Prevalence and Associated Factors of Adolescent Obesity among Rural School Adolescents in Nepal: A Cross-Sectional Study

Background Overweight and obesity are major risk factors for chronic diseases and are the leading cause of mortality worldwide. Obesity during adolescence is strongly associated with adulthood obesity leading to increased morbidities and mortality. As a developing country undergoing rapid urbanization, Nepal is in a transitional phase where undernutrition coexists with obesity; however, there is a dearth of literature on the status of adolescent obesity in the rural section of Nepal. The aim of this study was to determine the prevalence of adolescent obesity in a rural district of Nepal and find out its associated factors. Methods An institution-based cross-sectional study was conducted among the adolescent students studying in classes 8, 9, and 10 in four secondary schools of Gosaikunda rural municipality of Rasuwa district, Nepal. Total enumerative sampling was used, and Global School-based Health Survey (GSHS) standard questionnaires were used in collecting the information. Height and weight measurements were taken, and the body mass index was classified according to Asia-Pacific criteria. The collected data were analyzed using “SPSS” version 22. Logistic regression analysis was used to evaluate the associated factors, and a p value of ≤0.05 was considered statistically significant. Results Out of 267 adolescents, 14.6% were obese and 14.6% were overweight. Of the female participants, 39.6% were either obese or overweight, while 12.6% of the male adolescents were overweight/obese. Among the total participants, 16.5% were underweight, including 14.0% females and 20.4% males. Female adolescents were about five times (AOR: 5.2, 95% CI (2.5–10.9), p < 0.01) more likely of being overweight/obese than male adolescents. Conclusions More than one-quarter of the adolescents were found to be obese/overweight, and the prevalence was significantly more among female adolescents. It emphasizes the necessity of school-based programs promoting a healthy lifestyle among students to maintain healthy weight status.


Introduction
Overweight and obesity have been ranked as leading causes of mortality worldwide, with over 4 million individuals dying every year as a result of being overweight and obese [1].Tere has been a marked rise in the prevalence of overweight and obesity among children, adolescents, and adults around the world in the last few decades [2].Te global age-standardized prevalence of obesity increased from 0.7% in 1975 to 5.6% in 2016 in girls of 5-19 years range, and in boys, it went from 0.9% in 1975 to 7.8% in 2016.Over the course of 40 years , the number of girls with obesity increased by 10-fold, and there was a 12-fold rise in the number of boys with obesity [2].Overweight and obesity are major risk factors for a variety of chronic diseases including type 2 diabetes, cardiovascular diseases, and cancer [3,4].Obesity during childhood and adolescence is strongly associated with obesity in adulthood, leading to increased morbidities and mortality [5].Adolescents with obesity are also at a higher risk of having obese children later in their life [6].Childhood and adolescent obesity is associated with genetic factors, socioeconomic status, and behavioral and nutritional factors such as insufcient physical activity, insufcient consumption of fruits/vegetables, inadequate sleep, sedentary activities (watching TV and playing computer games), drinking sugarcontaining beverages, eating junk food, smoking, and alcohol consumption [7,8].
Te prevalence of childhood overweight and obesity has increased rapidly in low-and middle-income countries (LMICs) during previous few decades [2,9,10].In a recent study reported from India, the prevalence of obesity among adolescents was 6.8% and about 17.1% of adolescents were overweight [11].Likewise, in a review study, the prevalence of adolescent obesity and overweight in Asian countries was reported to be 8.6% and 14.6%, respectively [12].Due et al. in their study reported that the prevalence of overweight was higher among adolescents from less afuent socioeconomic backgrounds in most (21 out of 24) of the western countries [13].
Few studies have been reported from Nepal on childhood obesity, most of which were conducted in urban areas of the country [14][15][16][17].In a study conducted among urban primary school students, the prevalence of childhood overweight and obesity was reported to be 18.6% and 7.1%, respectively [14].In another study conducted among school students of 6-13 years studying in urban private schools, 14.6% were overweight and 11.3% were obese [15].Te prevalence of adolescent overweight/obesity among higher secondary school students was reported to be 8.1% with 2.3% obese and 5.8% overweight in Kaski district of Nepal [16].However, there is a dearth of literature reporting the status of adolescent obesity from the rural section of Nepal.Tis study aims to fnd out the prevalence of obesity among adolescents of rural Nepal and its associated sociodemographic and behavioral factors.After childhood, adolescence is the next unrivaled stage of life for preventive and health promotion activities.Identifcation of high-risk behaviors among such adolescents will contribute in designing the appropriate intervention programs for encouraging them toward a healthy lifestyle.

Study Design.
Tis study was an institution-based, crosssectional analytical study designed to screen obesity among adolescent students and to explore factors associated with adolescence obesity in Gosaikunda rural municipality of Rasuwa district, Nepal.Data collection was performed from Sep 1 to 30 2022.

Study Settings and Participants.
We conducted this study in secondary-level schools in Gosaikunda rural municipality of Rasuwa district, Nepal: Rasuwa Secondary School, Highland Secondary Boarding School, Namuna English Secondary Boarding School, and Shyame Wangphel Secondary School.All the students from grades 8, 9, and 10 present during the time of this study were enrolled in the study.Tose students who were absent on the day of data collection were excluded from the study.

Study Sample.
Sample size was calculated using openepi.com, an online statistical website.With a 4% absolute precision, 95% confdence interval, and an expected prevalence of adolescent obesity to be 11.1% (based on the prevalence of childhood obesity according to a previous study) [17], the sample size was calculated to be 237.Assuming a nonresponse rate of 12%, the total sample size was calculated to be about 267.Total enumerative sampling (consecutive sampling) was used for selecting both the study site and individual participants.Te study was conducted in all four secondary schools in Gosaikunda rural municipality of Rasuwa district.All the students studying in grades 8, 9, and 10 in these schools were enrolled.We visited each school and took permission from the school administrations before conducting the study.Te students and their parents were informed about the study objectives, and we took their consent for conducting the study.

Study Instruments. Te Nepalese version of the standard
Global School Health Survey (core questionnaire modules) was used to collect data on noncommunicable disease behavioral risk factors among the students.GSHS is a school health survey primarily conducted among students of the 13-17 years age group.In our study, we chose to enroll students from grades 8, 9, and 10.Te GSHS survey questionnaire was developed by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) for obtaining information from students to promote global school health and young health programs and policies.Te GSHS questionnaire consists of ten core questionnaire modules which measure the behavior and protective factors associated with the leading causes of morbidity and mortality among children and adults.Tey include questions related to demography, alcohol use, dietary behaviors, drug use, hygiene, mental health, physical activity, protective factors, sexual behaviors, tobacco use, and violence and unintentional injury.Te Nepalese version of the GSHS questionnaire has already been used in previous national school-based health surveys [18].Permission was granted to use the Nepalese version of the GSHS questionnaire.Among the ten core questionnaire modules, questions related to demography, alcohol use, dietary behaviors, mental health, physical activity, and tobacco use were used in the present study to explore association with adolescent obesity.

Data Collection.
After getting permission from the school administration and consent from students and parents, we distributed the self-administered questionnaires to all the students of grades 8, 9, and 10 of the selected schools, with instructions to fll up the questionnaires from coinvestigators and school teachers.Ten, after collecting the flled-up questionnaires from the students, the height and weight of each student were measured and noted down in the same questionnaire.Te height of the students was 2 Global Health, Epidemiology and Genomics measured twice using a portable stadiometer and without shoes.It was measured in centimeters in one decimal fgure, and the average of two readings was recorded.Weight was measured using digital weighing measures with minimal clothing and with shoes and taken in kilograms in two decimal fgures.Two readings were taken, and the average of the two readings was recorded.
2.6.Outcome Variables.Te prevalence of overweight/obesity was the main outcome of interest.Te classifcation of the body mass index (BMI) was performed according to the Asia-Pacifc classifcation of BMI.According to the classifcation, "overweight" was defned as having a BMI of 23-24.9kilograms per meter square."Obesity" was defned as having a BMI more than or equal to 25 kilograms per meter square.

Independent
Variables.Sociodemographic variables of the participants included age, gender, grade of study (8, 9, or 10), ethnicity (categorized as Tamang and others), and religion (categorized as Buddhists and others).

Dietary Characteristics.
As evidenced in the previous study [19], vegetable and fruit intake among students was measured by a single self-reported question for each.Te questions were "During the past 7 days, how many times did you eat fruit, such as banana and apple?" and "During the past 7 days, how many times did you eat fruit, such as green leafy vegetables, cucumber, or carrot?"Te options provided ranged from "I did not eat fruit during the past 7 days" to "4 or more times per day."Just like the previous study, these variables were dichotomized into categories of eating fruits or vegetables daily and not eating fruits or vegetables daily [19].Food security information was retrieved by the GSHS question "During the past 30 days, how often did you go hungry because there was not enough food in your home?" Te options consisted of a 5-point Likert scale: never, rarely, sometimes, most of the times, and always.As evidenced in a previous study [20], food insecurity was indicated when the response was "sometimes," "most of the time," or "always."

Physical Activity.
Physical activity was measured by a single self-reported question in the GSHS questionnaire module as used in a previous study [19].Te students were asked "During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day?" Te provided options ranged from one to seven days.According to the WHO recommendation that there should be a minimum of 60 minutes of physical activity per day for fve days and more drawing from past studies [19,21], the participants were categorized into two groups.Tose students who met the recommendation of engaging in physical activity of 5 days or more per week were categorized as "sufciently physically active" and those who did not meet the recommendation were categorized as "physically inactive."For assessing the attendance of students in physical education, the question was "During this school year, on how many days did you go to a physical education class each week?"Te provided options ranged from 0 days to "5 days or more."Students who attended physical education class at least 5 days per week were considered to have "regular attendance" [22].We assessed sedentary behavior through the question "How much time do you spend during a typical or usual day sitting and watching television, playing computer games, talking with friends, or doing other seated activities such as surfng the Internet?"Te provided responses were "less than 1 hour per day," "1-2 hours per day," "3-4 hours per day," "5-6 hours per day," "7-8 hours per day," and "more than 8 hours per day."Students spending 3 hours or more in these kinds of activities were considered to have "sedentary behavior" [22].

Smoking and Alcohol Use.
Te questions asked for collecting information about current alcohol and tobacco use among adolescents were "During the past 30 days, on how many days did you have at least one drink containing alcohol?" and "During the past 30 days, on how many days did you smoke cigarettes?," respectively.Te responses for both of these questions ranged from "0 day" to "all 30 days."Tose students who drank alcohol/smoked cigarettes for 1 day or more were considered among "current alcohol use" and "current smoking" [23].

Mental Health.
For assessing loneliness and anxiety among adolescents, the questions were "During the past 12 months, how often did you feel lonely?" and "During the past 12 months, how often were you so worried about something that you could not sleep at night?," respectively.Te response options for both of these questions were "never," "rarely," "sometimes," "most of the times," and "always."Adolescents responding "sometimes," "most of the times," and "always" for each question were considered as "feeling lonely" and having "anxiety" [24].We assessed information about suicidal ideation among the adolescents through the question "During the past 12 months, did you ever seriously consider attempting suicide?" Te response options were "yes" and "no," and we categorized the adolescents based on these two responses.
2.8.Data Analysis.Data entry and analysis were performed using "SPSS" (Statistical Package for the Social Sciences) version 22. Te dependent variable of the study was overweight/obesity based on the BMI of the participants.Te independent variables were sociodemographic characteristics, dietary characteristics, physical activities, and sedentary behaviors of the students.Te prevalence of adolescent obesity/overweight was reported as a proportion.Te descriptive analysis of independent variables was reported as means, frequencies, and percentages.Logistic regression analysis was used to determine the association of independent variables and prevalence of overweight/obesity.Univariate and multivariate logistic regression analyses were performed to determine the relationship between dependent and independent variables.At frst, variables were entered one at a time for univariate analysis, and unadjusted OR and Global Health, Epidemiology and Genomics 95% CI were computed with independent variables.Ten, all the independent variables were entered at a time for multivariate analysis for adjusting the confounding efects, and adjusted OR and 95% CI were calculated.A P value of less than 0.05 was considered statistically signifcant.
2.9.Ethical Consideration.Ethical approval for the study was taken from the Nepal Health Research Council (NHRC) (Ref.No. 774).Written permission was taken from all school administrations.Before data collection, informed written consent was taken for all the students and from all the parents if the students were below 18 years.Written assent was taken from students below 18 years.

Results of Descriptive Analysis
3.1.1.Nutritional Status of Participants.Out of total 267 participants, 14.6% (20.7% of females and 4.8% of males) were obese and 14.6% (18.9% of females and 7.8% of males) were overweight.Of total participants, 16.5% (14.0% of females and 20.4% of males) were underweight (Figure 1).Table 1 shows the distribution of overweight/obesity by sociodemographic variables and other associated factors.Among 267 respondents, the majority (68.2%) belonged to the 15-17 years age group, and the mean age was 15.57 ± 1.43 years.61.4% of the total respondents were female.Out of the total respondents, 29.6% studied in grade eight, 35.6% in grade nine, and 34.8% in grade ten.Of all the respondents, more than three-fourth (83.5%) belonged to the Tamang ethnicity and the majority (70%) were Buddhists.About three quarters of the participants (74.2%) were physically inactive, and only about 27.3% of them ate fruits daily.
In terms of gender, the prevalence of overweight/obesity was signifcantly higher among female participants (39.6%) than males (12.6%).In relation to the age group, the students of 15-17 years age had a signifcantly higher prevalence of overweight/obesity than age groups of 11-14 years and 18-21 years.Similarly, the number of obese/overweight students was signifcantly higher in grade ten (41.9%) than in grade nine (24.2%) and grade eight (20.2%).Te prevalence of overweight/obesity was signifcantly higher among physically inactive students (32.8%) than in those who were sufciently physically active (18.8%).Te chi-square analysis showed that gender (p value <0.001), age (p value 0.01), grade of study (p value 0.003), and physical activity (p value 0.03) were significantly associated with overweight/obesity among adolescents.

Factors Associated with Adolescent Obesity/Overweight (Multivariate Analysis Results) (n � 267).
As shown in Table 2, gender, age, grade of study, and physical activity of the participants were signifcant predictors for adolescent obesity in univariate regression analysis.While in multivariate analysis after adjusting for the confounding factors, female gender (AOR: 5.2, 95% CI (2.5-10.9),p < 0.01) was the only signifcant independent predictor for obesity/overweight among adolescents.

Discussion
To determine the prevalence of obesity among adolescents in rural Nepal and its associated sociodemographic and behavioral variables, we performed a survey among 267 school students from Rasuwa, Nepal.
According to our research, 14.6% of participants (20.7% of females and 4.8% of males) are obese and 14.6% of participants (18.9% of females and 7.8% of males) are overweight.Terefore, overweight and obesity were prevalent at a rate of 29.2%.According to a survey conducted in Lalitpur Metropolitan, 18.6% of children were overweight and 7.1% were obese, making up the prevalence of overweight/obesity among children to be 25.7% [14].According to another Indian survey, the frequency of obesity is 6.8% and the overweight population is roughly 17.1% [11].As a result, our results are similar to those of studies conducted in India and another region of Nepal, which both indicate that a quarter of adolescents are obese and overweight.
According to the results of our research, female students were 5 times more likely than male students to be obese or overweight, which is similar to those of a study conducted in Kaski, Nepal [16].Tis is in contrast to a study's result by Piryani S. et al. that indicated a greater prevalence in male than in female students [25].Te fact that the latter research was conducted in an urban setting as opposed to our study, which was conducted in a remote region of Nepal, could account for the discrepancy in the results.In our study setting which is a rural region of the country, adolescent boys are more active in sports and other outdoor activities compared to adolescent girls.Less physical activity among females may be one of the reasons for a higher prevalence of adolescent obesity among adolescent girls [26].
Furthermore, our study revealed a prevalence of underweight of 16.5% (14.0% of females and 20.4% of boys).Tis discovery falls outside of the focus of our research.However, we would like to stress that the rising prevalence of obesity and overweight does not rule out underweight; rather, as our research demonstrates, they coexist as an added burden.4 Global Health, Epidemiology and Genomics fruits and/or vegetables) had no apparent efect on obesity in the present study.Even after adjusting for possible confounding variables such as age, grade of study, and physical activity, the results of our research indicate that gender is a signifcant predictor of adolescent obesity.Te likelihood of becoming obese or overweight during adolescents appears to be greater for females than for males [28,29].Tese fndings are in accordance with a past study [16] that also found the female gender as a major risk factor for adolescent obesity.Gender disparities in BMI in adolescence may be linked to each gender's growth spurt and development of secondary sexual characteristics corresponding to the age range at which they have greater heights [28].Puberty causes sexual dimorphism due to which males get more muscle-bone mass and females gain more fat mass [29].Among females, early puberty has been associated with shorter height, higher BMI, and higher risk of obesity in adulthood [29].However, it is crucial to take into account that other elements, such as age, grades of study, and physical activity, may also contribute to the development of obesity/overweight in adolescents.While these factors were signifcant predictors in our univariate analysis, they did not remain signifcant after adjusting for confounding factors in the multivariate analysis.Our results have signifcant potential implications for the planning and implementation of preventive and therapeutic strategies for adolescent obesity.Particular attention may need to be paid to confronting gender-specifc risk factors for adolescent obesity.However, it is also crucial to take into account additional variables that might increase the risk of becoming obese and to create comprehensive treatments that target these variables holistically.

Limitations
As the design of this study is cross-sectional, a causal link between the variables could not be determined.However, this study presents probable risk factors of adolescent obesity which can further be studied in the future by longitudinal studies.Te study was conducted in secondary schools of a rural municipality of a rural district of Nepal, so the fndings may not refect the overall scenario of the country and may not be generalizable for adolescents in urban regions.We used the GSHS questionnaire to obtain information from the participants about the associated risk factors in which we used a single-item question to measure various characteristics such as "physical activity," "attendance in physical education," "fruit consumption," "vegetable consumption," "sedentary behavior," and "food insecurity."Each of these characteristics could be measured more comprehensively using elaborate tools which ofer better insights and assessment of risk behaviors.Te use of a self-reported questionnaire for data collection could have led to recall biases, so the fndings need to be interpreted cautiously.As the behavioral fndings were based on self-reported subjective measurements, social desirability bias was likely to occur which could have led to under reporting of undesirable variables, especially such as alcohol consumption and smoking.

. Conclusions
More than one quarter of school going adolescents in Rasuwa district of Nepal were either overweight or obese.Te prevalence of adolescent overweight/obesity was signifcantly more among adolescent females than males.Tis signifes the need to address gender-specifc risk factors for adolescent obesity.School-based health intervention programs to promote healthy lifestyles among adolescents for maintaining healthy weight status are suggested.Further comprehensive studies with more specifc analysis and objective measurements to determine the association between various risk behaviors and adolescent overweight/obesity among Nepalese adolescents are highly recommended.

Figure 1 :
Figure 1: Classifcation of BMI among the respondents according to the Asia-Pacifc classifcation.Te fgure shows the percentage of obese, overweight, and underweight participants in total and among males and females.

Table 2 :
Multivariate logistic regression analysis showing associated factors with obesity/overweight among adolescents.