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 Table of Contents  
REVIEW ARTICLE
Year : 2014  |  Volume : 1  |  Issue : 3  |  Page : 171-179

Child and adolescent obesity in Nigeria: A narrative review of prevalence data from three decades (1983-2013)


Department of Biochemistry, College of Natural and Applied Sciences, Michael Okpara University of Agriculture, Umudike, Umuahia, Abia State, Nigeria

Date of Submission26-Jun-2014
Date of Decision17-Aug-2014
Date of Acceptance18-Aug-2014
Date of Web Publication19-Sep-2014

Correspondence Address:
Chukwunonso E. C. C. Ejike
Department of Biochemistry, College of Natural and Applied Sciences, Michael Okpara University of Agriculture, Umudike, P.M.B. 7267, Umuahia, Abia State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-9906.141150

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  Abstract 

Child and adolescent overweight and obesity have become an important global public health problem. Prevalence data for pediatric overweight and obesity in Nigeria are available. However, a review of such data is unavailable, and is, therefore, reported in this paper. A total of 37 full-length papers and 5 detailed abstracts which met the inclusion criteria were reviewed. The subjects in the reviewed papers were 2-20 years of age. Sixty nine percent and 14% of the studies were conducted in urban and rural areas, respectively. As much as 74% of the papers and 65% of the participants were from the South of Nigeria. Half of the papers used the World Health Organization reference standards for diagnosis. When apparent outliers were excluded, the prevalence of obesity in the "adolescents only" and "children and adolescents" subgroups were 0.0-2.8% and 0.0-5.8%, while for overweight in the respective groups they were 1.0-8.6% and 5.0-12.0%. The data from this study suggests that prevalence rates of obesity and overweight in Nigeria are not only lower than the figures reported from other parts of the world, but have also remained stable (albeit within wide margins) during the period.

Keywords: Children and adolescents, Nigeria, obesity, overweight, pediatrics, prevalence


How to cite this article:
Ejike CE. Child and adolescent obesity in Nigeria: A narrative review of prevalence data from three decades (1983-2013). J Obes Metab Res 2014;1:171-9

How to cite this URL:
Ejike CE. Child and adolescent obesity in Nigeria: A narrative review of prevalence data from three decades (1983-2013). J Obes Metab Res [serial online] 2014 [cited 2018 Dec 17];1:171-9. Available from: http://www.jomrjournal.org/text.asp?2014/1/3/171/141150


  Introduction Top


Pediatric obesity is currently one of the most important global public health challenges. In fact, the World Health Organization (WHO) describes pediatric obesity as "one of the most serious public health challenges of the 21 st century." [1] The prevalence of overweight and obesity in pediatrics has supposedly increased alarmingly, not only in economically advanced countries, but also in developing countries of Africa, Asia, Oceania and South America. A 2012 estimate of the WHO reports that globally 40 million children younger than 5 years are overweight. [2] It is estimated that 81% of the 43 million children that were obese globally in 2010, reside in developing countries. The global prevalence of pediatric obesity is estimated to reach 60 million by the year 2020. [3]

It is currently thought that the rising prevalence of pediatric obesity in developing countries is attributable to economic development (that results in improved disposable incomes) and the lifestyle modifications that come with it (typically physical inactivity and poor food choices), as well the nutritional, epidemiologic and demographic transitions (which go with urbanization and globalization) occurring at different rates in such regions of the world. [4],[5],[6]

Pediatric obesity results in a wide range of unsolicited psychosocial and medical costs, including poor self-esteem and self-image, problems of integration with peers, depression, anxiety and the chronic diseases attributable to excess adiposity. Obese children and adolescents are often victims of stigmatization. In young girls, obesity has been additionally linked to potential menstrual disorders, fertility challenges and high blood pressure during pregnancy. [7] More worrisome is the fact that pediatric obesity is known to track into adulthood. [8] The epochs of strong fluctuations in body adiposity which takes place in pediatrics are thought to be critical points in the development of obesity. Studies on the tracking of obesity indicate that 70-80% of obese children and adolescents become obese adults. [9] It is reported that from age 6, about half of obese children turnout to become obese adults whereas just about a tenth of nonobese children eventually becomes obese adults. [10] These are indicators that addressing pediatric overweight and obesity (timely and wholesomely) not only preserves children and adolescents from morbidity and possible mortality, but also saves adults of the future from similar burdens.

Nigeria, like other developing countries, currently experiences the double-burden of nutritional disorders - co-existence of both under- and over-nutrition within the same population. This does not bode well for any economy that seeks to attain "industrial and economic development", and therefore calls for urgent public health action. There are many reports in the literature on the prevalence of overweight and obesity in Nigerian children and adolescents. What is however missing is a review of such published prevalence data. This paper is an attempt to fill-in that vacuum by reviewing the prevalence of pediatric obesity in the last three decades since the publication of the 1983 paper by Akesode and Ajibode. [11]


  Methods Top


A review of the literature on child and adolescent overweight and obesity in Nigeria was conducted using internationally accepted methods. [12],[13] After deciding on the research question and determining the search strategy to be employed, a comprehensive search of some electronic databases for scientific literature (Medline/PubMed, Scopus, Google Scholar, AJOL) was conducted. Appropriate search techniques using MESH terms such as "overweight", "obesity", "adiposity", "body mass index (BMI)", "pediatrics", "children", "adolescents" and specific keywords such as "Nigeria", "Nigerian children", and "Nigeria adolescents" were employed. Boolean operators such as "AND", "OR" and "NOT" were used to delimit the search results. In addition, the reference lists of relevant papers were cross-checked to identify studies that were inadvertently missed.

Only cross-sectional studies published in English between January 1983 and December 2013, which investigated overweight and obesity in Nigerian children and adolescents (using anthropometric tools), and which were traceable, were included. The initial search yielded 339 papers/abstracts which were pruned to 75 papers/abstracts after the initial relevance check of the titles or abstracts. After a thorough examination of the papers/abstracts, 37 full-length papers and 5 detailed abstracts that met the inclusion criteria were selected for review and result synthesis [Figure 1]. The 42 included papers/abstracts investigated overweight and obesity in Nigerians aged 2-20 years. [11],[14 ],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55]
Figure 1. Flowchart indicating the processes that led to the inclusion of the reviewed literature

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  Results and discussion Top


The subjects studied in the reviewed papers were between the ages of 2 and 20 years. For convenience purposes, the entire data will be discussed under 2 broad subgroups - papers that investigated children and adolescents, and papers that investigated adolescents only. According to the WHO, adolescents are those aged 10-19 years. [64] Two of the reviewed papers [19],[23] enrolled subjects who were not adolescents in the strict sense of the word, as they were 20 years old. The studies were retained because the bulk of their subjects were children and adolescents. Furthermore, one study [17] recruited only children but was nevertheless grouped under the "children and adolescents" subgroup to avoid singling it out as one subgroup. In all, but 5 of the reviewed studies, overweight and obesity in children and adolescents were the primary outcome measures [Table 1].
Table 1: Studies included in the review


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After the 1 st year of life, adolescence is the next critical period of an individual's physical growth. [65] During adolescence, vast physiologic, cognitive and psychosocial changes, which arise due to hormonal and environmental assaults, occur. About 25% of adult height and as much as 50% of adult weight are attained during this period of adolescence. This increase in height and weight comes with a concomitant increase in fat mass (especially in girls) and muscle mass (in boys). It has been argued that the combination of the high-energy demands in adolescence, the adolescent growth spurt and the often inappropriate and inadequate diet available to adolescents especially in resource-poor settings, results in the poor nutritional status of adolescents. [44]

Obesity, defined as the accumulation of unnecessary adipose tissue to a degree where it impairs physical and psychosocial health, [66] and diagnosed in pediatrics as BMI ≥ 95 th percentile for gender and age, [58] tracks into adulthood [8],[9] and results in a number of health consequences. Guo et al. [10] after analyzing lifelong data from the Fels longitudinal study and estimating the probabilities of having a BMI > 30 kg/m 2 at age 35, concluded that individuals who end their adolescence with moderately elevated BMI have a higher likelihood of becoming obese as adults. The association between pediatric obesity and other chronic comorbidities such as insulin resistance, hypertension, type 2 diabetes, hyperlipidemia, liver and renal disease, reproductive dysfunction, certain cancers and poor motor development highlight the public health significance of obesity. [2],[7],[67] It is, therefore, of paramount importance that a systematic and regular surveillance of the prevalence and trends in pediatric obesity be carried out with a view to keeping this public health challenge at bay.

Only two of the reviewed papers were published between 1983 and 2000. Between 2001 and 2010, 17 (40%) of the papers were published. As much as 23 (55%) of the papers were published recently, between 2011 and 2013. With the exception of the two papers that investigated only female subjects, [53],[32] all the other papers recruited both male and female subjects [Table 2]. Most of the reviewed papers (69%) were conducted in urban centers in Nigeria. Only 10% of the papers investigated children and adolescents in both urban and rural areas while 7% of the papers were conducted in semi-urban areas. Studies conducted in the rural areas constituted just 14% of the reviewed papers [Figure 2].
Figure 2. Distribution of the studies with respect to setting

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Table 2: Summary of the prevalence of overweight and obesity from the included studies


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The distribution of the reviewed papers shows that 26% of the papers were conducted in Northern Nigeria, and 35% of the subjects studied were from the region. As much as 74% of the papers and 65% of the participants were from the South of Nigeria. The South-West geopolitical zone contributed the most, with 51% of the reviewed papers and 44% of the subjects, while the North-East geopolitical zone contributed the least, with 5% of the papers and 2% of the studied population [Figure 3].
Figure 3. Distribution of papers and sample sizes based on the geopolitical zones in Nigeria

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Only two reviewed papers [11],[52] employed the triceps skinfold fold thickness (TSFT) technique in diagnosing overweight and obesity. One paper [45] used the waist circumference technique to define visceral obesity while two others [39],[46] employed both derivatives of the waist circumference and BMI. All the other papers reviewed used the BMI as the diagnostic parameter. The WHO reference standards were the most commonly used reference cut-off points for diagnosing overweight and obesity in the reviewed papers. They were used in 50% of the reviewed papers. The International Obesity Task Force (IOTF) reference standard was the next most commonly used method and was employed by 24% of the reviewed papers.

Though the right means of diagnosing obesity in pediatrics has remained controversial, several national and international agencies, and expert groups, still stick to BMI classifications. [68],[69] The advantages of the BMI diagnostic for which experts recommend it include its simplicity, strong correlation with body fat (more so at extremes of BMI), weak association with height, and sensitivity and specificity at the 85 th or 95 th percentile for age and gender. [63] Its simplicity and nonrequirement for elaborate (and expensive) equipment make using the BMI affordable in developing countries, though the gender- and age-specific tables make diagnosis a little cumbersome.

The studies that investigated obesity in both children and adolescents in Nigeria show that the prevalence figures have not changed so much between 1983 and 2013. While Akesode and Ajibode [11] using the TSFT method reported a prevalence of 3.2% for males and 5.1% for females living in an urban area, the figures have hovered around 0.0-5.8% during the period under review. The only exceptions are the studies of Owa and Adejuyigba [14] and Opara et al.[30] which reported 18.0% and 11.1% prevalence of obesity, respectively. The said studies used the gold standard BMI-for-age criteria as against the TSFT method. Irrespective of these apparent outliers, the weight of the evidence is in favor of the fact that obesity prevalence data in studies that investigated both children and adolescents have not changed dramatically in the last 30 years.

The oldest reviewed study on overweight in both children and adolescents investigated only 270 subjects in 2007 [17] and reported a prevalence of 13.7% in a rural area. However, two subsequent (independent) studies of about 600 subjects (published in 2009) each reported a prevalence of 0.0% in a rural [23] and an urban [24] setting. The prevalence of overweight reported in the more recent studies that each recruited more than 1500 subjects is 5-12%. [38],[47],[48],[50],[54] Since there is just one study in 2007, it is difficult to determine if the finding was an isolated case or representation of that period. The former is, however, unlikely. Nonetheless, if the studies reporting an absence of overweight in children and adolescents are overlooked for being outliers and for their implausibility, the prevalence of overweight in children and adolescents between 2007 and 2013 has either remained steady or declined.

The first reviewed paper that investigated overweight and obesity in only adolescents [16] was published in 2007. Between 2007 and 2013, the prevalence of overweight ranged from 1.0% to 8.6%. Three papers (that are apparently outliers) however reported prevalence values of 13.8%, [41] 18.6%, [53] and 18.9%. [25] For the prevalence of obesity in this subgroup, also between 2007 and 2013, the figures ranged from 0.0% to 2.8%. As was the case with overweight, two studies reported values that are apparently outliers (4.2% [46] and 9.4% [41] ). In fact, one of the two studies [46] reported a prevalence of 37.2% when obesity was defined using waist-to-height ratio or waist-to-hip ratio. A different study found visceral obesity in 24.5% of the subjects (but a general obesity prevalence of 5%). [39] It is nonetheless instructive that a 2013 study that used the TSFT method [52] (as used by the first study on child and adolescent obesity in Nigeria; [11] both of them being the only reviewed papers using the same method to define obesity), reported a prevalence of 0.8% for obesity which is a lot less than the 3.2-5.1% reported in the 1983 study. [11]

Given the available data from this review, it appears both overweight, and obesity are more prevalent in children than in adolescents. The prevalence of both disorders has apparently remained within the same (wide) ranges in the last 30 years. From the literature, it is evident that the prevalence of pediatric overweight and obesity continue to rise in countries such as Mexico, India, China, and Vietnam. [70],[71] In several European countries, in the US and in Australia, the prevalence of overweight and obesity has reportedly plateaued in the last decade, [70],[72] while there are reports of declining rates in some countries such as Germany. [73]

With a prevalence rate of 0.0-2.8% and 0.0-5.8% for obesity in the "adolescents only" and "children and adolescents" subgroups, respectively, and prevalence rate of 1.0-8.6% and 5.0-12.0% for overweight in the subgroups, respectively, the data from this study suggests that prevalence rates in Nigeria are still lower than the figures reported in most of the available literature. Some of the figures from around the world buttress this point. The prevalence of overweight/obesity increased significantly among both boys and girls in China from 1.8%/0.4%, respectively, between 1981 and 1985 to 13.1%/7.5%, respectively, between 2006 and 2010. [74] A comparison of data from 35 countries showed that there were large variations in adolescent overweight and obesity in those countries. The prevalence of obesity in adolescents (%; boys vs. girls) in France, Scotland, Canada, USA, and Malta were 1.6 versus 1.4, 3.0 versus 2.7, 4.4 versus 3.5, 8.4 versus 5.2 and 10.2 versus 5.0, respectively; while that of overweight in the same countries were 12.4 versus 9.2, 16.7 versus 13.3, 22.8 versus 14.7, 28.6 versus 20.1 and 31.7 versus 18.9, respectively. [75] Overweight and obesity prevalence in South African children has reached 17.2-22.8%. [76]

It is important to note that the prevalence of overweight and obesity is a derivative of the incidence and the duration of the disorder. Therefore, a stable prevalence necessarily does not indicate that the incidence and duration are both stable; and as such, one should not be carried away by an apparent stable prevalence of overweight and obesity in Nigeria. Theoretically, if the incidence of overweight and obesity continues to rise while the duration of the condition shortens, the prevalence will remain stable. It is, therefore, important to study the underlying characteristics of the trends reported here in order to appreciate better the data and develop appropriate public health response(s).

The increased research activity in recent years is suggestive of the current appreciation of the public health implications of pediatric obesity. Unfortunately, many of the studies are not of high quality. Future studies should cut across geopolitical zones, recruit more subjects, and employ methodologies and data deposition strategies that ensure easy comparison between studies. Clearly children and adolescents in rural areas have not received as much attention as their counterparts in urban areas. This is apparently because many of the researchers working on the subject are either pediatric doctors working in Teaching Hospitals or academics in Universities - both being institutions that are mostly located in urban centers. There is, therefore, need to conduct more studies in rural Nigeria, especially since the majority of Nigerians live in rural areas. Furthermore, this review shows that for every paper on pediatric overweight and obesity in the North of Nigeria, there are three in the South of the country. This disparity in the volume of research between the North and South needs urgent attention. Though there are indications that the bulk of the nutritional challenge in the North is that of deficit, not surplus, [77] it is important to monitor pediatric overweight and obesity in the region, especially in the urban and semi-urban areas where the westernization of lifestyles may be taking place.

Health education aimed at promoting healthy food choices, adequate physical exercise and reduced sedentary lifestyles (typically, for this age-bracket, by regulated television viewing and video/computer gaming) should be inculcated into the primary and secondary school curriculum. Parents should be made to realize that obesity tracks into adulthood. With such realization, they will understand that their obese child (who sends the erroneous cultural message that their parents are wealthy) is, in fact, on track for morbidity and maybe mortality in adulthood (if not earlier). These will immensely contribute positively to efforts at keeping overweight and obesity in check. [44] It is nonetheless known that such needed large-scale action such as public education, which often requires legislation and have budgetary implications are difficult to implement especially in resource-poor settings typified in developing economies. [78] However, if "developing countries" such as Nigeria will in the future become "developed", then the nutritional status of their children and adolescent, the so-called leaders of tomorrow, must be taken seriously not only for the improvement of their health, but also for the nation's overall future development.

This review is limited by the poor quality of many of the reviewed papers especially with respect to sample size, sample characteristics and data-reporting practices employed by the authors. Another limitation is the limited number of publications on the subject before 2007. This ensured that it was difficult to properly compare recent findings with those from the past. The limited number of studies, subjects and overall quality of the studies make it difficult to carry out a meta-analysis of the prevalence data for child and adolescent overweight and obesity in Nigeria. Though it is difficult to appropriately compare data from these reviewed studies due to differences in methodologies used in diagnosing overweight and obesity and difference in sample sizes and characteristics, these challenges may be attenuated by the fact that majority of the studies used BMI-for-age cut-off points. This review is, therefore, a good starting point for subsequent studies on the prevalence of pediatric overweight and obesity over time in Nigeria.


  Conclusion Top


The prevalence of overweight and obesity in children and adolescents published between 1983 and 2013 was reviewed. Of the 42 papers/abstracts that met the inclusion criteria, 69% of them were set in urban areas, 74% of them were set in the South of Nigeria, all but two of them recruited both boys and girls, and the BMI-for-age cut-off reference values were the most used reference standard. Contrary to reports in some literature, there appears to be no evidence that pediatric overweight and obesity have increased dramatically in Nigeria in the last 30 years. Further studies are warranted to understand the reasons behind this apparent stability in the prevalence rates for overweight and obesity with a view to informing appropriate public health response.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]


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