CHAPTER TWO

LITERATURE REVIEW

2.0 INTRODUCTION

This chapter presents related materials reviewed from books and journals such as published and

unpublished articles from University libraries and internet materials.

This presentation will be done under the following headlines : Conceptual Review; Concept of

BMI, Classification of BMI, the biological and p physiological basis of BMI, social and cultural

factors that influence the accuracy of BMI, ethical and legal issues associated with using BMI,

implications of using BMI to assess nutritional status of children, different methods used to

collect and analyze data on BMI in children, other measures that correlates with BMI.

Theorectical Review; Ecological Systems theory , Social cognitive theory and Health belief

model theory. Emperical Review of related studies and summary of literature review.

2.1 CONCEPTUAL REVIEW

2.1 Concept of BMI

The concept of BMI was first introduced in the early 1800s by Belgian statistician Adolphe

Quetelet, who was interested in the relationship between height and weight . However, it wasn’t

until the 1950s that the term “body mass index” was first used , by Ancel Keys and colleagues .

Since then, BMI has become a widely used measure of body fat and health. Many different

organizations and researchers have contributed to the research and understanding of BMI,

including the World Health Organization, the National Institutes of Health , and the Centers for

Diseases Control and Prevention.

BMI or body mass index , is a measure of body fat based on height and weight . it is calculated

by dividing a person’s weight in kilograms by dividing by the square of their height in meters.

In a adult BMI between 18.5 and 25 is considered to be within the healthy range, while a BMI of

25 or above is considered overweight, and a BMI OF 30 above is considered obese . It is based

on the idea that excess body fat is associated with an increased risk of health problems such as

diabetes , heart diseases , and some types of cancer . The concept of BMI in children is similar to

the concept of adults. However, there are some important differences.

In children , the references ranges for BMI are based on sex and age specific growth charts . This

means that a child’s BMI compared to other children of the same age and sex , rather than to a

single standard for adults. While BMI is a useful measure of health in adults, it’s not always a

reliable indicator of health in children. This is because children can have excess fat without being

overweight , and they can be at a healthy weight but have other health risks. For example, a child

may have a high BMI but be a very physically active and have strong muscles. Or, a child may

have a healthy BMI but have a poor diet and low levels of physical activity. These children may

be at risk for health problems even though their BMI is within the normal range.

In the review of Obesity,Dr Vijayakumar’s , (2019) shows the implications for health and

wellbeing of children. His findings suggest that children who are obese are at risk for a range of

negative outcomes, including cognitive and academic difficulties. This is especially concerning

given that childhood obesity is a growing problem in many parts of the world. To address this

issue, Dr Vijayakumar has suggested that interventions to promote healthy eating and physical

activity should be a priority . He has also called for increased research into the mechanisms

linking childhood obesity and cognitive and academics outcomes, so that we can better

understand how to prevent these negative outcomes.

Dr Richard Rosenkranz and his colleagues analyzed data from the avon Longitudinal study of

Parents and Children , a longitudinal study of over 14,000 children in the United Kingdom.

They found that children who were obese at age 7 were more likely to have poorer cognitive and

academic outcomes at age 11. ( Rosenkranz et al., 2019 ). Dr Deborah Frank and her colleagues

analyzed data from the Fragile Infant Feeding Study, a longitudinal study of premature infants in

the United States. They found that infants who were born premature and had a low birth weight

were more likely to have a lower BMI in childhood, and that this was associated with lower

cognitive and behavioral outcomes. This study adds to the growing body of evidence linking to

early childhood obesity to long term health and development outcomes. ( Frank et al., 2019 ).

Silverman and Trevor C.Lipscrombe derive the mathematically exact BMI probability density

function (PDF), as well as the exact bivariate PDF for human weight and height are shown to be

correlated bivariate lognirmal variables whose marginal distributions are each lognormal in form.

(Silverman and Lipscrombe, 2022). J. Thavamani has tried to create awareness and preventive

health measures among students on Body Mass Index, and preventive measure for obesity

through counselling students on healthy nutrition and the importance of physical activities

(Thavamani , 2019).

Apart from obesity among children, there are also children who are underweight. According to

the latest available data from the World Health Organization , about 11 percent of children in

Nigeria between the ages of 5 and 11 are underweight . This is significantly higher than the

global average of about 7 percent. Underweight is most common in the rural areas of Nigeria,

where poverty and food insecurity are more common. It’s important to note that this is only an

estimate , and the true number of underweight children may be even higher. This is because not

all children are weight and measured as part of routine checks, and many children may not be
able to assess health care services . Underweight generally can cause malnutrition and also be a

sign, but it’s not the only sign. Infact , some children may appear to be at a healthy weight or

even overweight but still be malnourished. This is because malnutrition can be caused by a

variety of factors , including lack of access to healthy foods, poor diet quality , and underlying

health conditions. In 2019, UNICEF published a report titled “ Children in the Middle : The

Double Burden of Malnutrition Among School- Aged Children,”, which focused on children

between the ages of five and eleven . The report found that while the undernutrition problem

among children in this age group has improved in recent years, overweight and obesity is

becoming increasingly common.

For healthy weight children , based on the data that is available , it is estimated that around 30%

of children in Nigeria are of healthy weight. This number may vary by region and socioeconomic

status .

2.2 CLASSIFICATION OF BMI ( BODY MASS INDEX )

The World Health Organization (WHO) classifies BMI for children into five categories :

underweight, healthy weight, overweight, moderate obesity , and severe obesity . These

categories are based on the child’s BMI relative to other children of the same age and sex. The

WHO also uses these categories to determine whether a child is at risk for developing chronic

diseases later in life.

The WHO classification of BMI for children is as follows :

1. Underweight : A child is considered underweight if their BMI is less than the 5th

percentile for their age and sex. Underweight can be caused by a variety of factors
 including inadequate nutrition , frequent illness, and lack of access to health care. It can

have serious consequences including delayed growth and development , increased risk of

illness and death , and increased risk of chronic diseases later in life.

2. Healthy Weight : WHO defines healthy weight for children as a BMI between the 5 th

and 85 th percentiles for their age and sex. This means that a child is considered to have a

healthy weight if their BMI falls within this range. Children who fall outside of this range

may be at risk for health problems.

3. Overweight : WHO defines overweight for children as a body mass index greater than or

equal to the 85 th percentile but less than the 95 th percentile for their age and sex. This

means that a child is classified overweight if their BMI IS higher than 85 percent of

children their age and sex. The 85 th percentile is used as a cut- off because it is a

common point where health risks begin to increase.

4. Moderate obesity : A child is considered to have moderate obesity of their BMI is at or

above the 95 th percentile for their age and sex. This means that their BMI is significantly

higher than that of the average child their age and sex. Moderate obesity can lead to a

number of health problems, including type 2 diabetes, high blood pressure, amd joint

problems .

5. Severe obesity : WHO defines severe obesity for children as a body mass index greater

than or equal to the 99 th percentile for their age and sex. This means that a child is

considered obese if their BMI is higher than 99 percent of children age and sex. Severe

obesity can have serious health consequences , including type 2 diabetes, high blood

pressure , sleep apnea , and joint problems . it can also lead to meantal health problems

such has depression and anxiety.

2.3 THE BIOLOGICAL AND PHYSIOLOGICAL BASIS OF BMI

BMI is a widely used measurements for assessing weight status, but it has its limitations . Here’s

an overview of the biological and physiological basis of BMI.

1. Weight and Height : BMI is calculated by dividing weight ( in kg ) by height ( in

meters ) squared ( kg/ m^2 ) . This simple formula doesn’t account for muscle mass, bone

density , or body composition.

2. Body composition : BMI doesn’t distinguish between lean body mass ( muscles, organs,

bones ) and body fat. Athletes or individuals with a muscular build may have a high BMI

without being overweight .

3. Fat distribution : BMI doesn’t account for fat distribution , which is important for health

risks. Central obesity ( visceral fat around the waist ) is associated with a higher risk of

chronic diseases with peripheral fat ( fat around the hips and thighs ).

4. Body water composition : BMI doesn’t account for variations in body water content,

which can affect weight . For example, athlethes may have a higher chances due to

increased muscle mass.

5. Bone density : BMI doesn’t account for variations in bone density , which can affect

weight. For example, individuals with osteoporosis may have a lower bone density ,

leading to a lower weight.

6. Hormonal influences : Hormones like testosterone , estrogen , and cortisol can affect

body composition and fat distribution , leading to variations in BMI.

7. Genetic factor: Genetic variations can influence body weight , body composition , and fat

distribution , making BMI less accurate for some individuals.

 8. Age- related changes : BMI doesn’t account for age-related changes in body composition

, such as the loss of muscle mass and bone density with aging .

9. Sex differences : BMI doesn’t account for sex differences in body fat distribution and

muscle mass.

10. Ethnicity and population-specific variations : BMI may not be suitable for all ethnic

groups or populations , as body composition and fat distribution can vary.

According to Journal Nature Medicine published a study in 2023 titled , “ Multiomic signatures

of body mass index identify heterogenous health phenotypes and responses to a lifestyle

intervention” . The study found that blood omic profiles can provide information on several

health conditions, and that a machine learning model trained to predict BMI through blood

metabolites was able to provide better clinical measurements than genetic predisposition or

observed BMI. Another study published in Nature found that BMI is flawed and needs to be

redefined . The study argued that BMI does not distinguish between lean body mass and body fat

and does not account for fat distribution , which is important for health risks. A third study

published in springer found that while BMI is an empirical and objective measure of health, it is

also an arbitrary and subjective label for categorizing the population. The study argued that

researchers should be aware of the definitional ambiguity of BMI across different research

methods and contexts.

It’s important to recognize that BMI is a roughestimate and should be used in conjunction with

other measurements ,such as waist circumference , skinfold measurements ,or more advanced

body composition assessments , to get a more accurate picture of health.

2.3 SOCIAL AND CULTURAL FACTOR THAT INFLUENCES THE ACCURACY OF

BMI

In the accuracy of BMI, social and cultural factors can definitely play a role. For example,

different cultures may have different perceptions of body image and what is considered “ideal”

or “healthy”. This can impact how people view and interpret their BMI results. Additionally,

social pressures and norms around body size and weight can influence how individuals perceive

and respond to their BMI. It’s important to remember that BMI is just one measure of health and

doesn’t take into account factors like muscle mass or body complications . So, it’s also good to

consider other indicators of health as well. The Body Mass Index (BMI) of children is influenced

by a variety of social and cultural factors that play a significant role in shaping their lifestyle

choices, dietary habits, and physical activity levels. These factors can vary across different

socioeconomic groups, ethnicities, and cultural backgrounds, impacting the prevalence and

severity of childhood obesity.

Some of the social and cultural factors that influences the accuracy of BMI in children

include:

1. Cultural norms and beauty standards : Different cultures have varying ideals of beauty

and body shape, which can influence perceptions of weight and body compositions . In

many western countries such as United states , United kingdom, and many European

countries , has a strong emphasis on being slim and having a lower BMI as a standard of

beauty. This perception is often perpetrated by media, fashion , industry and societal

expectations. While in some other cultures, such as certain parts of Africa , the pacific
 islands , and some Native American communities , there is a cultural preference of larger

body size and a higher BMI. Thes cultures view a higher BMI as a symbol of beauty,

fertility , and good health. This can really affect the BMI of children.

2. Food habit and dietary practices : Dietary habits and food choices can impact weight and

body composition , and may not be accurately reflected in BMI of children. However , a

study conducted by BMC Public Health (2020) in the united states found that lower-

uncome households purchased foods of lower nutritional quality compared to higher-

income households . This suggests that socioeconomic factors may influence dietary

choices by parents towards their children and potentially impact BMI.

3. Physical activity level :Cultural and social factors can influence physical activity levels,

which can affect weight and body composition.Physical activity level has a significant

impact on the Body Mass Index (BMI) of children. Increased physical activity is

associated with lower BMI values and a reduced risk of obesity in children. Studies have

shown that engaging in regular physical activity helps to maintain a healthy weight,

improve overall fitness, and reduce the likelihood of developing obesity-related health

issues.

Regular physical activity contributes to energy expenditure, which can help prevent excess

weight gain and promote weight loss when combined with a balanced diet. Physical activity also

plays a crucial role in improving metabolic health, enhancing cardiovascular fitness, and

supporting overall well-being in children.

Incorporating structured physical activity programs, such as school-based interventions that

include additional extracurricular activities or increased daily exercise time, has been shown to

be effective in reducing BMI and preventing obesity in school-aged children. These interventions
often lead to improvements in body composition, waist circumference, waist-to-height ratio, and

overall physical fitness levels among participants compared to control groups.

4. Age and general differences : Age and generational differences have a substantial impact

on the BMI of children. Research indicates that younger generations are being exposed to

an obesogenic environment from an earlier age compared to older generations. This early

exposure to factors contributing to obesity can lead to higher levels of obesity prevalence

at a younger age for children in these newer generations. However, despite this higher

and earlier exposure to obesity, studies have shown that younger generations do not

necessarily reach higher levels of BMI and obesity prevalence at midlife and beyond

compared to older generations.

The Doetinchem Cohort Study highlighted that while younger generations may experience

obesity at an earlier age, their BMI levels tend to plateau by midlife, showing convergence with

older generations. This unexpected observation suggests that there might be a population-specific

energy balance reached at this stage, influencing the BMI trends across different generations.

5. Ethnicity and race :BMI may not be suitable for all ethnic groups or races , as body

composition and fat distribution can vary. The disparities in obesity prevalence between

racial and ethnic groups can be partially explained by a number of behavioral and

socioeconomic risk factors. Studies have indicated that Asian children typically display

lower prevalence rates of obesity-related risk factors than African American children,

who typically have greater prevalence rates relative to other populations. The pace of

baby weight increase during the first nine months of life is a significant factor in the

discrepancy in BMI scores between white children and their minority counterparts. It has
 been determined that this early weight increase is a strong predictor of BMI scores at

later times.

6. Gender roles and expectations :Gender norms play a significant role in shaping body

image ideals for children. Societal expectations regarding body size and appearance differ

based on gender. For instance, girls are often encouraged to strive for a thin body ideal,

while boys may face pressure to achieve a muscular or larger physique. These gender-

specific ideals can influence how children perceive their bodies and may impact their

attitudes towards weight management.

Gender norms can influence weight control behaviors in children. Research suggests that

adherence to traditional gender norms may lead to different approaches to weight management.

Girls who conform more closely to feminine norms, which may include the pursuit of thinness,

are more likely to engage in weight loss behaviors such as dieting or skipping meals. On the

other hand, boys who conform to masculine norms emphasizing size and strength may be

inclined towards weight gain strategies like consuming supplements or increasing food intake.

This behaviours affects the BMI accuracy of children.

7. Stigma and discrimination: Research has indicated that children and teenagers who

encounter stigma related to their weight frequently have negative mental health

outcomes, such as signs of anxiety, despair, and low self-worth. These unfavorable

feelings can trigger unhealthy coping strategies, including eating out of emotion, which

can add to weight gain and feed the cycle of discrimination and stigma.

Furthermore, the stigma associated with being overweight can make people less inclined

to adopt healthy habits and seek out the right medical care. Children who experience
 weight stigma in medical settings, for example, may refuse treatment or show mistrust of

medical personnel, which can have a negative impact on their health. Weight-related

stigma and discrimination can impact mental and physical health, and may not be

2.4 ETHICAL AND LEGAL ISSUES ASSOCIATED WITH USING BMI

Ethical and Legal Issues Associated with Using BMI for Children

Body Mass Index (BMI) is a commonly used tool to assess weight status in both adults and

children. However, when it comes to using BMI specifically for children, there are several

ethical and legal considerations that need to be taken into account.

2.4. Ethical Concerns:

1. Stigmatization: One of the primary ethical concerns associated with using BMI for children is

the potential for stigmatization. Labeling a child as overweight or obese based solely on their

BMI score can have negative psychological effects on the child, leading to issues such as low

self-esteem and body image problems.

2. Inaccuracy: BMI does not differentiate between muscle mass and fat mass, which can lead to

misclassification of children who may be muscular but not necessarily overweight or obese. This

inaccuracy raises ethical questions about the validity of using BMI as the sole measure of a

child’s weight status.

3. Parental Pressure: Utilizing BMI to categorize children’s weight can also put undue pressure

on parents to take drastic measures to address their child’s weight, potentially leading to

unhealthy behaviors such as extreme dieting or excessive exercise.

4. Legal Considerations: Privacy Concerns: In some cases, using BMI measurements in schools

or healthcare settings may raise privacy concerns regarding the collection and storage of

sensitive health data about children without proper consent or safeguards.

5. Discrimination: There is a risk of discrimination based on a child’s BMI status, especially in

educational settings where decisions about participation in physical activities or access to certain

programs may be influenced by a child’s weight classification.

6. Parental Rights: Legal issues can arise when schools or healthcare providers use BMI

measurements without parental consent or fail to involve parents in discussions about their

child’s weight status and potential interventions.

Physicians’ Ethical Responsibilities

American Medical Association (AMA) Code of Medical Ethics talked about Physicians Ethical

responsibilities, this association does not directly address the use of BMI, 4 opinions are

particularly relevant to considering the use of BMI in clinical encounters. Opinion 1, “Quality,”

states that physicians have an obligation “to ensure that the care patients receive is safe,

effective, patient centered, timely, efficient, and equitable” and that “physicians should actively

engage in efforts to improve the quality of health care” by, among other things, monitoring the

use of “quality improvement tools.”While this opinion does not bar the use of BMI, it does

suggest that physicians have a responsibility to ensure that its use is patient centered and

equitable and that its effectiveness as a quality improvement tool should be monitored.

Opinion 2, “Disparities in Health Care,” dictates that, beyond monitoring quality improvement

tools, physicians have a professional obligation to support “the development of quality measures
and resources to help reduce disparities.” This obligation has important bearings on the use of

BMI as a diagnostic tool , as it has become increasingly clear that the current general cut point of

30 to diagnose obesity should be personalized to account for differences in sex and

race/ethnicity. As Stanford et al note in their research aimed at redefining BMI risk thresholds for

metabolic disease: “When obesity is defined by a correlation with the presence of metabolic risk

factors, the BMI cutoffs to define oesity would change for specific race/ethnicity and sex

subgroups instead of [there being] a single BMI threshold.”

Opinion 3, “Physician Responsibilities to Colleagues With Illness, Disability or Impairment,”

states: “In carrying out their responsibilities to colleagues, patients, and the public, physicians

should strive to … eliminat[e] stigma within the profession regarding illness and

disability.”11 Because BMI is often treated as measurably bjective despite being a cultural

construct, and thus can unintentionally dehumanize patients,4 physicians have a responsibility to

minimize and try to eliminate the stigma of obesity that can be exacerbated by the use of BMI as

a diagnostic tool. Similarly, Opinion 4, “Patient Rights,” articulates that the patient-physician

relationship should be a collaborative and mutually respectful alliance that upholds the patient’s

right to “courtesy, respect, dignity, and timely, responsive attention to his or her

needs.” Physicians’ awareness of the ways that implicit bias and physician stigma against

patients withoverweight or obesity can impact patient outcomes is critical to ensuring a

respectful and dignified clinical encounter. ( AMA J Ethics. 2023;25(7):E514-516.).

Apart from physicians responsibilities, parents also have their responsibilities which includes

their ;

1. Legal Responsibilities:
Parents have a legal responsibility to ensure the well-being and health of their children. When it

comes to using BMI (Body Mass Index) as a tool to assess a child’s weight status, parents should

be aware of the legal implications associated with this practice. In many jurisdictions, parents are

legally required to provide their children with proper nutrition, healthcare, and overall support

for their physical and mental development. Failing to address concerns related to a child’s weight

and health could potentially lead to legal consequences such as charges of neglect or

endangerment.

In some cases, schools may also play a role in monitoring students’ BMI as part of their wellness

programs. Parents should familiarize themselves with the laws and regulations in their region

regarding the collection and use of BMI .data in educational settings. It is essential for parents to

understand their rights in terms of consent and access to this information, as well as how it is

being utilized by schools or healthcare providers

2 .Ethical Responsibilities:

Beyond the legal obligations, parents also have ethical responsibilities when it comes to using

BMI for children. It is crucial for parents to approach discussions about weight and body image

with sensitivity and empathy. Using BMI as a sole indicator of health can be problematic, as it

does not account for factors like muscle mass, bone density, or overall fitness level.

Parents should focus on promoting healthy habits rather than solely focusing on weight numbers.

Encouraging balanced nutrition, regular physical activity, and positive body image can contribute

significantly to a child’s overall well-being. It is important for parents to avoid stigmatizing

language or behaviors that may negatively impact a child’s self-esteem or relationship with food

and exercise.
Additionally, respecting a child’s privacy and autonomy is essential when discussing sensitive

topics like weight. Parents should involve children in decision-making processes regarding their

health and well-being, fostering open communication and mutual respect.

In conclusion, while parents have legal obligations to ensure the health of their children, they

also bear ethical responsibilities when using BMI as a tool for assessing weight status. By

approaching this topic with care, understanding, and a focus on holistic well-being, parents can

support their children in developing healthy habits and positive self-image.( AAP, 2023 ).

2.5 IMPLICATIONS OF USING BMI TO ASSESS NUTRITIONAL STATUS OF

CHILDREN

Using BMI (Body Mass Index) to assess the nutritional status of children has several

implications, both positive and negative, which should be considered

2.5.1 Positive Implications

Screening for Malnutrition: BMI can serve as a simple and quick screening tool to identify

children who may be underweight, overweight, or obese, indicating potential malnutrition or

nutritional imbalances.

Early Intervention: Early detection of nutritional issues through BMI assessment allows for

timely intervention and support, potentially preventing further health complications and

promoting healthy growth and development.

Monitoring Growth Trends: Regular BMI measurements enable healthcare providers to monitor

children's growth trends over time, allowing for early detection of growth faltering or abnormal

weight gain.

Public Health Planning: Population-level BMI data can inform public health policies and

interventions aimed at addressing nutritional challenges in children, such as promoting healthy

eating habits and physical activity.

Educational Opportunities: BMI assessment in school settings can raise awareness among

educators, parents, and students about the importance of nutrition and healthy lifestyles, leading

to educational opportunities for behavior change.

2.5.2 Negative Implications

Limited Assessment of Body Composition: BMI does not directly measure body fat or muscle

mass, so it may not accurately reflect the body composition of children, particularly those with

higher muscle mass or different body proportions.

Stigmatization and Labeling: Focusing solely on BMI may lead to stigmatization or labeling of

children based on their weight status, potentially contributing to negative body image, low self-

esteem, and psychological distress.

Ethnic and Cultural Variations: BMI cutoffs and classifications may not account for ethnic and

cultural variations in body composition and growth patterns, leading to misclassification and

inappropriate interventions.
Inadequate Nutritional Assessment: BMI alone may not provide a comprehensive assessment of

nutritional status, as it does not consider dietary intake, micronutrient deficiencies, or other

health indicators.

Overemphasis on Weight: Relying solely on BMI may reinforce a narrow focus on weight as the

primary indicator of health, overlooking other important aspects of well-being such as physical

fitness, mental health, and overall quality of life.

2.6 METHODS USED TO COLLECT AND ANALYZE DATA ON BMI IN

CHILDREN

2.6.1 Data Collection Methods:

a. Anthropometric Measurements: Trained healthcare professionals or researchers take

anthropometric measurements using standardized techniques. This typically involves:

 Height Measurement: Using a stadiometer or height rod, the child's height is measured

while standing upright, without shoes, with their head, shoulders, buttocks, and heels

touching the measuring device.

 Weight Measurement: Weight is measured using a calibrated scale while the child is

barefoot and wearing light clothing.

b. BMI Calculation: BMI is calculated using the formula: BMI = weight (kg) / height (m)^2.

This calculation provides a numerical value that is used to assess the child's weight status.

c. Age and Gender Adjustment: For children, BMI values are often adjusted for age and gender

using growth charts or percentile curves, such as those provided by the CDC (Centers for
Disease Control and Prevention) or WHO (World Health Organization). These charts allow for

comparisons against population norms.

d. Data Recording: Recorded measurements should include the child's age, gender, height,

weight, and calculated BMI.

2.6.2 Data Analysis Methods

a. Classification of BMI Categories: Once BMI values are calculated, children are classified

into categories based on standard cutoff points. Common categories include underweight, normal

weight, overweight, and obese, with specific cutoffs defined by organizations like the CDC or

WHO.

b. Descriptive Analysis: Descriptive statistics, such as means, standard deviations, and

percentiles, are used to summarize the distribution of BMI values within the sample population.

c. Comparison and Interpretation: BMI data may be compared to reference standards or

population norms to assess the prevalence of underweight, overweight, or obesity within the

sample population.

d. Subgroup Analysis: Data may be analyzed by demographic variables (e.g., age, gender,

socioeconomic status) to identify patterns or disparities in BMI distribution.

e. Regression Analysis: In some studies, regression analysis may be used to examine

relationships between BMI and other variables, such as dietary habits, physical activity levels, or

health outcomes.
f. Trend Analysis: Longitudinal studies may analyze trends in BMI over time to assess changes

in nutritional status and identify potential risk factors or interventions.

2.6.3 Quality Assurance:

a. Training and Standardization: Data collectors should undergo training to ensure consistency

and accuracy in measurements. Standardized protocols should be followed to minimize

measurement error.

b. Data Cleaning: Prior to analysis, data should be checked for errors or inconsistencies and

cleaned as needed to ensure data quality.

c. Validation: Where possible, BMI measurements may be validated against other measures of

body composition, such as dual-energy X-ray absorptiometry (DEXA) or skinfold thickness

measurements.

2.7 THEORETICAL REVIEW

2.7.1 Ecological Systems theory

Ecological Systems Theory, proposed by Urie Bronfenbrenner, provides a comprehensive

framework for understanding human development within the context of multiple environmental

systems. It emphasizes the interplay between individuals and their immediate surroundings, as

well as broader societal influences. (Lightfoot, Cynthia et al 2020) This theory posits that

individuals are embedded within a series of nested environmental systems, including the

microsystem, mesosystem, exosystem, macrosystem, and chronosystem, all of which contribute

to their development and behavior.

Microsystem:

Within the microsystem, immediate interactions and relationships directly impact children's

nutritional status. This includes family dynamics, peer relationships, and school environments.

Assessment at this level involves examining how family eating habits, parental education on

nutrition, peer influences, and school meal programs influence children's BMI.

Methodologically, researchers can collect data through surveys, interviews, and observations to

understand family dietary patterns, peer influences on food choices, and the availability of

nutritious meals in school cafeterias. (Darling, 2022)

Mesosystem:

The mesosystem encompasses interactions between different microsystems, such as the

relationships between family and school environments in influencing children's nutrition.

Assessment at this level involves examining the coordination between family nutrition practices

and school-based nutrition education programs. (Bronfenbrenner, 2020) Researchers can collect

data on parental involvement in school nutrition initiatives, communication between parents and

teachers about nutrition, and the integration of nutrition education into the school curriculum.

Exosystem:

The exosystem consists of external environments that indirectly impact children's nutrition,

including community resources, policies, and cultural norms. Assessment at this level involves

understanding how community factors, such as access to grocery stores, food affordability, and

cultural norms around food, influence children's BMI. (Rosa, Edinete Maria et al 2021)

Researchers can gather data on the availability of healthy food options in the community,
socioeconomic factors affecting food access, and cultural beliefs and practices related to

nutrition.

Macrosystem:

The macrosystem encompasses broader cultural and societal influences on children's nutrition,

including socioeconomic conditions, cultural values, and government policies. Assessment at this

level involves considering how societal factors, such as economic inequalities, cultural attitudes

towards food, and government nutrition policies, impact children's nutritional status. Researchers

can examine data on socioeconomic indicators, cultural dietary practices, and government

policies related to nutrition and health promotion. (Ceci, 2021)

Chronosystem:

The chronosystem acknowledges the impact of historical changes and transitions over time on

children's nutrition. Assessment at this level involves considering how historical events, policy

changes, and societal shifts have influenced children's nutrition patterns. (Darling, 2022)

Researchers can examine historical trends in child nutrition, changes in government nutrition

programs, and shifts in cultural attitudes towards food over time.

2.7.2 Social cognitive theory

Social Cognitive Theory, proposed by Albert Bandura, posits that behavior is influenced by

interactions between personal factors, environmental influences, and individual behaviors. Key

constructs of social cognitive theory include observational learning, self-efficacy, outcome

expectations, and social influences. Observational learning suggests that individuals learn from
observing others, while self-efficacy refers to one's belief in their ability to perform a specific

behavior. In the context of nutrition, social cognitive theory suggests that children's dietary

behaviors are influenced by social models, environmental cues, and their perceived ability to

make healthy choices.

Social Cognitive Theory (SCT) is one of the social theories that integrate elements of

psychology, sociology and political science. It was developed by Albert Bandura in 1977 to

emphasize the role of observation and cognitive factors in learning and also to understand and

predict behavior (Glanz, Rimer, & Viswanath, 2021).The use of nursing theory in education,

practice, and research provides a framework for understanding different phenomena of health

care study, increases critical and creative thinking by assessing current knowledge, and probes

unanswered questions that can generate new disciplinary knowledge for nursing (Lipscomb,

2022).

SCT has been used in different contexts, in clinical settings, health promotion, education, health

policy initiatives and environmental education strategies (Glanz et al., 2020). In nursing, this

theory has contributed to broadening the perspective on contextual and social factors in different

health care settings. However, it has been questioned whether theories from other disciplines are

adequate to guide the different phenomena of the nursing science. Therefore, it is necessary to

know how the use of SCT has contributed to respond to the different areas of inquiry of the

nursing discipline (Lipscomb, 2022). Within this context and the available scientific evidence, an

analysis and evaluation of SCT was carried out using Fawcett and Desanto-Madeya (2021)

approach. This approach consists of a methodological framework that includes two steps: Firstly,

to analyze the origins of the theory and content and secondly, to evaluate the explanation of the

origins, understanding of the content, logical consistency, theory generation, legitimacy; and
contributions to the nursing discipline. This approach was used with the aim to increase the

understanding and approximation of the use of SCT in nursing practice and research.

2.7.3 Health belief model theory

The Health Belief Model is a psychological framework that posits individuals' health-related

behaviors are influenced by their perceptions of the threat posed by a health problem, the

perceived benefits of taking action, perceived barriers to action, and cues to action. Additionally,

individual characteristics and sociodemographic factors also play a role in shaping health

behaviors. (Austin, Latoya et al 2021) In the context of nutrition, the HBM suggests that

children's dietary behaviors are influenced by their beliefs about the risks of unhealthy eating

habits, the perceived benefits of maintaining a balanced diet, the barriers to healthy eating, and

external cues that prompt them to make healthier food choices.

The Health Belief Model (HBM) was developed in the early 1950s by social scientists at the U.S.

Public Health Service in order to understand the failure of people to adopt disease prevention

strategies or screening tests for the early detection of disease. (Rosenstock, Irwin et al 2020)

Later uses of HBM were for patients' responses to symptoms and compliance with medical

treatments. The HBM suggests that a person's belief in a personal threat of an illness or disease

together with a person's belief in the effectiveness of the recommended health behavior or action

will predict the likelihood the person will adopt the behavior.

The HBM derives from psychological and behavioral theory with the foundation that the two

components of health-related behavior are 1) the desire to avoid illness, or conversely get well if

already ill; and, 2) the belief that a specific health action will prevent, or cure, illness. Ultimately,
an individual's course of action often depends on the person's perceptions of the benefits and

barriers related to health behavior. (Schmiege 2022)There are six constructs of the HBM which

is stated below:

 Perceived susceptibility - This refers to a person's subjective perception of the risk of

acquiring an illness or disease. There is wide variation in a person's feelings of personal

vulnerability to an illness or disease.

 Perceived severity - This refers to a person's feelings on the seriousness of contracting an

illness or disease (or leaving the illness or disease untreated). There is wide variation in a

person's feelings of severity, and often a person considers the medical consequences (e.g.,

death, disability) and social consequences (e.g., family life, social relationships) when

evaluating the severity. (Abraham 2021)

 Perceived benefits - This refers to a person's perception of the effectiveness of various

actions available to reduce the threat of illness or disease (or to cure illness or disease).

The course of action a person takes in preventing (or curing) illness or disease relies on

consideration and evaluation of both perceived susceptibility and perceived benefit, such

that the person would accept the recommended health action if it was perceived as

beneficial. (Becker, Marshall et al. 2020)

 Perceived barriers - This refers to a person's feelings on the obstacles to performing a

recommended health action. There is wide variation in a person's feelings of barriers, or

impediments, which lead to a cost/benefit analysis. The person weighs the effectiveness

of the actions against the perceptions that it may be expensive, dangerous (e.g., side

effects), unpleasant (e.g., painful), time-consuming, or inconvenient. (Cerkoney, 2021)

  Cue to action - This is the stimulus needed to trigger the decision-making process to

accept a recommended health action. These cues can be internal (e.g., chest pains,

wheezing, etc.) or external (e.g., advice from others, illness of family member, newspaper

article, etc.).

 Self-efficacy - This refers to the level of a person's confidence in his or her ability to

successfully perform a behavior. This construct was added to the model most recently in

mid-1980. Self-efficacy is a construct in many behavioral theories as it directly relates to

whether a person performs the desired behavior. (Glanz, 2020)

Limitations of Health Belief Model

There are several limitations of the HBM which limit its utility in public health. Limitations of

the model include the following:

 It does not account for a person's attitudes, beliefs, or other individual determinants that

dictate a person's acceptance of a health behavior.

 It does not take into account behaviors that are habitual and thus may inform the

decision-making process to accept a recommended action (e.g., smoking).

 It does not take into account behaviors that are performed for non-health related reasons

such as social acceptability.

 It does not account for environmental or economic factors that may prohibit or promote

the recommended action.

 It assumes that everyone has access to equal amounts of information on the illness or

disease.
  It assumes that cues to action are widely prevalent in encouraging people to act and that

"health" actions are the main goal in the decision-making process.

EMPIRICAL REVIEW

According to Taiwo Oyeyoyin Olanipekun (2012) on her research on Assessment of nutritional

status of primary school children in Ibadan, South-West Nigeria. The purpose of this study is to

determine and compare the nutritional status of children aged 5-10 years attending private (fee

paying-FP) and public (non-fee paying-NFP) primary schools in Ibadan South-West Local

Government Area (ISWLGA) of Oyo State, Nigeria.

Anthropometry method was used in the study. Two basic variables (height and weight) and a

single derived variable (body mass index-BMI) were utilized. All the anthropometric

measurements were taken following standard techniques. Findings – The prevalence of

malnutrition was significantly higher ( p , 0.05) in the NFP pupils than in the FP pupils. The

incidence of stunting, underweight and wasting among NFP pupils (boys and girls) was 44.8

percent and 43.05 percent; 41.07 percent and 38.88 percent; 43.59 percent and 40.29 percent,

respectively. For the pupils from FP schools, the incidence of stunting, underweight and wasting,

respectively, (boys and girls) was 34.21 percent and 27.77 percent; 30.70 percent and 27.77

percent; 27.19 percent and 5.55 percent. Higher percentages of boys were malnourished in the

two groups of pupils studied. The study was limited to Ibadan South-West local Government

Area of Oyo state, Nigeria; it does not give a holistic view of the nutritional status of Nigerian

school children. The results of this study, shows that the average school child in Ibadan, Nigeria

is under nourished. Also, higher percentages of boys were malnourished in the two groups of
pupils studied. Urgent steps should therefore be taken to meet the nutritional needs of the

children.

Furthermore, Adelekan (2010) On His Research On Assessment Of Nutritional Status Of Public

Primary School Pupils In Odeda Local Government Area. This study was conducted to assess the

nutritional status of 200 public primary school pupils, comprising 84males and 116 females in a

rural setting. These pupils were scientifically selected (stratified sampling) from 2 public schools

in 2 villages with similar socioeconomic characteristics in the Odeda local government area of

Ogun state. A structured questionnaire was used to collect information on socio-demographic and

socio economic characteristics of the pupils and their parents. The questionnaire was also used to

collect information on the food consumption patterns of the pupils while a bathroom scale and a

height meter were used to obtain their weights and heights, respectively. A 24-hour dietary recall

was used to assess the food intakes and the ESHA food processor nutrients database was

employed in the analysis of energy and nutrients. To assess stunting and underweight among the

respondents, WHO Anthro plus software was used. T-test and chi-square statistics were used to

analyze differences and associations between variables. The results of the study revealed that

more than half of the pupils reported eating three times daily with breakfast and supper mainly

consumed at home. The 24-hour recall showed that the pupils did not meet their energy and

nutrient requirements except for three out of the seven nutrients investigated. The prevalence of

stunting and underweight were 16.5% and 13%, respectively, among the respondents. It was

concluded that the nutritional status of the respondents was poor since the incidence of stunting

and underweight were high while energy and some nutrients were below the recommended

intakes.
According to Sana Zahid (2017) on assessment of nutritional status of school children in public

and private sector schools by anthropometry. this study was designed to evaluate the nutritional

status of primary schools going children o f government and private schools in urban area. The

study was conducted from Feb 2017 to March 2017. Two hundred primary school children were

randomly selected out of which 100 were taken from government and private sector school each

from urban area of Faisalabad. The comparative cross sectional study was carried out in primary

school going children and nutritional status was interpreted using CDC growth curves and z

scores were evaluated for stunting, wasting and thinness through WHO criteria. The percentage

of stunted children was 25.5% and of this proportion, 71.6% belonged to government school.

20% children were found to be suffering from wasting out of which 57.1% belonged to

government school. It was observed that the students from the government school had a slightly

higher percentage of students with a normal BMI (56%) as opposed to the students of private

school at 54%. There were more underweight students in government school than in private

school (69.8% and 30.2% respectively). 64% of the overweight students belonged to private

school. The proportion of obese students was found to be highest in private school (94.7%). A

significant number of students had malnutrition in the form of stunting and wasting both in

government and private sector schools under study. Socio economic status directly a ffected

nutritional status.

Furthermore, Alaba, K.E (2021) had a research on Assessment of Nutritional Status of School

Age Children (5-12 Years) in Selected Private Primary Schools in Ilaro Metropolis Ogun State.

Nigeria. This study assessed the nutritional status of school age children (5-12years) in selected

private primary schools in Ilaro, Ogun state, Nigeria. A multistage random sampling technique

was used in selecting two hundred and fifty (250) respondents using a regular interval from the
school register. Questionnaire was used to collect data on socio demographic characteristics,

anthropometry (Height and Weight) measurement of the respondents were taken using a standard

procedure and values obtained was compared with the reference standard and their

anthropometric indies were computed using WHO Anthroplus software. Data obtained on socio

demographic characteristics were subjected to descriptive statistics using SPSS v 20.0.Result

reveals that majority of the school aged children are male (51.6%), aged between 10-12 years

(56.8%) , majority of the school aged children are from Christian background (78%) and Yoruba

(86.7%). Under the class variable, half of the pupils (50.4%) were in primary four and from a

monogamous home, 44,8% earns between ₦20- ₦50 as pocket money. The mean height of the

male (2.91) respondent was higher than that of female (1.95) respondent while the mean weight

of female (31.22) respondent was higher than that of male (30.51) respondents but the difference

was not significance (P < 0.05). The nutritional status assessment shows that half of the

respondents have normal nutritional status while high prevalence of underweight, stunting and

overweight was observed in the rest of the respondents. Conclusively, half of the school age

children in private primary school in the Ilaro are suffering from malnutrition.

Summary of literature review

Despite the extensive research on the use of BMI as a tool for assessing nutritional status in

children, there is a notable gap in the literature regarding the socio-cultural influences on BMI

measurement and interpretation among primary school children in low-income urban areas.

While numerous studies have explored the association between BMI and nutritional status in

children, many of these studies have focused on populations in high-income countries or urban
areas with relatively homogeneous socio-economic backgrounds. There is limited research

specifically examining the socio-cultural factors that may influence BMI measurement and

interpretation among primary school children in low-income urban areas, where access to

nutritious food, healthcare resources, and educational opportunities may be limited.

Understanding the socio-cultural influences on BMI measurement and interpretation is crucial

for accurately assessing the nutritional status of primary school children in low-income urban

areas. Factors such as cultural perceptions of body weight, dietary habits, access to healthcare

services, and socio-economic disparities may impact BMI measurements and contribute to

misinterpretation of nutritional status indicators. Addressing this gap in the literature is essential

for developing culturally sensitive and contextually relevant strategies for promoting healthy

nutrition and preventing malnutrition among vulnerable populations of primary school children.

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