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UNIVERSITY OF GHANA

DIETARY PRACTICES AND NUTRITIONAL STATUS OF

ADOLESCENT GIRLS IN KO SENIOR HIGH BOARDING

SCHOOL IN THEUPPER WEST REGION

BY

CHRISTOPHER ATAMBIRE AGANAH

(10397071)

THIS THESIS/DISSERTATION IS SUBMITTED TO THE

UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT

OF THE REQUIREMENT FOR THE AWARD OF MASTER OF

PHILOSOPHY DEGREE IN NUTRITION

JULY, 2014

University of Ghana http://ugspace.ug.edu.gh

i

DECLARATION

I, Christopher Atambire Aganah declare that this thesis is the results of my own work produced

from research under the supervision of Dr. Esi Colecraft and Dr. Gloria Otoo. All references to

other works have been duly acknowledged.

…………………………………… …………………………………………

Christopher Atambire Aganah Date

(Student)

…………………………………… ….……………………………………...

Dr. Esi Colecraft Date

(Principal Supervisor)

……………………………………. ………………………………………

Dr. Gloria Otoo Date

(Co-Supervisor)


ii

DEDICATION

This work is dedicated to my parents (Mr. and Mrs. Aganah) as well as my lovely wife

(Catherine Azupoka Aganah) whose unflinching love, support and encouragement have enabled

the successful completion of my thesis.


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ACKNOWLEDGEMENTS

My sincere thanks first and foremost go to the Almighty God for guiding me throughout the

coursework as well as the research aspect of this program successfully. I would like also to

express my sincere gratitude to the Almighty God for His strength, grace and blessings received

during my two years of study in the University of Ghana.

Without financial support and encouragement from my parents, relatives, guardians and all

concerned, I wouldn‟t have been able to succeed through my two years of study in this

university.

This list would not be complete without me extending my profound gratitude to my supervisors,

Dr. Esi Colecraft and Dr. Gloria Otoo for their motherly encouragement, patience, and above all

the knowledge they had impacted on me during the short time we spent together. I would like to

as well thank all the lecturers and staff of the department of Nutrition and Food Science for their

mentorship.

My heartfelt gratitude goes to my study participants as well as the caterers and teaching staff of

Ko senior high boarding school. To my friends Joe Nyefene Dare, Jonas Sebigbon, Benjamin

Ofori, Mawuli (Biochemistry department), Mr. Boateng Bannerman, my siblings

(ClementinaAganah and Christiana Aganah) and all the Nutrition and Food Science M.Phil Class

of 2012/2014, I really appreciate your love, care and constructive discussions.


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TABLE OF CONTENTS DECLARATION ............................................................................................................................. i

DEDICATION ................................................................................................................................ ii

ACKNOWLEDGEMENTS ........................................................................................................... iii

TABLE OF CONTENTS ............................................................................................................... iv

LIST OF TABLES ....................................................................................................................... viii

LIST OF FIGURES ....................................................................................................................... ix

LIST OF ACRONYMS .................................................................................................................. x

ABSTRACT ................................................................................................................................... xi

CHAPTER ONE ............................................................................................................................. 1

1.0 INTRODUCTION .............................................................................................................................. 1

1.1 Background .................................................................................................................................. 1

1.2 Rationale of the study: .................................................................................................................. 3

1.3 Research Questions ..................................................................................................................... 3

1.4 Main objective of the study: ....................................................................................................... 4

1.5 Specific objectives of the study: .................................................................................................... 4

CHAPTER TWO ............................................................................................................................ 5

2.0 LITERATURE REVIEW ................................................................................................................... 5

2.1 Growth during the period of adolescence ...................................................................................... 5

2.2 Nutritional needs during adolescence .......................................................................................... 6

2.3 Macronutrient requirement of adolescent girls ............................................................................. 6

2.4 Micronutrient requirements of adolescent girls ............................................................................. 8

2.4.1 Iron ........................................................................................................................................... 8

2.4.2 Calcium ................................................................................................................................... 10

2.4.3 Folate ..................................................................................................................................... 11

2.4.4 Riboflavin ............................................................................................................................... 12

2.4.5 Vitamin D................................................................................................................................ 12

2.5 Obesity/overweight and under-nutrition in adolescents ............................................................. 13

2.5.1 Consequences of under-nutrition/over-nutrition among adolescent girls ........................ 15

2.6 Factors contributing to nutritional problem of adolescent girls ................................................... 18

2.6.1 Disease and infection ............................................................................................................. 18


v

2.6.2 Socio-economic status ........................................................................................................... 18

2.6.3 Lack of Nutrition Education at school level ........................................................................... 19

2.6.4 Peer pressure ......................................................................................................................... 20

2.6.5 Eating disorders ..................................................................................................................... 20

2.7 Eating habits of adolescent girls ................................................................................................... 21

2.7.1 Meal skipping habits of adolescent girls ................................................................................ 22

2.7.2 Snacking habits of adolescent girls ........................................................................................ 23

2.8 Effects of unhealthy eating habits among adolescent girls .......................................................... 24

CHAPTER THREE ...................................................................................................................... 26

3.0 METHODOLOGY ........................................................................................................................... 26

3.1 Study Area ..................................................................................................................................... 26

3.2 Study Design .................................................................................................................................. 26

3.3 Study Population ......................................................................................................................... 26

3.4 Sample Size Determination ......................................................................................................... 27

3.4 Sample size determination and sampling procedures .................................................................. 28

3.5 Data Collection Procedures: ...................................................................................................... 28

3.6 Questionnaire administration: ................................................................................................... 29

3.6.1 Socio-demographic characteristics ........................................................................................ 29

3.6.2 Dietary practice: ................................................................................................................... 29

3.7 Dietary intake assessment: ......................................................................................................... 29

3.7.1 Weighed food intake: ............................................................................................................. 30

3.7.2 24-hour dietary recall ......................................................................................................... 30

3.8 Anthropometric Assessment ...................................................................................................... 31

3.9 Ethical Clearance ...................................................................................................................... 31

3.10 Data management and Analysis.................................................................................................. 32

3.11 Quality Assurance .................................................................................................................... 33


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CHAPTER FOUR ......................................................................................................................... 34

4.0 RESULTS ......................................................................................................................................... 34

4.1: Background characteristics of adolescent girls in Ko Senior High Boarding School .................... 34

4.2 Socio-economic characteristics of the households of adolescent girls in the study .................. 36

4.3 Dietary Practices of Adolescent Girls in Ko Senior High School .................................................. 38

4.3.1 Usual Meal Frequency and Pattern and Source of Meals .................................................... 38

4.3. 2 Meal Skipping and Snacking Habits ..................................................................................... 41

4.4 Classification of the dietary practice of adolescent girls in Ko Senior High Boarding School ....... 43

4.5 Nutritional status of adolescent girls in Ko Senior High Boarding School ................................... 44

4.6: Energy and Nutrient Intakes of Adolescent Girls in Ko Senior High Boarding School ................. 45

4.6.1 Type of meals served to adolescent girls in Ko Senior High Boarding School during a 2 weeks

observation period .......................................................................................................................... 45

4.6.2 Nutrient content of meals served to adolescent girls in Ko senior high school compared

with EAR .......................................................................................................................................... 46

4.7 Dietary intakes of adolescent girls in Ko Senior High Boarding School (based on a 24-hour

recall) .................................................................................................................................................. 48

4.7.1 Total Daily intakes of adolescent girls in Ko Senior High Boarding School in comparison

with EAR .......................................................................................................................................... 48

4.7.2 Percent contribution of nutrients from school meals and other food sources to total daily

intakes ............................................................................................................................................. 50

4.8 Chi-Square Analysis for the possible factors associated with the dietary practices of adolescent

girls in Ko Senior High Boarding School. ............................................................................................. 52

4.9 Factors associated with overweight conditions among adolescent girls in Ko Senior High School

............................................................................................................................................................ 53

4.9.1 Predicting factors of overweight among adolescent girls in Ko Senior High Boarding School

........................................................................................................................................................ 54


vii

CHAPTER FIVE .......................................................................................................................... 54

5.0 DISCUSSIONS ................................................................................................................................. 54

5.1 Dietary Practices of Adolescent Girls in Ko Senior High Boarding School ................................... 55

5.1.1 Usual meal frequency and pattern ...................................................................................... 55

5.1.2 Meal skipping and snacking habits ....................................................................................... 56

5.2 Nutritional status of adolescent girls in Ko Senior High Boarding School. ................................... 57

5.3 Energy and nutrient intakes in adolescent girls in Ko Senior High School .................................. 59

5.3.1 Nutrient content of meals served in the school dining hall of Ko Senior High School .......... 59

5.4 Predictors of dietary practices and overweight status of adolescent girls in KO Senior High

School .................................................................................................................................................. 63

CHAPTER SIX ............................................................................................................................. 65

6.0 CONCLUSION, LIMITATIONS AND RECOMMENDATION ............................................... 65

6.1 Conclusion ..................................................................................................................................... 65

6.2 Limitations ............................................................................................................................... 66

6.3 Recommendations .................................................................................................................... 66

REFERENCES ............................................................................................................................. 68

APPENDIX I: ETHICAL CLEARANCE CERTIFICATE .......................................................... 82

APPENDIX II: PARENTAL CONSENT FORM ........................................................................ 83

APPENDIX III: RESEARCH QUESTIONNAIRE...................................................................... 86

APPENDIX IV:PERCENTAGE HAZ AND BAZ DISTRIBUTION AMONG ADOLESCENT

GIRLS IN KO SENIOR HIGH SCHOOL.................................................................................... 93

APPENDIX V: DIETARY PRACTICE AND SOCIO-ECONOMIC SCORES ......................... 94

APPENDIX VI: MEAL SKIPPING AND SANCKING HABITS OF ADOLESCENT GIRLS IN

KO SENIOR HIGH SCHOOL ..................................................................................................... 96

APPENDIX VII: TYPICAL MENU OF THE TYPE OF MEALS SERVED DURING A

NORMAL SCHOOL WEEK IN KO SENIOR HIGH BOARDING SCHOOL .......................... 98

APPENDIX VIII:DETAILED DESCRIPTION OF THE TYPE OF MEALS SERVED TO

ADOLESCENT GIRLS IN KO SENIOR HIGH BOARDING SCHOOL .................................. 99


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LIST OF TABLES

Table 2.1: Role of some Vitamins and Minerals in the body and their deficiency

symptoms………………………………………………………………………………………..17

Table 3.1: Estimated sample size recruited from each class ..........................................................28

Table 4.1: Background characteristics of adolescent girls in Ko senior high boarding school and

their caregivers…………………………………………………………………………………...35

Table 4.2: Household and Socio-economic characteristics of adolescent girls in Ko senior high

boarding school ..............................................................................................................................37

Table 4.3: Nutrient content of meals served to adolescent girls in Ko senior high boarding school

compared with EAR……………………………………………………………………………..47

Table 4.4: Total daily intakes of adolescent girls in Ko senior high boarding school in

comparison with EAR……………………………………………………………………………49

Table 4.5: Percent contribution of nutrients from school meals and other food sources to total

daily intakes……………………………………………………………………………………...51

Table 4.6: Chi-square test of the possible factors associated with the dietary practices of

adolescent girls in Ko senior high boarding school……………………………………………..52

Table 4.7: Chi-square analysis to establish possible factors associated with overweight/obese

conditions among adolescent girls in Ko senior high boarding school…………………………53

Table 4.8: Logistics regression for possible factors that predict the overweight/obesity among

adolescent girls in Ko senior high boarding school……………………………………………...54


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LIST OF FIGURES

Figure 4.1:Self reported usual daily meal consumption frequency among adolescent girls in Ko

senior high boarding school ...........................................................................................................39

Figure 4.2: Self-reported frequency of eating breakfast, lunch and supper among adolescent girls during a

normal school week .................................................................................................................................... 39

Figure 4.3: Source of meals for adolescent girls in Ko senior high boarding school ....................40

Figure 4.4: Self-reported frequency of meal skipping among adolescent girls .............................41

Figure 4.5: Meals most likely to be skipped by adolescent girls at Ko senior high boarding

school……………………………………………………………………………………………………...42

Figure 4.6: Classification of dietary practice scores……………………………………………..43

Figure 4.7: Nutritional status of adolescent girls in Ko senior high boarding school using BAZ

and HAZ………………………………………………………………………………………….44


x

LIST OF ACRONYMS

BAZ Body Mass for Age Z scores

BMI Body mass index

CI Confidence interval

DRI Dietary Recommended Intakes

EAR Estimated average requirement

HAZ Height for Age Z scores

FNB Food and Nutrition Board

IOM Institute of Medicine

Kg Kilograms

cm Centimeters

WHO World Health Organization

PCD Partnership for Child Development

SES Socio-economic status

NAR Nutrient adequacy ratio

AMDR Acceptable macronutrient distribution ranges


xi

ABSTRACT

Background:

Adolescence is an important growth and development life stage which has implications for future

nutritional status and food consumption habits. School meals may offer an opportunity to

enhance dietary intakes and nutritional status of adolescent girls in boarding school settings.

However, there is limited information on the nutritional quality of school meals, dietary habits

and nutritional status of adolescent girls in senior high boarding schools in Ghana.

Objective:

The aim of the study was to assess the dietary practices and nutritional status of adolescent girls

in Ko Senior High Boarding School.

Methodology:

A cross-sectional survey of 180 adolescent school girls was used in this study. Semi-structured

questionnaire was used to solicit information on the girls‟ socio-demographic characteristics and

dietary practices. The 24-hour recall method was used to obtain information on dietary intakes

on 2 non-consecutive days. Additionally the weighed food method was used to ascertain weights

of foods consumed daily from the school dining hall by a random sample of the girl over a two

weeks period. The girls‟ height and weight measurements were also taken. Descriptive statistics,

bivariate and regression analysis were used to summarize the data and to assess for factors

associated with the girls‟ dietary practices and nutritional status.


xii

Results:

Meal skipping, particularly breakfast was observed as the main unhealthy eating habit among

adolescent girls in Ko Senior High Boarding School. Niacin, folate, riboflavin, calcium, vitamin

B12 and vitamin D intakes were found to be below the recommended dietary reference intakes

(EAR). The prevalence of stunting, thinness or low BMI for age and overweight as observed

among the girls were 2.2%, 1.2% and 16.1% respectively.

Conclusion:

The Mean % contribution of school meals and other food sources to the total daily nutrient

intakes of adolescent girls in Ko Senior High Boarding School was reported in this study to be

56.2 and 43.8 respectively. Following this, the quantity and quality of school meals served to the

girls needs to be reviewed by school authorities to increase its contribution to daily nutrient

intakes.


1

CHAPTER ONE

1.0 INTRODUCTION

1.1 Background

Adolescence is an important growth and development life stage which has implications for future

nutritional status and food consumption habits (Lytle, 2002). Adolescents experience growth

spurts associated with rapid physical growth and gain up to 50% of their adult weight and

skeletal mass and more than 20% of their adult height (Rogol et al., 2003). In this period of

accelerated growth, the demand for nutrients increases posing a greater risk of nutritional

deficiencies. Additionally, the adolescence life stage is a period of increasing independence with

respect to food choices and food habits and experimentation with diets which may increase

vulnerability to nutritional problems if unhealthy eating behaviors are adopted (Savige et al.,

2007).

Commonly reported nutritional problems among adolescents include stunting, underweight and

micronutrient deficiencies of iron, zinc, iodine and vitamin A (Drake et al., 2002).While

nationwide data on the nutritional status of adolescent girls in senior high boarding schools is

currently unavailable, a research study to assess the nutritional status of boarding and no-

boarding children in selected schools in Accra, Ghana showed that the prevalence of stunting,

underweight, overweight and obesity among the boarding school children were 0.8%, 0.8%,

12.1% and 11.3% respectively.Furthermore, the study found that both groups of students had

inadequate energy and micronutrient, particularly calcium intakes (Intiful et al., 2013).


2

Inadequate stores or intake of food nutrients can have adverse effects on the physical growth,

immune responsiveness and cognitive development of children and adolescents (Shinjini and

Sunita, 2001). According to Polnay (2002) adolescents have the highest prevalence of

unsatisfactory dietary behaviors of any age group. Adolescent girls are particularly vulnerable to

malnutrition due to increased requirements to support their growth spurt in addition to increased

demand for particularly iron to offset losses through menstruation. Furthermore, for girls,

adolescence is also a period of preparing nutritionally for their productive role. Adolescent girls

who become pregnant are at greater risk of various pregnancy and birth complications since they

may not yet have finished growing (Justin et al., 2000).

Adolescent girls thus need to be adequately nourished to ensure their own optimal growth and

maturation and in preparation for their future reproductive capacity. Girls in institutionalized

settings such as boarding schools may have opportunity to have less problematic eating

behaviours due to scheduled, regular meal times and limited opportunities for making poor food

choices, provided the school meals meet the nutrient requirements of the students.

The purpose of this study was to assess the dietary practices and nutritional status of adolescent

girls in Ko Senior High Boarding School in the Upper West Region. Research into this area

could provide some findings on the dietary practices that determine the state of nutrition of

adolescent girls attending senior high boarding schools. Findings from the study will inform

intervention strategies by parents, caretakers, school authorities and the government to address

the issue of malnutrition.


3

1.2 Rationale of the study:

Dietary habits and intakes of adolescent girls have implications for their physical growth and

maturation and future reproductive capacity. School meals may offer an opportunity to enhance

dietary intakes and nutritional status of adolescent girls in boarding school settings. However,

there is limited information on the nutritional quality of school meals, dietary habits and

nutritional status of adolescent girls in senior high boarding schools in Ghana.

This study will help fill this knowledge gap and also provide evidence to inform

recommendations on improving meals provided to adolescent girls in boarding school settings in

Ghana.

1.3 Research Questions

The research sought to answer the following questions about the dietary practices and nutritional

status of adolescent girls in Ko Senior High Boarding School.

1. What are the dietary practices and nutritional status of adolescent girls

2. What is the nutritional adequacy of school meals served to adolescent girls

3. What are the contributions of school meals and other sources of food consumed to the

total energy and nutrient intakes of adolescent girls

4. What are some of the factors that influence the dietary practices and nutritional status of

adolescent girls


4

1.4 Main objective of the study:

To assess the dietary practices and nutritional status of adolescent girls in Ko Senior High

boarding School.

1.5 Specific objectives of the study:

To determine the nutritional adequacy of school meals served to adolescent girls in Ko

Senior High Boarding School.

To determine the contribution of school meals and other sources of food consumed to the

total energy and nutrient intakes of adolescent girls attending Ko Senior High School

To determine the factors that influence the dietary practices and nutritional status of

adolescent girls


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CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Growth during the period of adolescence

Adolescence is the transitional stage of development between childhood and adulthood. It is one

of the fastest growth periods in the lifecycle. It is a dynamic period of development marked by

rapid changes in body size, shape, and composition (Rogol et al., 2002) that have an influence on

nutritional needs, while concurrent lifestyle changes associated with growing independence

during this period (Hill, 2002) may affect eating habits and food choices. Approximately 50% of

adult bone mass is developed during adolescence (Weaver, 2008), with boys experiencing

greater gains in bone size and bone mass compared to girls (Riggs, 2002)

The adolescent growth spurt is experienced differently by boys and girls. Girls generally begin

their adolescent growth spurt about two years earlier (at about 9 years of age) than boys (at about

11 years of age). However, boys experience greater gains in height (28cm versus 25cm)

compared to girls during the adolescent growth period because of a higher rate of growth and a

longer growth spurt (Hinton et al., 2009). Furthermore, throughout adolescence, boys gain more

lean mass and girls experience greater increases in adiposity, necessary for normal menstruation

(Siantz et al., 2010).


http://lpi.oregonstate.edu/infocenter/glossary.html#adipose

http://lpi.oregonstate.edu/infocenter/glossary.html#menstruation

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2.2 Nutritional needs during adolescence

Nutritional intakes during adolescence are important for growth, long-term health promotion and

development of lifelong eating behaviors. Total nutrient needs are higher in adolescence than

during any other time in the lifecycle because of rapid growth and development. Although

nutritional requirements during childhood are generally similar for both boys and girls, these

diverge considerably after the pubertal growth spurt. The reason for the sex differences in

nutrient recommendations after the age of 10 include earlier maturation of females and variations

in physiological needs for some nutrients by sex. Boys‟ and girls‟ nutrient requirements differ,

with boys needing more energy and protein and girls‟ iron requirements being higher because of

menstruation.

2.3 Macronutrient requirement of adolescent girls

Carbohydrates, proteins and fats are known as macronutrients and are required in large amounts

as they are energy giving foods (Story and Stang, 2005).During adolescence, macronutrient

intakes especially proteins helps to maintain and build muscles tissues as well as repair worn out

tissues to support growth, development and maturation (Petrie et al, 2004).According to (IOM,

2003), protein intake of 46g/d is the sufficient dietary requirement intake (DRI) necessary for

growth and development. However, research studies suggest that, adolescents consume twice as

much the recommended intake of protein per day (Story and Stang, 2005). Rolland-Cachery et

al., (2000) in his study to assess the nutritional status and food intake in adolescents living in

Western Europe reported that fat and protein intakes were higher compared to carbohydrate and

fibre intakes which were generally low.


7

In a study conducted to assess the nutrient intakes of adolescent girls in secondary schools and

universities in Abia State of Nigeria, it was reported that the mean intakes of carbohydrates

(757.10g vs. 937.60g), fat (49.97gvs 157.09g) and protein (93.45g vs. 135.39g) per day among

adolescent girls in both secondary schools and universities were generally higher than the

recommended nutrient intakes (Anyika et al., 2009). Also, Danquah et al., (2013) in a study to

assess the nutritional status of upper primary school pupils in a rural setting in Ghana reported

the mean intakes of carbohydrates among the students to be higher (193.1%) compared with the

recommended nutrient intakes. This was attributed to the fact that most diets consumed were

from starchy staples such as cassava, corn and rice. Results from the same study reported that,

the intakes of protein were met by more than half (66.8%) of the students partly because most of

the protein consumed were mostly of legumes and nuts.

Furthermore, Intiful et al., (2013) in assessing the nutritional status of boarding and non-boarding

school children in selected schools in the Accra Metropolis also reported higher intakes of

protein (100%) and carbohydrates (100%) among student boarders and non-boarders compared

to the EAR. Moreover, the mean intakes of fat among non-boarders (45.73 ± 19.78) were

significantly higher than that of the boarders(36.91± 16.81) partly because the non-boarders are

most of the times exposed to other food sources from home and the outside environment which

are likely to be high in fat. In addition to this, Bazhan et al., (2013) in his study to assess the

dietary habits and nutritional intakes of adolescent girls living in Northern Iran also reported the

mean energy intakes of the adolescent girls to be 2338 ± 611kcal/d of which carbohydrate,

protein and fat contributed 59.3%, 11.9% and 28.8% respectively.


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2.4 Micronutrient requirements of adolescent girls

Micronutrient malnutrition remains one of the most serious nutritional problems worldwide and

adolescents are particularly vulnerable to micronutrient deficiency owing to their high nutrient

requirements for growth and development (Chopra and Darnton-Hill, 2006).Micronutrients are

vital for general wellbeing and each nutrient is essential as the deficiency of one nutrient may

cause the dysfunction of the body. Steyn et al., (2007) highlighted the alarming (two billion)

number of people suffering from micronutrient deficiencies in developing countries, mostly

women and children.

2.4.1 Iron

Iron deficiency (ID) continues to be the most prevalent micronutrient deficiency in the world,

particularly in developing countries(Schneider et al., 2005; Kara et al., 2006), with the WHO

estimating that ID occurs in about 66–80% of the world‟s population(WHO, 2003). It is

estimated that on average 53% of school-age children suffer from Iron deficiency anemia

worldwide (WHO, 2000). The highest prevalence is reported in Asia (58.4%) followed by Africa

(49.8%).In a survey of nearly 14,000 rural school children in Africa and Asia, the prevalence of

IDA was more than 40% in five African countries (Mali, Tanzania, Mozambique, Ghana, and

Malawi) amongst children aged 7-11 years. In the two Asian countries studied, the overall

prevalence of IDA was found to be considerably lower than in Africa (around 12% in Vietnam

and 28% in Indonesia among 7-11 year olds).

Furthermore, in a study of 1,210 primary school girls aged 7-14, in Riyadh, Saudi Arabia, an

anemia level of 55.4% was found. The highest level (71.4%) was found among 14 year-old girls

(UNICEF, 2002). In a survey of 6,486 adolescent students (12-15 years) in East Java, Indonesia,

anemia levels of over 25% in girls, 24% in pre-pubertal boys and 12% in pubertal boys were


9

detected. Higher levels of anemia were found among adolescents of lower socioeconomic status

(Soekarjo et al., 2001).

Yasutake et al., (2013) in a study to assess anemia among adolescents and young women in low

and middle income countries reported an anemia prevalence ranging from 15% to over 50%

among countries. Findings from this study further revealed that African countries showed the

highest prevalence of anemia where Benin, Mali and Ghana had anemia prevalence of over 60%.

Alaofe et al., (2007) in a study on assessing the iron status of adolescent girls in two boarding

schools in southern Benin reported the prevalence of anemia (Hb< 120g/l) among 180 adolescent

girls aged 12 to 17 years to be 51% with about 24% of them suffering from iron deficiency

anemia(ID and Hb< 20g/l). The study further indicated that, the majority of girls suffering from

ID and IDA had a low consumption frequency of meat, poultry, legumes, vegetables and fruit (4

times per week).

Moreover, Monarrez-Espino et al., (2004) in a study on the nutritional status of indigenous

children in boarding schools in northern Mexico also reported iron deficiency anemia among

children aged 6-14years to be 24.2%. According to their findings, IDA was more prevalent in

girls than in boys (13 vs. 6.7%) and this tended to increase with age. In addition to this, Leenstra

et al., (2004) in a study to assess the prevalence and severity of anemia and iron deficiency in

adolescent schoolgirls in western Kenya reported the prevalence of anemia (Hb ˂ 120g/l) to be

21.1%. In this same study, the prevalence of iron deficiency (ferritin˂ 12µg/l) was reported as

19.8and 30.4% of anemic girls were iron deficient.

The detrimental public health effects of iron deficiency include anemia, decreased intellectual

and work performance, and functional alterations of the small bowel (Keskin et al., 2005; Pena-


10

Rosas et al., 2006). Besides other vulnerable age groups such as infancy and early childhood,

adolescence is also considered a high-risk period for developing ID owing to the combination of

rapid physical growth and losses of iron (Fe) through menstruation(Keskin et al., 2005).

2.4.2 Calcium

The calcium requirement during the adolescent period is higher than any other stage owing to the

growth spurt and framework development and approximately 45% of the peak bone mass is

attained at this stage (Story and Stang, 2005). Enough calcium is needed for the prevention of

cancer, strong bones and teeth and aids in the absorption of vitamin B12. The AI for calcium

intake for an adolescent is 1300 milligrams per day (Chemaly et al., 2004).

Story and Stangs (2005) suggest that only 9% or 2 out of 10 adolescent girls meet their calcium

requirements. Intiful et al., (2013) in a study to assess the nutritional status of boarding and non-

boarding school children aged 8 to 10 years in selected schools in the Accra Metropolis revealed

that none of the age groups met their requirements for calcium. Moreover, Nti et al., (2013) in a

study to assess the patterns of food consumption and nutrient intakes of senior high school

students in Accra, Ghana revealed in her findings that the mean calcium intakes in comparison

with the recommended nutrient intakes was particularly low in the girls and boys (264mg vs.

243mg).


11

2.4.3 Folate

Folate plays a vital role in DNA, RNA and protein synthesis. The folate demands increase for

adolescents following the rapid growth that occur during this period. With increasing evidence of

the role of folic acid in the prevention of birth defects, all adolescent girls of childbearing age are

encouraged to consume the recommended amount of folic acid from supplements in addition to

intake of food folate from varied diet. The Center for Disease Control and Prevention

recommend 300µgand 400 µg of folate for adolescents and all females in their reproductive age.

Ijarotimi, (2004) in his study to evaluate the energy and micronutrient intakes of Nigerian

adolescent females reported the mean intakes of folic acid to be 9.8µg/d lesser than the

recommended dietary intake required per day. Moreover, a study conducted by Vanderjagt et al.,

(2000), to assess the folate and Vitamin B12status of adolescent girls in Northern Iran also

reported that majority (97.6%) of the girls had their serum folate concentration within the

normal range for their age group.

In addition to findings as indicated above, Bolajoko et al., (2014) in a study on the nutrient

adequacy of foods eaten by students attending boarding and day secondary schools in Owo,

Nigeria reported that most students (55%) did not meet their dietary requirement for folate. Also,

Aazam et al., (2013) in a study on the nutritional status and dietary intake of adolescent girls

reported that dietary intakes of folate was insufficient (18.7%) among adolescent girls compared

to the dietary reference intakes(DRI).


12

2.4.4 Riboflavin

Riboflavin is an antioxidant involved in oxidation- reduction reactions, cellular respiration, and

energy metabolism. Riboflavin deficiency is endemic in populations who exist on diets lacking

dairy products and meat. Dairy products contribute to riboflavin intake, accounting for 29% and

38% of total riboflavin intake among children and adolescents in the United States and France,

respectively (Drewnowski, 2011).

The National Diet and Nutrition Survey of young people aged 4–18 yrs in the United Kingdom

collected dietary intake and riboflavin status data from a representative sample of 2127

schoolchildren. The survey revealed that the proportion of boys with biochemical values

indicative of poor riboflavin status rose from 59% among 4–6-yr-olds to 78% among 7–10-yr-

olds. Ninety-five percent of 15–18-yr-old girls had evidence of low riboflavin status. Riboflavin

status was significantly correlated with estimates of dietary intake. Mean riboflavin intakes

showed a progressive increase with age among boys, but this was not evident among girls.

Importantly, there was a marked decline in milk consumption with increasing age in both boys

and girls, and in 15–18-yr-olds, milk contributed only 10% of the daily riboflavin intake,

compared with 25% among 4–6-yr-olds.

2.4.5 Vitamin D

Vitamin D insufficiency affects almost 50% of the population worldwide. An estimated 1 billion

people worldwide, across all ethnicities and age groups, have a vitamin D deficiency (Holick,

2007). This pandemic of hypovitaminosis D can mainly be attributed to poor dietary habits and

environmental factors that reduce exposure to sunlight, which is required for ultraviolet-B

(UVB)-induced vitamin D production in the skin. Severe vitamin D deficiency results in the

failure of bone to mineralize, leading to a condition known as rickets during stages of puberty


13

and adolescence (Narchi et al., 2001).Inadequate vitamin D during puberty and adolescence

might prevent the attainment of peak bone mass and final height (Kremer et al., 2009 and

Valimaki et al., 2004) and could possibly increase the risk of osteoporosis or other diseases in

adulthood.

In a study conducted by Harinarayan et al., (2013) to determine vitamin D status and sun

exposure among individuals living in India, it was reported that the formation of previtamin

D3and Vitamin D3when exposed to sunlight was maximal between 11:00am to 2:00pm of the

day during the entire year (Median 11.5% and 10.2% respectively at 12:30pm).In addition to the

research findings as illustrated above, Binkley et al., (2007) in his study also reported the mean

serum 25(OH) D concentration among 93 adults with a mean age and body mass index of 24y

and 23.6kg/m² respectively to be 31.6ng/ml. With a cutoff point of 30ng/ml used in the study,

more than half (51%) of the population under study had low vitamin D status despite exposed to

abundant sunlight.

In study conducted by Talwar et al., (2007) to determine Vitamin D nutrition and bone mass in

adolescent black girls, it was reported that all participants in the study were Vitamin D

deficient(serum 25(OH)D level ˂ 50nmol/L) with about 43% of the study population being

severely deficient in Vitamin D (serum 25(OH)D level ˂ 20nmol/L).

2.5 Obesity/overweight and under-nutrition in adolescents

Obesity occurs as a result of imbalance between energy intake and energy expenditure, that is

when energy intake exceeds energy used (Hall et al., 2011). Overweight and obesity are

attributed to increased consumption of energy dense, nutrient poor foods with high levels of

sugar and saturated fats combined with reduced physical activity (WHO, 2003). In 2009, the


14

World Health Organization (WHO) estimated 155 million or one in 10 school-age (5 – 17 years

old) children worldwide to be either overweight or obese. In Africa, the estimated prevalence of

childhood overweight increased from 4% in 1990 to 7% in 2011, and is expected to reach 11% in

2025(Black et al., 2013), while underweight is projected to increase albeit at a slower pace from

24% in 1990 to 26.8% by 2015 (De-Onis et al., 2004). As of 2011, childhood and adolescent

overweight remained highest in developed countries (15%), but increasing rapidly as shown by

the estimated 7% and 5% prevalence in Africa and Asia respectively(Black et al., 2013).

According to Biritwum et al., (2005), the overall prevalence of obesity in Ghana was found to be

over (5.5%). Among females the prevalence was (7.4%) compared to males (2.8%).Obesity was

very high in Greater Accra (16.1%) and almost absent in Upper East or Upper West regions. By

ethnicity, obesity was highest among Ga Adangbe, Ewes and Akans (14.6%, 6.6% and 6.0%

respectively).

About 8%, 26% and 16% of children worldwide suffer from wasting, stunting and underweight

respectively while the prevalence is about 10%, 38% and 23% for developing countries and 9%,

28% and 14% in Ghana (UNICEF, 2013). The 2008 Ghana Demographic and Health survey

estimated the prevalence of childhood malnutrition (stunting, wasting and underweight) to be

declining from 35% in 2003 to 28% in 2008, 14% in 1993 to 9 percent in 2008, and 23% in 1993

to 14% in 2008 respectively.

Lou et al., (2009) in his study on malnutrition in rural boarding schools in china showed that

boarding school children (23%) were found to be worse off than non-boarding school children

(11%) in terms of stunting. He further reported that this was attributed to the poor living

conditions and nature of meals served in the boarding school. Studies also conducted by


15

Monarrez-Espino et al., (2004) among boarding school children 6 to 12 years saw a prevalence

of stunting, underweight and overweight to be 22.3%, 3.2% and 0.6%.

In the past, the malnutrition problems of developing countries like Ghana stemmed from under-

nutrition. However, with the changes in lifestyle and eating habits of adolescents, over-nutrition

has increased. The increase in the two extremes that is overweight and underweight results in an

epidemic of diseases including hypertension, cancers, stroke, diabetes and other non-

communicable diseases (Dimeglio, 2000). Chronic diseases were the cause of 35 million deaths

globally in 2005, 80% of which were in low and middle income countries.

2.5.1 Consequences of under-nutrition/over-nutrition among adolescent girls

Under-nutrition continues to be a public health challenge globally, despite a decrease in

prevalence. In 2011, 101 million (16%) children under-5 years of age were underweight, 165

million (26%) were stunted and 52 million (8%) were wasted. The majority (90%) of the world‟s

stunted children live in Africa and Asia (WHO, 2012). Under-nutrition in childhood leads to

underdevelopment and stunted growth, and is associated with higher morbidity and mortality.

Underweight is also associated with low energy levels, tiredness and poor perceptions of body

image (Reddy et al., 2009).Under-nutrition among women is a major predisposing factor for

morbidity and mortality among African women, with between 5% and 20% of African women

having low BMI (Lartey, 2008).

In adolescents, chronic under-nutrition delays normal maturation and is an important and

widespread problem with multiple adverse health outcomes. For example, pregnant adolescents

who are underweight or stunted are especially likely to experience obstructed labor and other

obstetric complications since they may not yet have finished growing (Justin et al., 2000)


16

Overweight and obesity in children is on the rise globally. WHO estimated that in 2005 there

were more than 1 billion overweight adults globally, at least 300 million of them obese (WHO,

2003), and up to 20 million children under 5 years of age who were overweight (WHO, 2006). In

2011, 43 million (7%) children under 5 years of age were overweight, an increase of 54% from

28 million in 1990 (WHO. 2012). According to Hoffman, the prevalence of obesity is increasing

worldwide and in some developing countries where the prevalence was previously very low

(Hoffman, 2001).

Overweight and obesity have been linked to adverse psychological and physical outcomes during

childhood and continuing into adolescence and adulthood (Rossouw et al., 2012).Overweight and

obesity pose major risk for serious diet related chronic disease including type 2 diabetes,

cardiovascular diseases, hypertension, stroke and certain forms of cancers, especially hormonally

related, large bowel cancers, gall bladder diseases, high cholesterol and triglycerides which

reduces the quality of life and can cause premature death (WHO, 2003). Other health problems

associated with overweight and obesity which are nonfatal include respiratory difficulties,

chronic musculoskeletal problems, skin problems and infertility (WHO, 2003). Overweight and

obese adolescents during adulthood are twice likely to develop cardiovascular diseases and the

risk for developing atherosclerosis increases seven times (PAHO, 2012).

Also, micronutrient malnutrition has serious consequences on the health and productivity of

more than 2 billion people worldwide. Micronutrient deficiencies such as iron, zinc, vitamin

A, folate, and iodine, are profound and include premature death, poor general health,

blindness, growth stunting, mental retardation, learning disabilities, and low work capacity.


17

Anemia, the main nutritional problem in the adolescent is estimated to be 27% and 6% in the

developing and industrialized countries respectively (WHO, 2012a).

Table 2.1: Role of some Vitamins and Minerals in the body and their deficiency symptoms

Nutrients Functions in the body Deficiency symptoms

Vitamin A Ensures good vision, needed for immune

system, function and resistance to infection,

maintenance of epithelial cells, membranes

and skin

Night blindness/vision problems,

rough skin, susceptibility to

infections

Vitamin

B2(Riboflavin)

Used in energy metabolism, supports health

and integrity of the skin, supports normal

vision

Eye problems, skin disorders

around the mouth and nose

Vitamin B12 Required in the synthesis of new cells

especially red blood cell formation,

maintenance of nerve cells

Anemia, glossitis (smooth tongue),

nerve degeneration resulting in

paralysis

Vitamin C Increases non-haeme iron absorption,

increases resistance to infections and acts as

an antioxidant, helps in protein metabolism

Scurvy/bleeding gums, anemia,

poor wound healing, muscle

degeneration, bone fragility

Vitamin D Required for the mineralization of bone &

teeth, aids in the body‟s absorption of calcium

Rickets in children, osteomalacia in

adults, abnormal growth, joint pains

Iron Hemoglobin formation for red blood cells,

transport of oxygen from the lungs to cells

throughout the body, required for utilization

of energy and metabolism

Anemia, weakness, headaches,

reduced resistance to infection,

inability to concentrate

Calcium Building strong bones & teeth, important for

normal heart & muscle function, blood

clotting and immune defence

Stunted growth in children, bone

loss(osteoporosis) in adults

Iodine Development and proper functioning of the

brain and nervous, growth & development

Goiter; cretinism


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2.6 Factors contributing to nutritional problem of adolescent girls

2.6.1 Disease and infection

Globally, helminthes infections affect more than one billion people in developing countries

(Diseases Control Priorities Project, 2008). Of these people, school-age children and

preschoolers are more infected than any other age group (Hotez et al., 2008). School-age

children have been reported to have the highest intensity of worm infection of any age group

(Disease Control Priority Project, 2008). Helminthes infections occur as a result of poor hygienic

habits, immune system and overcrowding (Alemu et al., 2011).

Worm infections are detrimental to the physical growth and educational advancement of

children (Disease Control Priority Project, 2008). Worm infections further affect human survival,

appetite and physical fitness (Alemu et al., 2011). Helminthes infections lead to iron loss from

blood in intestine and also reduced intake of iron rich foods as a result of reduced appetite

(Crompton and Neisham, 2002). In children and adolescents, consequences from helminthes

infections can result in anemia (Crompton and Neisham, 2002). Severe anemia that is caused as a

result of worm infections usually result in under-nutrition (Disease Control Priority Project,

2008).

2.6.2 Socio-economic status

Socio-economic status is known to be a great determinant of health and nutritional status.

Adequate availability of food in terms of quantity and quality is dependent on the socio-

economic status, food practices and cultural traditions of a given household (WHO, 2006). The

main environments that influences the way children and adolescents grow up include families,

neighborhood and school. The quality of these environments has a profound bearing on the

adolescents‟ chances of growing into healthy adults. Family income is thus the most important


19

factor in the determination of the quality of these environments as well as the health and

nutritional status of children and adolescents (Nilsen et al., 2009). Low income families tend to

either purchase less nutritious cheap food items as a means to cope with the situation or reduce

food intake. This practice however affects the nutritional needs of the vulnerable such as

adolescents where nutrient are high to support their physiological growth and development.

2.6.3 Lack of Nutrition Education at school level

Nutrition education as David et al., (2008) described it, is the process through which people gain

the knowledge, attitude and skills that are necessary for developing good dietary habits. Children

spend one-third of the day at school, thus providing a practical environment for education about

healthy food choices is necessary (Foster et al., 2008). Peres-Rodrigo and Aranceta, (2001)

argue that schools have the potential to reach out to children at a critical age when eating habits

are still forming and pave a way for healthy behavior and dietary habits to adulthood. The study

by Neira and De-Onis, (2006) indicated that schools can positively influence the lives of most

children and offer numerous opportunities for teaching children about healthy diets and physical

activity. Children who are already at risk due to health nutritional problems come to school tired,

hungry and unable to cope with learning demands or benefit from the lessons. Steyn, (2010)

stated that the curriculum-based nutrition programmes would significantly improve children‟s

nutrition knowledge and dietary behavior; hence the necessity for schools to develop school

wellness policies and limit access to unhealthier food should be every schools priority.


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2.6.4 Peer pressure

Food consumption in the adolescent stage of life is influenced by many factors including media,

financial feasibility, gaining new body image and many more. Adolescent years are a time when

the adolescent tries to establish their own identity yet desperately seeks to be socially accepted

by peers (Anyika et al, 2009). Adolescence is a nutritionally vulnerable developmental stage

because growth rate accelerates. Adolescent eating behavior in terms of nutrient intake and food

consumption may vary across different ethnic and socio-demographic sub-populations.

According to Benavides-Vaello, (2005) socio-environmental factors, family, peers and media,

are believed to influence individuals‟ food habits and food choices. Peers and friends can also

play a role in influencing each others‟ food selection and behavior or types of foods to consume

(Elmo, 2009). Basset et al., (2007) said peer pressure acceptance and conformity accelerate as

adolescents assume independence in purchasing food away from home. Peer approval and

identity compel teenagers to conform to the standard approved and acceptable to peers (Story et

al., 2002).

2.6.5 Eating disorders

Eating disorders were predominantly perceived to be western phenomenon. However, as western

cultural values have been embraced, eating disorders appear to have become prevalent across

racial, ethnic and socio-economic groups (Mould et al., 2011). This is because black females are

becoming more dissatisfied with the appearance of their bodies and as a result of this tend to

adopt unhealthy attitudes about being thin. The consequence of food behavior characterized with

insufficient nutrient intake results in eating disorders such as anorexia and bulimia nervosa.


21

An individual with anorexia nervosa has a relentless preoccupation with dieting and weight loss

that results in severe emaciation and sometimes death (Gowers and Bryant-Waugh, 2004).

Typically eating disorders begin during the adolescent years, which progresses to an out-of-

control stage (Mould et al., 2011). For teenagers, the intense desire for slim body size and shape

influences the eating behavior and subsequently leads either to anorexia or bulimia eating

disorders.

2.7 Eating habits of adolescent girls

Nutrition and physical growth are integrally related and thus optimal nutrition is a requisite for

achieving full growth potential. During adolescence, healthy eating behavior is a fundamental

prerequisite for physical growth, psychosocial development and cognitive performance, as well

as prevention of diet-related chronic diseases such as cardiovascular diseases, cancer and

osteoporosis in adulthood (Quatromoni PA et al 2002).

There exists a direct relationship between dietary habits during childhood years and growth,

development as well as the prevalence of disease throughout the life cycle (Oldewage-Theron

and Egal, 2010). Eating habits of adolescents are influenced by various physical and psycho-

social factors. Despite high nutrient requirements, adolescents usually have lower intake

probably due to poverty and poor nutritional knowledge.

Practicing healthy eating behaviors is one of the most important factors to meet the nutritional

needs of adolescents and proper eating behaviors that are learned in early life are maintained in

adulthood thus reducing the risk for major chronic disease (Chin et al., 2009; McNaughton et al.,

2008). Physical and psychological changes occurring during this period usually significantly

influence their dietary behaviors (Dapi et al., 2005).


22

Adolescence is a time of growing independence including increased opportunities to make

decisions about what and when to eat. Nevertheless, being influenced by a multitude of factors

(biological, social, physical, economic, psychosocial, attitudes, beliefs and knowledge about

food) and changing of lifestyle may affect their dietary choices and eating behaviors, thus

making them fail to adhere to healthy eating practices ( Taylor et al., 2005).

2.7.1 Meal skipping habits of adolescent girls

Skipping meals is a decision that adolescents frequently make (Shaw, 1998), and healthy eating

is often a low priority or not practiced (Neumark-Sztainer, 2004).Girls skip meals in their anxiety

to be thin. Female body image is intimately bound up with subjective perceptions of weight

(Hutchison, 2002). Research has therefore shown that with increasing age, the prevalence of

body shape and weight concerns among adolescent girls rises from one in ten among 11 year

olds to one in five among 15-16 year olds (Cooper and Goodyear, 1997).

Onyiriuka et al., (2013) in a school-based cross-sectional study on the eating habits of adolescent

girls in Nigerian urban secondary school found out that meal skipping, consumption of fast foods

along with soft drinks and low consumption of fruits and vegetables were the main eating habits

displayed. His study further revealed that, of the 3 main meals, breakfast was most frequently

skipped and dinner least frequently skipped.

A research conducted in Nordic countries (Denmark, Finland. Norway and Sweden) by

Samuelson et al., (2000) involving adolescents aged 13-18 years further revealed that, breakfast

was the main meal often skipped by the participants especially in females than males. Breakfast

skipping has been associated with poor health outcomes including higher body mass index


23

(BMI), poorer concentration and school performance, and increased risk of inadequate nutrient

intake, especially calcium and fiber (Rampersaud et al., 2005).

2.7.2 Snacking habits of adolescent girls

Snacking is a common feature of the diet of adolescents. Unfortunately, food choices made by

adolescents while snacking tend to be high energy dense foods, wide use of fast foods and low

consumption of fruits and vegetables and this among others are common in both the developed

and developing countries (Kerr et al., 2009).

A study in Nepalese school children showed that fast foods (ready to eat snacks, chips etc.) were

preferred by more than two-third of adolescents. Advertising, probably TV and magazines,

influenced preferences in 80% of these Nepalese adolescents (Sharma, 1998).

Owusu et al., (2007) in a study on measuring the nutritional intakes of adolescents in Ghana,

West Africa demonstrated that the food choices made by adolescents while snacking usually are

high in candy, soda and fried foods rather than fruits, vegetables and salads. Muthoni, (2012)

also in a study on snacking in association with dietary intake and nutritional status of adolescents

in two senior high schools in Nairobi Kenya demonstrated an increase in the frequency of

consumption of snacks among students from high socioeconomic class families than those of a

lower class. The study further established that 58.3% of the students ate energy-rich snacks,

22.2% sugar-sweetened beverages, 11.4% carbonated soft drinks and only 1.1 % consumed fruits

and vegetables.


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2.8 Effects of unhealthy eating habits among adolescent girls

Individuals‟ reasons for buying and eating particular foods have been described as a “complex

bio-psychosocial process that is relative to person, place and time” (Walsh & Nelson 2010).

Most researchers believe that dietary habits and food preferences developed in childhood, are

established by age 15, and become habitual in due course (Sweeting & Anderson 1994).

Adolescence is thus still a key formative period in the development of eating habits (Walsh &

Nelson, 2010).

Healthy eating during childhood and adolescence is an important factor in the promotion and

maintenance of good health throughout one‟s entire life course. Adolescence is therefore often

considered a critical period for many psychological and behavioral transitions including feeding

practice (Rolland-Cachery et al., 2000). A poor dietary practice during this period is thus one of

the most significant risk behaviors that pose a threat to the health of adolescents (Petrillo et al.,

2002). Unhealthy eating among young people is directly linked to deficiencies in intellectual

performance and cognitive development, behavioral and mental problems, obesity and

overweight conditions and eating disorders.

Abudayya et al., (2009) in a study on diet, nutritional status and school performance among

adolescents in Gaza Strip, found out that there was a positive association between the intake of

fruits and vegetables and school performance. Moreover, Taras et al., (2005) in a study on

obesity and performance at school also revealed that childhood overweight was associated with

poor school performance in later life.


25

The adolescent constitute a special group that is usually involved in mental process of learning

and understanding and it is the stage when they develop food choices and food habits.

Developmental changes during adolescence often affects both nutrient intakes and needs thereby

rendering adolescents nutritionally vulnerable with unhealthy eating behaviors that do not meet

dietary recommendations (Savige et al., 2007). Healthy eating behavior during adolescence is a

fundamental prerequisite for physical growth, psychosocial development, cognitive performance

and prevention of diet-related chronic diseases in adulthood (Onyiriuka & Ibeawuchi, 2013).

In boarding institutions, school meals may offer students an opportunity to meet their dietary

requirements for nutrients in order to sustain a vigorous and healthy life, yet much is not

documented about the nutritional status and dietary pattern of adolescent girls in boarding school

settings. This study will help fill this knowledge gap and also provide evidence to inform

recommendations on improving meals provided to adolescent girls in boarding school settings in

Ghana.


26

CHAPTER THREE

3.0 METHODOLOGY

3.1 Study Area

The study was carried out at Ko Senior High Boarding School, a mixed boarding school located

in Ko, a town located in Nandom District in the Upper West region of Ghana. Nandom District

lies in the North Western corner of the Upper West Region and has a population of size of

46,040 people living in about 84 communities, the majority of which are rural (GSS, 2010). The

main economic activity of people living in the district is farming. Ko Senior High School was

established in 1996 as a mixed sex boarding school. Currently the school has a population of 604

students comprising of 290 girls and 314 boys. There is about 28 teaching staff. The school has 5

residential facilities (dormitories) of which 2 houses girls and the remaining 3 accommodate the

boys. The school kitchen serves students with three meals (breakfast, lunch and supper) daily.

3.2 Study Design

A cross-sectional study design was used for the study.

3.3 Study Population

The study population comprised of adolescent girls between the ages of 10 to 19 years attending

Ko Senior High Boarding School of the Upper West Region. The inclusion criteria for

participation were:

1. Willingness of the child and their caregiver to participate in the study by signing an

informed consent form.


27

2. Study participants should have been enrolled in the school for at least one term

prior to the start of the study.

3.4 Sample Size Determination

The sample size calculation is based on Cochran‟s formula:

n = t² x p (1-p)

m²

Description of variables used in sample size calculation:

n = required sample size

t = confidence level at 95% (standard value of 1.96)

p = estimated prevalence of underweight among adolescents in the Upper West Region -13.1%

(Northern Ghana food security and nutrition monitoring system-June, 2009)

m = margin of error at 5%

So therefore; n = 1.96² x 0.131(1-0.131)

0.05²

= 3.842 x 0.114

0.0025

= 0.4380

0.0025

= 175.20

An estimated total sample size of 175.20 was calculated which was rounded up to 180 to take

into account possible exclusions due to incomplete data.


28

Proportionate weighting was used to determine the number of participants to be recruited from

each class. Proportionate weighting formulae used is as follows;

Estimated number of girls in each class x Sample size population (N)

Total number of girls in entire school

The sample size distribution of the study participants based on the proportionate weighting

computations is provided in Table 3.1 below:

Table 3.1: Total sample size recruited from each of the classes

KO Senior High School

(Class levels)

Total number of girls in

each class

Sample size

SHS 1 235 87

SHS 2 193 72

SHS 3 56 21

Total 484 180

3.4 Sample size determination and sampling procedures

Simple random sampling procedures were used to determine the sample size to be recruited from

each class. This was done through a balloting process where students per each class were given

an equal opportunity to ballot (Yes/No) to be part of the study.

3.5 Data Collection Procedures:

Data collection took place from the last week of January to ending of March, 2014. Data

collection included questionnaire administration, dietary intake assessment (24-hr recall and

weighed food record) and anthropometric assessment as detailed below:


29

3.6 Questionnaire administration:

Data were collected by 3 trained research assistants via face-to-face interviews using a semi-

structured questionnaire. The semi-structured questionnaire instrument included sections on

socio-demographic characteristics and dietary practices. Details on the information collected by

the different sections of the questionnaire are provided below.

3.6.1 Socio-demographic characteristics

This section focused on collecting information on background characteristics of the study

participant‟s (age, sex, class/form, ethnicity) and the socio-demographic characteristics of their

households- the occupation and highest educational level of their parents, number of children and

adults in each household, tenancy status and household ownership of assets using a semi-

structured questionnaire.

3.6.2 Dietary practice:

The section on dietary practices provides information on usual behaviors related to meal

consumption pattern and frequency, meal skipping and snacking. Open-ended questions were

used to obtain information on reasons for certain dietary behaviors.

3.7 Dietary intake assessment:

The dietary intake assessment methods included weighed food record of meals served in the

dining hall and 24-hour dietary recall with the adolescent girls.


30

3.7.1 Weighed food intake:

Permission was sought and obtained from school authorities to weigh randomly selected dished

portions of food served to students in the dining hall each day consecutively for two weeks.

Prior to each meal, four dining tables were randomly selected by lottery method with the help of

the dining hall master. At each selected dining table, dished out portion of food served to

students was weighed to the nearest 1 gram using a digital Compact Dietary Scale. The plate was

weighed and the scale zeroed before the food portion was served on the plate. After the meal,

any plate waste was weighed and subtracted from the previous weight of food to obtain the

weight of food consumed. For meals that contained more than one component, each component

was weighed separately.

3.7.2 24-hour dietary recall

The 24-hour recall method was used to collect information on all foods (from all sources) and

beverages, except water, consumed by adolescent girls on two non-consecutive school days i.e.

(one weekday and a weekend). With the aid of household measures and wooden food models,

participants were asked to estimate the actual quantities of food consumed in the past 24-hours.

For foods reported as being purchased from food vendors within the school compound, the cost

of food was obtained and the same quantities purchased and weighed to obtain the quantities

consumed by the participant.


31

3.8 Anthropometric Assessment

Height and weight measurements were completed on the adolescent girls. The height of

participants was measured to the nearest 0.5cm using a microtoise while they were in an upright

position. They were asked to remove their shoes and socks and hair bands before their height

measurements were taken.

The weight of the school girls was also determined with a Tanita digital weighing scale using

standard procedures. Weight measurement was taken with participants in uniform only without

shoes and socks being worn and this was recorded to the nearest 0.1kg. Weight and height

measurements of the study participants were taken in triplicates and their average calculated to

minimize errors (NHANES, 2007)

3.9 Ethical Clearance

The research protocol was reviewed and approved by the Ethics Committee for Humanities

(ISSER) of University of Ghana. Additionally approval was sought from the District Director of

Ghana Education Office (G.E.S) as well as the headmaster of the school before data collection

began. An informed consent was sought from the student and her caregiver using a consent form

where the caregiver and the student agree to be part of the study either by thumb printing or

signing.


32

3.10 Data management and Analysis

Data were entered and analyzed using SPSS software, version 20. A nutrient composition

database (RIING Nutrient Data base) was used in converting daily food intake into energy and

nutrient intakes. Descriptive statistics was used to describe the socio-demographic and household

characteristics of the girls and their caregivers. Means, standard deviations and ranges were

calculated for continuous variables while proportions and frequencies were computed for

categorical variables. Based on the responses of the girls to questions on some socio-

demographic characteristics such as the educational and occupational background of both

parents, previous school attended in Junior High School and household ownership of assets, a

socioeconomic score of low SES (5-8), middle SES (9-15) and high SES (16-31) was developed

to describe the socio-economic status of the girls (see appendix III & V)

Objective 1: Frequencies and proportions were used to describe the dietary practices of the

adolescents with respect to usual meal frequency, meal skipping and snacking habits.

Furthermore, a composite dietary practice score was computed based on responses to the dietary

practice questions that were scored as shown in appendix IV.

Also, height for age and BMI for age Z-scores were computed using the WHO Anthroplus

software and frequencies as well as proportions calculated to describe the nutritional status of the

girls.

Objective 2: Mean and standard deviations of energy, macronutrient and micronutrient intakes as

well as the percent contribution of energy, protein, carbohydrate and other relevant nutrients to

the total energy consumed per day was compared to their respective EAR and RDA

classifications in order to determine if the school meals served to adolescent girls in Ko Senior

High School was adequate enough to meet their nutritional requirement.


33

Objective 3: Mean and standard deviations of energy and nutrient intake were calculated. Percent

contribution of energy and nutrient intakes of school meals and other food sources in relation to

the total nutrient intake per day were also calculated to determine the mean percent contribution

of school meals and other food sources to the total daily food intake. Furthermore, the nutrient

composition of the school meals and other sources of food consumed daily were compared to

their respective EAR and RDA classifications to assess whether the adolescent girls were

meeting their nutritional needs or not.

Objective 4: Chi-square test was done to establish the possible factors that could affect the

dietary practices and nutritional status of the respondents. Based on the factors established in the

Chi-square test, logistic regression was done to find out some possible risk factors of

overweight/obesity among adolescent girls in Ko Senior High School. Level of statistical

significance using the logistic regression and Chi-squared test was set at P-value < 0.05.

3.11 Quality Assurance

To ensure reliability of data collected, three research assistants were trained to administer the

questionnaire and to undertake anthropometric measurements in a standardized manner. Each

day after data collection, questionnaires were reviewed for accuracy. Where responses were

missing, illegible or ambiguous, respondents were contacted by a follow-up visit to clarify

responses.


34

CHAPTER FOUR

4.0 RESULTS

4.1: Background characteristics of adolescent girls in Ko Senior High Boarding School

A total of 180 adolescent girls from the first (48.3%), second (40%) and third (11.7%) year of Ko

Senior High School participated in the study (Table 4.1). Their mean age was 17 ± 2 years. The

majority were Dagaos (87.2%) and of Christian faith (94.4%). On vacations about one-half of the

girls stayed with both parents and the remainder stayed with either their mother or father (27.7%)

or with other relatives (22.7%).

One out of every five of the participants‟ mothers and about 14% of their fathers had completed

higher than junior high school education. About 38% and 45% of mothers and fathers

respectively had no formal education. The most common occupation for both the mothers (78%)

and fathers (57%) of the girls was trading and farming.


35

Table 4.1: Background characteristics of adolescent girls in Ko Senior High School and

their caregivers (N=180)

Characteristic Mean ± SD/n (%)

Age(y) 17 ± 2

Senior high school year:

1 87(48.3)

2 72(40.0)

3 21(11.7)

Ethnicity:

Dagaos 157(87.2)

Other northern ethnicity* 23(12.8)

Religion:

Christianity 170(94.4)

Islam 10(5.6)

During vacation lives with:

Both parents 89(49.4)

Mother/Father 50(27.7)

Other relatives # 41(22.7)

Mother’s education:

None 68(37.8)

Primary 38(21.1)

JHS/Middle school 38(21.1)

>JHS 36(20.0)

Father’s education:

None 81(45.0)

Primary 38(21.1)

JHS/Middle school 36(20.0)

>JHS 25(13.8)

Mother’s occupation:

Trade/farming 103(57.2)

Housewife 55(30.5)

Professional¹ 10(11.1)

Vocational ² 5(2.7)

Others³ 7(3.8)

Father’s occupation:

Trade/farming 141(78.3)

Professional¹ 27(15.0)

Vocational² 8(4.4)

Others³ 4(2.2)

*Other northern ethnicity (Sisala, Wala, Mossi, Frafra, Bulisa and Dagbani); #Other relatives

(Uncle, Auntie, Grandfather, Grandmother, Sister); ¹Professional (Teacher, Nurse, secretaries,

civil servants); ²Vocational (Seamstress/Tailor, Mason, Carpentry, Auto mechanic); ³Others (Pito

brewing, contractor, labourer, mining (galamsey);


36

4.2 Socio-economic characteristics of the households of adolescent girls in the study

The girls were from homes with an average household size of 9 ± 5 members, comprising of a

mean of 6 ± 4 and 5 ± 4 adults and children (<18y) respectively (Table 4.2). Electricity was the

main source of light for the 60% of the adolescents‟ homes, with the remainder reporting that

their main source of light was the flashlight (35%), kerosene lamp (3.3%), and generator (1.7%).

Most (78.9%) of the girls reported that their main source of drinking water was a borehole with

less than 20% reporting piped water as the main source of drinking water in their homes.

The most common household assets owned by the adolescents‟ households were bicycles (97%),

standing or ceiling fan (94%) and mobile phones (61%). The least common household assets

were car (21%), internet access (7%) and air conditioner (2%). The mean household socio-

economic status score of adolescent girls was 13± 6 with 27.2%, 44.4% and 28.3% classified as

being of low, middle and high socio-economic class.


37

Table 4.2: Household and Socio-economic characteristics of Adolescent girls in Ko Senior

High boarding school

Characteristic Mean ± SD/n (%)

Household size: 9 ± 5

Number of Adults 6 ± 4

Number of children(<18y) 5 ± 4

Main source of light:

Electricity 108(60.0)

Kerosene lamp 6(3.3)

Flash light 63(35)

Generator 3(1.7)

Main source of drinking water:

Pipe-borne 32(17.8)

Borehole 142(78.9)

Dam/Rivers/Wells 6(3.3)

Ownership of Household

assets:

Mobile phone 174(96.7)

Bicycle 170(94.4)

ceiling/standing fan 109(60.5)

Television 88(48.9)

Fridge 51(28.3)

Computer 50(27.8)

Car 37(20.6)

Internet access 12(6.7)

Air-conditioner 4(2.2)

Socio-economic status(SES):

Mean SES score 13 ± 6

Low SES (5-8) 49(27.2)

Middle SES (9-15) 80(44.4)

High SES (16-31) 51(28.3)


38

4.3 Dietary Practices of Adolescent Girls in Ko Senior High School

In examining the dietary practices of the girls, self-reported usual behaviors related to meal

consumption frequency, meal pattern, meal skipping and snacking were assessed.

4.3.1 Usual Meal Frequency and Pattern and Source of Meals

Approximately 80% of the adolescent girls in Ko Senior High Boarding School reported that

they usually ate 3 meals a day (Figure 4.1). The remaining reported eating just 2 meals (11%) or

more than 3 meals (9%) a day. When asked about their frequency of consuming breakfast, lunch

and dinner during a normal school week, approximately 40%, 63% and 54% of the girls reported

that they always consumed breakfast, lunch and supper respectively (Figure 4.2). Lunch as

reported in this study was the least skipped meal.

The main source of meals for the girls was the school dining hall with about 90% of them

reporting that they usually ate breakfast, lunch and supper there (Figure 4.3)


39

Figure 4.1: Self-reported usual daily meal consumption frequency among

adolescent girls in Ko Senior High Boarding School

Figure 4.2: Self-reported frequency of eating breakfast, lunch and supper

among adolescent girls during a normal school week

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Breakfast Lunch Supper

Pe

rce

nt

of

resp

on

de

nts

Type of meal

never

sometimes

always

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

2 3 >3

% o

f re

spo

nd

en

ts

Number of meals consumed per day


40

Figure 4.3: Source of meals for adolescent girls in Ko Senior High Boarding

School

0

10

20

30

40

50

60

70

80

90

100

School dinning hall Food fromchopbox

food purchased

% o

f re

spo

nd

en

ts

Source of meal

breakfast

lunch

supper


41

4.3. 2 Meal Skipping and Snacking Habits

The most frequently skipped meal was breakfast (50.6%) and lunch was the least frequently

skipped meal. Some of the main reasons given for meal skipping included dislike for school

meals (28.3%), lack of appetite (25.6%), avoid sleeping in class (15.0%) and food allergies

(11.1%) (Figure 4.5).

Snacking was a part of the eating habits for the majority (95%) of adolescent girls in the study.

Major reasons for snacking included hunger(38.9), an appetite for snacks (30.6%), promotion of

good health (15.6%) and dislike for meals served in the school dining hall (9.4%). The most

frequently consumed snacks during a normal school week as reported by the girls in study were

groundnuts (70.6%) cookies/biscuits (57.8%), gari (59.4%) and pie/chips (27.2%). The girls

further reported that they usually consumed most of these snacks from their chop-box.

(Appendix VI)

Figure 4.4: Self-reported frequency of meal skipping among adolescent girls in

the study

0

10

20

30

40

50

60

70

80

Very often Quite often Sometimes Never

% o

f re

spo

nd

en

ts

Meal skipping frequency


42

Figure 4.5: Meals most likely to be skipped by adolescent girls at Ko Senior

High Boarding School

0

10

20

30

40

50

60

Breakfast Lunch Supper

% o

f re

spo

nd

en

ts

Type of meal


43

4.4 Classification of the dietary practice of adolescent girls in Ko Senior High Boarding

School

Overall, most (62.2%) adolescent girls in Ko Senior High Boarding School had a moderate

dietary practice with just about 20.6% and 17.2% of them having a poor and good dietary

practice respectively. The mean dietary practice score of the girls was 8 ± 2.

Figure 4.6: Classification of dietary practice scores

0

10

20

30

40

50

60

70

poor dietary practice moderate dietary practice good dietary practice

% c

lass

Dietary practice classifications


44

4.5 Nutritional status of adolescent girls in Ko Senior High Boarding School

Approximately 2.2% of adolescent girls in Ko Senior High Boarding school were stunted and

1.2% had low BMI for age or were thin with just a few (16.1%) being overweight. Cumulatively,

3.4% of the girls in the study had at least one nutritional deficit of either stunting, or thinness.

(Figure 4.7)

Figure 4.7: Nutritional status of adolescent girls in Ko Senior High Boa rding

School

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HAZ BMI for Age

Overweight

Deficit(Stunting/Thinness)

Normal


45

4.6: Energy and Nutrient Intakes of Adolescent Girls in Ko Senior High Boarding School

4.6.1 Type of meals served to adolescent girls in Ko Senior High Boarding School during a 2

weeks observation period

A 14-day observation period of the type of food served to adolescent girls in Ko Senior High

Boarding school revealed a repetitive pattern in the meals served from one week to another. The

types of meals usually served were mainly plant based (cereals and legumes). Except for rice

porridge and tea where milk was provided for the girls, school meals served to students were

inadequate in animal source foods such as meat, poultry and eggs (Appendix VII).

Food was usually served from large iron cooking pots in the school kitchen into a medium sized

source-pan each for students in groups of 10 to share equally. Meals eaten during breakfast,

lunch and supper on a normal school day (Monday to Friday) by the girls were usually served at

9:00am, 2:00pm, and 5:30pm each day respectively. Except for lunch that was served at

12:30pm during weekends (Saturday and Sunday), other meal times such as breakfast and supper

did not differ from that served during a normal school week. Table 4.3 below shows a typical

menu served on a normal school week during the observation period.


46

4.6.2 Nutrient content of meals served to adolescent girls in Ko senior high school compared

with EAR

With the exception of energy (92.8%), the intakes of protein (122.11%), and fat (171.82%) from

school meals were slightly higher than the EAR. Also intake of carbohydrates (343.02%) from

the present study was found to be approximately 3 times higher than the EAR. Furthermore, the

percent contribution of protein, fat and carbohydrate from the total energy consumed from school

meals in comparison with their respective AMDR ranges were 9%, 27% and 67% respectively.

Results from the study further shows that with the exception of riboflavin, folate, calcium and

copper where intakes were very low, the micronutrient needs of thiamine, zinc and vitamin C

were met by the meals in increased amounts above the EAR. Iron content of the school meals

served to adolescent girls was found to be approximately 3 times more than the EAR. However,

just about 2.5mg of the iron consumed per day was in their bio-available form. The most

deficient nutrient from the meals served to the girls in the study was vitamin D (0.0%) and

vitamin B12 (0.0%).


47

Table 4.3: Nutrient content of meals served to adolescent girls in Ko Senior High Boarding

School compared with the EAR# using weighed food record method

Nutrients¹

Estimated

Average

Requirement Average intake per day

%

contribution(NAR²)

Mean ± SD

Energy³

(kcal/day) 2200 2041.69 ± 442.36 92.80

Protein (g/d) 38 (10-30%)* 46.40 ± 5.83 (9%) ª 122.11

Fat(g/d) (25-35%)* 60.14 ± 17.59 (27%) ª

Carbohydrate(g/d) 100 (45-65%)* 343.02 ± 76.97 (67%) ª 343.02

Thiamine(mg/d) 0.9 1.06 ± 0.62 117.78

Riboflavin(mg/d) 0.9 0.30 ± 0.12 33.33

Niacin(mg/d) 11 8.78 ± 0.72 79.82

Folate(µg/d) 330 6.70 ± 2.53 0.77

Calcium(mg/d) 1300 409.80 ± 197.39 31.52

Copper(µg/d) 685 0.96 ± 0.51 0.14

Iron (mg/d) 7.9 25.83 ± 8.00 (2.5)# 326.96

Zinc (mg/d) 7.3 9.90 ± 2.22 135.62

Phosphorus(mg/d) 1055 881.80 ± 182.30 83.58

Vitamin C(mg/d) 56 77.75 ± 35.92 138.84

Vitamin D(µg/d) 10 0.00 ± 0.00 0.00

Vitamin

B12(µg/d) 2 0.00 ± 0.00 0.00

¹Nutrient intakes based on a two weeks weighed food record; ² NAR (Nutrient Adequacy Ratio);

Daily nutrient intake/recommended EAR x 100; ³ RDA was the dietary reference used for

energy; #Estimated Average Requirement; Food and Nutrition Board, Institute of Medicine-

National Academy of Sciences (2000); * Nutrient values for protein, fat and carbohydrate in

brackets represent the acceptable macronutrient distribution ranges (AMDR); # based on 10%

dietary iron bio-availability of typical African diet; FAO/WHO expert consultation on human

vitamin and mineral requirements(1988); ª represent the percent protein, fat and carbohydrate

from total energy.


48

4.7 Dietary intakes of adolescent girls in Ko Senior High Boarding School (based on a 24-

hour recall)

4.7.1 Total Daily intakes of adolescent girls in Ko Senior High Boarding School in comparison

with EAR

Over 50% of the girls in the study met their EAR for energy (64.4%), protein (87.8%) and fat

(91.7%). Results from the present study again show that the macronutrient (protein, fat,

carbohydrate) needs in relation to the EAR were met by all the girls. However, except for protein

(9%), the percent fat (26%) and carbohydrate (68%) from the total energy consumed were within

the acceptable macronutrient distribution ranges (AMDR)

The intakes of riboflavin, folate, calcium, and vitamin B12 were met by just less than 10% of the

girls in the study. Majority of the girls were reported to have met the EAR for thiamine, zinc,

vitamin A and vitamin C. None of the girls met the EAR for vitamin D. Despite all the girls

meeting their daily EAR for iron, approximately3.0mg of the total iron consumed was bio-

available.


49

Table 4.4: Total Daily intakes of adolescent girls in Ko Senior High Boarding School in

comparison with EAR

Total Intake

Nutrients¹ EAR² Mean ± SD n(%) who met EAR

Energy(kcal/d) 2200

2463.05 ± 657.01

116(64.4)

Macronutrients:

Protein(g/d) 38(10-30%)*

54.18 ± 15.93 (9%) ª

158(87.8)

Fat(g/d) (25-35%)*

70.58 ± 27.18 (26%) ª

165(91.7)

Carbohydrate(g/d) 100(45-65%)*

423.19 ± 114.39

(68%) ª

180(100.0)

Minerals:

Thiamine(mg/d) 0.9

1.30 ± 0.53

142(78.9)

Riboflavin(mg/d) 0.9

0.51 ± 0.27

10(5.6)

Niacin(mg/d) 11

12.42 ± 6.22

81(45.0)

Folate(µg/d) 330

39.96 ± 12.52

1(0.6)

Calcium(mg/d) 1100

596.65 ± 250.78

6(3.3)

Iron(mg/d) 7.9

27.98 ± 8.28 (2.8)#

180(100.0)

Zinc(mg/d) 7.3

10.73 ± 3.13

154(85.6)

Phosphorus(mg/d) 1055

1043.92 ± 341.88

78(43.3)

Vitamins:

Total Vitamin A(µg/d) 485

1142.16 ± 1014.96

110(61.1)

Vitamin C(mg/d) 56

82.70 ± 35.44

136(75.6)

Vitamin D(µg/d) 10

0.22 ± 1.25

0(0.0)

Vitamin B12(µg/d) 2 0.46 ±1.60 6(3.3)

¹Nutrient Intakes based on a 2 day 24-hour recall; ² Estimated Average Requirement; Food and

Nutrition Board, Institute of Medicine- National Academy of Sciences (2000); * Nutrient values

for protein, fat and carbohydrate in brackets represent the acceptable macronutrient distribution

ranges (AMDR); # based on 10% dietary iron bio-availability of a typical African diet ;

FAO/WHO expert consultation on human vitamin and mineral requirements (1988); ªrepresent

the percent protein, fat and carbohydrate from total energy.


50

4.7.2 Percent contribution of nutrients from school meals and other food sources to total daily

intakes

The percent contribution of energy and macronutrients (protein, fat, carbohydrate) from school

meals to the total daily intakes of the girls in the study were well above 50% (Table 4.6).

Furthermore, of the total daily intakes of thiamine, riboflavin and niacin, school meals

contributed about 71.5%, 54.9% and 55.4%. In addition to this, intakes of calcium, iron, zinc,

phosphorus, vitamin A and vitamin C from school meals were higher in terms of their

contribution to the total daily intakes of the girls. The contribution of folate and vitamin B12

from school meals to the total daily intakes of the girls were 10% and 4.3%.


51

Table 4.5: Percent contribution of nutrients from school meals and other food sources to

total daily intakes using the 24-hr recall method

Total Intake School meals

Other food

sources

Nutrients ¹ Mean ± SD Mean ± SD Mean ± SD

%

contribution

from school

meals

Energy(kcal/d) 2463.05 ± 657.01 1768.33 ± 723.83 694.72 ± 520.70 71.8

Protein (g/d) 54.18 ± 15.93 37.72 ± 15.51 16.46 ± 15.01 69.6

Fat(g/d) 70.58± 27.18 46.11 ± 24.07 38.14 ± 15.68 65.3

Carbohydrate(g/d) 423.19 ± 114.39 314.83 ± 126.78 108.36 ± 82.00 74.4

Thiamine(mg/d) 1.30 ± 0.53 0.93 ± 0.54 0.37 ± 0.35 71.5

Riboflavin(mg/d) 0.56 ± 0.27 0.28 ± 0.13 0.28 ± 0.22 54.9

Niacin(mg/d) 12.42 ± 6.22 6.88 ± 2.76 6.49 ± 5.54 55.4

Folate(µg/d) 12.52 ± 39.96 2.16 ± 3.99 10.35 ± 4.24 17.2

Calcium(mg/d) 596.65 ± 250.78 351.34 ± 160.79 252.73 ± 245.31 58.9

Copper(µg/d) 2.17 ± 2.06 0.69 ± 0.55 1.48 ± 2.07 31.8

Iron(mg/d) 27.98 ± 8.28 22.10 ± 9.18 5.95 ± 5.88 79.0

Zinc(mg/d) 10.73 ± 3.13 8.46 ± 3.48 2.26 ± 2.09 78.8

Phosphorus(mg/d) 1043.92 ± 341.88 711.22 ± 301.22 332.70 ± 328.96 68.1

Total Vitamin A (µg/d) 1142.16 ± 1014.96 1025.32 ± 1020.92 116.83 ± 270.11 89.8

Vitamin C(mg/d) 82.70 ± 35.44 66.25 ± 35.44 16.45 ± 19.43 80.1

Vitamin D(µg/d) 0.22 ± 1.25 0.00 ± 0.00 0.22 ± 1.25 0.0

Vitamin B12(µg/d) 0.46 ±1.60 0.02 ± 0.06 0.43 ± 1.60 4.3

Mean % contribution from school meals and other food sources is 56.2 and 43.8 respectively.

¹Nutrient intakes based on a 2 day 24-Hour recall method; # based on 10% dietary iron bio-

availability of a typical African diet; FAO/WHO expert consultation on human vitamin and

mineral requirements (1988);


52

4.8 Chi-Square Analysis for the possible factors associated with the dietary practices of

adolescent girls in Ko Senior High Boarding School.

Results from the study shows that 25.3% of those in SHS1 compared to 9.8% of those in

SHS2/SHS3 had good dietary practices. Also, 21.3% of persons with average socioeconomic

status compared to 14.3% of high socioeconomic status and 13.7% of low socioeconomic status

had good dietary practices. School year, socioeconomic status and educational status (both

parents) were significant factors associated with the dietary practices of adolescent girls in Ko

Senior High School.

Table 4.6: Chi-square(X²) test of the possible factors associated with the dietary practices

of adolescent girls in Ko Senior High School

Dietary Practices

Variable Poor Moderate Good p-value

School year:

SHS 1 13(14.9) 52(59.8%) 22(25.3%)

SHS 2/SHS 3 24(25.8) 60(64.5%) 9(9.8%) 0.01

Socio-economic status(SES)

Low SES 5(9.8%) 39(76.5%) 7(13.7%)

Average SES 16(20%) 47(58.7%) 17(21.3%) 0.04

High SES 16(32.6) 26(53.1%) 7(14.3%)

Age:

15-17 9(14.3%) 44(69.8%) 10(15.9%)

18-19 28(23.9) 68(58.2%) 21(17.9%) 0.23

Fathers educational level

Primary 5(13.2%) 22(57.8) 11(29.0%)

JHS/SHS/tertiary 24(32.4%) 38(51.4%) 12(16.2%) 0.03

None 9(13.2%) 51(75.0%) 8(11.8%)

Mothers educational status

Primary 5(13.2%) 23(60.5%) 10(26.3%)

JHS/SHS/Tertiary 20(32.8%) 32(52.5) 9(14.7%) 0.03

None 12(14.8) 57(70.4%) 12(14.8%)


53

4.9 Factors associated with overweight conditions among adolescent girls in Ko Senior High

School

Results from this study showed a positive association between the socio-economic status of

adolescent girls and overweight (Table 4.8). This implies that28.6% of persons with high

socioeconomic status compared to 17.6% of low socioeconomic status and 10% of average

socioeconomic status were overweight/obesed.

Table 4.7: Chi-Square (X²) analysis to establish possible factors associated with overweight

conditions among adolescent girls in Ko Senior High School

Overweight/Obesity

Variable Yes No p-value

School year:

SHS 1 18(20.7%) 69(79.3%)

SHS 2/SHS 3 13(14%) 80(86%) 0.23

Socio-economic status (SES)

Low SES 9(17.6%) 42(82.4%)

Average SES 8(10%) 72(90%) 0.03

High SES 14(28.6%) 35(71.4%)

Age:

15-17 10(15.8%) 53(84.2%)

18-19 21(17.9%) 96(82.1) 0.72

Energy:

Met energy intake 22(16.5%) 111(83.5%)

Did not meet energy intake 9(19.1%) 38(80.9) 0.68

Dietary practice:

Poor dietary practice 8(21.6%) 29(78.4%)

Average dietary practice 15(13.4%) 97(86.6%)

Good dietary practice 8(25.8%) 23(74.2%) 0.19

Fathers Occupational status :

Professional/farmer 26(18.4%) 115(81.6%)

Trade/other business 5(12.8%) 34(87.2%) 0.41

Mothers occupational status:

Professional/farmer 22(19.6%) 90(80.4%)

Trade/other business 9(13.2%) 59(86.8%) 0.27


54

4.9.1 Predicting factors of overweight among adolescent girls in Ko Senior High Boarding

School

Poor dietary practices and high socio-economic status were significant predictors of overweight.

The odd of being overweight/obese was 4.92 times higher among persons with poor dietary

practices compared to those of good dietary practice (P= 0.02).

The odd of being overweight/obese was 75% less likely to occur among persons with an average

socioeconomic status compared with those of high socioeconomic status (P= 0.01)

Table 4.8: Logistic Regression for the possible factors that predict overweight among

adolescent girls in Ko Senior High Boarding School

Overweight/Obesity

95% Confidence

Interval

Variable

n OR Lower Upper

p-

Value

Dietary practice:

Poor dietary practice 37 4.92 1.23 19.65 0.02

Average dietary practice 112 2.75 0.86 8.73 0.08

Good dietary practice 31 Reference

Socio-economic status(SES):

Low SES 51 0.49 0.18 1.32 0.16

Average SES 80 0.25 0.09 0.67 0.01

High SES 49 Reference

Age:

15-17 63 0.77 0.32 1.83 0.56

18-19 117 Reference

Energy:

Met energy intake 133 0.88 0.35 2.18 0.78

Did not meet energy intake 47 Reference

CHAPTER FIVE

5.0 DISCUSSIONS


55

5.1 Dietary Practices of Adolescent Girls in Ko Senior High Boarding School

5.1.1 Usual meal frequency and pattern

Over 50% of adolescent girls in this study reported eating 3 times a day during a normal school

day. According to FAO, the daily meals of school children should be composed of 3 meals and

some snacks (FAO, 2004a). Aside snacks, the school did provide three main meals (breakfast,

lunch and supper) to the girls. Consistent with this finding, Alkoly et al., (2011) in a study to

determine the nutritional status and eating behaviors among adolescents of some intermediate

schools in Jeddah reported that majority (84.3%) of the girls consumed three meals daily.

Despite breakfast being a very important meal that is usually not compensated for in other meals,

it was interesting to note from this study that respondents always ate both lunch (63%) and

supper (54%) more than breakfast (40%) during a normal school week. Consistent with the

findings of this study, Stewart &Menning (2009) reported that adolescents ate lunch and dinner

more often than breakfast. Similar findings can be shown in a study by Savige et al., (2007)

where he reported that more adolescents skipped breakfast (20%) than skipped lunch (12%) or

dinner (2%).

The main source of meal (breakfast, lunch and supper) of most adolescent girls in this study was

from the school dining hall. Meals mostly provided to students in the school dining hall were

mainly of cereal and leguminous based crops since these crops were typical of the area where the

study was conducted. Results from this study further reported that except for milk which was

served for some breakfast cereals, animal source foods such as meat, poultry and eggs during the

observation period were not served as part of the meals provided to the girls in the school dining

hall. This probably might be due to the huge student number population which makes such

animal source foods very expensive to provide to the girls at meal times. Since school meals was


56

the main source of breakfast, lunch and supper among respondents, there is the need to ensure

that the kind of meals served to students are wholesome and nutritious given that, these children

are restricted to the confines of the school and therefore do not have any alternative than to eat

from what is provided to them in school. The kind and amount of food eaten by a person have an

influence on his well-being and thus eating properly especially at meal times at this stage of life

is very important in achieving optimum growth (Stang et al., 2005).

5.1.2 Meal skipping and snacking habits

Due to delayed breakfast which usually is taken after the first lesson, some students reported

eating food from their chop-box before going to class and thus at the time they are supposed to

go for breakfast they are most at times not hungry and hence skip breakfast. Moreover, most

students generally reported their dislike for the kind of meals prepared as breakfast. This finding

is consistent with the results of Onyiriuka et al., 2013 who reported that meal skipping especially

breakfast, consumption of fast foods along with soft drinks and low consumption of fruits and

vegetables were the main eating habits displayed among adolescent girls in Nigerian urban

secondary school. Also, Owusu et al., 2007 in a similar finding among adolescent girls in senior

high schools in Greater Accra Region and Eastern Region observed that poor dietary habits

among adolescent girls resulted in frequent meal skipping and bad food choices at meal times.

Skipping of meals especially breakfast significantly affects adolescent development. A survey of

young people aged 11–16 years found that nearly one in five did not eat breakfast before going

to school. An individual who skips breakfast misses some very important dietary needs that are

not usually compensated for in other meals. In fact, adolescents who skip breakfast have


57

significantly lower vitamin and mineral intake compared to those that regularly eat breakfast

(Nicklas et al., 2000).

Snacking was also reported in this study by majority (95%) of adolescent girls as being part of

their eating habits. Among the reasons cited by the girls for snacking, hunger was the main

reason why they snacked. This is because most respondents disliked foods served to them in the

school dining hall and thus resulted into snacking to complement inadequate intakes from school

meals.

5.2 Nutritional status of adolescent girls in Ko Senior High Boarding School.

Height for age Z-score (HAZ) and BMI for age Z-score (BAZ) gives an indication of the long

term impact of nutrition on the growth of the children and adolescents. Stunting and underweight

are conditions that are widely spread among adolescents in developing countries. In a study that

was carried out in 5 developing countries including Ghana, stunting and underweight rates were

observed to be 48-56% and 34-62% among these countries respectively (PCD, 2002).

Among the respondents in this present study, 2.2 percent of them were stunted. This figure as

compared to the national figure is lower (PCD, 2002). Consistent with this finding, Intiful et al

(2013) reported a lower prevalence of stunting (0.8%) among boarding school children in

selected schools in the Accra Metropolis.

The prevalence of thinness or low BMI for age among respondents in the study was 1.2 percent.

It was interesting to note from this study that a few (3.3%) of the girls actually did skip meals

because they wanted to check/reduce their weight. This finding could however be attributed to


58

the low BMI for age reported in the study. In contrast with this finding, Ani et al., (2014) found

the prevalence of thinness among adolescents to be 13.9 percent higher than the present study.

Apparently other studies have also found the prevalence of thinness among adolescent girls to be

higher than the current study (Mogre et al., 2013; Owusu et al., 2009).

In 2004, the global prevalence of overweight and obesity among children and adolescents (5 to

17 years) was estimated by the International Obesity Task Force (IOTF) to be 10%. Findings

from this present study however show that the prevalence of overweight among adolescent girls

is 16.1% higher than the IOTF. The prevalence rate of 16.1% observed in this study could be

attributed to the high energy intakes in school meals and also due to the frequent meal skipping

behaviour observed in the study.Consistent with this finding, Ene-Obong et al., (2012) also

reported an overweight/obesity prevalence of 14.2 percent which is lower than the present study.


59

5.3 Energy and nutrient intakes in adolescent girls in Ko Senior High School

5.3.1 Nutrient content of meals served in the school dining hall of Ko Senior High School

The pattern of food intake during the 14-days observation period using a weighed food record

did not differ in terms of type of food and frequency of intake. The foods served to the

adolescent girls were bulky staples like banku, T.Z, rice and beans accompanied by stews or

soups. These meals were usually served for lunch and supper. Breakfast meals include bread and

tea, millet and corn-dough porridge and local- tom brown porridge. Fruits and vegetables were

lacking in their menu but from observation, some students were found climbing and plucking

mangoes from the few mango trees within the campus premises for consumption.

The analysis of dietary intakes in the present study showed that the mean energy intake (2041.69

± 442.36 Kcal/day) and the percent of mean energy intake (92.8%) of adolescent girls were

lower than dietary recommended intake (EAR). With regard to growth spurts in adolescents, the

actual need of energy in this time varies greatly by physical activity level, basal metabolic rate

(BMR), and body composition (Gleason P. et al, 2001).

The results of the study in relation to the mean energy of macronutrients (protein, fat and

carbohydrates) among adolescent girls were highly above the EAR for adolescents. Similar

findings were found in a study conducted by Anyika et al., (2009) where he reported relatively

high intakes of carbohydrate, fat and protein among adolescent girls in secondary schools and

universities in Abia State of Nigeria. Consistent with the findings of the present study, Danquah

et al., (2013) also reported the mean intakes of carbohydrates among Upper Primary School

pupils in a rural setting in Ghana to be higher (193.1%) compared with the recommended

nutrient intakes. concurrently, Intiful et al., (2013) in assessing the nutritional status of boarding

and non-boarding school children in selected schools in the Accra Metropolis also reported


60

higher intakes of protein (100%) and carbohydrates (100%) among student boarders and non-

boarders compared to the EAR. This high energy intake can be explained based on the fact that

the typical staples consumed by the subjects are mainly starchy foods.

Protein intake of respondents constituted mainly those of plant origin notably legumes (beans

and groundnut) and cereals as well as some animal source proteins. This is similar to the findings

by Ukegbu et al., (2007) who reported high proportion of plant proteins in the diet of adolescent

boys and girls in a public secondary school in Umuahia, Nigeria. Danquah et al., (2013) in a

similar finding compared to the present study also reported the intakes of protein being met by

more than half (66.8%) of the students partly because most of the protein consumed were mostly

of legumes and nuts.

Despite the high protein intake in the present study, the percent protein from the total energy

consumed was 9% lower than the AMDR. This is because most proteins consumed from school

meals were of plant origin and thus the question of digestibility and bioavailability comes to

mind since protein from plant foods are of low biological value compared to animal sources.

A general overview of the nutrient adequacy of school meals served to adolescent girls using the

weighed food record method revealed that intakes of riboflavin, folate, calcium, copper, vitamin

D and vitamin B12 were inadequate compared to the EAR. Similar results were reported from

this study using the 24-hour recall method where intakes of folate, copper, vitamin D and

vitamin B12 from school meals were inadequate compared to EAR unless compensated for from

food consumed from other sources. Consistent with the findings in this study, Aazam et al.,

(2013) in a study to assess the nutritional status and dietary intakes of adolescent girls in Iran


61

also reported that the daily intake of vitamin B12, vitamin A, folate, calcium, zinc, and fiber

were less than the EAR for majority of the girls.

Calcium, one of the major micronutrients is needed especially in the developing years for strong

bone formation. However, from the present study calcium intakes among adolescent girls was

low (32.5%) compared with EAR. The low calcium levels as reported in this study could

probably be due to the inadequate consumption of calcium source foods among adolescent girls.

Similar to the findings of the present study, Intiful et al., (2006) in study to assess breakfast

habits of primary school children in the district of the Eastern Region of Ghana, reported that no

child was able to meet the calcium requirements. This they said could be attributed to the low

consumption of milk and milk products among Ghanaian children (Intiful and Lartey, 2006).

Their study further showed that even though other sources of calcium were consumed, they were

in small quantities and therefore could not meet the required recommendations. Similar findings

were reported by Damastuti et al., (2011) in a study to assess micronutrient daily intake of

elementary school children in Bandung, Indonesia.

Another micronutrient of public health importance to adolescent girls is folate. However,

findings from this study reveal that over 90% of adolescent girls did not meet their folate needs.

Similar to the findings of this study, Bolajoko et al., 2014 in a study on the nutrient adequacy of

foods eaten by students attending boarding and day secondary schools in Owo reported low

intakes of folate (55%) among students compared to the RDA. Consistent with findings from this

study, Ijarotimi, 2004 in his study to evaluate the energy and micronutrient intakes of Nigerian

adolescent females reported the mean intakes of folic acid to be 9.8µg/d lesser than the

recommended dietary intake required per day. The complete lack of fruits and vegetables in the

meals of respondents could probably be the reason why adolescent girls could not meet their


62

folate needs. With increasing evidence of the role of folic acid in the prevention of birth defects,

adolescent girls of reproductive age are encouraged to consume foods rich in folate to avert the

adverse consequences of folate deficiencies.

Iron deficiency is of particular importance to adolescent girls in the present study because of the

rapid increase in physical growth and reproductive development that occurs. Results from the

present study shows that, the requirements of iron per the EAR recommendations were met by all

adolescent girls in the present study. The high iron content in the meals provided as observed in

this study could probably be due to the fact that their meals were prepared using iron cooking

pots. From literature, the utensil in which food is cooked plays a major role in determining the

final iron content of food. Several studies have documented that most of the foods (90%)

contained significantly more iron (6 to 11mg/d) when cooked in iron utensils depending on the

acidity, moisture content, and cooking time of food.

This observation is consistent with other works carried out by Intiful et al., (2013) and Egbi,

(2012) among Ghanaian boarding school children. Even though the calculated value of iron in

the diet was high, the level of bioavailability is 2.5mg lower than the EAR of 7.9 required per

day. The low bioavailability of iron could be as a result of the consistent lack of a nutritious and

adequate diet served to adolescent girls at meal times. Furthermore, unlike in developed

countries where intake of animal source foods such as meat, poultry and fish is relatively high, in

developing countries such as Ghana and in this present study, intakes of animal source foods was

low and compounded with greater exposure to inhibitors of iron absorption such as polyphenols

and phytates from plant foods, the uptake of iron was further worsened.


63

Moreover, the contribution of infections (worm infestation and malaria) resulting from the

unhygienic environment in which they find themselves could further accentuate the development

of iron deficiency among the girls. This in effect calls for the needed attention towards ensuring

that the kind of food served to adolescent girls are wholesome and balanced enough to enable

them compensate for the increase lost of blood observed during their menstrual cycle.

5.4 Predictors of dietary practices and overweight status of adolescent girls in KO Senior

High School

Poor dietary practice as established as meal skipping or irregular meal patterns in this study was

found to be positively associated with overweight conditions among adolescent girls in Ko

Senior High School. Onyiriuka et al., (2013) in assessing the eating habits among Nigerian urban

secondary school girls also reported that poor dietary practices such as meal skipping was

associated with weight gain at a later age. Niemeier et al., (2006) in his study also reported that

skipping of meals especially breakfast was associated weight gain from adolescence to

adulthood.

Results from this study further showed a positive association between students of an average

socioeconomic status and overweight. Socioeconomic status influences the taste, choice and kind

of food consumed by adolescents. Observation from this study revealed that those of an average

or high socioeconomic status were more likely to practice poor dietary practices such as skipping

main meals from the school dining hall compared to those of a low socioeconomic status. This

could probably be due the fact that they had an increased purchasing power and thus could buy

any food of their choice within the school environment. Also, the kind of food being purchased

for them in their chop-box could be enough reason for them to have an irregular meal pattern.

This observation is consistent with the findings of Muthoni, 2012 who in her study in two senior


64

high schools in Nairobi, Kenya reported an increase consumption of energy-rich snacks, sugar

sweetened beverages, carbonated soft drinks and fast foods among children of high socio-

economic status compared to those of low socio-economic status.


65

CHAPTER SIX

6.0 CONCLUSION, LIMITATIONS AND RECOMMENDATION

6.1 Conclusion

Based on findings of this study, it can be concluded that meal skipping, particularly of breakfast,

was the main unhealthy eating habit observed among adolescent girls in Ko Senior High School.

It can also be concluded from this study that majority of respondents were within the normal

range of nutritional status (i.e. BMI for age and the height for age) with some of them being

thin(1.2%), stunted(2.2%) and overweight(16.1%).

Moreover, the weighed food record and 24-hour recall conducted in the study showed that most

nutrients from school meals were adequate except for riboflavin, folate, calcium, copper, vitamin

D and vitamin B12 where intakes were very low compared to the EAR.

Finally, this study again indicates that most of the socio-demographic characteristics, dietary

intakes and health related variables did not predict significantly nutritional deficits among

respondents. Conversely, socioeconomic status, mother‟s education, father‟s education and year

level of respondents showed statistically significant association with the dietary practices of

adolescent girls in Ko Senior High Boarding School.


66

6.2 Limitations

There are some limitations of the present study. Firstly, the present study involved only female

adolescents and therefore, the results cannot be generalized to include male adolescents.

Secondly, the findings are limited by the sampling location since the participants were derived

from a senior high boarding school located in the rural area. These limitations notwithstanding,

this study gives an insight into the dietary practices and nutritional status of adolescent school

girls in this locality. The strength of the study lies in the large study population which allows for

meaningful conclusions.

6.3 Recommendations

Considering the low consumption of fruits and vegetables observed in the study, school

authorities should at least provide students with snacks such as fruits weekly to boost

their health.

Meals provided to students were inadequate in animal source foods. School authorities

should therefore ensure that animal source foods such as meat, poultry and eggs are

incorporated into meals provided to students in Ko senior high school.

Since students were found to miss meals, particularly breakfast in the dining hall, school

authorities must ensure that there is enough discipline in the school so that students will

patronize dining hall meals. More education should also be geared towards enhancing

good dietary practices and nutritional status among adolescent girls to prevent them from

adverse nutritional deficits and complications prior to and during pregnancy.


67

Parents as part of their responsibilities should provide in their wards chop-box diversified

foods of good nutritional value and pocket money to enhance their nutritional well-being in

school since only school meals as observed from the 24-hour recall could not meet all the

nutrient requirement of adolescent girls

School authorities should as part of their student welfare issues conduct a half-year nutrition

surveillance on their students to find out if school meals provided to them really do meet

their nutritional requirements or not.

Since students depend on food vendors around their campus for some of their meals, school

authorities should ensure that food sold at the campus premises are wholesome.

Since this study investigated the dietary practices and nutritional status of adolescent girls in

a boarding school, it is suggested that the scope of future studies on the subject should be

broadened to include male adolescents, day students and secondary schools in other localities

such the urban areas. Assessment methods like clinical observations and laboratory tests and

skin-folds measurements which were not used in this study should be employed, in

combination with the diet survey to get a more accurate assessment of their nutritional status.


68

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APPENDIX I: ETHICAL CLEARANCE CERTIFICATE


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APPENDIX II: PARENTAL CONSENT FORM UNIVERSITY OF GHANA

OFFICE OF RESEARCH, INNOVATION AND DEVELOPMENT

Ethics Committee for Humanities (ECH)

PROTOCOL CONSENT FORM

Section A- BACKGROUND INFORMATION

Title of Study:

d Dietary practices and nutritional status of adolescent girls in Ko senior high boarding

school, Upper West Region. Principal Investigator:

Christopher Atambire Aganah

Certified Protocol Number

Section B– CONSENT TO PARTICIPATE IN RESEARCH

General Information about Research

This study seeks to assess the dietary practices and nutritional status of adolescent girls in Ko

senior high boarding school. 45 minutes will be required of each participant in the study.

Participants in an interview will be asked to answer questions pertaining to their demographic

characteristics and dietary habits. Also participants will be taken through a dietary intake

assessment using a 24-hour dietary recall where they will be required to provide information on

their meals and snacks consumed the previous day. Weighed food intake will also be done and

participants are required to give out food portions served to them at breakfast, lunch and dinner for

weighing before consumption. They are also as part of this exercise required to report on any plate

waste. Weight and height of participants will be measured in duplicates and their Body Mass Index

calculated to estimate their nutritional status. Participants during weight measurement will be

required to be on minimal clothing with head gear and shoes removed. They will also be required

to be in an upright position with their arms by their sides for the height measurement.

Official Use only Protocol number


84

Benefits/Risk of the study

This study has no direct benefits in terms of financial reward to participants. However, the study

will indirectly inform participants on their eating habits and will also serve as a reference

document for further research regarding the dietary practices and nutritional status of adolescent

girls in senior high boarding schools. Also, the study poses no risk physically, psychologically and

socially to the participants involved in the study. Participants might only suffer from fatigue

considering the different data collection procedures they will be taken through to achieve the

desired results.

Confidentiality

All records obtained from participants will be kept out of public view. In the eventuality that any

information about the study is to be publicized, caution will be taken to ensure that participants’

identity is not revealed.

Compensation

Participants who fully participate in the study to the end will be rewarded with an exercise book

and a pen each as a token of my appreciation for their cooperation and time spent.

Withdrawal from Study

Participants should note that their involvement in the study is voluntary and thus they may decide

to either decline or withdraw from participating in the study without any penalty or adverse

consequences.. If there are any reasons to necessitate your continuation or withdrawal from the

study, your legal representative would be timely and adequately informed.

Contact for Additional Information

If there are any questions or additional information pertaining to the study, you can contact

Christopher Atambire Aganah at [email protected] or on the number

0265770474, Dr. Esi Colecraft at [email protected] and Dr. Gloria Otoo at

[email protected].


mailto:[email protected]

85

Section C-VOLUNTEER AGREEMENT

"I have read or have had someone read all of the above, asked questions, received answers

regarding participation in this study, and am willing to give consent for me, my child/ward

to participate in this study. I will not have waived any of my rights by signing this consent

form. Upon signing this consent form, I will receive a copy for my personal records."

________________________________________________

Name of Volunteer

_________________________________________________ _______________________

Signature or mark of volunteer Date

If volunteers cannot read the form themselves, a witness must sign here:

I was present while the benefits, risks and procedures were read to the volunteer. All questions

were answered and the volunteer has agreed to take part in the research.

_________________________________________________

Name of witness

________________________________________________ _______________________

Signature of witness Date

I certify that the nature and purpose, the potential benefits, and possible risks associated with

participating in this research have been explained to the above individual.

__________________________________________________

Name of Person who Obtained Consent

___________________________________________ ______________________

Signature of Person Who Obtained Consent Date


86

APPENDIX III: RESEARCH QUESTIONNAIRE

PART A: DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS

Instructions for questions number 1-17 administration:

Fill in answers where necessary and circle appropriate answers given by participants.

1. How old are you? …………………………..

2. Which class are you?

1. SHS1 2. SHS 2 3. SHS 3

3. Which tribe do you belong to?

1. Dagao. 2. Other northern tribes (specify)…………………………. 3. Akan

4. Ga adangbe

4. Which religion do you belong to?

1. Christianity 2. Islam 3.Traditional 4. None

5. Did you attend a public/private school previously?

1. Private JHS 2. Public JHS

6. Are both of your parents alive?

1. Yes both alive 2. No both dead 3. No father alive 4. No mother alive

7. Who do you live with when you are on vacation?

1. Both parents 2.Mother 3.Father 4.Other relatives (specify)……........................

5. Non-Relatives (specify)……………………

8. Who is mainly responsible for your up-keep?

1. Both parents 2.Mother 3.Father 4.Othe relatives (specify)……...................

5. Non-Relatives (specify)……………………

9. What educational level did your father attain?

1. Primary 2. JHS/Middle school 3.S.S.S/SHS 4.Tertiary 5. None

6. Don‟t know

10. What educational level did your mother attain?

1. Primary 2. JHS/Middle school 3.S.S.S/SHS 4.Tertiary 5. None

6. Don‟t know

11. What is the main occupation of your father?

1. Farmer 2. Trader 3. Civil servant 4. Others (specify)…………………………


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12. What is the main occupation of your mother?

1. Trader 2. Nurse 3. Housewife 4. Others (specify)………………………..

13. Who own the house you live in?

1. Yes 2. No

14. What is the total number of children less than 18 in your household? ...............................

15. What is the total number of adults in the household? …………………….

16. How many rooms do you live in? ………………………

17. What is the main source of lighting at home?

1. Electricity 2. Kerosene lamp 3. Flashlight/Torch 4. Generator

18. What is your main source of drinking water at home?

1. Pipe-borne water 2. Borehole water 3. Dam/Rivers 4. Well

19. Which of the following assets as mentioned below do you have in your household?

Note: Fill in the appropriate answers provided by respondents.

Name of assets Yes (1) No (2) Name assets Yes (1) No (2)

Car Computer

Bicycle Fridge

Television Mobile

Internet access Standing fan

Ceiling fan Air condition


88

PART B: DIETARY PRACTICES OF ADOLESCENT GIRLS

Meal consumption habits/Meal frequency:

Note: Circle and fill in appropriate codes answers by respondents

20. How many times do you usually eat main meals in a day?

1. Once a day 2. Twice a day 3.Thrice a day 4. Four or more times a day

21.

During a normal school

week, how often do you

eat the following?

Tick as appropriate

22.

What is the main

source of the meals

you mostly

consume?

( 1= school meals)

( 2= chop box)

(3= purchased food)

Always/often

(√)

sometimes

(√)

Never/Rarely

(√)

Breakfast

Lunch

Supper

Snacks

Note: Circle the appropriate answer provided by the participant in the questions below

Meal skipping:

26. How often do you skip meals?

1. Very often 2. Quite often 3.Sometimes 4. Never

27. When you skip meals, which meal are you most likely to skip?

1. Breakfast 2. Lunch 3.Supper 99. Not applicable

28. Why do you skip meals? ……..……………………..................................................................

………………………………………………………………………………………………………

………………………………………………………………………………………………………


89

Snacking Habits:

29. Do you take in snacks in-between meals?

1. Yes 2. No

30. At what time of the day are you most likely to eat snacks?

1. Morning 2. Afternoon3. Evening

31. How many times have you

consumed the following snacks in the

last week?

Number of times

(n)

Source of snack

(1= Chop box)

(2= Common market)

(3 = School meals)

Beverages:

Tea(Milo/Lipton)

Carbonated soft drink (eg. Coca-Cola,

sprite, Fanta drink)

Flavoured juice drink /fruit juices

Pastries:

Bread

Pie/chips

Cookies/Biscuits

Sweets:

Chocolate

Toffees

Milk/dairy based snacks:

Ice cream

Cheese

Other snacks:

Gari

Indomie

Groundnuts


90

32. What are some of the reasons why you snack? ..........................................................................

………………………………………………………………………………………………………

………………………………………………………………………………………………………

PART C: ANTHROPOMETRY

Measurements First reading Second reading

Weight

Height


91

PART C: DIETARY INTAKE ASSESSMENT

DIETARY ASSESSMENT SHEET (2 DAY 24-HOUR RECALL)

Time of day Type of food eaten Quantities of food eaten

(use of food models)

Source of food

(1 = School meals)

(2 = Chop Box)

(3 = Purchased food)


92

WEIGHED FOOD RECORD SHEET

School

meals &

estimated

food

quantities

Food sample 1 Food sample 2

Type of food eaten Weight of

type of

food eaten

Weight of

left-over’s

if any

Type of food eaten Weight of

type of food

eaten

Weight of

left-over’s

if any

Breakfast

(9:30am)

Lunch

(2:00pm)

Supper

(5:30pm)


93

APPENDIX IV: Percentage HAZ and BAZ distribution among adolescent

girls in Ko Senior High School

Anthropometry Measurements Cut-offs n(%)

HAZ <-2 SD (Stunted) 4(2.2)

-2 to 3 SD (Normal) 176(97.8)

-3 SD (Above normal) 0(0.0)

BAZ <-2 SD (Thinness/low BMI for age) 2(1.1)

-2 to 1 SD (Normal) 149(82.8)

> 1 SD (Overweight) 29(16.1)

> 2 SD (Obese) 0(0.0)


94

APPENDIX V: DIETARY PRACTICE AND SOCIO-ECONOMIC SCORES

Scoring system for socioeconomic status

SCORES

Variables Mother Father

Educational status:

None 0 0

Primary 1 1

JHS/SSS 2 2

Tertiary 3 3

Occupational status :

Others 1 1

Trade/farming 2 2

Professional 3 3

School attended previously in JHS:

Public

Private

1

2

Ownership of Assets:

Bicycle

Television

Mobile phone

Standing fan

Ceiling fan

Fridge

Air-condition

Car

Internet access

Computer

1

1

1

1

2

2

3

3

3

3


95

Scoring system for meal consumption frequency

Responses (Scores)

Meal types Always/often Sometimes Never/rarely

Breakfast 3 2 1

Lunch 3 2 1

Supper 3 2 1

Total score 9 Minimum score 3

Scoring system for meal skipping

Responses

Meal skipping Never Sometimes Quite often Very often

Score 3 2 1 0

Type of meals

skipped

Breakfast

Any other meal skipped (either Lunch/Supper)

Score -2 0

Total score 3 Minimum score: 1


96

APPENDIX VI: MEAL SKIPPING AND SANCKING HABITS OF ADOLESCENT

GIRLS IN KO SENIOR HIGH SCHOOL

Meal skipping n(%)

Reasons:

Dislike for school meals 51(28.3)

Lack of appetite 46(25.6)

Avoid sleeping in class 27(15.0)

Allergies to some foods 20(11.1)

Lack of time 11(6.1)

To reduce/check weight 6(3.3)

Satisfied with other foods 4(2.2)

For religious/spiritual reasons 2(1.1)

Snacking pattern of adolescent girls

Food Habits n(%)

Do you snack:

Yes 171(95)

No 9(5)

Snack time:

Morning 56(31.1)

Afternoon 66(36.7)

Evening 49(27.2)

Reasons for snacking:

To satisfy hunger 70(38.9)

Appetite for snacks 55(30.6)

To promote good health 28(15.6)

Dislike for school meals 17(9.4)

Inadequate meal portions 5(2.8)


97

Snack items, source of snack and frequency of consumption among adolescent girls in the

past week

Snack items Chop box Common market

Beverages

Tea (Milo/Lipton) 59(32.8%) 1 (0.6%)

Carbonated soft drink 17 (9.4%) 11 (6.1%)

Fruit juice 24 (17.3%) 13 (7.2%)

Pastries

Bread 14 (7.8%) 6 (3.3)

Pie/Chips 49 (27.2%) 14 (7.8%)

Doughnuts/Bread fruit 6 (3.3%) 28 (15.6%)

Cookies/Biscuits 104 (57.8%) 18 (10.0%)

Sweets

Chocolate/Toffees 16 (8.8%) 40(22.2%)

Milk/diary based snacks

Ice cream/cheese 7 (3.8%) 11 (6.1%)

Others

Gari 107 (59.4%) 4 (2.2%)

Indomie 9 (5%) 19 (10.6%)

Groundnuts 127 (70.6%) 19 (12.2%)


98

APPENDIX VII: TYPICAL MENU OF THE TYPE OF MEALS SERVED DURING

A NORMAL SCHOOL WEEK IN KO SENIOR HIGH BOARDING SCHOOL DAYS BREAKFAST LUNCH SUPPER

Monday Millet porridge with sugar Bean-stew with plain

rice

T.Z with dry okro soup

Tuesday Tea with milk, sugar and

bread

Beans with palm-oil

and gari

Rice-balls with groundnut

soup

Wednesday Local tom-brown porridge Jollof rice Banku with groundnut soup

Thursday Corn porridge with sugar

and bread

Rice and beans with

groundnut soup


Friday Millet porridge with sugar Plain rice with

groundnut soup

Banku with groundnut soup

mixed with dry okro

Saturday Rice porridge with milk and

sugar

Beans with palm-oil

and gari


Sunday Local tom-brown porridge Jollof rice Banku with groundnut soup

mixed with dry okro


99

APPENDIX VIII: DETAILED DESCRIPTION OF THE TYPE OF MEALS

SERVED TO ADOLESCENT GIRLS IN KO SENIOR HIGH BOARDING SCHOOL

Food item Description Major ingredients

Millet porridge Local porridge prepared out of

millet flour

Millet flour and sugar

Local-tombrown Viscous porridge prepared out

of roasted corn-flour

Roasted corn flour, sugar

Rice porridge Viscous porridge prepared

from rice

Rice, milk and sugar

Corn porridge Viscous porridge made out of

fermented corn

Corn-dough, sugar

Tea Beverage made from tea-

leaves

Tea-leaves(Lipton), sugar and

milk

Banku Thick cereal meal made from

fermented maize/corn

Fermented maize/corn flour

Touzaafi Thick cereal meal made from

either maize/millet

Millet/ Maize flour

Rice-ball Thick cereal made from boiled

rice and molded into balls

Rice

Rice and beans Cereal meal made up of rice

and beans boiled together

Rice, beans

Jollof rice Rice cooked in tomatoes stew Rice, vegetable oil, anchovies,

salt, onions, pepper, tomatoes

Beans with palm oil and gari A mixture of boiled beans and

grainy flour prepared from

peeled and grated cassava

Beans, palm oil, pepper, salt,

onions and gari

Bean stew Stew made up of boiled beans Beans, vegetable oil, pepper,

anchovies, tomatoes, onions,

salt

Groundnut soup Soup made with mainly

roasted groundnuts in its paste

form

Groundnut paste, pepper,

onions, anchovies, salt,

tomatoes

Dry Okro soup Soup made with mainly dry

okro

Powdered dry okro, tomatoes,

pepper, salt, anchovies, onions


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