research about nutritional status of students

• Research article
• Open access
• Published: 29 April 2021

Adolescents’ nutritional status and its association with academic performance in South Ethiopia; a facility-based cross-sectional study

• Selamawit Woldeyohanes Katiso 1 ,
• Amene Abebe Kerbo 1 &
• Samson Kastro Dake   ORCID: orcid.org/0000-0002-7687-4674 1  

BMC Nutrition volume  7 , Article number:  15 ( 2021 ) Cite this article

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Adolescence is a particularly vulnerable stages of life in which malnutrition inhibits academic performance through poor growth and development, mental retardation, poor overall cognitive function and poor health status. However, there is a dearth of evidence regarding the association between nutritional status and academic performance among adolescent students. Therefore, this study aimed to determine the association of nutritional status and academic performance among adolescent secondary school students in Wolaita Sodo town, Southern Ethiopia.

A facility-based cross-sectional study was conducted among 670 systematically selected adolescents in secondary schools of Wolaita Sodo town from April to June 2019. The academic performance of the adolescents was measured using the mean mark score of two consecutive semesters’ results of all subjects. Data were analyzed using Stata software Version 15. Descriptive statistics, binary and multiple linear regression analysis were done. Statistical association of dependent and independent variables was declared at p- valu e  < 0.05.

The mean academic performance of students was 69.21 ± 0.42 (95% CI: 68.34–70.02%). A mean mark score of students increased by 1.89 (β = 1.89; 95%CI: 1.14, 2.64) for a unit increase in BMI for age z-score. Being female decreased a mean mark score by 2.63 (β = − 2.63; 95%CI: − 4.28, − 0.98) and being from a separated parents decreased by 4.73 (β = − 4. 73; 95%CI: − 6.73, − 2.74). A mean mark score of students from the first wealth class decreased by 9.92 (− 9.92; 95%CI: − 12.79, − 7.04) as compared to students from the highest wealth class. Attending private schools increased the mean mark score of students by 4.18 (β = 4.18; 95% CI: 2.46, 5.90).

Conclusions

Interventions targeted at adolescents’ nutritional status should be designed and implemented. The town education office and concerned bodies s hould launch a school feeding program for public schools. Development and income generation activities should target households in the first wealth status. Schools are recommended to design additional teaching and learning schemes such as tutorial classes for girl students.

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Adolescent population comprises one-sixth of the world’s population; of which over 90% live in Sub-Saharan Africa and South and Southeast Asia [ 1 ]. Successful transition of adolescence to adulthood has a significant role in reducing problems lie ahead in the future and in breaking the intergenerational cycle of poverty [ 2 ].

Nutritional status is one of the main factors that could affect academic achievement by limiting students’ ability to learn [ 3 ]. Despite the economic growth observed in many developing countries, undernutrition continued to be highly prevalent underlying cause of poor health status and poor academic attainments’ [ 4 ].

Several studies were conducted on the magnitude and consequences of nutritional status of adolescent students [ 5 , 6 , 7 ]. According to the Global School-Based Student Health Survey, the mean Body Mass Index (BMI) estimates adolescents in South Asia, Southeast Asia, East Africa, West Africa and Central Africa is < 20. The lowest BMIs were seen in Ethiopia, Niger, Senegal, India, Bangladesh, Myanmar, and Cambodia [ 8 ]. On the other hand, globally, 10% of adolescents are overweight and obese with the prevalence of overweight and obesity varying between 2 and 3%. The prevalence ranges from 10% in Africa and Asia to more than 20% in the United States of America (USA) and Europe [ 9 ].

.According to the World Bank report, academic performance of students of Sub-Saharan African countries is less than half of what is expected for their age [ 10 ]. Ethiopia is among the countries where adolescent students’ academic achievement is unacceptably low [ 11 ]. Adolescence is one of the vulnerable stages of life where absolute nutrient needs are greater than that of infancy or childhood [ 12 ]. Undernutrition inhibits academic attainment through poor growth and mental development, reduced motivation and poor cognitive development [ 13 , 14 ] while, ooverweight and obesity has the potential to impair academic performance via social pathways such as discrimination and stigma [ 15 ].

Research evidences also show that academic performance is affected by factors such as the wealth status of the parents, the type of school, parents’ educational status, marital and occupational status of the adolescents [ 16 , 17 , 18 , 19 ]. However, the association between nutritional status and the academic performance of the adolescent students in Ethiopia is left unknown fully. Therefore, the aim of this study was to assess the association of nutritional status with academic performance among adolescent students in Wolaita Sodo town, Southern Ethiopia.

Study setting, study design and study period

Wolaita Sodo town is the administrative capital of Wolaita Zone administration in Southern Ethiopia located at 380 km South from Addis Ababa. The town has 3 sub-cities and 11 lower administrative units. The total population of the town is estimated to be 182,607; from which 49% are females [ 20 ]. According to the information obtained from Wolaita Zone Agriculture and education departments, the common staple foods in the area are cereals, roots, tubers, and vegetables and there are two private and five public secondary schools in the town respectively. A facility-based cross-sectional study was conducted among adolescent students from April to June, 2019.

Population and sampling

The source population for this study was all adolescents of secondary schools of Wolaita Sodo town and the study population are adolescent students of the selected schools. Pregnant adolescent girls, adolescents who were ill at the time of the study and with physical or visual disability were excluded from the study. A single population proportion formula was used to calculate the sample size with the following assumptions; 95% confidence level, 5% margin of error, an estimated magnitude of students’ academic performance of 72.8% taken from a similar study in Ethiopia [ 21 ], design effect of 2 and 10% non-response rate and the final sample size calculated is 670. There are seven schools in Wolaita Sodo town, two private and five public, and were stratified into public and private by assuming socio-economic differences among the families of the students and differences in teaching and learning resources between public and private schools. Among the seven secondary schools, one private and three public were randomly selected. The total sample size was allocated to the schools proportional to the number of students in each selected school. The study participants were selected by systematic sampling technique using the list of students enrolled in each school as a sampling frame. The sampling interval was determined by dividing the total number of students in the respective school grade level by the allocated sample size and was found to be five. The first participant was selected randomly by the lottery method, and then every fifth adolescent student was included in the study.

Data collection

Data were collected using a structured interviewer-administered questionnaire. The questionnaire was developed and adopted from the Ethiopian Demographic and Health Survey (EDHS) validated tool and other related literature reviews [ 22 , 23 , 24 ] (Additional file  1 ). The questionnaire was pre-tested on 5% of the sample size on adolescent students from schools which were not selected for the actual data collection but no modification has been made. The data were collected by four data collectors and two supervisors after training was given for 2 days on the objective of the study, data collection procedures, anthropometric measurements, the confidentiality of the information and participant rights.

To ensure the reliability of anthropometric measurements, standardization test was done on five participants prior to actual data collection. First, the expert has taken the measurements and then the data collectors repeated the measurements on the same participants with some time intervals. The collected data were entered into ENA SMART software to check relative Technical Error of Measurements (TEM) and was found to be in the acceptable range, < 2.0%. Weight was measured using a portable digital flat Seca scale (Scale electronic scale, 770 Hamburg). Height was measured by Seca body meter (Seca 274 body meter). All measurements were taken three times, and the average was recorded as the final measurement. Academic performance and absenteeism data were taken from respective schools’ records.

Dependent variable

The academic performance of the students which was calculated using two consecutive semesters mean mark scores out of 100.

Independent variables

Socio-economic and socio-demographic variables.

Age of the adolescents, sex of adolescents, marital status of parents, educational and occupational status of parents and wealth status of the adolescents households. Wealth status was generated by using principal component analysis (PCA) and based on the results household wealth index/status was converted into quartiles and categorized as First, Second, Middle, Fourth, and Highest [ 22 ].

Nutritional status measurements and indices

Underweight - is BMI for age z-score (BAZ) of < − 2 standard deviation (SD) on the WHO growth reference cut-off point [ 25 ].

Overweight - was computed with BMI for age z-score (BAZ) of > + 1 SD on the WHO growth reference cut-off point [ 25 ].

Obesity - was computed with BMI for age z-score (BAZ) of > + 2 SD z-score based on the WHO reference cut-off point [ 25 ].

Stunting - is the height for age z-score (HAZ) of <− 2 SD on the WHO growth reference cut-off point [ 25 ].

Dietary diversity score

Dietary diversity was determined by using the Dietary Diversity Score (DDS). Three non-consecutive days 24-h recall of adolescents’ consumption of commonly consumed foods in the area was used to collect information on the DDS [ 23 ]. Foods were categorized into 10 groups based on FAO recommendations [ 1 ]; starch stable food [ 2 ], vegetables, 3) fruits [ 4 ], meat [ 5 ], egg [ 6 ], fish and other sea foods [ 7 ], legumes, nuts and seeds [ 8 ], milk and milk products [ 9 ], oil and fats [ 10 ], sweets, spices, condiments and beverage [ 26 ]. The response categories were “Yes” if at least one food item in the group was consumed and “No” when a food item in the group was not consumed. The results were summed and classified into <  4 food items and > 4 food items [ 27 ].

Behavioural factors

Alcohol consumption, the purpose of spending much time on the internet and being absent for 10% or more of school days for any reason in a calendar year.

Data management and analysis

Data were entered into Epi-Data version 3.1 and analyzed using Stata version 15 statistical software. Anthropometric data were analyzed using the WHO Anthro-plus software version 1.0.4 and nutritional status of the adolescents was determined using WHO reference 2007 cut-off point [ 28 ]. Normality assumption was assessed for the dependent variable and the data were normally distributed ( p -value is 0.77). Descriptive statistics such as frequencies, percentages, mean and standard deviation of the mean were done. Binary and multiple linear regression analysis were conducted to check the association between the dependent and independent variables. Variables with a p -value of less than 0.25 in the binary linear regression analysis were candidate variables for multiple linear regression analysis. Variables with the p -value < 0.05 in the multiple linear regression analysis were considered as statistically significantly associated with the dependent variable and parameter estimate (ß) with its 95% CI was reported.

Socio-demographic characteristics

In this study, a total of 670 adolescents participated making the response rate of 100%. The mean age of the respondents was 16.2 ± 1.7. Of the total respondents, 50.6% were girls. The majority (81.3%) of the parents were currently married. More than one-fourth (27.3%) of the mothers and 47.5% fathers of the students completed college or university education. More than one-third (34.8%) of the mothers were merchants, while 42.4% of the fathers were government employees. Regarding the wealth index, 23.6%, of the study participants were from the fourth class households (Table  1 ).

Nutritional status, dietary diversity and behavioural factors

The overall prevalence of any form of malnutrition was 29.3%; 6.3% (95% CI: 4.5, 8.5) were underweight, 9.7% (95% CI: 7.6, 12.2) overweight, 4.1% (95% CI: 2.8, 5.7) obese, and 9.2% (95% CI: 7.2, 11.4) were stunted. The majority (76.4%) of the adolescents spend much their time on the internet for social media purpose and about one-fourth (24.8%) reported drinking alcohol at least once before the study. About (24.3%) of the adolescents were absent for 10% or more of school days in the studied academic year. More than half (59.0%) of the adolescents had a dietary diversity score of ≤4 food items (Table  2 ).

Description of participants according to their academic performance

More than three-fourth (74.7%) of the adolescents aged 15–19 years performed below the mean academic score. Nearly one-fifth (79.2%) of the boys and 68.7% of the girls had below the mean academic performance respectively. More than half (56.4%) of the respondents who live in the first wealth quintile performed below the mean. The majority (89.2%) of those who live in a household with the highest wealth quintile performed above the mean academic score. The majority (88.1%) of the respondents who attended public schools and 66.7% who attended private schools academic performance was below the mean score. Fifty six (88.9%) of the overweight and 89.3% obese respondents performance was below the mean academic score. Two hundred twenty eight (83.2%) of the participants with a dietary diversity of more than four and 71.9% who spend their time on the internet for social media purposes performed below the mean academic score. Three-fourth (75.2%) of the participants who consume alcohol also performed below the mean (Table  3 ).

Proportion and predictors of academic performance

The mean academic performance of the students was 69.2 ± 11.0 SD (95% CI: 68.4, 70.0%) out of hundred. Being a girl decreased the mean score of academic performance by 2.6 (β = − 2.6; 95% CI: − 4.3, − 0.9). The mean score of students from separated parents decreased by 4.7 (β = − 4.7; 95% CI: − 6.7, − 2.7) as compared to students from married parents. Being from the first-class wealth index decreased the mean score of students by 9.9 (β = − 9.9; 95% CI: − 12.8, − 7.0). The mean mark score of students from a wealth index of the second class decreased by 5.7 (− 5.7; 95% CI: − 8.1, − 3.2) as compared to students from the highest wealth class. Attending private schools increased the average mark score of students by 4.2 (β = 4.2; 95% CI: 2.5, 5.9) compared to their counterparts. BAZ was positively associated with academic performance. A unit increase in BAZ increased the mean mark score of students by 1.9 (β = 1.9; 95% CI: 1.1, 2.6) (Table  4 ).

This study has attempted to determine the association between nutritional status and academic performance among adolescent students. The result of the current study shows the mean academic score of students was 69.2 ± 1 (95% CI: 68.3, 70.0%). The study findings also revealed that being a girl student, nutritional status measures (BAZ and HAZ), being from the first-class wealth index household, attending private schools and separation of parents were statistically significantly associated with the academic performance of the students.

In this study, the mean academic score of the students was 69.2 ± 1 (95% CI: 68.3, 70.0%). This result is consistent with a study from Hawa Gelan (Ethiopia) where the mean academic performance was (67.2 ± 15.4%) [ 24 ]. However, the result is higher when compared with a study result of Nigeria which reported the mean academic performance of (53.3 ± 7.2) [ 29 ]. The result of this study is lower than the other study result in Debre-Tabor (Northern Ethiopia) where the mean academic score was (71.7 ± 12.6) [ 30 ]. This difference may be owing to the differences in the students’ assessment techniques, the curriculum and teaching-learning resources availability and accessibility. The other possible reason for the difference might be, in Ethiopia, although there exists nationally standardized testing system, the test is given only for 8th and 12th grades and the testing scheme and types of the tests depend on the school and the teachers.

There was a statistically significant and positive association between nutritional status (HAZ) and academic achievements. This finding agrees with studies from Northern and Southeast Ethiopia, where HAZ was associated with students’ academic performance [ 30 , 31 ]. Despite the agreement with these studies, the correlation coefficient in the current study is relatively low. The possible reason might be the small sample size used in the mentioned studies. This finding is inconsistent with a study finding of Meskan District in Southern Ethiopia, where the study reported the absence of a statistically significant association between HAZ and academic performance [ 32 ].

In this study, the nutritional status measure (BAZ) is also statistically positively and significantly associated with the academic performance of the students. This result is not in line with another study conducted in North Ethiopia where the study reported that there was no statistical association between BAZ and academic performance [ 30 ]. This might be due to differences in sample size or variation of the variables considered during analysis.

In the current study, being a girl student decreased academic performance, this result is reported similarly in studies conducted in Ethiopia, Kenya, and Nigeria [ 33 , 34 , 35 ]. ,The most possible reason could be the differential and higher workload, lack of time to work on the assignments and shortage of time to eat meals timely and adequately among girls in the households when compared to boy students. A different finding was reported from Ghana where the academic achievement of girls was significantly higher than boys [ 36 ]. This difference might be due to the socio-cultural difference in the study settings.

The findings of the present study also disclosed that separation of parents has significantly lowered the academic performance of students when compared with students whose parents are in marital union. This result is consistent with the results of studies conducted in Addis Ababa (Ethiopia) and Ghana [ 37 , 38 ]. This could be due to psycho-social and financial crises caused by separation or divorce the associated parental instability.

Academic performance of the students from a household of first wealth index or second wealth index class family was decreased students’ when compared to the students from the highest wealth index household families, This finding is in agreement with studies conducted in Dessie (Northwest Ethiopia) and Hawa Gelan district in Southwest Ethiopia [ 24 , 39 ]. Similarly, another study from Goba town in Ethiopia depicted that a higher wealth index is associated with better mathematics scores [ 31 ]. This might be explained by the enabling environment created by providing educational materials and other resources which could have motivated students.

In the present study, a significant difference in academic performance among students attended private and a public school was found. Attending private schools increased the mean mark score of students as compared to their counterparts. This finding is in line with a study finding of Northwest Ethiopia [ 40 ]. Studies conducted in Nigeria and India also revealed that students who attended private schools scored better in reading, writing and mathematics as compared to students from public schools [ 41 , 42 ]. This difference might be attributed to private schools better equipment in a library and laboratory facilities, regular and tight monitoring and evaluation of the teaching and learning process and students who attend private schools are mostly from a well to do families to provide better, adequate and timely nutrition than students of public schools.

Limitations

The study sample consisted of adolescents students in Wolaita Sodo town secondary schools and therefore, the study results cannot be generalized to other schools elsewhere in Ethiopia or other Sub-Saharan Africa or other developing countries. The mean academic score used to assess the academic performance of the students is also not from standardized testing across the whole country. Thus, it might be difficult to extrapolate the proportion to the overall adolescent population in the country. We used cross-sectional data and the estimate might be better represented if longitudinal follow-up data were used. In this study, only anthropomorphic measurements were used to determine the nutritional status and did not assess the micronutrient status and its possible association with the academic performance of study participants. In the present study, other covariates such as cigarette smoking and time devoted to physical exercise have not been assessed. Furthermore, this study did not assess Intelligence Quotient (IQ) test due to a lack of standardized, culturally appropriate and contextualized testing systems in Ethiopia.

This study ascertained poor academic performance was reported among female sex adolescent students, students whose parents were separated, and students of the first or second wealth index status households. Better academic performance was also seen in students with better nutritional status indicators such as BAZ and HAZ.

Wolaita Sodo town health office should design interventions targeted at improving adolescents’ nutritional status. A school feeding program should be launched particularly for underweight students. Microfinance institutions and other development and income-generation activities should target students from households of the first wealth status. Schools should give tutorial classes for girl students. Further studies to determine the association of nutritional status with school performance by including the micronutrient status data are recommended.

Availability of data and materials

The datasets analyzed for this study are available with the corresponding author which can be accessed on reasonable request.

Abbreviations

BMI for Age Z-score

Body mass index

Confidence interval

Food and Agricultural Organization

Height for Age Z-score

Non-Governmental Organization

Norwegian Programme for Capacity Development in Higher Education and Research for Development

Standard Deviation

South Ethiopia Network Universities in Public Health

Technical error of measurement

United States of America

World Health Organization

Wolaita Sodo University

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Acknowledgments

We are grateful to SENUPH-NORHED for granting the study. We would also like to thank the School of Public Health, WSU for facilitating the research process. We would also like to acknowledge Wolaita Zone Education Department and local authorities for official giving permission and for their cooperation. We are also grateful to the study participants for their voluntarily participation in the study and data collectors and supervisors for their responsible data effort.

This study was financially supported by South Ethiopia Network Universities in Public Health (SENUPH) project from the Norwegian Programme for Capacity Development in Higher Education and Research for Development (NORHED). The fund was facilitated by Wolaita Sodo University through a graduate-level research program. Neither of the parties had roles in the design, conduct, and decision to publish this research work.

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Selamawit Woldeyohanes Katiso, Amene Abebe Kerbo & Samson Kastro Dake

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Contributions

SW conceived the study, designed the protocol, coordinated data collection, analyzed the data, interpreted the findings and drafted the manuscript. AA contributed to the design, analysis, and interpretation of the findings, and reviewed the manuscript. SK contributed to the design, analysis, interpretation of the findings, reviewed progressive drafts, and proofread the manuscript. All authors read and approved the final version of the manuscript.

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Correspondence to Samson Kastro Dake .

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Ethics approval and consent to participate.

Ethical clearance was received from the ethical review committee of the College of Health Science and Medicine, Wolaita Sodo University, Ethiopia. The ethical clearance and letter of request for permission were presented to Wolaita Zone Education Department and permission was obtained sequentially from the Department and its lower administrative structures. Finally, a detailed explanation was given for both the selected adolescents’ parents/caregivers and the adolescents whose age is less than 18 years and for the adolescents themselves whose age is 19 years on the objective of the study, risk and benefits of the study, data collection procedures and confidentiality of the information. Informed written consent was obtained from adolescents whose age is 19 years. Informed written consent to participate in the study from parents/caregivers and assent was obtained from the adolescents whose age is less than 18 years respectively.

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Katiso, S.W., Kerbo, A.A. & Dake, S.K. Adolescents’ nutritional status and its association with academic performance in South Ethiopia; a facility-based cross-sectional study. BMC Nutr 7 , 15 (2021). https://doi.org/10.1186/s40795-021-00420-8

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DOI : https://doi.org/10.1186/s40795-021-00420-8

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SYSTEMATIC REVIEW article

Nutritional status and dietary intake of school-age children and early adolescents: systematic review in a developing country and lessons for the global perspective.

• 1 Division of Women and Child Health, Aga Khan University Hospital, Karachi, Pakistan
• 2 Institute of Global Health and Development, Aga Khan University, Karachi, Pakistan
• 3 Policy and Strategic Planning Unit, Ministry of Health, Government of Punjab, Lahore, Pakistan
• 4 Faculty of Health and Medical Sciences, Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia
• 5 Centre for Global Child Health, The Hospital for Sick Children (SickKids), Toronto, ON, Canada
• 6 Government Services Hospital, Karachi, Pakistan
• 7 Ministry of Health, Government of Sindh, Karachi, Pakistan

Background: The prevalence of double burden of malnutrition (DBM) is high in low- and middle-income countries (LMICs). Data on malnutrition trends is present for children <5 years of age, however the data for school-going children and adolescents aged 5–15 years is scarce.

Objective: This systematic review presents the pooled prevalence of nutritional status and dietary intake among school-going children and adolescents (5–15 years of age) in an LMIC of Pakistan and the perspective for broader global nutrition in this age group.

Methods: An electronic search of databases was run on Pubmed and Medline (via Ovid) along with gray literature and archives of local scientific journals till 2nd January 2021. Studies meeting the eligibility criteria were included and relevant data were extracted, and a pooled proportional analysis was performed.

Results: A total of 51 studies including 62,148 children of 5–15 years met the inclusion criteria, of which 30 studies reported on anthropometric indices alone, eight on dietary intake patterns while 13 reported both. All of the included studies had a cross-sectional study design. There were 20 studies from the province of Punjab, 15 from Sindh, eight from Khyber Pakhtoonkhwa, two from Balochistan, and three from multiple cities across Pakistan. The pooled proportional analysis showed that the proportion of underweight children and adolescents was 25.1% (95% CI 17.3–33.7%); stunting 23% (95% CI 11.8–36.7%); wasting 24% (95% CI 15.2–34%); thinness 12.5% (95% CI 9.4–16.1%); overweight 11.4% (95% CI 7.2–16.3%); and obesity 6.9% (95% CI 3–12%). A relatively high intake of carbohydrates, soft drinks, and sweets/chocolates; and a low intake of protein-rich foods, fruits, and vegetables, compared to the recommended daily allowance (RDA), was reported.

Conclusion: The limited data suggests the presence of DBM amongst children aged 5–15 years and also identified that dietary intake patterns are not meeting the recommended allowance. This review highlights the gaps and the need for larger, well-designed studies for this age group with the representation of different contexts and the need for similar studies in various LMICs, so that appropriate actions be deliberated and appropriate programs should be designed focusing on this vital population.

Introduction

Populations in which there is co-existence of under- and over-nutrition are known to be facing the double burden of malnutrition (DBM) ( 1 ). According to Global Nutrition Reports 2018, one in three people suffer from malnutrition, one in 20 children complain of hunger, and one in every five deaths around the world is attributed to poor diet ( 2 ). DBM is more prevalent in low- and middle-income countries (LMIC), with a higher prevalence in poorer LMICs ( 3 ). It is especially prevalent in sub-Saharan Africa, South-East Asia, and the Pacific ( 3 ). The progress in the reduction of the burden of malnutrition worldwide has been slow and it is therefore advised to collect population-specific data to better understand the nutrition dynamics across the world and to allow the nutritional needs of communities to be addressed adequately ( 2 , 4 ).

An issue being ignored is malnutrition trends in children over the age of 5 years. The World Health Organization (WHO) reports 1.8 billion children to be in the age bracket of 5–15 years worldwide, with 90% of this population residing in LMICs ( 5 ). There is no consistent terminology used to describe children age 5–15 years which proves the narrow focus on younger children and neglect of this age group, however, children age 5–10 years are often referred to as school-going children ( 6 ), while adolescent has been defined by the WHO as children aged 10–19 years, with early adolescent defined to be in an age bracket of 10–14 years and late adolescent between 15 and 19 years ( 7 ). Whether DBM exists in this age bracket and to what extent is a query that is yet to be adequately explored.

In 2011, the United Nations Children's Fund (UNICEF) published a report stating that adolescence provides a second window of opportunity to improve the nutritional status of children and prevent future health consequences of malnourishment ( 8 ). However, nutritional challenges occur throughout the life cycle of an individual, therefore, nutritional needs through each phase must be assessed and addressed adequately ( 7 ), especially school-going children and adolescents age 5–15 years. Mental and physical development continues through this age bracket and it gives individuals a chance to improve their nutritional deficiencies, thereby preventing impairment of growth, development, and cognitive achievement ( 8 ). It is known that major developmental and physical changes occur within the early adolescence phase. This includes growth spurt, development of sex organs, secondary sexual characteristics, and, according to recent neuroscientific research, significant increase and reorganization in the neuronal network ( 8 ). A relatively newer concept referred to as developmental origins of adult health and disease (DOHaD) postulates that poor nutrition during the early phases of life is associated with chronic illnesses in adulthood ( 9 ). The current scarcity of data on school-going children and adolescents and now, with the increase in child survival rates, the number of children entering their second decade is increasing and their health and nutritional needs compel attention.

The WHO proposes strategic guidance and planning on actions for child health in the South-East Asian Region (SEAR), however, it is limited to adolescents alone ( 10 ). It has been reported that 20% of the population in the South-East Asian Region comprises of adolescents, which make up to a total of 360 million adolescents in the region ( 11 ). The process used by WHO in developing strategic guidance for improving adolescent health was by first conducting relevant reviews under national, regional, or global categories, followed by surveys in those regions to identify lessons learned and proposals for future actions. They also took input from experts in the field and then finally developed the guidance ( 10 ). This process should be adopted by other LMICs to identify the gaps and make the necessary interventions for improvement.

It is imperative that children above 5 years of age be assessed for undernutrition, overnutrition, and nutritional deficiencies, and therefore this systematic review aims to present a narrative on the trends of nutritional status and dietary intake patterns among school-going children and adolescents 5–15 years of age across Pakistan with a broader commentary related to global nutrition status, and challenges in this age group across other LMICs. This systematic review can be used as an example to synthesize the available literature and identify gaps in nutritional status and dietary intake patterns amongst school-going children and early adolescents aged 5–15 years in other LMICs.

Materials and Methods

Types of studies and participants.

We included observational studies (prospective and retrospective cohort, and cross-sectional studies) reporting data on nutritional status and dietary intake and their association to gender, locale (urban vs. rural), school type (government vs. private), family income, and lifestyle (sedentary vs. active) amongst school-going children and early adolescents aged 5–15 years in Pakistan. We also included studies reporting nutrition trends in children affected by natural disasters or employed as laborers. Studies that assessed dietary intake and prevalence of malnutrition amongst children were included, as long as data on our age group of interest was also present. Studies exclusively assessing children with known co-morbidities or on Pakistani children living abroad were excluded. We included studies that were published during and after the year 2000 to ensure we get information on current trends, with the last date of the search conducted on the 2nd of January 2021.

Types of Outcomes

We included studies that met our eligibility criteria and reported outcomes on anthropometric indices or dietary intake, such as underweight [weight-for-age Z (WAZ) score < −2 SD], stunting [height-for-age Z (HAZ) score < −2 SD], wasting [weight-for-height Z (WHZ) score< −2 SD], thinness (BMI-for-age < −2 SD), overweight (BMI-for-age > +1 SD), obesity (BMI-for-age > +2 SD), macro/micronutrient deficiencies, food, and nutrient intake. We also extracted the associations of these outcomes, such as gender, socio-economic status, private vs. government schools, family income, and sedentary lifestyles.

Search Methods

We conducted an electronic literature search until 2nd January 2021 using Pubmed, Medline (via Ovid), and Google Scholar. Gray literature search was conducted on databases from the WHO, UNICEF, Food and Agriculture Organization (FAO), World Food Programme (WFP), Global Alliance for Improved Nutrition (GAIN), Scaling Up Nutrition (SUN), Action Against Hunger, International Food Policy Research Institute (IFPRI), and Google web. We also searched the archives of local journals [Journal of Pakistan Medical Association (JPMA) and Journal of Ayub Medical College (JAMC)] separately and went through the reference lists of included studies. We included articles that provided data on nutritional status and dietary intake patterns and their associations amongst school-aged children and early adolescents aged 5–15 years in Pakistan. Nutritional status was defined as “a physiological state of an individual, which results from the relationship between nutrient intake and requirements, and from the body's ability to digest, absorb and use these nutrients” ( 12 ).

The completed search strategy used for Pubmed and Medline (via Ovid) is presented as Supplementary Tables 1a,b ). The following MeSH terms and their variants were used for our search strategy: “Nutritional Status” OR “Nutrition Assessment” OR “Diet” OR “Micronutrients” AND (“Schools” OR “Child” OR “Child/education” OR “Adolescent”) AND (“Pakistan” OR “South Asia”). Studies conducted by the same author on the same population were scrutinized for overlapping data and the studies with the inclusion of more relevant variables were chosen. There were no language restrictions placed while screening articles.

Data Collection and Analysis

Two reviewers (DSK and JKD) screened titles and abstracts for eligibility using EndNote X8 ( 13 ). We retrieved full texts of the remaining articles and examined them based on our eligibility criteria. Studies that fulfilled the inclusion and exclusion criteria were selected for this review. Any conflicts regarding article selection were resolved through mutual consensus. We extracted data on Microsoft Excel from the included studies on variables including study background (province, city), population, age group, sample size, setting (rural vs. urban, school vs. community, government vs. private schools), socioeconomic status, anthropometric indices (underweight, stunting, wasting, thinness, overweight and obesity), dietary intake patterns and associations ( 14 ).

Data were analyzed and pooled prevalence was performed on the Joanna Briggs Institute (JBI) SUMARI software ( 15 ). The meta-analysis pooled overall prevalence using Dersimonian and Laird random-effect meta-analysis after transforming data using Freeman-Tukey transformation arcsine square root transformation. The review pooled overall means and proportion for the age group of 5–15 years and reported their 95% confidence intervals (CI) and the percentage of variation across studies that is due to heterogeneity rather than chance using I 2 statistics. Studies with participants of age 0–19 years, from which data specifically for 5–15 years age group could not be extracted, were placed in the age category of either 5–19 years or 0–19 years; and pooled separately. We also pooled performed subgroup analysis based on gender, geographic setting i.e., urban/rural, provinces, natural disaster, special population i.e., children who were laborers, school attended (private or government), and socio-economic class, for children age 5–15 years.

We used the National Institute of Health (NIH)—National Heart, Lung, and Blood Institute (NHLBI) quality assessment tool for cross-sectional studies to assess the quality and potential risk of bias for all the included studies ( 16 ). This tool helps evaluate the internal validity of a study, hence ensuring that the results are truly due to the exposure being evaluated.

This systematic review follows the guidelines recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) ( 17 ). The PRISMA checklist is presented in Supplementary Table 2 .

Our electronic search for all databases yielded a total of 11,539 articles that underwent title and abstract screening. A total of 276 articles were selected for full-text review, of which 39 met the eligibility criteria. Through cross-referencing of included articles and local journals, another 12 articles were added, leading to a total of 51 studies being selected for inclusion as depicted in Figure 1 . Results were reported according to two categories, namely “anthropometry” and “dietary intake”.

Figure 1 . Search flow diagram.

Description of Included Studies

A total of 51 studies were included, all of which had a cross-sectional study design ( 18 – 68 ). The studies were conducted between the years 2002 and 2020 in different cities across Pakistan. Twenty-eight studies reported data specifically on children between 5 and 15 years of age ( 19 , 21 – 23 , 25 – 29 , 31 , 32 , 35 , 38 , 44 , 45 , 47 – 50 , 52 , 54 , 55 , 59 , 60 , 62 – 64 , 67 ). The remaining 23 studies had children in our age group of interest but beyond it too, with seven reporting data on children between 0 and 19 years of age ( 24 , 34 , 51 , 56 , 58 , 61 , 65 ) and 16 reporting on children 5 and 19 years of age ( 18 , 20 , 30 , 33 , 36 , 37 , 39 – 43 , 46 , 53 , 57 , 66 , 68 ). There were only five studies that reported data specifically on children in the 5 to 10 age group ( 29 , 34 , 64 – 66 ) and only three studies in the 10 to 15 years age group ( 21 , 24 , 47 ). Province wise; 20 studies were conducted in Punjab ( 19 , 22 , 24 , 28 , 29 , 31 , 39 , 40 , 44 , 46 , 52 – 54 , 58 , 65 , 67 ), 15 in Sindh ( 18 , 20 , 21 , 23 , 30 , 32 , 36 – 38 , 43 , 45 , 49 , 55 , 63 ), eight in Khyber Pakhtoonkhwa (KP) ( 26 , 34 , 35 , 47 , 48 , 50 , 61 , 64 ), two in Balochistan ( 25 , 51 ), four from the federal capital ( 27 , 42 , 66 , 68 ), and three from multiple cities across Pakistan ( 41 , 56 , 57 ). The remaining three studies failed to report their location ( 33 , 59 , 62 ).

A total of 35 studies were conducted in urban areas ( 18 – 46 , 52 , 63 , 65 – 68 ), while five were conducted in rural areas ( 47 – 51 ), six in both ( 53 – 58 ), and the remaining five did not report their setting ( 59 – 62 , 64 ). Forty studies were carried out in a school setting ( 15 , 16 , 19 – 22 , 24 – 40 , 42 , 44 – 52 , 55 , 58 , 59 , 61 , 63 – 65 ), nine in community setting ( 21 , 27 , 45 , 47 , 57 , 58 , 60 , 61 , 66 ), and two studies did not specify ( 22 , 64 ). Of the forty conducted in schools, 22 studies were conducted across both government and private schools ( 18 , 20 , 23 , 24 , 26 , 28 , 29 , 31 , 35 , 37 , 38 , 40 , 43 , 44 , 48 , 52 – 54 , 56 , 62 , 67 , 68 ), seven in private schools exclusively ( 19 , 25 , 30 , 36 , 39 , 41 , 65 ), and five were carried out in government schools ( 32 , 33 , 49 , 50 , 55 ). Six studies did not specify their study setting ( 34 , 42 , 46 , 51 , 59 , 63 ). There were two studies which reported nutritional status amongst children affected by natural disasters ( 47 , 50 ) and two on child laborers ( 45 , 68 ). For the age group of 5–15 years particularly, 17 studies reported anthropometric indices with respect to gender ( 19 , 21 – 23 , 26 , 28 , 29 , 32 , 35 , 38 , 44 , 48 , 49 , 54 , 60 , 62 , 63 ), 18 with respect to geographic setting; urban or rural ( 19 , 21 – 23 , 26 – 29 , 32 , 35 , 38 , 44 , 48 , 49 , 52 , 63 , 67 ), three with respect to socioeconomic status ( 29 , 35 , 52 ) and eight with respect to school attended; private or government ( 19 , 26 , 28 , 32 , 44 , 49 , 62 , 65 ).

The included studies in this review targeted 62,148 individuals. Two studies had a sample size of >10,000 ( 56 , 57 ), 14 studies had a sample size of 1,000–9,999 individuals ( 21 , 24 , 28 , 29 , 31 , 37 , 42 , 47 – 49 , 51 , 54 , 55 , 58 ), six had a sample size of 500–999 ( 18 , 30 , 33 , 38 , 53 , 60 ), 27 studies between 100 and 499 ( 19 , 20 , 22 , 23 , 25 – 27 , 32 , 34 – 36 , 39 – 41 , 43 – 46 , 50 , 52 , 59 , 62 , 64 – 68 ), and two studies with a sample size of <100 individuals ( 61 , 63 ).

Of the selected 51 studies, 30 reported data on anthropometric indices only ( 18 , 23 , 26 – 29 , 33 – 35 , 37 – 39 , 43 – 45 , 47 – 52 , 54 , 56 , 60 – 66 ), eight reported data on dietary intake alone ( 20 , 25 , 31 , 41 , 53 , 55 , 57 , 68 ), while 13 reported both, anthropometric indices and dietary intake patterns across our population of interest ( 19 , 21 , 22 , 24 , 30 , 32 , 36 , 40 , 42 , 46 , 58 , 59 , 67 ). The characteristic of each included study is presented briefly in Table 1 below with a detailed version included as Supplementary Table 3 .

Table 1 . Brief overview of characteristics of included studies.

Quality of Studies

Quality assessment using NHLBI tool for cross-sectional studies, as presented in Supplementary Table 4 and briefly as Table 2 , showed that all studies had clearly stated their objective and had a participation rate of >50%, with all the subjects selected from the same population. 88.2% of studies had specified and defined their population, while only 33.3% had justified sample size calculation. Since all the studies were cross-sectional, exposure was not measured prior to outcomes, studies were assessed at one point in time and therefore had no follow-ups. Outcomes were defined by 74.5% of the studies, while none of the studies reported outcomes to be blinded to assessors. 25.5% of studies measured confounding variables and adjusted them statistically to assess associations to the outcomes.

Table 2 . Summary of NHLBI quality assessment.

Anthropometric Indices

We identified 43 studies reporting data on anthropometric indices ( 18 , 19 , 30 , 32 – 40 , 42 – 52 , 54 , 56 , 58 , 59 , 61 – 68 ). Our focus was to report the prevalence of malnutrition for the age group 5–15 years, however, some studies reported data beyond our age group of interest due to which an overall analysis, with overlapping data from 5 to 15 years age group, was also conducted for age groups zero to 19 and 5–19 years as depicted in Table 3 , Supplementary Figures 1–3 . The age group 5–19 was also separately reported to understand the overall malnutrition trends in children above 5 years of age. Anthropometric indices reported amongst school-going children and early adolescents age 5–15 years across provinces in Pakistan are depicted in Table 4 , Figure 2 , however, no data amongst children from Balochistan in this age group was available. Anthropometric indices with respect to gender, geographic setting (urban or rural), and type of school attended (private or government), along with indices of children affected by natural disasters (e.g., flood, earthquake, etc.) and child laborers in this age group have also been reported in Table 4 , Supplementary Figures 4–9 .

Table 3 . Prevalence of Anthropometric Measures in Pakistan according to age groups.

Table 4 . Setting specific anthropometric indices in children age 5–15 years.

Figure 2. (A) Underweight pooled prevalence in 5–15 years. (B) Stunting pooled prevalence in 5–15 years. (C) Wasting pooled prevalence in 5–15 years. (D) Thinness pooled prevalence in 5–15 years. (E) Overweight pooled prevalence in 5–15 years. (F) Obese pooled prevalence in 5–15 years.

We noticed similar trends of pooled prevalence for children age 0–19 and 5–19 across all anthropometric indices as shown in Table 3 . This could be because of the overlap in data across all three age groups.

The pooled prevalence of underweight amongst school-going children and adolescents age 5 to 15 years was 25.1% (95% CI: 17.3–33.7%; 18 studies; 9,611; I 2 : 98.8) ( Table 4 , Figure 2A ). The prevalence was found to be higher amongst females (31.2%; 95% CI: 21.7–41.5%), children from government schools (24.6%; 95% CI: 16.1–33.4%), belonged to low SES (41%; 95% CI: 30.3–52.2%), from the province of Punjab (24.8% 95% CI: 12–40.2%), and Sindh (22.7%; 95% CI: 15.9–30.4%), and from disaster striken areas (36.3%; 95% CI: 30.9–41.9%) ( Supplementary Figure 4 ).

The overall pooled prevalence of stunting in school-going children and adolescents age 5–15 years was 23% (95% CI: 11.8–36.7%; 14 studies; 12,380 participants; I 2 : 99.6) ( Figure 2B ). The prevalence was was higher amongst females (19.1%; 95% CI: 11.5–28%), children going to government schools (22.4%; 95% CI: 10.7–36.7%), those from a low SES (16.7%; 95% CI: 14–19.7%), and those who lived in rural areas (27.8%; 95% CI: 7.9–54%) ( Table 4 ). The highest stunting pooled prevalence was noted to be amongst children from the province of Punjab (29.4%; 95% CI: 17.1–43.3%), those who were laborers (54.4%; 95% CI: 0–100%), and disaster striken areas (37.7%; 95% CI: 27.3–48.7%) ( Supplementary Figure 5 ).

The pooled prevalence of wasting amongst school-going children and adolescents age 5–15 years was 24% (95% CI: 15.2–34%; 4 studies; 2,946 participants; I 2 : 95.5) ( Figure 2C ). Wasting was reported to be higher amongst females (27.7%; 95% CI: 5–59.1%), and those who lived in rural areas (33.3%; 95% CI: 30.1–36.6%). Data on wasting prevalence was only available for the province of Punjab with a pooled prevalence of 21.8% (95% CI: 11.1–34.8%) ( Supplementary Figure 6 ).

The overall prevalence of thinness was 12.5% (95% CI: 9.4–16.1; 4 studies; 4,669 participants; I 2 : 88.7) ( Figure 2D ). Thinness was reported to be higher amongst males (15%; 95% CI: 7.8–23.9%), those attending government schools (28.8%; 95% CI: 17.2–42%), and those from a low SES (14.3% 95% CI: 11.7–17.1%) ( Table 4 ). Data on thinness prevalence was only available for the province of Punjab with a pooled prevalence of 14.2% (95% CI: 8.9–20.6). For children from disaster-affected regions and child laborers, the pooled prevalence of thinness was reported to be 12% (95% CI: 10.6–13.5%) and 9.4% (95% CI: 6.6–12.5%), respectively ( Supplementary Figure 7 ).

The overall overweight pooled prevalence for school-going children and adolescents age 5–15 years was 11.4% (95% CI: 7.2–16.3%; 11 studies; 4,281 participants; I 2 : 94.8) ( Figure 2E ). Overweight pooled prevalence was noted to be higher amongst males (12.6%; 95% CI: 7.1–19.4%), children going to private schools (17.1%; 95% CI: 8.7–27.4%), and those from a high SES (24.1%; 95% CI: 15.4–33.9%) ( Table 4 ). Between provinces, the highest overweight prevalence was amongst children from Punjab (12.5%; 95% CI: 6.5–20%), followed by Sindh (7.6%; 95% CI: 5.6–9.9%) and the least in KP (5.5%; 95% CI: 2.7–9.1%) ( Supplementary Figure 8 ).

The pooled prevalence on obesity was 6.9% (95% CI: 3–12%; 14 studies; 8,065 participants; I 2 : 98.1) ( Figure 2F ). The pooled prevalence of obesity was noted to be higher amongst males (7.5%; 95% CI: 4.9–10.5%), children attending private schools (13%; 95% CI: 10.9–15.3%), those from high SES (12%; 95% CI: 5.8–20%), and those living in urban areas (8.4%; 95% CI: 2.9–16.2%) ( Table 4 ). The highest obesity pooled prevalence was reported amongst children from Punjab (10.5%; 95% CI: 2.7–22.3%), followed by KP (4.8%; 95% CI: 4.1–5.5%), and least in Sindh (3.8%; 95% CI: 0.7–8.8%). Only 5.2% (95% CI: 3.2–7.7%) obesity pooled prevalence was reported amongst child laborers ( Supplementary Figure 9 ).

For the age group of 5–10 years, we could only calculate pooled prevalence for underweight which was 6.5% (95% CI: 2–13.1%; 5 studies, 1,569 participants, I 2 : 94.7%) and stunting at 4% (95% CI: 0 to 12.7%; 4 studies, 1,044 participants, I 2 :96%) ( Supplementary Figure 10 ). While for the age group 10–15 years, pooled prevalence was only calculated for overweight at 5.9% (95% CI: 3.4 to 8.9%; 2 studies, 678 participants, I 2 : 56.8%) and obesity at 2.5% (95% CI: 0.5–5.8%; 2 studies, 678 participants, I 2 :79.3%) ( Supplementary Figure 11 ). This is due to lack of data on anthropometric indices for these age groups specifically.

Dietary Intake

Our systematic review includes 21 studies which reported dietary intake trends amongst school-going children and adolescents aged 5 to 15 years ( 19 – 22 , 24 , 25 , 30 – 32 , 36 , 40 – 42 , 46 , 53 , 55 , 57 – 59 , 67 , 68 ). The tools used to assess dietary intake patterns are presented in Table 1 .

The recommended percentage of daily energy contribution, according to the Acceptable Macrnonutrient Distribution Ranges (AMDR), for carbohydrates, proteins, and fats in children age 4–18 years is 45–65%, 10–30%, and 25–35%, respectively ( 69 ). Aziz 2014 reported that children from schools across Pakistan had an overall increased daily intake of carbohydrates (60–75%) ( 57 ). Two separate studies conducted in different cities across Pakistan reported the highest carbohydrate consumption amongst children from Balochistan ( 41 , 57 ). Aziz et al. ( 30 ) conducted a study on children from Karachi and reported they have an upper limit of carbohydrate consumption ( 30 ).

Aziz et al. ( 41 ) reports children generally had the lowest consumption of protein compared to the recommended daily allowance (RDA) ( 41 ). Sultana et al. ( 42 ) conducted a study on children from Punjab and reported they have the highest protein intake (12%) when compared to other provinces ( 57 ). A study assessing lunch box contents amongst 1,360 students noticed meals to be low in proteins and fiber but high in fat ( 42 ). Aziz et al. ( 41 ) and Aziz and Hosain ( 57 ) conducted two studies assessing fat intake and it was noted that fat intake amongst children across Pakistan was below the recommended daily standards ( 41 , 57 ).

For micronutrients , Kausar 2018 reported girls to have inadequate dietary intake with their daily consumption being less than the Recommended Daily Allowance (RDA) ( 22 ). This was seconded by Zaman et al. ( 46 ), reporting female participants to have an overall lower energy intake and failure to meet the recommended intake of vitamins A, C, D, E, folic acid, phosphorus, zinc, sodium, potassium, iron, and magnesium as compared to the RDA ( 46 ). Males on the other hand were found to have a higher carbohydrate, sugar, fiber, and fat consumption ( 46 ). Children from high socioeconomic status settings were observed to have a higher vitamin and supplements intake ( 68 ).

Aziz et al. ( 55 ) reported breakfast consumption varied with socioeconomic status as children from rural areas or squatter settlements were more likely to skip breakfast. However, Shaukat et al. ( 40 ) reported 29% of their population from an urban setting skipped breakfast. A single study reported 8% of their population skipped breakfast and were more likely to be overweight or obese ( p < 0.002) ( 31 ). Qureshi et al. ( 32 ), on the other hand, reports 82.2% of their population had insufficient breakfast and found a higher prevalence of thinness and stunting amongst them.

There are 11 studies included in our systematic review that reported dietary intake in children according to food groups. Table 5 below gives an overview of the dietary intake patterns. It can be noted that children have suboptimal vegetable and fruit intake while consumption of soft drinks and sweets/chocolates is high.

Table 5 . Dietary intake frequency.

In the present systematic review targeting 62,148 individuals, the limited evidence suggests the presence of DBM among school-going children and adolescents age 5 to 15 years. Our pooled analyses have found that approximately one-quarter of these children are underweight (25.1%), stunted (23%), wasted (24%); while 12.5% have thinness, 11.4% are overweight and 6.9% are obese. Dietary intake patterns in school-going children and adolescents aged 5–15 years show relatively high carbohydrate intake and low intake of protein-rich foods, compared to RDA, with suboptimal consumption of fruits and vegetables and increased intake of soft drinks and sweets/chocolates.

In the 1990s, using data on children <5 years of age, Pakistan was only dealing with a high prevalence of undernutrition. However, in the 2010s, this rhetoric changed and Pakistan emerged as a country facing DBM with >30% overweight prevalence ( 3 ). A similar transition was noted amongst countries within the lower quartile Gross Domestic Product (GDP) per capita purchasing power parity. This change has been associated with the concept of nutritional transition, which is about changes in the dietary patterns, physical activity, and tendency toward a sedentary lifestyle affecting body composition, fat distribution, and nutritional problems thereby leading to a rapid increase in overweight, obesity, and nutritional related non-communicable diseases ( 70 ). Pakistan has also been experiencing this nutritional transition with the rapid urbanization and change in diets. This trend is observed in our systematic review with children reporting an increased intake of carbohydrates, soft drinks, and sweets/chocolates.

The subgroup analysis ( Table 4 ) revealed a higher prevalence of undernutrition (underweight, stunting, and wasting), except thinness, amongst girls, while overweight, obesity, and thinness were higher amongst boys. This disparity highlights the issue of gender inequality which has been embedded in the Pakistani culture, with parents having a strong preference for sons, leading to girls being neglected ( 54 ). The National Nutrition Survey (NNS) 2018 of Pakistan, on the other hand, reports higher prevalence of underweight and obesity in adolescent boys and higher overweight prevalence in adolescent girls age 10–19 years ( 71 ). 78.4% of the studies were conducted in a school setting and according to Pakistan Annual Report 2016 by UNICEF, 22.6 million children age 5–16 years in Pakistan are out of school ( 72 ), hence, more data is needed from communities and rural areas to generalize trends of different anthropometric indices for children across Pakistan ( 71 ). Although this is a region-specific finding, even globally there is limited data on school-going children and early adolescents 5–15 years of age ( 6 ).

Higher undernutrition prevalence was also noted amongst children attending government schools, children from low socioeconomic backgrounds, and children living in rural areas. This could be attributed to poor living standards and food insecurity coupled with poor dietary practices amongst individuals living in poverty ( 26 ). The NNS 2018 survey reports 36.7% households in Pakistan to be facing food insecurity ( 71 ). A higher prevalence of overnutrition (overweight and obesity) was noted amongst children attending private schools, children from high socioeconomic backgrounds, and children living in urban areas. This trend is most likely due to the rapid urbanization and change in diet to higher consumption of carbohydrate rich foods, fast foods and carbonated/energy drinks with high sugar content along with a change to a more sedentary lifestyle.

Best 2010 conducted a review to assess the nutritional status of children age 5–12 years from Latin America, Africa, Asia, and the Eastern Mediterranean region and reported high underweight and thinness prevalence in South-East Asia and Africa while overweight prevalence was reported to be below 15% ( 73 ). In 2010, East Africa, the Pacific, and sub-Saharan Africa were reported to have a greater overweight prevalence (26.5 and 22.2%, respectively) than that of underweight (7.9 and 12.1%, respectively) ( 74 ). A cross-sectional study conducted in Lebanon also reported coexistence of under- and over-nutrition manifested as an overall prevalence of stunting to be 13.7% and overweight to be 7.2% amongst 153 5–14 years ( 75 ). On the other hand, a more recent analysis by Caleyachetty 2018 of data from global school-based student health surveys on children age 12–15 years from 57 LMICs and reported an overall 10.2% stunting prevalence, 5.5% thinness, and 21.4% overweight and obesity prevalence ( 76 ).

Dietary studies of school-aged children in Pakistan depict relatively high carbohydrate intake and low intake of protein-rich foods, fruits, and vegetables ( 46 , 57 , 77 , 78 ). The culture, myths, and misconceptions about dietary habits are different in every region and hence cannot be used to generalize this trend across Pakistan. Two studies have reported the highest carbohydrate intake amongst children from Quetta and Balochistan ( 41 , 55 ), however, more evidence is needed as not many studies have reported data specifically from these regions. There is a need to develop context-specific behavior change messages for school-aged children to encourage consumption of easily available, accessible, and affordable protein- and vitamin-rich foods such as lentils, seasonal fruits, and vegetables, as well as milk and its derivatives. An increase in consumption of a healthy, balanced diet will also help support the agrarian economy and encourage the utilization of local products to boost immunity and reduce chances of chronic diseases and, therefore, a reduction in the burden on the health sector ( 79 ).

Ochola 2014 conducted a systematic review on dietary intake habits of children age 6–12 years from different LMICs. They reported limited diversity and availability of food groups for children and reported children to have a higher intake of plant-based food sources, but an overall low fruit and vegetable intake and limited animal foods, thereby many being deficient in micronutrients. In Kuala Lumpur, 20% of school-going children and adolescents skipped at least one meal a day, with the most commonly skipped meal being breakfast (12.6%) while 32% of adolescents rarely consumed breakfast in Ghana. An increasing trend of processed and fast-food consumption was noted amongst children living in urban areas, with a greater preference for foods high in sugar, salt, and saturated fats. Ochola and Masibo ( 80 ) highlighted the need for nutrition education, not only for the school management, children, and parents but also the community at large, to spread awareness and sensitize the people about healthy eating habits ( 80 ).

The limitations identified in this review included that (i) studies used different tools and standards, such as the WHO or CDC criteria or did not specify, to categorize anthropometric indices, which led to lack of uniformity and possibility of over-or under-estimation of anthropometric measures, (ii) majority of the studies were conducted in urban setting with most of the data collected from the cities of Lahore and Karachi alone, (iii) majority of the studies had a sample size <500 ( n = 27), (iv) poor assessment of macro-and micronutrient consumption amongst children and (v) overall poor quality assessment of the included studies with 88.2% studies clearly specified and defined their population, while only 33.3% provided justification for sample size calculation with outcomes defined by 74.5% of the studies, no study had outcomes blinded to assessors and only 25.5% of the studies measured confounding variables and adjusted them statistically to assess associations to the outcomes. We could not measure publication bias for this review using SUMARI, as the estimates were proportions. It is recommended that good quality, large-scale cross-sectional surveys should be conducted for this age group especially in LMICs, along with micronutrient assessment as a component of future research for a better understanding of the problems and to help design specific programs to ameliorate the specific needs.

This systematic review identifies the burden of malnutrition and dietary patterns in school-going children and early adolescents from Pakistan and highlights the gaps that need to be addressed. Large-scale population-representative studies are still required, with standardized tools for anthropometry and dietary assessment. As the prevalence of DBM for school-going children and early adolescents age 5–15 years in other LMICs is not known, similar reviews from each region also need to be conducted. Such reviews will allow epidemiologists to first assess the availability of data in this age group, then identify their malnutrition trends, and thereby allow them to recognize the gaps and formulate interventions that can better tackle the issue of DBM in this age group globally. Notwithstanding, the need for more evidence; the recent review identifies the high burden of both under- nutrition and over- nutrition in this age group and the relevant mult-sectoral stakehlders should a take a note and plan for programs for this specific and very important age goup.

Data Availability Statement

The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author/s.

Author Contributions

DK and JD: formed the search strategy, identified relevant articles, extracted data, and analyzed it. They also conducted a quality assessment for all included studies. ZB and JD: conceptualized and designed this study. ZL: performed the analysis. ZB, JD, and ZL: guided other authors throughout the process. SZ, AS, MR, AD, and AK: reviewed, provided critical inputs, and revised the manuscript. All authors contributed to the article and approved the submitted version.

This systematic review was funded by SCANS consortium including the Trust for Vaccines & Immunizations (Pakistan) and the Aga Khan University (Karachi, Pakistan). The authors declare that this study also received funding from Mother & Child Care & Research Inc. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fnut.2021.739447/full#supplementary-material

Abbreviations

DBM, Double Burden of Malnutrition; LMIC, Low- and middle-income country; NWFP, North West Frontier Province; RDA, Recommended Daily Allowance.

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Keywords: malnutrition, dietary intake, school-going children, adolescents, double burden of malnutrition

Citation: Khan DSA, Das JK, Zareen S, Lassi ZS, Salman A, Raashid M, Dero AA, Khanzada A and Bhutta ZA (2022) Nutritional Status and Dietary Intake of School-Age Children and Early Adolescents: Systematic Review in a Developing Country and Lessons for the Global Perspective. Front. Nutr. 8:739447. doi: 10.3389/fnut.2021.739447

Received: 11 July 2021; Accepted: 23 December 2021; Published: 02 February 2022.

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*Correspondence: Zulfiqar A. Bhutta, zulfiqar.bhutta@sickkids.ca

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Literature review: nutritional factors influencing academic achievement in school age children

Background and objective.

Adolescence is a transition period involving tremendous physical, psychological and cognitive growth. For appropriate growth of adolescents in these aspects, a correct quantity and quality of nourishment is required, as a lack of such nourishment among adolescents can lead to various degrees of malnutrition, which may have implications on their health as well as their academic achievements.

Materials and methods

This review examines the research topics around factors that influence the nutritional status of adolescent students which can affect their academic performance.

Some of the vital factors include knowledge and attitude about nutrition, eating behaviour, physical activity, socio-economic status of the family, the surrounding environment at school and home, the frequency and timing of meals, nutritional contents and amount of food intake.

Students who consume a balanced diet perform better in exams, show better behaviour as well as attendance at school and get their assigned tasks done more thoroughly compared with those who do not consume a balanced diet.

Acknowledgements

The authors acknowledge the M.Sc. course in School Health, Faculty of Tropical medicine, Mahidol University which allowed us to meet and develop this paper.

Conflict of interest statement: The authors declare that there is no conflict of interest.

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Nutritional status and correlation with academic performance among primary school children, northwest Ethiopia

• Biachew Asmare 1 ,
• Mekuanint Taddele 1 ,
• Sileshi Berihun 1 &
• Fasil Wagnew 1  

BMC Research Notes volume  11 , Article number:  805 ( 2018 ) Cite this article

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This study aimed to determine the association between nutritional status and academic performance among primary school children in Debre Markos Town, northwest Ethiopia, 2017.

The prevalence of stunting, underweight and wasting were 27.5% (95% CI 23.2–31.9%), 20.4% (95% CI 16.5–24.3%) and 8.7% (95% CI 6.2–11.5%), correspondingly. The low level of educational performance was significantly higher (p < 0.05) among the stunted, underweight and wasted children than that of the normal children. In multivariable logistic regression, age of the child (Adjusted Odds Ratio (AOR) = 0.177, 95% CI 0.07, 0.4), monthly income less < 1000.00 birr (AOR = 0.05, 95% Cl 0.02, 0.15), stunted children (AOR = 0.21, 95% CI 0.10, 0.43) and under-weight (AOR = 0.63, 95% CI 0.26, 0.84) were associated with academic performance. This study revealed that indicators of undernutrition were prevalent among school-age children. Thus, collaboration between the health and education sectors is required to alleviate the problem.

Introduction

Quality education plays a pivotal role in the economic, social and political development. Currently, getting children into schools is not enough; government ensure that children attain the basic knowledge and skills needed for personal well-being [ 1 ]. Primary school is an important stage in the development of consciousness and personality of the child [ 1 , 2 ].

Nutrition is also a vital component of human health, life, and brain development through the entire lifespan [ 3 ]. Balanced nutritious is crucial for endurance, physical growth, cognitive development and productivity [ 4 ]. As well, malnutrition is considered a pressing problem that affects the ability of children to learn and causes them to perform at a lower level in school [ 5 , 6 , 7 ]. Undernutrition is a major public health challenging affecting academic school achievement [ 8 ]. Ethiopia is one of the sub-Saharan African countries basically affected by child malnutrition. Previous studies conducted in different areas have shown that under nutrition is common among school-age children; it was reported in the form of stunting range from 11 to 48.7% and underweight from 7.2 to 59.7% [ 9 ]. A study conducted in eastern Ethiopia reported that the prevalence of stunting was 8.9%, of which, 2% had severe stunted among school-aged children [ 10 ]. Though evidence about the prevalence of malnutrition is well studied in Ethiopia, there is insufficient evidence regarding nutritional status allied with academic performance among school-age children [ 9 ]. The association between nutritional status and educational achievement among school-age children in developing countries have not been recognized well [ 9 , 11 ]. Stunting is referred as the best indicator for a chronic type of under nutrition [ 9 ]. Children who are stunted have low ability to learn at school and poor scholastic achievement [ 12 ]. Furthermore, poor feeding practices are associated with stunted and impaired brain development [ 6 , 13 ].

On this background, there is a necessity to overlook the relationship between nutritional status and educational performance among school-age children in the Debre Markos town. This study was aimed to determine nutritional status and correlation with academic performance among first cycle governmental primary school in Debre Markos Town, northwest Ethiopia.

Study area, setting and period

The study was conducted at Debre Markos town primary school. In the town, there were a total of 7473 population. Of them, 3831 were females studying in the school. Debre Markos is a city of East Gojjam Zone which is located 299 km away from Addis Ababa in the North. It had 15 governmental and 8 private primary schools. The study was conducted between January15 to March 17/2018.

Study design and population: An institutional-based, cross-sectional study was employed at primary school in Debre Markos town.

Sample size and sampling techniques: The sample size was determined using double population proportion by considering the following statistical assumptions: prevalence of stunting among school children (p 1 ) is 48% and p 2 is 29% and level of significance (α) = 5%, at 95% level of confidence, power of the study 90% and design effect 1.5. Finally, the overall sample size was found 442.

Sampling procedure: Participants were carefully chosen using a multi- stage sampling technique. Out of 15 primary schools, 4 schools were selected randomly by lottery method at stage one. Students were allocated proportionally at stage two. Then participants from selected schools were selected by systematic random sampling method using students’ name list by calculating ‘k’ value for each class.

Data collection methods: Data were collected using a pre-tested structured questionnaire and translated into the local language (Amharic version) by trained and experienced data collectors. Respondents were parents/caregivers of the children identified in the study schools. After students were systematically selected from the schools, their household address was traced in the students’ parent database. Then data collectors went to the children’s house to interview parents/caretakers. Training on the standard procedures and technique how to collect data were given for the data collectors and supervisors for 2 consecutive days. The contents on questionnaires were briefly described to reduce interviewer bias.

Data processing and analysis: Data were entered into Epi-Data version 3.1 and then exported to SPSS version 20 for further analysis. Emergency Nutrition Assessment (ENA) for SMART software was used to calculate the Z-score of weight-for-age, height-for-age and weight -for-height of the children. Variables which were significant at p-value < 0.2 in the bivariable analyses were candidate for entering into the multivariable logistic regression model to identify the independent predictors for academic performance. Before inclusion of factors, we checked multicollinearity using variance inflation factor (VIF) < 10.

Definition of academic performance

The overall subjects the students were given in the academic year 2017/18 were considered to examine the academic achievements of the students. The annual average score was computed by taking the result of two consecutive semesters of the year. To verify the relationship between nutritional status and academic performance, average marks of the overall subjects the students received were either poor academic achievement or good academic achievement, in accordance with an average mark of 50%. This cut off average point was decided by considering the pass mark set by Ethiopian ministry of education.

Socio-demographic characteristics

A total of 436 children were included in the study with a response rate of 98.6%. Of them, 245 (56.2%) were males. The mean age of the study participants was 8.57 (± 1.12) ranging from 7 to 10 years. Majority of the study participants 398 (90.8%) were located in urban, 389 (89.2%) orthodox and 153 (35.1%) from grade one. Educational status of parents of the study participants showed that 81 (19.5%) mothers and 67 (17.7%) fathers had no formal education (Table  1 ).

Out of the 436 children, 37 (8.5%) were being sick in the last semester and only 140 (32.1%) of school-age children were attending preschool. Majority of study participants 403 (92.44) were traveled to school with in 2.18 km (Additional file 1 : Table S1).

Level of nutritional status in study participants: The overall prevalence of stunting, underweight and wasting were 27.5% (95% CI 23.2–31.9%), 20.4% (95% CI 16.5–24.3%) and 8.7% (95% CI 6.2–11.5%) respectively. The percentage of children having any kind of under nutrition (stunting, wasting and underweight) was 56.2%. The prevalence of stunting was significantly higher in males than females (Fig.  1 ).

Prevalence of under nutrition by gender among children in Debre Markos town, Northwest, Ethiopia, 2017 (n = 436)

Nutritional status and academic performance: In comparison of median t-test analysis revealed that there was significant mean difference in all subject average score between children who were having any kind of undernutrition (Additional file 2 : Table S2).

After adjusting factors, age, family income, nutritional indicators (WAZ and HAZ) had significant positive associations with academic achievement of students ( p  < 0.05). Age of the child (AOR = 0.177, 95% CI 0.07, 0.4), Monthly income less < 1000.00 birr (AOR = 0.05, 95% CI 0.02, 0.15), stunted children (AOR = 0.21, 95% CI 0.10, 0.43) and under-weight (AOR = 0.63, 95% CI 0.26, 0.84) were significantly associated with academic performance. Students those nutritional status had stunted were 79% less likely to score high academic performance as compared with normal. Students whose nutritional status had under-weight were 37% less likely to score high academic performance compared with their counterparts (Table  2 ).

Discussions

The aim of this study was to determine the relationship between nutritional status and academic performance among governmental primary school children. In this study, the prevalence of stunting, underweight and wasting were 27.5%, 20.4%, and 8.7% respectively. This finding was comparable with a study done in Zambia reported that 28.9% of stunted, 14.5% of underweight and 3. 9% of wasted [ 14 ]. In addition, the prevalence of stunting and wasting in this study was also in line with the findings of Sri Lanka among school-age children which indicated that the prevalence of under-nutrition in the central province was 26.6% stunted and 8.5% wasted [ 15 ], and in northwest Ethiopia, 27.1% stunted [ 16 ]. In contrast, this finding was higher as compared to other previous studies conducted in Brazil was found (14.9% stunted and 9.7% wasted) [ 9 ], in Kenya (24% stunted, 14.9% underweight, 9.7% wasted) [ 17 ], in Nicaragua (5% wasted) [ 18 ], in eastern Ethiopia (8.9% stunted) [ 19 ]. The reason for this observed discrepancy might be due to sociodemographic characteristics, area of sampling and study period.

Regarding factors, the present study revealed that age and monthly income were significant factors for academic performance among primary school children. This finding was consistent with a systematic review and meta-analysis showed that there is a strong association between academic performance and socio-economic status including age [ 20 ]. Compromised socio-economic status of a family was statistically associated with poor academic performance in children [ 21 ]. Similarly, other studies done in Southeast Ethiopia [ 22 ] and in Malaysia [ 23 ] reported that minimum wealth indexed score of the family were a positive association with poor academic performance. This might be due to balanced nutritional intake is required for adequate biological functioning affect such complex brain functions as the cognitive processes related academic performance [ 24 ].

Moreover, in developing countries macronutrient and micronutrient deficiencies are a devastating problem. Consequently, this obstacle has been either direct or indirect influence on children future of life [ 25 ]. Improved nutritional status has been exposed to have a positive and direct impact on academic performance of children [ 4 ]. In the current study, under-weight and stunting were associated factors for good academic performance among school-age children. This finding is in line with a study done in Sri Lanka [ 26 ] and in Uganda [ 27 ] which revealed that child with a high score of WHZ and HAZ had good academic performance as compared to their counterparts. Also, marasmic-kwashiorkor children may acquire delay brain development. Chronic types of malnutrition (stunting) had a negative impact on child cognitive development [ 20 ]. Similarly, a study done in Southeast Ethiopia revealed that higher score of HAZ was significantly associated with a higher academic score [ 20 ]. In this study, wasting (WHZ) was not statistical association with child academic performance. This non-significance effect might be due to the fact that wasting is acute malnutrition which implies a temporary nutritional disorder that may not negative substantial impact on academic performance [ 28 , 29 ].

The study revealed that indicators of undernutrition were prevalent among Debre Markos town primary school children. Age, income, HAZ and WAZ scores showed significant association with academic performance. Therefore, the government should paid attention to implement nutrition screening program and intervention strategy to improve academic performance at primary school children.

Limitation of the study

Finally, some important limitations of this study was cross-sectional nature of the study could not establish a cause and effect relationship between the dependent and independent variables. The other limitation of the study is that it was done in an urban areas which may inadequate representative for rural area.

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Authors’ contributions

BA, MT, SB and FW were participated in proposal writing, analyzing the data, and drafting the paper. MT and FW prepared the manuscript for publication. All authors read and approved the final manuscript.

Acknowledgements

The author’s deep gratitude goes to Debre Markos University, college of medicine and health sciences for proper review and approval of this paper. The authors would also like to extend their gratitude to Debre Markos town educational office and primary schools in the town, data collectors, and supervisors for valuable contribution for the success of this study.

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The authors declare that they have no competing interests.

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Data set: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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The study was carried out after getting approval from Debre Markos University institutional review board (IRB). Written permission was obtained from educational office and administrative leaders of respective schools. The verbal (non-written) consent was obtained because written consent needed a certain level of education to read and sign the consent. Participants had the right to refrain from answering some questions or withdraw from the study process at any time. To maintain confidentiality, each and every one collected data were coded and locked in a separate room prior to enter into the computer. Following entered into the computer all data were protected by password.

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Additional files

Additional file 1: table s1..

General characteristics of study participants in Debre Markos town, March, 2017 (n = 436).

Additional file 2: Table S2.

Prevalence of low educational performance (marks < median of student result of nutritional status of children, Debre Markos, 2017 (n = 436).

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Asmare, B., Taddele, M., Berihun, S. et al. Nutritional status and correlation with academic performance among primary school children, northwest Ethiopia. BMC Res Notes 11 , 805 (2018). https://doi.org/10.1186/s13104-018-3909-1

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Nutritional Status and Academic Performance of Grade 7 Students

• Jonriel O. Curada

INTRODUCTION

Nutrition is a fundamental pillar of human life, health, and development across the entire lifespan. From the earliest stages of fetal development, at birth, through infancy, childhood, adolescence, and into adulthood and old age, proper food and good nutrition are essential for survival, physical growth, mental development, performance and productivity, health, and well-being. This study determined the significant relationship between the level of nutritional status and academic performance of Grade VII students in Mathematics.

It utilized the descriptive -correlational research design. Frequency and percentage distribution were used to depict the level of nutritional status and academic performance of the students of San Roque National High School. Spearman rho correlation was used to test the significant relationship between the two variables used.

Nutritional status of students was at a normal level, however; their academic performance is in approaching proficiency level. The study also showed that nutritional status and academic performance in Math generated positive but high correlation; implying that nutritional status influences the level of academic performance of the students. The study further attests that nutritional status may hinder a child`s ability to learn; academic performance of students in the school was greatly affected. Health and education are essential to formulating new possible policy interventions targeted at the improvement of children's status in developing countries. The importance of nutrition and schooling in developing countries the analysis presented in this work makes progress in sorting out such a causal relationship. Furthermore, investments in health are expected to have positive effects on education since the returns from investment in education last for many periods and health status is positively correlated with life expectancy.

DISCUSSIONS

The development of any nation or community depends largely on the quality of education of such a nation. Understanding the nature of the causal relationship between health and education is important to determine the exact relationship between them. Health and nutrition influence educational achievement, but poor health and malnutrition in early childhood may affect cognitive abilities. School authority should take a look with the performance of the learners and has to have thorough observation and analysis with its impact in relation to their physical status.

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Nutritional Knowledge, Practice, and Dietary Habits among school Children and Adolescents

Marjan manouchehri naeeni.

Provincial Health Center, Isfahan University of Medical Sciences, Isfahan, Iran

Sakineh Jafari

Maryam fouladgar, kamal heidari.

1 Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Ziba Farajzadegan

2 Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran

Maryam Fakhri

3 Medical Students’ Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Parvaneh Karami

4 Isfahan Provincial Education and Training Organization, Isfahan, Iran

Razieh Omidi

Background:.

Although nutritional status of children and adolescents is of great concern various interventions and modifications aiming at promotion of healthy eating behaviors have limited impact due to insufficient understanding of dietary habits between different age groups and genders. The aim of this study in not only evaluation of nutritional knowledge, practice, and dietary habits of primary school and junior high school students in Isfahan province, but also this research explore crucial differences regarding gender and living area of the above-mentioned population in Iran.

This cross-sectional study was conducted on 4700 primary school and junior high school pupils in Isfahan province. Data were collected through standard 24-h recall food frequency questionnaire and researcher-designed questionnaire. Independent t -test was applied for comparison of mean values of total units of consumed food materials. Qualitative variables were compared by using the Chi-square test. Data were analyzed by ACCESS 2010 and SPSS 18 software.

Nutritional knowledge of female pupils and junior high school students was higher than their male and elementary school students respectively; still, theses superiorities did not lead to higher practice score. Bread and cereals group received daily intakes in accordance with food and drug administration (FDA) recommendations. Indeed, vegetables, milk, and dairy products, as well as meat daily intakes, were lower than the FDA recommendation, whereas fats, oils, and sugars intakes were higher. In comparison to females, male participants had significantly lower consumption of vegetables and fruits whilst they had a higher intake of carbohydrates, fats, and meats.

Conclusions:

Our results showed that adolescents failed to meet sufficient nutritional requirements, and they had an imbalanced diet, which was considerably low in several essential nutrients and high in some food materials.

INTRODUCTION

Nutritional intake as a pivotal element contributing to human health and well-being is of great importance and its role in childhood and adolescence is more prominent and of greater concern. Nutritional intake has a special direct effect on children's health due to their physical and mental growth as well as cognitive development. Furthermore, it has long-term effects on general health status through formation of life-long eating behaviors in children.[ 1 , 2 ] Food intake patterns and overweight are associated with different immediate complications and major long-term consequences including cardiovascular diseases, diabetes, high blood pressure, stroke, cancer, dental caries, asthma, and some other psychological disorders like depression.[ 3 , 4 , 5 ] Thus, quality of children's and adolescents’ diet has become a major concern for researchers. In recent decades, there have been considerable efforts following changes in diet and types of consumed foods leading substitution of fast foods with salutary traditional meals. However, the majorities of children do not meet recommended standards of dietary guidelines and are devoid of healthy dietary habits.[ 2 , 6 ] In addition, dietary quality would be exacerbated when children grow up by not only lower consumption of fruits, vegetables, and milk, but also higher consumption of soft drinks.[ 7 , 8 ]

In recent years, health organizations have implemented a variety of interventions to promote healthy eating behaviors of young population, yet they have had limited impact, which might be attributable to insufficient understanding of dietary habits and necessary interventions implemented in accordance with children ages.[ 2 , 9 ] As Shepherd et al . indicated in their study, dietary influences vary with age, and not all interventions are suitable for all age groups.[ 3 ] Yet, to date, relatively little research has examined nutritional knowledge, practice and attitudes of Iranian young population and related differences between different age groups and genders in many aspects of this field have not clearly been defined. On the other hand, more than 27% of the Iranian population are between 10 and 19 years of old,[ 10 ] which prioritize promotion of dietary healthy programs aiming healthier society development. Therefore, we aimed to evaluate dietary program and nutritional knowledge of a representative sample of primary school and junior high school students in Isfahan province, beside evaluation of their food intake status in comparison to recommendations, underscoring probable existent differences and imbalances regarding age, gender and living area.

This survey was a cross-sectional study conducted between September 2009 and March 2010 on 4700 primary and junior high school pupils of Isfahan province, which is one of the largest provinces of Iran.

Study design and sampling

Sample size comprised 4700 students, which included 2867 and 1833 primary school and high junior school students, respectively. Nutritional practice score was applied for sample size calculation while level of confidence and drop-out rate were 95% and 2%, respectively. Bunches of multistage cluster sampling were proportionally selected in accordance with the student population of different towns in Isfahan province as well as the total number of the student population at each educational level. In addition, the proportion of urban population to rural one was considered in every town whilst male to female ratio was considered to be equal. Inclusion criteria comprised students residing in Isfahan province and were studying at either primary school or junior high school. Exclusion criteria included either refusal announcement or discontent expression for being a subject. Under missing analysis was implemented for incomplete questionnaires.

Data collection tools

Questionnaire-based method was implemented for data collection through trained questioners and participating students and parents. Two various questionnaires were used included standard and researcher-designed questionnaire. All questionnaires were coded. Former questionnaire was used to determine average daily consumption in every seven food groups, whereas the latter one was applied for evaluation of nutritional knowledge and practice in the respective groups. All of the 24 questions, in the standard questionnaire, were answered by mothers on a holiday and 2 nonholiday days. The standard questionnaire consisted of a variety of multiple-choice, open-ended and yes/no questions. Serving size and details of consumed foods were provided by subjects as far as possible. Questioners’ guidance was available for mothers within the period they were completing the questionnaire at home. Afterward, amounts of food ingredients were calculated and prepared in standard tables regarding available routinely used recipes.

On the other hand, researcher-designed questionnaire consisted of 39 questions, which concerned about demographic nutritional knowledge and nutritional practice in 10, 19, and 10 questions respectively. All 39 questions were answered by students within 20 min (determined according to the pilot study).

Final score was calculated in base of the percentage for each individual whilst practice evaluation section had the main portion of the total score. Total scores being above 75 out of 100 were mentioned to be favorable while scores being between 50% and 74% or lower than 50% were reported as medium and poor nutritional practice, respectively.

Validity of the questionnaire was checked and obtained by consulting a number of experts, and the Cronbach's alpha coefficient was calculated to obtain reliability. Reliability analysis yielded Cronbach's alpha value of 0.70 for knowledge and practice scales. In order to make, necessary modifications pilot study questionnaires were distributed among 30 students of primary school and junior high school. Students’ knowledge and awareness were assessed with regard to 5 main aspects including healthy eating, main food groups, main meals, minerals, and vitamins, as well as nutritional habits. Nutritional practice was evaluated by inquiry about food choices and daily consumption of food materials.

Ethical considerations

The study protocol was approved by Ethic Committee of Isfahan University of Medical Sciences. Participation in this study was voluntary. All information was anonymously collected, and the outcomes were used for research purposes.

Data analysis

Data extracted from questionnaires were analyzed in accordance with gender, living area (urban or rural), and educational level (primary or junior high school). Independent t -test was applied for comparison of mean scores of the above-mentioned groups, who completed nutritional knowledge and practice evaluation. Qualitative variables were compared using Chi-square test and finally all data were analyzed by ACCESS 2010 and (SPSS Inc., Chicago, IL, USA).

Total sample size comprised of 4700 participants, standard questionnaire and researcher-designed one reached 3673 and 4691, respectively, due to missing data and uncompleted returned questionnaires. Eighty-four percent (3923 students) of the understudied population were from urban areas while the rest 16% (768 cases) settled in rural regions. The ratio of males to females in sample groups from both urban and rural areas was equal. Almost 70% of cases were elementary school pupils, and the rest were students of junior high schools. Baseline characteristic data are demonstrated in Table 1 .

Distribution of students in terms of gender and living area

Nutritional knowledge and practice evaluation

In general, 4691 filled questionnaires were collected from 4700 pupils. Data extracted from all filled questionnaires went under statistical analysis and missing analysis. As previously mentioned, students’ knowledge score was analyzed in 3 steps comprising gender, age, and living area. Total mean scores were calculated for 5 distinct aspects of nutritional knowledge and were compared. Average total knowledge score for healthy eating was 48.95 ± 11.4, which was shown to be significantly different between males and females. As shown in Table 2 female students’ awareness regarding healthy eating tended to be higher than their male counterparts ( P < 0.001). In comparison, students from urban areas seemed to have a higher awareness about healthy eating ( P < 0.001). Likewise, junior high school students had significantly higher knowledge score on this issue than younger ones ( P < 0.001). Detailed analyzed data regarding students’ knowledge about healthy eating is shown in Table 2 .

Comparison of nutritional knowledge and practice score of students in terms of gender, living area, and educational level

The same results were obtained with regard to main food groups and nutritional habits awareness status. Indeed, males and females did not show any difference except for food meals. To elaborate, urban pupils had a higher level of knowledge in all aspects except for minerals and vitamins and food meals. Whole data of knowledge evaluation in all 5 mentioned aspects are summarized in Table 2 .

For both sections of nutritional practice part distinct mean scores were calculated and compared. Total average score for participants’ food choices and consumption of different food groups was 85.8 ± 10.9, while male participants gained higher mean score than girl students. Likewise, urban students were shown to be superior to rural ones in this regard. Primary school students had significantly higher practice score for this aspect in comparison with their junior high school counterparts. Moreover, students’ mean score for daily consumption of food materials and groups was 55.4 ± 14.6 out of 100. Mean score of girls tended to be higher than boys, whereas this score was not affected by living area. Finally, primary school pupils had a higher practice score for this part than junior high school ones. All mentioned differences were statistically meaningful, and related data are reported in Table 2 .

Food frequency evaluation

Almost 77% of 24-h recall food frequency distributed questionnaires were analyzable. Indeed, 1813 of them were filled by males and the rest (1860 questionnaire) were filled by female counterparts. Table 3 presents average amounts of daily consumption of food materials based on a defined unit of food groups. Average amount of daily consumption for bread and cereal group was 7.4 ± 2.1 units. Average amount of daily intake of fruits, vegetables, dairy products, meat, fats, sugar were 2.1 ± 1.2, 1.0 ± 0.7, 0.8 ± 0.6, 3.5 ± 1.2, 6.2 ± 2.4, 1.3 ± 1.1, respectively. Females had significantly higher daily consumption of fruits and vegetables, while males had higher consumption of bread and cereals, fats, and meat products. Neither dairy consumption of products nor daily consumption of sugar differed between girls and boys. Mean units of consumed foods and P values are summarized in Table 3 . While daily consumption of vegetables and meat were significantly higher in urban areas, no significant differences were found in daily consumption of other foods between urban and rural parts. In addition, milk and dairy group was the only one, which elementary school students had a higher intake than their junior high school counterparts [ Table 3 ].

Comparison of average daily intake of distinct food groups among students in terms of gender, living area, and educational level

Prevalence distribution for eating meals showed that 0.8% of students did not eat a breakfast meal at all while regular consumption of this meal was significantly higher in primary school children. On the other hand, gender and living area did not statistically affect aforesaid meal. Details regarding consumption of 3 main meals and before noon, afternoon, and after dinner snack are shown in Table 4 . In fact, the prevalence of people who did not eat lunch meal, afternoon snack, dinner and after dinner snack was 0.1%, 2.9%, 0.1%, and 16.1%, respectively. In comparison to males, females had higher consumption of each meal except for breakfast and dinner. Lunch consumption was the only criterion, which was not affected by educational level. Indeed, Compared to junior high school participants, elementary school pupils had significantly higher frequency in consumption of other meals In addition, afternoon snack was more frequently consumed by urban students; still, frequency consumption of other meals did not affect by living area.

Comparison of prevalence distribution of consumption of meals among students in terms of gender, living area, and educational level

Carbohydrates were found to meet 64.1% of daily energy requirements in both female and male adolescent groups. Proteins and fats were the source of 12% and 23.8% of daily energy respectively, while they did not differ significantly between males and females ( P = 0.698).

According to our findings mean values of nutritional knowledge score were lower than half of the total score, so it was not favorable in both female and male students as a whole. The most information of the students was recognized in the scope of nutritional habits whereas the poorest awareness was found in the scope of food groups, minerals, and vitamins. Compared to males, females were most aware in almost all aspects of nutritional knowledge evaluation, and this finding is corroborated in a number of previous surveys.[ 11 , 12 , 13 , 14 ] Older pupils had higher levels of nutritional knowledge, which was mostly attributable to increased understanding of students when they were more trained and educated. Nevertheless, as with the previous studies, association between age and nutritional awareness was less consistent.[ 15 ] Some studies have reported a direct correlation between age and nutritional awareness, whereas this correlation was inconstant with some other studies.[ 12 , 13 ] Since rural students were considerably less aware of nutritional information more efforts, should be concentrated on educational program in rural areas. Nonetheless, higher awareness does not necessarily results in more favorable nutritional practice and behavior.[ 12 , 13 ] For example, while females had higher levels of nutritional knowledge, they showed weaker nutritional attitudes regarding daily consumption of food meals and food groups in comparison with males. On one hand, it seems that some other influencing variables such as body image psychological issues, food preferences, family dietary pattern, environmental factors influencing on children and adolescents’ nutritional behavior are accountable for this discrepancy.[ 16 , 17 ] On the other hand, scientists implies that less favorable attitude of adolescent girls may be due to their inclination to lose weight and remain slim which affects their food choices and amount of daily intake, causing weaker behaviors regarding daily food consumption despite of enough knowledge and awareness in this field.[ 10 ] Still, some female students had stronger performance, which is in accordance with the concept that conscious individuals pursue standard eating recommendations more often and less aware people overrule recommended patterns of eating for daily consumption of food groups.[ 15 ] This study also demonstrated that compared with junior high school students, primary school children were so susceptible to be influenced by family food pattern and parents’ recommendations. In fact, younger children's food intake was more a reflection of parental choices and functions rather than their own knowledge-based behavior while adolescents and teenagers make more independent food choices. The level of control over food choices is higher in older children whereas in the case of preference for unhealthy foods, younger children have limited opportunity to choose, and parents encourage their children for healthy eating.[ 18 , 19 , 20 ]

The results of this research demonstrated that males in primary school had higher intakes of meat, carbohydrates, and fats, but fruit, and vegetable intakes were significantly higher in female primary school students. Indeed, daily carbohydrate and protein intakes were appropriate, whilst the portion of fat was notably high, which was in accordance with the previous studies.[ 21 , 22 ] However, consumption of some macro-nutrients in adolescents did not meet standard recommendations. In fact, the bread and cereals group met standard recommendation of FDA, whereas fat and oils, sugar intakes were higher than recommended daily amounts. Both males and females had low consumption of fruits, though its consumption was considerably lower in males. In general, this research and similar ones demonstrated that male participants had significantly lower consumption of vegetables and fruits and higher intakes of carbohydrates, fats, and meats in comparison to their female counterparts.[ 23 ] Both males and females showed acceptable status for meal consumption except for venial individuals who missed main meals in spite of the fact that female participants showed a higher intake of meals, especially between-meal snacks.

CONCLUSIONS

This study indicates that adolescents had an imbalanced diet, which was not only considerably low in several essential food materials, but also high in some nutrients; however, they had acceptable nutritional knowledge.

Thus, necessity of developing nutritional interventions and education strategies aiming promotion of healthy eating habits in children is indispensable.

ACKNOWLEDGMENTS

Authors would like to gratefully acknowledge not only the students who participated in the survey, their teachers and parents, but also the supportive staff of educational department and its ancillary staff in Isfahan Province for their kind collaboration in designing and implementation of the study.

Source of Support: This research was funded by Isfahan University of Medical Sciences

Conflict of Interest: None declared.

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Nutritional status of the student nurses of a tertiary health-care center - A mixed-method study

Affiliation.

• 1 Department of Community Medicine, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India.
• PMID: 31041246
• PMCID: PMC6482778
• DOI: 10.4103/jfmpc.jfmpc_314_18

Context: Nursing students are the future role model of health; so critical evaluation of their nutritional status is imperative for effective functioning of health sector.

Aims: The aim is to assess the nutritional status of nursing students using basal metabolic index and exploring the causes of malnutrition along with uncovering the causes behind these causes of malnutrition.

Setting and design: Nutritional status of student's nurses was assessed by mixed-method study design in tertiary care center of Mumbai, India.

Materials and methods: The method is to use the census method for sampling 280 nursing students of a tertiary care center interviewed using a semistructured interview schedule. Focus group discussions were held with student nurses, which were selected through purposive sampling technique to interpret the instigator causes behind causes of malnutrition.

Statistical analysis: Descriptive statistics was applied on qualitative data. Conceptual model framed on themes and subthemes based upon the codes from qualitative data.

Results: Students having BMI less than 18 and more than 24.9 were 189 and 11, respectively, out of 280 students. About 64.20% had acidity and 11.07% performed regular exercises evolving major themes: challenges, stress, attitude, knowledge, social barriers, and motivators.

Conclusion: About 67.5% of nursing students had BMI less than 18. Inappropriate dietary pattern, frequent ailments, and improper personal habits ensued their malnourished status. Lack of proper knowledge on balanced diet, work place stress, and challenges such as financial constrain, peer pressure, and health ailments along with improper perception of body image of the student nurses are major triggering factors behind the causes of malnutrition.

Keywords: Diet; malnutrition causes; student nurses.

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Conflict of interest statement

There are no conflicts of interest.

Conceptual model summarizing the themes…

Conceptual model summarizing the themes and associated subthemes determining the significant reasons behind…

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