ABSTRACT
Overweight and obesity have become topical issues in public health due to the morbidities and mortalities associated with them. Among teenagers, the prevalence has been increasing as in other age groups; Nigeria has recorded up to 11.4% for overweight in previous studies.
‘In-School’ teenagers were recruited into the study: the control had one thousand and twenty five (1025) and the intervention had one thousand and twenty six (1026) participants. After stratifying the schools into public and private owned, two public and three private schools were selected using a simple random sampling technique from each stratum. The respondents were recruited using a systematic random sampling from the class register. Variables assessed were socio-demographic profile, anthropometric values, physical and sedentary activities, dietary pattern and hours of sleep.
Results show that most of the participants’ parents belonged to the high socioeconomic class while most of the respondents belonged to the age bracket of 10-14 years. The mean age of participants was 13.77±1.96 years, while the mean BMI was 21.29±3.75kg/m2. The prevalence of overweight and obesity were 5.6% and 19.0% respectively. Factors associated with overweight and obesity were being female, belonging to the high socio-economic class, attending a private school, high intake of snacks, not being physically active and a largely sedentary life. In addition, overweight and obese teenagers had shorter sleeping hours compared to those with normal BMI. Logistic regression models assessing the influence of demographic and lifestyle variables showed the following risk factors; gender 1.33 (95% CI: 1.06-1.67), attending private school 1.79 (95% CI: 1.32-1.42), high socioeconomic class 1.74 (1.12-2.70), high level of sedentary activities 1.31(1.02-1.67), skipping of breakfast 1.37(1.05-1.79) and frequent consumption of snacks 1.32(1.00-1.74).
CHAPTER ONE
INTRODUCTION
1.1 Background to the study
The terms overweight and obesity are ranges of weight that are greater than what is generally considered healthy for a given height1. The terms also identify ranges of weight that have been shown to increase the likelihood of certain diseases and other health problems. These terms have become issues of public health concern in recent years. In some countries, overweight and obesity have been recognized as leading health indicators2. The problem cuts across all the age groups, from preschool children to teenagers and unto adulthood. Initially, it was a problem of the high income industrialized society, but now it has become an issue of major concern even in the low and middle income countries where the prevalence is increasing especially in the urban areas3.
Globally, between 1980 and 2013 the prevalence of obesity has nearly doubled from 8.1% to 12.9% among boys and 8.4% to 13.4% among girls4 and presently, 65% of the world’s population lives in countries where overweight and obesity kill more people than underweight. At least 2.8 million people die each year as a result of being overweight or obese5 and an estimated 35.8 million (2.3%) of the global Disability Adjusted Life Years (DALYs) are caused by overweight or obesity6. In 2010, 43 million children (35 million or 81.4% in developing countries) were estimated to be overweight and obese; and 92 million were at the risk of overweight. The worldwide prevalence of childhood overweight and obesity increased from 4.2% in1990 to 6.7% in 2010. This trend is expected to reach 9.1% in 20206.
The estimated prevalence of childhood overweight and obesity in Africa in 2010 was 8.5% and is expected to reach 12.7% in 2020. The situation in Africa is peculiar because, the continent is still battling with communicable diseases and malnutrition. This makes the situation double legged: under nutrition at one end and over nutrition at the other7.
Teenagers are young people between the ages of 10 and 19 years. Worldwide, their population is 1.2 billion, meaning that every 1 in 6 persons is an teenager; this makes them an important population group demographically7. The prevalence and severity of overweight/obesity in this group has been on the increase. It is one of the most serious health problems affecting this age group8. In 2010, the prevalence was 18.1% globally. However, among teenager blacks in the developed countries such as the United States of America, the prevalence is as high as 29.2% 2.
In Africa, there is a wide disparity between the various countries. In Sudan, the prevalence is 28.5% for overweight and 5.6% for obesity9. In South Africa, it is 16.9% for overweight and 4% for obesity10. In Ghana and Uganda it is 10.4% and 0.9%11.
In Nigeria, there is also much variation due to the heterogeneity. It is as low as 3.3% in the Northern part and as high as 11.4% in the Southern part 12, 13 but more importantly the prevalence just as in other parts of the world has been increasing as previous studies had much lower values14.
The fundamental cause of overweight and obesity is an energy imbalance between calories consumed and calories expended. In the developed countries, teenager obesity has been attributed mainly to increased sedentary lifestyle, while in the case of developing countries such as Nigeria in addition to a sedentary life style, there is an epidemiological transition in diet from one rich in vegetables, fruits, complex carbohydrates, fibers and other natural nutrients to refined foods rich in animal protein, sugars and saturated fats15. These foods which are poor in fibers and micronutrients are easy to access especially through fast foods consumption and because they contain more of saturated fats are deposited as excess fats in the tissue16. Moreover, teenagers generally do not have good eating habits. They prefer fast foods and snacks resulting in the challenge of malnutrition of which obesity is one extreme of the spectrum17. There is also a genetic interplay in obesity as children who are obese tend to have one or more of the parents being overweight or obese18.
Overweight and obesity have numerous adverse effects on health; they are risk factors for certain Non-Communicable Disease (NCDs) that could cause lifelong debilities. For most NCDs resulting from obesity, the risks depend partly on the age of onset and on the duration of obesity. Such diseases include Type 2 Diabetes Mellitus (T2D), musculoskeletal disorders, especially osteoarthritis, kidney and gall bladder stones and certain types of cancer such as endometrial, breast and colon cancer3. The risks of coronary heart disease, ischemic stroke and type 2 diabetes mellitus increase steadily with increasing body mass index (BMI), mortality rates also increase with increasing degrees of overweight19. Apart from the obvious health implications, concern about obesity is particularly important in teenagers because they are very interested in their body image and physical appearance. Teenagers who are obese are known to have a poor self image and low self esteem20.
Intervention programs have been carried out in the developed countries. The programs can be school, family or clinic-based. These interventions are characterized by nutritional education emphasizing change in dietary habits such as increasing fruit and vegetable while reducing fat and sugar intake. The nutritional education also high-lights the benefits of reducing sedentary behavior such as television viewing and video games while increasing physical activity. Family and school-based interventions have been successful in reducing BMI, Weight to hip ratio (WtHR) and sedentary life, while increasing aerobic fitness and fiber intake within the study group 21, 22 .
In sub-Saharan Africa, generally there is paucity of information on this public health challenge with intervention studies being almost non-existent especially in Nigeria. This may be due to the fact that under-nutrition has not yet been fully addressed and so overweight and obesity even though present in this group have not been given much attention. Much of the works in the developed countries have been based on evaluating the western life-style and some of the interventions carried out cannot be applied to the developing countries as they are very technical. The present study aims to carry out a culturally, economically and technologically appropriate intervention within the context of a developing country with limited resources’.
1.2 Statement of the problem:
The prevalence of overweight/obesity has been increasing among teenagers and adolescence has actually been identified as one of the critical periods to develop obesity 13, 23, 24. There is also substantial evidence to support the fact that this could continue unto adult life25, 26.
In Nigeria, earlier studies showed a low prevalence of overweight and obesity (3.7% and 4.0%) 14, 23, whilst more recent studies showed an increasing prevalence (7.5% and 13%) 13, 24.
However, this prevalence does not give a true reflection of the problem as overweight and obesity differ markedly between age groups, between boys and girls, between ethnic groups and between geographical areas17.
Overweight children are likely to become obese adults; they are also more likely than non- overweight children to develop diabetes and cardiovascular diseases at a younger age7. These are associated with a higher chance of premature death and disability. Obesity at any stage of life is a known amplifier for certain non-communicable diseases. Globally, 44% of diabetes, 23% of ischaemic heart disease and 7–41% of certain cancers such as cancer of the endometrium and breast are attributable to overweight and obesity7. Type 2 diabetes (T2D) which was thought to be a disease of adulthood is now not only present among children but is on the increase because of increasing prevalence of obesity among children27, 28, 29. Similarly, the prevalence of a pre- hypertensive blood pressure is high among overweight and obese teenagers30. Overweight and obesity are linked to more deaths worldwide than underweight; at least 2.8 million people die each year as a result of being overweight or obese7.
In Nigeria, the problems associated with this public health challenge are already being noticed. A study carried out in Kogi state showed a higher prevalence of pre-point hypertension and point hypertension among teenagers who were overweight/obese30. Apart from this, in 2011, there was a case report of Type 2 Diabetes (T2D) in a 9 year obese girl29, although this was just a case report, there may be other unreported cases or missed diagnosis due to inaccessibility to proper medical attention. Type 2 diabetes at this stage of life is known to run a more aggressive course with complications arising early 27. Managing diabetes in adolescence can be quite challenging in an environment such as ours. On its own, T2D has been associated with numerous life threatening and chronic conditions such as hypertension, dislipidemia, proteinuria, non-alcoholic fatty liver disease, polycystic ovarian syndrome and respiratory obstructive diseases such as asthma27. These conditions which were relatively uncommon in our society especially among the young populace are now more common in our health system30, 31
Apart from individual risk factors associated with obesity, there are important longer term financial implications for the health system. In Nigeria, the health system is already over burdened with communicable diseases; this additional burden from NCDs will definitely lead to a complete breakdown with a worsening of already bad health statistics.
Risk factors for teenagers’ obesity are becoming more common in our society. Such risk factors include but not limited to reduced physical activity, and a sedentary life style32. Traditional recreational activities that involve more vigorous outdoor activities like playing football, running, jumping, are now being replaced by indoor sedentary activities like watching television, on-line communication programs such as chatting, twitting, face book and in-door games. This means that more time is spent on sedentary activities leading to the conservation of energy with the overall threat of excess weight gain and obesity.
In addition, there has been an indiscriminate proliferation of schools with little or no attention to the standard physical and environmental requirement for the citing of schools. Ideally, schools should be cited with enough space for children to play and do sports. Most schools in our environment, especially the private ones lack such facilities due to insufficient space. In public schools where space may not be a problem, there are no provisions made for such activities to be supervised. It is equally important to note that the security challenge in this country has forced people to stay indoors. This means that even when teenagers have recreational facilities in their neighborhood, fear of insecurity may hinder utilization of such facilities.
Apart from this sedentary life style, teenagers do not have good eating habits; they prefer fast foods and snacks to balanced meals. Fast foods and snacks have been known to contain a lot of calories as the carbohydrates in them are refined. These refined foods and easy to cook meals which may not have enough nutrients are very handy and easy for them to prepare. In addition, most teenagers have a habit of consuming sweetened beverages which have high sugar content and enhance weight gain 17. With this scenario, little attention is paid to the intake of fruits and vegetables which are known to be protective against excessive weight gain.
Furthermore, many teenagers do not have the recommended eight hours of sleep. They stay awake a greater part of the night making mid-night calls which are free on most net works and watching late night movies.33, 34. In this wakeful state, the urge to snack may not be resisted.
In some Nigerian cultures, obesity is desirable as female children and teenagers are allowed to go through a period of fattening in preparation for womanhood35. The health implications of overweight and obesity may not be obvious to this group of people and much public health campaigns need to be done for them to change their perception.
A close watch of events will reveal that mortality due to non-communicable diseases has been on the increase in Nigeria; an epidemiological transition from infectious disease. One of such major killers is stroke from a variety of causes ranging from diabetes to hypertension. This may not be unconnected with the increase in obesity among teenagers which may continue till adulthood18. Some developed countries such as America in recognition of the potential danger of teenager obesity have set up nutrition education and lifestyle modification programs for children and teenagers. Such facilities and interventions do not exist in our environment as the country is still battling with the control/eradication of infectious diseases such as poliomyelitis, measles, and malaria. Generally, little attention is paid to teenager health and teenager friendly services are lacking in the country. Obesity as a health challenge may not be obvious until the present cohort of teenagers with their poor lifestyle and feeding pattern enter into adulthood, and then there will be an upsurge in the number of non-communicable diseases.
1.3 Aim of the study:
The general objective of the study was to investigate the effect of physical exercise participation on overweight and obesity among in-school teenagers.
1.4 Specific objectives:
1. To determine the prevalence of overweight and obesity among in-school teenagers in Chanchaga L.G.A OF Niger State.
2. To determine the risk factors for overweight and obesity among in-school teenagers.
3. To measure the effect of physical exercise participation on the BMI scores of overweight and obese in-school teenagers.
4. To reduce the proportion of overweight/obese teenagers in the intervention group by at least 0.35% compared to the baseline.
1.5 Null Hypothesis:
Ø Nutritional counselling will not lead to any significant change in the prevalence of overweight/obesity, lifestyle pattern, unhealthy dietary habit and mean BMI of ‘In- School’ teenagers in Chanchaga L.G.A OF Niger State.
1.6 Alternative (Research) Hypothesis:
Ø Nutritional counselling will lead to a significant change in the prevalence of overweight/obesity, lifestyle pattern, unhealthy dietary habit and mean BMI of ‘In- School’ teenagers in Chanchaga L.G.A OF Niger State.
1.7 Significance for the study.
Globally, every 1 in 6 persons is an teenager meaning they constitute almost 20% of any population; in absolute figure, there are about 1.2 billion teenagers7. Of this number, 85% live in developing countries. In most developing countries where the population pyramid shows a young generation, the percentage of young people will be higher and will keep on increasing just as the population increases, for example in Nigeria, teenagers make up nearly one quarter of the total population, this makes them an important population group demographically whose health status has important economic implications for the country36.
Of the total disease burden in adults, one third is associated with conditions or behaviors that began in youth; furthermore, death among teenagers constitutes nearly two thirds of premature deaths7. Obesity is one of such health conditions that usually begin much earlier in life, but the health complications become more apparent in adulthood when some of them may no longer be reversible37. Obesity is a preventable problem. This prevention can begin at any stage of life including adolescence. Most teenagers and even those who care for them may not be aware of the problems and health challenges of this condition. Rather than wait for the present teaming population of teenagers to enter into adulthood uninformed about this health challenge, and stand the risk of developing certain non-communicable diseases, it is needful to begin on time and address the risk factors associated with the condition.
Information on teenager obesity in Nigeria is limited, and more of the research work has been on prevalence with a handful on the determinants of the condition. Much of the information available on the role of lifestyle modification such as increasing physical activity and healthy diet on teenager obesity has come from studies conducted in developed countries. Furthermore, in the developed countries research has been done on how the risk factors can be modified or completely removed, but in Nigeria, literature search has not revealed any interventional study.
Apart from this, literature on the relationship between sleep and BMI is scarce in Nigeria. In this computer age with increasing internet activities and less sleep, it is necessary to fill this gap in knowledge and ascertain as to the effect duration of sleep has on overweight and obesity.
Since young people represent the future of the country, one of the most important commitments a country can make for future economic, social and political progress is to address their health and development needs. The fact that teenager obesity is a pathological condition that can be prevented makes it even more imperative for research to be carried out in this area in order to provide a useful tool in planning and developing appropriate interventions and informed policies that will lead to the control of this condition and address health problems associated with the condition.
Results from the study will be used to plan intervention at the individual, family, school and community level at large.
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