Both obesity and undernutrition rising in the North

• Children between 6-16 years affected

• Stunting, wasting, being overweight, and obesity prevalent 

An increasing trend of all forms of malnutrition is seen among schoolchildren in the Northern Province with stunting or linear growth failure, wasting, being overweight, and obesity prevalent among six to 16-year-olds in the region, which is still recovering from the 27-year civil war, a study conducted on schoolchildren in the Province found.

The low prevalence of stunting and the high prevalence of wasting and the presence of overweight/obesity in this population suggest public health concerns and the existence of the double burden of malnutrition (the rate of being overweight and obesity, particularly in the urban setting, and the high prevalence of undernutrition, with both these problems co-existing), the research further noted, adding that many households, particularly in middle-income countries, have both underweight and obese individuals, exemplifying the co-existence of the paradoxical situation of adult obesity with childhood malnutrition.

The nutritional problems, it was found, vary significantly according to the geographical location, maternal education, and household income.

This was noted in a research article titled “Nutritional status of school children living in the Northern part of Sri Lanka” authored by M.G. Sathiadas, A. Antonyraja, A. Viswalingam, K. Thangaraja, and V.P. Wickramasinghe and published recently in the BMC Paediatrics.

A community-based cross-sectional study was carried out using a multistage stratified proportionate cluster among a recruited sample of 1,012 six to 16-year-old healthy children (girls and 496 boys) attending grades one to 10 classes (with a minimum of 10 students) in secondary schools in five educational zones in the North, namely Jaffna (10 schools in the District), Valikamam, Vadamaradchi, Thenmaradchi, and the islands. The study period was November 2015 to August 2016.

Body mass index (BMI) was calculated using weight and height while the BMI for age z-score was used to determine the nutritional status. Maternal education (low when reported as no education, primary-incomplete and primary-complete, while good was considered as secondary-incomplete, secondary-complete, and higher degree), household income (monthly average income considered low if less than Rs. 15,000 and adequate if over Rs. 15,000), family size (over five considered as large) and residential area (rural and urban) were used as indicators of the socioeconomic status.

The mean heights of girls between the ages of nine to 13 years were higher than that of same-age boys, which could be due to the pubertal growth spurt occurring in girls earlier. Similarly, nine to 13-year-old girls were slightly heavier than the boys, but this reversed after 14 years. The mean z-scores for height and weight are closer to zero, hence the distribution is more homogenous. The differences in the mean values between boys and girls were, however, not significant and further, significant differences were not seen when the anthropometric parameters were segregated according to educational zones. The mean z-scores for the height were below the median except for eight-year-old girls and boys. The mean z-scores for the weight and BMI of all ages in both gender groups were below the median.

The prevalence of stunting was in 10.9% of the boys and 11.8% of the girls. The study population has a low prevalence (11.3%) of stunting. The low prevalence of stunting may be influenced by the demography where the District is urban, and the economic status and educational level of the population is higher. Stunting in early childhood has shown to increase the risk of dying from childhood illnesses, impaired cognitive development, lowered educational performance, and reduced job opportunities later in life. Stunting can be accompanied by later excessive weight gain thus increasing the risk of developing obesity and non-communicable diseases as adults. Furthermore, stunting has contributed to the increase in the prevalence of being overweight. Stunting has been shown to have a high morbidity and mortality, especially with infectious diseases like pneumonia and diarrhoea. They also demonstrated high incidence of tuberculosis, hepatitis, and cellulitis, indicating association with generalised immune suppression. According to national surveys and the United Nations International Children’s Emergency Fund (UNICEF)/World Health Organisation (WHO)/World Bank Group Joint Child Malnutrition report, it is estimated that 17.3% of children would be stunted in Sri Lanka.

Wasting was seen in 30.6% of the boys and 29.1% of the girls. The study population has a very high prevalence of 29.8%. This may be due to food insecurity and the lack of knowledge on healthy eating habits. There are factors such as traditional food habits, poor infant feeding practices, inadequate clean water and sanitation, and farming a limited variety of crops which are contributory towards such. Poor living standards in certain areas and risk of infections can also contribute to wasting.

The 2015 Annual Health Bulletin of Sri Lanka reported that among primary schoolchildren, the prevalence of wasting was 20.3% and stunting 8.7%.

In the population, the prevalence of being overweight was 11% and obesity was 6.3%. Being overweight was predominantly seen in nine to 14-year-old girls. Obesity was predominantly seen in boys (8.7%) and it was significantly higher when compared to the girls (4.1%). The data also demonstrated a significant difference between girls and boys when considering obesity. The difference even years apart may be explained by the economic status of the populations. Older boys (over 10 years) were significantly affected than younger ones. Childhood obesity is also increasing in Sri Lanka and the World Bank report in 2016 estimates that 2% of children under the age of five years are affected. Obesity is caused by an imbalance between energy intake and expenditure.     

The prevalence of the types of malnutrition in the different educational zones suggested that the Thenmaradchi zone had a significantly higher prevalence of stunting while obesity and being overweight were more prevalent in the Jaffna zone. The islands and the Thenmaradchi zones had very minimal prevalence of obesity and being overweight.

Maternal education and family income had a significant impact on the prevalence of stunting, wasting, being overweight, and obesity.

Family size had a significant impact on wasting, being overweight, and obesity.

The residential area had a significant impact on stunting but not in wasting, being overweight, and obesity.

Out of the eight key nutrition indicators to track the progress of malnutrition, three are in children, namely childhood stunting, wasting, and obesity. The WHO Sustainable Development Goal targets for 2025 are to reduce stunting in childhood by 40%, have no increase in obesity, and to reduce childhood wasting to less than 5% and to maintain such.

The study was able to demonstrate that the maternal educational level and family income have a significant association with stunting, wasting, being overweight, and obesity. A low level of education was associated with poor nutritional status. The employment status of mothers also contributed to the nutritional status of the children. The study was able to demonstrate that family size contributed to wasting, overweight, and obesity, but not to stunting.

The children in this region are vulnerable to inadequate prenatal, infant, and childhood nutrition. They are also exposed to high fat, salt and sugar, and energy-dense food, which is easily available for those who are economically stable. This problem co-exists with the lower level of physical activity, leading to an increase in obesity, while undernutrition remains unsolved.

Nutritional status is an important indicator for measuring the quality of life in children. School age is identified as a dynamic age for physical growth and mental development. Malnutrition manifests in many ways, ultimately affecting growth and development. A country that faces a serious public health challenge from malnutrition would experience adverse economic outcomes. It has been shown that 11% of the Gross Domestic Product (GDP) every year in Asia is spent on treating and managing problems related to malnutrition, whereas preventing malnutrition delivers $ 16 in returns on investment for every $ spent.

Different stakeholders, the researchers note, can now make decisions on the interventions to be made, especially with regard to the problem of obesity so that its metabolic derangements can be dealt with early in life.

Since maternal education and socioeconomic status have been proven to be contributing factors for childhood nutritional problems, the authors pointed out that the ability to acquire the needed knowledge to practice feeding among the main carers is important to prevent such, whilst also noting that the time and effort spent on childhood feeding practices has contributed to the nutritional status of children. Community-based interventions were therefore recommended by the researchers to prevent and arrest the increasing trend of all forms of malnutrition.