Double burden of undernutrition and obesity in Palestinian schoolchildren: a cross-sectional study

Abstract

Background Previous studies of nutrition were undertaken in adolescent schoolchildren in the West Bank or Gaza Strip, occupied Palestinian territory; most of the children were selected from only a few geographical areas. We assessed factors associated with stunting (height-for-age standardised scores Methods We surveyed a sample of 22 schools run by the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and Palestinian Government. Using UNRWA's and the government's lists, we selected 1500 students from those attending school at the time the study was undertaken. We selected a set number of students per class from the first (mean age 6·71 years [SD 0·45]), sixth (11·82 years [0·57]), and ninth grades (14·83 years [0·61]), with a 1:1 ratio of boys to girls. The number of classes in each grade was between one and five. Siblings were excluded; we selected one student per household. We stratified the lists of students attending the UNRWA and government schools by location and sex. Within each school, 42 students per grade were selected using random sampling and recruited to the study—eg, if there were two classes A and B, we randomly selected 21 students from the alphabetical list for each class. BMI was defined according to age-specific and sex-specific cutoff values reported as per the 2000 growth charts of the Centers for Disease Control and Prevention, Atlanta, GA, USA, and height and weight measures as per WHO standards. Columbia University's Institutional Review Board, New York, NY, USA, approved the study protocol in December, 2008. Written informed consent and assent were obtained from sixth and ninth grade students and their parents. Findings Data were obtained from 1484 (99%) of 1500 students. Prevalence of stunting was 97 (7%) of 1446 and underweight 94 (7%) of 1444 students. 180 (12%) of 1444 students were overweight and 86 (6%) obese. There were non-significant differences in stunting (52 [7%] of 772 vs 45 [7%] of 674; difference 0·98, 95% CI 0·67–1·44; p=0·96), underweight (25 [3%] of 771 vs 24 [4%] of 673; 0·92, 0·52–1·58; p=0·73), and overweight (99 [13%] vs 81 [12%]; 1·07, 0·81–1·40; p=0·64) between the children in government and UNRWA schools. Obesity was more prevalent in UNRWA schools than in government schools (56 [7%] vs 30 [4%]; 1·63, 1·06–2·51; p=0·0246). The hunger index, which is a composite score from the eight questions on the food insecurity questionnaire, was negatively associated with height for age (p=0·018). Factors associated with underweight were male sex (odds ratio 2·8, 1·5–5·3; p=0·002), mother being unemployed (3·0, 1·0–8·4; p=0·04), and households not having enough food to eat for at least 2 days in the past month (1·8, 1·0–3·3; p=0·05). Factors associated with obesity were age, with children in the ninth grade more likely to be obese (1·1, 1·02–1·2; p=0·01) than were younger children, and time spent watching television (1·1, 1·0–1·3; p=0·014). When overweight and obesity were combined in the analysis, they were significantly and inversely associated with increasing number of days spent playing sports (0·87, 0·77–0·98; p=0·02). Interpretation By contrast with the results of previous studies, our data do not suggest an association between birth order, birthweight, size of the household, maternal education, and the child's nutritional status. Our results show the need to target food insecurity and improve child health in the occupied Palestinian territory, partly through increased awareness and promotion of sustainable healthy lifestyle changes for the prevention and management of undernutrition and obesity. The dissemination of information about the social, emotional, and cognitive effects of regular physical activity should be integral to health and nutrition programmes. We need to focus simultaneously on food insecurity and the establishment of a simple and reliable system for the detection of malnutrition; and we need to implement programmes related to the negative effects of adverse lifestyles. Funding UNRWA, UNICEF, Juzoor for Health and Social Development, Institute of Human Nutrition, Columbia University, and Flagship Project.