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 To 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 ii 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. iii DEDICATION This work is dedicated to God Almighty, who alone is worthy of all the praise and glory. iv 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! v 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 vi 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 vii 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 viii 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 ix 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 x 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 xi 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 xii 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.