Pattern and Determinants of Nutritional Status Among Children Attending Primary Schools in a Rural and an Urban Community in Osun State; a Comparative Study

Pattern and Determinants of Nutritional Status among Children attending Primary Schools in a Rural and an Urban Community in Osun State; a Comparative study

BY ADEOMI, Adeleye Abiodun DEPARTMENT OF COMMUNITY MEDICINE, LAUTECH TEACHING HOSPITAL, OSOGBO

The National Postgraduate Medical College of Nigeria Faculty of Public Health

In partial fulfilment of the requirements for the award of the Fellowship of the National Postgraduate Medical College of Nigeria (Public Health)

November, 2013

DECLARATION

I, ADEOMI Adeleye Abiodun, hereby declare that this work was carried out by me under the supervision of Dr. J. O. Bamidele. This work has not been submitted for any other examination or publication.

______Dr. ADEOMI Adeleye Abiodun Candidate

CERTIFICATION

We hereby certify that this research titled “Pattern and Determinants of Nutritional Status among School-Age Children in a Rural and an Urban Community in Osun State; a

Comparative study” was carried out and completed by ADEOMI Adeleye Abiodun in the

Department of Community Medicine, LAUTECH, Osogbo and under the supervision of Dr.

J. O. Bamidele.

______Dr. Bamidele J. O. Supervisor Consultant and Reader, Community Medicine Department, LAUTECH Teaching Hospital.

______Dr. Olugbenga-Bello A.I.

Head of Department Community Medicine Department, LAUTECH Teaching Hospital. Ogbomoso.

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DEDICATION

This work is dedicated to God Almighty, who alone is worthy of all the praise and glory.

ACKNOWLEDGEMENT

I wish to heartily acknowledge the understanding, support, encouragement and assistance of my supervisor Dr J.O. Bamidele during the course of carrying out this research. Thank you for always believing in me, and accepting to guide me through this work. I also appreciate the efforts of Dr. Abodunrin for always being there. I appreciate the Head of Department, Dr

(Mrs) Olugbenga-Bello, and other Consultants in the Department for their encouragement and support.

I appreciate the support given to me by the Ministry of Education, the Local Inspector for

Education (Miss Tutu Olunlade), Headmaster of St Peter Primary school, (Mr Ogunleye) pupils and the research assistants. I wish to express my gratitude to my wife (Olaitan

Adeomi), for her love, understanding and encouragement without which it would have been extremely difficult to go this far.

I wish to appreciate my friend and my brother, Dr Tosin Adeoye for his continual support throughout this project and my entire residency programme. I also wish to appreciate other family members and my friends, and especially Ayomide Adebonojo and Sunday Adeomi for their assistance throughout this research work.

Thank you all!

TABLE OF CONTENTS Content Page Number Title page i Declaration ii Certification iii Dedication iv Acknowledgement v Table of Contents vi List of Tables viii List of Figures x List of Plates xi Abbreviations xii Abstract xiii CHAPTER ONE - INTRODUCTION 1.1 Background to the Study 1 1.2 Magnitude of the Problem 3 1.3 Justification of the Study 5 1.4 Objectives 8 CHAPTER TWO – LITERATURE REVIEW 2.1 Introduction 9 2.2 The Double Burden of Malnutrition 9 2.3 Childhood Malnutrition 11 2.4 Childhood Obesity 12 2.5 Epidemiology of Childhood Undernutrition 13 2.6 Epidemiology of Childhood Obesity 15 2.7 Determinants of Childhood Undernutrition 17 2.8 Determinants of Childhood Obesity 19 2.9 Measurement of Nutritional Status of School-Age Children 20 2.10 Health Implications of Childhood Undernutrition 22 2.11 Health Implications of Childhood Obesity 22 CHAPTER THREE – METHODOLOGY 3.1 Description of the Study Area 25 3.2 Study Design 26 3.3 Study Population 26

3.4 Sample Size Determination 26 3.5 Sampling Technique 27 3.6 Research Instruments 29 3.7 Pretesting of Research Instrument 30 3.8 Data Collection 30 3.9 Data Management 31 3.10 Ethical considerations 33 3.11 Limitations of the Study 33 CHAPTER FOUR – RESULTS 35 CHAPTER FIVE – DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS Discussion 59 Conclusions 69 Recommendations 70 REFERENCES 72 APPENDIX 1 List of Local Government Areas in Osun State 83 2 Selected Schools in the Selected Rural and Urban Communities 84 3 Number of Respondents Selected in each Class in the Selected Schools 85 4 Questionnaire 86 5 Questionnaire in Yoruba Language 90 6 Ethical Clearance 94 7 Permission from Osun State Ministry of Education 95 8 Consent form for Parents 96 9 Map of Osun State 97 10 Approval from National Postgraduate Medical College 98 PLATES 99

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LIST OF TABLES

Table 4.1: Socio-Demographic Profile of the Respondents by their Residence 35

Table 4.2: Socio-economic Status of the Parents of Respondents by their Residence 36

Table 4.3: Nutritional History of Respondents by Residence 37

Table 4.4: Physical Activities of Respondents by their Residence 39

Table 4.5: Pattern of Nutritional Status of Respondents by their Residence 41

Table 4.6: Respondents’ Perception of their Nutritional status by Residence 42

Table 4.7: Intestinal Helminthic Infection Pattern among Respondents by their Residence 43

Table 4.8: Effect of Socio-Demographic Factors on the Nutritional Status of Respondents according to the WHO criteria 44

Table 4.9: Effect of Socio-Demographic Factors on the Nutritional Status of Respondents according to the IOTF criteria 45

Table 4.10: Effect of Socio-Economic Status on the Nutritional Status of Respondents according to the WHO criteria 46

Table 4.11: Effect of Socio-Economic Status on the Nutritional Status of Respondents according to the IOTF criteria 47

Table 4.12: Effect of Food Patterns on the Nutritional Status of Respondents according to the WHO criteria 48

Table 4.13: Effect of Food Patterns on the Nutritional Status of Respondents according to the IOTF criteria 49

Table 4.14: Effect of Categorized Food Patterns on the Nutritional Status of Respondents 50

Table 4.15: Effect of Physical Activity on the Nutritional Status of Respondents according to the WHO criteria 51

Table 4.16: Effect of Physical Activity on the Nutritional Status of Respondents according to the IOTF criteria 52

Table 4.17: Effect of Categorized Activity Patterns on the Nutritional Status of Respondents 53

Table 4.18: Effect of Helminthic Infection on the Nutritional Status of Respondents 54

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Table 4.19: Effect of Selected Numeric Variables on the Nutritional Status of Respondents according to the WHO criteria Using Analysis of Variance (ANOVA) 55

Table 4.20: Effect of Selected Numeric Variables on the Nutritional Status of Respondents according to the IOTF criteria Using Analysis of Variance (ANOVA) 56

Table 4.21: Relationship between BMI and other Continuous Variables using Linear Regression and Correlation Analyses 57

Table 4.22: Multiple Regression Analysis between BMI and the Significantly Associated Continuous Variables 59

LIST OF FIGURES

Figure 4.1: Categorized Food Patterns of Respondents by their Residence 38

Figure 4.2: Categorized Activity Patterns of the Respondents by their Residence 40

LIST OF PLATES

Plate 1: Photograph showing a Research Assistant during Data Collection in one of the 99

Primary Schools

Plate 2: Photograph showing a pupil showing Universal bottle for Stool Collection 100

Plate 3: Photograph showing the Researcher taking the Height of a pupil in one of the 101 Primary Schools

Plate 4: Photograph showing a Research Assistant taking the Weight of a Pupil 102

ABBREVIATIONS

ANOVA - Analysis of Variance

BMI - Body Mass Index

DBM - Double Burden of Malnutrition

IOTF - International Obesity Task Force

LGA - Local Government Area

NCD - Non-Communicable Disease

NDHS - Nigeria Demographic and Health Survey

NGO - Non-Governmental Organisation

UNICEF - United Nations Children Fund

WHO - World Health Organisation

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ABSTRACT

BACKGROUND AND OBJECTIVES: Childhood undernutrition has been the major problem among children in low-income countries. Nevertheless, owing to progressive urbanization and the associated changes in lifestyle, childhood overweight/obesity is becoming an equally challenging, yet under-recognized problem in many emerging countries.

This study therefore aimed to determine the prevalence of underweight and overweight/obesity and to compare the pattern and determinants of nutritional status among children attending primary schools in two communities, one rural and the other urban, in

Osun state, Nigeria.

MATERIALS AND METHODS: A cross sectional analytical study was carried out among school-age children attending primary/elementary schools in a purposefully selected rural

(Boripe Local Government Area) and urban (Osogbo Local Government Area) communities of Osun State. Three hundred respondents each were selected from the rural and urban communities using multi-stage sampling technique. Information from respondents was obtained using pre-tested semi-structured questionnaires and their weights and heights were measured and used to calculate their Body Mass Index (BMI). The BMI was used to classify them into those underweight, normal and overweight/obese using the World Health

Organisation (WHO) and the International Obesity Task Force (IOTF) criteria. Data analysis was done with Statistical Package for Social Sciences (SPSS) version 16.

RESULTS: There were significant differences in the religion, tribes, number of children in the families and family settings of children in the urban and rural communities. The children also differed significantly in their nutrition history, activity patterns and intestinal helminthic infection patterns according to their residence. The mean Body Mass Index (BMI) for children in the urban and rural communities were 16.24 ± 2.42 and 14.90 ± 2.02 respectively

xiii and this difference was also statistically significant. Using the WHO growth reference for school-age children, the prevalence rates of underweight and overweight/obesity in the rural community were 41.0% and 0.0% respectively; and 18.3% and 14.7% in the urban community respectively. With the IOTF criteria, the prevalence rates of underweight and overweight/obesity in the rural community were 36.7% and 0.0% respectively; and 17.3% and 9.7% in the urban community respectively. Socio-demographic characteristics like family size and family setting were significantly associated with nutritional status, while nearly all the variables used to estimate the socio-economic status were significantly associated with the nutritional status of the children. The feeding patterns, activity patterns and intestinal helminthic infection were also significantly associated with the nutritional status of the children.

CONCLUSION: The study concluded that undernutrition is still a major problem among school-age children in Osun State, especially for those living in rural communities. There is also a rising trend of overweight/obesity in the urban communities in the State. The factors associated with these patterns of nutritional status among the school-age children included socio-demographic and socio-economic factors, feeding patterns, activity patterns and intestinal helminthic infection. A comprehensive school health programme for the primary schools with emphasis on good nutrition is hereby recommended. Decision makers in primary education should also include sports as a mandatory component of primary school education in Nigeria.

KEY WORDS: School-Age; Children; Rural; Urban; Nutritional Status; Undernutrition;

Overweight; Obesity;

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CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Thirty years ago, the focus of international nutritionists was on childhood malnutrition and the related problem of how to feed the world’s burgeoning population, especially the children.1 Today, the World Health Organization (WHO) finds itself needing to deal with the new pandemic of obesity and its accompanying non-communicable diseases (NCDs), while the challenge of childhood malnutrition is still far from being over.1

Deficiency in macro- and micronutrients has been the major problem among children in low- income countries for many years.2–5 Nevertheless, owing to progressive urbanisation, economic growth and the associated changes in lifestyle, the energy balance is shifting;6 childhood overweight and obesity is becoming equally challenging, yet under-recognised, problem in many emerging countries.2,7–9 Childhood overweight/obesity was previously a health problem for developed countries because of their high calorie foods, labour-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.10 This epidemic of obesity sits alongside the problem of undernutrition in many developing countries thereby creating a double burden of nutrition- related ill health among children,10–13 which has been more appropriately referred to as the

'Double Burden of Malnutrition' (DBM).14

Anthropometry is internationally recognized as an important public health indicator for monitoring nutritional status and health in populations.15 Childhood undernutrition, measured as poor anthropometric status has been found to have an association with child mortality, and

xv a substantial contribution is made by all degrees of undernutrition to child mortality.15–17

There is also strong evidence that poor growth is associated with delayed mental development, reduced intellectual achievement, significant functional impairment in adult life and reduced work capacity.15,18,19

Obesity is the consequence of a long-term imbalance between energy intake and energy expenditure, determined by food intake and physical activity and influenced by biological and environmental factors.20–24 These factors affect energy balance on different levels and may interact, thereby making the particular causal pathways involved to remain unclear to a certain extent.25 The rapid rate of increase in obesity however, suggests that behavioural and environmental influences play a fundamental role in its development.26,27 The prevalence of obesity has continued to rise at an alarming rate worldwide to such an extent that it has been described as a global epidemic in the academic literature as well as in the popular media.28

Some authorities have even warned that the rising prevalence of childhood obesity will be

“modernity’s scourge” and that it is capable of reversing the observed improvements in life expectancy trends.29,30

Lucas, in the book Nutrition, Food and Diet Therapy,31 described growth assessment (which is the process of measuring a child’s weight, height/length and/or head circumference with the aim of evaluating the health of the child) as the best method for determining health and nutritional status in children. Using growth assessment, it would be possible to identify children with nutritional problems. Among the nutritional assessment methods, the anthropometric technique has been said to be the cheapest and quickest method that shows nutritional condition in both short and long terms.32 The Body Mass Index (BMI), derived from body weight in kilogrammes divided by height in metres squared, has been described as

xvi the most appropriate variable for nutritional status among school-age children and adolescents.33

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1.2 Magnitude of the Problem

Studies have shown that malnutrition remains the world's most serious health problem and the single biggest contributor to child mortality.34 Garrow et al in 2000 reported that about half of the world’s children suffer from stunting (height-for-age criteria) and 10%-15% of them from wasting (weight-for-height criteria).35 The United Nations Children’s Fund

(UNICEF) in the State of the world’s children, 2005 estimates that about 90 million children suffer from severe malnutrition.36

The vast majority of these underweight children live in developing regions, mainly in Asia and Africa.37 de Onis et al19 did a systemic analysis in the year 2000, on nationally representative data derived from surveys conducted in developing countries and found that nearly one third of the children in the developing world were either underweight or stunted and more than 30% of them suffered from micronutrient deficiencies. They also reported that although child malnutrition, as measured by stunting, had generally declined globally, progress had been uneven across regions. Despite this decline, they found that malnutrition continues to remain a major public health problem particularly in sub-Saharan Africa and that the rates of stunting in much of sub-Saharan Africa and South-central Asia were rising.19

The United Nations University (UNU) in collaboration with UNICEF in the year 2000 reported that more than 200 million school-age children are stunted and if no action is taken, and at this rate, about 1 billion stunted school children will be growing up by 2020 with impaired physical and mental development.38 In 2010, according to the Growth and

Assessment Surveillance Unit of the WHO, the global prevalence rate of malnutrition among school-age children as indicated by the prevalence of stunting, was approximately 28% (171 million children), with Eastern Africa suffering a higher rate of 45%.39 Drake and colleagues in 2002 conducted one of the largest studies in anthropometric status of school-age children

xviii in low income countries like Ghana, Tanzania, Indonesia, Vietnam and India, the overall prevalence of stunting and underweight was found to be high in all the five countries ranging from 48% to 56% for stunting and from 34% to 62% for underweight.40 Similarly, Abidoye and Soroh, in their study carried out in south-western Nigeria in the year 1999, reported prevalence rates of 38.2% and 40.5% for wasting and stunting respectively in school-age children (5-10 years).41

According to Wang and Lobstein,42 the prevalence of overweight and obesity among school- age children is rising in almost all industrialized countries for which data are available, and in several lower-income countries. Estimates for the global prevalence of overweight and obesity among children were made for 2006 by Wang and Lobstein,42 when it was concluded that approximately 10% of school-age children (5-17 years) were overweight and 2-3% were obese. In actual numbers, the estimate suggested some 150–160 million school-age children in the world were overweight, of which some 35-40 million were obese.43

There has been a worldwide increase in obesity among people of all ages. As many as 250 million people, or about 7% of the current world population, are obese. Two to three times more people are overweight.44 Overweight and obesity now ranks as the fifth leading global risk for mortality.45 In addition, 44% of the diabetes burden, 23% of the ischaemic heart disease burden and between 7% and 41% of certain cancer burdens are attributable to overweight and obesity.45,46 It is even more worrisome that the incidence of these chronic or non-communicable diseases is escalating much more rapidly in developing countries than in industrialized countries.47 According to World Health Organization estimates, by the year

2020, non-communicable diseases will account for approximately three quarters of all deaths in the developing world.48 In this regard, a potential emerging public health issue for developing countries may be the increasing incidence of childhood obesity, which is likely to

xix create an enormous socioeconomic and public health burden for poorer nations in the near future.47,49

Most public health nutrition programmes have focused on undernutrition and food security.1,43 From the information available, the prevalence of childhood obesity remains low in this region, although it appears to be rising in several countries with Nigeria inclusive.50 A

Nigerian survey reported the prevalence of childhood obesity among urban girls and boys

(aged 6-13 years) ranging from 0.9-21.4% and 0.9-12.9% respectively.51 Studies in Nigeria have also shown a marked difference in the prevalence of overweight/obesity in urban and rural areas, with urban areas having more overweight or obese children.51,52 A study that was conducted in Lagos, Nigeria reported prevalence rates of 3.3% and 0.2% for urban and rural areas respectively.52

1.3 Justification of the Study

Growth assessment is the single measurement that best defines the health and nutritional status of children, because disturbances in health and nutrition, regardless of their aetiology, invariably affect child growth.19 Poor growth is attributable to a range of factors closely linked to overall standards of living and the ability of populations to meet their basic needs, such as access to food, housing and health care. The assessment of growth not only serves as a means of evaluating the health and nutritional status of children, but also provides an excellent measurement of the inequalities in human development faced by populations.19

Growth assessment thus serves as a means for evaluating the health and nutritional status of children, just as it also provides an indirect measurement of the quality of life of an entire population.19

The school-age children form a substantial fraction of the world’s population, estimated at

24% of the population of developing countries and about 15% in industrialised countries.53 In

Kenya, school children aged 5-14 years form the largest fraction (27.5%) of the total population, making their nutritional status to be of importance.53 However, not much emphasis has been put on this group, instead the focus of most nutritional surveys and interventions has been on pre-school children only.54 There is therefore a need for necessary attention to be given to this group of children, as it will have an impact on the social and economic development of a country.55 This is so because, preventing malnutrition (either undernutrition or obesity) will prevent the morbidity and mortality associated with these states, hence helping to build a healthy workforce that will ensure a higher productivity at individual, societal and national levels.56

Until now, most national public health programmes and policies, as well as national-level research on children of low- and middle-income countries, have focused on undernutrition and its effects on the survival and mortality of mothers and children. However, based on current knowledge and extrapolation from studies carried out in adults and high-income countries, it may be more appropriate to consider childhood overweight/obesity and its complications, in addition to nutritional deficiencies.47 It is important to increase research into the prevalence of childhood overweight/obesity in developing countries because childhood obesity and related co-morbidity will increase the impact of a number of risk factors for adult diseases, and this will be a double burden to many developing countries that are still grappling with the public health effects of undernutrition and micronutrient deficiencies.47 The knowledge of nutritional status at younger ages carry greater importance because younger children possess improved potential for early intervention.57,58

The lack of comparability between survey results has presented a major difficulty in monitoring trends in nutritional status of children.19 Many of nutritional surveys have been conducted, but various anthropometric indicators, reporting systems, cut-off points and

xxi reference values were used, making comparison between the studies difficult.19 Recently, two growth references that apply the indicator of BMI-for-age have been developed for the classification of overweight and thinness in school-age children and adolescents based on international survey of nationally representative samples of children.59–61 The International

Obesity Task Force (IOTF) released a growth reference for overweight and obesity in 200059 and seven years later, they developed three grades of thinness60 for school-age children and adolescents. Also in 2007, the WHO released a growth reference for 5-19 years, based on the same principle as the IOTF.61 Only very few studies have been done on nutritional status of school-age children in Nigeria using these growth references. It is therefore important that studies of this nature be carried out using these references, so as to ensure comparability with findings from other parts of the world.

This study is therefore intended to describe the pattern and find out the determinants of nutritional status among school-age children in a rural and an urban community in Osun

State, Nigeria. It will further compare the status and the determinants in rural and urban communities. It is envisaged that data from this study will be useful for health policy makers, educators and other stakeholders in planning appropriate intervention programmes targeting school-age children.

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1.4 Objectives

1.4.1 General Objective

To compare the pattern and determinants of nutritional status among children attending primary schools in a rural (Boripe LGA) and an urban (Osogbo LGA) community in Osun state, Nigeria

1.4.2 Specific Objectives

1. To evaluate the demographic and socio-economic status of children attending primary

schools in a rural (Boripe LGA) and an urban (Osogbo LGA) community in Osun

state.

2. To determine the prevalence of underweight, overweight and obesity among children

attending primary schools in a rural (Boripe LGA) and an urban (Osogbo LGA)

community in Osun state.

3. To identify the determinants of the nutritional status among children attending

primary schools in Boripe and Osogbo LGAs in Osun state.

4. To compare the pattern and determinants of nutritional status of children attending

primary schools in a rural (Boripe LGA) and an urban (Osogbo LGA) community in

Osun state.

xxiii

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

Despite the economic growth observed in developing countries, undernutrition is still highly prevalent.62 Concurrently, a growing prevalence of obesity and its related chronic diseases is being observed in these countries.1 Increasing obesity is already a major concern in developed countries for pre-school children63 as well as school-age children.64 In developing countries, this rising epidemic along with the persistence of undernutrition and infections typifies the 'Double Burden of Malnutrition' (DBM),14 which is becoming of great concern for African countries.65 Indeed, the DBM is a real threat at the population, household and even individual level,66 and it is now observed among school-age children.67,68

2.2 The Double Burden of Malnutrition

The paradoxical coexistence of obesity with undernutrition has been stressed by a number of commentators, particularly in relation to the situation in Central and South America where the nutrition transition is more advanced.69 Doak et al69 have shown that a large number of households, particularly in middle-income countries, contain both underweight and obese individuals and describe these as ‘dual burden’ households.1

Today the WHO finds itself needing to deal with a ‘double burden’ of disease that threatens to overwhelm the health services of many resource-poor countries; the new pandemic of obesity and its accompanying NCDs while the challenge of childhood undernutrition has far from disappeared. WHO warns that the greater future burden of obesity and diabetes will affect developing countries, and the projected numbers of new cases of diabetes run into the hundreds of millions within the next two decades. The obesity pandemic is transmitted through the vectors of subsidized agriculture and multinational companies providing cheap,

xxiv highly refined fats, oils, and carbohydrates, labour-saving mechanized devices, affordable motorized transport, and the seductions of sedentary pastimes such as television. This epidemic of obesity co-existing with the problem of undernutrition in many developing countries as been termed the 'Double Burden of Malnutrition' (DBM).10–14

A number of low- and middle-income countries have experienced a transition from under- to over- nutrition problems or, quite frequently, a double burden of both undernutrition and obesity.14 For example, in Brazil between 1974 and 1997, the prevalence of overweight among children aged 6-18 years more than tripled (4.1% to 13.9%), while the prevalence of underweight decreased from 14.8% to 8.6%.7 There is increasing evidence that underweight and overweight may exist among family members within the same household, especially as low income, urbanized populations adopt westernized diets.42,70

The sub-Saharan Africa is also not left out of this double burden of malnutrition. Kennedy et al71 in 2006 assessed the double burden of malnutrition in some developing countries and found that countries, such as South Africa and the United Republic of Tanzania, report no decline in numbers of cases of infectious diseases including tuberculosis (TB), malaria and

HIV/AIDS, while the incidences of coronary heart disease (CHD), diabetes and stroke are on the rise. They also reported that there was increasing documentation of rising rates of overweight and obesity among children and adults in these countries, and slow progress in reducing undernutrition, particularly in children under five years of age.71 For instance in

South Africa, stunting has remained at levels of public health importance, underweight and wasting are declining while childhood overweight/obesity is on the increase. In adults, overweight/obesity is more of a problem than underweight and there is rising incidence of non-communicable diseases and cancer.71,72

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2.3 Childhood Malnutrition

The term “malnutrition” is no exception to those highly ambiguous terms in scientific literature.73 It has been defined as any physical condition resulting either from an inappropriate or inadequate diet, such as a diet that either provides too much or too little of necessary nutrients, or from a physical inability to absorb or metabolise nutrients.74

Malnutrition causes disease and death, and has a negative impact on both quality of life and learning. Indeed, malnutrition refers not only to inadequate dietary intake or undernutrition, but also to over-nutrition and nutritional deficiencies.74 The term malnutrition, however, is usually used to refer solely to undernutrition,73 therefore this term (i.e. malnutrition) will be used in this study to refer to undernutrition.

According to WHO global database on child growth and nutrition released in 1997,75 malnutrition signifies an imbalance between the supply of protein and energy and the body’s demand for them to ensure optimal growth and function. This imbalance of protein and energy intake leads to malnutrition in the form of stunting, wasting and underweight. In practice, stunting is defined as a height-for-age measurement and it is generally considered a marker of chronic malnutrition.76 By contrast, acute malnutrition, termed as wasting is defined by a weight-for-height indicator. In addition, a composite form of malnutrition, known as underweight or undernutrition is defined with a weight-for-age indicator and it is an indicator of both chronic and acute malnutrition.76

Drake et al, in the article “school-age children: their health and nutrition” prepared for

Partners in Child Development in 200240 reported that stunting occurs mainly in early childhood and through a cumulative process. Children stunted at school-age are likely to have been exposed to poor nutrition since early childhood and the degree of stunting tends to increase throughout the school-age years.40 They further opined that underweight among

xxvi school-age children, like stunting, can reflect a broad range of insults such as prenatal undernutrition, deficiencies of macro- and micro-nutrient, infection and, possibly, inadequate attention by care givers. Wasting, which reflects acute malnutrition, was said to be not as common as either stunting or underweight in school-age children.40

The challenge of malnutrition is much greater in Sub-Saharan Africa. The region is home to most of the world’s poorest countries, where prevalence of undernourishment is high and prospects for immediate and rapid economic growth limited.77 Osibogun, in his book, “a handbook of public health nutrition for developing countries” opined that the heavy depletion of state funds by corrupt political leaders as well as the ravaging effects of wars and strife result in economic instability and translates to low standard of living of the people.78 This low standard of living, according to the World Bank, has been strongly associated with malnutrition, because levels of malnutrition are higher in poor countries than in better-off countries.79

2.4 Childhood Obesity

Obesity can be defined as a disease in which excess body fat has accumulated such that health may be adversely affected.80 In clinical practice, body fat is most commonly and simply estimated by using a formula that combines weight and height. The underlying assumption is that most variation in weight for persons of the same height is due to fat mass, and the formula most frequently used in epidemiological studies is Body Mass Index

(BMI).80

The World Health Organization81 defined overweight and obesity as abnormal or excessive fat accumulation that may impair health. Childhood obesity is also said to be associated with a higher chance of obesity, premature death and disability in adulthood.81 Although not all obese children become obese adults, research reveals that obesity in early childhood is predictive of obesity later in life,82,83 and this is a reason for the concern about childhood

xxvii obesity. Nader et al in 2006 carried out a longitudinal study on 1042 healthy US children in

10 locations and found that, children who were overweight at ages 24, 36, or 54 months were five times more likely to be overweight at age 12 years compared to those not overweight.84

Moreover, Janssen et al in 2005 also found that overweight and obesity during childhood are strong predictors of obesity and coronary heart disease risk factors in young adulthood.83

Furthermore, Schonfeld-Warden and Warden in 1997 reported that obesity in children can predispose to hypertension, high cholesterol, impaired glucose tolerance, respiratory problems, dermatological manifestations and orthopaedic problems as well as negative psychological effects.85

A graded classification of overweight and obesity using BMI values provides valuable information about increasing body fatness. It allows meaningful comparisons of nutritional status within and between populations and the identification of individuals and groups at risk of morbidity and mortality.80 Knowing the pattern and determinants of nutritional status of children will help in planning appropriate interventional programmes for them at an individual or community level and for evaluating the effectiveness of such interventions.

According to Frongillo in 1999, children can exhibit catch-up growth if their environment improves. This suggests that interventions in school-age children can supplement efforts in the preschool years to reduce levels of stunting and related effects on children’s health and education.86

2.5 Epidemiology of Childhood Undernutrition

According to estimates from the food and agriculture organization (FAO) reported in the state of food insecurity in the world 2000,77 826 million people in the world were undernourished;

792 million people in the developing world and 34 million in the developed world.

Worldwide, malnutrition affects one in three people and each of its major forms dwarfs most

xxviii other diseases globally.87 The World Health Organization in 2001 reported that malnutrition affects all age groups, but that it is especially common among the poor and those with inadequate access to health education and to clean water and good sanitation. In the same report, WHO stated that more than 70% of children with protein-energy malnutrition lived in

Asia, 26% lived in Africa, and 4% in Latin America and the Caribbean.87,88

Globally, undernutrition among children is a major public health concern.55 Garrow et al in their book, Nutrition and dietetics published in the year 2000 estimated that about half of the world children were suffering from stunting and 10%-15% of them from wasting.35 Ninety million children were estimated to be suffering from severe malnutrition, according to

UNICEF in 2005,36 and most of these children live in developing regions, mainly in Asia and

Africa.37 Although child undernutrition, as measured by stunting, has generally declined globally, research has shown that it remains a major public health problem particularly in sub-Saharan Africa.19 In fact, the rates of stunting in much of sub-Saharan Africa and South- central Asia are rising.19

Studies in Nigeria about childhood malnutrition are scattered. Oninla et al in Ile-Ife, Osun state89 studied 749 pupils and reported overall prevalence rates of underweight, wasting and stunting to be 61.2%, 16.8% and 27.6% respectively, with the rural communities having a prevalence rate of underweight to be a little above 70%. Goon et al90 in Benue state also found that underweight and stunting occurred in 43.4% and 52.7% respectively, of the 2015 school-age children studied, and the boys were found to be more underweight (48.8%) than girls (38.5%). In Cross River state, Meremikwu and colleagues in 200091 reported prevalence rates of 37.9%, 21.5% and 6.7% for underweight, stunting and wasting respectively for rural school-age children. Fetuga et al in 201192 studied the nutritional status of semi-urban

Nigerian School Children using the 2007 WHO Reference Population in Ogun state and

xxix found the prevalence rates of underweight, stunting and thinness to be 25.5%, 14.2% and

22.2% respectively. Another Nigerian study among school-age children (5-10 years) in Lagos by Abidoye and Soroh in 1999,41 revealed rates as high as 38.2% and 40.5% for wasting and stunting rates respectively.

2.6 Epidemiology of Childhood Obesity

The prevalence of obesity has increased worldwide among people of all ages. In the consensus statement on childhood obesity by Speiser et al in 2005, as many as 250 million people, or about 7% of the world population, were said to be obese. Two to three times more people were overweight.44 In one of the most extreme examples, the prevalence of overweight doubled among children 6 –11 years of age and tripled among those 12–17 years of age in the United States between the second National Health and Nutrition Examination

Survey, conducted between 1976 and 1980, and the most recent such survey, conducted in

1999 and 2000. Approximately 14–15% of all 15 year olds in the United States can be classified as obese.44,93

Wang and Lobstein in 2006 found that the prevalence of childhood overweight and obesity varied considerably worldwide. North America, Europe, and parts of the Western Pacific had the highest prevalence of overweight among children (approximately 20-30%). Parts of South

East Asia and much of sub-Saharan Africa appeared to have the lowest prevalence. South and

Central America, Northern Africa and Middle Eastern countries fell in between. Importantly, the prevalence of overweight among school-age children in several countries undergoing economic growth, such as Brazil, Chile, Mexico and Egypt, had reached a level comparable to those in fully industrialized countries. When grouped according to WHO regions, Africa had the lowest prevalence of childhood overweight/obesity, put at 1.8%.42

xxx

Childhood obesity is currently a major health problem in many countries of the world.

According to Pierre et al in 2005, 16% of children 6-11 years old were overweight and an additional 14.3% were at high risk of becoming overweight.94 In a more recent report by

Lobstein in 2010, it was concluded that approximately 10% of school-age children (age range: 5-17 years) were overweight and 2-3% were obese. In actual numbers, the estimate suggested some 150-160 million school-age children worldwide were overweight, of which some 35-40 million were obese.43 Statistics also show that, prevalence of overweight continues to increase during the school-age and adolescent stages.95,96

Based on the secular trends, and assuming they continue on a linear basis, Wang and

Lobstein42 estimate that over 46% of school-age children will be overweight (IOTF criteria) in the Americas by 2010; along with approximately 41% of children in the Eastern

Mediterranean region, and 38% of children in the European region (which includes the countries of the former Soviet Union); 27% in the Western Pacific region, and 22% in South

East Asia. Data for sub-Saharan Africa were not adequate to make predictions.42 The prevalence of childhood overweight and obesity remains low in many lower-income countries, in particular those in Asia and sub-Saharan Africa where undernutrition is still a major public health problem.42

There are only a small number of surveys examining the prevalence of overweight and obesity among children in sub-Saharan Africa, with Nigeria inclusive. Available data however show that the prevalence of childhood obesity appears to be rising in many middle and low income countries.42,43 In a Nigerian study carried out in Ile-Ife, Osun State by Owa and Adejuyigbe in 1997,97 904 healthy children between 5 and 15 years were studied. The body fat mass, body mass index and mid-upper arm circumference were determined; 18% of them were discovered to be obese based on US standards 164. Another Nigerian survey

xxxi carried out in 2001 among urban children aged 6-13 years, reported the prevalence of childhood obesity in the range of 0.9-21.4% and 0.9-12.9% for girls and boys respectively.51

Adeleke, in a survey of Nigerian school children, found the prevalence of childhood obesity to be 16.7% among males and 20% among females, reiterating gender difference.98,99 Ansa et al100 studied 1005 school-age children (6-18 years) and reported prevalence of 2.3% in 6-12 years, 4% in 13-15 years and 3% in 16-18 years.

2.7 Determinants of Childhood Undernutrition

Individual nutritional status depends on the interaction between food that is eaten, the overall state of health and the physical environment. Malnutrition is both a medical and a social disorder, often rooted in poverty. Combined with poverty, malnutrition contributes to a downward spiral to a poor state of health that is fuelled by an increased burden of disease, stunted development and reduced ability to work.88

According to de Onis et al, poor growth is attributable to a range of factors closely linked to overall standards of living and the ability of populations to meet their basic needs, such as access to food, housing and health care.19 They further opined that assessment of growth not only serves as a means of evaluating the health and nutritional status of children, but also provides an excellent measurement of the inequalities in human development faced by populations.19 Fishman et al also reported that poverty is a strong underlying determinant that leads to household food insecurity, poor childcare, maternal undernutrition, unhealthy environments and poor health care.15 These factors then lead to the immediate determinants of childhood undernutrition, that is, low birth weight, inadequate dietary intake of nutrients and frequent infectious diseases.15,101

In their report on childhood and maternal underweight, Fishman et al stated that low birth weight, primarily due to intra-uterine growth retardation (IUGR) in developing countries, is a

xxxii consequence of maternal undernutrition prior to and during pregnancy and that it subsequently contributes to undernutrition in infancy and childhood.15 They also reported that the diets of many children in developing countries were inadequate, and these dietary deficiencies may involve not only the macronutrients, but also the so called micronutrients, that is, vitamins and minerals.15 Fishman et al opined that in young children, the frequently contaminated environments and poor childcare practices cause high rates of infectious disease. These infections result in a reduction in nutrient intake, as well as increased utilization and loss of nutrients, such as vitamin A and zinc.15

Nutritional status is clearly compromised by diseases with an environmental component, such as those carried by insect or protozoan vectors, or those caused by an environment deficient in micronutrients. But the effects of adverse environmental conditions on nutritional status have been reported to be more pervasive.102 Environmental contamination (e.g. destruction of ecosystems, loss of biodiversity, climate change, and the effects of globalization) has contributed to an increasing number of health hazards,103 and all affect nutritional status.

Overpopulation has been said to be a breakdown of the ecological balance in which the population may exceed the carrying capacity of the environment. This then undermines food production, which leads to inadequate food intake and/or the consumption of non-nutritious food, and thus to malnutrition.102

Helminthic infection, which has been reported to be highly prevalent in Nigeria, has also been reported to contribute to the high prevalence of malnutrition.91,104 Sur et al in India worked on periodic de-worming with albendazole and its impact on growth status, and they found that asymptomatic children with Ascaris lumbricoides grow better after they have been de-wormed.105 According to Runsewe-Abiodun and Olowu, frequent helminthic infections

xxxiii put a very heavy toll on the nutritional status of children through increased metabolic rate, anorexia and diarrhoea among other things.104

2.8 Determinants of Childhood Obesity

The aetiology of childhood obesity and subsequent diseases is poorly understood. Obesity is not a single disorder but a heterogeneous group of conditions with multiple causes. Body weight is determined by an interaction between genetic, environmental and psychosocial factors acting through the physiological mediators of energy intake and expenditure.80

Although genetic differences are of undoubted importance, the marked rise in the prevalence of obesity is best explained by behavioural and environmental changes that have resulted from technological advances.80

Obesity is likely to be explained by alterations in the regulation of energy balance between energy expenditure and energy intake.96 Energy balance is determined by a number of complex biological, behavioural, cultural, social, and environmental factors and the interactions between them.42,106,107 There is evidence suggesting that, reduced energy expenditure may be involved in the aetiology of childhood obesity.108 A study by Epistein and Nueman in 1998109 showed that, more than 65% of children 6-19 years of age eat a lot of fat and half of young people do not engage in regular physical activities. This creates an imbalance between intake and expenditure of energy, hence favouring accumulation of fats in the body. Changes in lifestyles in which children lead sedentary lifestyles lead to a low energy expenditure. An example is a child whose parents’ economic status improves, and so is carried around in cars, sits long hours behind the television and does no house chores.

Frequent use of cars to facilitate movement rather than walking and lack of aerobic exercises has been shown to contribute to low energy expenditure.110 Similarly, studies have shown that extensive use of electrical/electronic appliances such as television, video games and

xxxiv radios has made children spend much time watching television, and listening to radio programmes and playing electronic games and sports which make children more inactive.96,111,112

Socioeconomic status (SES) and ethnicity can affect overweight and obesity prevalence among adults and children, and these influences may vary according to the economic context.

For example, in middle-income countries, members of better-off households are more likely to be at risk of adiposity compared with members of poorer households, and urban residents may be more at risk than rural ones. In South Africa, the highest prevalence levels for overweight were found among young white (23%) and Indian populations (25%) compared with young Africans (17%).113 As the economies develop, the pattern changes to one where higher obesity levels are found among lower income groups.114 In industrialized, economically developed countries, children in the lowest SES groups may be at greatest risk, as may be children in specific racial or ethnic groups.7,93,115,116

2.9 Measurement of Nutritional Status of School-Age Children

The internationally recommended way to assess nutritional status at population level is to take body or anthropometric measurements (e.g. weight and height). Based on combinations of these body measurements anthropometric indices are constructed.117 These indices are essential for the interpretation of body measurements as, for example, weight alone has no meaning unless it is related to an individual’s age or height. While carrying out an analysis of changes in levels of child malnutrition since 1980 in the year 2000, de Onis et al found that the lack of comparability between survey results presented a major difficulty in monitoring trends in child malnutrition and obesity.19,117 de Onis et al also found out that many nutritional surveys had been conducted since the 1980s, but various anthropometric

xxxv indicators, reporting systems, cut-off points and reference values were used, making comparison between the studies difficult.19

In recent years, BMI has been increasingly accepted as a valid indirect measure of adiposity in school-age children and adolescents for survey purposes,118 leading to various approaches to selecting appropriate BMI cut-off values to take account of the fluctuations in BMI during normal growth. BMI-for-age reference charts have been developed by several organizations, such as the US National Centre for Health Statistics119 and national authorities in the UK and

France.43

Lobstein in his work on the prevalence and trends in childhood obesity opined that defining a single standard for children is more difficult than it is for adults. Healthy children have also been reported to show significant fluctuations in the relationship between weight and height as they grow through infancy and childhood.43 Confusion over the use of different reference curves led to the establishment of an expert panel, convened by the International Obesity

Taskforce (IOTF), which proposed a set of BMI cut-offs based on pooled data collected from surveys of children in Brazil, Britain, Hong Kong, Singapore, the Netherlands and the USA.

The panel agreed that overweight and obesity would be defined in children according to the

BMI centile curves that passed through the adult cut-off points of BMI 25 and 30 at age 18.

The resulting set of age- and gender-specific BMI cut-off points for children was published in

2000,59 and has been widely used by researchers and governments in subsequent years.43

Seven years later, the panel produced BMI cut offs for underweight using the same principle.60 Also in 2006, the World Health Organization (WHO) released a growth reference for 5-19 years61 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

xxxvi that were based on data collected between 1997 and 2003 in children aged 18-71 months living in favourable socioeconomic conditions in six developed and developing countries.120

2.10 Health Implications of Childhood Undernutrition

Children who suffer from growth retardation as a result of poor diets and/or recurrent infections tend to have increased numbers of severe diarrhoea episodes and a heightened susceptibility to certain infectious diseases, for example malaria, meningitis and pneumonia.121 A moderately underweight child has a five times higher risk of dying of diarrhoea and a four times higher risk of dying of respiratory infections and malaria compared to a child with normal weight.102

There is an association between increasing severity of anthropometric deficits and mortality, and a substantial contribution is made by all degrees of malnutrition to child mortality.17,34

Although the risk of dying is highest among the severely malnourished, when one considers the elevated risk of mortality associated with moderate malnutrition in combination with their high prevalence worldwide, it becomes clear that much of the burden of deaths as a result of undernutrition in young children is attributable to moderate, rather than to severe, undernutrition.17

Strong evidence exists that poor growth is associated with delayed mental development and that there is a relationship between impaired growth status and both poor school performance and reduced intellectual achievement.18 Long-term malnutrition results in shorter adult height, reduced economic productivity, lifelong impairments in neuro-cognitive and socio- emotional development and reduction in the long-term quality of adjusted life years.122

2.11 Health Implications of Childhood Obesity

Childhood obesity is now recognized as a major medical and public health problem. Obesity in adults is strongly associated with many serious medical complications that impair quality

xxxvii of life and lead to increased morbidity.44 Obese children are at high risk for adult obesity, but there are as yet insufficient data to assign specific risk levels in childhood. However, obesity in childhood provides an independent contribution to the development of adult morbidity.

Without proper intervention, adult morbidities will likely begin to appear in the young.44

There are strong epidemiologic and causal links between obesity in the young and earlier- onset Type 2 Diabetes Mellitus.123 Over the past decade, there has been an alarming increase in the appearance of Type 2 Diabetes Mellitus (T2DM) in children, a disease that formerly occurred almost exclusively in adults. T2DM in youth represents the most rapidly growing form of diabetes in America, Europe, Japan, and Australasia, now responsible for up to about one fifth of new diagnoses of diabetes in pubertal children.44,124

Hypertension occurs more commonly in obese persons at every age. Childhood obesity is the leading cause of paediatric hypertension.125 Genetic, metabolic and hormonal factors44 such as insulin resistance, increased serum aldosterone levels, salt sensitivity, and possibly elevated leptin levels are linked to the hypertension of obesity. Systolic blood pressure correlates positively with BMI, skin fold thickness, and waist-to-hip ratio in children and adolescents.44,125

Overweight children are susceptible to developing bony deformities that can predispose them to other orthopaedic problems later in life. Excess weight may cause injury to the growth plate and result in slipped capital femoral epiphysis, genu valga, tibia vara (Blount’s disease), flat kneecap pressure/pain, flat foot, spondylolisthesis (low back pain), scoliosis, and osteoarthritis.44,126 Acanthosis nigricans, frequently found in young obese individuals, is characterized by hyperpigmented, hyperkeratotic, velvety plaques on the dorsal surface of the neck, in the axillae, in body folds, and over joints. Severe skin changes correlate with elevated serum insulin levels and can be ameliorated by weight loss and consequent reduction

xxxviii in insulin resistance. Other skin problems commonly encountered include skin tags and keratosis pilaris.127

xxxix

CHAPTER THREE

MATERIALS AND METHODS

3.1 Description of the Study Area

The study area was Boripe LGA (rural community) and Osogbo LGA (urban community) in

Osun State which is situated in the South-western part of Nigeria and was carved out of old

Oyo State in 1991. It covers an area of approximately 14,875 square kilometres with Osogbo city as the State capital. The official population figure for the state is 3,416,959.128 Osun State lies within the tropical rain forest belt with thick, deciduous vegetation in the Southern part which becomes grassland towards the North. The State has numerous natural resources, a vast growing ecosystem, a growing economy and diverse culture.

Osun State has three senatorial districts namely Osun Central, Osun West and Osun East, each comprising of ten local government areas (making thirty (30) local government areas) and one area office, located in Osun East senatorial district. The thirty Local Government

Areas (LGAs) are grouped into eighteen (18) rural and twelve (12) urban local government areas according to Osun State Local Government Commission (Appendix 1). The people residing in the State are predominantly Yorubas, but tribes from other parts of the country such as the Hausas, Igbos, Edos and other nationalities such as Ghanaians and Togolese have also settled there.

Boripe LGA is one of the rural LGAs with the headquarters at Iragbiji. The official population figure for Boripe LGA is 138,742 and majority of the inhabitants are farmers.

Osogbo LGA on the other hand is one of the urban LGAs with headquarters at Oke-Baale.

Most of the inhabitants are traders, artisans, cloth dyers and civil servants with a population of 155,507.129

There are 1,207 public primary schools and 326 public secondary schools in the State. In addition there are numerous private nursery, primary and secondary schools in the State.

Tertiary institutions owned by both government and private organizations are situated in the

State. There are only a few private recreational parks for children in Osun State, while there are quite a number of eateries scattered all over the State. In different parts of the State there are 562 public health facilities (512 at Local Government Areas, 48 at State and 2 at tertiary levels). In addition there are 345 private and 10 missionary health institutions.129,130

3.2 Study Design

This is a cross sectional analytical study. It was carried out in one rural and one urban community in Osun State, Nigeria.

3.3 Study Population

Children attending primary/elementary schools in the two selected rural (Boripe LGA) and urban (Osogbo LGA) communities of Osun State formed the study group.

3.3.1 Inclusion criteria:

 Children attending primary schools in Boripe and Osogbo LGAs who were within the

age group 6 to 12 years where included in the study

3.3.2 Exclusion criteria:

 Children within the age group (i.e. 6 to 12 years), but who were already in the

secondary school were excluded from this study.

 Children within the age group, but who had acute illnesses like gastroenteritis, or

chronic illnesses like sickle cell anaemia were also excluded from the study.

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3.4 Sample Size Determination

The sample size was calculated using the formula for comparing two groups:131

2 N = 2(Zα + Zβ) P0(1- P0)

Where;

N = Minimum sample size

Zα = Critical ratio at significance level of 5%

Zβ = Statistical power at 90%

P0 = Means of the 2 prevalence in the 2 comparison groups i.e. (P1 + P2) /2

Taking the Prevalence in the two groups (P1 and P2) to be 70.5% and 52.2% from a previous

89 similar study. P0 = 0.71 + 0.52/2 = 0.615 d = Difference between P1 and P2 = 0.19

2 N = 2(1.96 + 1.28) 0.615(1-0.615)

0.192

= 137.7

= 138 respondents

The calculated minimum sample size is 138 children each for the selected rural and urban communities. After taking care of an anticipated non-response rate of 10%, the minimum sample size increased to 152 respondents, but 300 respondents each from urban and rural areas (i.e. total sample size of 600) were interviewed to enhance representativeness and to improve the precision of the study.

3.5 Sampling Technique

Multistage sampling technique was used

First stage: Using the grouping of the thirty (30) Local Government Areas (LGAs) in Osun

State into 18 rural and 12 urban LGAs by the Local Government Commission in Osun State

xlii

(Appendix 1), one rural and one urban LGA were selected by simple random sampling using balloting technique, which were Boripe and Osogbo LGAs respectively.

Second stage: The list of all primary/elementary schools in the selected rural and urban

LGAs were obtained from the Local Inspectors of Education. Four primary schools in each of the selected LGAs (ie Boripe and Osogbo LGAs) were selected by simple random sampling using balloting technique, making a total of eight schools (Appendix 2).

Third stage: The desired sample size was selected using stratified random sampling with proportional allocation of respondents from the different classes in the selected primary/elementary schools (i.e. Primary 1 to 6). Seventy five respondents were proportionally allocated to the different classes of each of the selected schools. This was done by dividing the total number of pupils in the class by the total number in the school and multiplying this by the desired number of the respondents in that school (ie 75) as shown below;

Number of pupils in the class X Desired number of pupils in that school (75) Total number of pupils in the school

The respondents were then selected using systematic sampling, (with the sampling fraction determined based on the number of pupils in the class and the number of respondents to be selected) using the teacher’s class register. The respondents selected per class in each of the selected schools are as presented in Appendix 3.

xliii

3.6 Research Instruments

3.6.1 Quantitative method using Semi-structured questionnaire

A pre-tested semi-structured questionnaire was used as the survey instrument. The questionnaire (Appendices 4 and 5) included the children’s socio-demographic characteristics (and of their parents), nutritional history, physical activities and their anthropometric measurements were recorded.

3.6.1.1 Nutritional history

Information on the nutritional history was sought by asking about frequency of food consumption for different kinds of foods including animal proteins, pastries, fruits and vegetables in the one week preceding the study.

3.6.1.2 Physical activities

Questions were asked about time spent in media consumption (e.g. Television/Video viewing), sleeping, sporting activities and other vigorous activities.

3.6.2 Instruments for Anthropometric Measurements.

The instruments for anthropometric measurements were the Seca® electronic bathroom weighing scale for measuring weight in kilograms (kg). Every morning before taking measurements, the weighing scales were standardized using known weights. Height was measured with a stadiometer. From these, the Body Mass Index (BMI) was calculated, defined as body weight in kilograms divided by the square of height in meters (kg/m2), and used as the measure of nutritional status in this study. The nutritional status of the respondents were then classified using the two recent growth references by the International

Obesity Task Force (IOTF) 59,60 and the World Health Organization (WHO).61

xliv

3.6.3 Stool collection for Intestinal Helminthic infection

The process of stool collection was explained to the parents through the Parents-Teachers

Association (PTA) forum. The respondents were provided with universal bottles, which were labelled with the serial numbers assigned to each respondent. The stool samples were collected by the parents/guardians the morning of the collection day just before the child left for school, so that the research team collected them within 30 – 45 minutes of its collection.

All returned stool specimen were collected and transported to the Microbiology department of LAUTECH Teaching Hospital. A senior laboratory scientist was arranged to examine the stool samples for ova of parasites within one hour. The results were recorded in the questionnaire.

3.6.4 Pretesting of Research Instrument

The pre-testing of the questionnaires was done among children attending primary schools in

Olorunda (urban) and Egbedore (rural) LGAs, which are outside the selected ones. This helped to address some areas of ambiguity in the questionnaire.

3.7 Data Collection

The questionnaires were administered using interviewer method by the researcher and other trained research assistants. The questionnaires were administered to children in both the rural and urban communities. Seven research assistants were recruited and trained to administer the questionnaire, four were females and three were males. The research assistants together with the researcher went out in pairs so as to complement each other in both the administration of the questionnaires and the taking of the various measurements of the children. Anthropometric measurements were taken according to standard protocols recommended by the International Society for the Advancement of Kinanthropometry

(ISAK).132

xlv

In order to ensure precise measurement techniques, the research assistants were junior residents in the department of Community Medicine, LAUTECH Teaching Hospital,

Osogbo who were trained for 3 days by a certified anthropometrist. After the training, six measurements were taken by the anthropometrist and each of the research assistants on the same set of subjects to ensure minimal or no inter-tester and intra-tester errors. This exercise was repeated at intervals during the entire study to further assure strict quality control.

3.7.1 Body Weight/Mass

The weight of each pupil was measured in their underclothes, barefoot and the pupils stood still without support and a research assistant of same sex took the measurements for privacy, especially for the older children. Measurements were taken to the nearest tenth of a kilogramme.

3.7.2 Height

The height of each pupil was taken as the maximum vertical distance from the floor to the highest point on the skull (i.e. the vertex) when the head is held in the Frankfort plane. The pupils stood erect, barefoot, heels together, both heels touching the base of the stadiometer and arms hanging freely by the sides. Measurements were taken to the nearest tenth of a centimeter.

3.8 Data Management

3.8.1 Measurement of Outcome Variables

The socio-economic status of the respondents were assessed using an indirect method by asking about the possession of television sets, generating sets, cars, air conditioner sets and the occupations of their parents.

xlvi

The frequencies of consumption of some selected food groups in the week preceding the survey were also scored. For food groups considered healthy like fruits, vegetables, meats, fish, egg and starchy foods/tubers; those who did not take the food group at all were scored 0, less than 3 times were scored 1, more than 3 times were scored 2 and daily/more than once daily were scored 3. For food groups considered unhealthy like food from eateries, pastries, sugar sweetened drinks and sweets; those who did not take the food group at all were scored

3, less than 3 times were scored 2, more than 3 times were scored 1 and daily/more than once daily were scored 0. All these scores were added and the mean calculated was 18.49 (Range:

9.0 – 28.0). Those who scored less than the mean were regarded as having unhealthy food patterns while those who scored up to or above the mean were regarded as having healthy food patterns.

The activities of the respondents were also scored. Those who went to school on foot or bicycle, helped in parents’ business, involved in house chores, involved in vigorous sports 3 or more days a week, slept 10 hours or less daily and spent 2 hours or less for media consumption were scored 2 each for all these activities, others were scored 1. All these scores were added and the mean score calculated was 11.59 (Range: 7.0 – 14.0). Those who scored less than the mean were regarded as having sedentary lifestyles while those who scored up to or above the mean were regarded as having active lifestyles.

3.8.2 Data Analysis

The questionnaires were sorted out, entered into a computer and the obtained data was analyzed using Statistical Package for Social Sciences (SPSS) version 16. Frequency distribution tables were generated from variables while cross-tabulations using chi-square for bivariate analysis were done as applicable. T-test, Analysis of Variance (ANOVA),

xlvii regression and correlation were also used in the analysis of continuous variables as appropriate. Level of significance was set with p-value less than 0.05.

3.9 Ethical Considerations

Ethical clearance for the study was obtained from the Ethical Review Committee of

LAUTECH Teaching Hospital,(Appendix 5) and permission was obtained from Osun State

Ministry of Education,(Appendix 6) Head masters or mistresses of selected primary schools and the Parents-Teachers Association (PTA) of selected schools.

The parents of the respondents (who were 6 – 12 years of age) were told that participation is voluntary and their children would not suffer any consequences if they chose not to participate. Individual written consent to interview and examine the children was obtained from the parents via letters sent through their children. (Appendix 7)

All information gathered was kept confidential and participants were identified using only serial numbers. The findings of this study were communicated to the children, their parents and teachers, and they were health educated accordingly. Arrangements for the de-worming of all the pupils in the selected schools in the rural community were made.

3.10 Limitations of the study

1. Some of the children (especially the very young ones) found it difficult to recall their

feeding patterns. In order to reduce the effect of this, a very simple and easy-to-

understand approach was used and the history was restricted to a week prior to the study,

although the effect could not be totally eliminated.

2. Socio-economic status could not be directly assessed as income and educational

background of the parents could not be assessed because of the age of the pupils. Thus,

xlviii

ownership of certain household or personal items and the parents’ occupation were used

as proxy for their socio-economic status.

3. The determinants of nutritional status that this study tested are not exhaustive, as there are

other factors that were not included in this study.

4. In this study, eating from eateries was regarded as unhealthy whereas sometimes it may

be for such healthy food as starchy rather than pastries and sweets.

xlix

CHAPTER FOUR

RESULTS

Six hundred questionnaires were administered in all, 300 in the rural and 300 in the urban communities. All the questionnaires were completed, giving a response rate of 100%.

Table 4.1: Socio-Demographic Profile of the Respondents by their Residence

Residence (%) Chi Variables Urban Rural Total square df p-value n= 300 n= 300 N=600 χ2 Sex Male 158 (52.7) 151 (50.3) 309 (51.5) 0.33 1 0.567 Female 142 (47.3) 149 (49.7) 291 (48.5) Religion Christianity 196 (65.3) 142 (47.3) 338 (56.3) 19.76 1 *< 0.001 Islam 104 (34.7) 158 (52.7) 262 (43.7) Tribe ** Yoruba 293 (97.7) 300 (100.0) 593 (98.8) 7.08 1 *0.015 Others (Igbo, Hausa) 7 (2.3) 0 (0.0) 7 (1.2) Class group Primary 1 – 3 163 (54.3) 158 (52.7) 321 (53.5) 0.17 1 0.682 Primary 4 – 6 137 (45.7) 142 (47.3) 279 (46.5) Number of children in the family 1 – 4 children 217 (72.3) 165 (55.0) 382 (63.7) 19.48 1 *<0.001 More than 4 children 83 (27.7) 135 (45.0) 218 (36.3) Family setting Monogamous 248 (82.7) 179 (59.7) 427 (71.2) 38.67 1 *<0.001 Polygamous 52 (17.3) 121 (40.3) 173 (28.8) * Significant **Fisher’s test used *** T-test for two independent samples was used

Table 4.1 shows the socio-demographic characteristics of the respondents according to their residence. The distribution of respondents according to religion, tribes, family setting and the number of children in the family were significantly different between the rural and urban communities (p < 0.05) as shown above.

Table 4.2: Socio-economic Status of the Parents of Respondents by their Residence

Residence (%) Chi Variables Urban Rural Total square df p-value n= 300 n= 300 N=600 χ2

Television set (s) Yes 300 (100.0) 245 (81.7) 545 (90.8) 60.55 1 *<0.001 No 0 (0.0) 55 (18.3) 55 (9.2) Generating set (s) Yes 212 (70.7) 156 (52.0) 368 (61.3) 22.04 1 *<0.001 No 88 (29.3) 144 (48.0) 232 (38.7) Car (s) Yes 229 (76.3) 102 (34.0) 331 (55.2) 108.7 1 *<0.001 No 71 (23.7) 198 (66.0) 269 (44.8) Air conditioner set (s) Yes 90 (30.0) 3 (1.0) 93 (15.5) 96.32 1 *<0.001 No 210 (70.0) 297 (99.0) 507 (84.5) Father’s Occupation Skilled 151 (50.3) 56 (18.7) 207 (34.5) Semi-skilled 128 (42.7) 141 (47.0) 269 (44.8) 112.3 3 *<0.001 Unskilled 11 (3.7) 96 (32.0) 107 (17.8) Unemployed 10 (3.3) 7 (2.3) 17 (2.8) Mother’s Occupation Skilled 125 (41.7) 34 (11.3) 159 (26.5) Semi-skilled 152 (50.7) 180 (60.0) 332 (55.3) 94.36 3 *<0.001 Unskilled 15 (5.0) 74 (24.7) 89 (14.8) Unemployed 8 (2.7) 12 (4.0) 20 (3.3) * Significant

Significantly more of the respondents in the urban community had television sets (p < 0.001), generating sets (p < 0.001), cars (p < 0.001) and air conditioner sets (p < 0.001) than respondents in the rural community. Majority of the fathers of respondents in the urban community (151, 50.3%) were skilled workers (such as professionals) while majority of those in the rural community (141, 47.0%) were semi-skilled workers (such as artisans), and this difference was statistically significant. Similarly, there was a significant difference in the mothers’ occupation between respondents in the urban and rural communities (as shown above).

Tables 4.3: Nutritional History of Respondents by Residence

Residence (%) Chi Variables Urban Rural Total square df p-value n= 300 n= 300 N=600 χ2 Fruits+ Less than 3 times** 169 (56.3) 254 (84.7) 423 (70.5) 57.90 1 *<0.001 3 times or more 131 (43.7) 46 (15.3) 177 (29.5) Vegetables+ Less than 3 times** 151 (50.3) 232 (77.3) 383 (63.8) 47.37 1 *<0.001 3 times or more 149 (49.7) 68 (22.7) 217 (36.2) Food from eateries Less than 3 times** 247 (82.3) 300 (100.0) 547 (91.2) 58.14 1 *<0.001 3 times or more 53 (17.7) 0 (0.0) 53 (8.8) Pastries Less than 3 times** 200 (66.7) 295 (98.3) 495 (82.5) 104.2 1 *<0.001 3 times or more 100 (33.3) 5 (1.7) 105 (17.5) Sugar sweetened drinks Less than 3 times** 172 (57.3) 285 (95.0) 457 (76.2) 117.2 1 *<0.001 3 times or more 128 (42.7) 15 (5.0) 143 (23.8) Sweets Less than 3 times** 201 (67.0) 265 (88.3) 466 (77.7) 39.36 1 *<0.001 3 times or more 99 (33.0) 35 (11.7) 134 (22.3) Meats+ Less than 3 times** 108 (36.0) 214 (71.3) 322 (53.7) 75.31 1 *<0.001 3 times or more 192 (64.0) 86 (28.7) 278 (46.3) Fish+ Less than 3 times** 127 (42.3) 206 (68.7) 333 (55.5) 42.12 1 *<0.001 3 times or more 173 (57.7) 94 (31.3) 267 (44.5) Egg+ Less than 3 times** 189 (63.0) 280 (93.3) 469 (78.2) 80.87 1 *<0.001 3 times or more 111 (37.0) 20 (6.7) 131 (21.8) Starchy foods+ Less than 3 times** 12 (4.0) 3 (1.0) 15 (2.5) 5.54 1 *<0.019 3 times or more 288 (96.0) 297 (99.0) 585 (97.5) * Significant ** In the last one week + Healthy food types

Table 4.3 above shows that significantly more respondents in the urban community took fruits, sugar sweetened drinks, sweets, pastries and ate vegetables, food from eateries, meats, fish and eggs more frequently than those from the rural community, while those in the rural community consumed starchy foods significantly more frequently than those in the urban community.

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70.0% 58.3% 60.0% 54.3% 50.0% 45.7% 41.7% 40.0%

30.0%

20.0%

10.0%

0.0% Unhealthy Healthy

Urban Rural

n (urban) = 300, n(rural) = 300

Figure 1: Categorized Food Patterns of Respondents by their Residence

The categorized food patterns of respondents by their residence are as depicted in figure 1 above. (This categorization was done after the scoring of outcome variables as explained earlier in the methodology) Majority of respondents in the urban community (175, 58.3%) had unhealthy feeding patterns, and this was significantly different for rural dwellers where majority (163, 54.3) had healthy feeding patterns (χ2 = 9.64; df = 1; p = 0.002).

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Table 4.4: Physical Activities of Respondents by their Residence

Residence (%) Chi Variables Urban Rural Total square df p-value n= 300 n= 300 N=600 χ2 Transport to school On foot 114 (38.0) 256 (85.3) 370 (61.7) Parents’ car 151 (50.3) 6 (2.0) 157 (26.2) 224.9 3 *<0.001 Public transport 32 (10.7) 8 (2.7) 40 (6.7) School bus 3 (1.0) 30 (10.0) 33 (5.5) Involvement with chores at home Yes 273 (91.0) 277 (92.3) 550 (91.7) 0.35 1 0.56 No 27 (9.0) 23 (7.7) 50 (8.3) Involvement in vigorous sports < 3 days a week 114 (38.0) 78 (26.0) 192 (32.0) 9.93 1 *0.002 3 or more days a week 186 (62.0) 222 (74.0) 408 (68.0) Average daily sleep time 10 hours or less 238 (79.3) 289 (96.3) 527 (87.8) 40.57 1 *<0.001 More than 10 hours 62 (20.7) 11 (3.7) 73 (12.2) Average daily mass media consumption 0 – 2 hours 148 (49.3) 200 (66.7) 348 (58.0) 18.50 1 *<0.001 More than 2 hours 152 (50.7) 100 (33.3) 252 (42.0) Involvement in parents’ business Yes 104 (34.7) 205 (68.3) 309 (51.5) 68.07 1 *<0.001 No 196 (65.3) 95 (31.7) 291 (48.5) * Significant

Table 4.4 shows the pattern of physical activities of respondents by their residence.

Significantly more respondents in the rural areas walked to school (p < 0.001), involved in their parents’ businesses (p < 0.001), involved in vigorous sports (p = 0.002), slept less (p <

0.001) and consumed less of mass media (p < 0.001).

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74.0% Active 46.0%

26.0% Sedentary 54.0%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%

Rural Urban

n (urban) = 300, n(rural) = 300

Figure 2: *Categorized Activity Patterns of the Respondents by their Residence

As illustrated in Figure 2 above, significantly more of the respondents in the rural community lived active lifestyles (χ2 = 48.94; df = 1; p < 0.001) than those in the urban community.

* This categorization was done after scoring of outcome variables for physical activities as earlier explained in the methodology.

Table 4.5: Pattern of Nutritional Status of Respondents by their Residence

Residence (%) Chi Variables Urban Rural Total square df p-value n= 300 n= 300 N=600 χ2

Mean Body Mass Index 16.24 ± 14.90 ± 15.57 ± ** 598 *< 0.001 2.42 2.02 2.32 Using WHO criteria Under weight 55 (18.3) 123 (41.0) 178 (29.7) 71.50 2 *<0.001 Normal 201 (67.0) 177 (59.0) 378 (63.0) Overweight/Obese 44 (14.7) 0 (0.0) 44 (7.3) Using IOTF criteria Under weight 52 (17.3) 110 (36.7) 162 (27.0) 51.82 2 *<0.001 Normal 219 (73.0) 190 (63.3) 409 (68.2) Overweight/Obese 29 (9.7) 0 (0.0) 29 (4.8) * Significant ** T-test for two independent samples was used

The pattern of nutritional status of respondents by their residence is shown in table 4.5 above.

The mean BMI for the children from the urban and rural communities was 16.24 ± 2.42 and

14.90 ± 2.02 respectively, and their difference was statistically significant. Using the WHO criteria, 55 (18.3%) and 44 (14.7%) were underweight and overweight/obese respectively among the urban children, while 123 (41.0%) were underweight and none were overweight/obese among rural children. Using IOTF criteria, 52 (17.3%) and 29 (9.7%) were underweight and overweight/obese respectively among the urban children, while 110 (36.7%) were underweight and none were overweight/obese among the rural children.

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Table 4.6: Respondents’ Perception of their Nutritional status by Residence

Residence (%) Chi Variables Urban Rural Total square df p-value n= 300 n= 300 N=600 χ2 Perception of figure Thin/underweight 103 (34.3) 129 (43.0) 232 (38.7) Normal 152 (50.7) 120 (40.0) 272 (45.3) 7.05 2 *0.029 Fat/overweight 45 (15.0) 51 (17.0) 96 (16.0) Like figure Yes 247 (82.3) 160 (53.3) 407 (67.8) No 47 (15.7) 122 (40.7) 169 (28.2) 57.88 2 *<0.001 Don’t know 6 (2.0) 18 (6.0) 24 (4.0) Preferred figure Thinner 28 (9.3) 3 (1.0) 31 (5.2) Normal 179 (59.7) 88 (29.3) 267 (44.5) 105.7 3 *<0.001 Fatter 76 (25.3) 197 (65.7) 273 (45.5) Indifferent 17 (5.7) 12 (4.0) 29 (4.8) * Significant

The respondents’ perception of their nutritional status is as shown in table 4.6 above. There was a significant difference in the perception of respondents in the rural and urban communities about their figure, with significantly more of the rural dwellers dissatisfied with their figures. The preferred figure for many pupils in the urban community (179, 59.7%) was a normal figure while that for those in the rural community (197, 65.7%) was a fat figure.

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Table 4.7: Intestinal Helminthic Infection Pattern among Respondents by their Residence

Residence (%) Chi Variables Urban Rural Total square df p-value χ2 De-wormed in the last 6 months Yes 92 (30.7) 36 (12.0) 128 (21.3) 32.71 2 *<0.001 No 113 (37.7) 128 (42.7) 241 (40.2) Don’t know 95 (31.7) 136 (45.3) 231 (38.5) Total 300 (100.0) 300 (100.0) 600 (100.0) Made stool available for stool test Yes 201 (67.0) 208 (69.3) 409 (68.2) 0.376 1 0.540 No 99 (33.0) 92 (30.7) 191 (31.8) Total 300 (100.0) 300 (100.0) 600 (100.0) Stool microscopy result Ova of parasite present 17 (8.5) 60 (29.7) 77 (18.8) 27.81 1 *<0.001 Ova of parasite absent 184 (91.5) 148 (70.3) 332 (81.2) Total 201 (100.0) 208 (100.0) 409 (100.0) * Significant

Table 4.7 shows the intestinal helminthic infection pattern among respondents by their residence. Significantly more respondents in the urban community were de-wormed in the 6 months preceding the study (p < 0.001). Of those who made stool available, ova of parasites

(includes all common intestinal parasites like Ascaris lumbricoides and Hook worm) were present in 17 (8.5%) of those in the urban community and 60 (29.7%) of those in the rural community, and this difference was statistically significant (p < 0.001).

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Table 4.8: Effect of Socio-Demographic Factors on the Nutritional Status of

Respondents according to the WHO criteria

WHO classification (%) Variables Under- Normal Overweight Total χ2 p-value weight n = 378 /Obese N = 600 n = 178 n = 44 Sex Male 94 (52.8) 196 (51.9) 19 (43.2) 309 (51.5) 1.36 0.507 Female 84 (47.2) 182 (48.1) 25 (56.8) 291 (48.5) Tribe ** Yoruba 161 (99.4) 404 (98.8) 28 (96.6) 593 (98.8) 1.38 0.501 Others (Igbo, Hausa) 1 (0.6) 5 (1.2) 1 (3.4) 7 (1.2) Class group Primary 1 – 3 96 (53.9) 203 (53.7) 22 (50.0) 321 (53.5) 0.24 0.889 Primary 4 – 6 82 (46.1) 175 (46.3) 22 (50.0) 279 (46.5) Number of children in the family 1 – 4 children 98 (55.1) 247 (65.3) 37 (84.1) 382 (63.7) 14.10 *0.001 More than 4 children 80 (44.9) 131 (34.7) 7 (15.9) 218 (36.3) Family setting Monogamous 114 (64.0) 275 (72.8) 38 (86.4) 427 (71.2) 9.81 *0.007 Polygamous 64 (36.0) 103 (27.2) 6 (13.6) 173 (28.8) **Fisher’s exact test used * Significant

The nutritional status of the pupils was significantly associated with their family settings (p =

0.007) and number of children in the family (p = 0.001), while other factors such as sex, tribe and class groups were not significantly associated with the nutritional status of the respondents.

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Table 4.9: Effect of Socio-Demographic Factors on the Nutritional Status of Respondents according to the IOTF criteria

IOTF classification (%) Variables Under- Normal Overweight Total χ2 p-value weight n = 409 /Obese N = 600 n = 162 n = 29 Sex Male 82 (50.6) 218 (53.3) 9 (31.0) 309 (51.5) 5.44 0.066 Female 80 (49.4) 191 (46.7) 20 (69.0) 291 (48.5) Tribe ** Yoruba 161 (99.4) 404 (98.8) 28 (96.6) 539 (98.8) 1.38 0.501 Others (Igbo, Hausa) 1 (0.6) 5 (1.2) 1 (3.4) 7 (1.2) Class group Primary 1 – 3 93 (57.4) 214 (52.3) 14 (48.3) 321 (53.5) 1.54 0.463 Primary 4 – 6 69 (42.6) 195 (47.7) 15 (51.7) 279 (46.5) Number of children in the family 1 – 4 children 93 (57.4) 266 (65.0) 23 (79.3) 382 (63.7) 6.14 *0.046 More than 4 children 69 (42.6) 143 (35.0) 6 (20.7) 218 (36.3) Family setting Monogamous 109 (67.3) 291 (71.1) 27 (93.1) 427 (71.2) 7.99 *0.018 Polygamous 53 (32.7) 118 (28.9) 2 (6.9) 173 (28.8) **Fisher’s test used * Significant

The effect of socio-demographic factors on the nutritional status of respondents according to

IOTF is as shown in table 4.9 above. The nutritional status of the pupils was significantly associated with their family settings (p = 0.018) and number of children in the family (p =

0.046), while other factors such as sex, tribe and class groups were not significantly associated with the nutritional status of the respondents.

Table 4.10: Effect of Socio-Economic Status on the Nutritional Status of Respondents according to the WHO criteria

WHO classification (%) Variables Under- Normal Overweight Total χ2 p-value weight n = 378 /Obese N = 600 n = 178 n = 44 Television set (s) ** Yes 158 (88.8) 343 (90.7) 44 (100.0) 545 (90.8) 6.39 *0.040 No 20 (11.2) 35 (9.3) 0 (0.0) 55 (9.2) Generating set (s) Yes 107 (60.1) 230 (60.8) 31 (70.5) 368 (61.3) 1.69 0.429 No 71 (39.9) 148 (39.2) 13 (29.5) 232 (38.7) Car (s) Yes 75 (42.1) 215 (56.9) 41 (93.2) 331 (55.2) 38.38 *<0.001 No 103 (57.9) 163 (43.1) 3 (6.8) 269 (44.8) Air conditioner set (s) Yes 12 (6.7) 59 (15.6) 22 (50.0) 93 (15.5) 50.41 *<0.001 No 166 (93.3) 319 (84.4) 22 (50.0) 507 (84.5) School type Public 114 (64.0) 181 (47.9) 5 (11.4) 300 (50.0) 41.0 *<0.001 Private 64 (36.0) 197 (52.1) 39 (88.6) 300 (50.0) Father’s Occupation ** Skilled 43 (24.2) 130 (34.4) 34 (77.3) 207 (34.5) 43.46 *<0.001 Semi-skilled 91 (51.1) 170 (45.0) 8 (18.2) 269 (44.8) Unskilled 37 (20.8) 69 (18.3) 1 (2.3) 107 (17.8) Unemployed 7 (3.9) 9 (2.4) 1 (2.3) 17 (2.8) Mother’s Occupation ** Skilled 35 (19.7) 92 (24.3) 32 (72.7) 159 (26.5) 48.09 *<0.001 Semi-skilled 105 (59.0) 215 (56.9) 12 (27.3) 332 (55.3) Unskilled 32 (18.0) 57 (15.1) 0 (0.0) 89 (14.8) Unemployed 6 (3.4) 14 (3.7) 0 (0.0) 20 (3.3) **Fisher’s test used * Significant

As shown in Table 4.10 above, the nutritional status of the pupils (according to WHO criteria) was significantly associated with their parents’ possession of television sets (p =

0.040), cars (p < 0.001) and air conditioner sets (p < 0.001), and with other factors such as their school type (p < 0.001) and their parents’ occupations (p < 0.001).

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Table 4.11: Effect of Socio-Economic Status on the Nutritional Status of Respondents according to the IOTF criteria

IOTF classification (%) Variables Under- Normal Overweight Total χ2 p-value weight n = 409 /Obese N = 600 n = 162 n = 29 Television set (s) ** Yes 142 (87.7) 374 (91.4) 29 (100.0) 545 (90.8) 5.05 0.072 No 20 (12.3) 35 (8.6) 0 (0.0) 55 (9.2) Generating set (s) Yes 91 (56.2) 254 (62.1) 23 (79.3) 368 (61.3) 5.87 0.053 No 71 (43.8) 155 (37.9) 6 (20.7) 232 (38.7) Car (s) Yes 63 (38.9) 241 (58.9) 27 (93.1) 331 (55.2) 36.57 *<0.001 No 99 (61.1) 168 (41.1) 2 (6.9) 269 (44.8) Air conditioner set (s) ** Yes 12 (7.4) 65 (15.9) 16 (55.2) 93 (15.5) 33.95 *<0.001 No 150 (92.6) 344 (84.1) 13 (44.8) 507 (84.5) School type Public 102 (63.0) 195 (47.7) 3 (10.3) 300 (50.0) 30.01 *<0.001 Private 60 (37.0) 214 (52.3) 26 (89.7) 300 (50.0) Father’s Occupation ** Unemployed 7 (4.3) 9 (2.2) 1 (3.4) 17 (2.8) 40.86 *<0.001 Skilled 35 (21.6) 149 (36.4) 23 (79.3) 207 (34.5) Semi-skilled 83 (51.2) 181 (44.3) 5 (17.2) 269 (44.8) Unskilled 37 (22.8) 70 (17.1) 0 (0.0) 107 (17.8) Mother’s Occupation ** Unemployed 6 (3.7) 14 (3.4) 0 (0.0) 20 (3.3) 29.54 *<0.001 Skilled 30 (18.5) 109 (26.7) 20 (69.0) 159 (26.5) Semi-skilled 96 (59.3) 227 (55.5) 9 (31.0) 332 (55.3) Unskilled 30 (18.5) 59 (14.4) 0 (0.0) 89 (14.8) **Fisher’s test used * Significant

Table 4.11 shows the effect of socio-economic status on the nutritional status of respondents according to IOTF criteria. The nutritional status of the pupils (according to IOTF criteria) was significantly associated with their parents’ possession of cars (p < 0.001) and air conditioner sets (p < 0.001), and with other factors such as their school type (p < 0.001) and their parents’ occupations (p < 0.001).

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Table 4.12: Effect of Food Patterns on the Nutritional Status of Respondents according to the WHO criteria

WHO classification (%) Variables Under- Normal Overweight Total χ2 p-value weight n = 378 /Obese N = 600 n = 178 n = 44 Fruits+ Less than 3 times** 132 (74.2) 276 (73.0) 15 (34.1) 423 (70.5) 30.34 *<0.001 3 times or more 46 (25.8) 102 (27.0) 29 (65.9) 177 (29.5) Vegetables+ Less than 3 times** 120 (67.4) 250 (66.1) 13 (29.5) 383 (63.8) 24.27 *<0.001 3 times or more 58 (32.6) 128 (33.9) 31 (70.5) 217 (36.2) Food from eateries *** Less than 3 times** 174 (97.8) 342 (90.5) 31 (70.5) 547 (91.2) 28.73 *<0.001 3 times or more 4 (2.2) 36 (9.5) 13 (29.5) 53 (8.8) Pastries Less than 3 times** 164 (92.1) 311 (82.3) 20 (45.5) 495 (82.5) 53.28 *<0.001 3 times or more 14 (7.9) 67 (17.7) 24 (54.5) 105 (17.5) Sugar sweetened drinks Less than 3 times** 153 (86.0) 294 (77.8) 10 (22.7) 457 (76.2) 79.16 *<0.001 3 times or more 25 (14.0) 84 (22.2) 34 (77.3) 143 (23.8) Sweets Less than 3 times** 152 (85.4) 294 (77.8) 20 (45.5) 466 (77.7) 32.45 *<0.001 3 times or more 26 (14.6) 84 (22.2) 24 (54.5) 134 (22.3) Meats+ Less than 3 times** 114 (64.0) 201 (53.2) 7 (15.9) 322 (53.7) 32.97 *<0.001 3 times or more 64 (36.0) 177 (46.8) 37 (84.1) 278 (46.3) Fish+ Less than 3 times** 117 (65.7) 201 (53.2) 15 (34.1) 333 (55.5) 16.54 *<0.001 3 times or more 61 (34.3) 177 (46.8) 29 (65.9) 267 (44.5) Egg+ Less than 3 times** 163 (91.6) 291 (77.0) 15 (34.1) 469 (78.2) 69.14 *<0.001 3 times or more 15 (8.4) 87 (23.0) 29 (65.9) 131 (21.8) Starchy foods+ *** Less than 3 times** 2 (1.1) 9 (2.4) 4 (9.1) 15 (2.5) 7.01 *0.023 3 times or more 176 (98.9) 369 (97.6) 40 (90.9) 585 (97.5) * Significant ** In the last one week *** Fisher’s exact test used + Healthy food types

Table 4.12 shows the effect of food patterns on the nutritional status of respondents according to the WHO criteria. The nutritional status of the respondents (according to WHO criteria) was significant associated with their consumption pattern of all the selected food groups (p <

0.05).

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Table 4.13: Effect of Food Patterns on the Nutritional Status of Respondents according to the IOTF criteria

IOTF classification (%) Variables Under- Normal Overweight Total χ2 p-value weight n = 409 /Obese N = 600 n = 162 n = 29 Fruits+ Less than 3 times** 117 (72.2) 295 (72.1) 11 (37.9) 423 (70.5) 15.54 *<0.001 3 times or more 45 (27.8) 114 (27.9) 18 (62.1) 177 (29.5) Vegetables+ Less than 3 times** 111 (68.5) 262 (64.1) 10 (34.5) 383 (63.8) 12.37 *0.002 3 times or more 51 (31.5) 147 (35.9) 19 (65.5) 217 (36.2) Food from eateries *** Less than 3 times** 158 (97.5) 368 (90.0) 21 (72.4) 547 (91.2) 20.25 *<0.001 3 times or more 4 (2.5) 41 (10.0) 8 (27.6) 53 (8.8) Pastries Less than 3 times** 148 (91.4) 335 (81.9) 12 (41.4) 495 (82.5) 42.87 *<0.001 3 times or more 14 (8.6) 74 (18.1) 17 (58.6) 105 (17.5) Sugar sweetened drinks Less than 3 times** 142 (87.7) 307 (75.1) 8 (27.6) 457 (76.2) 49.76 *<0.001 3 times or more 20 (12.3) 102 (24.9) 21 (72.4) 143 (23.8) Sweets Less than 3 times** 140 (86.4) 313 (76.5) 13 (44.8) 466 (77.7) 25.49 *<0.001 3 times or more 22 (13.6) 96 (23.5) 16 (55.2) 134 (22.3) Meats+ Less than 3 times** 111 (68.5) 209 (51.1) 2 (6.9) 322 (53.7) 40.97 *<0.001 3 times or more 51 (31.5) 200 (48.9) 27 (93.1) 278 (46.3) Fish+ Less than 3 times** 110 (67.9) 216 (52.8) 7 (24.1) 333 (55.5) 22.83 *<0.001 3 times or more 52 (32.1) 193 (47.2) 22 (75.9) 267 (44.5) Egg+ Less than 3 times** 148 (91.4) 312 (76.3) 9 (31.0) 469 (78.2) 55.16 *<0.001 3 times or more 14 (8.6) 97 (23.7) 20 (69.0) 131 (21.8) Starchy foods+ *** Less than 3 times** 2 (1.2) 10 (2.4) 3 (10.3) 15 (2.5) 6.24 *0.038 3 times or more 160 (98.8) 399 (97.6) 26 (89.7) 585 (97.5) * Significant ** In the last one week *** Fisher’s exact test used + Healthy food types

As shown in Table 4.13 above, the nutritional status of the respondents (according to IOTF criteria) was significant associated with their consumption pattern of all the selected food groups (p < 0.05).

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Table 4.14: Effect of Categorized Food Patterns on the Nutritional Status of Respondents

Categorized food Nutritional status (%) pattern Under- Normal Overweight Total χ2 p-value weight n = 378 /Obese N = 600

n = 178 n = 44 Using WHO criteria Unhealthy 85 (47.8) 202 (53.4) 24 (54.5) 311 (51.8) 1.71 0.426 Healthy 93 (52.2) 176 (46.6) 20 (45.5) 289 (48.2) Using IOTF criteria Unhealthy 80 (49.4) 216 (52.8) 15 (51.7) 311 (51.8) 0.547 0.761 Healthy 82 (50.6) 193 (47.2) 14 (48.3) 289 (48.2)

The effect of categorized food patterns on the nutritional status of respondents is as shown in table 4.14 above. There was no significant association between the nutritional status of the respondents and their categorized food patterns using both WHO and IOTF criteria (p >

0.05).

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Table 4.15: Effect of Physical Activity on the Nutritional Status of Respondents according to the WHO criteria

WHO classification (%) Variables Under- Normal Overweight Total χ2 p-value weight n = 378 /Obese N = 600 n = 178 n = 44 Transport to school ** On foot 132 (74.2) 235 (62.2) 3 (6.8) 370 (61.7) 101.36 *<0.001 Parents’ car 18 (10.1) 103 (27.2) 36 (81.8) 157 (26.2) School bus 12 (6.7) 21 (5.6) 0 (0.0) 33 (5.5) Public transport 16 (9.0) 19 (5.0) 5 (11.4) 40 (6.7) Involvement in parents’ business Yes 108 (60.7) 188 (49.7) 13 (29.5) 309 (51.5) 14.96 *0.001 No 70 (39.3) 190 (50.3) 31 (70.5) 291 (48.5) Involvement with chores at home ** Yes 169 (94.9) 343 (90.7) 38 (86.4) 550 (91.7) 4.78 0.096 No 9 (5.1) 35 (9.3) 6 (13.6) 50 (8.3) Involvement in vigorous sports < 3 days a week 54 (30.3) 115 (30.4) 23 (52.3) 192 (32.0) 8.97 *0.011 3 or more days a week 124 (69.7) 263 (69.6) 21 (47.7) 408 (68.0) Average daily sleep time 10 hours or less 153 (86.0) 341 (90.2) 33 (75.0) 527 (87.8) 9.37 *0.009 More than 10 hours 25 (14.0) 37 (9.8) 11 (25.0) 73 (12.2) Average daily mass media consumption 0 – 2 hours 106 (59.6) 226 (59.8) 16 (36.4) 348 (58.0) 9.13 *0.010 More than 2 hours 72 (40.4) 152 (40.2) 28 (63.6) 252 (42.0) * Significant ** Fisher’s test used

Table 4.15 shows the effect of physical activity on the nutritional status of respondents according to the WHO criteria. The nutritional status of the pupils was significantly associated with all the variables used to assess physical activity, except their involvement in chores at home.

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Table 4.16: Effect of Physical Activity on the Nutritional Status of Respondents according to the IOTF criteria

IOTF classification (%) Variables Under- Normal Overweigh Total χ2 p-value weight n = 409 t /Obese N = 600 n = 162 n = 29 Transport to school ** On foot 117 (72.2) 250 (61.1) 3 (10.3) 370 (61.7) 68.45 *<0.001 Parents’ car 17 (10.5) 117 (28.6) 23 (79.3) 157 (26.2) School bus 12 (7.4) 21 (5.1) 0 (0.0) 33 (5.5) Public transport 16 (9.9) 21 (5.1) 3 (10.3) 40 (6.7) Involvement in parents’ business Yes 93 (57.4) 210 (51.3) 6 (20.7) 309 (51.5) 13.29 *0.001 No 69 (42.6) 199 (48.7) 23 (79.3) 291 (48.5) Involvement with chores at home ** Yes 153 (94.4) 373 (91.2) 24 (82.8) 550 (91.7) 4.67 0.081 No 9 (5.6) 36 (8.8) 5 (17.2) 50 (8.3) Involvement in vigorous sports < 3 days a week 51 (31.5) 123 (30.1) 18 (62.1) 192 (32.0) 12.77 *0.002 3 or more days a week 111 (68.5) 286 (69.9) 11 (37.9) 408 (68.0) Average daily sleep time ** 10 hours or less 137 (84.6) 369 (90.2) 21 (72.4) 527 (87.8) 9.48 *0.007 More than 10 hours 25 (15.4) 40 (9.8) 8 (27.6) 73 (12.2) Average daily mass media consumption 0 – 2 hours 101 (62.3) 239 (58.4) 8 (27.6) 348 (58.0) 12.30 *0.002 More than 2 hours 61 (37.7) 170 (41.6) 21 (72.4) 252 (42.0) * Significant ** Fisher’s exact test used

The effect of physical activity on the nutritional status of respondents according to the IOTF criteria is as shown in table 4.16 above. The nutritional status of the pupils was significantly associated with all the variables used to assess physical activity, except their involvement in chores at home.

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Table 4.17: Effect of Categorized Activity Patterns on the Nutritional Status of Respondents

Categorized Activity Nutritional status (%) pattern Under- Normal Overweight Total χ2 p-value weight n = 378 /Obese N = 600

n = 178 n = 44 Using WHO criteria Sedentary 55 (30.9) 150 (39.7) 34 (77.3) 239 (39.8) 31.67 *<0.001 Active 123 (69.1) 228 (60.3) 10 (22.7) 361 (60.2) Using WHO criteria Sedentary 54 (33.3) 158 (38.6) 27 (93.1) 239 (39.8) 37.44 *<0.001 Active 108 (66.7) 251 (61.4) 2 (6.9) 361 (60.2) * Significant

The effect of the categorized activity patterns on the nutritional status of respondents is as shown in table 4.17 above. There was a significant association between the nutritional status of respondents and their activity patterns using both WHO and IOTF criteria.

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Table 4.18: Effect of Intestinal Helminthic Infection on the Nutritional Status of Respondents

Nutritional status (%) Helminthic Infection Under- Normal Overweight Total χ2 p-value weight n = 247 /Obese N = 409 n = 127 n = 35 Using WHO criteria Ova of parasite present 49 (38.6) 27 (10.9) 1 (2.9) 77 (18.8) 48.35 *<0.001 Ova of parasite absent 78 (61.4) 220 (89.1) 34 (97.1) 332 (81.2) Using IOTF criteria Ova of parasite present 49 (42.2) 28 (10.4) 0 (0.0) 77 (18.8) ** Ova of parasite absent 67 (57.8) 240 (89.6) 25 (100.0) 332 (81.2) 55.01 *<0.001 * Significant ** Fisher’s exact test used

Table 4.18 shows the effect of helminthic infection on the nutritional status of the pupils. The nutritional status of the respondents (using both WHO and IOTF criteria) was significantly associated with their helminthic infection pattern (p < 0.001).

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Table 4.19: Effect of Selected Numeric Variables on the Nutritional Status of Respondents according to the WHO criteria Using Analysis of Variance (ANOVA)

WHO classification (%) Variables Under- Normal Overweight Total F p-value weight n = 378 /Obese N = 600 n = 178 n = 44 Age (in years) Mean 9.54 8.87 7.89 9.00 15.71 *<0.001 Standard deviation 2.07 1.87 1.26 1.94 Number of children in the family 5.35 *0.005 Mean 4.40 4.21 3.39 4.20 Standard deviation 1.70 1.96 1.17 1.85 Average daily sleep time (in hours) Mean 9.04 9.10 9.59 9.12 4.11 *0.017 Standard deviation 1.15 1.15 1.26 1.16 Average daily mass media consumption (in hours) Mean 2.37 2.44 3.57 2.50 12.66 *<0.001 Standard deviation 1.33 1.48 1.84 1.50 * Significant

Table 4.19 shows the effect of selected numeric variables on the nutritional status of respondents according to the WHO criteria using ANOVA. The nutritional status of respondents was significantly associated with their age (p < 0.001), number of children in the family (p = 0.005), average daily sleep time (p = 0.017) and average daily mass media consumption (p < 0.001).

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Table 4.20: Effect of Selected Numeric Variables on the Nutritional Status of Respondents according to the IOTF criteria Using Analysis of Variance (ANOVA)

IOTF classification (%) Variables Under- Normal Overweigh Total F p-value weight n = 409 t /Obese N = 600 n = 162 n = 29 Age (in years) Mean 9.35 8.94 7.76 9.00 8.89 *<0.001 Standard deviation 2.06 1.89 1.35 1.94 Number of children in the family Mean 4.30 4.22 3.41 4.20 2.90 0.056 Standard deviation 1.70 1.93 1.27 1.85 Average daily sleep time (in hours) Mean 9.14 9.09 9.48 9.12 1.62 0.20 Standard deviation 1.13 1.15 1.40 1.16 Average daily mass media consumption (in hours) Mean 2.29 2.49 3.86 2.50 14.21 *<0.001 Standard deviation 1.33 1.47 2.10 1.50 * Significant

Table 4.20 shows the effect of selected numeric variables on the nutritional status of respondents according to the IOTF criteria using ANOVA. The nutritional status of respondents was significantly associated with their age (p < 0.001) and average daily mass media consumption (p < 0.001).

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Table 4.21: Relationship between BMI and other Continuous Variables using Linear Regression and Correlation Analyses

Regression Analysis BMI F p-value 95% confidence Correlation statistic interval Age 5.16 *0.023 0.01 0.21 -0.03 Number of children in the family 2.31 0.129 -0.18 0.02 0.01 Number of television sets 21.29 *<0.001 0.29 0.71 0.18 Number of generating sets 9.38 *0.002 0.28 1.3 0.04 Number of cars 3.08 0.080 -0.02 0.44 0.07 Number of air conditioning sets 1.97 0.164 -0.14 0.82 0.17 Hours of sleep per day 0.18 0.669 -0.13 -.20 0.03 Hours of television watching per day 5.04 *0.025 0.02 0.34 0.34 Hours of video games 41.03 *<0.001 0.50 0.95 0.08 * Significant

Table 4.21 shows the relationship between BMI and other continuous variables using linear regression and correlation analyses. The age, number of television sets, generating sets, hours of television watching and video games playing were significantly associated with BMI. The direction of the relationship between BMI and age was negative, while others were positive on correlation, although all the variables had weak relationship with BMI on correlation analysis.

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Table 4.22: Multiple Regression Analysis between BMI and the Significantly Associated Continuous Variables

BMI Coefficients Standard Beta Statistics error coefficient Age 0.07 0.06 0.06 F = 8.41 Number of television sets 0.38 0.12 0.17 p = <0.001 Number of generating sets 0.40 0.26 0.08 Hours of television watching per day 0.17 0.11 0.07 Hours of video games playing per day 0.45 0.13 0.18

Table 4.22 shows multiple regression analysis between BMI and the significantly associated continuous variables. This relationship was significant, with hours spent playing games daily being the strongest predictor of BMI using the beta coefficient. The multiple regression model will be;

y = β0 + β1ϰ1 + β2ϰ2 + β3ϰ3 + β4ϰ4 + β5ϰ5 y = Dependent variable (BMI)

ϰ1 = Age

ϰ2 = Number of television sets

ϰ3 = Number of generating sets

ϰ4 = Hours of television watching per day

ϰ5 = Hours of video games playing per day

β0 = Constant

β = Regression coefficients

Therefore, y = 13.40 + 0.07 ϰ1 + 0.38 ϰ2 + 0.40 ϰ3 + 0.17 ϰ4 + 0.45 ϰ5

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CHAPTER FIVE

DISCUSSION

At the millennium summit in 2000, representatives from 189 countries committed themselves toward a world in which sustaining development and eliminating poverty would have the highest priority.37,133 The increased recognition of the relevance of nutrition as a basic pillar for social and economic development placed childhood undernutrition among the targets of the first Millennium Development goal to “eradicate extreme poverty and hunger.”37,133

Childhood underweight is internationally recognized as an important public health problem and its devastating effects on human performance, health and survival are well established,17,37,134 hence nutritional status has been said to be the best indicator of the global well-being of children.19,90 It is even more worrisome that over-nutrition is becoming an emerging problem in segments of sub-Saharan African society, while the problem of undernutrition is far from being over.1,11,135 This rising epidemic along with the persistence of undernutrition typifies the ‘Double Burden of Malnutrition’ (DBM),14 which is becoming of great concern for African countries.65

This study showed statistically significant differences between many of the socio- demographic characteristics of the respondents in the rural and urban communities that were studied, including age, number of children in the family and the family settings, but there was no significant difference in the sex and class distributions. The children in the urban community were significantly younger than their counterparts in the rural community, with 7 out of 10 children in the urban community less than ten (10) years of age compared to just about 4 out of 10 children in rural community less than 10 years. Concerning the number of children in the family, more than 70% of urban families had less than five (5) children, while nearly 50% of the rural families had more than 5 children. Also, more than four-fifths of

lxxiv urban children were from monogamous homes, while two-fifths of the rural dwellers were from polygamous homes. The difference in socio-demographic characteristics between the urban and rural communities may be explained by the socio-economic status of the parents,15,19 because educated parents will tend to send their children to school earlier and are also more likely to have smaller family sizes when compared to parents with little or no education.

The socio-economic status of the children could not be directly assessed especially as the children could not tell the income and educational status of their parents, therefore indirect methods such as the occupation of their parents and their possession of some household properties like cars, television sets, generators and air conditioners were used. There was a significant difference between all the variables used to measure socio-economic status of respondents in the rural and urban communities. Significantly more families in the urban community had television sets, generating sets, cars and air conditioner sets than the rural families, with more than three-quarters of urban families having cars, as compared to just about a third of the rural families. Concerning the occupation of the parents, majority in the urban community were skilled (eg professionals) and semi-skilled (eg artisans) workers, while majority of rural dwellers were semi-skilled and unskilled (eg farmers, night guards etc) workers.

This difference in socio-economic status between the urban and the rural dwellers corroborates the finding of the Nigeria Demographic and Health survey (NDHS)136 where similar differences were found between urban and rural dwellers in Nigeria. Fotso in 2007137 also worked on the urban-rural differentials in child malnutrition in sub-Saharan Africa, and found that there were urban-rural gaps in socio-economic status and health in Nigeria and some other countries in sub-Saharan Africa. This may not be surprising in view of the fact

lxxv that urban communities usually have a higher concentration of professionals, middle and high income earners, western culture, services and modern equipment, whilst rural communities usually spell out poverty, illiteracy, underdevelopment and lack of services.137 The government and other Non-governmental organisations (NGOs) involved in development should however design relevant policies or review existing ones in order to bridge the rural- urban gap and provide the necessary environment for rural dwellers to live healthy and productive lives, especially as a greater proportion of the population still live in rural communities.128,130

The nutritional history of the respondents revealed significant differences in all the food classes considered between children in the rural and urban communities. The children in the urban community consumed significantly more of all the food classes considered except for starchy foods which the rural dwellers consumed more. After scoring and categorizing the food patterns of the respondents, nearly three-fifths of the children in the urban community had unhealthy food patterns, as compared to less than half in the rural community, and this difference was statistically significant. The higher consumption of food categories like pastries, sugar sweetened drinks and food from eateries by urban dwellers may be understood if not condoned, but it is surprising that the urban dwellers consumed fruits and vegetables more than the rural dwellers especially because fruits and vegetables are cheaper and usually more readily available in the rural areas. This may therefore be a reflection of the poor knowledge about the importance of fruits and vegetables by the rural dwellers, and hence a need for proper health education to address this knowledge deficit.

Concerning the pattern of physical activities of the respondents, the rural dwellers lived more active lifestyles than their urban counterparts. After the scoring and categorizing of the outcome variables for physical activity, about three quarters of the rural dwellers lived active

lxxvi lifestyles while less than half of the urban dwellers lived active lifestyles. This is similar to the finding of Epistein and Nueman in America109 which showed that, half of the school children studied did not engage in regular physical activities. This may not be difficult to understand in view of the higher socioeconomic status of the urban dwellers and the higher possession of cars and televisions sets by their parents, which all hold the potential of making children live more inactive lifestyles. Since some of these may be difficult to modify, one that holds a high potential for increasing the activity levels of the children may be involvement in sports especially in their schools. Policy makers and stakeholders in primary education should hence include sports as a mandatory component of primary school education in

Nigeria.

Concerning the perception of the respondents about their nutritional status, significantly more of the rural dwellers felt they were underweight. It was however interesting to find that significantly more of the rural dwellers disliked their figure, because they preferred to be fat.

This finding underscores the need for comprehensive nutrition education programmes for children that will help them develop the right value system for their weights.

Ova of parasites were found in the stool samples of about 3 out of 10 respondents in the rural community, while they were found in less than 1 out of 10 respondents in the urban community who made stool available for examination, and this difference was statistically significant. This may generally be due to the relatively poorer level of hygiene associated with the rural dwellers,138 which may not be unconnected with the low educational and socioeconomic status of majority of the rural dwellers.137 The total prevalence of intestinal helminthic infection in this study (18.8%) is similar to what was found by Uneke et al in

South-Eastern Nigeria,139 but lower than the 44.2% which was reported by Adekunle140,

43.0% that was reported by Adeyeba and Tijani,141 and the 52% reported by Adefioye et al.142

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This difference may be due to the fact that many of these studies were carried out more than 5 years ago. It however still shows a high level of intestinal heminthic infection especially among the rural dwellers.

Intestinal helminthic infections have been said to put a very heavy toll on the nutritional status of children through increased metabolic rate, anorexia and diarrhoea among other things hence contributing to undernutrition,104 therefore health education on the need for personal and environmental hygiene is necessary, especially for the rural dwellers. There is also the need for regular de-worming of school-age children, especially those living in the rural communities.

The mean BMI was significantly higher among urban children than the rural dwellers. Using the WHO growth reference for school-aged children,61 the overall prevalence rates of underweight and overweight/obesity were 29.7% and 7.3% respectively. In the rural community these were 41.0% and 0.0%, while in the urban they were 18.3% and 14.7%, respectively. With the IOTF criteria,59,60 overall prevalent rates of underweight and overweight/obesity were 27.0% and 4.8% respectively. In the rural community these were

36.7% and 0.0%, while in the urban they were 17.3% and 9.7%, respectively.

Underweight is used as a composite indicator to reflect both acute and chronic undernutrition, although it cannot distinguish between them.143 About 3 out of 10 children in this study were found to be underweight, and this is similar to the 25.5% that was reported in a recent study carried out in 2011 by Fetuga et al in Ogun State.92 Higher rates of underweight were however reported by Oninla et al89 in Osun State who reported 61% in the year 2007, Goon et al90 in 2011 who reported 43% to be underweight in Benue State, Meremikwu et al91 who reported 37.9% in the year 2000. This may generally reflect the nutritional transition being reported in developing countries, where underweight rates are taking a downward turn.14,69

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This may be the probable reason why the prevalence rate of underweight that was reported by

Oninla et al89 in the same Osun State six years ago doubles the finding of this study. It however, may just be a reflection of the socio-economic status of the different study areas.42,70

About two-fifths of children from the rural community were underweight, as compared to the less than a fifth of children in the urban community that were underweight. Although this prevalence is lower than the 70% and the 50% reported by Oninla et al89 in rural and urban communities of Osun State, the study similarly found that underweight rates were significantly higher among rural children than in the urban children. Fotso in 2007137 similarly reported urban-rural differentials in malnutrition in Nigeria, while other researchers have also generally reported that the prevalence of malnutrition is higher in rural than urban areas.68,91,137 The problem of undernutrition is not yet over in Nigeria. According to the

World Health Organization, undernutrition contributes to a downward spiral to a poor state of health that is fuelled by an increased burden of disease, stunted development and reduced ability to work. There is therefore the need for more to be done in ensuring food security and adequate nutrition education, especially for the rural dwellers.

The overall prevalence rate for obesity in this study was relatively low and this corroborates the finding of previous authors who reported that the prevalence of childhood overweight and obesity was low in Nigeria.5,42,92,100 Although, the prevalence rate for childhood overweight/obesity in this study is lower than what was reported by Adeleke in Ekiti state,98 it was higher than the 1.8% reported for Africa by Wang and Lobstein,42 the 1.9% reported by Sebanjo and Oshikoya in Abeokuta,12 the 2.3% reported by Ansa et al100 in Calabar, the

3.0% - 3.7% reported in Lagos by Ben-Bassey et al52 and the 3.5% reported by Fetuga et al92 in Sagamu, South-western Nigeria using the WHO reference.

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It is even more instructive that about 15% and 10% of the urban dwellers were overweight/obese using the WHO and IOTF growth references respectively, while there was no single case of overweight/obesity in the rural community. Childhood overweight/obesity therefore seems to be more of a problem in urban communities, as has been previously reported.14,42,68,71 The prevalence of childhood overweight/obesity in the urban community is already nearing the global estimate of 10% using the IOTF criteria as reported by Lobstein in

2010.43 Childhood overweight/obesity therefore seems to be rising in Nigeria especially in urban communities while undernutrition is still a big nutritional problem in the country especially in the rural communities. This corroborates the double burden of malnutrition14,69,71 that has been much talked about and poses a particular challenge for the government and other stakeholders in nutrition and health. There is need for more investment in nutrition education and government legislation to control the eating of unhealthy food types especially among the urban dwellers. In rural communities where the prevalence of childhood overweight/obesity remains very low, health enhancing traditional practices need to be protected.

There were significant associations between many of the socio-demographic characteristics and the nutritional status of the children in this study. Age was found to be significantly associated with the nutritional status of the children such that the younger children tended to have higher rates of overweight/obesity. This finding was consistent even when ANOVA, linear regression and correlation analyses were applied. This corroborates the finding of

Daboné et al in Burkina Faso, were it was detected that a higher prevalence trend of overweight/obesity were found in the youngest group of children.68 The Gender of the children had no significant effect on the nutritional status, and this is contrary to what has been reported by other previous studies in sub-Saharan Africa, were gender was significantly

lxxx associated with nutritional status.68,92,135,144 It is however largely unclear what the reason for this association could be, although some authors have proposed a cultural reason.

The significant relationship between family size and nutritional status may not be difficult to understand. Large families will put a great strain on the family income and hence only little will remain to ensure food security for the family. Even in agrarian communities, heads of large families may be forced to sell most of the food they produce on the farm in order to take care of their large families. All these will result into limited food for the family with many mouths to feed, and the little children usually have to bear the brunt.

All the variables used to measure socioeconomic characteristics including the occupation of the parents, the school types, the possession of air conditioner sets and cars were also found to be significantly associated with their nutritional status using both the WHO and IOTF criteria. The relationship between nutritional status and the occupation of the parents was such that children of skilled workers were less likely to be underweight and more likely to be overweight/obese, while the children of unemployed or unskilled workers were more likely to be underweight and less likely to be overweight/obese. It was interesting to find that about 8 out of 10 overweight/obese children had a skilled worker as a father, while there was 0% prevalence of overweight/obesity among unemployed mothers. Furthermore, nearly 90% of overweight/obese children attended private schools and children whose parents possessed more expensive properties like cars and air conditioner sets were less likely to be underweight and more likely to be overweight/obese.

This finding corroborates the reports by previous authors who have all highlighted the relationship between nutritional status and socio-economic factors.15,19,88,113 Nutritional status has been said to be an integral component of the overall health of an individual,145 and provides an indicator of the well-being of children living in a particular region.90,146

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Nutritional status is attributable to a range of factors closely linked to overall standards of living and the ability of populations to meet their basic needs, such as access to food, housing and health care.19 Assessment of growth not only serves as a means of evaluating the health and nutritional status of children, but also provides an excellent measurement of the inequalities in human development faced by populations.19 This inequalities in human development, especially between the rural and urban areas will need to be properly addressed so as to eliminate the rural-urban gaps in health.

Concerning the children’s feeding patterns and their effect on their nutritional status; all the food categories considered were found to be significantly associated with the nutritional status of the children. It was such that those who consumed the food categories for more than

3 times in the week preceding the survey were less likely to be underweight and more likely to be overweight/obese. This corroborates the work of Fishman et al in 2005 where it was reported that the diets of many children in developing countries were inadequate, and that the dietary deficiencies were an important determinant of childhood nutritional status.15 Many other researchers have similarly reported an association between food patterns and nutritional status of children.19,80,88,96,102 This is an important reason for all stakeholders in child health to focus more on nutritional education and interventions for children. These children are the future of the nation, and their growth and development should be the concern of everybody.

There was, however, no significant association between the categorized feeding patterns and nutritional status. This may be due to the fact that significantly more of the children from the urban community consumed both the healthy and unhealthy food categories, and so their effects might have balanced out.

The activity patterns of the children had a significant effect on their nutritional status, such that the urban children who lived more sedentary lifestyles had a higher rate of

lxxxii overweight/obese children. The average daily consumption of the electronic/electrical media was significantly associated with nutritional status using ANOVA, and the number of hours spent playing video games was the strongest predictor of nutritional status on multiple regression analysis, followed by the number of television sets in the house. This pattern has been similarly reported by various authors who have all reported activity patterns as an important determinant for childhood overweight/obesity.96,110–112 The extensive use of electrical/electronic appliances such as television and video games has also been shown to put children at risk of childhood overweight/obesity.111,112 As it is important for physical exercise to be included in the school curriculum, so also is the need for parents to regulate their children’s consumption of the electrical/electronic media. This will help to nip in the bud this rising prevalence of childhood overweight and obesity especially for the urban dwellers.

Intestinal helminthic infection was found to be significantly associated with the nutritional status of the children, such that significantly more of the children who had helminthic infection had higher rates of underweight children while those without intestinal helminthic infection had higher rates of overweight/obese children. Previous authors have similarly reported an association between nutritional status and intestinal helminthic infection.91,104,105,138,139,141 Intestinal helminthic infection is related to various factors ranging from poverty to poor hygiene.138 There is therefore the need to sustain and even possibly scale up the efforts at improving the socio-economic status of all Nigerians. In the short term, the regular de-worming of school children, especially those living in rural communities is recommended.

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CONCLUSION

The study showed that significant differences existed between the respondents from the rural and urban communities in their socio-demographic characteristics, their socio-economic characteristics, their feeding patterns, their activity patterns and intestinal helminthic infection. The prevalence rates of undernutrition in the rural community were 41.0% and

36.7% using the WHO and IOTF criteria respectively, and 18.3% and 17% respectively in the urban community. The prevalence rates of obesity for the urban community were 14.7% and

9.7% using WHO and IOTF criteria, but 0% for the rural community.

Therefore, undernutrition is still a major problem among school-age children in Osun State especially for those living in rural communities. There is also a rising trend of overweight/obesity in the urban communities in the State. The factors associated with these patterns of nutritional status among the school-age children included socio-demographic and socio-economic factors, feeding patterns, activity patterns and intestinal helminthic infection.

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RECOMMENDATIONS

In view of the findings of this study, the following recommendations are hereby made;

To the Policy Makers

1. There is the need to explore all measures necessary to bridge the rural-urban gap in

socio-economic development and health.

2. A comprehensive school health programme for the primary schools, with emphasis on

good nutrition is also recommended.

To the School Authority

1. It is recommended that nutrition should be included in the primary school curriculum

as a compulsory subject, so as to help the children in this impressionable age.

2. Decision makers in primary education should include sports as a mandatory

component of primary school education in Nigeria.

To the Parents

1. Parents should also limit their family size as family size was found to be a significant

factor affecting the nutritional status of children.

2. Parents should regulate the consumption of the mass media by their children and help

them to live more active lifestyles.

3. Parents in the urban communities should discourage the consumption of unhealthy

food types by their children.

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REFERENCES

1. Prentice AM. The emerging epidemic of obesity in developing countries. International Journal of Epidemiology. 2006;35:93–9.

2. Jafar TH, Qadri Z, Islam M, Hatcher J, Bhutta ZA, Chaturvedi N. Rise in childhood obesity with persistently high rates of undernutrition among urban school-aged Indo- Asian children. Archives of Disease in Childhood. 2008;93:373–8.

3. Khor GL. Update on the prevalence of malnutrition among children in Asia. Nepal Med Coll J. 2003;5:113–22.

4. Chatterjee P. India sees parallel rise in malnutrition and obesity. Lancet. 2002;360:1948.

5. Bamidele JO, Asekun-Olarinmoye EO, Olajide FO, Abodunrin OL. Prevalence and Socio-demographic Determinants of under-weight and pre-obesity among in-school adolescents in Olorunda Local Government Area, Osun State, Nigeria. TAF Preventive Medicine Bulletin. 2011;10(4):397–402.

6. Goran MI, Sun M. Total energy expenditure and physical activity in prepubertal children: recent advances based on the application of the doubly labeled water method. Am J Clin Nutr. 1998;68:944S–949S.

7. Wang Y, Monteiro C, Popkin BM. Trends of obesity and underweight in older children and adolescents in the United States, Brazil, China, and Russia. Am J Clin Nutr. 2002;75:971–7.

8. Bin Zaal AA, Musaiger AO DR. Dietary habits associated with obesity among adolescents in Dubai, United Arab Emirates. Nutr Hosp. 2009;24:4.

9. Ojofeitimi EO, Olugbenga-Bello AI., Adekanle DA, Adeomi AA. Pattern and determinants of obesity among adolescent females in private and public schools in the Olorunda Local Government Area of Osun State, Nigeria: a comparative study. Journal of Public Health in Africa. 2011;2(1).

10. Agarwal R K. Childhood Obesity : Emerging Challenge. INDIAN PEDIATRICS. 2008;45:443–4.

11. Van der Sande MA, Ceesay SM, Milligan PJ, OA N, Banya WA, Prentice A, et al. Obesity and undernutrition and cardiovascular risk factors in rural and urban Gambian communities. Am J Public Health. 2001;91(10):1641–1644.

12. Senbanjo IO, Oshikoya KA. Physical activity and body mass index of school children and adolescents in Abeokuta, Southwest Nigeria. World J Pediatr. 2010;6(3):217–22.

13. Popkin B.M, Horton S., Kim S, Mahal A, Shuigo J. Trends in diet, nutritional status and diet related communicable diseases in China and India: the economic costs of the nutrition transition. Nutr. Rev. 2001;59:379–90.

lxxxvi

14. Food and Agriculture Organization. The double burden of malnutrition: Case studies from six developing countries. FAO: Food and nutrition paper No84, Rome 2006. 2006;

15. Fishman SM, Caulfield LE, Onis M De, Blössner M, Hyder AA, Mullany L, et al. Childhood and maternal underweight. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, editors. Comparative Quantification of Health Risks; Global and Regional Burden of Disease attributable to Selected Major Rosk factors, Volumes 1-3. 1st ed. Geneva: World Health Organization (WHO); 2005. p. 39–161.

16. Rice AL, Sacco L, Hyder A, Black RE. Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries. Bulletin of the World Health Organization. 2000;78:1207–21.

17. Caulfield LE, de Onis Mercedes, Blössner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria and measles. American Journal of Clinical Nutrition. 2004;80:193–8.

18. Mendez MA, Adair LS. Severity and timing of stunting in the first two years of life affect performance on cognitive tests in late childhood. Journal of Nutrition. 1999;129:1555–62.

19. De Onis Mercedes, Frongillo EA, Blo M. Is malnutrition declining ? An analysis of changes in levels of child malnutrition since 1980. Bulletin of the World Health Organization. 2000;78(10):1222–33.

20. Arenz S, Rückerl R, Koletzko B, von Kries R. Breast-feeding and childhood obesity – a systematic review. Int J Obes 2004. 2004;28:1247–56.

21. Ong KK. Size at Birth, Postnatal Growth and Risk of Obesity. Horm Res. 2006;65(Suppl 3):65–9.

22. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84:274–88.

23. Moreno LA, Rodríguez G. Dietary risk factors for development of childhood obesity. Curr Opin Clin Nutr Metab Care. 2007;10:336–3341.

24. Monteiro POA, Victora CG. Rapid growth in infancy and childhood and obesity in later life – a systematic review. Obes Rev. 2005;6:143–54.

25. Kleiser C, Rosario AS, Mensink GBM, Prinz-langenohl R, Kurth B. Potential determinants of obesity among children and adolescents in Germany : results from the cross-sectional KiGGS study. BMC Public Health. 2009;9(46).

26. Oliveira AM, Oliveira AC, Almeida MS, Oliveira N, Adan L. Influence of the family nucleus on obesity in children from northeastern Brazil : a cross-sectional study. BMC Public Health. 2007;7:235.

lxxxvii

27. Butte NF, Cai G, Cole SA, Comuzzie AG. Viva la Familia Study: genetic and environmental contributions to childhood obesity and its comorbidities in the Hispanic population. Am J Clin Nutr. 2006;84:646–54.

28. O’Dea J.A. Gender , ethnicity , culture and social class influences on childhood obesity among Australian schoolchildren : implications for treatment , prevention and community education. Health and Social Care in the Community. 2008;

29. Waters E.B. & Baur L.A. Childhood obesity: Modernity’s scourge. Medical Journal of Australia. 2003;178(9):422–423.

30. Olshansky S.J., Passaro D.J., Hershow R.C., et al. A potential decline in life expectancy in the United States in the 21st century. New England Journal of Medicine. 2005;352:1138– 1145.

31. Lucas BL. Nutrition in Children. In: Kathleen Mahan L, Escoott-Stump S, editors. Kraus’s Nutrition, Food and Diet Therapy. Pliladelphia: W.B. Sunders; 2004. p. 260– 2.

32. Shils M, Olson J, Shils M, Ross AC. Modern Nutrition in Health and Disease. 9th ed. Pliladelphia: Lippinctton-Williams Wilkins; 1999.

33. Karlberg J, Kwan CW, Albertsson-Wikland K. Reference values for change in BMI from birth to 18 years of age. Acta. Pediatr. 2003;96:648–52.

34. Bhoite R, Iyer U. Magnitude of Malnutrition and Iron Deficiency Anemia among Rural School Children : An Appraisal. Applied Sciences. 2011;2(2):354–61.

35. Garrow JS, James WPT, Ralph A. Human Nutrition and Dietetics. 10th ed. Churchill Livingstone, USA; 2000.

36. United Nations Children’s Fund(UNICEF). State of the World’s Children: Children under Threat [Internet]. 2005 [cited 2011 Dec 1]. Available from: http://www.unicef.org/publications/files/SOWC_2005_(English).pdf

37. De Onis Mercedes, Blossner M, Borghi E, Frongillo EA, Morris R. Estimates of Global Prevalence of Childhood Underweight in 1990 and 2015. JAMA. 2004;291(21):2600–6.

38. United Nations University. Food and Nutrition Bulletin, (Supplement). UNICEF, New York, [Internet]. 2000;21(3):6–17. Available from: http://www.foodandnutritionbulletin.org/downloads/FNB_v30n1_Supplement_izinc.p df

39. De Onis M, Blossner M, Borghi E. Prevalence and trends of stunting among pre- school children, 1990–2020. Public Health Nutr. 2012;15(1):142 – 148.

40. Drake L., Maier C, Jukes M, Patrikios A. School-Age Children: Their Health and Nutrition prepared for Partners in Child Development [Internet]. 2002 [cited 2011 Dec 30]. Available from: www.schoolsandhealth.org

lxxxviii

41. Abidoye R, Soroh K. A study on the effects of urbanization on the nutritional status of primary school children in Lagos, Nigeria. Nutrition and Health. 1999;13(3):141–51.

42. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. International Journal of Pediatric Obesity. 2006;1:11–25.

43. Lobstein T. Prevalence and trends in childhood obesity. Obesity Epidemiology: From Aetiology to Public Health. 2nd ed. Oxford University Press; 2010. p. 3–16.

44. Speiser PW, Rudolf MCJ, Anhalt H, Camacho-hubner C, Chiarelli F, Eliakim A, et al. Consesus Statement: Childhood Obesity. Journal of Clinical Endocrinology & Metabolism. 2005;90(3):1871–87.

45. World Health Organisation (WHO). Population-based prevention strategies for childhood obesity: report of a WHO forum and technical meeting, Geneva, 15–17 December 2009. 2010;

46. World Health Organization (WHO). Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva. 2009;

47. Kelishadi R. Childhood Overweight, Obesity, and the Metabolic Syndrome in Developing Countries. Epidemiol Rev. 2007;29(1):62–76.

48. World Health Organisation (WHO). Global strategy for non-communicable disease prevention and control (draft). (Publication no. WHO/NCD/GS/97.1). Geneva, Switzerland. 1997;

49. Freedman DS, Khan LK, Dietz WH, et al. Relationship of childhood obesity to coronary heart disease risk factors in adulthood: The Bogalusa Heart Study. Pediatrics. 2001;100:712–8.

50. De Onis M., Blössner M. Prevalence and trends of overweight among preschool children in developing countries. Am J Clin Nutr. 2000;72:1032–9.

51. Afaire F. Body composition in urban children aged 6-13 years. Biol. Sci. J. Warri. 2001;2:62–7.

52. Ben-Bassey UP, Oduwole AO, Ogundipe OO. Prevalence of overweight and obesity in Eti-Osa LGA, Lagos, Nigeria. Obes Rev. 2007;8(6):475–9.

53. Government of Kenya. Household Health and Expenditure and Utilisation Survey Report, A publication of the Government of Kenya by Ministry of Health (MOH). 2003;15–7.

54. 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. Nutrition Journal [Internet]. BioMed Central Ltd; 2011;10(1):65. Available from: http://www.nutritionj.com/content/10/1/65

lxxxix

55. Chesire EJ, Orago ASS, Oteba LP, Echoka E. Determinants of undernutrition among school-age children in a Nairobi peri-urban slum. East African Medical Journal. 2008;85(10):471–9.

56. Bloom DE, Canning D, Sevilla J. The Effect of Health on Economic Growth : A Production Function Approach. World Development. 2004;32(1):1–13.

57. Zeena Salman, Gregory D. Kirk, Mark D. DeBoer. High Rate of Obesity-Associated Hypertension among Primary Schoolchildren in Sudan. Int J Hypertens. 2011;2011:629492.

58. Dehghan M, Akhtar-Danesh N, Merchant AT. Childhood obesity, prevalence and prevention. Nutrition Journal. 2005;4.

59. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: International survey. BMJ. 2000;320(7244):1240–5.

60. Cole TJ, Flegal KM, Nicholls D, Jackson AA. Body mass index cut offs to define thinness in children and adolescents : international survey. BMJ. 2007;335:194–7.

61. De Onis Mercedes, Onyango AW, Borghi E, Siyam A, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bulletin of the World Health Organization. 2007;85(9):660–7.

62. Muller O, Krawinkel M. Malnutrition and health in developing countries. Cmaj. 2005;173(3):279–86.

63. Cattaneo A, Monasta L, Stamatakis E, Lioret S, Castetbon K, Frenken F, et al. Overweight and obesity in infants and pre-school children in the European Union: a review of existing data. Obes Rev. 2010;11(5):389–98.

64. Bertoncello C, Cazzaro R, Ferraresso A, Mazzer R, Moretti G. Prevalence of overweight and obesity among school-aged children in urban, rural and mountain areas of the Veneto Region, Italy. Public Health Nutr. 2008;11(9):887–90.

65. Thiam I, Samba K, Lwanga D. Diet related chronic disease in the West Africa Region. in Diet-related chronic diseases and the double burden of malnutrition in West Africa. SCN News. 2006;33:6–10.

66. Delisle HF. Poverty: the double burden of malnutrition in mothers and the intergenerational impact. Ann N Y Acad Sci. 2008;1136:172–84.

67. Fernald LC, Neufeld LM. Overweight with concurrent stunting in very young children from rural Mexico: prevalence and associated factors. Eur J Clin Nutr. 2007;61(5):623–32.

68. Daboné C, Delisle HF, Receveur O. Poor nutritional status of schoolchildren in urban and peri-urban areas of Ouagadougou (Burkina Faso). Nutrition Journal [Internet]. 2011;10:34. Available from: http://www.nutritionj.com/content/10/1/34

69. Doak CM, Adair LS, Bentley M, Monteiro C, Popkin BM. The dual burden household and the nutrition transition paradox. Int J Obes. 2005;29:129–36.

70. Doak CM, Adair LS, Monteiro C, Popkin BM. Overweight and underweight coexist within households in Brazil, China and Russia. J Nutr. 2000;130:2965–71.

71. Kennedy G, Nantel G, Shetty P. Assessment of the double burden of malnutrition in six case study countries. FAO, Food and Nutrition Paper 84. Food and Agriculture Organization of the United Nations. Rome. 2006;

72. Chopra M. From apartheid to globalization: Health and social change in South Africa. Hygiea Internationalis. 2004;4(1):153–74.

73. Rahman A, Biswas S. Nutritional status of under-5 children in Bangladesh. South Asian Journal of Population and Health. 2009;2(1):1–11.

74. WHO, FAO, Education International. Healthy Nutrition: An Essential Element of a Health-Promoting School. WHO, Geneva. [Internet]. WHO Information Series on School Health. 1998 [cited 2012 Jan 3]. Available from: http://www.who.int/school_youth_health/media/en/428.pdf

75. De Onis Mercedes. WHO Global Database on Child Growth and Malnutrition. World Health Organization (WHO). WHO/NUT/97.4. 1997;

76. Mitra, Satindra N., Al-Sabir A, Saha T, Kumar S. Bangladesh Demographic and Health Survey 1999-2000, Dhaka: NIPORT and Mitra & Associates. 2001;

77. Food and Agriculture Organization. The state of food insecurity in the world 2000 [Internet]. FAO, Rome. 2000 [cited 2012 Jan 6]. Available from: http://www.fao.org/FOCUS/SOFIOO/img/sofirep-e.pdf

78. Osibogun A. The epidemiology of undernutrition. In: Osibogun A, editor. A handbook of public health nutrition for developing countries. 1st ed. Miral press. First Edition; 1998. p. 13–30.

79. World Bank. World Development Indicators. Washington DC: The World Bank. 2000;

80. Kopelman PG. Obesity as a medical problem. Nature. 2000;404(April):635–43.

81. World Health Organization (WHO). Obesity and Overweight; Factsheet No 31 [Internet]. WHO, Geneva. 2012. Available from: http://www.who.int/mediacentre/factsheets/fs311/en/index.html

82. Robbins JM, Khan KS, Lisi LM, Robbins SW, Michel SH, Torcato BR. Overweight among young children in the Philadelphia health care centers: incidence and prevalence. Arch Pediatr Adolesc Med. 2007;161(1):17–20.

83. Janssen I, Katzmarzyk P, Srinivasan S, Chen W, Malina R, Bouchard C, et al. Utility of childhood BMI in the prediction of adulthood disease: comparison of national and international references. Obes Res. 2005;13(6):1106–15.

xci

84. Nader P, O’Brien M, Houts R, Bradley R, Belsky J, Crosnoe R, et al. Identifying risk for obesity in early childhood. Pediatrics. 2006;118(3):e594–e601.

85. Schonfeld-Warden N, Warden CH. An overview of etiology and treatment. Pediatr Clin North Am. 1997;44(2):339–356.

86. Frongillo E. Causes and etiology of stunting. American Society for Nutritional Sciences Journal of Nutrition. 1999;129:529–30.

87. World Health Organization (WHO). Turning the tide of malnutrition: responding to the challenge of the 21st century. Geneva: WHO, 2000. WHO/NHD/00.7. 2000;

88. World Health Organization (WHO). Water Sanitation and Health (WSH): Malnutrition. Prepared for World Water Day 2001. Reviewed by staff and experts from the Department of Nutrition for Health and Development and the Water, Sanitation and Health Unit. WHO, Geneva. 2001;

89. Oninla SO, Owa JA, Onayade AA, Taiwo O. Comparative study of nutritional status of urban and rural Nigerian school children. J Trop Pediatr. 2007;53(1):39–43.

90. Goon DT, Toriola AL, Shaw BS, Amusa LO, Monyeki MA, Akinyemi O. Anthropometrically determined nutritional status of urban primary schoolchildren in Makurdi , Nigeria. BMC Public Health [Internet]. BioMed Central Ltd; 2011;11(1):769. Available from: http://www.biomedcentral.com/1471-2458/11/769

91. Meremikwu MM, Antia-Obong OE, Asindi AA, Ejezie GC. Nutritional status of pre- school children in rural Nigeria: relationship with intestinal helminthiasis. JOMIP. 2000;1:18–20.

92. Fetuga MB, Ogunlesi TA, Adekanbi AF, Alabi AD. Nutritional status of semi-urban Nigerian school children using the 2007 WHO reference population. West African Journal of Medicine. 2011;30(5):331–6.

93. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999–2000. JAMA. 2000;288:1723–7.

94. Pierre IB, Huang CL, Lee JY, Lin BH. Dietary habits, demographics and the development of overweight and obesity among children in the United States. Food Policy. 2005;30:115–28.

95. Musaiger O. Overweight and obesity in the Eastern Mediterranean region. Eastern Mediterranean Health Journal. 2004;10:789.

96. Mosha E, Fungo S. Prevalence of overweight and obesity among children aged 6 ‐ 12 years in Dodoma and Kinondoni Municipalities , Tanzania. Tanzania Journal of Health Research. 2010;12(1).

97. Owa JA, Adejuyigbe O. Fat mass, Fat mass percentage, Body mass index and mid- upper arn circumference in a healthy population of Nigerian children. J. Tropic. Paediatrics. 1997;43:13–9.

xcii

98. Adeleke E. The prevalence of childhood obesity in Ekiti State of Nigeria. Obesity Report. 2005;1.

99. Adegun JA, Olumuyiwa BA. The Nigerian Built-Environment and childhood obesity. Pakistan Journal of Social Sciences. 2008;5(2):160–4.

100. Ansa VO, Odigwe CO, Anah MU. Profile of body mass index and obesity in Nigerian children and adolescents. Nig. J. Med. 2001;10:78–80.

101. Baqui AH, Black RE. Childhood infectious diseases and their contribution to undernutrition. In: Public health issues in infant and child nutrition. Black RE, Michaelson KF, eds. (Nestlé Nutrition Workshop Series, Pediatric Program, Volume 48.) Lippincott Williams & Wilkins, . 2002;

102. Blössner M, de Onis Mercedes. Malnutrition Quantifying the health impact at national and local levels. In: Prüss-üstün A, Campbell-lendrum D, Corvalán C, Woodward A, editors. WHO Environmental Burden of Disease Series, No. 12. Geneva: World Health Organization (WHO); 2005.

103. Johns T, Eyzaguirre PB. Nutrition for sustainable environments. SCN News,. 2000;21:25–9.

104. Runsewe-Abiodun TI, Olowu AO. Study on Prevalence and Nutrional effect of Helminthic infection in rural children in Nigeria. Nigerian Medical Practitioners. 2008;54(1):16–20.

105. Sur D, Saha DR, Manna B, Rajendran K, Bhattacharya SK. Periodic deworming with albendazole and its impact on growth status and diarrhoeal incidence among children in an urban slum of India. Trans. of the Royal Society of Tropical Medicine and Hygiene. 2005;99(4):261–7.

106. World Health Organisation (WHO). Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organization Technical Report Series. 2000;894:i-xii:1–253.

107. Davison KK, Birch LL. Childhood overweight: a contextual model and recommendations for future research. Obes Rev. 2001;2:159–71.

108. Goran, M. I. & Min S. Prevalence of obesity in children. American Journal of Clinical Nutrition. 1998;6:944–9.

109. Epistein, F. A. & Nueman J. Defining overweight and obesity. American Journal Clinical Nutrition. 1998;72:1067.

110. Maletnlema T. A Tanzanian perspective on the nutrition transition and its implications for health. Public Health Nutrition. 2002;5(1A):163–8.

111. Robinson TN. Television viewing and childhood obesity. Paediatric Clinics of North America. 2001;48:1017–25.

xciii

112. Dennison BA, Erb TA, Jenkins PL. Television viewing and television in bedroom associated with overweight risk among low‐income pre-school children. Paediatrics. 2002;109:1028–35.

113. Reddy SP, Panday S, Swart D, Jinabhai CC, Amosun SL, James S, et al. The South African Youth Risk Assessment Survey 2002. Cape Town: South African Medical Research Council,. 2003;

114. Monteiro C, Conde WL, Lu B, Popkin BM. Obesity and inequities in health in the developing world. Int J Obes Relat Metab Disord. 2004;28.

115. Wang Y. Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. Int J Epidemiol. 2001;30:1129–36.

116. Saxena S, Ambler G, Cole TJ, Majeed A. Ethnic group differences in overweight and obese children and young people in England: cross sectional survey. Arch Dis Child. 2004;89:30–6.

117. De Onis Mercedes, Blössner M. The World Health Organization Global Database on Child Growth and Malnutrition : methodology and applications. International Journal of Epidemiology. 2003;32:518–26.

118. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obes Rev. 2004;5(Suppl 1):4–104.

119. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: Methods and Development. National Centre for Health Statistics. Vital Health Statistics. 2002;11(246):1–190.

120. World Health Organisation (WHO). Multicentre Growth Reference Study Group: WHO Child Growth Standards: length/height-for-age, weight-for-age, weight-for length, weight-for-height and body mass index-for-age: methods and development. WHO, Geveva. 2006;

121. Man WDC, Weber M, Palmer A, Schneider G, Wadda R, Jaffar S, et al. Nutritional status of children admitted to hospital with different diseases and its relationship to outcome in the Gambia, West Africa. Tropical Medicine and International Health. 1998;3(8):678–86.

122. Grantham-McGrego S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. The International Child Development Steering Group: Developmental potential in the first five years for children in developing countries. Lancet. 2007;369:60–70.

123. Sinha R, Fisch G, Teague B, Tamborlane WV, Banyas B, Allen K, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med. 2002;346:802–10.

124. Gahagan S, Silverstein J. Prevention and treatment of type 2 diabetes mellitus in children, with special emphasis on American Indian and Alaska Native children: The

xciv

Committee on Native American Child Health and Section on Endocrinology. Paediatrics. 2003;112:e328.

125. Lurbe E, Alvarez V, Redon J. Obesity, body fat distribution, and ambulatory blood pressure in children and adolescents. J Clin Hypertens (Greenwich). 2001;3:362–7.

126. Yanovski JA. Pediatric obesity. Rev Endocr Metab Disord. 2001;2:371–83.

127. Jabbour SA. Cutaneous manifestations of endocrine disorders: a guide for dermatologists. Am J Clin Dermatol. 2003;4:315–31.

128. Federal Republic of Nigeria Official Gazette. Legal Notice on Publication of 2006 Census Final Results. Abuja. 2009;96(2):B1–42.

129. Osun State Government. Osun State in Brief. [Website] Osogbo: Bureau of computer services and information technology, Osun state [Internet]. 2008 [cited 2013 Jun 9]. Available from: http://osunstate.gov.ng/geography.htm

130. The Osun State Ministry of Information and women affairs. Osun State at a glance. In Osun state diary; 2004 and 2006. :5–12.

131. Kelsey J, Whitte A, Evans A, Thompson WD. Methods in observational epidemiology. 2nd ed. Oxford University Press; 1996. p. pp332.

132. International Society for the Advancement of Kinanthropometry. International Standards for anthropometric Assessment. 2001;53–5.

133. United Nations. Millennium development goals. [Internet]. 2000 [cited 2012 May 21]. Available from: http://www.un.org/millenniumgoals

134. Chang S, Walker S, Grantham-McGregor S, Powell C. Early childhood stunting and later behaviour and school achievement. J Child Psychol Psychiatry. 2002;43:775–83.

135. Akinpelu AO, Oyewole OO, Oritogun KS. Overweight and Obesity : Does It Occur In Nigerian Adolescents in an Urban Community? International Journal of Biomedical and Health services. 2008;4(1):11–7.

136. National Population Commission(Nigeria), ICF Macro. Nigeria Demographic and Health Survey 2008. Abuja, Nigeria. 2009;

137. Fotso JC. Urban-rural differentials in child malnutrition: trends and socioeconomic correlates in sub-Saharan Africa. Health Place. 2007;13(1):205–23.

138. Bamidele JO, Adebimpe WO. Knowledge, attitude and practice of basic personal hygiene and pattern of helminthic infection among school children in Osun State, Southwestern Nigeria. Journal of Community Medicine & Primary Health Care. 2009;21(2):59–66.

xcv

139. Uneke CJ, Eze O, Oyibo P, Azu N, Ali E. Soil-transmitted helminth infection in school children in South-Eastern Nigeria: The public health implication. The internet journal of third world Medicine. 2007;4(1):1–12.

140. Adekunle L. Intestinal parasites and nutritional status of Nigerian children. Afr. J. Biomed. Res. 2002;5:115–9.

141. Adeyeba O, Tijani B. Intestinal helminthiasis among malnourished school children in peri-urban area of Ibadan, Nigeria. Afri Jour. Cli & experi. Micro. 2002;3(1):24–8.

142. Adefioye OA, Efunshile AE, Ojurongbe O, Akindele AA, Adewuyi IA, Bolaji OS, et al. Intestinal Helminthiasis among School Children in Ilie , Osun State ,. Sierra Leone Journal of Biomedical Research. 2011;3(1):36–42.

143. Bose K, Bisai S, Chakraborty J, Dutta N, Banerjee P. Extreme levels of underweight and stunting among pre-adolescent children of low socioeconomic class from Madhyamgram and Barasat, West Bengal, India. Coll Anthropol. 2008;1:73–7.

144. Fetuga M, Ogunlesi T, Adekanmbi A, Alabi A. Growth Pattern of Schoolchildren in Sagamu, Nigeria Using the CDC Standards and 2007 WHO Standards. Indian Paediatrics. 2011;48:523 – 528.

145. Som S, Pal M, Bharati P. Role of individual and household level factors on stunting: a comparative study in three Indian states. Ann Hum Biol. 2007;34:(6):632–46.

146. Dutta A, Pant K, Puthia R, Sah A. Prevalence of undernutrition among children in the Garhwal Himalayas. Food and Nutr Bull. 2009;30:(1):77–81.

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APPENDIX 1

LIST OF LOCAL GOVERNMENT AREAS IN OSUN STATE Rural Local Government Areas 1. Aiyedire 2. Atakumosa East 3. Atakumosa West 4. Boluwaduro 5. Boripe 6. Egbedore 7. Ejigbo 8. Ife North 9. Ife South 10. Ifedayo 11. Irepodun 12. Irewole 13. Isokan 14. Obokun 15. Odo-Otin 16. Ola-Oluwa 17. Oriade 18. Orolu

Urban Local Government Areas

1. Aiyedade 2. Ede North 3. Ede South 4. Ife central 5. Ife East 6. Ifelodun 7. Ila 8. Ilesa East 9. Ilesa West 10. Iwo 11. Olorunda 12. Osogbo

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APPENDIX 2

SELECTED SCHOOLS IN THE SELECTED RURAL AND URBAN COMMUNITIES

Communities Selected LGAs Selected Schools Rural Boripe LGA Greater Future Nursery and Primary School, Aagba

A2 Nursery and Primary School, Iragbiji

St Peter Primary School, Iragbiji

Local Authority Primary School, Ada Urban Osogbo LGA Olive Branches Schools, Osogbo

Osun Baptist Conference Nursery and Primary School, Osogbo

Christ African Church Primary School, Osogbo

Anthony Udofia Model Primary School, Osogbo

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APPENDIX 3

NUMBER OF RESPONDENTS SELECTED IN EACH CLASS

IN THE SELECTED SCHOOLS

CLASSES NAME OF SCHOOL 1 2 3 4 5 6 T S T S T S T S T S T S URBAN Olive Branches Schools, 88 15 58 10 70 12 93 16 76 13 53 9 Osogbo (N = 438) Osun Baptist Conference 36 13 30 11 52 19 39 14 28 10 22 8 Nursery and Primary School, Osogbo (N =207) Christ African Church 86 16 65 12 70 13 60 11 65 12 60 11 Primary School, Osogbo (N = 406) Anthony Udofia Model 54 16 48 14 41 12 37 11 44 13 31 9 Primary School, Osogbo (N = 255) RURAL Greater Future Nursery 18 13 15 11 32 24 14 10 14 10 10 7 and Primary School, Aagba (N =207) A2 Nursery and Primary 49 14 46 13 63 18 38 11 38 11 28 8 School, Iragbiji (N =262) St Peter Primary School, 56 10 62 11 66 12 73 13 73 13 90 16 Iragbiji (N = 420) Local Authority Primary 32 11 29 10 32 11 44 15 37 13 44 15 School, Ada (N =218) *T – Total number of students in all the arms of a class *S – Selected number from each class

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APPENDIX 4

QUESTIONNAIRE

Pattern and Determinants of Nutritional Status among School-Age Children in a Rural and an Urban Community in Osun State; a Comparative study

Serial No: ______

Section A: Socio-Demographic Data 1. Residence a) Rural [ ] b) Urban [ ] 2. School type a) Public [ ] b) Private [ ] 3. Age in years (as at the last birthday) ______4. Gender a) Male [ ] b) Female [ ] 5. Religion a) Christianity [ ] b) Islam [ ] c) Traditionalist [ ] d) Others (Specify)______6. Ethnicity a) Yoruba [ ] b) Hausa/Fulani [ ] c) Igbo [ ] d) Others (Specify)______7. Class a) Primary 1 [ ] b) Primary 2 [ ] c) Primary 3 [ ] d) Primary 4 [ ] e) Primary 5 [ ] f) Primary 6 [ ] 8. Number of Children in the family ______9. Birth order a) First [ ] b) Second [ ] c) Third [ ] d) Fourth [ ] e) Greater than 4 [ ] 10. Father’s occupation a) Unemployed [ ] b) Skilled worker (eg Professionals (Doctor, lawyer..), entrepreneurs, etc ) [ ] c) Semi-skilled (Artisans, traders) [ ] c) Unskilled worker (eg labourers, cleaners etc) [ ] 11. Mother’s occupation a) Unemployed [ ] b) Skilled worker (eg Professionals (Doctor, lawyer..), entrepreneurs, etc ) [ ] c) Semi-skilled (Artisans, traders) [ ] c) Unskilled worker (eg labourers, cleaners etc) [ ] 12. Family setting a) Monogamous [ ] b) Polygamous [ ] 13. Custodian a) Single parent; Divorced [ ] b) Single parent; Widowed [ ] c) Both parents [ ] c) Guardian; Relatives [ ] d) Guardian; Non-relatives [ ]

14. Which of these do you have at home? How many? Television ______Generator ______Car (s) ______Air conditioner ______Section B: Nutritional History of Respondents In the last one week, at home or in school (but not special occasions); on average, how many times have you taken the following? SN None <3times ≥3times Daily >once daily

1 Fruits 2 Vegetables 3 Food from eateries 4 Pastries (cake, cookies, meat/fish pies etc)

5 Sugar-Sweetened Drinks (viju, lacasera, coca cola, juice etc) 6 Sweets (chocolate, candy, ice cream) 7 Animal protein (meat) 8 Animal protein (fish) 9 Animal protein (egg) 10 Carbohydrates (eg amala, eba, yam etc)

Section C: Physical Activities 1. How do you go to school? a) On foot [ ] b) Parents Car [ ] c) School Bus [ ] d) Public transport (taxi, bus or okada) [ ] e) Bicycle [ ] f) Others (Specify)______2. Do you help in parents’ work/business? a) Yes [ ] b) No [ ] 3. Are you involved with chores at home? a) Yes [ ] b) No [ ] 4. Vigorous sports in a way that makes you sweat. a) Rarely/Never [ ] b) Less than 3 days a week [ ] c) 3 or more days a week [ ] d) Daily [ ] 5. Average hours of sleep per day ______6. Average hours spent watching TV/Video/Satellite in a day______

7. Average hours spent with video games, computer/internet daily______

Section: D: Perceived Family History of Overweight/Obesity 1. Do you consider your mother to be very fat? a) Yes [ ] b) No [ ] c) Don’t know [ ] 2. Do you consider your father to be very fat? a) Yes [ ] b) No [ ] c) Don’t know [ ] 3. Do you consider any of your siblings to be very fat? a) Yes [ ] b) No [ ] c) Don’t know [ ] Section F: Respondents’ Perception about Obesity 1. How do you perceive your figure? a) Thin [ ] b) OK [ ] c) Fat [ ] 2. Do you like your figure? a) Yes [ ] b) No [ ] c) I don’t know [ ] 3. Do your peers make fun of you because of your figure? a) Yes [ ] b) No [ ] 4. If yes to above, for what reason? ______5. What would you prefer your figure to be? b) Thin [ ] b) Normal [ ] c) Fat [ ] d) Indifferent [ ]

Section E: Anthropometry 1. Weight (in kg) ______2. Height (in metres) ______3. BMI ______4. Weight classification (according to 2007 WHO reference) a) Severe thinness(<-3SD) [ ] b) Thinness(<-2SD) [ ] c) Normal [ ] d) Overweight(>+1SD) [ ] e) Obese(>+2SD) [ ] 5. Weight classification (according to IOTF recommendation) a) Grade III Thinness [ ] b) Grade II Thinness [ ] c) Grade I Thinness [ ] d) Normal [ ]

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e) Overweight [ ] f) Obese [ ] Section F: Helminthic Infection 1. Have you been de-wormed in the last 6 months? a) Yes [ ] b) No [ ] c) Don’t know [ ] 2. Stool sample collection. Stool sample made available [ ], Stool sample not made available [ ] 3. Stool Microscopy result: ______

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APPENDIX 5

QUESTIONNAIRE (In Yoruba Language)

Nomba: ______

Ipin A: Irohin nipa Irisi Awon eniyan Awujo 1. Ibugbe a) Abule [ ] b) Igboro [ ] 2. Iru ile-iwe ti o nlo a) ile-iwe ijoba [ ] b) Aladini [ ] 3. Ojo ori (Nigba ti o se ojo ibi kehin) ______4. Okunrin/obinrin a) Okunrin [ ] b) obinrin [ ] 5. Esin a) Kristiana [ ] b) Musulumi [ ] c) Esin ibile [ ] d) Esin miran(so)______6. Eya a) Yoruba [ ] b) Hausa/Fulani [ ] c) Igbo [ ] d) Others (Specify)______7. Kilasi ni ile-iwe a) 1 [ ] b) 2 [ ] c) 3 [ ] d) 4 [ ] e) 5 [ ] f) 6 [ ] 8. Iye awon omo ninu idile re ______9. Ipo ti o wa laarin awon idile re a) Akobi [ ] b) Ekeji [ ] c) Eketa [ ] d) Ekeerin [ ] e) Ekaarun soke [ ] 10. Ise oojo baba re a) ko ni ise lowo [ ] b) Akosemose (bii dokita, agbejoro, agbanisise etc) [ ] c) Onise owo (Artisans, traders) [ ] d) Alagbase (bii agbale, alagbaro etc) [ ] 11. Ise oojo momo re a) ko ni ise lowo [ ] b) Akosemose (bii dokita, agbejoro, agbanisise etc) [ ] c) Onise owo (Artisans, traders) [ ] d) Alagbase (bii agbale, alagbaro etc) [ ] 12. Iru idile re a) oko ati iyawo kan [ ] b) ile orogun [ ]

13. Tani o n gbe pelu? a)Obi re kan ti o ndagbe; ti a ti ko sile [ ] b) Obi re kan; Oko tabi aya re ti ku [ ] d) Awon obi meejeji [ ] e) Alagbato; Iyekan re [ ] e) Alagbato; Alaro lasan[ ]

14. Ewo ninu awon wonyi ni e ni nile/melo?

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Mohunmaworan ______Ero amunawa ______Oko ayokele ______Ero amule tutu ______Ipin B: Alaye lori bi o tin je lateyinwa; se afoju dare, o to bi igba melo ti o ti je awon onje wonyi laarin ose ti o lotan? SN Rara Emeta O ju Jooju O ju emeta lo mo eekan lojumo 1 Eso 2 Efo/tabi ewebi 3 Ounje ile-ounje igbalode 4 Ounje oniyefun (bii keeki oyinbo, etc) 5 Awon oti elerindodo (bii viju, kooki etc) 6 Ounje aladidun bii suuti, aisi krimu etc 7 Ounje asaralore lati inu eran 8 Ounje asaralore lati inu eja 9 Ounje asaralore lati inu eyin 10 Ounje afaralokun (bii eba, amala, iyan, isu etc)

Ipin D: Awon ere Idaraya 1. Bawo ni ose nlo si ile-iwe? a) O ma nrin [ ] b) Oko awon obi mi [ ] c) Oko ile- iwe [ ] d) Oko ero (bii taksi, kabukabu, tabi okada) [ ] e) keke [ ] g) Omiran (so)______2. Nje o ma nran awon obi re lowo ninu okoowo won? a) Beeni [ ] b) Beeko [ ] 3. Nje o ma nse ise ile? a) Beeni [ ] b) Beeko [ ] 4. Nje o ma nse ere idaraya Kankan ti o mu o laagun dada a) N o ki nsaba se/mi ko se rara [ ] b) Ko to ojo meta lose [ ] c) Bi ojo meta tabi jubee lo lose [ ] d) Lojoojumo [ ] 5. Iye wakati ti o fin sun lojoojumo ______6. Iye wakati ti o fi nwo mohunmaworan lojoojumo ______7. Iye wakati ti o fi gba geemu (ti fidio, komputa, ero aye lukara) lojoojumo ______Ipin E:Bi awaon ara ile mi se sanra si

1. Nje o ro pe momo re sanra ju? a) Beeni [ ] b) Beeko [ ] c) Nko mo [ ] 2. Nje o ro pe baba re sanra ju? a) Beeni [ ] b) Beeko [ ] c) Nko mo [ ] 3. Nje o ro pe awon omo iya re sanra ju? a) Beeni [ ] b) Beeko [ ] c) Nko mo [ ] Ipin E: Ero re nipa ara asanju 1. Bawo ni o se ro pe ara re ri? a) O tinrin [ ] b) O dara [ ] c) Mo sanra [ ] 2. Nje bi ara/tabi irisi re se ri te o lorun? a) Beeni [ ] b) Beeko [ ] c) Nko mo [ ] 3. Nje awon elegbe re ma nfi o se yeye nitori bi o se ri? a) Beeni [ ] b) Beeko [ ] 4. Ti idahun ba je beeni, kini idi re? ______5. Bawo ni o ti fe ki ara re ri? a) ko tirin [ ] b) Kowa ni iwon tunwonsi [ ] c) ko sanra [ ] d) nko kaasi [ ]

Ipin F: Osunwon ara sisan 1. Osuwon sisanra (ni kg) ______2. Bi o ti ga si (ni osunwon metres) ______3. BMI ______4. Weight classification (according to 2007 WHO reference) a) Severe thinness(<-3SD) [ ] b) Thinness(<-2SD) [ ] c) Normal [ ] d) Overweight(>+1SD) [ ] e) Obese(>+2SD) [ ] 5. Weight classification (according to IOTF recommendation) a) Grade III Thinness [ ] b) Grade II Thinness [ ] c) Grade I Thinness [ ] d) Normal [ ] e) Overweight [ ]

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f) Obese [ ] Ipin G: Aran 4. Nje o ti lo ogun aran losu mefa seyin? a) Beeni [ ] b) Beeko [ ] c) Nko mo [ ] 5. Igbe fun ayewo Igbe wa fun ayewo [ ], ko si igbe fun ayewo [ ] 6. Eesi ayewo igbe ______

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APPENDIX 6

ETHICAL CLEARANCE

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APPENDIX 7

PERMISSION FROM OSUN STATE MINISTRY OF EDUCATION

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APPENDIX 8

CONSENT FORM FOR PARENTS Appendix 1 - Consent form for participants Greetings.

I am Dr Adeomi AA, from LAUTECH Teaching Hospital, Osogbo. I am here to conduct a research titled “Pattern and Determinants of Nutritional Status among School-Age Children in a Rural and an Urban Community in Osun State; a Comparative study” The hope is that the findings from this research will improve current understanding of related issues especially as it relates to the health of your child.

To achieve the objectives of the study, your child will be interviewed and his/her anthropometric measurements (i.e. the weight and height) and stool sample will be taken. We will ensure that the information given cannot be traced back to your child. His/her names will not be included in any of the study documents. The data will be kept securely in a computer only accessible to the principal researcher.

You are free to refuse to allow your child to participate and also to ask him/her to withdraw at any time during the interview if you decide so. There will be no adverse effects of such a decision. You can also raise any concerns that you may have during the session. If you have any questions to ask concerning the study, please contact the principal researcher on phone 08036535077 or e-mail; [email protected]

If you are willing to allow your child to participate, kindly affirm by signing in the space provided below;

“I have read the consent form and do hereby give my consent for my child to be included in this study.”

Signature ______Date ______

Signature of Witness/Date: ______

APPENDIX 9

MAP OF OSUN STATE

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APPENDIX 10

APPROVAL FROM NATIONAL POSTGRADUATE MEDICAL COLLEGE

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Plate 1: A Research Assistant during Data Collection in one of the Primary Schools

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Plate 2: A pupil showing Universal bottle for Stool Collection

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Plate 3: The Researcher taking the Height of a pupil in one of the Primary Schools

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Plate 4: A Research Assistant taking the Weight of a Pupil

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