Underweight, overweight and obesity among Sudanese secondary school children of Khartoum State.

Salih, Osama Awad ; AbdelAziz, Enayat

Abstract

This cross-sectional study was undertaken to determine the prevalence of underweight, overweight and obesity among 270 Sudanese school-children aged 15-18 years in Khartoum State, Sudan. Anthropometric measurements of height and weight were made on 270 girls and boys in six secondary schools located in different areas of socio-economical strata. The body mass index (BMI) was computed according to areas of the standard equation. Under nutrition, overweight and obesity was defined following the internationally accepted BMI cut-off points. Results revealed that the overall rates of overweight and obesity were 28.5%% and 5.6%, respectively along 'with the 19.6% prevalence of undernutrition. Rate of overweight was very high among females (64%) compared to males (36); while the opposite was true for the obesity rates (60% males; 40% females). Results indicated a very strong correlation between the incidence of overweight and obesity from one side and the life style from the other side including: levels of physical activities, number of meals, nutrient contents of the meals, sleeping hours, hours of TV watching and means of transportation to and from the school. Results clearly showed the links between the obesity and overweight and the presence of chronic and nutrition related diseases such as diabetes, hypertension, and asthma. In addition, typical obesity-psychological symptoms such as feelings of social isolation, frustration and depression were also observed in this study.

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Introduction

Under- nutrition is still considered one of the major problems in public health in many countries affecting 30% or more of children under 5 years of age; being the most important mortality cause (55%) in this age group in developing countries (UNICEF, 1998). In developing countries nutritional deficit during prenatal and continuing in post-natal life is very common. This condition leads to stunting and important metabolic changes. Studies (Sawaya et al. 2005) suggested that, developing countries are harbouring double burden of obesity and undernutrition, especially among the poor, and suggests that stunting or chronic undernutrition increases the risk of obesity and hypertension later in life. Obesity has become a global health problem, affecting more than 1.3 billion adults in both developed and developing countries (WHO 2005). Overweight and obesity in childhood are known to .have significant impact on both physical and psychological health. Environmental factors, lifestyle preferences, and cultural environment play pivotal roles in the rising prevalence of obesity worldwide (Dehghan et.al, 2005). There is no consensus on a cutoff point for excess fatness of overweight or obesity in children and adolescents. Williams et a,1992, classified children as fat if their percentage of body fat was at least 25% and 30%, respectively, for males and females. The Center for Disease Control and Prevention defined overweight as at or above the 95th percentile of BMI for age and "at risk for overweight" as between 85th to 95th percentile of BMI for age. European researchers classified overweight as at or above 85th percentile and obesity as at or above 95th percentile of BMI (Dehghan et al. 2005). According to Bose et al. (2007) and Cole et al. (2000) individuals are classified as overweight or obese based on their body mass index (BMI), with the latter category having the higher BMI.

Materials and Methods

This study was conducted during the period April to December 2006. Two Hundred and Seventy Sudanese schoolchildren aged 6-9 years in Khartoum State, Sudan. Anthropometric measurements of height and weight were made on 270 girls and boys in six secondary schools located in areas of different socio-economical strata. The body mass index (BMI) was computed following the standard equation (BMI (kg/([m.sup.2]) = weight/[height.sup.2] ). Under nutrition, overweight and obesity was defined following the internationally accepted BMI cut-off points. All schoolchildren were invited to participate in this study and, only 270 agreed to participate. All subjects were required to complete a questionnaire that included specific questions on age and ethnicity under the supervision of their class teachers. Formal written ethical consent was obtained from the university and school authorities before commencement of the study. Written consents were obtained from parents of all the subjects after verbal concents were given by the students. Anthropometric measurements included height and weights were done by trained investigators made all anthropometric measurements following standard techniques. Height was measured without shoes correct to the nearest 0.1 cm using a stadiometer, and weight was measured in light clothes measured to the nearest 0.1 kg using a portable scale. The weighing scale was calibrated daily before the first measurement was taken. Height and weight were recorded to the nearest 0.1 cm and 0.5 kg, respectively. BMI was computed using the standard formula given below: Overweight and obesity was classified following the internationally recommended cut-off points (Cole et al. 2000). A chi-square test was undertaken to test for the association of age with the prevalence of overweight and obesity. All statistical analyses were performed using the Statistical Package for Social Sciences 5 (SPSS) package. Statistical significance was set at P < 0.05.

Results and Discussion

Nutritional status and prevalence of Undernutrition and Obesity

The global prevalence of obesity in children aged 5-17 years is approximately 10%, but this is unequally distributed, with the prevalence ranging from less than 2% in sub-Saharan Africa to over 30% in the Americas (Bose et al, 2007).

One of the limitations of this study was the small sample size (n=270). However, the findings are interesting; they showed that, 19.6% of the sample was underweight; 28.5% overweight and 5.6% obese. The percentage of underweight boys was higher (53%) compared to girls (47%), Table 1 similarly in the obese category 60% were boys, while in the overweight category, the percentage of girls (64%) was higher than the boys (36%). The rates of overweight and obesity observed in the present study are close to those reported Bose et al. (2007) who found that the overall rates of overweight and obesity were 17.63% and 5.10%, respectively. However, Dehghan et al. (2005) stated that 25% of children in the US are overweight and 11% are obese.

Results also showed that the percentage of underweight subjects decreases with increasing age in both boys and girls; 72% for age 15 to 16 years; 23% for age 16 to 17 years and 50% for age 17 to 18 years.

An opposite trend was observed in the overweight category were 40% the overweight subjects, their age was 15-16 years compared to 57% of the age group 16-17 years. Similarly the highest percentage of the obese (60%) were in the same age group. Bose et al. (2007) in their studies on obese children found that, there was a significant increase in the rate of overweight with increasing age

Lifestyle and Nutritional behavior of the underweight and obese boys and girls

There is supporting evidence that excessive sugar intake by soft drink, increased portion size, and steady decline in physical activity have been playing major roles in the rising rates of obesity all around the world (Dehghan et al. 2005). The self reported nutritional behaviors and the lifestyle of the respondents in this study are shown in table2. Results indicated that, the majority of respondents used to take three meals per day (66% underweight; 57% overweight and 53% for the obese categories). However, taking more than 3 meals, was higher among the obese (20%) followed by overweight (16%) and underweight (9%) categories.

The major meal for the underweight categories was the lunch (42%), while breakfast was the major meal for the obese (47%) and overweight (44%). However, supper comes second to breakfast for the overweight (35%) and obese (33%).

Looking into the nutrient composition of the major meal as stated by the respondents, it, was found that carbohydrate rich meals represents 100% of the meals of the underweight, normal weight, and the obese categories, compared, to the overweight group where 5% of them eat meat rich meals. The most noticeable observation for all groups is the very poor intake of vegetable and legumes.

Other nutritional behaviours were investigated among the study population, and the response was also reported in Table2. The results of the number of dishes per meal, showed that, the majority of all categories took in average 3 dishes per meal (53% for underweight; 50% for normal; 47% for obese and 39% for the overweight). The overweight and obese categories were higher in the number of dishes per meal that is more than 3 dishes (51% & 47% respectively) compared to the other groups. This result contradicts the previous one (poor intake of vegetables and legumes), this is mostly due to the fact that most respondents did not considered the cooked vegetables or legumes when they answered the question of vegetable and legumes intake. It was also found that, almost all categories used to eat in shared dishes which is the common eating style in the Sudanese culture. In order to have an insight on the availability of food for the offhand consumption by the respondents, they were asked about having refrigerators and/or fridges in their home. Results revealed that the majority of the respondents had refrigerators and/or fridges in their homes. However, the highest percentages were noticed among the Obese and overweight groups.

Lifestyle and physical activities of the underweight and obese boys and girls

Numerous studies have shown that sedentary behaviours like watching television and playing computer games are associated with increased prevalence of obesity (Dehghan et al, 2005). It is also agreed that the duration of sleep, television viewing and consumption of fried foods may be significant factors that contribute to overweight (Kuriyan et al. 2007; Merchant et al. 2007; Kain and Andrade, 1999).

Results (table 3) indicated that nutritional status of the respondents was closely related to physical activity. The obese group showed the lowest physical activity (33%), followed by 43% for overweight, 70% of the normal and 81% for the underweight. Looking into the means of transportation mainly to and from school as another indicator of physical activity, showed that only the obese (27%)and overweight (21%) had private cars (family car)to get them to school. On the other hand, respondents who used to walk to school were mainly from the underweight category (51%)compared to 17% overweight and 13% in the obese group. Similar results were also obtained when the study looked into sleeping hours of the respondents. Regarding the sleeping hours, the majority of the underweight (64%) used to sleep for less than 8 hours, compared to 31% of the overweight and 20% of the obese. However, respondents who sleep for more than 8 hours /day were higher in the overweight (21%) and obese (13%) compared to only 4% in the underweight. It was also found that 80% and 52% of the obese and overweight groups used to slept immediately after eating compared to only 9% of the underweight. Another interesting result was also observed regarding the hours spent in watching T.V. which reflects the sedentary lifestyle of the respondents. For instant the majority of the obese (40%) and overweight (38%) used to watch T.V. for more than 4 hours/day compared to only 4% of the underweight group where the majority (85%) of them spent less than 4 hours watching TV. Results showed that almost 80% of both obese and overweight groups had air cooler/air conditioner compared to 25% of the underweight. Regarding doing house work by respondents, it was found that, very few of respondents did some inside-house work (mostly girls). However, among those, the highest percentages were among the underweight (28%) compared to 20% of the overweight and only 7% of the obese group.

Psychological characteristics and behaviors of the underweight and obese boys and girls

Overweight and obesity in childhood are known to have significant impact on both physical and psychological health (Dehghan et al. 2005). The author found that psychological disorders such as depression occur with increased frequency in obese children

Certain psychological indicators (Table 4), were more pronounced among the obese and overweight groups. For instance, feeling of social isolation was found among 47% and 16% of obese and overweight respectively. Feeling of depression and frustration was common among (87% and 40% respectively) the obese groups and also among the overweight (65% and 23% respectively). However, 9% of the underweight expressed the same feeling of depression. Feeling of anxiety was also common among 27% of obese and 13% of overweight. Results also showed that 73% of obese and 54% of overweight were having a feeling of ashamed among their peers this was also found among 13% of underweight.

Self-reported diseases among the underweight and obese boys and girls

The increasing prevalence of obesity, particularly in developing countries is a major health concern due to the high risk factor that overweight and obesity present in a number of chronic diseases such as diabetes, cardiovascular diseases and certain types of cancers Both under- and over nutrition are known to alter immune competence (Samartin and Chandra, 2001). In the present study, respondents self-reported having different nutrition related diseases (Table5), mostly among the obese and overweight groups. For instant, diabetes was found common among 18% of the obese and 14% of the overweight compared to 14% in the underweight group. Eighteen percent of the obese and 16% of the overweight groups self-reported hypertension along with 14% of the respondents with normal nutrition status. However, Sawaya et al (2005) stated that undemutrition should also be recognized as a factor associated with increased blood pressure in childhood. It is suggested that not only intrauterine undemutrition but also its occurrence during childhood may influence the incidence of hypertension in adulthood.

Heart problems were reported by 9% and 2% of obese and overweight groups respectively. Stomach problems were more common among the underweight group (43%) and the normal group (33%) compared to 9% of the obese group. Joints pain was found among 9% of both the obese and overweight groups but, was higher among the normal subjects (29%). Only obese and overweight subjects reported asthma.

References

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Cole T.J; Bellizzi M.C; Flegal, K.M. and Dietz, W.H. (2000). Establishing a standard definition for child overweight and obesity worldwide: international survey. British Medical Journal 320:1240-1243.

Dehghan, M; Danesh, N.A and Merchant, A.T. (2005). Childhood obesity, prevalence and prevention. Nutrition Journal 4:24

Kain, J. and Andrade, M. (1999). Characteristics of the diet and patterns of physical activity in obese Chilean preschoolers. Nutrition Research. Volume 19, Issue 2, February 1999, Pages 203-215

Kuriyan, R; Bhat, S; Thomas, T; Vaz, M. and Kurpad, A.V. (2007). Television viewing and sleep are associated with overweight among urban and semi-urban South Indian children. Nutrition Journal, 6:25

Merchant, A.T; Dehghan, M; Behnke-Cook, D.and Anand, S.S. (2007). Diet, physical activity, and adiposity in children in poor and rich neighbourhoods: a cross-sectional comparison. Nutrition Journal 2007, 6:1

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Osama Awad Salih and Enayat AbdelAziz, (Nutrition Centre for Training and Research--Ahfad University for Women)

Table 1. Distribution of respondents by sex, age and nutritional Status

 Underweight Normal
 n=53 (19.6%) n=125 (46.3%)

Sex: % from % within % from % within
 Underweight Sex Normal Sex

Male 52.8 22.6 47.2 47.6
Female 47.2 17.1 52.8 45.2

Age % from % within % from % within
(years): Underweight Age Normal Age

15-16 71.7 24.5 64.8 52.3
16-17 22.6 11.9 28.8 35.6
17-18 5.7 21.4 6.4 57.1

 Overweight Obese
 n=77 (28.5%) n=15 (5.6%)

Sex: % from % within % from % within
 Overweight Sex Obese Sex

Male 36.4 22.6 60 7.3
Female 63.6 33.6 40 4.1

Age % from % within % from % within
(years): Overweight Age Obese Age

15-16 40.3 20 33.3 3.2
16-17 57.1 43.6 60 8.9
17-18 2.6 14.3 6.7 7.1

Table 2. Nutritional behaviour of the study population

 Underweight Normal
 n = 53 (19.6%) n = 125 (46.3%)

 % from % % from %
Number of Underweight within Normal within
Meals

Two meals 24.5 18.1 28 48.6
Three meals 66 20.8 64 47.6
> Three meals 19.4 16.7 8 33.3

Major meal % from % % from %
 Underweight within Normal within

Breakfast 37.7 18.3 38.4 44
Lunch 41.5 27.8 30.4 48.1
Supper 20.8 13.4 31.2 47.6

Major nutrients % from % % from %
per meal Underweight within Normal within

Carbohydrates 100 20.2 97.6 46.4
Meat 0.0 0.0 0.8 20
Legumes 0.0 0.0 0.8 100
Vegetables 0.0 0.0 0.8 100

Average No. of % from % % from %
dishes/meal Underweight within Normal within

< Three 30.2 37.2 14.4 41.9
Three 52.8 22 49.6 48.8
> Three 17 9 36 45

Eating style % from % % from %
 Underweight within Normal within

Separate Dish 7.5 17.4 13.6 73.9
Shared Dish 92.5 19.8 86.4 43.7

Ownership of % from % % from %
 Underweight within Normal within

Refrigerator 60.4 14.5 81.6 46.4
Fridge ' 30.2 11.9 48.8 45.5

 Overweight Obese
 n = 77 (28.5%) n = 15 (5.6%)
 % from % % from %

Number of Overweight within Obese within
Meals

Two meals 26 27.8 26.7 5.6
Three meals 58.4 26.8 53.3 4.8
> Three meals 15.6 40 20 10

Major meal % from % % from %
 Overweight within Obese within

Breakfast 44.2 31.2 46.7 6.4
Lunch 20.8 20.3 20 3.8
Supper 35.1 32.9 33.3 6.1

Major nutrients % from % % from %
per meal Overweight within Obese within

Carbohydrates 94.8 27.8 100 5.7
Meat 5.2 80 0.0 0.0
Legumes 0.0 0.0 0.0 0.0
Vegetables 0.0 0.0 0.0 0.0

Average No. of % from % % from %
dishes/meal Overweight within Obese within

< Three 10.4 18.6 6.7 2.3
Three 39 23.6 46.7 5.5
> Three 50.6 39 46.7 7

Eating style % from % % from %
 Overweight within Obese within

Separate Dish 1.3 4.3 6.7 4.3
Shared Dish 98.7 30.8 93.3 5.7

Ownership of % from % % from %
 Overweight within Obese within

Refrigerator 93.5 32.7 81.5 100
Fridge 59.7 34.3 73.3 8.2

Table 3. Distribution of respondents by physical activities;
transportation; sleeping hours and TV watching.

 Underweight Normal
 n = 53 (19.6%) n = 125 (46.3%)

Physical % from % % from %
activities Underweight within Normal within

Practicing 81.1 25.6 69.6 51.8

Means of % from % % from %
transportation Underweight within Normal within

Private car .0 .0 7.2 31
Service bus 28.3 13.8 47.2 54.1
Public transport 20.8 19 20 43.1
Walking 50.9 36.5 25.6 43.2

Sleeping hours % from % % from %
 Underweight within Normal within

< 8 hours 64.2 26.2 55.2 53.1
hours 32.1 16 33.6 39.6
> 8 hours 3.8 5.9 11.2 41.2
Sleeping after 9.4 5.8 23.2 33.7
eatin

TV watching % from % % from %
hours Underweight within Normal within

< 4 hours 84.9 26 71.2 51.4
4 hours 11.3 14 15.2 44.2
> 4 hours 3.8 3.7 13.6 31.5

Others % from % % from %
 Underweight within Normal within

Ownership of 28.3 9.3 59.2 46
collar/condition
Doing house 28.3 125.4 22.4 147.5
work

 Overweight Obese
 n = 77 (28.5%) n = 15 (5.6%)

Physical % from % % from %
activities Overweight within Obese within

Practicing 42.9 19.6 33.3 3

Means of % from % % from %
transportation Overweight within Obese within

Private car 20.8 55.2 26.7 13.8
Service bus 40.3 28.4 26.7 3.7
Public transport 22.1 29.3 33.33 8.6
Walking 16.9 17.6 13.3 2.7

Sleeping hours % from % % from %
 Overweight within Obese within

< 8 hours 31.2 18.5 20 2.3
hours 48.1 34.9 66.7 9.4
> 8 hours 20.8 47.1 13.3 5.9
Sleeping after 51.9 46.5 80 14
eatin

TV watching % from % % from %
hours Overweight within Obese within

< 4 hours 44.2 19.7 33.3 2.9
4 hours 18.2 32.6 26.7 9.3
> 4 hours 37.7 53.7 40 11.1

Others % from % % from %
 Overweight within Obese within

Ownership of 77.9 37.3 80 7.5
collar/condition
Doing house 19.5 25.4 6.7 1.7
work

Table 4. Some psychological indicator among the targeted study group:

 Underweight Normal
 n = 53 (19.6%) n = 125 (46.3%)

 % from % % from %
 Underweight within Normal within

Feeling of social .0 .0 4 20.8
isolation
Feeling of 9.4 5.1 24 30.6
depression
Feeling of 1.9 3.6 2.4 10.7
frustration
Feeling of 0.0 .0 3.2 22.2
anxiety
Feeling 13.2 8.6 16.8 25.9
ashamed among
peers

 Overweight Obese
 n = 77 (28.5%) n = 15 (5.6%)

 % from % % from %
 Overweight within Obese within

Feeling of social 15.6 50 46.7 29.2
isolation
Feeling of 64.9 51 86.7 13.3
depression
Feeling of 23.4 64.3 40 21.4
frustration
Feeling of 13 55.6 26.7 22.2
anxiety
Feeling 54.4 51.9 73.3 13.6
ashamed among
peers

Table 5. Presence of self-reported diseases among the targeted study
group
 Underweight Normal
 n = 53 (19.6%) n = 125 (46.3%)

 % from % % from %
 Underweight within Normal within

Diabetes 14.3 11.1 .0 .0
Hypertension .0 .0 14.3 25
Hypotension .0 .0 .0 .0
Heart .0 .0 .0 .0
problems
Joint pain .0 .0 14.3 37.5
Stomach 42.9 33.3 28.8 55.6
problems
Asthma .0 .0 .0 .0

 Overweight Obese
 n = 77 (28.5%) n = 15 (5.6%)

 % from % % from %
 Overweight within Obese within

Diabetes 14.3 66.7 18.2 22.2
Hypertension 16.7 58.3 18.2 16.7
Hypotension 4.8 66.7 9.1 33.3
Heart 2.4 25 27.3 75
problems
Joint pain 9.5 50 9.1 12.5
Stomach .0 .0 9.1 11.1
problems
Asthma 2.4 50 9.1 50