Nigerian Journal of Paediatrics

Prevalence of overall and central obesity among adolescent girls in Port Harcourt a comparison of different methods

Niger J Paediatr 2016; 43 (3): 209 – 214

ORIGINAL

Jaja T

Prevalence of overall and central

Alex Hart B

obesity among adolescent girls in

Port Harcourt: a comparison of

different methods

DOI:http://dx.doi.org/10.4314/njp.v43i3.10

Accepted: 2nd June 2016

Abstract : There is no universally

analysed.

accepted criterion for classifica-

Results: Prevalence of overall and

Jaja T

(

)

tion of overall weight status and

central obesity varied with differ-

Alex Hart B

central obesity in adolescents.

ent methods. The prevalence of

Department of Paediatrics and Child

Health, College of Health Sciences,

Several criteria have been used

overall obesity was 106(8.02%),

University of Port Harcourt and

which include that recommended

69(5.22%) and 39(2.75%) using

University of Port Harcourt Teaching

by Centre for Disease control,

the CDC, WHO and IOTF criteria

Hospital, Rivers State, Nigeria

World Health Organization and

respectively. Prevalence of central

Email: Tamunopriyej@yahoo.com

the International Obesity Task

obesity

was

1.5%,

16.26%,

Force.

47.81% using the WC, WHtR, and

Aim: The study compared various

WHR respectively. The agreement

methods for determination of

between criteria of WHO Z score

overall obesity in adolescents

and BMI Percentile was highest

using the BMI percentiles recom-

for overall obesity. (K=0.81).

mended by the Centre for Disease

There was a statistically significant

Control (CDC), the International

association between overall weight

Obesity Task Force (IOTF) and

status and central obesity using the

the World Health Organization

different criteria of determination

(WHO) BMI Z score and determi-

of central obesity.

nation of central obesity using the

Conclusion: Prevalence of overall

waist circumference (WC), Waist

obesity and central obesity varied

Hip Ratio (WHR) and Waist

based on the methods used. The

Height Ratio (WHtR).

highest level of agreement for

Methods: The study subjects con-

overall obesity determination was

sisted of 1320 girls aged 10-19

obtained between WHO Z score

years from randomly selected

and BMI percentile compared to

girl’s high school. Weight status

WHO Z score and IOTF criteria.

to determine overall obesity was

Prevalence of central obesity in-

determined according to the CDC,

creased significantly with overall

IOTF and WHO criteria and cen-

obesity in study population.

tral obesity determined using the

WC, WHR, and WHtR. Compari-

Key words: adolescents, Girls,

son of methods was done and

overall and central obesity

Introduction

In adolescents, the Body Mass Index (BMI) is used as a

reliable indicator of body fat but many adolescents clas-

Obesity has remained a global health problem with

sified as overweight or obese may not have high adipos-

ity. The BMI is dependent on stature, age, fat distribu-

6, 7

prevalence increasing in both developed and developing

countries and in both young and adult popula-

tion and musculature and its use is limited on a lack of

tions.

1,2,3

Obesity has also increased in frequency and

consensus on the cut off to be used in classification of

severity in children and adolescents with a dramatic

weight status in children and adolescents.

global increase in prevalence in preschool children in

144 countries since 1990. In Sub- Saharan Africa, there

There are different criteria of classification of BMI in

is an evidence of transition to obesity in children despite

adolescents based on age and sex. Obesity determination

historically known food shortages. Overweight and obe-

can also be done independent of the BMI by measuring

sity constitute a major risk factor for most non- commu-

the degree of central adiposity using simple measure-

nicable diseases such as hypertension, type 2 diabetes

ments such as waist circumference, Waist Hip Ratio and

and other cardiovascular diseases in both adolescents

Waist Height Ratio. The determination of degree of adi-

and adults.

posity especially central adiposity has been identified as

210

the most important correlate and independent predictor

searcher and assistants. Each researcher and an assistant

of risk factors and morbidity.

9, 10

Adiposity generally

were assigned to do a particular measurement to reduce

tracks from childhood and has been associated with

variability.

adult health outcome. Therefore early identification of

Body weight was measured using calibrated digital scale

adolescents with central adiposity is very important to

brand SECA 780 with a capacity of 150kg and 100g

prevent metabolic complications. Adiposity generally

precision. Weight was recorded with subject standing

tracks from childhood into adulthood.

erect without shoes and weight

to the nearest 0.5kg.

Studies on prevalence of overall and central obesity in

The scales were standardized each morning with a

children and adolescents using different classification

known weight and adjusted to zero marks before each

criteria have observed differences in prevalence in dif-

reading. The height was performed using a stadiometer

ferent populations,

12-14

The observed differences may be

with subject erect without shoes with the back placed

due to difference in the population used in constructing

against the stadiometer and the head in Frankfurt plane

the various references. The choice of what represents

to the nearest 0.5cm. Body Mass Index (BMI) was cal-

normal weight may vary with different population

culated as the weight in Kilograms divided by the height

groups. For Nigerian adolescents, the WHO references

in meters squared. Weight category was divided into

may seem the most adequate because of the population

underweight, normal weight, overweight and obesity

used in developing the references. The aim of this study

using The BMI percentile by CDC, according to limit

was to compare the prevalence of overall obesity and

proposed by Cole et al (IOTF)

and WHO BMI Z

score.

15, 16, 17

central obesity among adolescent girls in public secon-

dary schools in Port Harcourt using different criteria of

BMI and Waist, Hip and height measurements.

WHO BMI Z score which classifies individual as val-

ues < -2 with thinness, adequate weight as -2 and 1,

overweight as Z score of >1 and < 2 and obesity as Z

score of ≥ 2.

Methodology

Using the IOTF criteria and limits proposed by Cole et

al, thinness is defined as BMI of < 18.5Kg/m , normal

weight as BMI of 18.5 to < 25kg/m and overweight as

This cross- sectional observational

study was done

amongst secondary school girls in selected public secon-

BMI of ≥25kg/m2 and obesity as BMI of ≥ 30kg/m 2 . 16

dary schools in Port Harcourt Local Government Area

Waist Circumference was performed in the horizontal

of Rivers State, Nigeria. Port Harcourt Local Govern-

plane, with the subject in standing position and abdomen

ment Area is one of the largest Local Government Area

exposed and measurement using an inelastic tape meas-

situated in the capital of Rivers State an oil producing

ure at the mid- point between the lower rib cage and

state in the Niger Delta region of Nigeria. It has three

iliac crest after a normal expiration. Hip circumference

districts, Diobu, Town and Trans-Amadi districts.

The

was measured in a standing position using an inelastic

study population consisted of girls aged between 10 and

tape at the widest circumference over the buttocks run-

19 years in public day secondary schools in Port Har-

ning over the femoral canal outlet anteriorly and meas-

court. Three of the girls schools with no boarding facil-

ured to the nearest 0.1cm.

ity were selected from a list of girl’s secondary schools

Abdominal or central obesity was defined as WC ≥ 90 th

percentile for age and sex,

in the three Districts of Port Harcourt LGA by simple

WHR>0.80

or WHtR ≥

0.50.

random sampling. One school was selected from each of

the three districts.

Data analysis involved initially descriptive statistics for

Approval for this study was obtained from the school

all the variables. Statistical analysis was performed with

authority and ascent obtained from the students. All

statistical package for Social sciences version 19.0. Sta-

subjects who were willing to participate and were pre-

tistical significance was set at 0.05. The Cohen’s Kappa

sent in school on the 3 days of sampling allotted to each

statistics was used to analyse the correlation between the

school were recruited. An average of 450 students that

WHO BMI Z score criteria and the other measures of

met the inclusion criteria were recruited from each se-

overall obesity.

lected school and analysed.

The participation of the subjects was voluntary and

anonymous, and we adopted the use of a negative term

of consent (passive parental consent form). No personal

Results

identification was allowed in the instruments to ensure

the anonymity of responses. Information on biodata and

A total of 1322 out of 1350girls had complete data and

general characteristics was obtained by a self- adminis-

were analysed. They were aged

between 10 and 19

tered

questionnaire supervised by researchers and

years with a mean age of 15.74±1.45. Table 1 shows the

trained assistants. Inclusion criteria involved students

mean of various anthropometric measures for the study

who were present on the day of data collection, who did

populations and different ages. There was a progressive

not have any chronic medical condition and were willing

increase in mean weight, BMI and Hip circumference

to participate in the study by giving assent.

with age. The waist hip ratio however showed a progres-

Anthropometry which included the weight, height, waist

sive reduction in mean value with age.

and hip circumferences was done by pretrained re-

211

Table 1: Mean of Anthropometric Measures for Study Population

BMI (kg/m )

Age (yrs)

Weight (kg)

Height (cm)

WC (cm)

HiC (cm)

WHR

WHtR

Mean (s.d)

General

54.35 (9.30)

157.80 (6.68)

21.77 (3.55)

72.26 (7.17)

90.38 (7.81)

0.80 (0.06)

0.46 (0.05)

<13 (n=32)

47.06 (8.57)

150.50 (7.65)

20.69 (3.25)

69.75 (4.74)

83.03 (10.59)

0.85 (0.13)

0.46 (0.03)

13-13.9 (n=78)

52.36 (10.09)

156.74 (6.9)

21.24 (3.66)

72.65 (8.08)

88.96 (8.08)

0.82 (0.06)

0.46 (0.05)

14-14.9 (n=265)

53.06 (8.17)

157.97 (6.50)

21.15 (3.49)

71.79 (7.43)

89.22 (7.82)

0.81 (0.06)

0.46 (0.05)

15-15.9 (n=363)

53.85 (10.16)

157.97 (6.54)

21.62 (3.78)

71.86 (6.84)

89.61 (7.55)

0.80 (0.05)

0.45 (0.04)

16-16.9 (n=256)

55.66 (8.52)

158.39 (6.77)

22.12 (3.13)

73.14 (6.88)

91.78 (7.52)

0.80 (0.06)

0.46 (0.04)

17-17.9 (n=223)

55.95 (9.57)

158.28 (6.36)

22.34 (3.69)

72.49 (7.96)

92.11 (7.55)

0.79 (0.05)

0.46 (0.05)

18-18.9 (n=105)

56.43 (7.78)

157.17 (6.25)

22.56 (3.27)

72.79(6.17)

92.21 (6.50)

0.79 (0.05)

0.46 (0.04)

Total (n=1320)

Table 2 shows the prevalence of various weight catego-

Table 3 shows the prevalence of central obesity using

ries according to the BMI criteria using the BMI percen-

WC, WHR and WHtR. The prevalence of central obe-

tile, WHO Z score and the IOTF classification. The BMI

sity was highest using WHR (47.81). WC and WHtR

percentile followed by the WHO Z score showed the

gave prevalence of 1.51 and 16.26 respectively.

highest prevalence of obesity of 8.02 and 5.22 respec-

There was a statistically significant relationship between

tively. Highest prevalence of overweight was also re-

measures of central obesity and overall obesity using the

c o r d e d

b y

t h e

W H O

s c o r e .

BMI Z score. WC, WHR, WHtR increased with increas-

BMI weight status. (X =

Using Cohen’s Kappa, there was a moderate agreement

ing weight category and

between BMI Z score and IOTF criteria (K= 0.505) but

179.02, X2= 20.19, X2= 448.51 respectively with p

a strong agreement between BMI Z score and BMI per-

value of 0.001 for each). Eighteen (90%) of subjects

centile. (K= 0.806) These findings were statistically

with central obesity using the WC were also overweight

significant.

or obese. This is compared to 24% using WHR and 71%

using WHtR.

Table 2: Prevalence of Various Weight Status according to

BMI Percentile, IOTF, WHOBMI Z score

Weight Category

BMI Percentile

IOTF

WHO BMI Z

score

Underweight

35(2.64)

171(13.21)

16(1.21)

Normal weight

1049(79.35)

974(73.52)

1039(78.59)

Overweight

132(10.21)

138(10.51)

198(14.9)

Obesity

106(8.02)

39(2.95)

69(5.22)

Table 3: Distribution of Subjects based on overall obesity measured by WHO Z score and central obesity using various methods

WC Percentiles

WHR

WHtR

BMI Z Score

n(%)

<90th

≥90th

≤0.80

>0.80

<0.5

≥0.50

Classification

n (%)

Underweight

16 (1.21)

16 (100.0)

0 (0.00)

14 (87.50)

2 (12.50)

16 (100.0)

0 (0.0)

Normal

1039 (78.59)

1037 (99.81)

2 (0.19)

560 (53.90)

479 (46.10)

977 (94.03)

62 (49.49)

Overweight

198 (14.98)

194 (97.98)

4 (2.02)

92 (46.46)

106 (53.54)

100 (50.51)

98 (49.49)

Obese

69 (5.22)

55 (79.71)

14 (20.29)

24 (34.78)

45 (65.22)

14 (20.29)

55 (79.71)

Total

1322 (100.0)

1302 (98.49)

20(1.51)

690(52.19)

632(47.81)

1107 (83.74)

215(16.26)

χ2=179.02,

χ2=20.19

χ2=448.51

p-value=0.001

Central Obesity = Waist circumference ≥90 th for age and sex; WHR >0.80; WHtR ≥0.50

waist hip ratio (WHR) had the highest prevalence while

Waist circumference (WC) gave the lowest prevalence

of 1.5%.

Discussion

The diagnosis of overweight and obesity in Nigerian

children have used several methods. In a review of stud-

This study shows a high prevalence of overweight and

ies on childhood and adolescent obesity in Nigeria,

obesity among adolescent girls in public secondary

WHO reference standard were the most commonly used

schools in Port Harcourt. The prevalence values of dif-

in about 50% of the studies, the IOTF was the second

most commonly used in 24% of studies.

ferent weight category also varied according to the crite-

Other meth-

ria used for the evaluation. The prevalence of obesity

ods used include skin fold thickness, waist circumfer-

was 8.02%, 5.22% and 2.95% using the CDC BMI per-

ence, Waist Hip Ratio and Waist Height ratio. Although

centile, the WHO BMI Z score and

IOTF criteria re-

no study compared different criteria for the prevalence

spectively. In using various methods in determining cen-

of obesity in a particular population, the prevalence of

tral obesity, this study illustrates that the percentage of

obesity in adolescents using the WHO reference was

adolescent girls with central obesity varied considerably

between 0- 5.8% similar to the 5.2 % reported in this

study.

depending on the method used. The value using the

In using the IOTF criteria in various studies

212

among Nigeria Adolescents, the prevalence of obesity

study amongst Portuguese adolescents, the classifica-

20, 21

among females was low usually less than 2%.

In a

tion of obesity showed agreement between the BMI per-

study in Kano metropolis, the prevalence of obesity

centile and the IOTF criteria with a substantial agree-

amongst the females using the IOTF was 1.0% similar to

ment in the age group 10-12 years (K= 0.79) and excel-

1.7% reported also in the Western part of Nige-

lent in age group 13 -16 years (K=0.88).

ria.

20,21

This is similar to the prevalence of 2.95% using

the IOTF reported in this study. Also in a study of ado-

Various criteria have been used by various researchers

lescents in Lagos, the prevalence of obesity using the

in the determination of weight category in children and

CDC criteria reported a prevalence of obesity of 9.4%,

adolescents. The major limitation for the use of the

this was similar to 8.02% reported in this study.

IOTF is that the sample used to determine the values

was not a worldwide representation since five out of the

In a study of 966 students aged 10-16 years from pub-

six countries used had a gross domestic product (GDP)

lic secondary schools in Portugal

the prevalence of

that was above the world average with GDP known to

obesity amongst the girls was also lowest (2%) using

influence the occurrence of obesity, this may have ac-

the IOTF similar to finding in this study, the prevalence

counted for the low prevalence recorded in this study

was however 5.4% in girls similar to the 5.22% using

using IOTF since this population will not represent the

WHO Z score reported in this study. In a study by Sar-

Nigerian population. The WHO reference is however a

dinha et al of 22048 adolescents aged 10-18 years, the

combination of a multicentre growth study and a USA

IOTF also gave the lowest prevalence of obesity similar

pooled data. Although the IOTF are more widely used

to the finding in this study.

The study using the WHO

the WHO Z score may be a better representative of

Z score was however 9.9% higher than the 5.22% re-

population from different regions. The BMI Z score is a

ported in this study. In a study by Wang and Wang

measure of relative weight adjusted for child age and

done in Russian, American and Chinese children aged 6-

sex. It is equivalent to the BMI percentile for age but

18year, the prevalence of obesity using the WHO Z

BMI Z score is calculated based on an international ref-

score were all higher than the prevalence reported using

erence compared to the BMI percentile which is from an

the IOTF. The prevalence of obesity amongst the Rus-

internal reference. The BMI Z score has an advantage of

sian children using the WHO Z score was double the

assessing change in adiposity and to compare group

means of children unlike the BMI percentile.

value by the IOTF which was also similar to the report

in this study where prevalence of obesity was 5.22%

using the WHO Z score almost double the prevalence of

In addition to overall obesity, central obesity is a better

2.95% reported using the IOTF.

predictor of cardiovascular risk. Body Mass Index fails

to distinguish between muscle and fat and is a poor de-

The report in this study of prevalence

of obesity

terminant of central fat. Using various criteria in this

amongst females of 8.02% using the CDC BMI percen-

study, the prevalence of central obesity as determined

tile was however higher than the prevalence of 4.5%

using the Waist Circumference (WC), Waist Hip Ratio

reported in female adolescents in Ile Ife Nigeria while a

(WHR) and Waist Height Ratio (WHtR) was 1.5%,

much lower prevalence of 1.0% was also reported in

47.81% and 16.26% respectively. In a study by Rafraf

and colleagues

adolescents girls aged 10-20 years in Ondo state in Ni-

of 985 adolescent high school girls

geria. The difference in prevalence between this study

aged 10-19 years in Tabriz Iran, the prevalence of cen-

and the previous studies may be a reflection of the in-

tral obesity using the WC, WHR and WHtR was 13.2%,

creasing obesity trend. There are no studies comparing

14.0% and 18.2% respectively. The prevalence of cen-

the various methods of determination of overall obesity

tral obesity using the WC was much higher than the

in adolescents in our region, however different authors

1.5% recorded in this study. The report of 47.18% was

have used different methods.

however much higher than the report of 14.0% in Iran.

The difference in prevalence between this study and the

The prevalence of obesity in most studies highlighted

study in Tabriz is not very obvious but may be due to

above has shown that the prevalence of obesity in ado-

difference in the age of children in the two studies. In a

study in Ile Ife in Osun State amongst adolescents, the

lescents is lowest in the classification using BMI accord-

ing to the IOTF criteria. The agreement between the

prevalence of central obesity using the WHR was 68%

various criteria for overall weight status determination

amongst the females much higher than the prevalence in

varied from moderate to strong.

The agreement be-

this study. Although the WHR was high in this study

tween the WHO Z score and the BMI according to the

and in study in Ile Ife, the higher rate in Ile Ife study

IOTF was moderate (K= 0.505) while the agreement

may be due to the fact that it was done in adolescents in

between the WHO Z score and the BMI percentile was

private and public schools. There are no studies com-

strong (K= 0.81) this is contrary to the finding in the

paring methods on determination of central obesity in

report by Minghelli and colleagues amongst Portu-

adolescent’s girls in Nigeria, however in a study by

Abolfotouh et al on prevalence of central obesity in

guese adolescents who reported best agreement for the

classification obtained between the BMI percentile and

Egyptian adolescents, the prevalence of central obesity

the IOTF criteria. In a data reported by Twells and New

was lowest(4.5%) using the WC similar to the finding in

hook

there was a similar strength of agreement be-

this study. In South Africa, 15% of rural adolescent girls

tween the BMI percentile and WHO Z score with K=

aged 10-20years had abdominal obesity using WHtR,

0.84 similar to K= 0.81 reported in this study. In the

this was similar to the 16.26% reported in this study ,

213

however there was no comparison with other meth-

tively, the WHtR can be used due to its accurate tracking

ods. In another study amongst adolescent girls in Te-

indicator of fat distribution and accumulation by age it

hran using age and sex specific WC percentile, 10.1%

takes into account growth in both WC and Height on

age.

had central obesity. The difference in prevalence from

different population may be due to the fact that popula-

tions vary in the rate of proportional growth and fat par-

titioning. The ethnicity may influence body fat distribu-

tion. The differences can also be due to the methods

Conclusion

used to construct the various references and the popula-

tion studied. The choice of what will be normal or refer-

This study shows prevalence of overall and central obe-

ence can therefore vary substantially between countries

sity varies and depends on the criteria used. Highest

prompting development of country specific growth ref-

prevalence for obesity was by the BMI percentile while

erences.

WC reported lowest prevalence for central obesity. In

comparison among the various criteria for classification

The comparison of results of central obesity in this study

of overall obesity in adolescent girls, the BMI percen-

with results from other studies shows that the prevalence

tile and the WHO Z score agreed strongly. There was

Central Obesity using WC is much lower than re-

statistically significant relationship between the BMI Z

ports from other countries. In this report, high propor-

score and the various measures of central obesity. Popu-

tion of obese subjects also had central obesity with a

lation specific charts may need to be developed.

statistically significant association between overall

weight and BMI according to the WHO Z score. Almost

all subjects with central obesity using the waist circum-

Recommendation

ference and 70% of those using the WHtR were obese or

overweight showing a possible strong correlation be-

Surveillance and preventive Programmes should be put

tween the methods, this rate was however low with the

in place to reduce prevalence of obesity in adolescents

WHR.A low correlation between BMI and WHR

and WC and WHtR should be routinely done to identify

( r=0.02) was also reported in the study in Ile Ife. The

those at risk for developing cardiometabolic problems.

WC is a good predictor of cardiometabolic risk and it’s

use have been advocated by the World Health Organiza-

Conflict of interest: None

tion and the International Diabetes Federation. Alterna-

Funding: None

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