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Evidence of an Overweight/Obesity Transition among School-Aged Children and Youth in Sub-Saharan Africa: A Systematic Review

  • Stella K. Muthuri ,

    smuthuri@cheo.on.ca

    Affiliations Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada, University of Ottawa, Ottawa, Ontario, Canada

  • Claire E. Francis,

    Affiliation Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

  • Lucy-Joy M. Wachira,

    Affiliation Kenyatta University, Nairobi, Kenya

  • Allana G. LeBlanc,

    Affiliations Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada, University of Ottawa, Ottawa, Ontario, Canada

  • Margaret Sampson,

    Affiliation Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada

  • Vincent O. Onywera,

    Affiliations Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada, Kenyatta University, Nairobi, Kenya

  • Mark S. Tremblay

    Affiliations Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada, University of Ottawa, Ottawa, Ontario, Canada, Kenyatta University, Nairobi, Kenya

Evidence of an Overweight/Obesity Transition among School-Aged Children and Youth in Sub-Saharan Africa: A Systematic Review

  • Stella K. Muthuri, 
  • Claire E. Francis, 
  • Lucy-Joy M. Wachira, 
  • Allana G. LeBlanc, 
  • Margaret Sampson, 
  • Vincent O. Onywera, 
  • Mark S. Tremblay
PLOS
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Correction

19 Jun 2014: The PLOS ONE Staff (2014) Correction: Evidence of an Overweight/Obesity Transition among School-Aged Children and Youth in Sub-Saharan Africa: A Systematic Review. PLOS ONE 9(6): e101098. https://doi.org/10.1371/journal.pone.0101098 View correction

Abstract

Background

Prevalence of childhood overweight/obesity has increased considerably in recent years. The transition to higher rates of overweight/obesity has been well documented in high income countries; however, consistent or representative data from lower income countries is scarce. It is therefore pertinent to assess if rates of overweight/obesity are also increasing in lower income countries, to inform public health efforts.

Objective

This systematic review aimed to investigate the evidence for an overweight/obesity transition occurring in school-aged children and youth in Sub Saharan Africa.

Methods

Studies were identified by searching the MEDLINE, Embase, Africa Index Medicus, Global Health, Geobase, and EPPI-Centre electronic databases. Studies that used subjective or objective metrics to assess body composition in apparently healthy or population-based samples of children and youth aged 5 to 17 years were included.

Results

A total of 283 articles met the inclusion criteria, and of these, 68 were used for quantitative synthesis. The four regions (West, Central, East, and South) of Sub Saharan Africa were well represented, though only 11 (3.9%) studies were nationally representative. Quantitative synthesis revealed a trend towards increasing proportions of overweight/obesity over time in school-aged children in this region, as well as a persistent problem of underweight. Weighted averages of overweight/obesity and obesity for the entire time period captured were 10.6% and 2.5% respectively. Body composition measures were found to be higher in girls than boys, and higher in urban living and higher socioeconomic status children compared to rural populations or those of lower socioeconomic status.

Conclusions

This review provides evidence for an overweight/obesity transition in school-aged children in Sub Saharan Africa. The findings of this review serve to describe the region with respect to the growing concern of childhood overweight/obesity, highlight research gaps, and inform interventions.

PROSPERO Registration Number

CRD42013004399

Introduction

Worldwide populations are facing “modern” health risks due to increasing prevalence of overweight and obesity (overweight/obesity), physical inactivity, and sedentary behaviours, which are associated with obesogenic environments. This has caused a shift in the major causes of death from “traditional” health risks associated with poverty such as undernutrition, unsafe water, and poor sanitation, to a growing burden of modifiable non-communicable diseases (NCDs) [1]. The World Health Organization (WHO) classifies overweight/obesity as the fifth leading cause of global mortality, and one of the greatest health challenges and determinants for various chronic diseases such as heart disease, hypertension, diabetes, and psychosocial problems, in the 21st century [1], [2][6]. This growing population health threat has garnered much attention in view of the declaration and global campaign on the prevention and control of NCDs signed by the United Nations in 2011 [7].

While the health benefits of maintaining healthy body weights and an active lifestyle are well established [6], consumption of calorie-dense foods, declines in habitual physical activity, and increases in sedentary behaviour have been on the rise across developing nations [8]. Traditional practices such as walking long distances, and habitual physical labour have been replaced by motorized transport, and sedentary activities, particularly in urban settings [9]. Furthermore, in many Sub Saharan Africa (SSA) countries, an increased level of body fat is associated with beauty, prosperity, health, and prestige, while in contrast, thinness is perceived to be a sign of ill health or poverty [9]. These factors are now leading to increases in the occurrence of overweight/obesity and related risk factors for NCDs in SSA's children and youth [1], [9].

The health risks associated with overweight/obesity are particularly problematic in children due to the potential for long-term health concerns. A growing body of evidence has shown that overweight/obesity in childhood is significantly associated with increased risk of obesity, physical morbidity, and premature mortality in adulthood [10], [11], [12]. Fortunately, children who are able to attain a normal weight by adolescence have better cardiovascular disease risk factor profiles when compared to those that remain overweight [10]. Childhood is therefore a crucial time to learn basic life skills, including proper nutrition, and how to accumulate sufficient levels of activity in order to attain healthy body weights.

While we must recognise the diversity of populations in SSA, there are certain long-term developmental problems in this region that tend to adversely affect most or all of its countries and peoples [13]. Being the poorest continent in the world, with the highest population growth rate, the concern for an immense double burden of disease due to persistent infectious diseases and modern risks such as an overweight/obesity transition is troubling. The need for population wide interventions to reduce or prevent the adoption of less healthy lifestyles and body weights, particularly for children in SSA has never been greater [9], [14].

The objective of this systematic review was to determine if SSA is indeed undergoing an overweight/obesity transition. Specifically, this review aimed to examine time trends in the proportions of overweight/obesity in school-aged children and youth in SSA, thereby highlighting any research gaps and identifying areas of need for healthy active living interventions.

Methods

Study inclusion criteria

Studies were included if they reported using either subjective (e.g., parent or self-report questionnaires) or objective (e.g., directly measured) measures of body composition (weight, height, body mass index, waist/hip circumference, skin-folds, or body image assessment) in children aged 5–17 years. No date or language limits were set, but due to feasibility, only studies presented in either English or French were included. In addition, only studies of populations from SSA countries were included.

Study exclusion criteria

All published, peer-reviewed studies were eligible for inclusion; however, in order to obtain information on a general population living under ordinary conditions, intervention programs and studies were excluded unless they conducted baseline assessments. Studies done on children with chronic conditions were excluded.

Search strategy

Studies were identified using the following electronic databases: Ovid MEDLINE (1948 to May, Week 4, 2013), Ovid Embase (1974 to Week 21, 2013), Africa Index Medicus (database dates not available, latest search on June 3, 2013), Global Health (1973 to June 3, 2013, through the CAB direct interface), Geobase (1884-June 3, 2013 through the Engineering Village interface), and EPPI-Centre database of health promotion research (Bibliomap) (dates of coverage not available, latest search on June 3, 2013). In addition, several open access journals relevant to SSA were identified and those journal web sites were searched for additional relevant papers. The search strategy for this systematic review was completed in tandem with a sister publication examining the evidence for a physical activity, sedentary behaviour, and physical fitness transition among school-age children and youth in SSA; hence, the inclusion of these terms in the search strategy. The search strategy was created and run by MS. The complete search strategy used for MEDLINE is presented in table 1. The PRISMA flow chart in figure 1 accounts for the number of articles included to inform this systematic review. References were exported, de-duplicated and reviewed using Reference Manager Software (Version 11, Thompson Reuters, San Francisco, CA). Titles and abstracts of potentially relevant articles were screened by two independent reviewers (SKM and one of CEF or LJW), and full text copies were obtained for articles meeting initial screening criteria. Full text articles were screened in duplicate for inclusion in the review (SKM and one of CEF or LJW), and any discrepancies were discussed and resolved by the reviewers. This review is registered with the international prospective register of systematic reviews PROSPERO network (registration number: CRD42013004399); available at http://www.crd.york.ac.uk/prospero/.

Data extraction, quality assessment, and synthesis

Data extraction was completed using a standardized data extraction template (SKM, CEF, AGL, and LJW). Study quality was assessed by SKM and CEF using a modified Downs and Black instrument [15]. Due to limitations in study design, questions selected from the Downs and Black quality assessment instrument excluded any questions that referred to intervention and trial study methodology. Ten out of the possible 27 questions were used for quality assessment as represented in table 2. Table 3 provides the score out of ten for all studies included in this systematic review. Due to heterogeneity in study methodology and cut-points used to categorize samples into under, healthy, overweight, and obese, we were unable to carry out a meta-analysis in this review. However, quantitative syntheses were conducted by calculating the weighted averages (by sample size) of the prevalence of overweight/obesity. Our goal was to examine time trends and thereafter compute an overall prevalence of overweight/obesity in the region, by comparing the crude rates or prevalence of overweight/obesity in the individual populations or samples. As such, we attempted to standardize the crude rates by acknowledging and adjusting with respect to the sample sizes in each of the included studies, and indicating graphically the sample size upon which a particular data point was based. Findings from the quantitative synthesis were also complemented with narrative syntheses of the included studies.

Results

Figure 1 shows the PRISMA flow chart with numbers of included and excluded articles at each step of the review process, while table 3 provides a summary of all studies that met the inclusion criteria. A total of 2657 records were identified through database searches and other sources. Following de-duplication, 2242 articles were screened for eligibility, and 663 articles were selected for a full-text review. Of these, 283 articles met the inclusion criteria, and 68 of the studies (comprising 190,149 participants) were used in quantitative synthesis. Reasons for exclusion included: ineligible population (e.g., studies that did not involve children 5–17 years of age with no pre-existing condition) (n = 181); ineligible country (e.g., population living in a country/region outside of SSA) (10); ineligible outcome (n = 122); or ineligible study design (n = 67). It is important to note that all the studies included in this review were found to have used objective methods of collecting body composition data.

Regional representation

As shown in table 3, which includes a summary of the 283 studies included in the review, the four regions of SSA were well represented, with 91 (32.1%) from West African countries - with Nigeria represented in 60 of these records; 7 (2.5%) from Central African countries; 75 (26.5%) from East African countries - with Kenya represented in 28 of these records; 108 (38.2%) from South African countries - with South Africa represented in 102 of these records; and 2 (0.7%) that were East and West combined. In total, 27 countries were captured in this review.

Publication rate

The earliest relevant record captured was published in 1964. There was a marked increase in the publishing rate from the earliest to the current studies: 5 articles between 1960 and 1969, 15 from 1970–1979, 32 from 1980–1989, 31 from 1990–1999, 92 from 2000–2009, and 108 articles from 2010 to May/June 2013.

Data quality assessment

The average modified Downs and Black score out of ten for all studies included in this systematic review was 7.4; indicative that data quality was fairly high among the included records, within the prescribed limitations of study designs included in this review. The majority of studies used in the quantitative synthesis scored 7 or higher. As presented in table 3, the scoring process further revealed that only 38 (13.4%) of 283 included articles targeted a sample that was representative of their population of interest, and 31 (11.0%) recruited a sample that was representative of their population of interest. Only 11 (3.9%) articles explicitly mentioned using a nationally representative sample, one of which used the same study sample as that of another already included study.

Body composition measures

Of the 283 included studies, 88 (31.1%) articles [16][103] reported on mean BMI, BMI-z-score, and/or weight z-scores of the sample population, 50 (17.7%) articles [104][153] reported on body fat percentage, waist circumference, skin fold measures, and/or weight and height measures, and a total of 30 (10.6%) articles [154][183] reported finding no prevalence of overweight/obesity in their study samples. Of the remaining 115 (40.6%) records, 82 articles [184][265] used the more widely accepted international cut-points (namely, the International Obesity Task Force (IOTF), the Centers for Disease Control and Prevention (CDC), and the most recent WHO cut-points) to further categorize their samples into underweight, normal-weight, and overweight/obese. The other 33 articles [266][298] mentioned using one of a number of other cut-points and reference standard groups including but not limited to Tanner et al., 1966, Seoane & Latham, 1971, Frisancho 1990, Rosner et al., 1998, Harvard Standards, Waterlow 1972/77, and various US and UK reference samples. Of the 30 studies reporting no prevalence of overweight/obesity, a majority had not used the more widely accepted international cut-points, while the reminder did not provide the required prevalence estimates to be included in the quantitative synthesis.

Quantitative synthesis

Of the 82 articles that used more widely accepted international cut-points, 11 studies [187], [191], [192], [198], [206], [215], [224], [225], [234], [246], [265] were removed due to having an identical study sample as an already included study, and 3 studies [214], [218], [264] were removed for having not indicated the sample sizes in the age range of interest. As represented in table 4, the remaining 68 (24.0%) articles [184][186], [188][190], [193][197], [199][205], [207][213], [216], [217], [219][223], [226][233], [235][245], [247][263] were used in quantitative synthesis. Of these, the largest proportion (44.1%) used the IOTF cut-points [299], 30.9% used CDC cut-points [300], and 25.0% used the most recent WHO cut-points [301] for weight status. Briefly, the IOTF methodology involved obtaining the body mass index for children from six large nationally representative cross sectional surveys on growth from Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States. Thereafter, centile curves for body mass index were constructed for each dataset by sex, and passed though the widely used cut off points of 25 and 30 kg/m2 for adult overweight and obesity at age 18 years. The resulting curves were averaged to provide age and sex specific cut off points for children 2–18 years of age [299]. In the case of the CDC cut-points, growth charts were developed based on data from five national health examination surveys conducted in the United States, including limited supplemental data. Smoothed percentile curves were created by first smoothing selected empirical percentiles, then creating parameters obtain the final curves, additional percentiles, and z-scores [300]. Finally, the WHO cut-points were developed after data from the 1977 National Center for Health Statistics (NCHS)/WHO growth reference for 1–24 years, were merged with data from the under-fives growth standards' cross-sectional sample to smooth the transition between the two samples. The new curves filled the gap in growth curves and provided an appropriate reference for the 5 to 19 years age group [301].

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Table 4. Proportions of overweight/obesity as reported by studies used in quantitative synthesis.

https://doi.org/10.1371/journal.pone.0092846.t004

Figure 2 shows a distinctive time trend towards increasing proportions of overweight/obesity in school-aged children in SSA. The figure also shows a similar but less prominent trend towards increasing proportions of obesity over time. Figure 3, shows increasing trends in proportions of overweight/obesity over time for both boys and girls; however, the proportions are consistently higher in girls than in boys. To determine the robustness of these findings, we examined the trends in overweight/obesity over time using the few studies that indicated having recruited a representative sample of the population. We similarly found a trend towards increasing proportions of overweight/obesity among school-aged children in this region. The findings were also similar when boys and girls were assessed separately. While not the focus of this manuscript, as shown in Figure 4, we also examined trends in underweight over time for the included studies that had also reported this proportion. We found a trend towards decreasing proportions of underweight over time in boys, a trend towards increasing proportions over time in girls, and a largely unaltered trend over time - at approximately 20% - when boys and girls were considered together.

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Figure 2. Proportions of overweight/obesity (combined) and obesity over time in Sub Saharan Africa.

https://doi.org/10.1371/journal.pone.0092846.g002

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Figure 3. Proportions of overweight/obesity (combined) in Sub Saharan Africa's boys and girls.

https://doi.org/10.1371/journal.pone.0092846.g003

The weighted averages (for the entire time period and all studies included in the quantitative analysis) of overweight/obesity proportions in boys and girls were calculated as 7.6% and 15.4% respectively. Weighted averages of obesity alone for boys and girls were 2.0% and 3.9% respectively. Weighted averages of overweight/obesity and obesity proportions for boys and girls combined were 10.6% and 2.5%. Weighted proportion of underweight was calculated as 25.0% for boys, 8.3% for girls, and 17.6% for boys and girls combined.

Narrative synthesis

Narrative descriptions of the relationship between body composition and age, sex, socioeconomic status (SES), and urban/rural differences are discussed below based largely on the studies not included in the quantitative synthesis:

Sex differences.

Of the 96 studies [16][18], [20], [24][26], [29], [36], [39], [40], [43], [45], [46], [48], [51], [53][56], [59][61], [63][68], [70][72], [74], [76][80], [83], [85], [86], [89], [91], [92], [95], [96], [98], [103][105], [107], [109][114], [116][120], [123], [124], [126], [128], [129], [132], [133], [135], [136], [140], [143], [147], [149][152], [163], [169], [170], [214], [215], [218], [225], [281], [287], [289], [292], [293], [295] that reported their data by sex, 31 articles [20], [25], [29], [40], [45], [59], [67], [68], [70], [71], [74], [76], [78], [79], [85], [86], [89], [92], [95], [96], [103], [107], [124], [126], [132], [147], [151], [163], [170], [214], [215] reported that girls had higher body composition measures than boys, while 5 articles [265], [267], [289], [292], [293] reported that boys had higher body composition measures than girls. The remaining studies either found no significant difference or did not report a difference between boys and girls.

Urban/rural differences.

Thirty-three articles compared body composition measures in urban and rural populations. Of these, 29 studies (including 7 studies used in the quantitative synthesis) [17, 24, 27, 31, 34, 37, 54, 58, 79, 84, 87, 98, 119, 128, 129, 138, 156, 163, 206, 212, 282, 298, (185, 189, 200, 217, 233, 240, 260)] reported significantly higher body composition measures in the urban compared to the rural sample, with the remaining studies [110], [111], [140], [280] reporting no significant difference between the two populations.

Socioeconomic status (SES) differences.

Twenty four articles reported on outcomes of interest by some measure of socioeconomic status (e.g., income quartile, public/private school attendance). Of these, 19 articles (including 8 studies used in the quantitative synthesis) [45, 54, 61, 68, 75, 77, 84, 92, 99, 101, 156, 163, 169, 218, 296, 297, (212, 228, 231, 237, 247, 250, 255, 256)] reported that higher SES was associated with higher body composition measures, whilst the remaining articles [54], [75], [92], [169], [256] found no significant association of SES on body composition.

Age differences.

Of the articles that reported on body composition measures by age, 15 studies found a largely positive relationship with age [287], [170], [70], [147], [103], [95], [151], [20], [42], [242], [256], [229], [230], [199], [297], while 7 studies found a largely negative relationship with age [83], [264], [233], [19], [190], [196], [245]. In some cases, the relationship between age and body composition measures differed between sexes; as such, we may conclude that there was no convincing or consistent evidence of an independent age effect.

Discussion

To our knowledge, this systematic review is the first to comprehensively examine if there is evidence supporting an overweight/obesity transition in school-aged children and youth in SSA.

An overweight/obesity transition

Due to vast heterogeneity in types of measurement, classification, and analysis, both narrative and quantitative analyses (weighted proportions and bubble plots of overweight/obesity) were presented in this review. Quantitative synthesis was completed using 68 studies that categorized children and youth based on internationally accepted cut-points for weight status. The weighted averages of overweight/obesity proportions in boys and girls was 7.6% and 15.4% respectively, while obesity proportions in boys and girls was 2.0% and 3.9% respectively. Weighted averages of overweight/obesity, and obesity for the total population were 10.6% and 2.5%. Current evidence revealed a clear transition of increasing proportions of overweight/obesity in school-aged children in SSA, and a similar, but less prominent trend towards increasing proportions of obesity over time. This transition to higher proportions of overweight/obesity is similar to observed trends in developed countries; however, the weighted averages fall far below proportions in various high income countries. For example, in Canada, research has shown that the prevalence of overweight/obesity has more than doubled (14% to 29%) and the obesity rate has tripled (3% to 9%) over the last 25 years in children and youth 5 to 17 years of age [302], [303]. In the USA, 33% of children and youth 6–19 years are considered to be overweight/obesity, and 18% are considered to obese [304].

It is important to note that across all age groups, WHO cut-points yield higher proportions of boys and girls classified as overweight/obesity than do the IOTF, or CDC cut-points [305]. While studies that used any of the three cut-points were analysed together in this review, when interpreting prevalence estimates of overweight/obesity, it is important to consider the choice of cut-point used in each study. With the largest proportion of included studies using IOTF cut-points, it could be argued that this may “dilute” the weighted average of the proportions of overweight/obesity calculated for SSA. Nonetheless, these results indicate that while there is an imminent threat of continued increases in levels of childhood overweight/obesity in SSA, implementing viable population health interventions may mitigate the associated health risks in these earlier stages.

Persistence of underweight

In discussing an overweight/obesity transition, it is important to recognize that child under-nutrition remains one of SSA's most fundamental challenge for improved human development [306], [307], [308]. This is particularly concerning when considering the school-aged child population as malnutrition affects their education outcomes, and consequently opportunities for success in later years [306]. Inadequate access to food and health services as a result of poverty and broader social determinants of health are some of the underlying determinants of child under-nutrition. The underweight trend over time was largely unaltered at approximately 20% for boys and girls combined, providing the evidence of a persisting underweight problem among SSA's children and youth, and substantiating the emergence of a public health double-edged sword. This persistence in underweight coupled with an overweight/obesity transition may place undue strain on the limited healthcare resources in SSA countries [14]. As such, frameworks for interventions to improve the nutritional status of SSA children will have to account for broader concepts such as societal organization, economic structures, and political ideologies [306]. We would however like to caution the reader that describing an underweight trend was not an objective of this systematic review; as such, pertinent articles reporting on underweight may have been omitted during the literature search thereby skewing these results.

Sex differences

Both quantitative and narrative synthesis revealed that there were increasing trends in proportions of overweight/obesity over time for both boys and girls; however, body composition measures and the proportions of overweight/obesity were proportionally higher in girls than in boys. In contrast, in North America, obesity is more common in boys than in girls, with the most significant differences observed among younger children 5–11 years [304], [309]. Higher proportions of overweight/obesity in SSA girls may be related to differences in gender roles particularly those requiring higher physical exertion (e.g., boys participating in higher energy expending roles/activities); and, cultural desirability whereby being overweight (i.e., “rounder”) is an admired trait and seen as a sign of wealth and prestige, particularly in girls.

Urban/rural and SES differences

Narrative synthesis revealed higher body composition measures in the urban compared to the rural population. In addition, higher SES was associated with higher body composition measures, pointing to a positive SES relationship. Factors associated with overweight/obesity span various behavioural, social, environmental, and biological constructs making them difficult to ascertain; however, urban residence and higher SES may be positively associated with overweight/obesity in SSA owing to improved access to governance, health care, education, employment and income, in addition to increased availability of packaged foods high in saturated fats and sugars and increased sedentary behaviour, all of which are more accessible to and/or affordable for those of higher SES or individuals living in urban areas.

Strengths, limitations, and future directions

The main strength of this review was the use of high quality standards to conceptualize and conduct the methodology and synthesis. Further, as many decisions as possible were made a priori to limit possible bias, and all levels of the review process were conducted in duplicate, ensuring a higher level of accuracy. Our assessment indicated that the quality of included studies was relatively high. The main limitation of this study lies in the vast heterogeneity in study methodology. The variety in the types of body composition measurements, analyses, definitions of SES, and reference standards limited our interpretation and presentation of the results. Quantitative synthesis was limited to those using the more widely accepted cut-points to further categorise study samples by weight status. It is also unclear if any material relevant for this review may have been published in un-indexed journals and hence not captured by the literature search.

Recognizing that future studies may increasingly employ WHO cut-points, since they represent a more robust criterion-based standard, we recommend that studies use the WHO cut-points for categorizing childhood overweight/obese in SSA, as this would allow for improved comparability and time trend analyses as attempted in this paper. A repository of studies, particularly those that are representative may be set up to this end, to allow for periodic comparative analysis for the whole of SSA. Measurements on more population representative samples are also required e.g., a multi-country survey using common measurement techniques and sampling procedures would be most desirable.

Conclusion

This systematic review provides evidence for an overweight/obesity transition in school-aged children in SSA. While the weighted averages of overweight/obesity in SSA are lower, this transition to higher proportions of overweight/obesity is similar to findings in various developed countries. The weighted average of overweight/obesity was higher in girls than in boys, and higher in those with higher SES. The review also revealed a persisting problem of underweight in the region, underpinning a double burden of risk factors. Findings of this review indicate that more nationally representative studies are needed to strengthen this field of research, and that interventions and strategies to address the growing threat of childhood overweight/obesity should focus on the higher SES and urban populations, with greater attention placed on girls.

Acknowledgments

The authors are grateful to Alison McFarlane and Afekwo Mbonu for their contributions towards locating the full text articles and for assistance with manuscript formatting.

Supporting Information

Author Contributions

Conceived and designed the experiments: SKM LMW AGL MS VOO MST. Performed the experiments: SKM CEF LMW AGL MS VOO MST. Analyzed the data: SKM CEF LMW. Contributed reagents/materials/analysis tools: MS MST. Wrote the paper: SKM CEF LMW AGL MS VOO MST.

References

  1. 1. World Health Organization (2009) Global health risks: mortality and burden of disease attributable to selected major risks. Geneva, Switzerland.
  2. 2. Alamian A, Paradis G (2009) Correlates of multiple chronic disease behavioral risk factors in Canadian children and adolescents. Am J Epidemiol 170: 1279–1289.
  3. 3. Batty D, Lee I (2004) Physical activity and coronary heart disease. BMJ 328: 1089–1090.
  4. 4. Ross R, Janssen I (2007) Physical activity, fitness, and obesity. In: Bouchard C, Blair S, Haskell W, editors. Physical activity and health. Champaign, III: Human Kinetics Inc. pp. 173–190.
  5. 5. Tanuseputro P, Manuel D, Leung M, Nguyen K, Johansen H (2003) Risk factors for cardiovascular disease in Canada. Can J Cardiol 19: 1249–1259.
  6. 6. US Department of Health and Human Services (1996) Physical activity and health: a report of the Surgeon General. Atlanta, Georgia: National Center for Chronic Disease Prevention and Health Promotion.
  7. 7. United Nations News Center (2011) UN launches global campaign to curb death toll from non-communicable diseases. Available: www.un.org/news/. Accessed 19 September 2011.
  8. 8. World Health Organization (2004) Global strategy on diet, physical activity and health. Geneva, Switzerland.
  9. 9. Steyn K, Damasceno A (2006) Lifestyle and related risk factors for chronic diseases. In: Jamison DT, Feachem RG, Makgoba MW, et al.., editors. Disease and mortality in Sub-Saharan Africa. 2nd edition.Washington, DC: World Bank. Available: http://www.ncbi.nlm.nih.gov/books/NBK2290/. Accessed 24 June 2013.
  10. 10. Lawlor D, Benfield L, Logue J, Tilling K, Howe L, et al. (2010) Association between general and central adiposity in childhood, and change in these, with cardiovascular risk factors in adolescence: prospective cohort study. BMJ 341: c6224.
  11. 11. Reilly J, Kelly J (2011) Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review. Int J Obes (Lond) 35: 891–898.
  12. 12. The NS, Suchindran C, North KE, Popkin BM, Gordon-Larsen P (2010) Association of adolescent obesity with risk of severe obesity in adulthood. JAMA 304: 2024–2027.
  13. 13. McNamara RS (1985) the challenges for Sub-Saharan Africa: Sir John Crawford memorial lecture, presidential speech.Washington, DC: World Bank. Available: http://documents.worldbank.org/curated/en/1985/11/438287/challenges-sub-saharan-africa. Accessed 24 June 2013.
  14. 14. Unwin N, Setel P, Rashid S, Mugusi F, Mbanya J, et al. (2001) Noncommunicable diseases in sub-Saharan Africa: where do they feature in the health research agenda? Bull World Health Organ 79: 947–953.
  15. 15. Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52: 377–384.
  16. 16. Sigman M, Neumann C, Jansen AA, Bwibo N (1989) Cognitive abilities of Kenyan children in relation to nutrition, family characteristics, and education. Child Dev 60: 1463–1474.
  17. 17. Ekpo EB, Udofia O, Andy JJ (1990) A disappearing urban/rural blood pressure difference in Nigerian children: an evaluation of possible determining factors. Ann Trop Paediatr 10: 211–219.
  18. 18. Neumann C, McDonald MA, Sigman M, Bwibo N (1992) Medical illness in school-age Kenyans in relation to nutrition, cognition, and playground behaviors. J Dev Behav Pediatr 13: 392–398.
  19. 19. Benefice E (1992) Physical activity and anthropometric and functional characteristics of mildly malnourished Senegalese children. Ann Trop Paediatr 12: 55–66.
  20. 20. ms-Campbell LL, Ukoli FA, Silverman JA, Omene JA, Nwankwo MU, et al. (1992) Tracking of blood pressure and anthropometric measures in Nigerian children. J Hum Hypertens 6: 47–51.
  21. 21. Williams CL, Wyinder EL (1992) Cardiovascular risk factors in children from fifteen countries. Cardiovascular Risk Factors 2: 45–55.
  22. 22. McDonald MA, Sigman M, Espinosa MP, Neumann CG (1994) Impact of a temporary food shortage on children and their mothers. Child Dev 65: 404–415.
  23. 23. Lawless JW, Latham MC, Stephenson LS, Kinoti SN, Pertet AM (1994) Iron supplementation improves appetite and growth in anemic Kenyan primary school children. J Nutr 124: 645–654.
  24. 24. Proctor MH, Moore LL, Singer MR, Hood MY, Nguyen US, et al. (1996) Risk profiles for non-communicable diseases in rural and urban schoolchildren in the Republic of Cameroon. Ethn Dis 6: 235–243.
  25. 25. Benefice E, Malina R (1996) Body size, body composition and motor performances of mild-to-moderately undernourished Senegalese children. Ann Hum Biol 23: 307–321.
  26. 26. Pettifor JM, Moodley GP (1997) Appendicular bone mass in children with a high prevalence of low dietary calcium intakes. J Bone Miner Res 12: 1824–1832.
  27. 27. Longo-Mbenza B, Bayekula M, Ngiyulu R, Kintoki VE, Bikangi NF, et al. (1998) Survey of rheumatic heart disease in school children of Kinshasa town. Int J Cardiol 63: 287–294.
  28. 28. Benefice E, Cames C (1999) Physical activity patterns of rural Senegalese adolescent girls during the dry and rainy seasons measured by movement registration and direct observation methods. Eur J Clin Nutr 53: 636–643.
  29. 29. Levitt NS, Steyn K, de WT, Morrell C, Edwards R, et al. (1999) An inverse relation between blood pressure and birth weight among 5 year old children from Soweto, South Africa. J Epidemiol Community Health 53: 264–268.
  30. 30. Sellen DW (1999) Growth patterns among seminomadic pastoralists (Datoga) of Tanzania. Am J Phys Anthropol 109: 187–209.
  31. 31. Garnier D, Benefice E (2001) Habitual physical activity of Senegalese adolescent girls under different working conditions, as assessed by a questionnaire and movement registration. Ann Hum Biol 28: 79–97.
  32. 32. Benefice E, Garnier D, Ndiaye G (2001) High levels of habitual physical activity in West African adolescent girls and relationship to maturation, growth, and nutritional status: results from a 3-year prospective study. Am J Human Biol 13: 808–820.
  33. 33. Benefice E, Garnier D, Ndiaye G (2001) Assessment of physical activity among rural Senegalese adolescent girls: influence of age, sexual maturation, and body composition. J Adolesc Health 28: 319–327.
  34. 34. Pawloski LR (2002) Growth and development of adolescent girls from the Segou Region of Mali (West Africa). Am J Phys Anthropol 117: 364–372.
  35. 35. Bhargava A, Fox-Kean M (2003) The effects of maternal education versus cognitive test scores on child nutrition in Kenya. Econ Hum Biol 1: 309–319.
  36. 36. Eckhardt CL, Adair LS, Caballero B, Avila J, Kon IY, et al. (2003) Estimating body fat from anthropometry and isotopic dilution: a four-country comparison. Obes Res 11: 1553–1562.
  37. 37. Garnier D, Simondon KB, Hoarau T, Benefice E (2003) Impact of the health and living conditions of migrant and non-migrant Senegalese adolescent girls on their nutritional status and growth. Public Health Nutr 6: 535–547.
  38. 38. Grillenberger M, Neumann CG, Murphy SP, Bwibo NO, van't VP, et al. (2003) Food supplements have a positive impact on weight gain and the addition of animal source foods increases lean body mass of Kenyan schoolchildren. J Nutr 133: 3957S–3964S.
  39. 39. Leman CR, Adeyemo AA, Schoeller DA, Cooper RS, Luke A (2003) Body composition of children in south-western Nigeria: validation of bio-electrical impedance analysis. Ann Trop Paediatr 23: 61–67.
  40. 40. Schutte AE, Huisman HW, van Rooyen JM, de Ridder JH, Malan NT (2003) Associations between arterial compliance and anthropometry of children from four ethnic groups in South Africa: the THUSA BANA Study. Blood Press 12: 97–103.
  41. 41. Larsen HB, Christensen DL, Nolan T, Sondergaard H (2004) Body dimensions, exercise capacity and physical activity level of adolescent Nandi boys in western Kenya. Ann Hum Biol 31: 159–173.
  42. 42. Benefice E, Garnier D, Ndiaye G (2004) Nutritional status, growth and sleep habits among Senegalese adolescent girls. Eur J Clin Nutr 58: 292–301.
  43. 43. Monyeki MA, Toriola AL, Monyeki KD, Brits SJ, Pienaar AE (2004) Body size, body composition and physical fitness of 7-years-old Ellisras rural children, South Africa: Ellisras Longitudinal Study (ELS). African Journal for Physical, Health Education, Recreation and Dance 10: 154–162.
  44. 44. McVeigh JA, Norris SA, Cameron N, Pettifor JM (2004) Associations between physical activity and bone mass in black and white South African children at age 9 yr. J Appl Physiol 97: 1006–1012.
  45. 45. Prista A, Maia AJ, Saranga S, Nhantumbo L, Marques AT, et al. (2005) Somatic growth of a school-aged population from Mozambique: trend and biosocial meaning. Hum Biol 77: 457–470.
  46. 46. Benefice E, Ndiaye G (2005) Relationships between anthropometry, cardiorespiratory fitness indices and physical activity levels in different age and sex groups in rural Senegal (West Africa). Ann Hum Biol 32: 366–382.
  47. 47. Friedman JF, Phillips-Howard PA, Mirel LB, Terlouw DJ, Okello N, et al. (2005) Progression of stunting and its predictors among school-aged children in western Kenya. Eur J Clin Nutr 59: 914–922.
  48. 48. Aandstad A, Berntsen S, Hageberg R, Klasson-Heggebo L, Anderssen SA (2006) A comparison of estimated maximal oxygen uptake in 9 and 10 year old schoolchildren in Tanzania and Norway. BJSM online 40: 287–292.
  49. 49. Munday K, Ginty F, Fulford A, Bates CJ (2006) Relationships between biochemical bone turnover markers, season, and inflammatory status indices in prepubertal Gambian boys. Calcif Tissue Int 79: 15–21.
  50. 50. Djarova T, Dube S, Tivchev G, Chivengo A (2006) Nutritional profiles, physical development and daily activities of African children in Zimbabwe with insulin-dependent diabetes mellitus. South African Journal of Science 102: 4–6.
  51. 51. Onyewadume IU (2006) Fitness of Black African early adolescents with and without mild mental retardation. Adapted Physical Activity Quarterly 23: unpaginated.
  52. 52. Vidulich L, Norris SA, Cameron N, Pettifor JM (2006) Differences in bone size and bone mass between black and white 10-year-old South African children. Osteoporos Int 17: 433–440.
  53. 53. Micklesfield LK, Norris SA, Nelson DA, Lambert EV, van der ML, et al. (2007) Comparisons of body size, composition, and whole body bone mass between North American and South African children. J Bone Miner Res 22: 1869–1877.
  54. 54. Ben-Bassey UP, Oduwole AO, Ogundipe OO (2007) Prevalence of overweight and obesity in Eti-Osa LGA, Lagos, Nigeria. Obes Rev 8: 475–479.
  55. 55. Vidulich L, Norris SA, Cameron N, Pettifor JM (2007) Infant programming of bone size and bone mass in 10-year-old black and white South African children. Paediatr Perinat Epidemiol 21: 354–362.
  56. 56. Monyeki MA, Koppes LL, Monyeki KD, Kemper HC, Twisk JW (2007) Longitudinal relationships between nutritional status, body composition, and physical fitness in rural children of South Africa: The Ellisras longitudinal study. Am J Human Biol 19: 551–558.
  57. 57. Andries MM, Koppes LLJ, Monyeki KD, Kemper HCG, Twisk JWR (2007) Longitudinal relationships between nutritional status, body composition, and physical fitness in rural children of South Africa: The Ellisras longitudinal study. Am J Human Biol 19: 551–558.
  58. 58. Ejike CE, Ugwu CE, Ezeanyika LU, Olayemi AT (2008) Blood pressure patterns in relation to geographic area of residence: a cross-sectional study of adolescents in Kogi state, Nigeria. BMC Public Health 8: 411.
  59. 59. Nienaber C, Pieters M, Kruger SH, Stonehouse W, Vorster HH (2008) Overfatness, stunting and physical inactivity are determinants of plasminogen activator inhibitor-1activity, fibrinogen and thrombin-antithrombin complex in African adolescents. Blood Coagul Fibrinolysis 19: 361–368.
  60. 60. Funke OM (2008) Prevalence of underweight: A matter of concern among adolescents in Osun State, Nigeria. Pakistan Journal of Nutrition 7: 503–508.
  61. 61. Lennox A, Pienaar AE, Wilders C (2008) Physical fitness and the physical activity status of 15-year-old adolescents in a semi-urban community. South African Journal for Research in Sport, Physical Education and Recreation 30: 59–73.
  62. 62. Goon DT, Toriola AL, Shaw BS, Amusa LO, Musa DI (2008) Sex Differences In Anthropometric Characteristics Of Nigerian School Children Aged 9-12 Years. African Journal for Physical, Health Education, Recreation and Dance 14: 130–142.
  63. 63. Micklesfield LK, Norris SA, van der ML, Lambert EV, Beck T, Pettifor JM (2009) Comparison of site-specific bone mass indices in South African children of different ethnic groups. Calcif Tissue Int 85: 317–325.
  64. 64. Demerath EW, Jones LL, Hawley NL, Norris SA, Pettifor JM, et al. (2009) Rapid infant weight gain and advanced skeletal maturation in childhood. J Pediatr 155: 355–361.
  65. 65. Cameron N, Jones LL, Griffiths PL, Norris SA, Pettifor JM (2009) How well do waist circumference and body mass index reflect body composition in pre-pubertal children? Eur J Clin Nutr 63: 1065–1070.
  66. 66. Hawley NL, Rousham EK, Norris SA, Pettifor JM, Cameron N (2009) Secular trends in skeletal maturity in South Africa: 1962-2001. Ann Hum Biol 36: 584–594.
  67. 67. Berntsen S, Lodrup Carlsen KC, Hageberg R, Aandstad A, Mowinckel P, et al. (2009) Asthma symptoms in rural living Tanzanian children; prevalence and the relation to aerobic fitness and body fat. Allergy 64: 1166–1171.
  68. 68. Senbanjo IO, Njokanma OF, Oshikoya KA (2009) Waist circumference values of Nigerian children and adolescents. Ann Nutr Metab 54: 145–150.
  69. 69. Naiho AO, Ebite LE, Aloamaka CP, Nwangwa KE (2009) The effect of crude oil exploration on growth and peak expiratory flow rate of children. Biomedical and Pharmacology Journal 2: 467–468.
  70. 70. Adegoke SA, Olowu WA, Adeodu OO, Elusiyan JBE, Dedeke IOF (2009) Prevalence of overweight and obesity among children in Ile-ife, south-western Nigeria. West Afr J Med 28: 216–221.
  71. 71. Poopedi MA, Norris SA, Pettifor JM (2011) Factors influencing the vitamin D status of 10-year-old urban South African children. Public Health Nutr 14: 334–339.
  72. 72. Harmse B, Kruger HS (2010) Significant differences between serum CRP levels in children in different categories of physical activity: the PLAY study. Cardiovasc 21: 316–322.
  73. 73. Goon DT, Toriola AL, Uever J, Wuam S, Toriola OM (2010) Growth status and menarcheal age among adolescent school girls in Wannune, Benue State, Nigeria. BMC Pediatr 10: 60.
  74. 74. Poopedi MA, Norris SA, Pettifor JM (2009) Factors influencing the vitamin D status of 11 year old urban South Africa children. Bone Conference: 5th International Conference on Childrens Bone Health Cambridge United Kingdom. Conference Start: 20090623 Conference End: 20090626. Conference Publication: S84.
  75. 75. Ansa VO, Anah MU, Odey FA, Mbu PN, Agbor EI (2010) Relationship between parental socio-economic status and casual blood pressure in coastal Nigerian adolescents. West Afr J Med 29: 146–152.
  76. 76. Micklesfield LK, Norris SA, Pettifor JM (2011) Determinants of bone size and strength in 13-year-old South African children: The influence of ethnicity, sex and pubertal maturation. Bone 48: 777–785.
  77. 77. Griffiths PL, Rousham EK, Norris SA, Pettifor JM, Cameron N (2008) Socio-economic status and body composition outcomes in urban South African children. Arch Dis Child 93: 862–867.
  78. 78. Henry-Unaeze HN, Okonkwo CN (2011) Food consumption pattern and calcium status of adolescents in Nnewi, Nigeria. Pakistan Journal of Nutrition 10: 317–321.
  79. 79. Hadley C, Belachew T, Lindstrom D, Tessema F (2011) The shape of things to come? Household dependency ratio and adolescent nutritional status in rural and urban Ethiopia. Am J Phys Anthropol 144: 643–652.
  80. 80. Thandrayen K, Norris S, Pettifor J (2009) Heterogeneity in fracture pathogenesis of urban South African children: The birth to twenty cohort. Bone Conference: 5th International Conference on Childrens Bone Health Cambridge United Kingdom. Conference Start: 20090623 Conference End: 20090626. Conference Publication: S100.
  81. 81. Goon DT, Toriola AL, Shaw BS (2012) Using receiver operating characteristic curve analysis in detecting excess adiposity in 9-13-year old South African children. West Indian Med J 61: 670–673.
  82. 82. Kruger HS, Steyn NP, Swart EC, Maunder EM, Nel JH, et al. (2012) Overweight among children decreased, but obesity prevalence remained high among women in South Africa, 1999-2005. Public Health Nutr 15: 594–599.
  83. 83. Semproli S, Canducci E, Ricci E, Gualdi-Russo E (2011) Nutrient intake in 5-17-year-old African boys and girls in a rural district of Kenya. Nutr Hosp 26: 765–774.
  84. 84. Stevens W, ddo-Yobo E, Roper J, Woodcock A, James H, et al. (2011) Differences in both prevalence and titre of specific immunoglobulin E among children with asthma in affluent and poor communities within a large town in Ghana. Clin Exp Allergy 41: 1587–1594.
  85. 85. Nwizu SE, Njokanma OF, Okoromah CA, David NA (2011) Relationship between bioelectrical impedance analysis and body mass index in adolescent urban Nigerians. West Afr J Med 30: 99–103.
  86. 86. Naude CE, Senekal M, Laubscher R, Carey PD, Fein G (2011) Growth and weight status in treatment-naive 12-16 year old adolescents with alcohol use disorders in Cape Town, South Africa. Nutr J 10: 87.
  87. 87. Abolarin TO, Aiyegbusi AI, Tella BA, Akinbo SR (2011) Relationship between selected anthropometric variables and prevalence of flatfoot among urban and rural school children in south west Nigeria. Niger 21: 135–140.
  88. 88. Abrahams Z, de VA, Steyn NP, Fourie J, Dalais L, et al. (2011) What's in the lunchbox? Dietary behaviour of learners from disadvantaged schools in the Western Cape, South Africa. Public Health Nutr 14: 1752–1758.
  89. 89. Motswagole BS, Kruger HS, Faber M, van Rooyen JM, de Ridder JH (2011) The sensitivity of waist-to-height ratio in identifying children with high blood pressure. Cardiovasc 22: 208–211.
  90. 90. McHiza ZJ, Goedecke JH, Lambert EV (2011) Intra-familial and ethnic effects on attitudinal and perceptual body image: a cohort of South African mother-daughter dyads. BMC Public Health 11: 433.
  91. 91. Benefice E, Luna Monrroy SJ, Lopez Rodriguez RW, Ndiaye G (2011) Fat and muscle mass in different groups of pre-pubertal and pubertal rural children. Cross-cultural comparisons between Sahelian (rural Senegal) and Amazonian (Beni River, Bolivia) children. Ann Hum Biol 38: 500–507.
  92. 92. Dapi LN, Hornell A, Janlert U, Stenlund H, Larsson C (2011) Energy and nutrient intakes in relation to sex and socio-economic status among school adolescents in urban Cameroon, Africa. Public Health Nutr 14: 904–913.
  93. 93. Cameron N, Johnson W, Anderson EL (2011) Rapid growth (>1.33SDS) rather than catch-up growth (>0.67 to <1.33 SDS) during infancy is associated with significantly greater risk for obesity in childhood. Obesity (Silver Spring) Conference: 29th Annual Scientific Meeting of the Obesity Society, Obesity 2011 Orlando, FL United States. Conference Start: 20111001 Conference End: 20111005. Conference Publication: S220.
  94. 94. Armstrong ME, Lambert EV, Lambert MI (2011) Physical fitness of South African primary school children, 6 to 13 years of age: discovery vitality health of the nation study. Percept Mot Skills 113: 999–1016.
  95. 95. Musa DI, Williams CA (2012) Cardiorespiratory fitness, fatness, and blood pressure associations in Nigerian youth. Med Sci Sports Exerc 44: 1978–1985.
  96. 96. Adesina AF, Peterside O, Anochie I, Akani NA (2012) Weight status of adolescents in secondary schools in port Harcourt using Body Mass Index (BMI). Ital 38: 31. Bafor A, Omota B, Ogbemudia AO (2012) Correlation between clinical tibiofemoral angle and body mass index in normal Nigerian children. Int Orthop 36: 1247–1253.
  97. 97. Bafor A, Omota B, Ogbemudia AO (2012) Correlation between clinical tibiofemoral angle and body mass index in normal Nigerian children. Int Orthop 36: 1247–1253.
  98. 98. Ojiambo RM, Easton C, Casajus JA, Konstabel K, Reilly JJ, et al. (2012) Effect of urbanization on objectively measured physical activity levels, sedentary time, and indices of adiposity in Kenyan adolescents. J Phys Act Health 9: 115–123.
  99. 99. Fetuga B, Olanrewaju D, Ogunlesi T, Jonsson B, bertsson-Wikland K (2012) Growth in prepubertal Nigerian children is highly socio-economy dependent. Hormone Research in Paediatrics Conference: 51st Annual Meeting of the European Society for Paediatric Endocrinology, ESPE 2012 Leipzig Germany. Conference Start: 20120920 Conference End: 20120923. Conference Publication: 213.
  100. 100. Girma M, Loha E, Bogale A, Stoecker BJ (2012) Child nutritional status and cognitive performance in Hawassa Town, Southern Ethiopia. FASEB Journal Conference: Experimental Biology 2012, EB San Diego, CA United States. Conference Start: 20120421 Conference End: 20120425. Conference Publication.
  101. 101. Wolff PT, Arison L, Rahajamiakatra A, Raserijaona F, Niggemann B (2012) High asthma prevalence and associated factors in urban malagasy schoolchildren. Journal of Asthma 49: 575–580.
  102. 102. Wolff PT, Arison L, Rahasamiakatra A, Raserisaona F, Niggemann B (2012) Bronchial asthma in urban malagasy children: The vavanystudy. Journal of Allergy and Clinical Immunology Conference: 2012 Annual Meeting of the American Academy of Allergy, Asthma and Immunology, AAAAI 2012 Orlando, FL United States. Conference Start: 20120302 Conference End: 20120306. Conference Publication: AB166.
  103. 103. Senbanjo IO, Oshikoya KA, Olutekunbi OA, Njokanma OF (2013) Body fat distribution of children and adolescents in Abeokuta, Southwest Nigeria. Am J Phys Anthropol 150: 647–654.
  104. 104. Prinsloo JG (1964) Heights and Weights of White Nursery-School Children in Pretoria. SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde. 38: 601–606.
  105. 105. Sloan AW, Wiggett R (1967) Inter-racial comparison of tests of physical fitness on high school children at Cape Town. J Sports Med Phys Fitness 7: 192–197.
  106. 106. Smit PJ, Potgieter JF, Neser ML, Fellingham SA (1967) Sex, age and race variations in the body measurements of white, Bantu, Coloured and Indian children aged 7-15 years. SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde 41: 422–426.
  107. 107. Leary PM (1969) The use of percentile charts in the nutritional assessment of children from primitive communities. SAMJ , S Suid-Afrikaanse Tydskrif Vir Geneeskunde 43: 1165–1169.
  108. 108. Areskog NH, Selinus R, Vahlquist B (1969) Physical work capacity and nutritional status in Ethiopian male children and young adults. Am J Clin Nutr 22: 471–479.
  109. 109. Fisher M, Davison W (1970) Growth curves for some Zambian school children. J Trop Pediatr 16: 103–111.
  110. 110. Davies CTM (1973) Physiological responses to exercise in East African children. I. Normal values for rural and urban boys and girls aged 7-15 years. Journal of Tropical Pediatrics and Environmental Child Health 19: 110–114.
  111. 111. Davies CT, Mbelwa D, Dore C (1974) Physical growth and development of urban and rural East African children, aged 7-16 years. Ann Hum Biol 1: 257–268. Amuta EU, Houmsou RS (2009) Assessment of nutritional status of school children in Makurdi, Benue State. Pakistan Journal of Nutrition 8: 691–694.
  112. 112. Walker ARP (1974) Studies on sugar intake and overweight in South African black and white schoolchildren. SAMJ, S 48: 1650–1654.
  113. 113. Booyens J, Luitingh ML, Edwards H, van Rensburg CF (1977) Skinfold thickness measurements in assessment of nutritional status of Indian and White schoolchildren. SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde 52: 1044–1048.
  114. 114. Clegg EJ, Pawson IG (1978) The influence of family characteristics on the heights, weights and skinfolds of highland and lowland children in Ethiopia. Ann Hum Biol 5: 139–146.
  115. 115. Walker AR, Walker BF, Daya L, Ncongwane J (1980) Blood pressures of South African Black adolescents aged 16 to 17 years. Trans R Soc Trop Med Hyg 74: 595–600.
  116. 116. Grassivaro GP, Franceschetti MM (1980) Growth of children in Somalia. Hum Biol 52: 547–561.
  117. 117. Rao UK, Katzarski M, Mehta L, Brady K (1981) Growth of Zambian children. Med J Zambia 15: 87–91.
  118. 118. Singer R, Kimura K (1981) Body height, weight, and skeletal maturation in Hottentot (Khoikhoi) children. Am J Phys Anthropol 54: 401–413.
  119. 119. Kulin HE, Bwibo N, Mutie D, Santner SJ (1982) The effect of chronic childhood malnutrition on pubertal growth and development. Am J Clin Nutr 36: 527–536.
  120. 120. Little MA, Galvin K, Mugambi M (1983) Cross-sectional growth of nomadic Turkana pastoralists. Hum Biol 55: 811–830.
  121. 121. Rekart ML, Plastino J, Carr C (1985) Health status of teenage school boys in eastern Sudan. East Afr Med J 62: 54–59.
  122. 122. Stephenson LS, Latham MC, Kurz KM, Miller D, Kinoti SN, et al. (1985) Urinary iron loss and physical fitness of Kenyan children with urinary schistosomiasis. Am J Trop Med Hyg 34: 322–330.
  123. 123. Ndamba J (1986) Schistosomiasis: its effects on the physical performance of school children in Zimbabwe. Cent Afr J Med 32: 289–293.
  124. 124. Ogunranti JO (1986) Weight of contemporary Nigerian growing children in clinical anthropology. J Trop Pediatr 32: 218–224.
  125. 125. Corlett JT (1986) Growth of urban schoolchildren in Botswana. Ann Hum Biol 13: 73–82.
  126. 126. ms-Campbell LL, Ukoli F, Young MP, Omene J, Nwankwo M, et al. (1987) An epidemiological assessment of blood pressure determinants in an adolescent population of Nigerians. J Hypertens 5: 575–580.
  127. 127. Ogunranti JO (1987) The mid-arm circumference in healthy eastern Nigerian children. A nutritional-clinical anthropometric parameter. Child Care Health Dev 13: 59–67.
  128. 128. Corlett JT (1988) Strength development of Tswana children. Hum Biol 60: 569–577.
  129. 129. Corlett JT, Woollard E (1988) Growth patterns of rural children in the Kgalagadi region of Botswana. Ann Hum Biol 15: 153–159.
  130. 130. Adeniran SA, Toriola AL (1988) Effects of different running programmes on body fat and blood pressure in schoolboys aged 13-17 years. Journal of Sports Medicine and Physical Fitness 28: 267–273.
  131. 131. Adeniran SA, Toriola AL (1988) Effects of continuous and interval running programmes on aerobic and anaerobic capacities in schoolgirls aged 13 to 17 years. Journal of Sports Medicine and Physical Fitness 28: 260–266.
  132. 132. Prazuck T, Fisch A, Pichard E, Sidibe Y, Gentilini M (1989) Growth of adolescents in Mali (West Africa). J Trop Pediatr 35: 52–54.
  133. 133. Ng'andu NH (1992) Blood pressure levels of Zambian rural adolescents and their relationship to age, sex, weight, height and three weight-for-height indices. Int J Epidemiol 21: 246–252.
  134. 134. Goduka IN, Poole DA, otaki-Phenice L (1992) A comparative study of black South African children from three different contexts. Child Dev 63: 509–525.
  135. 135. Oli K, Tekle-Haimanot R, Forsgren L, Ekstedt J (1994) Blood pressure patterns and its correlates in schoolchildren of an Ethiopian community. J Trop Pediatr 40: 100–103.
  136. 136. Mabrouk AA, Ibrahim SA (1995) Normal values for lung function tests in Sudanese children. East Afr Med J 72: 258–262.
  137. 137. Dufetel P, Wazni A, Gaultier C, Derossi G, Cisse F, et al. (1995) [Growth and ventilatory function in Black children and adolescents]. [French]. Rev Mal Respir 12: 135–143.
  138. 138. Brabin L, Ikimalo J, Dollimore N, Kemp J, Ikokwu-Wonodi C, et al. (1997) How do they grow? A study of south-eastern Nigerian adolescent girls. Acta Paediatr 86: 1114–1120.
  139. 139. Akinkugbe FM, Akinwolere AO, Kayode CM (1999) Blood pressure patterns in Nigerian adolescents. West Afr J Med 18: 196-202. Hamidu LJ, Okoro EO, Ali MA (2000) Blood pressure profile in Nigerian children. East Afr Med J 77: 180–184.
  140. 140. Hamidu LJ, Okoro EO, Ali MA (2000) Blood pressure profile in Nigerian children. East Afr Med J 77: 180–184.
  141. 141. Dibba B, Prentice A, Ceesay M, Stirling DM, Cole TJ, et al. (2000) Effect of calcium supplementation on bone mineral accretion in gambian children accustomed to a low-calcium diet. Am J Clin Nutr 71: 544–549.
  142. 142. Perzanowski MS, Ng'Ang'A LW, Carter MC, Odhiambo J, Ngari P, et al. (2002) Atopy, asthma, and antibodies to Ascaris among rural and urban children in Kenya. J Pediatr 140: 582–588.
  143. 143. Gray SJ, Wiebusch B, Akol HA (2004) Cross-sectional growth of pastoralist Karimojong and Turkana children. Am J Phys Anthropol 125: 193–202.
  144. 144. Cameron N, Griffiths PL, Wright MM, Blencowe C, Davis NC, et al. (2004) Regression equations to estimate percentage body fat in African prepubertal children aged 9 y. Am J Clin Nutr 80: 70–75.
  145. 145. Nyati LH, Norris SA, Cameron N, Pettifor JM (2006) Effect of ethnicity and sex on the growth of the axial and appendicular skeleton of children living in a developing country. Am J Phys Anthropol 130: 135–141.
  146. 146. Micklesfield LK, Levitt NS, Carstens MT, Dhansay MA, Norris SA, et al. (2007) Early life and current determinants of bone in South African children of mixed ancestral origin. Ann Hum Biol 34: 647–655.
  147. 147. Goon DT, Toriola AL, Shaw BS (2007) Sex differences in body fatness in Nigerian children. African Journal for Physical, Health Education, Recreation and Dance 13: 294–305.
  148. 148. Mulugeta A, Gebre M, Abdulkadir M, Gtsadik A, Gyesus A, et al.. (2009) Micronutrient deficiencies among school girls from tigray, northern Ethiopia. The FASEB Journal Conference: Experimental Biology.
  149. 149. Rankin D, Ellis SM, Macintyre UE, Hanekom SM, Wright HH (2011) Dietary intakes assessed by 24-h recalls in peri-urban African adolescents: validity of energy intake compared with estimated energy expenditure. Eur J Clin Nutr 65: 910–919.
  150. 150. Vidulich L, Norris SA, Cameron N, Pettifor JM (2011) Bone mass and bone size in pre- or early pubertal 10-year-old black and white South African children and their parents. Calcif Tissue Int 88: 281–293.
  151. 151. Goon DT, Toriola AL, Shaw BS, Amusa LO (2011) Centripetal fat patterning in South African children. Pakistan Journal of Medical Sciences 27: 832–836.
  152. 152. Prentice A, Dibba B, Sawo Y, Cole TJ (2012) The effect of prepubertal calcium carbonate supplementation on the age of peak height velocity in Gambian adolescents. Am J Clin Nutr 96: 1042–1050.
  153. 153. Goon DT, Toriola AL, Shaw BS (2012) Stature and body mass of Nigerian children aged 9-12 years. Minerva Pediatr 64: 325–331.
  154. 154. Haller L, Lauber E (1980) [Health of school children on the Ivory Coast. Development of anthropometric parameters of 5- to 15-year-old children and the effect of parasitic diseases on their growth]. [French]. Acta Trop 37: 63–73.
  155. 155. Nnanyelugo DO (1982) Anthropometric indices and measurements on primary school children of contrasting parental occupations. Growth 46: 220–237.
  156. 156. Walker MB, Omotade OO, Walker O (1996) Height and weight measurements of Ibadan school children. Afr J Med Med Sci 25: 273–276.
  157. 157. Benefice E (1998) Growth and motor performances of rural Senegalese children. 117–131.
  158. 158. Prista A (1998) Nutritional status, physical fitness and physical activity in children and youth in Maputo (Mozambique). 94–104.
  159. 159. Oelofse A, Faber M, Benade JG, Benade AJ, Kenoyer DG (1999) The nutritional status of a rural community in KwaZulu-Natal, South Africa: the Ndunakazi project. Cent Afr J Med 45: 14–19.
  160. 160. Nyirongo LO, Chideme-Maradzika J, Woelk G, Chapman GN, Siziya S (1999) A comparison of nutritional indices of children in Chitungwiza, Zimbabwe, with the international reference standard.[Erratum appears in Can Afr J Med 1999 Oct;45(10):281]. Cent Afr J Med 45: 198–203.
  161. 161. Zverev Y, Gondwe M (2001) Growth of urban school children in Malawi. Ann Hum Biol 28: 384–394.
  162. 162. Beasley M, Brooker S, Ndinaromtan M, Madjiouroum EM, Baboguel M, et al. (2002) First nationwide survey of the health of schoolchildren in Chad. Trop Med Int Health 7: 625–630.
  163. 163. Mukudi E (2003) Nutrition status, education participation, and school achievement among Kenyan middle-school children. Nutrition 19: 612–616.
  164. 164. Mukuddem-Petersen J, Kruger HS (2004) Association between stunting and overweight among 10-15-y-old children in the North West Province of South Africa: the THUSA BANA Study. Int J Obes Relat Metab Disord 28: 842–851.
  165. 165. Garnier D, Simondon KB, Benefice E (2005) Longitudinal estimates of puberty timing in Senegalese adolescent girls. Am J Human Biol 17: 718–730.
  166. 166. Rohner F, Zimmermann MB, Wegmueller R, Tschannen AB, Hurrell RF (2007) Mild riboflavin deficiency is highly prevalent in school-age children but does not increase risk for anaemia in Cote d'Ivoire. Br J Nutr 97: 970–976.
  167. 167. Madhavan S, Townsend N (2007) The social context of children's nutritional status in rural South Africa. Scand J Public Health Suppl Supplement. 69: 107–117.
  168. 168. Ekpo UF, Omotayo AM, Dipeolu MA (2008) Changing lifestyle and prevalence of malnutrition among settled pastoral Fulani children in Southwest Nigeria. Ann Agric Environ Med 15: 187–191.
  169. 169. Anyiam JO, Ogala WN, Onuora CU (2008) Body mass index of healthy Nigerian children. Niger J Med 17: 407–413.
  170. 170. Olivieri F, Semproli S, Pettener D, Toselli S (2008) Growth and malnutrition of rural Zimbabwean children (6-17 years of age). Am J Phys Anthropol 136: 214–222.
  171. 171. Ayoola O, Ebersole K, Omotade OO, Tayo BO, Brieger WR, et al. (2009) Relative height and weight among children and adolescents of rural southwestern Nigeria. Ann Hum Biol 36: 388–399.
  172. 172. Amuta EU, Houmsou RS (2009) Assessment of nutritional status of school children in Makurdi, Benue State. Pakistan Journal of Nutrition 8: 691–694.
  173. 173. Bamidele JO, Abodunrin OL, Olajide FO, Oke YF (2010) Prevalence and determinants of anemia among primary school pupils of a peri-urban community in Osun State, Nigeria. Int J Adolesc Med Health 22: 461–468.
  174. 174. Olumakaiye MF, Atinmo T, Olubayo-Fatiregun MA (2010) Food consumption patterns of Nigerian adolescents and effect on body weight. J Nutr Educ Behav 42: 144–151.
  175. 175. Bogale A, Stoecker BJ, Kennedy T, Hubbs-Tait L, Thomas D, et al.. (2010) Anthropometric measures and cognitive performance of mother-child pairs from Sidama, Southern Ethiopia. FASEB Journal Conference: Experimental Biology 2010, EB Anaheim, CA United States. Conference Start: 20100424 Conference End: 20100428. Conference Publication.
  176. 176. Mulugeta A, Gebre M, Abdelkadir M, Tsadik AG, yesus A, et al.. (2010) Iron deficiency in adolescent school girls from tigray, northern ethiopia. FASEB Journal Conference: Experimental Biology 2010, EB Anaheim, CA United States. Conference Start: 20100424 Conference End: 20100428. Conference Publication.
  177. 177. Ramos EM, Munoz JS, Sanchez JCP, Santana ER, Garcia MCV, et al.. (2011) Nutritional assessment in an elementary school in Kenya. Tropical Medicine and International Health Conference: 7th European Congress on Tropical Medicine and International Health Barcelona Spain. Conference Start: 20111003 Conference End: 20111006. Conference Publication: 307.
  178. 178. Cordeiro LS, Wilde PE, Semu H, Levinson FJ (2012) Household food security is inversely associated with undernutrition among adolescents from Kilosa, Tanzania. J Nutr 142: 1741–1747.
  179. 179. Craig EM, Reilly JJ, Bland RM (2012) How best to assess unhealthy weight status? Arch Dis Child Conference: Annual Conference of the Royal College of Paediatrics and Child Health, RCPCH 2012 Glasgow United Kingdom. Conference Start: 20120522 Conference End: 20120524. Conference Publication: A45–A46.
  180. 180. Amare B, Moges B, Fantahun B, Tafess K, Woldeyohannes D, et al.. (2012) Micronutrient levels and nutritional status of school children living in Northwest Ethiopia. Nutr J 11.
  181. 181. Neumann CG, Jiang L, Weiss RE, Grillenberger M, Gewa CA, et al. (2013) Meat supplementation increases arm muscle area in Kenyan schoolchildren. Br J Nutr 109: 1230–1240.
  182. 182. Degarege A, Erko B (2013) Association between intestinal helminth infections and underweight among school children in Tikur Wuha Elementary School, Northwestern Ethiopia. Journal of Infection and Public Health 6: 125–133.
  183. 183. Amare B, Ali J, Moges B, Yismaw G, Belyhun Y, et al.. (2013) Nutritional status, intestinal parasite infection and allergy among school children in Northwest Ethiopia. BMC Pediatr 13.
  184. 184. Jinabhai CC, Taylor M, Sullivan KR (2003) Implications of the prevalence of stunting, overweight and obesity amongst South African primary school children: a possible nutritional transition? Eur J Clin Nutr 57: 358–365.
  185. 185. Onywera VO, Adamo KB, Sheel AW, Waudo JN, Boit MK, et al. (2012) Emerging evidence of the physical activity transition in Kenya. J Phys Act Health 9: 554–562.
  186. 186. Goon DT, Toriola AL, Shaw BS (2010) Screening for body-weight disorders in Nigerian children using contrasting definitions. Obes Rev 11: 508–515.
  187. 187. Underhay C, De Ridder JH, Van Rooyen JM, Kruger HS (2002) Obesity, blood pressure and physical activity among 10-15 year-old children: The Thusa Bana study. African Journal for Physical, Health Education, Recreation and Dance 8.
  188. 188. Benefice E, Caius N, Garnier D (2004) Cross-cultural comparison of growth, maturation and adiposity indices of two contrasting adolescent populations in rural Senegal (West Africa) and Martinique (Caribbean). Public Health Nutr 7: 479–485.
  189. 189. Agyemang C, Redekop WK, Owusu-Dabo E, Bruijnzeels MA (2005) Blood pressure patterns in rural, semi-urban and urban children in the Ashanti region of Ghana, West Africa. BMC Public Health 5: 114.
  190. 190. Jinabhai CC, Taylor M, Sullivan KR (2005) Changing patterns of under- and over-nutrition in South African children-future risks of non-communicable diseases. Ann Trop Paediatr 25: 3–15.
  191. 191. Monyeki KD, Kemper HC, Makgae PJ (2006) The association of fat patterning with blood pressure in rural South African children: the Ellisras Longitudinal Growth and Health Study. Int J Epidemiol 35: 114–120.
  192. 192. Underhay JDR, Van Rooyen JM, Kruger HS (2005) Ethnicity and prevalence of obesity and high blood pressure among 10–15 year-old South African children. African Journal for Physical, Health Education, Recreation and Dance 11: 121–131.
  193. 193. Armstrong ME, Lambert MI, Sharwood KA, Lambert EV (2006) Obesity and overweight in South African primary school children — the Health of the Nation Study. SAMJ , S Suid-Afrikaanse Tydskrif Vir Geneeskunde 96: 439–444.
  194. 194. Kruger R, Kruger HS, Macintyre UE (2006) The determinants of overweight and obesity among 10- to 15-year-old schoolchildren in the North West Province, South Africa - the THUSA BANA (Transition and Health during Urbanisation of South Africans; BANA, children) study. Public Health Nutr 9: 351–358.
  195. 195. Jinabhai CC, Reddy P, Taylor M, Monyeki D, Kamabaran N, et al. (2007) Sex differences in under and over nutrition among school-going Black teenagers in South Africa: an uneven nutrition trajectory. Trop Med Int Health 12: 944–952.
  196. 196. Semproli S, Gualdi-Russo E (2007) Childhood malnutrition and growth in a rural area of Western Kenya. Am J Phys Anthropol 132: 463–469.
  197. 197. Bovet P, Auguste R, Burdette H (2007) Strong inverse association between physical fitness and overweight in adolescents: a large school-based survey. International Journal of Behavioral Nutrition and Physical Activity 4: 05.
  198. 198. Makgae PJ, Monyeki KD, Brits SJ, Kemper HC, Mashita J (2007) Somatotype and blood pressure of rural South African children aged 6-13 years: Ellisras longitudinal growth and health study. Ann Hum Biol 34: 240–251.
  199. 199. Monyeki KD, Kemper HC, Makgae PJ (2008) Relationship between fat patterns, physical fitness and blood pressure of rural South African children: Ellisras Longitudinal Growth and Health Study. J Hum Hypertens 22: 311–319.
  200. 200. Goon DT, Toriola AL, Musa DI, Akusu S, Wuam S, et al. (2010) Cardiorespiratory fitness of 7–14 year-old Andibila children in Oju, Nigeria. Gazzetta Medica Italiana Archivio per le Scienze Mediche 169: 287–295.
  201. 201. Koueta F, Dao L, Dao F, Djekompte S, Sawadogo J, et al. (2011) [Factors associated with overweight and obesity in children in Ouagadougou (Burkina Faso)]. [French]. Sante 21: 227–231.
  202. 202. Peltzer K, Pengpid S (2011) Overweight and obesity and associated factors among school-aged adolescents in Ghana and Uganda. Int J Environ Res Public Health 8: 3859–3870.
  203. 203. Armstrong ME, Lambert MI, Lambert EV (2011) Secular trends in the prevalence of stunting, overweight and obesity among South African children (1994-2004). Eur J Clin Nutr 65: 835–840.
  204. 204. Kimani-Murage EW, Kahn K, Pettifor JM, Tollman SM, Klipstein-Grobusch K, et al. (2011) Predictors of adolescent weight status and central obesity in rural South Africa. Public Health Nutr 14: 1114–1122.
  205. 205. Amusa LO, Goon DT (2011) Blood pressure among overweight children aged 7-13 years in 10 rural communities in South Africa: The Tshannda Longitudinal Study. Pakistan Journal of Medical Sciences 27: 664–667.
  206. 206. Adamo KB, Sheel AW, Onywera V, Waudo J, Boit M, et al. (2011) Child obesity and fitness levels among Kenyan and Canadian children from urban and rural environments: a KIDS-CAN Research Alliance Study. Int J Pediatr Obes 6: e225–e232.
  207. 207. Kemp C, Pienaar AE, Schutte A (2011) The prevalence of hypertension and the relationship with body composition in Grade 1 learners in the North West Province of South Africa. South African Journal of Sports Medicine; Vol 23, No 4 (2011).
  208. 208. Feeley AB, Musenge E, Pettifor JM, Norris SA (2013) Investigation into longitudinal dietary behaviours and household socio-economic indicators and their association with BMI Z-score and fat mass in South African adolescents: the Birth to Twenty (Bt20) cohort. Public Health Nutr 16: 693–703.
  209. 209. Ene-Obong H, Ibeanu V, Onuoha N, Ejekwu A (2012) Prevalence of overweight, obesity, and thinness among urban school-aged children and adolescents in southern Nigeria. Food Nutr Bull 33: 242–250.
  210. 210. Monyeki MA, Neetens R, Moss SJ, Twisk J (2012) The relationship between body composition and physical fitness in 14 year old adolescents residing within the Tlokwe local municipality, South Africa: the PAHL study. BMC Public Health 12: 374.
  211. 211. Griffiths PL, Sheppard ZA, Johnson W, Cameron N, Pettifor JM, et al. (2012) Associations between household and neighbourhood socioeconomic status and systolic blood pressure among urban South African adolescents. J Biosoc Sci 44: 433–458.
  212. 212. Reddy SP, Resnicow K, James S, Funani IN, Kambaran NS, et al. (2012) Rapid increases in overweight and obesity among South African adolescents: comparison of data from the South African National Youth Risk Behaviour Survey in 2002 and 2008. Am J Public Health 102: 262–268.
  213. 213. Moselakgomo VK, Toriola AL, Shaw BS, Goon DT, Akinyemi O (2012) Body mass index, overweight, and blood pressure among adolescent schoolchildren in Limpopo province, South Africa. Revista Paulista de Pediatria 30: 562–569.
  214. 214. Micklesfield L, Pedro T, Twine R, Kinsman J, Pettifor J, et al.. (2012) Physical activity patterns and determinants in rural South African adolescents. Journal of Science and Medicine in Sport Conference: Be Active 2012 Sydney, NSW Australia. Conference Start: 20121031 Conference End: 20121103. Conference Publication: S251.
  215. 215. Monyeki M, Neetens R, Moss S, Twisk J (2012) Therelationship ofbodycomposition with physical fitness in the 14 years adolescents residing within the Tlokwe Local Municipality, South Africa: The PAHL-Study. Journal of Science and Medicine in Sport Conference: Be Active 2012 Sydney, NSW Australia. Conference Start: 20121031 Conference End: 20121103. Conference Publication: S170–S171.
  216. 216. Truter L, Pienaar AE, Du TD (2012) The relationship of overweight and obesity to the motor performance of children living in South Africa. South African Family Practice 54: 429–435.
  217. 217. Musa DI, Toriola AL, Monyeki MA, Lawal B (2012) Prevalence of childhood and adolescent overweight and obesity in Benue State, Nigeria. Tropical Medicine and International Health 17: 1369–1375.
  218. 218. Bovet P, Paccaud F, Chiolero A (2012) Socio-economic status and obesity in children in Africa. Obes Rev 13: 1080.
  219. 219. Toriola OM, Monyeki MA (2012) Health-related fitness, body composition and physical activity status among adolescent learners: The PAHL study. African Journal for Physical, Health Education, Recreation and Dance 18: 795–811.
  220. 220. Wilson ML, Viswanathan B, Rousson V, Bovet P (2013) Weight Status, Body Image and Bullying among Adolescents in the Seychelles. Int J Environ Res Public Health 10: 1763–1774.
  221. 221. Ginsburg C, Griffiths PL, Richter LM, Norris SA (2013) Residential mobility, socioeconomic context and body mass index in a cohort of urban South African adolescents. Health Place 19: 99–107.
  222. 222. Malete L, Motlhoiwa K, Shaibu S, Wrotniak BH, Maruapula SD, et al.. (2013) Body image dissatisfaction is increased in male and overweight/obese adolescents in Botswana. Journal of Obesity 2013 , 2013. Article Number: 763624. Date of Publication: 2013.
  223. 223. Mang'eni OR, Maguta K, Thairu K, Takahashi R, Wilunda C (2013) The relation between physical activity and indicators of body fatness in Kenyan adolescents. J Appl Med Sciences 2: 43–59.
  224. 224. Onywera VO, Heroux M, Jaureguiulloa E, Adamo KB, Taylor JL, et al. (2013) Adiposity and physical activity among children in countries at different stages of the physical activity transition: Canada, Mexico and Kenya. AJPHERD 19: 132–142.
  225. 225. Heroux M, Onywera VO, Tremblay MS, Adamo KB, Taylor JL, et al.. (2013) The relation between aerobic fitness, muscular fitness, and obesity in children from three countries at different stages of the physical activity transition. ISRN Obesity http://dx.doi.org/10.1155/2013/134835doci.
  226. 226. Fetuga MB, Ogunlesi TA, Adekanmbi AF, Alabi AD (2011) Growth pattern of schoolchildren in Sagamu, Nigeria using the CDC standards and 2007 WHO standards. Indian Pediatr 48: 523–528.
  227. 227. Prista A, Nhantumbo L, Silvio S, Lopes V, Maia J, et al. (2009) Physical activity assessed by accelerometry in rural African school-age children and adolescents. Pediatr Exerc Sci 21: 384–399.
  228. 228. Padez C, Varela-Silva MI, Bogin B (2009) Height and relative leg length as indicators of the quality of the environment among Mozambican juveniles and adolescents. Am J Human Biol 21: 200–209.
  229. 229. Omigbodun OO, Adediran KI, Akinyemi JO, Omigbodun AO, Adedokun BO, et al. (2010) Gender and rural-urban differences in the nutritional status of in-school adolescents in south-western Nigeria. J Biosoc Sci 42: 653–676.
  230. 230. Mosha TC, Fungo S (2010) Prevalence of overweight and obesity among children aged 6-12 years in Dodoma and Kinondoni municipalities, Tanzania. Tanzan J Health Res 12: 6–16.
  231. 231. Opara DC, Ikpeme EE, Ekanem US (2010) Prevalence of stunting, underweight and obesity in school aged children in Uyo, Nigeria. Pakistan Journal of Nutrition 9: 459–466.
  232. 232. Nagwa MA, Elhussein AM, Azza M, Abdulhadi NH (2011) Alarming high prevalence of overweight/obesity among Sudanese children. Eur J Clin Nutr 65: 409–411.
  233. 233. Dabone C, Delisle HF, Receveur O (2011) Poor nutritional status of schoolchildren in urban and peri-urban areas of Ouagadougou (Burkina Faso). Nutr J 10.
  234. 234. Goon DT, Toriola AL, Shaw BS, Amusa LO, Monyeki MA, et al. (2011) Anthropometrically determined nutritional status of urban primary schoolchildren in Makurdi, Nigeria. BMC Public Health 11: 769.
  235. 235. Fetuga MB, Ogunlesi TA, Adekanmbi AF, Alabi AD (2011) Nutritional status of semi-urban Nigerian school children using the 2007 WHO reference population. West Afr J Med 30: 331–336.
  236. 236. Puckree T, Naidoo P, Pill P, Naidoo T (2011) Underweight and Overweight in Primary School Children in eThekwini District in KwaZulu-Natal, South Africa. African Journal of Primary Health Care & Family Medicine 3: 1–6.
  237. 237. Kamau JW, Wanderi MP, Njororai WWS, Wamukoya EK (2011) Prevalence of overweight and obesity among primary school children in Nairobi province, Kenya. African Journal for Physical, Health Education, Recreation and Dance 17..
  238. 238. Oldewage-Theron W, Napier C, Egal A (2011) Dietary fat intake and nutritional status indicators of primary school children in a low-income informal settlement in the Vaal region. South African Journal of Clinical Nutrition 24: 99–104.
  239. 239. Kramoh KE, N'goran YN, ke-Traboulsi E, Boka BC, Harding DE, et al. (2012) [Prevalence of obesity in school children in Ivory Coast]. [French]. Ann Cardiol Angeiol (Paris) 61: 145–149.
  240. 240. Opare-Addo PM, Stowe M, nkobea-Kokroe F, Zheng T (2012) Menarcheal and pubertal development and determining factors among schoolgirls in Kumasi, Ghana. J Obstet Gynaecol 32: 159–165.
  241. 241. Motswagole BS, Kruger HS, Faber M, Monyeki KD (2012) Body composition in stunted, compared to non-stunted, black South African children, from two rural communities. South African Journal of Clinical Nutrition 25..
  242. 242. Puoane TR, Fourie JM, Tsolekile L, Nel JH, Temple NJ (2013) What Do Black South African Adolescent Girls Think About Their Body Size? Journal of Hunger and Environmental Nutrition 8: 85–94.
  243. 243. Wagstaff L, Reinach SG, Richardson BD, Mkhasibe C, de VG (1987) Anthropometrically determined nutritional status and the school performance of black urban primary school children. Hum Nutr Clin Nutr 41: 277–286.
  244. 244. de Villiers FP (1987) The growth pattern of adolescent Tswana schoolchildren. J Trop Pediatr 33: 143–152.
  245. 245. Monyeki KD, van Lenthe FJ, Steyn NP (1999) Obesity: does it occur in African children in a rural community in South Africa? Int J Epidemiol 28: 287–292.
  246. 246. Jinabhai CC, Taylor M, Coutsoudis A, Coovadia HM, Tomkins AM, et al. (2001) A health and nutritional profile of rural school children in KwaZulu-Natal, South Africa. Ann Trop Paediatr 21: 50–58.
  247. 247. Prista A, Maia JA, Damasceno A, Beunen G (2003) Anthropometric indicators of nutritional status: implications for fitness, activity, and health in school-age children and adolescents from Maputo, Mozambique. Am J Clin Nutr 77: 952–959.
  248. 248. Steyn NP, Labadarios D, Maunder E, Nel J, Lombard C, et al. (2005) Secondary anthropometric data analysis of the National Food Consumption Survey in South Africa: the double burden. Nutrition 21: 4–13.
  249. 249. Zerfu M, Mekasha A (2006) Anthropometric assessment of school age children in Addis Ababa. Ethiop Med J 44: 347–352.
  250. 250. Longo-Mbenza B, Lukoki LE, M'Buyamba-Kabangu JR (2007) Nutritional status, socio-economic status, heart rate, and blood pressure in African school children and adolescents. Int J Cardiol 121: 171–177.
  251. 251. Alaofe H, Zee J, Dossa R, O'Brien HT (2009) Impact of socioeconomic and health related factors on the iron status of adolescent girls from two boarding schools in Southern Benin. Int J Adolesc Med Health 21: 545–554.
  252. 252. Kimani-Murage EW, Kahn K, Pettifor JM, Tollman SM, Dunger DB, et al. (2010) The prevalence of stunting, overweight and obesity, and metabolic disease risk in rural South African children. BMC Public Health 10: 158.
  253. 253. Chukwunonso Ejike ECC, Chidi UE, Lawrence Ezeanyika US (2010) Physical growth and nutritional status of a cohort of semi-urban Nigerian adolescents. Pakistan Journal of Nutrition 9: 392–397.
  254. 254. Truter L, Pienaar AE, Toit D (2010) Relationships between overweight, obesity and physical fitness of nine- to twelve-year-old South African children. South African Family Practice 52: 227–233.
  255. 255. Dapi LN, Janlert U, Nouedoui C, Stenlund H, Haglin L (2009) Socioeconomic and gender differences in adolescents' nutritional status in urban Cameroon, Africa. Nutr Res 29: 313–319.
  256. 256. Senbanjo IO, Oshikoya KA (2010) Physical activity and body mass index of school children and adolescents in Abeokuta, Southwest Nigeria. World J Pediatr 6: 217–222.
  257. 257. Salman Z, Kirk GD, Deboer MD (2010) High Rate of Obesity-Associated Hypertension among Primary Schoolchildren in Sudan. Int J Hypertens 2011: 629492.
  258. 258. Odenigbo UM, Nkwoala CC, Okpala OC (2010) Impact of birth weight on the nutritional status and academic performance of school age children. Pakistan Journal of Nutrition 9: 1157–1161.
  259. 259. Croteau K, Schofield G, Towle G, Suresh V (2011) Pedometer-determined physical activity of Western Kenyan children. J Phys Act Health 8: 824–828.
  260. 260. Larbi IA, Klipstein-Grobusch K, Amoah AS, Obeng BB, Wilson MD, et al. (2011) High body mass index is not associated with atopy in schoolchildren living in rural and urban areas of Ghana. BMC Public Health 11: 469.
  261. 261. Goon DT, Toriola AL, Uever JN, Wuam S, Toriola OM (2011) Prevalence of body weight disorders among adolescent school girls in Tarka, Nigeria. Minerva Pediatr 63: 467–471.
  262. 262. Okoh BA, Alikor EA, Akani N (2012) Prevalence of hypertension in primary school-children in Port Harcourt, Nigeria. Paediatr Int Child Health 32: 208–212.
  263. 263. Naidoo T, Konkol K, Biccard B, Dudose K, McKune AJ (2012) Elevated salivary C-reactive protein predicted by low cardio-respiratory fitness and being overweight in African children. Cardiovasc 23: 501–506.
  264. 264. Chinedu SN, Eboji OK, Emiloju OC (2012) Trends in weight abnormality of school children and adolescents in Nigeria. Journal of Medical Sciences (Faisalabad) 12: 239–243.
  265. 265. Toriola AL, Moselakgomo VK, Shaw BS, Goon DT (2012) Overweight, obesity and underweight in rural black South African children. South African Journal of Clinical Nutrition 25.
  266. 266. Davies JC (1971) A screening programme for rural school-children in Rhodesia: pilot study. Dev Med Child Neurol 13: 779–783.
  267. 267. Richardson BD, Wadvalla M (1977) The bearing of height, weight and skinfold thickness on obesity in four South African ethnic groups of school pupils of 17 years. Trop Geogr Med 29: 82–90.
  268. 268. Margo G, Baroni Y, Brindley M, Green R, Metz J (1976) Protein energy malnutrition in coloured children in Western Township, Johannesburg. Part II. Prevalence and severity. SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde. 50: 1241–1245.
  269. 269. Coovadia HM, Adhikari M, Mthethwa D (1978) Physical growth of Negro children in the Durban area. Trop Geogr Med 30: 373–381.
  270. 270. Richardson BD (1977) Underweight, stunting and wasting in black and white South African schoolchildren: malnutrition or adaptation? Trans R Soc Trop Med Hyg 71: 210–216.
  271. 271. Richardson BD (1977) Underweight - a nutritional risk? SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde 51: 42–48.
  272. 272. van Rensburg CF, Booyens J, Gathiram P, Khan J, Luitingh ML, et al. (1977) The relationship between scholastic progress and nutritional status. Part I. A study of 488 school beginners. SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde 52: 644–649.
  273. 273. Walker AR, Bhamjee D, Walker BF, Richardson BD (1978) Growth, school attendance, and serum albumin levels in South African black children of 10-12 years. J Trop Med Hyg 81: 2–8.
  274. 274. Sukkar MY, Kemm JR, Makeen AM, Khalid MH (1979) Anthropometric survey of children in rural Khartoum, Sudan. Ann Hum Biol 6: 147–158.
  275. 275. Carswell F, Hughes AO, Palmer RI, Higginson J, Harland PS, et al. (1981) Nutritional status, globulin titers, and parasitic infections of two populations of Tanzanian school children. Am J Clin Nutr 34: 1292–1299.
  276. 276. Oyemade A, Olugbile A, Janes MD (1981) Health of Nigerian rural school children. J Trop Pediatr 27: 101–105.
  277. 277. Griffin L, Fast M (1982) A preliminary study on poly-parasitism and the size of primary school children in Kenya. Cent Afr J Med 28: 219–222.
  278. 278. Sukkar MY, Kemm JR, Kardesh M (1982) Age-independent anthropometry: an examination of data from rural Khartoum, Sudan. Ann Hum Biol 9: 265–275.
  279. 279. Power DJ (1982) An anthropometric study of young schoolchildren in an area of Cape Town. SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde 61: 303–305.
  280. 280. Richardson BD, Laing PM, Rantsho JM, Swinel RW (1983) The bearing of diverse patterns of diet on growth and menarche in four ethnic groups of South African girls. J Trop Med Hyg 86: 5–12.
  281. 281. Akesode FA, Ajibode HA (1983) Prevalence of obesity among Nigerian school children. Soc Sci Med 17: 107–111.
  282. 282. Ng'andu NH (1984) Growth of urban and rural children in Zambia (a limited study). Med J Zambia 18: 30–35.
  283. 283. Jacobs M, Joubert G, Hoffman M (1988) Anthropometric assessment of children in Mamre. SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde. 74: 341–343.
  284. 284. Walker AR, Walker BF, Locke MM, Cassim FA, Molefe O (1991) Body image and eating behaviour in interethnic adolescent girls. J R Soc Health 111: 12–16.
  285. 285. Ng'andu NH, Watts TE, Siziya S (1992) Age at menarche and the weight-for-height index. SAMJ, S Suid-Afrikaanse Tydskrif Vir Geneeskunde. 81: 408–411.
  286. 286. Cole AH, Taiwo OO, Nwagbara NI, Cole CE (1997) Energy intakes, anthropometry and body composition of Nigerian adolescent girls: a case study of an institutionalized secondary school in Ibadan. Br J Nutr 77: 497–509.
  287. 287. Owa JA, Adejuyigbe O (1997) Fat mass, fat mass percentage, body mass index, and mid-upper arm circumference in a healthy population of Nigerian children. J Trop Pediatr 43: 13–19.
  288. 288. Sellen DW (2000) Age, sex and anthropometric status of children in an African pastoral community. Ann Hum Biol 27: 345–365.
  289. 289. Mabalia-Babela JR, Massamba A, Ntsila R, Senga P (2003) [Nutritional status of school-age children in Brazzaville: effects of environmental factors]. [French]. Arch Pediatr 10: 732–733.
  290. 290. Micklesfield LK, Zielonka EA, Charlton KE, Katzenellenbogen L, Harkins J, et al. (2004) Ultrasound bone measurements in pre-adolescent girls: interaction between ethnicity and lifestyle factors. Acta Paediatr 93: 752–758.
  291. 291. Calvert J, Burney P (2005) Effect of body mass on exercise-induced bronchospasm and atopy in African children. J Allergy Clin Immunol 116: 773–779.
  292. 292. Monyeki MA, Koppes LL, Kemper HC, Monyeki KD, Toriola AL, et al. (2005) Body composition and physical fitness of undernourished South African rural primary school children. Eur J Clin Nutr 59: 877–883.
  293. 293. Travill AL (2007) Growth and physical fitness of socially disadvantaged boys and girls aged 8-17 years living in the Western Cape, South Africa. African Journal for Physical, Health Education, Recreation and Dance 13: 279–293.
  294. 294. Jeremiah ZA, Uko EK, Usanga EA (2008) Relation of nutritional status, sickle cell trait, glucose-6-phosphate dehydrogenase deficiency, iron deficiency and asymptomatic malaria infection in the Niger Delta, Nigeria. Journal of Medical Sciences 8: 269–274.
  295. 295. Hawkesworth S, Sawo Y, Fulford AJ, Goldberg GR, Jarjou LM, et al. (2010) Effect of maternal calcium supplementation on offspring blood pressure in 5- to 10-y-old rural Gambian children. Am J Clin Nutr 92: 741–747.
  296. 296. Faye J, Diop M, Gati OR, Seck M, Mandengue SH, et al. (2011) [Prevalence of child and teenage obesity in schools in Dakar]. [French]. Bull Soc Pathol Exot 104: 49–52.
  297. 297. Olubanji Ojofeitimi E, Iyanuoluwa Olugbenga-Bello A, debode Adekanle D, Adeomi AA (2011) Pattern and determinants of obesity among adolescent females in private and public schools in olorunda local government area of osun state, Nigeria: a comparative study. Journal of Public Health in Africa 2: e11.
  298. 298. Monyeki M, Mamabolo R (2012) Relationships between physical activity with BMI and percentage body fat among girls by locality in Tlokwe Local Municipality, South Africa: The PAHL-Study. Journal of Science and Medicine in Sport Conference: Be Active 2012 Sydney, NSW Australia. Conference Start: 20121031 Conference End: 20121103. Conference Publication: S42.
  299. 299. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320: 1240–1243.
  300. 300. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, et al. (2002) CDC Growth Charts for the United States: methods and development. Vital Health Stat 11 246: 1–190.
  301. 301. de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J (2007) Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ 85: 660–667.
  302. 302. Shields M (2005) Overweight Canadian children and adolescents. Health Rep 17: 27–42.
  303. 303. Tremblay M, Katzmarzyk P, Willms J (2002) Temporal trends in overweight and obesity in Canada, 1981-1996. Int J Obes Relat Metab Disord 26: 538–543.
  304. 304. Ogden CL, Carroll MD, Kit BK, Flegal KM (2012) Prevalence of obesity and trends in body mass index among US children and adolescents, 1999–2010. JAMA 307: 483–490.
  305. 305. Shields M, Tremblay MS (2010) Canadian obesity estimates based on WHO, IOTF and CDC cut-points. Int J Pediatr Obes 3: 265–73.
  306. 306. Benson T, Shekar M. (2006) Trends and issues in child undernutrition. In: Jamison DT, Feachem RG, Makgoba MW, Bos ER, Baingana FK, Hofman KJ, et al.., editors. Disease and mortality in Sub-Saharan Africa. 2nd edition. Washington, DC: World Bank. Available: http://www.ncbi.nlm.nih.gov/books/NBK2301/. Accessed 24 June 2013.
  307. 307. de Onis M, Blössner M, Borghi E, Morris R, Frongillo EA (2004) Methodology for estimating regional and global trends of child malnutrition. Int J Epidemiol 33: 1260–1270.
  308. 308. World Health Organization (2003) Global database on child growth and malnutrition. Geneva, Switzerland.
  309. 309. Roberts KC, Shields M, de Groh M, Aziz A, Gilbert JA (2012) Over weight and obesity in children and adolescents: results from the 2009 to 2011 Canadian Health Measures Survey. Health Rep 23: 37–41.