003). Thus, when problems such as malnutrition, decreased immuno-resistance, infectious diseases, and other health outcomes are improved, new health problems appear.

Childhood obesity has also been identified in lower socioeconomic groups in the industrially developed countries, which suggests that obesity is due mainly to poor lifestyle behaviors, such as the consumption of cheaper fats and sugar products, commonly combined with reduced physical activity. Given the widespread nature of obesity, particularly under conditions of an improving economic and social situation, the adequate management of the condition during growth is an urgent challenge for most countries of the world (Florencio et al., 2001). The best approach is the prevention of obesity by closely monitoring energy intake, output, and turnover, mainly by monitoring diet and physical activity levels from as early as possible in childhood, especially in children at risk (Davison and Birch, 2001). Such individuals may include, for example, children with obese parents or with a strong family background of obesity (Dietz, 1986; Epstein et al., 1998; Parˇízková, 1977; Parˇízková, 1996; Burniat, 2002; Zwiauer et al., 2002). Based on large epidemiological studies, the child-to-adult adiposity relationship is now well documented, although methodological differences can hinder meaningful comparisons (Dietz, 1998; Guillaume and Lissau, 2002). Fatter children are more predisposed to becoming overweight or obese adults in spite of the findings that the correlation between, for example, BMI assessed at an age younger than 18 years and adult values is often only mild or moderate.

There is a call for the surveillance of trends of the major risk factors for the double burden of mal-nutrition such as stunting, underweight, obesity, dietary patterns etc (Rolland-Cachera et al., 1997; Shumei et al., 2002; Thiam et al., 2006).                             Although several genetic factors have been associated with obesity and its comorbidities, environmental factors, have also been proposed as important determinants of obesity (Hill et al., 2003; Meirhaeghe et al., 1999). Therefore, adequate assessment of feeding pattern is of critical importance in order to identify children with poor diet and at increased risk for becoming underweight, wasted, overweight or obese. However, the assessment of feeding pattern is complicated because people consume meals as opposed to single nutrients or foods. Several national epidemiological studies have examined dietary intakes of toddlers and preschoolers. These studies have revealed increased total energy intake, inadequate intake of certain nutrients (i.e. fibre), excessive intake of other nutrients (i.e. total fat, saturated fat and sugars) (Kranz et al., 2005; Devaney et al., 2004; Manios et al., 2008; Kranz et al., 2005) and low intake of fruits and vegetables (Ballew et al., 2000; Hampl et al., 1999). These observations indicate inadequacies in some nutrients and foods; however, they do not reflect the overall diet quality. There are many factors that can affect children's eating practices. Dietary pattern analysis has recently best known as a holistic dietary approach to evaluate diet quality and examine whether adherence to a certain pattern may be of benefit to human health (Jacques and Tucker, 2001; Hu, 2002). Among the approaches proposed to determine dietary patterns, dietary quality indices have received increased attention because they capture the multi-dimensional nature of people’s diets, and also because they are based on general dietary guidelines as guiding principles, which make them objective (Michels and Schulze, 2005).                                                                According to UNICEF. (2015), Nigeria is facing a problem of child malnutrition and ranks second behind India among all countries with the highest number of malnutrition cases. Almost 30 percent of Nigerian children are underweight and that is more than double the proportion of Ghanaian children who are underweight. Results from a survey conducted by UNICEF (2014), shows that Nigeria has a stunting prevalence of 32 percent among children less than 5 years of age; while about 21 percent and 9 percent are underweight and wasted respectively. Overall, prevalence of malnutrition in the North West and East regions are higher than in the South. Nigeria’s rates of severe wasting are among the highest in the world at 1.9 million children each year. The factors associated with these patterns of weight status among the school-age children included sociodemographic and socioeconomic factors, feeding patterns and activity patterns (Adeomi et al., 2015).

The prevalence of childhood obesity is on the rise since 1971 in developed countries. The most prevalence rates of childhood obesity have been observed in developed countries, however, its prevalence is increasing in developing countries as well. The prevalence of childhood obesity is more in the Middle East, Central and Eastern Europe (James, 2004). The vast body of literature supporting that childhood obesity persists through adult life (Rooney et al., 2011) makes it very imperative to study and understand factors associated with childhood obesity including knowledge of children themselves towards obesity. There is need for a collective approach to the prevention, treatment, and management of underweight, wasting, overweight and obesity in developing countries such as Nigeria, and to implement these prevention strategies as early as childhood by involving families, schools and the whole community, particularly with respect to the problems of the condition during the growing years. Published data regarding weight status and feeding pattern of school children aged 6–12 years in Umuahia is scarce.This study is aimed at assessing weight status and feeding pattern among school children aged 6 to 12years in Umuahia-North Local Government Area, Abia State.

1.2       STATEMENT OF THE PROBLEM

Childhood malnutrition remains a public health problem in Nigeria as the status did not improve substantially during the last two decades. The implications of this unrelenting situation for the well being of children and the development of the nation as a whole are unacceptable because malnutrition contributes to the high rates of morbidity, disability and mortality among children (WHO, 2000). In addition, malnutrition constrains people’s ability to fulfil their potential as it is also associated with impaired growth, mental development and school performance, reduced adult size and reduced work capacity, which in turn impacts on economic productivity at the national level (Hart and Atinmo, 2003). Low body weight had been reported to be associated with greater mortality risk; it was suggested that people who are underweight do not have a lot of nutritional reserves to call upon when illness does occur (Flegal et al., 2005). High prevalence of underweight therefore makes these age bracket vulnerable to infectious diseases such as malaria, pneumonia, diarrhoea, measles and HIV/AIDS which is said to account for more than 70% of the deaths in Nigeria. As long as underweight remains high in early childhood, the likelihood of cutting down under-five mortality rates is low. Efforts must therefore be intensified to improve the nutritional status of this age group as this will contribute to their mental and physical development, as well as improved health and school performance through reduced vulnerability to diseases.

Wasting or thinness is often associated with acute starvation and/or severe disease. Wasting is a strong predictor of mortality among children under five. It is usually the result of acute significant food shortage and/or disease. There are 24 developing countries with wasting rates of 10 per cent or more, indicating a serious problem urgently requiring a response However, wasting may also be the result of a chronic unfavourable condition. Provided there is no severe food shortage, the prevalence of wasting is usually below 5%, even in poor countries but the prevalence of wasting in Nigeria is observed to be 7.9% (UNICEF/WHO, 2014). A prevalence exceeding 5% is alarming given a parallel increase in mortality that soon becomes apparent. On the severity index, prevalence between 10-14% are regarded as serious, and above or equal 15% as critical. Lack of evidence of wasting in a population does not imply the absence of current nutritional problems: stunting and other deficits may be present.

Childhood obesity is a multisystem disease with potentially devastating consequences (Must and Strauss, 1998). Several complications warrant special attention. The prevalence of obesity in Nigeria is observed to be 1.8% (UNICEF/WHO, 2014). As with adults, obesity in childhood causes hypertension, dyslipidaemia, chronic inflammation, increased blood clotting tendency, endothelial dysfunction, and hyperinsulinaemia (Freedman et al., 1999; Srinivasan et al., 2002). This clustering of cardiovascular disease risk factors, known as the insulin resistance syndrome, has been identified in children as young as 5 years of age (Young-Hyman et al., 2001). Among adolescents and young adults who died of traumatic causes, the presence of cardiovascular disease risk factors correlated with asymptomatic coronary atherosclerosis, and lesions were more advanced in obese individuals (Strong et al., 1999; McGill et al., 2000). Type 2 diabetes, once virtually unrecognised in adolescence, now accounts for as many as half of all new diagnoses of diabetes in some populations (Fagot-Campagna et al., 2000). Frequent pulmonary complications include sleep disordered breathing (sleep apnoea), (Redline et al., 1999) asthma, (Figueroa-Munoz et al., 2001) and exercise intolerance (Reybrouck et al., 1997). Development of asthma or exercise intolerance in an obese child can limit physical activity and thus cause further weight gain. Furthermore, serious hepatic, renal, musculoskeletal, and neurological complications have been increasingly recognised (Balcer et al., 1999; Strauss et al., 2000; Adelman et al., 2001; Goulding et al., 2001).


1.3       OBJECTIVES OF THE STUDY

1.3.1    General objective of the study

The general objective of this study is to determine the anthropometric status and feeding pattern of children aged 6 to 12years attending public and private schools in Umuahia-North Local Government Area of Abia State, Nigeria. 

1.3.2    Specific objective of the study

The specific objectives of the study are to:

(i).               Determine the social characteristics of the children

(ii).             Determine the economic characteristics of the children.

(iii).           Determine the demographic characteristics of the children

(iv).           Assess the feeding pattern of school children using food frequency questionnaire. 

(v).             Determine the anthropometric status of children aged 6 to 12years in Umuahia-North LGA using anthropometry.

(vi).            Determine the prevalence of malnutrition (underweight, overweight, stunting, wasting and obesity) between males and females in both public and private schools.

(vii).         Compare the anthropometric status of children in public and private schools in Umuahia North LGA.

(viii).       Compare the feeding pattern and anthropometric status in both locations.

1.4              SIGNIFICANCE OF THE STUDY

Body weight is related to health status. Good nutrition is important to the growth and development of children. Individuals who are at a healthy weight are less likely to develop malnutrition (underweight, wasting, overweight and obesity), iron-deficiency anemia, heart disease, high blood pressure, dyslipidemia (poor lipid profiles), type 2 diabetes, osteoporosis, oral disease, constipation, diverticular disease and some cancers (Black et al., 2013).   
Weight status screenings could provide valuable information for monitoring trends at the state and local levels where data are limited. It can assist in identifying children who are at risk for poor weight related diseases. Healthy children results in healthy communities, where the available resources match the needs. The significance for recent advanced studies on children is the search for understanding of poor weight related problems and the effective management of children who are, or who may be at risk of, becoming underweight, wasted, overweight and obese. Most importantly, this study will provide more knowledge to health workers, parents and educators on the subject of the study. It will help the general public, since no documentation has been made on this study in umuahia north, to be aware of poor weight status as a growing disease in the country and the world at large. It will help to determine the prevalence of underweight, wasting, overweight and obesity in umuahia north.   Also, research on the feeding pattern of children provides insight into the providers who care for children, the children themselves, and the communities in which they live and this will help to determine the relationship between weight status and feeding pattern in children.

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