Nutritional Status of Adolescents in Eastern Sudan: A Cross-Sectional Community-Based Study

Background: Malnutrition among adolescents is a major public health issue. This problem is particularly pressing in Sudan, an African country where there is scarce published data on the nutritional status of adolescents. In this study, we aimed to assess the nutritional status of adolescents in eastern Sudan. Methods: A community-based cross-sectional survey was carried out in Gadarif, eastern Sudan. A questionnaire was used to collect sociodemographic data, and the anthropometric measurements (weight and height) of adolescent participants were recorded. Height-for-age and body mass index-for-age Z-scores were calculated using the WHO anthropometric standards. Binary and multivariate multinomial regression analyses were performed. Results: A total of 388 adolescents were included in this survey, 207 (53.4%) were female, and 181 (46.6%) were male. The median (interquartile) age was 13.9 (12.0–16.0) years. The results showed that a total of 29 (7.5%), 93 (24.0%), 33 (8.5%), and 16 (4.1%) adolescents were stunted, thin, overweight, and obese, respectively. None of the investigated factors (age, sex, parents’ education levels, and occupation) were associated with stunting. In the multivariate multinomial analysis, the male sex was associated with thinness (OR = 2.41, 95.0% CI = 1.47–3.94). Moreover, adolescents whose mothers had an education lower than secondary level were at a lower risk of overweight/obesity (OR = 0. 0.35, 95.0% CI = 0. 0.35). Conclusions: While both undernutrition and overnutrition exist in eastern Sudan, undernutrition is more common. Male sex and mothers’ education levels are associated with malnutrition.


Introduction
Adolescence is the period of human age between 10 and 19 years.This period represents a pivotal phase of puberty, marked by significant physical, mental, and psychosocial transformations necessitating a diverse array of nutrients [1].The global population of adolescents is about 16% or 1.3 billion [2].Malnutrition during adolescence is associated with long-term consequences, including potential reductions in cognitive function, school performance, and reproductive life [1,3,4].
However, there are few published studies on the prevalence of nutritional status and its associated factors among adolescents in Sudan, the third-largest African country [20,23].In 2019, 4.3% of girls and 8.7% of boys categorized as children and adolescents (5-19 years) in Sudan were reported to exhibit thinness, indicating that Sudan has one of the largest numbers of malnourished children and adolescents in the world [24].Malnutrition is one of the main health problems among children in our selected study area of Gadarif City, especially among children whose mothers had low educational levels and in children living with large families [25].Moreover, malnutrition is one of the main causes of pediatric admission and death in Gadarif Hospital in eastern Sudan [26].Furthermore, a communitybased survey showed that 15.6% of the adolescents in New Halfa in eastern Sudan were underweight [27].On 15 April 2023, the Sudanese military and the Rapid Support Force in Khartoum State commenced an armed conflict.The war eventually extended to other regions of Sudan, leading to at least 50,000 deaths, 2.6 million internal displacements, and 730,000 forced to seek refuge elsewhere [28].
Providing data on the prevalence and associated factors for undernutrition in adolescents in Sudan is necessary for academicians, health planners, and providers to facilitate the planning of services and food assistance and to help manage the negative impact of undernutrition on future adults in Sudan.Therefore, this study aimed to assess the nutritional status of adolescents in eastern Sudan.

Study Design and Setting
A community-based cross-sectional study was conducted in Gadarif City, eastern Sudan, from August to October 2023.Gadarif City was chosen because it might be representative of the other regions of Sudan, and a previous study has shown a high rate of malnutrition among adults in this region [29].Gadarif City, the capital of Gadarif State, which is on the Ethiopian border, has a total population of 1,400,000 [30].The Gadarif locality (including Gadarif City) is the largest of the 11 localities in Gadarif State.This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [31].

Sampling
Gadarif City is divided into four squares (Mouraba) comprising 13 blocks (Hay).The total population in each block was obtained from the local authorities.The desired sample size was 388 adolescents, including both males and females.The probability proportion, including the number of adolescents enrolled from each block, was proportionate to the total number of adolescents in each block.

Inclusion and Exclusion Criteria
The inclusion criteria included adolescents aged between 10 and 19 residing in the study area of Gadarif City.The exclusion criteria consisted of those younger than 10 or older than 19, those who did not consent to participate in the study component on diet, and those who were sick, pregnant, or lactating.

Study Variables and Measures
After the adolescents and their guardians signed the informed consent and witness form, two trained medical officers conducted face-to-face interviews with the participants and completed the study questionnaire.The questionnaire included data on date of birth (confirmed via ID to calculate the participant's age), sex (male or female), parents' educational levels (<secondary or ≥secondary), mother's occupation (housewife or employed), and father's occupational status (laborer or skilled worker).
Following the interview process, each participant was weighed.After removing shoes and excess clothing, the adolescents were instructed to stand still with their hands by their sides on the weighing scale.Their weights and heights were measured twice and recorded, and then the means of the two measurements for weight and height were computed and documented as the final values.A Seca 874 weighing scale (Seca, Deutschland, Germany) was used to weigh each adolescent (to the nearest 100 g), and its well-calibrated scales were adjusted to zero before each measurement.A Seca stadiometer (Shorr Board, Olney, MD, USA) was used to measure the adolescents' height to the nearest 0.1 cm.During the measurement, the adolescents stood straight with their backs against a wall and feet together.
The WHO reference was used to compute the body mass index-for-age Z-score (BMIZ) and height-for-age Z-score (HAZ) [32].Stunting was considered for a HAZ of <−2 SD.Thinness was considered when the BMIZ was <−2 SD.Overweight was considered when 1 SD < BMIZ ≤ 2 SD, while obesity was considered when BMIZ > 2 SD.

Sample Size
The sample size (388 adolescents) was calculated using the OpenEpi Menu [33].The sample size of 388 adolescents (n) was estimated based on an assumed prevalence (25.0%) of thinness among adolescents (ratio of 3:1).This assumption (25.0% of the adolescents would have thinness) was based on the recently reported prevalence of thinness among adolescents in north Sudan [23].We then assumed that 60.0% of thin adolescents were female, while 40.0% of the adolescents with normal weight were female.This sample size (388) had a confidence interval (CI) of 95% and a precision of 0.05.

Statistics
Analysis was performed using the Statistical Package for the Social Sciences ® for Windows Version 22.0 (SPSS Inc., New York, NY, USA).The age, weight, height, HAZ, and BMIZ values of the adolescents were continuous data found to be non-normally distributed after the Shapiro-Wilk test evaluation.Therefore, these data were expressed as the median (interquartile range (IQR)) and compared between two groups using a non-parametric test (the Mann-Whitney U test).A chi-square test was used to compare categorized variables expressed as a frequency (proportion).Normal weight, thinness, and overweight/obese were used as dependent variables for univariate multinomial analysis, while stunting was used as the dependent variable for univariate binary analysis.The gathered sociodemographic data, namely the adolescents' age, gender, and their parents' educational levels, were used as the independent variables for both analyses.Thereafter, variables with p < 0.20 in the univariate analysis were shifted to perform multivariate regression with backward elimination.The results of adjusted odds ratios (AORs) and a 95% CI were calculated, and a p-value of <0.05 was considered statistically significant.

Anthropometric Measurements
The median (IQR) height of the enrolled adolescents in this study was 156.0 (146.5-164.0)cm, while the median (IQR) of their weight was 42.

Factors Associated with Stunting
Twenty-nine (7.5%) adolescents had stunting.The investigated factors (age, sex, parents' education, and occupation) were not associated with stunting (Table 1).
In the univariate multinomial analysis, the male sex was associated with thinness (OR = 2.37, 95.0%CI = 1.45-3.88),whereas age, parents' education, and occupation were not associated with thinness.

Discussion
The main findings of this study revealed that 7.5%, 24.0%, and 12.6% of the adolescents were stunted, thin, and overweight/obese, respectively.The observed prevalence (7.5%) of stunting among adolescents in this study was lower than the prevalence of stunting that we recently reported among adolescents in north Sudan (19.8%) [23]; among schoolchildren aged 5-15 years in eastern Sudan (22.1%) [20]; among school-age children in Ebonyi State in Nigeria (9.9%) [19]; among street adolescents in the city of Adama, Oromia Region, Ethiopia (34.1%) [10], and Tanzania (18%) [14]; and among 7625 adolescents from 8 countries in sub-Saharan Africa (18.1%) [15].Moreover, our results revealed a lower prevalence of stunting compared with the pooled prevalence of stunting reported in a meta-analysis among adolescents in South Africa (9•6%) [6] and Ethiopia (22.4%) [7].On the other hand, the prevalence (7.5%) of stunting in our study was higher than that recently reported (5.7%) among school adolescents in high schools in the town of Durame in Ethiopia [11].Although none of the investigated factors (age, sex, parents' education, and occupation) were associated with stunting in our study, several previous studies in Africa have shown that increasing age [20,21], male sex [7,15], and female sex [17] were associated with stunting.The difference in the prevalence of stunting between our study and the other studies could be attributed to the differences in sociodemographic, economic, and genetic factors in the different regions.A previous study in Southeast Asia showed that several socio-economic and demographic factors, such as age, sex, father's occupation, and family income, were associated with stunting among adolescents [34].
In the current study, 24.0% of the adolescents were thin, and the male sex was associated with thinness (OR = 2.41).The prevalence of thinness in our study was higher than what was reported (pooled prevalence of 22.0%) in a recent meta-analysis, which included 39 articles and enrolled 24,716 schoolchildren in neighboring Ethiopia [21], as well as among 10-17-year-old adolescents in Rivers State University, Nigeria (6.9%) [8]; in Ebonyi State, Nigeria (7.2%) [19]; and in Tanzania (14%) [14].However, the observed prevalence of thinness was lower than the prevalence of thinness (32.3%) recently reported among schoolchildren aged 5-15 years in eastern Sudan [20].
In the present study, as well as in previous studies in north Sudan [8], eastern Sudan [20], Ethiopia [5], and Nigeria [19], thinness was associated with the male sex.Specifically, in this study, the male sex was associated with a 2.41 higher risk for thinness.Some factors could explain the difference in the association of thinness between adolescent boys and girls.For example, the difference in age of maturation between boys and girls could explain the increased susceptibility to thinness observed between them [15,35].The traditional practice of allowing boys to spend more time engaged in outdoor activities and physical pursuits that require more energy/nutrients could also contribute to their thinner physiques compared with girls.By contrast, girls may spend more time indoors, leading to higher food intake [36].In addition, some cultural beliefs encourage girls to be overweight or obese, associating such physiques with beauty, attractiveness, and wealth [37].
In the current study, 8.5% and 4.1% of the adolescents were overweight and obese.Our results were slightly lower than the prevalence of overweight and obesity reported in sub-Saharan Africa.For example, of the 498 adolescents in Ethiopia, 9.2% were overweight [11], and in the Bauchi metropolis, Nigeria, 11.0% and 9.7% of the adolescents were overweight and obese, respectively [22].Moreover, at Rivers State University in Nigeria, 19.9% of 10-17-year-old adolescents were overweight/obese [8].However, the prevalence of overweight and obesity observed in the current study was higher than the prevalence of overweight (0.5%) and obesity (2.3%) recently reported in north Sudan [23].
In the current study, adolescents whose mothers had an education lower than secondary level were at a lower risk of overweight/obesity (OR = 0.0.35), which means that the increased prevalence of overweight/obesity was associated with the mothers' education levels.This finding aligns with the results of a recent meta-analysis (2024) that included 35 studies, showing that higher maternal education was associated with the weight-for-age Z-score (WAZ) and HAZ [3].On the other hand, previous studies in north Sudan [22] and eastern Sudan [20] reported that maternal education level had no significant effect on nutritional status [20].Several previous studies in different regions in Africa presented different results of parental education on adolescent nutrition [38][39][40].Educated parents could have a positive influence on the nutrition of their children (adolescents) through their ability to provide the optimum environmental and nutritional status of the households [41].On the other hand, education is associated with family income.Income is an important determinant of food availability (and type of food available) and nutritional status [34].Although our study showed no difference in the prevalence of overweight/obesity between males and females, previous studies have shown sex differences in the prevalence of overweight/obesity among adolescents [36,42].The difference in the prevalence of overweight/obesity between male and female adolescents was attributed to the difference in types of consumed food, eating habits, and physical activities [36,42].
It is worth mentioning that weight, height, and associated BMIZ values were used to determine the nutritional status of adolescents in this study.The BMI is not without limitations when assessing the status of undernutrition among children and adolescents.Previous research has shown some limitations of using BMI to assess nutritional status, such as studies in edema, inappropriate muscle mass in cerebral palsy, and debilitating diseases (cancer) [43,44].

Conclusions
The results of the community-based cross-sectional survey conducted in this study determined that while undernutrition and overnutrition exist in eastern Sudan, undernutrition is more common.Moreover, our study results showed that male sex and mothers' education levels are associated with malnutrition.
Therefore, there is a need for intervention programs that consider the dissemination of nutrition knowledge at the population level to ameliorate the nutritional status among adolescents; however, the implementation of such intervention programs could be difficult due to the ongoing war in Sudan.Informed Consent Statement: All the adolescents and their guardians signed a written informed consent form.The authors followed all measures to ensure the privacy and confidentiality of the participants, including excluding personal identifiers during data collection.All the methods and procedures of this study were carried out in accordance with appropriate guidelines and regulations.

Author
Contributions: M.A.A.A. and I.A.: conception, design, acquisition of data, analysis, interpretation of data, and drafting of the article.A.A.-N., A.A., J.A. and I.A.: conception, design, acquisition of data, analysis, interpretation of data, and revising the manuscript critically for important intellectual content.M.A.A.A. and I.A.: design, acquisition of data, analysis, interpretation of data, and revising the manuscript critically for important intellectual content.A.A.-N., A.A., J.A. and I.A.: design, acquisition of data, analysis, interpretation of data, and revising the manuscript critically for important intellectual content.All authors have read and agreed to the published version of the manuscript.Funding: This research received no external funding.Institutional Review Board Statement: The present study was conducted in accordance with the Declaration of Helsinki and good clinical research practices.This study received ethical approval from the Research Ethics Committee of the Republic of the Sudan University of Gadarif, Faculty of Medicine and Health Sciences (0002030, 14 July 2023).

Table 1 .
Univariate analysis of the factors associated with stunting among adolescent schoolchildren in easternSudan, 2023.

Table 2 .
Comparison of sociodemographic characteristics between adolescents with thinness, overweight, and obesity in easternSudan, 2023.

Table 3 .
Univariate multinomial analysis of factors associated with thinness and overweight/obesity among adolescents in easternSudan, 2023.

Table 4 .
Multivariate multinomial analysis of factors associated with thinness and overweight/obesity among adolescents in easternSudan, 2023.