Revista de Investigación Talentos Volumen V. (1) Enero – Junio 2018

ISSN Impreso: 1390-8197 ISSN Digital: 2631-2476

NUTRITIONAL STATUS, FOOD CONSUMPTION, PHYSICAL ACTIVITY AND EATING DISORDERS IN ADOLESCENTS FROM URBAN AND RURAL AREAS IN THE ANDEAN REGION OF ECUADOR

ESTADO NUTRICIONAL, CONSUMO DE ALIMENTOS, ACTIVIDAD FISICA Y DESORDENES ALIMENTARES EN ADOLESCENTES DE ZONAS URBANA Y RURAL DE LA REGION ANDINA DE ECUADOR

Carpio-Arias TanniaValeria1,2, Ramos-Padilla Patricio1,3, Delgado-López Verónica1, Villavicencio-Barriga

Veronica1, Carpio-Salas José Gabriel,4, Morejón-Terán Yadira5

1Public Health Research Group, University of Alicante-Spain

2Research Group on Food and Human Nutrition (GIANH), Superior Polytechnic School of Chimborazo (ES- POCH), Riobamba- Ecuador.

3Doctoral Program in nutrition. Posgaduate school National Agrarian University “La Molina”.

4Department of Languages, Superior Polytechnic School of Chimborazo (ESPOCH), Riobamba-Ecuador.

5Institute of Collective Health, Federal University of Bahía. Salvador, Bahía-Brazil.

Abstract: Main: The aim of this study was to evaluate the nutritional status, dietary intake, physical activity and eating disorders of adolescents in a population from the Andean region of Ecuador and compare differences between urban and rural areas. Materials and methods: This was a cross-sec- tional study (n = 131). 24-hour recall, anthropometry, physical activity and risk of eating disorder ques- tionnaires were collected. Results: 19.1% of the population had short stature by age, and 17.6% risk of overweight according to BMI/Age. Adequate macronutrient percentages throughout the population were low (66.5% carbohydrate, 60.5% protein and 79.8% fat). Statistically significant differences were found between protein (p = 0.012), fats (p <0.001) carbohydrates (p = 0.013) and energy (p <0.001) according to the zones; (urban areas showed higher consumption compared to rural areas). Conclu- sions: The study found that diet of adolescents differs according to the geographical area with poorer diets consumed in rural areas.

Keywords: Diet, adolescents, eating disorders, urban, rural.

Resumen: Objetivo: El objetivo de este estudio fue evaluar el estado nutricional, la ingesta dietética, la actividad física y los trastornos alimentarios de los adolescentes en una población de la región an-

dina de Ecuador y comparar las diferencias entre las áreas urbanas y rurales. Materiales y métodos: este fue un estudio transversal (n = 131). Se recogieron los cuestionarios de 24 horas de recordación, antropometría, actividad física y riesgo de trastorno alimentario. Resultados: el 19.1% de la población tenía estatura baja por edad y el 17.6% de riesgo de sobrepeso según el IMC / edad. Los porcentajes de adecuación de macronutrientes en toda la población fueron bajos (66,5% de carbohidratos, 60,5% de proteínas y 79,8% de grasas). Se encontraron diferencias estadísticamente significativas entre proteína

Recibido: 9 de abril de 2018

Aceptado: 31 de mayo de 2018

Publicado como artículo científco en Revista de Investigación Talentos V(1) 84-93

I. INTRODUCTION

In Ecuador, adolescents represent 19.3% of the population according to the 2010 census (INEC,

2017) According to the World Health Organization (WHO), adolescence is defined as the period of life between the ages of 11 to 19, a period which is characterized by many physical, physiological and psychological changes in which a child becomes an adult (Chulani, 2014; WHO, 2016). During this period, adolescents gain up to 50% of their adult weight, 50% of their adult skeletal mass and growth stops. This transition requires an adapta- tion of the factors that allow to the adolescent to develop all the organic functions with normality (Chulani, 2014; Maiti 2011).

In addition, there is a change in body compo- sition according to sex (increase in lean mass in males and fat mass in females). Accelerated phys- ical growth during puberty requires an increase in daily energy of both macro and micronutrients (Marugán de Miguel Sanz, 2010).

Nutrition is crucial for the development and growth of human beings from the moment of conception and throughout their lives, according to the Minis- try of Public Health of Ecuador. Like most coun- tries in the region, the population shows simulta- neously deficits and nutritional excesses, problems that can be grouped into three categories: delay in height, micronutrient deficiency, and overweight and obesity (Freire, 2013). In recent decades, Ec- uador has undergone significant demographic and socioeconomic changes in the supply and market- ing of food, all changes that have probably influ- enced the quality of food and dietary preferences of Ecuadorians (Freire, 2013).

Nutritional transition is a process that is character- ized by changes in eating behaviour that are ob- served in a country at a time of economic expan-

sion. The main change observed is the replacement of traditional foods with processed foods, gener- ally high in fat and sodium (Drewnowski, 1997; Popkin, 2012). Food patterns are modified by dif- ferent factors: psychological, social, economic, friends, purchasing power, urbanization, etc. that continue in the future. Adolescence from a nutri- tional point of view is a vulnerable stage for sev- eral reasons, such as omission of foods, increase in consumption of foods rich in sugar, and sugars, body dissatisfaction especially in women, diets with dietary restrictions, among others (Guidetti,

2016, Salam, 2016).

In the Andean countries, as well as in Ecuador, im- portant data have been found reflecting about the high prevalence of malnutrition in children espe- cially in rural areas (Freire, 2014, Iannotti, 2017). Diet can influence the health status of adolescents. This study aims to evaluate nutritional status, food consumption, physical activity and eating disor- ders of adolescents from a population of the Ande- an region of Ecuador and differences between the urban and rural areas.

II. MATERIALS AND METHODS

A. Study design and study population

A cross-sectional study was carried out between September 2015, and March 2016 with 131 ado- lescents of both sexes, aged between 10 to 18 years old, who live in the urban and rural areas in the province of Chimborazo, Ecuador. Sampling was non-probabilistic. Data from adolescents were first collected in the urban areas and then rural adoles- cents were matched by age and sex. Students from the urban zone were from the canton Riobamba, Captain Edmundo Chiriboga High school and from the rural zone from the Guano canton, San Andrés Parish, San Andrés National High school. All the parents, and adolescents participating in the

study were informed about the procedures and the privacy of the study, and they signed an informed consent form. Exclusion criteria: Pregnant ado- lescents and teenagers with some pathology relat- ed to nutritional components and affecting nutrient intake were excluded.

B. Nutritional status:

Gender, date of birth, weight and height, anthropo- metric measurements were taken according to the National Health and Nutrition Examination Sur- vey (NANHES, 2007) The weight was taken using a “SECA “ measuring scale, with the minimum amount of clothing, with a reading range from 0 to

120 kg and an accuracy of 100 grams, height was measured with an inextensible rigid wall height meter of 60 to 210 cm, with a precision of 0.1 cm. Using the Anthro Plus V-14.1 (WHO, 2011) pro- gram, the Z-score of the Body Mass Index kg/m2 for age (BAZ) and height-for-age (HAZ) were cal- culated.

C. Assessment of energy intake and macronutri- ents:

In order to determine the energy intake, the fol- lowing were determined: a) Food habits through a 24-hour recall for a weekday, energy and mac- ronutrient calculations were then performed using the Composition Table of Ecuadorian Foods, ob- taining the amounts of energy (Kcal.), Macro (gr.) and micronutrients (mgr.) Adequacy was calcu- lated according to the recommendations for mac- ronutrients and energy of the National Institute of Medicine of the United States (Food and Nutrition Board, 2005) according to age and sex.

D. Risk assessment of eating disorders and levels of physical activity.

To evaluate the risk of eating disorders, the SCOFF questionnaire (Morgan, 1999; Rueda, 2005) was used. This instrument rates five questions: Do you have the feeling of being sick because you feel your stomach so full that you find it uncomfortable? Are you worried that you have to control how much you eat? Have you recently lost more than 6Kgs

of weight over a period of three months? Do you think you’re fat even though others say you’re too thin? Would you say that food dominates your life? It is rated with a point for affirmative answers and zero for negative answers, to obtain the final score. If the final score is 0-1 there is no risk of having an eating disorder, while if => 2 there is a risk of having an eating disorder. To assess the level of physical activity of adolescents, the questionnaire, IPAQ-A (Kowalski, 2004) was used, consisting of 9 questions about sports and games, physical activities at school or in their free time. Each ques- tion scores 1 point (did not practice any activity) to 5 points (practiced every day of the week) and the final score is evaluated with the average of the questions establishing a range from very sedentary to very active (from 1 to 5): 1 = very sedentary;

2 = sedentary; 3 = moderately active; 4 = active; and 5 = very active. All the data were collected by trained personnel (students on the Nutrition and Dietetics course at the School of Public Health, Superior Polytechnic School of Chimborazo).

E. Statistical analysis

The z scores for HAZ and BAZ were calculated in

WHO Anthro Plus software version 10.4 (WHO,

2011). Data are presented as: overage, standard deviation, 95% confidence intervals, and/or per- centages, the statistical analysis of the variables was performed with the student T test, the statis- tical significance for all cases was assumed when the p-value was <0.05. The mentioned data were calculated with the statistics software STATA, ver- sion 14 (Stata, 2014).

III. RESULTS

A total of 131 adolescents of both sexes living in the urban (N = 64) and rural (n = 67) areas in the province of Chimborazo-Ecuador were evaluat-

ed. The youngest were 10 years old and the oldest

17.89 years old at the time of the survey.

Nutritional status or nutritional assessment:

19.1% and 9.2% of adolescents (total sample) pre-

sented low HAZ and very low HAZ respectively.

17.6% presented risk of overweight and 4.6% had very high weight as a function of the BAZ (data not presented in the Tables). The mean weight and height of adolescents in the urban area were higher than those of students from the rural area (p

<0.001). However, the mean BAZ was higher in

rural adolescents than in urban areas (p = 0.009), a

lower HAZ was found among adolescents in rural areas than in urban areas. (p <0.001). No statisti- cally significant differences were found in BAZ in urban and rural areas. (Table 1)

Physical activity level:

The study found 58% of adolescents to be sed- entary according to the IPAQ-A survey applied (95% CI 49.3-66.3). No adolescents with “active” or “very active” levels of physical activity were found. Statistically significant differences were found between the levels of physical activity of adolescents in urban areas (less activity) compared

TABLE I

ANTHROPOMETRIC AND PHYSICAL ACTIVITY CHARACTERISTICS OF RURAL AND URBAN.

Mean			Urban				Rural	P-value
Mean		SD			Mean	SD		P-value
Age. Years		14.6			0.67	14.3		0.69	0.563
Weight. Kg		53.6			12.18	44.7		8.58	0.000
Height. Cm		157.1			11.90	148.2		8.27	0.000
BMI. kg/m2		20.2			4.05	21.8		2.59	0.009
BMI/age z-score		0.5			1.14	0.2		0.81	0.034
Height/Age z-score		0.6			0.67	1.9		2.09	0.036
HEIGHT / AGE Z-SCORE
Geographical area	Very Low Height (%)			Low Height (%)		Low height alert (%)	Normal (%)		P-value
Rural	83.3			80.0		55.6	35.5		<0.001
Urban	16.7			20.0		44.4	64.5
BMI/ AGE Z-SCORE
Geographical area	Low weight alert (%)	Normal (%)		Overweight risk (%)		High weight alert (%)	High weight (%)		P- value
Rural	40.0	58.3		34.8		16.7	0.0		0.072
Urban	60.0	41.7		65.2		83.3	100.0
Physical activity level	Mean	SD		IC 95%		Rural (%)	Urban (%)		P-value
Very sedentary	32.1	0.04		(24.55-40.63)		33.3	66.7		0.000
Sedentary	58.0	0.43		(49.29-66.26)		40.4	59.6
Moderately Active	9.9	0.03		(5.80-16.44)		82.4	17.7

TABLE 2.

FOOD CONSUMPTION, FEEDING PRACTICES AND PHYSICAL ACTIVITY OF THE POPULATION.

Food Consumption (g) Mean SD Minimum Maximum

Carbohydrates	239.4	82.2 40.7		481.3
Protein	52.8	27.8 16.4		293.0
Fat	55.7	28.2 14.6		230.0
Energy	1670.2	496.9 704.4		2918.4
Macronutrient consumption	Rural	Urban		P-value
	Mean (IC 95%)	Mean (IC 95%)
Carbohydrates (gr)	222.2 (200.98 - 243.50)	257.5(239.23 - 275.69)		0,013
Fats (gr)	48.5 (42.82 - 54.14)	63.3(55.49 - 71.020)		0.001
Proteins (gr)	46. 8 (42.10 - 51.46)	59.0(50.63 - 67.45)		0,012
Energy (Kcal)	1512.4 (396.23 - 1628.63)	1835.3(1718.73- 1951.88)		<0,001
Food practices	% (IC 95%)	Rural (%)	Urban (%)	P-value
A) Use of sweeteners
White sugar	79.4(71.50-85.54)	43.3	56.7	0.005
Brown sugar	12.9(8.17-19.99)	82.4	17.7
Cane sugar	6.1(3.05-1.18	75.0	25.0
Artificial sweeteners	1.5(0.37-6.00)	0.0	100.0
b) Drinkin water
No	16.8(11.26-24.30)	40.9	59.1	0.292
Yes	83.2(75.70-88.74)	53.2	46.8
c) Have breakfast
Never	2.3(0.73-6.96)	33.3	66.7	0.000
Sometimes	71.8(63.34-78.88)	40.4	59.6
Always	25.9(19.09-34.24)	82.3	17.65

TABLE 3.

RISK OF EATING DISORDER IN ADOLESCENTS MEASURED BY THE SCOFF QUESTIONNAIRE

Risk of eating disorder in the total number of adolescents	Yes	No
	% (IC 95%)	% (IC 95%)
Do you have the feeling of being sick or because you feel so full that you feel uncomfortable?	21.5 (15.23-29.55)	78.5(70.45-85.77)
Are you worried because you feel you have to control how much you eat?	32.3(24.75-40.92)	67.7(59.07-75.25)
Have you recently lost more than 6Kgs over a period of three months?	28.5(21.29-36.92)	71.5(63.08-78.71)
Do you think you are fat or even though others say you are too thin?	15.4(10.08-22.76)	84.61(77.24-89.91)
Would you say that food dominates your life?	26.2(19.24-34.49)	73.85(65.51-80.76)
Risk of eating disorder (Total)	32.3 (24.75- 40.92)	67.7 (59.07- 75.25)
Risk of Eating Disorder by Sex	Yes (%)	No (%) P-value
Mens	34.9	65.1 0.353
Women	27.0	72.9
Risk of Eating Disorder by Geographic zone	Yes (%)	No (%) P-value
Rural	59.5	47.2 0.188
Urban	40.5	52.8

Enero – Junio 2018

IV. DISCUSSION

The data reported in this study show that there are differences between geographic areas and nutri- tional status, food consumption, physical activity and food disorders. Adolescents in rural areas have a poorer diet according to Aguilar (2011). The bet- ter nutritional status among students from an urban area could be explained by the higher cultural and socioeconomic level of the families in these areas. Nutritional habits in humans greatly condition their quality of life, in the case of adolescents or children, these predispose the individual to long- term effects either as protective agents or as risk factors of many pathologies especially obesity (Freire, 2013).

A lower percentage of adequacy can be seen in the normal intervals (90%-110%) with respect to the values recommended by the National Institute of Medicine of the United States the National Health and Nutrition Survey of Ecuador (Freire, 2013) They also reported an energy deficit of more than

200 kcal in adolescents between 13 to 18 years. According to Berti (2014) the diet in the Central Andes region (Bolivia, Colombia, Ecuador and Peru), in general terms lacks fat and energy. No statistically significant differences were found with regard to energy intake and sex, unlike other

investigations in adolescents (González-Jiménez ,

2013; Velasco, 2009).

In Ecuador, the main source of protein is rice, fol-

lowed by chicken and meat to a lesser extent. Ac- cording to ENSANUT-ECU (2013) around 6% of Ecuadorian adolescents do not consume the pro- tein requirement per day. In this study a percent- age of protein adequacy of 70.04% was found. As adolescents are constantly growing, their protein requirements increase. A deficient consumption of protein can therefore contribute to inappropriate development in adolescents resulting in for exam- ple a delay in sexual maturation, reduction of lin- ear growth and decrease in muscle mass formation Akseer (2017).

Akseer (2017) evaluated the disability rate for protein-energy malnutrition in many regions of the world. The lowest was in Europe with less than 10 per 100,000 people and the highest was found in sub-Saharan Africa at approximately 150 per 100,000 people. Latin America presented rates approximately 50 per 100,000 especially in men from 10 to 14 years old in 2015, a remarkable re- duction since 1990. In this investigation height- age z-score was 1.89 (SD 2.09) which represents a higher risk for adolescents living in rural areas. Excessive consumption of carbohydrates is one of the causes of overweight and obesity in Ecuador, especially since simple carbohydrates mainly from sugary drinks, rice and white bread are consumed (ENSANUT-ECU, 2013). Zazpe (2014) stated that the consumption of complex carbohydrates is as- sociated with a better adaptation of micronutrients. While simple carbohydrates contain less vitamins and minerals. That is, by reducing the consump- tion of simple carbohydrates we are improving the intake of micronutrients. Despite the many recom- mendations on appropriate consumption of fruits and vegetables, a low consumption among the ad- olescents in this study was found. Ochoa-Avilés (2014) showed low consumption of fruit, vegeta- bles and fish in adolescents, while the consump- tion of processed products with added sugar and

refined grains constituted most of their diet Ochoa- Avilés (2014). Daly (2017) found that 13-year-old children from rural areas consume less than one serving of fruit (0.60) and vegetables (0.40) a day. While in a study developed in 33 countries in Eu- rope and North America on the trend of consump- tion of fruit and vegetables in adolescents between

2002 and 2010, Vereecken (2015) observed a sig- nificant increase in consumption after the imple- mentation of national policies. at the beginning of the year 2000 education and subsidy. Likewise, in Finland or Switzerland, low prevalence of fruit consumption are maintained, while Spain or Italy show low prevalence in the consumption of vege- tables.

Another of the factors to evaluate within a healthy lifestyle is physical activity, since sedentarism is a predisposing factor for the appearance or worsen- ing of other cardiovascular risk factors especially of obesity (Rivera, 2009). In this study there were no adolescents with “active” or “very active” levels of physical activity, most being sedentary (58%). Encouraging the practice of regular physical activ- ity is very important. Of the sixth grade students residing in a rural low income areas, 79.2% were sedentary. However, this percentage was lower than that found by Rivera (2010) (92.5%) in his study on adolescents in Brazil.

Eating behaviour disorders are a complex patho- logical picture accentuated during adolescence. Treatment requires a multidisciplinary team where the doctor, psychologist / psychiatrist, nutritionist, dietitian and nurse must work together with the adolescent and family. The prevalence of this con- dition has historically been higher in the female population. However, in our study sample these differences were not statistically significant. The SCOFF questionnaire which has been used in sev- eral publications, including the AVENA (Estecha,

2016) study conducted in adolescents in Spain, is an initial guide to the risk of eating disorders that should be re-evaluated and applied by the respec- tive professionals.

V. CONCLUSIONS

19.1% of the population had low stature by age and 17.6% of risk of overweight according to the BMI / age. The percentages of adequacy of macro- nutrients in the entire population were low. Statis- tically significant differences were found between the levels of physical activity of adolescents in ur- ban areas (less activity) compared to adolescents in rural areas (greater activity). 32.3% of the ad- olescents were classified as presenting an Eating Disorder Risk. Differences between sex and rural/ urban area were not statistically significant.

The authors express no conflict of interest in the present work.

VI. ACKNOWLEDGMENTS AND FUNDING

The authors extend their appreciation to the stu- dents of the 5th semester of the Career of Nutrition and Dietetics of the Superior Polytechnic School of Chimborazo. To the “Capitan Edmundo Chiri- boga “and” San Andres “ High Schools for the re- ceptiveness and facilities for data collection and the” Vicente Anda Aguirre “ High School. This project did not receive any type of financing for its realization. The authors express no conflict of interest in the present work.

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