|Year : 2013 | Volume
| Issue : 3 | Page : 276-281
Co-existence of child and adolescent obesity and thinness in a city in Nigeria: Comparison of results derived from different reference standards
Chukwunonso E. C. C. Ejike, JN Onyemairo, IA Onukogu
Department of Biochemistry, College of Natural and Applied Sciences, Michael Okpara University of Agriculture, PMB 7267 Umudike, Umuahia, Abia State, Nigeria
|Date of Submission||18-Feb-2012|
|Date of Acceptance||23-Mar-2013|
|Date of Web Publication||10-Jul-2013|
Chukwunonso E. C. C. Ejike
Department of Biochemistry, College of Natural and Applied Sciences, Michael Okpara University of Agriculture, Umudike, PMB 7267 Umuahia, Abia State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: The nutrition transition in developing countries has resulted in the "nutrition paradox" where both under- and over-nutrition exist in the same population. This phenomenon is scarcely reported in Nigeria. The prevalence of thinness and overweight/obesity was therefore studied in Umuahia, Nigeria using two international references and the results compared. Subjects and Methods: A total of 1911 children and adolescents (51.3% females) were recruited and anthropometric data obtained from them using the standard procedures. Age was determined from each subject's school records. Overweight, obesity, and thinness (stages 1-3) were defined using the Cole et al. International surveys (IS) and the World Health Organization (WHO) study references. Appropriate statistical analyses were carried out on data generated. Results: As much as 24.2% of the boys and 19.2% of the girls were thin, based on the WHO standards, whereas, 17.3% of the boys and 15.5% of the girls were thin based on the IS standard. A total of 4.9% of boys and 9.2% of girls (WHO); and 3.9% of boys and 5.8% of girls (IS) were overweight. Obesity was found in 1.1% and 1.8% of the boys and girls respectively (WHO); and 0.3% and 1.0% of the boys and girls respectively (IS). Irrespective of age, there were no significant differences ( P > 0.05) between the proportions of the population diagnosed with thinness, overweight or obesity by the two standards used. Conclusion: Under- and over-nutrition, typified by thinness and overweight/obesity respectively co-exist in the studied population. The IS and WHO reference methods give statistically similar estimates of the nutritional status in this population.
Keywords: Nutrition transition, obesity, overweight, thinness, under-nutrition
|How to cite this article:|
Ejike CE, Onyemairo J N, Onukogu I A. Co-existence of child and adolescent obesity and thinness in a city in Nigeria: Comparison of results derived from different reference standards. Int J Nutr Pharmacol Neurol Dis 2013;3:276-81
|How to cite this URL:|
Ejike CE, Onyemairo J N, Onukogu I A. Co-existence of child and adolescent obesity and thinness in a city in Nigeria: Comparison of results derived from different reference standards. Int J Nutr Pharmacol Neurol Dis [serial online] 2013 [cited 2020 Feb 18];3:276-81. Available from: http://www.ijnpnd.com/text.asp?2013/3/3/276/114856
| Introduction|| |
Overweight and obesity are thought to result from the genetic pre-disposition, excessive consumption of energy-dense foods, and physical inactivity. The prevalence of obesity (globally) has nearly tripled since the 1970s and has become a global public health challenge.  In developing countries like Nigeria, overweight and obesity have been reported to affect as much as 13.2% of adolescents living in a semi urban area,  a figure that is comparable to figures from developed countries. The worry is that these conditions are known to track into adult-life and result in obesity-related morbidity. , Overweight and obese children and adolescents have also been shown to suffer significant mental-health and psychosocial morbidities  that inadvertently affect their quality of life. 
Thinness, though less studied is also prevalent in developing countries and is known to arise from acute or chronic under-nutrition, or the presence of infectious disease (s).  In Nigeria, the prevalence of thinness (grades 2 and 3) has been reported to be as high as 10.2% among school children in Markudi.  Thinness, just like stunting and wasting are known to lead to delayed mental development, reduced intellectual capacity, poor educational achievement, and higher morbidity and mortality rates. , Thinness is however not always a pathological condition as some thin children still have good overall health status.
The co-existence of overweight and obesity on the one hand and thinness on the other hand in children and adolescents is a nutrition paradox and indicates that there exists, sharp disparities in access to proper nutrition within the population. Yet this phenomenon is understudied, especially in Nigeria, despite the economic implications attributable to it. Sequel to the development of body mass index (BMI)-for age cut-off points for children and adolescents that match BMI at 18 years of age, ,, the diagnosis of overweight, obesity and thinness (stages 1-3) in pediatric populations has become easier and international comparisons have become more reliable. This study therefore investigated the prevalence of overweight, obesity and thinness (stages 1-3) in a population of children and adolescents (aged 7-17 years) in Umuahia, Nigeria, using two international growth reference data, and compares the results generated by the different reference standards.
| Subjects and Methods|| |
One thousand nine hundred and eleven subjects (51.3% females) aged 7-17 years, attending primary and secondary schools (selected at random from the schools list) in Umuahia, the capital city of Abia State, Nigeria, were studied. Umuahia is an urban city that is surrounded by semi-urban communities. Inclusion criteria for this cross-sectional population-based study included (a) an informed verbal consent given by the candidate after consulting with his/her parents or legal guardians; (b) absence of any signs of overt illness; (c) a report of non-usage of alcohol, or any prescription drugs for the treatment of any diseases; and (d) being a non-cigarette smoker. The consent of head teachers of selected schools were also sought and obtained. No honoraria were paid to participants.
Data on students' ages were obtained from their school records. Age (in months) was recorded for each student. Height was measured (with the student standing on bare feet) with a non-elastic measuring tape, to the nearest 0.5 cm. Weight was measured (with the student on bare feet and with light clothing) with an electronic weighing balance (BF 214, OMRON Health-care Europe BV, Hoofddorp, Netherlands), to the nearest 0.1 kg. From the heights and weights got, BMI was calculated using the formula BMI = Weight (kg)/[Height (m)] 2 . The same trained personnel took all measurements in all locations. The weighing balances used were appropriately calibrated before use each morning according the manufacturer's instructions. The study protocol was prepared in accordance with the Helsinki Declaration and was approved by the Board of the Department of Biochemistry, Michael Okpara University of Agriculture, Umudike.
Overweight, obesity and thinness (Stages 1-3) were defined using the age and gender specific BMI cut-off points of (a) the Cole et al. International Surveys (IS) , and (b) the World Health Organization (WHO) study.  The IS were based on nationally representative samples of children aged 6-18 years collected between 1963 and 1993 in the United States, Brazil, Great Britain, Hong Kong, Netherlands and Singapore. The WHO growth reference based on a representative sample of children aged 1-17 years collected between 1963 and 1974 in the United States, merged with the WHO Child Growth Standards that were based on data collected between 1997 and 2003 in children aged 18-71 months living in favorable socio-economic conditions in six developed and developing countries - Brazil, Ghana, India, Oman, Norway, United States. The cut-offs for the studies were determined using the LMS method, which summarizes the distribution of BMI by age and gender in terms of three curves called L (lambda), M (mu) and S (sigma). 
Descriptive statistics was carried out on data generated and their results reported as mean ± standard deviation (SD) for continuous data and as percentages for categorical data. Differences between means for continuous data were compared by one-way ANOVA and by Chi-square test for categorical data. The significant threshold was fixed at P < 0.05. Data analyses was carried out using the statistical software package SPSS for windows version 18.0 (SPSS Inc., Chicago, IL). The results are presented in tables and line graphs.
| Results|| |
Girls were taller than boys (albeit non-significantly [ P > 0.05]) from age 7 years to age 13 years. From age 14 years and above, the boys were taller than the girls, though the differences were not significant ( P > 0.05). From age 11 years, the subjects were shorter than the median values of their respective WHO reference population [Figure 1].
|Figure 1: Mean heights of the subjects stratifi ed by age and sex, compared to the World Health Organization reference median values|
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Girls weighed more than the boys from age 8 years to age 15 years. Conversely, boys weighed more than the girls at ages 16 years and 17 years. The differences were significant ( P < 0.05) only at ages 12 years and 17 years, at which girls and boys, respectively, weighed more than their respective counterparts [Figure 2].
|Figure 2: Mean weights of the subjects stratifi ed by age and sex, compared to the World Health Organization reference median values|
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On the average, girls had higher BMI relative to boys at all the ages above 10 years. This difference was however significant ( P < 0.05) only at age 14 years. The girls had lower BMI from age 7 years to 11 years; higher BMI from age 12 years to 15 years; and similar BMI at ages 16 years and 17 years compared to the WHO reference median. The boys matched the reference BMI standard only at ages 7 years and 13 years. For all the other ages, the boys had lower BMI compared to the WHO reference median [Figure 3].
|Figure 3: Mean body mass index of the subjects stratifi ed by age and sex, compared to the world health organization reference median values|
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The prevalence of thinness in the population is shown in [Table 1]. A total of 24.2% of the boys and 19.2% of the girls were thin, based on the WHO standards, whereas 17.3% of the boys and 15.5% of the girls were thin based on the IS standard. Significantly ( P < 0.05) more girls were thin at ages 7 years and 8 years; conversely, significantly ( P < 0.05) more boys were thin at ages 16 years and 17 years, based on the WHO standards. Based on the IS standards, significantly ( P < 0.05) more boys were thin only at age 16 years while significantly more girls were thin at ages 10, 13, and 15 years. However, irrespective of age, there were no significant differences ( P > 0.05) between the proportions of the population diagnosed with any stage of thinness by the two standards used.
|Table 1: Prevalence of the three stages of thinness in the studied population|
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The prevalence of overweight and obesity in the population is shown in [Table 2]. A total of 4.9% of the boys and 9.2% of the girls were overweight based on the WHO standards while 3.9% of the boys and 5.8% of the girls were overweight based on the IS standards. Significantly ( P < 0.05) more girls were overweight compared to the boys at ages 7, 8, 13, and 14 years based on the WHO standards whereas such was observed only at age 14 years for diagnosis based on the IS standards. Based on the WHO standards, 1.1% and 1.8% of the boys and girls respectively were obese, whereas 0.3% and 1.0% of the boys and girls respectively were obese based on the IS standards. The prevalence of obesity determined by the WHO standards was similar ( P > 0.05) between the sexes. Based on the IS standards; however, significantly ( P < 0.05) more girls we obese only at age 12 years. Irrespective of age, there were no significant differences ( P > 0.05) between the proportions of the population diagnosed with overweight or obesity by the two standards used.
| Discussion|| |
Nutritional status measured by anthropometry is a good indicator of the overall health and well-being of children and adolescents.  The WHO and IS references provide a common denominator in assessing paediatric nutritional status, their use makes international comparisons and the study of global trends easy. , The 24.2% (18.9%, 4.3% and 1.0% for stages 1, 2, and 3 thinness respectively) reported for boys, and the 19.2% (14.7%, 3.2%, and 1.2% for stages 1, 2, and 3 thinness respectively) reported for girls, using the WHO standard are all lower than the values reported by a recent study (77.3%, 6.4%, and 3.8% for stages 1, 2, and 3 respectively) employing the same definition in a different city in Nigeria.  The 17.3% (13.3%, 2.7%, and 1.3% for stages 1, 2, and 3 thinness respectively) reported for boys, and the 15.5% (11.2%, 2.6% and 1.6% for stages 1, 2, and 3 thinness respectively) reported for girls, using the IS standard are much more lower than the values reported in the said study. An earlier study in Nigeria, employing different techniques had reported prevalence of 4.8% (boys) and 2.4% (girls) for thinness.  A recent study in Ouagadougou reported prevalence of 13.7% for stage 2 thinness in schoolchildren  while another similar study in Pakistan reported prevalence of 10%.  The data presented here are however, comparable to figures reported in a study in Seychelles (25.7%, 6.7%, 1.2% for WHO standard and 21.4%, 6.2% and 2% for IS standard) that used both definitions used in this study.  The finding that more boys were thin, relative to girls corroborates an earlier report from Nigeria.  The IS standard under-diagnosed thinness relative to the WHO standard (though not significantly so), an observation that is seen in the study in Seychelles (especially for stages 1 and 2). This could have serious implications especially in the clinical practice and in public health epidemiology. However, it is crucial to note that for thinness while the IS reference is constructed to show how current BMI would correspond with the BMI at age 18, the WHO reference was constructed to refer to − 1, −2, and − 3 SD Though the above may justify the minor differences in diagnostic ability of the two methods in this population, the clinical implications of the three stages of thinness is unfortunately difficult to illumine due to factors like changes in body composition with growth, differences in the onset and velocity of growth spurts and variations in sexual maturation, and body frame characteristics in different groups/populations. ,,, These data however must be interpreted in the context as there is (as yet) no nationally representative study to develop threshold values for thinness that correlate with poor health in Nigerian children. This is important because at the individual level, parents may over-feed naturally slim children, in a bid to get them chubby - a situation that should be discouraged.
The prevalence of overweight was higher when the WHO standard was used (4.9% boys and 9.2% girls) relative to the IS standard (3.9% boys and 5.8% girls). The same trend is observed for obesity (WHO standard: 1.1% boys and 1.8% girls vs. IS standard: 0.3% boys and 1.0% girls). These figures are however a lot higher than the >0.2% reported by a recent study in Makurdi, Nigeria,  but lower than the 13.2% reported by an earlier study in Ajaokuta, also in Nigeria.  Overweight or obesity had been reported in 3.2% of boys and 10.4% of girls in Ghana, and in 0.5% of boys and 0.9% of girls in Uganda.  The said study however used self-reported height and weight to calculate the BMI, a procedure that is prone to bias. A study in Canada had reported prevalence of 26.7% and 11.3% for overweight and obesity respectively in children, using the WHO reference standards.  Our results show that girls were more overweight or obese compared to boys and this has been reported in other studies from developing countries. ,,,, The reverse is however the case in developed economies were boys are reportedly more overweight or obese than girls. , The explanation may be found in cultural practices that make boys do the difficult tasks that require physical exertion on one hand and that encourage the girls to gain weight in preparation for marriage on the other hand, in developing countries.  Furthermore, energy dense fast foods are often more available in developed countries. Even when such foods are found in developing countries, they are often out of reach of the majority of the population. This phenomenon (the effect of economics on nutrition) may also explain the difference in thinness and overweight/obesity found between our study and the recent study from Nigeria. 
Both boys and the girls were shorter than their respective median reference group after age 11-12 years. The females in this study were taller than the boys at the younger age groups, but were shorter from age 14 years. Between the ages 12 years and 15 years, the females weighed more and had higher BMI than the boys, who "over-took" them from age 16 onwards. This is not an isolated observation. Slight (but insignificant) differences have been reported in the prevalence of combined overweight and obesity in Western Sydney, Australia.  Furthermore, among well-nourished children, there is a common case of dimorphism where females experience the growth spurt first, and are initially taller and heavier than males, and males later as adolescents are taller and heavier than the females. 
This study is limited by the inclusion of only school-going children and adolescents. This necessarily implies that the study does not represent the general population (especially within the studied age-bracket). It is also known that BMI, as a diagnostic criterion for obesity, may miss out individuals who have more body fat than is healthy and yet may still have a normal BMI. Though BMI does not differentiate between the different storage sites of fat and does not define body fat composition properly, it is still a valid index and is usually very useful in epidemiologic studies like this, especially in developing countries, or when large sample sizes are required. This is the first study to our knowledge that compares two international reference data for the study of nutritional status in Nigerian children and adolescents. This and our sample size coupled with our robust design are the strengths of this study.
| Conclusion|| |
Of the studied population, 19.2% (WHO) and 15.5 (IS) of the girls, and 24.2 (WHO) 17.3 (IS) of the boys were thin. Though (irrespective of gender) the WHO standard diagnosed more of thinness in the subjects, the IS standard diagnosed more stage 3 thinness. Overweight/obesity was found in 6.0% (WHO), 4.2% (IS) of the boys and 11.0% (WHO), 6.8% (IS) of the girls. More boys were thin, whereas more girls were overweight/obese. The differences in the proportions of the population diagnosed with any of the studied conditions by the two methods used were not statistically significant. Under- and over-nutrition, typified by thinness and overweight/obesity respectively co-exist in the studied population. This poses tremendous health-care and health policy challenges as it shows that evidence of chronic nutrient deprivation on one hand, and positive energy balance on the other hand, paradoxically co-exist in the studied population. Urgent public health action is required to address the situation especially as adolescent health is a reflection of morbidity in late life.
| Acknowledgments|| |
We thank, immensely, our subjects and their parents/guardians, and the head teachers, principals and staff of the schools that participated in this study. Without them, this work would not have been carried out.
| References|| |
|1.||Nader PR, O'Brien M, Houts R, Bradley R, Belsky J, Crosnoe R, et al. Identifying risk for obesity in early childhood. Pediatrics 2006;118:e594-601. |
|2.||Ejike CE, Ugwu CE, Ezeanyika L. Physical growth and nutritional status of a cohort of semi-urban Nigeria adolescents. Pak J Nutr 2010;9:392-7. |
|3.||Kemp MW, Kallapur SG, Jobe AH, Newnham JP. Obesity and the developmental origins of health and disease. J Paediatr Child Health 2012;48:86-90. |
|4.||Zametkin AJ, Zoon CK, Klein HW, Munson S. Psychiatric aspects of child and adolescent obesity: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 2004;43:134-50. |
|5.||Schwimmer JB, Burwinkle TM, Varni JW. Health-related quality of life of severely obese children and adolescents. JAMA 2003;289:1813-9. |
|6.||Mushtaq MU, Gull S, Khurshid U, Shahid U, Shad MA, Siddiqui AM. Prevalence and socio-demographic correlates of stunting and thinness among Pakistani primary school children. BMC Public Health 2011;11:790. |
|7.||Goon DT, Toriola AL, Shaw BS, Amusa LO, Monyeki MA, Akinyemi O, et al. Anthropometrically determined nutritional status of urban primary schoolchildren in Makurdi, Nigeria. BMC Public Health 2011;11:769. |
|8.||Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. Maternal and child undernutrition: Global and regional exposures and health consequences. Lancet 2008;371:243-60. |
|9.||Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B, et al. Developmental potential in the first 5 years for children in developing countries. Lancet 2007;369:60-7. |
|10.||Cole TJ, Flegal KM, Nicholls D, Jackson AA. Body mass index cut offs to define thinness in children and adolescents: International survey. BMJ 2007;335:194. |
|11.||Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: International survey. BMJ 2000;320:1240-3. |
|12.||WHO Multicentre growth reference study group. WHO child growth standards based on length/height, weight and age. Acta Paediatr Suppl 2006;450:76-85. |
|13.||Cole TJ, Green PJ. Smoothing reference centile curves: The LMS method and penalized likelihood. Stat Med 1992;11:1305-19. |
|14.||de Onis M. The use of anthropometry in the prevention of childhood overweight and obesity. Int J Obes Relat Metab Disord 2004;28 Suppl 3:S81-5. |
|15.||Bovet P, Kizirian N, Madeleine G, Blössner M, Chiolero A. Prevalence of thinness in children and adolescents in the Seychelles: Comparison of two international growth references. Nutr J 2011;10:65. |
|16.||Daboné C, Delisle HF, Receveur O. Poor nutritional status of school children in urban and peri-urban areas of Ouagadougou (Burkina Faso). Nutr J 2011;10:34. |
|17.||Wang Y, Wang JQ. A comparison of international references for the assessment of child and adolescent overweight and obesity in different populations. Eur J Clin Nutr 2002;56:973-82. |
|18.||Deurenberg P, Deurenberg-Yap M, Guricci S. Asians are different from Caucasians and from each other in their body mass index/body fat per cent relationship. Obes Rev 2002;3:141-6. |
|19.||Duggan MB. Anthropometry as a tool for measuring malnutrition: Impact of the new WHO growth standards and reference. Ann Trop Paediatr 2010;30:1-17. |
|20.||Rosario AS, Kurth BM, Stolzenberg H, Ellert U, Neuhauser H. Body mass index percentiles for children and adolescents in Germany based on a nationally representative sample (KiGGS 2003-2006). Eur J Clin Nutr 2010;64:341-9. |
|21.||Peltzer K, Pengpid S. Overweight and obesity and associated factors among school-aged adolescents in Ghana and Uganda. Int J Environ Res Public Health 2011;8:3859-70. |
|22.||Twells LK, Newhook LA. Obesity prevalence estimates in a Canadian regional population of preschool children using variant growth references. BMC Pediatr 2011;11:21. |
|23.||Kimani-Murage EW, Kahn K, Pettifor JM, Tollman SM, Klipstein-Grobusch K, Norris SA. Predictors of adolescent weight status and central obesity in rural South Africa. Public Health Nutr 2011;14:1114-22. |
|24.||Hamaideh SH, Al-Khateeb RY, Al-Rawashdeh AB. Overweight and obesity and their correlates among Jordanian adolescents. J Nurs Scholarsh 2010;42:387-94. |
|25.||Kamath R, Kumar M, Pattanshetty S, Kamath A. Nutritional status assessment of school children in Mangalore city using the multicenter growth reference study WHO 2007 Z-scores. Int J Nutr Pharmacol Neurol Dis 2012;2:233-6. |
|26.||Yngve A, De Bourdeaudhuij I, Wolf A, Grjibovski A, Brug J, Due P, et al. Differences in prevalence of overweight and stunting in 11-year olds across Europe: The pro children study. Eur J Public Health 2008;18:126-30. |
|27.||Achat HM, Stubbs JM. Socio-economic and ethnic differences in the prevalence of overweight and obesity among school children. J Paediatr Child Health 2012; (e-pub ahead of print). |
|28.||Ozgüven I, Ersoy B, Ozgüven AA, Erbay PD. Evaluation of nutritional status in Turkish adolescents as related to gender and socioeconomic status. J Clin Res Pediatr Endocrinol 2010;2:111-6. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]