Undernutrition and Associated Factors Among School Adolescents in Wonago District Gedeo Zone South Ethiopia

Background Adolescence is a life spanning the age range of 10-19 years characterized by remarkable physical and psychological growth and development. One-third of adult weight and more than one-fth of adult height is gained during this period of life. This make adolescents the key population group highly vulnerable to malnutrition. This study was aimed to assess the level of undernutrition among school adolescents in Wonago district, Gedeo Zone, South Ethiopia. Methods A school based cross sectional study was conducted among 443 randomly selected school adolescents of Wonago district. Nutritional status of adolescents was assessed using body mass index for age z-score (BAZ) and height for age z-score. Descriptively, prevalence of thinness and other anthropometric measurements, socio-economic and socio-demographic variables were described. Multivariable logistic regression was conducted to assess the factors associated with adolescents’ undernutrition (thinness).


Introduction
Adolescence is a life spanning in the age range of 10-19 years(1) characterized by remarkable physical and psychological growth and development (2,3). It is the period of transition from childhood and adulthood (1). It is an intense anabolic state where, nearly one-third of adult weight and more than onefth of adult height is gained during this period of life(4) and described as a window of opportunity for growth catch up in human life cycle (3). This make adolescence a sensitive period of rapid growth which need adequate nutrition for optimal growth and development (5). There is signi cant difference in nutritional recommendation for adolescents from that of adult or child(6) and the consequences of nutritional de ciencies are far reaching among adolescents (7).
Nutrition and physical activity are major determinants of adolescents' energy levels and in uence growth and body composition. Inadequate nutrition can delay sexual maturation, slow or stop linear growth, and compromise peak bone mass. Undernutrition among adolescents also compromises cognitive development, which affects learning, concentration, and school performance (8).
In developing countries, adolescents are highly vulnerable to socio-cultural maltreatments, poverty, political turmoil, poor access to education and health service. This factors increases the adolescents vulnerability to nutritional health problems (9). Other factors increasing risk of poor nutrition among adolescents in developing countries include early marriage, which is declining but still common, and low secondary school enrollment, which is widespread (10).
Large number of adolescents in low and middle income countries adversely affected by acute or chronic malnutrition in general and underweight in particular (11). In some countries in Africa and Asia, 10% or higher number of adolescent girls are very thin for their age and height (12), and as many as half of all adolescents are stunted (13). For instance, more than half of adolescent girls and women in Bangladesh consume inadequately diverse diets in 2014 national survey and prevalence of stunting among adolescent girls 10-18 years old range from 23%-32% (10).
Gender norms are leaving girls disproportionately impacted by food insecurity and malnutrition. But signi cant number of adolescent boys are malnourished as well. Adolescent girls are at higher risk of dropping out of school, marrying, and becoming pregnant-all of which can harm their nutrition and health as well as that of their offspring. Moreover, adolescence marks the last window of opportunity to reverse stunting and this makes adolescents a nutritionally very important segment of population (10).
Nutritional disorders in adolescence, including unhealthy weight status and/or nutritional de ciency (e.g., inadequate energy, macronutrient, and/or micronutrient intake), contribute globally to morbidity and mortality and should be area of focus (14).
Compared to other portion of population segment, particularly under ve children, the scope and severity of adolescents undernutrition is less clear (15). There is less nutritional data on adolescents though they experience a high burden of malnutrition, especially thinness(10).
Adolescence is a critical point of intervention for current and future health, and intergenerational nutritional health. Responsible health providers should screen adolescents comprehensively for nutritional risk, make timely referrals, and initiate developmentally appropriate interventions (14). Body mass index (BMI) has been recommended for use in screening of adolescents' and adults' nutritional health problems, particularly, thinness, overweight and obesity (16).
Being in transition, adolescents may no longer bene t from the attention and care that usually go to children, but they may not get the protections associated with adulthood either (17). Though there are considerable attention towards reproductive health issues of adolescents in Ethiopia, the work on nutritional status of adolescents is signi cantly limited. There is paucity of nutrition related information of adolescent's health and adolescents has been receiving scanty attention due to a misconception which consider adolescents as a low risk group for poor health and nutrition. Hence this study was planned to assess adolescents' nutritional status and its associated factors to contribute for lling the gap in the evidence.

Study area and period
This study was conducted in Wonago wereda, Gedeo Zone South Ethiopia during April 2018. The study area (Wonago district) is known for its densely populated population distribution characterized by young age (18). In the district there are 23 schools out of which 15 schools were randomly selected for this study.
Study Design: A school based cross sectional study was conducted.

Sample size determination and sampling technique
The sample size for this study was calculated using single population proportion formula for calculating sample size (Z α/2 2 p (1-p)/d 2 ) assuming estimated 50% prevalence (p) of undernutrition (to maximize the possible sample size), a 95% con dence interval and a relative precision (d) of 5%. Based on the above assumptions and assuming 15% non-response rate the total sample size used in this study was 443 adolescents.
To select the schools for this study simple random sampling technique was used and the total sample was proportionally allocated to each schools based on the number of eligible adolescents in the schools. Finally, the each participant from the schools were selected by simple random sampling method using the list of students in the registry of schools.

Data collection personnel and tool
Questionnaires adapted from WHO nutritional survey tools (19) was pretested. Trained health extension workers were used as a data collectors and the overall work was closely supervised by the investigators.
Assent was requested from families of participants who are minors and the overall objective and procedure was clearly explained for the participants of the study.

Measurement
Anthropometric assessment: Height and weight was measured based on WHO guideline. Battery powered digital scale was used to measure weight and it was measured to the nearest 0.1 kg. Height was measured to the nearest 0.1 cm using a wooden height-measuring board with a sliding head bar following standard anthropometric techniques(20). BMI for age z-score (BAZ) and height for age z-score (HAZ) was used as anthropometric indicators. Adolescents with BAZ score less than − 2 were classi ed as thin and those below − 2 HAZ score were classi ed as stunted.
Stool examination: Stool examination was done to assess geo-helminthes infection (strongloides, hookworm stercoralis, ascaris lumbricoides and trichuris trichuria) and Kato-Katz method was used to examine the stool within one hour of staining.

Data analysis
Descriptive analysis was done to present socio-demographic and socio-economic information, nutritional status and feeding practices. Bivariate association was assessed using binary logistic regression analysis and independent association of the explanatory variables with the outcome variable was assessed using multivariable logistic regression based on the adjusted odds ratio (AOR) with their corresponding 95% con dence interval.

Socio-demographic characteristics and nutritional status among adolescents
A total of 424 adolescents were participated in this study and nearly sixty percent (247 adolescents) of the participants were male and 180 (42.4%) of the participants were in the middle period of adolescence period (14-16 years). Two hundred forty eight (58.5%) of the participants were from households with family size of above six members. Nearly 50% (205) of the participants' mothers are illiterate while most of the fathers, 337 (79.4%), are literate. On bivariate analysis, adolescents in the middle adolescence age range, female adolescents, adolescents in grade ve and above, adolescents whose their mother is farmer or merchant were more likely to be thin. On the other hand, adolescents whose father is merchant and who live with parents were more likely to be underweight/thin (Table 1). With regard to feeding practices and nutritional status, 116 (27.4%) of the respondents reported that their usual daily meal frequency was two times or below. For half of the respondents (214 adolescents), their family produces/cultivates the food needed for household daily consumption. In the school of 245 (57.8%) adolescent, there is a regular feeding program for the last six months. On bivariate analysis, adolescents whose daily meal frequency was above two and whose their family achieve food need through purchase/aid were at higher risk of being underweight. In this study, 11.6% (CI: 8.55-14.65%) were underweight/thin (BAZ < -2) and 14.6% (CI: 11.24-17.96%) of adolescents were stunted (HAZ < -2). There were no adolescents that were overweight. From stool examination result, about sixty percent of the adolescents have stool parasites (Table 2).

Factors associated with undernutrition among school adolescents
After controlling for confounders using multivariable logistic regression, sex of the adolescents, source of drinking water, mother occupation, father occupation, household wealth and family food need source were signi cantly associated with undernutrition among adolescents. Accordingly, the likelihood of being undernourished was decreased by 70% for female adolescents compared to male adolescents [AOR: 0.30, CI: 0.12, 0.77]. Adolescents whose the source of drinking water was spring were more than four times at higher risk of malnutrition  27.22] were also found to have a higher risk of being undernourished. For adolescents whose the occupation of their mother was farmer, the probability of being undernourished was decreased by about 85% [OR: 0.14, CI: 0.41, 0.65] compared to those of housewife (Table 3).

Discussion
Eradication of underweight/thinness resulting from insu cient energy intake is expected to be a current and future challenge of global nutrition policy (21). Adolescents constitute a nutritionally critically important group for several reasons, including their high requirements for growth, their eating patterns, and their susceptibility to environmental in uences. However, there is a dearth of data on adolescent's nutritional status (22).
In this study, considerable number of adolescents were found to be stunted where nearly twelve percent of them were underweight. The nding of this study is comparable with the previous report from national nutrition baseline survey report for the NNP of Ethiopia which was14% (23). Complying nding was also obtained from study conducted among female adolescents from northern Ethiopia, 13.6% (24). Similar nding was found from eastern Sudan where 13.7% of adolescent girls were stunted (25) and from study conducted in Aligarh, Uttar Pradesh, India, 14.6% of adolescent boys were found to be stunted (26).
The level of adolescent underweight in this study is lower than a ndings from different parts of India.
From study conducted in Wardha, India 53.8% of the adolescents were found to be thin and 50.7% adolescents were stunted (27). Correspondingly, studies from West Bengal, India identi ed 48.3% prevalence (28,29).This could be due to the difference in the study population and study area. However, the nding of this study is higher than the 6.4% nding from study conducted on nutritional status of inschool adolescents in Ibadan, Nigeria (30). Likewise, study from Brazil found lower prevalence (7%) of underweight among adolescents in the study area (31).
Regarding factors associated with underweight/thinness in this study, sex of the adolescents, source of drinking water, mother occupation, father occupation, household wealth and family food need source were signi cantly associated with underweight/thinness among adolescents. From the nding female adolescents were less likely to be underweight compared to male adolescents. This nding complies with the nding from Ibadan, Nigeria where male adolescents were at higher risk of being underweight (30).
Similarly study from Indian National Nutrition Monitoring Bureau identi ed males to be at a higher risk of undernutrition compared to females (32). This could be due to the fact that, female adolescents in developing countries may have better access to food because they always do domestic works and they may not miss the meals. In addition, most of the time adolescent males have heavier labor work than females in developing country.
Among family socio-demographic characteristics maternal working status was associated with underweight. In this regard, adolescents whom their mothers were farmers were less likely to be underweight compared to those who were housewife. Mothers who are engaged in routine income generation of the family could have signi cant effect on the nutritional status of adolescents. Particularly, women who are farmers increases the family productivity and family food sources. On the other hand adolescents whom their fathers are merchants were about six times more likely to be underweight. This may be due to difference in educational status of the fathers where fathers who are government employee were more educated compared to merchant fathers. They could have more information about nutritious food that are important for children health. For instance, in study from Brazil, maternal schooling was negatively associated with the probability of being thin (31).
Adolescents whom their source of drinking water is spring were four times more likely to be underweight compared to those whom the source was tap water. This could be possibly due to higher risk of repetitive infection from contaminated water for those who use spring water as a drinking water and most of the households do not treat the water used as drinking water. In addition adolescents of families who purchase the food needed for daily consumption were more likely to be underweight compared to those who produce by their own. This might be associated with the more access to variety and amount of food source for adolescents of families who produce by their own.
On the other hand, adolescents from households with medium economic status were less likely to be underweight compared to those from higher economic status. This nding is relatively contrary to the usual ndings of the studies on factors associated with nutritional status (27,33,34). The reason why adolescents in the middle economic status were less likely to be underweight in this study could be due to the difference in nutritionally important characteristics among the population in the middle and higher economic status. Families in the higher economic status in this study area were mostly merchants and less educated compared to those who are in the middle economic status who are who are mostly government employees and more educated. In addition most of those in the middle economic status were farmers and their main source of food for consumption for such families is producing by their own. In this study adolescents of families who produce the food they consume by their own were less likely to be underweight.
In this study we have tried to assess the nutritional status of adolescents and associated factors in which there are scanty of evidences with respect to this research area. We have tried to identify important risk factors for adolescents' malnutrition in the study area. Nevertheless there are important limitations of this study. Considerable limitations of this study are small sample size and exclusion of out of school adolescents which could have be in different scenario.
In general Signi cant number of adolescents in this study were found to be underweight and female adolescents, adolescents using spring water for drinking, adolescents whose their mother was unemployed and those whose their family achieve food need through purchase were at higher risk of underweight. Responsible stakeholders working on nutrition programs should give due consideration for adolescents particularly in developing countries. Further studies with stronger design should be conducted to determine the nutritional status and its determinants Sciences and Medicine. Written informed consent was also obtained from the parent of each students and the purpose of the study was deeply explained for the study subjects. Con dentiality of the information obtained was assured and privacy of the respondents was also maintained.