Prevalence and determinants of overweight among high school adolescents in pastoralist communities of the Somali Region, Ethiopia: a school-based cross-sectional study

Introduction

Many developing countries, including Ethiopia, suffer from double burden of malnutrition. Adolescent overweight has an immediate detrimental effect on health and are associated with an increased risk of developing major chronic diseases early in life, such as cardiovascular disease (CVD) and type 2 diabetes. Adolescent overweight has detrimental psychosocial effects on students’ academic performance and overall well-being, which are exacerbated by stigma, discrimination, and bullying. Adolescents who are overweight are more likely to become overweight adults and are also more likely to have adult-onset non-communicable diseases (NCDs) (1).

Adolescence, which spans from 10 to 19 years old, marks the transition from childhood to adulthood and accounts for approximately 25.1% of the global population, with the majority living in developing nations (88%). Adolescence is a time when many physiological behaviors change, which has a big impact on lifestyle and food choices. The prevalence of malnutrition among teenagers is on the rise as a result of the impacts of urbanization, globalization, and ongoing food insecurity. These difficulties have led to the globalization of malnutrition, including underweight and overnutrition, as a serious public health concern (2,3).

Adolescent overweight is defined as abnormal or excessive fat storage that may have negative health effects, and they can be assessed in a variety of ways. For adolescents, overweight is defined using age- and sex-specific monograms for body mass index (BMI). Those with a BMI equal to or exceeding the 85^th percentile but below the 95^th percentile is defined as overweight. But World Health Organization (WHO) recommends the new WHO Growth Reference Curves (4,5).

Overweight are major risk factors for chronic NCDs, which include musculoskeletal problems, type 2 diabetes, CVD, and certain type of cancers. As such, they are a major public health concern. Overweight or obesity causes 35.8 million years of life with a disability and approximately 2.8 million deaths globally each year. In Africa, 27% of adults 20 years of age and above are overweight, while 8% are obese (6).

Throughout the world, the prevalence of overweight and obesity among adolescents has significantly increased. Approximately 30% of adolescence in the United States and 22–25% of European adolescents excepting the Czech Republic and Italian adolescents, which showed a prevalence of 13.7% and 17.9%, respectively, were overweight or obese overall in Europe. Among Oceanian adolescents, the prevalence ranged from 23.2% in Australia in 2004 to 34.2% in New Zealand in 2007. In Africa, the overall prevalence of overweight was lower than 20%. The prevalence of being overweight or obese for Asian boys and girls ranged from 5.2% in China in 2002 to 36.4% in Bahrain in 2000 (7). In 2022, 16% of adults over the age of 18 were obese, while 43% of overweight adults in 2022, there were approximately 390 million overweight children and adolescents (5–19 years old), 160 million of them were obese (8).

Ethiopia, like many other low- and middle-income countries, is going through a nutrition shift or nutrition transition. Overweight prevalence there has increased recently. Thus, the pooled prevalence of overweight among Ethiopian children and adolescents was 11.30%, according to a systematic study conducted there. Additionally, the respective pooled prevalences of obesity and overweight were 2.39% and 8.92%, respectively (9).

Previous studies showed that numerous factors may be associated with overweight in children and adolescents. Those factors that are of maternal origin are socioeconomic status, education level, marital status, and smoking status during pregnancy. The children’s and adolescence’s gender, birth weight, birth rank, and place of residence were also linked to overweight in them. Sugar, high-fat salts, energy-rich foods, and micronutrient-poor foods that are less costly and lower in nutrient quality are common among children and adolescents in developing countries. These food practices, along with other factors, cause a significant increase in the prevalence of overweight (10,11).

There is scarce information on issues of overweight in pastoralist areas, especially Jigjiga, but the current evidence in Ethiopia shows that managing and preventing adolescent overweight is one of the best strategies to prevent overweight in adulthood (12). Finding the risk factors behind the fast rise in overweight is a critical first step in controlling and preventing overweight. In light of this, therefore, the present study aims to provide baseline and reference data on the prevalence and associated factors of overweight among urban school communities in Jigjiga, one of Ethiopia’s fastest-growing cities in terms of modernization, expansion of urban settlement, and economy growth.

Methods

A school-based institutional cross-sectional study was conducted in Jigjiga from October 2020 to December 2020. Jigjiga is located 626 kilometers east of Addis Ababa, the capital city of Ethiopia. As of the 2023 Ethiopian fiscal year, Jigjiga had a total population of 428,759, of which 207,968 are considered to be female and 220,791 are males. The city is divided into 20 sub-districts, or kebeles (the smallest administration units) (13). The city has 1 hospital, 1 primary and 1 referral, a comprehensive specialized hospital, 3 health centers, 14 health posts, 1 private hospital, 8 clinics, and 20 pharmacies. According to the Jigjiga Administrative Education Office, there are 8 high schools, of which 4 are public and the rest are private. The total number of students in all schools is 14,500. Of the total number of students, 12,570 were in public schools, of which 7,608 were male and 4,962 were female, while the rest of the total number of students in 1,930 were in private schools, of which 1,030 were male and 900 were female. The study was conducted from October 2020 to December 2020. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Ethical clearance was obtained from Jigjiga University Institution of Research and Ethics Review Board (JJURERB0041/2021). An official letter was written to the selected schools for facilitation. Voluntary written and signed consent was obtained from each study participant after informing them of the objective, confidentiality, and right to withdrawal, and the participants were told that they might stop participation at any time during the study during data collection.

Sample size calculation

The sample size was calculated using a formula for a single population proportion. By considering the proportion of overweight, P=0.129 will be used from the prevalence of overweight among adolescents in school age bet 10–19 years, according to a study in Hawassa (11). These levels and the margin of error are 5%. The total sample size calculated for this study was 530. A multistage sampling method was used to select the study participants.

Map of the study area in Jigjiga, Ethiopia (Figure 1)

Figure 1 Map of the study area in Jigjiga, Ethiopia. The green circle on the Somali region map indicates Jigjiga City. SRS indicates Ethiopia.

The study area map in Jigjiga, Ethiopia, provides a detailed overview of the urban and rural landscape, highlighting its strategic location near the Ethiopia-Somalia border, key infrastructure, and population density. This context is crucial for understanding socioeconomic and environmental factors affecting the region.

Data collection tools and technique

The study used two types of measurement tools: a questionnaire and an anthropometric tool. A structured questionnaire was used to collect the data; most of the questionnaires were adapted from the WHO STEP tool for chronic disease risk surveillance (14), and some modifications to the questionnaire were done in accordance with the local situation. The questionnaire has three parts: sociodemographic and behavioral, such as the dietary intake part, physical activity part, movement activities, recreational activities, and sedentary activity, and the last part is anthropometric measurement. To investigate the nutritional status of the adolescent, anthropometric measurements on height and weight were taken from each eligible adolescent. The heights of the adolescents were measured using measuring tape, and their weight was measured using a UNICEF electronic weight scale or portable electronic weight scale with a digital screen (15). All measurements were taken according to the WHO anthropometric measurement guidelines. The original English version of the questionnaire was translated into Amharic and Somali versions to avoid doubts about the concept of the question, and then the local version was translated back into English by a professional to check its consistency and modifications. The weight scale was calibrated to 0 daily before starting measurement, and both height and weight were measured twice for every subject. In cases where the two results were different, the last measurement of the two was used.

Data quality assurance

A pre-test was done on 5% of the questionnaire before the actual data collection for tool applicability and to pave the way for any modifications required. Data collectors and supervisors were trained by the principal investigator; during the data collection training, the supervisor checked in the field how the data collectors were doing their tasks and responsibilities. At the end of each data collection day, the principal investigator also checked the completeness of the filled-out questionnaires.

Study variables

Overweight was a dependent variable, while age, religion, ethnicity, educational level, dietary habits, physical activity, and socioeconomic status, physical activity data, type, frequency, duration, and intensity of physical activity during learning, transportation, and leisure time in a typical week, frequency of meals, favourite foods, vegetable and fruit consumption, parent food preference, type of food available at home, parent encouragement, and parent monitoring of the adolescent’s behaviour were independent variables.

Data processing and statistical analysis

The data was coded, cleaned, and entered into Excel, then exported to SPSS version 25 for analysis. The height, weight, age, and sex of the study subjects were used to calculate the BMI for the age Z-score. The adolescent’s BMI for age Z-score was calculated using WHO [2007] Anthro-plus software, and Z-score values were taken. The WHO [2007] cut-off points are: normal when BMI for age ≥−2 to ≤+1 and overweight when BMI for age >+1 standard deviation (SD) (16). Descriptive analyses (frequency, mean, proportion, and SD) were used to describe the characteristics of the sample. Multicollinearity was used to choose variables with a P value <0.2 in order to include them in the final multivariable logistic regression. Multivariable logistic regression was done to measure the association between explanatory variables and overweight. The odds ratio, along with the 95% confidence interval (CI), was assessed to identify factors associated with overweight while adjusting for all possible cofounders using multivariate logistic regression. The level of statistical significance was set at a value less than or equal to (P<0.05).

Results

Sociodemographic characteristics

A total of 530 adolescents participated, with a 100% response rate. Among these, 270 (50.9%) were male. The mean (± SD) age of participants was 17.07 (±1.25) years. Nearly the majority, 326 (61.5%) of them, were in the 17 and below age groups. Most participants, 459 (86.6%), were private school students. More than half (56.6%) of the participant’s fathers had attended secondary school and above, whereas 431 (81.3%) of the mothers had attended below secondary school. The major sources of income for the participants families were government employees 167 (31.5%) (Table 1).

Prevalence of overweight

The overall prevalence of overweight was 5.28% (95% CI: 2.1–9.2%), see Figure 2.

Figure 2 Nutritional status of adolescents among Jigjiga High School students, Jigjiga, Ethiopia. BMI, body mass index.

Distribution of adolescent BMI by socio demographic characteristics

This study found that the distribution of overweight by sex was as follows: 6 (1.13%) of the overweight were male, and 22 (4.15%) were female. The distribution above indicates that girls were more likely than boys to be overweight. With respect to the type of school and the students’ weight status, students from private 18 (3.39%) and public schools 10 (1.89%), were overweight students (Table 2).

Dietary habit and physical exercise characteristics

Nearly every participant, among total participants, responded that they did not consume fruits; 153 (28.9%) consume fruits 1 day per week; and 311 (58.7%) consume fruits 2 or more days per week; 52 (9.8%) did not consume vegetables; 295 (55.7%) consume vegetables 1–2 days per week; and 183 (34.5%) consume vegetables 3 and more days per week. On the other hand, 126 (23.8%) of the adolescents responded that they did not consume any sweet food items, 264 (49.8%) consumed one to two sweet food items per day, and 140 (26.4%) consumed three or more sweet food items per day. Three hundred and two (56.98%) of participants did not use snacks; 204 (89.47%) used snack once per day; 16 (7.02%) used snacks two times a day; and 8 (3.51%) used snacks three and more times a day. The majority of 326 (61.5%) of adolescents were walking for at least 30 minutes a day, and 252 (47.5%) of participants spent 3 or more hours sitting and watching TV (Table 3).

Contributing factors to overweight

In the bivariable logistic regression analysis, variables included in the analysis were sex, age category, school type, family size, number of snacks, eating while watching TV, moderate or vigorous sport activity for at least 10 minutes, and number of walking or bicycling days for at least 30 minutes per day.

However, in the multivariate analysis, which was done to adjust for potentially confounding variables, only sex, age category, school type, family size, and using snack, walking, or bicycling days for at least 30 minutes per day were significantly associated with overweight.

Being female in sex [adjusted odds ratio (aOR) =6.670; 95% CI: 1.758–25.305], private school (aOR =5.214; 95% CI: 1.571–17.310), small family size (aOR =5.466; 95% CI: 1.190–25.097), and using snacks (aOR =3.098; 95% CI: 1.058–9.070) were positively and significantly associated with overweight. In adolescents who were in the 15–17 age groups (aOR =0.167; 95% CI: 0.049–0.568), walking for at least 30 minutes a day was negatively associated with overweight (aOR =0.238, 95% CI: 0.066–0.854) (Table 4).

Discussion

The extent and contributing variables of overweight among adolescent high school students in Jigjiga were revealed by this study. In this research, the combined prevalence of overweight was 5.28%. However, this study also showed that the only factors that were significantly associated with overweight were sex, age group, school type, family size, and the use of snacks, walks, or bicycle rides for at least half an hour each day.

The overall prevalence of overweight among adolescents was 5.28%, and this finding is comparable with the studies in Gonder town 5.9% (17), Addis Ababa City 8.5% (18), Bahirdar Town 6.9% (19), Nigeria 7.5% (20), and Sub-Saharan Africa 6.8% (21). The reason for these similarities could be that the study environment, socioeconomic background, cultural background, dietary habits, and lifestyle-related features.

But the current finding was lower than the research findings in and out of the country, from Hawassa City (15.6%) (11), Sudan (14.8%) (22), Ghana (16.4%) (23), and China (20.0%) (24). And the observed discrepancy in prevalence might be due to socio-cultural variations, like high socio-economic status in the previous studies. This may lead to changes in lifestyle, such as the introduction of negative eating habits and increased sedentary behavior. economic and urbanization factors. As a result, adolescents residing in urban regions may have higher rates of overweight due to dietary disparities and modes of mobility.

According to this study, sex was a factor that was highly associated with becoming overweight. As a result, female students had 6 times higher risk of becoming overweight than male students. Furthermore, a related study by Hawassa City reveals that, compared to boys, girls had a 5.14 times higher likelihood of being overweight (11). This may be due to the fact the fact that in developing nations like Ethiopia, girls are more likely than boys to spend a significant amount of time at home and have far more restrictions on their travels owing to cultural norms. This leads to a lack of physical activity, which in turn causes overweight. A behavioral component is also crucial in understanding the variations between the sexes. When it comes to physical activity, boys are typically more active than girls, especially in their adolescent years (25,26).

According to this study, overweight was significantly associated with age; it showed that early adolescents had a 0.17 lower likelihood of being overweight. This finding was consistent with the study done in Addis Ababa (27). This might be that as the age of the individual increases there will be a decrease in physical activity and exposure to high-energy-dense foods. In contrast to our results, however, US studies found that in 2003–2004, overweigh was positively and strongly associated with age (meaning older children were more likely to be overweight than younger children), but not in 2011–2012 (meaning older children were not more likely to be overweight than younger children) (28). Thus, more research is required to determine the relationship between overweight and aging.

The results of this study indicated that students attending private schools had a higher likelihood of being overweight. Specifically, students attending private schools had a 5.2 times higher risk of becoming overweight than students attending public schools. This study is consistent by research conducted in the Seychelles, which found that the prevalence of overweight was significantly higher in private schools than in public ones (29). Another study conducted in Addis Ababa found that students in private schools were 2.73 times more likely than their peers to become overweight (27).

This could be explained by the fact that teenagers attending private schools typically come from higher socioeconomic backgrounds. Additionally, lifestyle factors such as increased junk food intake, decreased physical activity, and bus transportation to school may be the cause of the high rate of overweight among teenagers attending private schools, while students attending government schools may have to deal with a heavier workload that causes stress and requires them to walk more than an hour to get to class. Junk food is not available at side schools.

According to this study, family size was another factor associated with overweight, so small families with less than 4 family members were 5.5 times more likely to develop overweight than their counterparts, and this study is supported by a study done in Addis Ababa that reported A small family size was significantly associated with overweight (27). And this might be explained by the fact that people with small families may enjoy better economic circumstances, which provide them with more opportunities to ensure the availability, accessibility, and affordability of their home needs (food security). A family with a small number of siblings is linked to a better diet and reduced television viewing. Study conducted in the USA show that, indeed, family size matters—every additional sibling is associated with a 2.6 percentage point decline in the likelihood of overweight in early adolescence (30).

This present study shows that using snack is 6 times more likely to be overweight to their counterpart and this study is in line with systematic review done in Asian developing countries that reveals presence of snacking is 2.34 times more likely to be overweight to their counterpart (31). And other study done in Ethiopia revealed that children consuming soda frequently were almost 4 times more likely to be overweight compared with those who did not consume soft drinks (32). This can be explained by the fact that the greater the number of sugary beverages a person has each day, the more calories he or she takes, which leads to a positive energy balance resulting in overweight. Snacking, like any dietary behavior, can be practiced in a manner that is healthy or not. is that snacking is problematic, primarily due to its contribution to positive energy balance and the promotion of overweight. There is strong evidence that snacking is associated with greater energy intake (33). However, a study done in Hawassa City contradicts our findings and reported that there is no association between using snacks and overweight (11). Therefore, more investigation is needed to ascertain the association between snacking and overweight.

This study demonstrated that walking for at least 30 minutes a day was inversely related to the prevalence of overweight in those who don’t walk for at least 30 minutes; therefore, walking for at least 30 minutes and above could prevent being overweight. and this inline in this study done in Gondar Town, North West Ethiopia, reported that moderate or vigorous sport activity for at least ten minutes continuously was marginally significant. Thus, students who did not do any moderate or vigorous sport activity for at least ten minutes continuously were 1.99 times more at risk of being overweight than those who did moderate or vigorous sport activity (17).

This could be explained by the fact that exercise causes the body to waste energy, which reduces body fat. To achieve weight loss, the American Diabetes Association (ADA), the American Academy of Clinical Endocrinologists (AACE), and the National Academy of Nutrition and Dietetics all recommend exercise as an integral part of any weight loss program. Physical activity and exercise are often used interchangeably (34).

Limitation of the study

In this study, other factors that can affect excess body weight, like the genetic factors of participants, were not investigated like skinfold measurement, which might eliminate the limitation of BMI measurement. Since the study is cross-sectional, it may not be strong to demonstrate a direct cause-and-effect relationship between risk factors and outcomes.

Conclusions

The results of this study indicate that the overall prevalence of overweight among adolescent high school students in Jigjiga was 5.28%, which is relatively moderate in the study area. Being female, learning in private school, having a small family size, and using snacks were positively and significantly associated with being overweight. While adolescents who were in the 15–17 age groups, walking for at least 30 minutes a day was negatively associated with overweight.

Therefore, more emphasis should be given to promoting gender mainstreaming in nutritional programs and adolescents’ learning in public schools; health education should be given to both parents and adolescents about the consequences of snacks and overweight; and schools should be designed in a way that promotes active living, such as by providing adequate space for physical activity. Therefore, the Education Bureau, Health Bureau, and concerned non-governmental organization (NGO) giving emphasis to adolescents with these identified factors and formulating preventive programs and policies during their early years is highly recommended.

Acknowledgments

The authors thank the schools found in Jigjiga, including the directors of schools and teachers, and we would like to recognize and acknowledge the data collectors, supervisors, and students who took part in the research.

Funding: None.

Footnote

Data Sharing Statement: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-30/dss

Peer Review File: Available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-30/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jxym.amegroups.com/article/view/10.21037/jxym-24-30/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Ethical clearance was obtained from Jigjiga University Institution of Research and Ethics Review Board (JJURERB0041/2021). An official letter was written to the selected schools for facilitation. Voluntary written and signed consent was obtained from each study participant after informing them of the objective, confidentiality, and right to withdrawal, and the participants were told that they might stop participation at any time during the study during data collection.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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