CHAPTER ONE

Introduction

Cardiovascular disease (CVD is a major public health concern of the twenty-first century and

the global leading cause of death (Boateng et al., 2017). Cardiovascular disease alone

accounts for 31% of global deaths and causes the death of 17.9 million people annually

(WHO, 2017).

The trend is largely attributable to the new working and leisure standards that most of the

population in the low- and medium-income countries, including Nigeria, have adopted and

the significant changes in the quality, content, and quantity of food consumed, especially with

the proliferation of fast-food outlets and the attendant risk they post to healthy nutrition.

(Yilgwan, 2017).

The rise in cardiovascular disease is mostly due to a rise in key risk factors, mainly

hypertension and overweight/obesity (Ejike et al., 2008). The rise in the prevalence of

overweight/obesity has been largely attributed to the more sedentary lifestyle and nutrition

transition. There has been a shift in the patterns of diet and physical activity towards

unhealthy foods higher in fat, sugar and energy, and low in fruit and vegetable and fibers,

alongside more sedentary lifestyles [Popkin BM and Gordon-Larsen, 2004].

Adolescence and early adulthood are periods characterized by many behavioral choices that

could predispose an individual to cardiovascular disease later in life (Chu, 2017). Thus,

young people have increasingly become the targets of many cardiovascular disease

prevention strategies (WHO, 2021). However, for these strategies to be successful, especially

in low- and middle-income countries, including Nigeria, baseline data on the prevalence of

modifiable cardiovascular disease risk factors among young people are needed. While there is

an extensive body of literature on modifiable cardiovascular disease risk factors among

various sections of the Nigerian and indeed the SSA population, many have been restricted to

single risk factors to the exclusion of others; hospital-based as against the general population;

among the middle aged and elderly, while neglecting young people; and, in some cases,

focused on patients who have already developed the disease. (Hamid et al., 2019).

Adolescence is an important period in the life cycle of man. It is the transitional period

between childhood and adulthood (WHO, 2022). The National Adolescent Health Policy in

Nigeria regarded ages 10 to 24 years as acceptable for adolescence. It is during this period

that they experience various social, nutritional and personal developments (NPHS, 2007). In

fact, according to Christie and Viner, "Adolescence is increasingly recognized as a life period

that poses specific challenges for treating disease and promoting health" (Christie and Viner,

2008).

The risk factors for cardiovascular disease are often developed during childhood and

adolescence and established in adulthood (Bogdańska et al., 2005). Therefore, early

identification of its risk during childhood and adolescence could help prevent or delay the

onset of cardiovascular disease (Hong, 2010). Adolescents who are between the ages of ten to

nineteen (WHO, 2019) go through changes in their social environment and social life as they

transit to adulthood.

An individual’s nutritional status is defined as “particular physiological and pathological

status” (Andreoli et al., 2016).

Nutritional status is an important indicator enabling. Nutritional status is assessed using

anthropometric and biochemical tests, among others diagnosis [Verdich et al., 2011].

Anthropometric measurements used to determine nutritional status include the assessment of

the physiological status of the body based on its height and weight.
Nutritional status is the balance between the intake of nutrients by an organism and the

expenditure of these nutrients in the processes of growth, reproduction and health

maintenance. Because this process is quite highly individualized, nutritional status can be

directed at a wide variety of aspects of nutrition (Folahan and Odugbemi, 2013). These

ranges from nutrient levels in the body to the products of their metabolism and to the

functional processes they regulate. Nutritional status is the combination of an individual’s

health as influenced by intake and utilization of nutrients and determined from information

obtained by physical, biochemical and dietary studies (Price, 2005).

The consumption of adequate amount of food both in terms of quantity and quality is one of

the key determinants, which has a significant impact on the nutritional status. (Park, 2009)

Furthermore, the eating pattern of an individual is a crucial factor that dictates the occurrence

of a disease, especially some chronic conditions such as coronary heart disease, hypertension,

stroke, diabetes mellitus, and cancer (Herder, 2004). Body mass index (BMI) is the most

popular and common method for nutritional status assessment.

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to

classify overweight and obesity in adults. It is defined as a person's weight in kilograms

divided by the square of his height in meters (kg/m2). The World Health Organization

(WHO) has implemented the body mass index (BMI) scale, which can be obtained by

dividing the total weight of the body in kilograms by the square of the height measured in

meters, as a substitute of the over-all body fat measure (WHO 2016). With this, obesity can

be well-defined if BMI value is ≥30Kg/m2. It usually correlates with the fraction of body fat

in individuals having high prevalence of obesity (Chouke., et al 2020). BMI is predisposed by

certain determinants that can either be environmental or genetic. Such environmental factors

include physical activity, gender, marital status, job and education level, diet, co-morbidities

i.e. diabetes, hypertension, cardiac and endocrinal issues, cancers etc.

In the past, there are few published studies on cardiovascular disease risk factors among

Nigerian adolescents which were mainly conducted in urban settings (Ujunwa et al. 2013;

Senbanjo and Oshikoya 2012, Odunaiya et al. 2010, Ansa et al. 2005). Research suggests that

adequate level of nutritional knowledge is related to optimal nutritional behaviours while

dietary habits affect nutritional status (Miller and Cassady, 2015). Dietary habit is one of the

modifiable risk factors for obesity in childhood and adolescence. Therefore, this research

work is aim at assessing the nutritional knowledge, nutritional status and risk of

cardiovascular diseases among adolescents in bida metropolis, Niger state.

Justification of the study

Adolescence period is a period that requires adequate nutrition habits to prevent diet-related

NCDs can be prevented in later life, nutritional needs are high for both male and female

adolescents (Lassi et al., 2017). Unfortunately, it is also during this period adolescents may

exhibit unhealthful dietary practices, sedentary lifestyle and other unhealthful risky behaviors

(smoking. unprotected sexual activities, alcohol and drug abuse) (Rao et al., 2015).

Good knowledge and understanding of cardiovascular diseases will lead to better health-

seeking behavior, which will in turn influence judgments and decisions in cardiovascular

diseases prevention and control (Angosta et al., 2014; Kanungo et al., 2015). Improved

knowledge of a condition and predisposition to it has been shown to improve adherence to

lifestyle changes (Safeer et al., 2006).

Dietary habits, and risky behaviors, such as smoking and drinking are experimented with and

established in childhood and adolescence [Odunaiya et al., 2015]. Furthermore, researchers

have advocated that children and adolescent populations should be the target for

cardiovascular risk factors prevention programs [] because lifestyle risk factors are usually

learnt and established during this period. Cardiovascular disease prevention program is thus
likely to be more effective in this subpopulation. Modifiable risk factors can be prevented,

treated and controlled, hence the need for early detection of risk factors and cardiovascular

disease prevention programs so that adolescents adopt healthy behaviors into adulthood

(WHO, 2014). This is particularly important in rural Nigerian regions where there are very

limited facilities and health personnel to manage cardiovascular disease. The knowledge of

cardiovascular disease and its risk factors are essential for the prevention of cardiovascular

disease; especially among adolescence (Magnani et al., 2018). Therefore, this study will

assess of nutritional knowledge, nutritional status and risk of cardiovascular diseases among

adolescents in doko metropolis.

Statement of the Problem

Cardiovascular disease poses an enormous economic burden due to its effect on the working

population and the high cost of its care (Akintunde et al, 2014).

The prevalence of overweight and obesity among children and adolescents is rising all over

the world, with the rate of increase being particularly high in low- and middle-income

countries such as Nigeria, and attributed to nutrition transition (Oguoma et al. 2015). This

transition is characterized by a shift from traditional diets to diets which are typically high in

energy, fat, sugar, and salt (NPC, 2013). This has led to an increased risk of developing

chronic non-communicable diseases such as diabetes and cardiovascular disease. This shift is

driven by factors such as globalization, urbanization, and increased marketing of unhealthy

food and drinks (Henrietta et al., 2012).

Social pressures to achieve a distorted body image is creating under nutrition among some

groups of adolescents. (Dona, 2000) On the other hand, overweight and obesity continue to

increase due to nutrition transition to energy and lipid-rich diets and decrease in physical

activity, especially among urban adolescents (Foluke, 2020).

1.4 Aim and Objectives

1.4.1 General Objective:

To assess the nutritional knowledge, nutritional status and risk of cardiovascular diseases

among adolescents in doko metropolis Niger State.

1.4.2 Specific objectives;

To describe the socio economic and demographic characteristics of the respondents

To assess the dietary habits and food consumption pattern of the respondents

To assess the nutritional status using anthropometric indices (BMI,MUAC,Waist and

hipratio) and clinical features of the respondents

To access the physical activity level of the respondent

To evaluate the relationship between the socio-economic and demographic characteristics,

food habit, anthropometric indices and Clinical features of the respondents.

1.5 Scope of study

The scope of this study will only be limited to assessing the nutritional knowledge, nutritional

status and risk of cardiovascular diseases among adolescents in rural area of doko metropolis

Niger State.
 CHAPTER TWO

2.0. Literature review

2.1. The prevalence of cardiovascular diseases

Cardiovascular disease (CVD) is any disease involving the heart or blood vessels (WHO,

2014). Cardiovascular diseases constitute a class of diseases that includes: coronary artery

diseases (e.g., angina, heart attack), stroke, heart failure, hypertensive heart disease,

rheumatic heart disease, cardiomyopathy, abnormal heart rhythms, congenital heart disease,

valvular heart disease, carditis, aortic aneurysms, peripheral artery disease, thromboembolic

disease, and venous thrombosis (Shanthi et al., 2011; Naghavi et al., 2015).

The underlying mechanisms vary depending on the disease. It is estimated that dietary risk

factors are associated with 53% of CVD deaths (Petersen et al., 2021). Coronary artery

disease, stroke, and peripheral artery disease involve atherosclerosis (Shanthi et al., 2011).

This may be caused by high blood pressure, smoking, diabetes mellitus, lack of exercise,

obesity, high blood cholesterol, poor diet, excessive alcohol consumption, and poor sleep,

(Jackson et al., 2015; Wang et al., 2017) among other things. High blood pressure is

estimated to account for approximately 13% of CVD deaths, while tobacco accounts for 9%,

diabetes 6%, lack of exercise 6%, and obesity 5%. Rheumatic heart disease may follow

untreated strep throat (Shanthi et al., 2011).

It is estimated that up to 90% of CVD may be preventable (McGill et al., 2008; O'Donnell et

al., 2016). Prevention of CVD involves improving risk factors through: healthy eating,

exercise, avoidance of tobacco smoke and limiting alcohol intake (WHO, 2014). Treating risk

factors, such as high blood pressure, blood lipids and diabetes is also beneficial (Shanthi et
al., 2011). Treating people who have strep throat with antibiotics can decrease the risk of

rheumatic heart disease (Spinks et al., 2021). The use of aspirin in people who are otherwise

healthy is of unclear benefit (Sutcliffe et al., 2013).

2.2. Overview of cardiovascular disease in Nigeria

In the previous 50 years, Nigeria can be said to have been in the first stage, when most of the

presentations of cardiovascular conditions were as a result of malnutrition and communicable

diseases. Rheumatic heart disease and cardiomyopathies were the major presenting CVDs

then (Ajayi et al., 1999).

However, by 1999, Nigeria had progressed through the second and third stages and is

currently getting toward stages four and five (Ajayi et al., 1999). At the second and third

stages, Nigeria witnessed increases in per capita income and life expectancy (Ogah et al.,

2012). Improvements in the public health systems, with cleaner water supplies, and improved

food production and distribution all combined to reduce deaths from infectious disease and

malnutrition (Ezeala-Adikaibe et al., 2014).

Improvements in medical education and health care delivery, along with other public health

changes, contributed to dramatic declines in infectious disease-related mortality rates (Ike,

2008). Continued improvements in economic circumstances, combined with urbanization and

radical changes in the nature of work-related activities, led to dramatic changes in diet,

activity levels, and behaviors such as smoking (Ngwogu et al., 2015).

Hypertension, rheumatic valvular disease, and cardiomyopathy caused most of the CVDs

over the next decade.Few cases of CHD were reported during this period (Oguanobi et al.,

2013). Between 1999 and 2000, most publications reflected the new importance attached to

hypertension and heart failure as increasing CVD problems with a view to characterizing
these conditions as well as the risk/prognostic factors (Ajayi et al., 1999; Osuji et al., 2014).

While some publications looked at the clinical correlates of hypertension and related

complications, some examined the impact of lipids and lipoproteins in hypertension

(Ahaneku et al., 1999; Famodu et al., 1999). Some authors assessed investigative modalities,

especially electrocardiography (ECG)-based investigations, while few echocardiographic-

based studies were published as echo was still emerging then as an investigative modality

(Oguanobi et al., 2013). Medications in hypertension management and other treatment

modalities were part of the issues of interest to clinicians and researchers then. Hypertensive

Heart Failure was also being described by a few authors who were characterizing the

different types and their correlates (Dosumu, 1999; Ogah et al., 2012). Over the next decade,

more cases of heart failure from different primary conditions (mostly hypertension and

cardiomyopathy) were reported and characterized (Onwuchekwa and Asekomeh, 2009).

Echocardiography also became more prominent among the routine investigative modalities

for CVDs (Adebayo et al., 2009).

Advances in drug development had also yielded major benefits on both acute and chronic

outcomes. The widespread use of an “old” drug, aspirin, had by this period been shown to

reduce the risk of dying of acute or secondary coronary events (Oluyombo et al., 2015). Low-

cost pharmacologic treatment for hypertension and the development of highly effective

cholesterol-lowering drugs such as statins had also begun to make forays into both primary

and secondary prevention, by reducing CVD deaths. Efforts to improve the acute

management of myocardial infarction led to the application of lifesaving interventions that

include the use of beta-adrenergic blocking agents (beta-blockers), PCI, thrombolytics,

statins, and angiotensin-converting enzyme inhibitors (WHO, 2019).

All these manifested in a change in the areas for emphasis on the management of CVDs in

Nigeria. This change also reflected in the pattern of presentation of CVDs in the following

decade (2010–2019). As a result, better characterization of the major CVDs was embarked

on, with the review of treatment protocols and medications (especially for hypertension and

its complications) (Adejumo et al., 2015). Protocols for the modifications of risk factors

were incorporated in care.

The World Health Organization (WHO) in 2016 revealed that in Nigeria, noncommunicable

diseases were estimated to account for 29% of all deaths, of which CVDs contributed 11%

(WHO, 2016). CVDs which have been found to be on the increase over the past 20 years in

Nigeria include hypertension, heart failure, and stroke. A marked increase in the prevalence

of CVD of 150% was reported by Adedapo,[42] in South-West Nigeria, and this finding

tallies with a study by Ifeoma et al.:[43] High prevalence and low awareness of hypertension

in a market population in Enugu, Nigeria. An increased trend in the prevalence of

hypertension was also observed in urban Nigeria by several other studies (Ogah et al., 2013).

A study in South-West Nigeria by Adedoyin and Adesoye showed that out of all the patients

presenting with CVDs over a 4-year period, heart failure had the highest occurrence

(Adedoyin and Adesoye, 2005).

2.3. Risks factors of Cardiovascular

Cardiovascular diseases (CVDs) are a leading cause of death worldwide with an accelerated

increase in CVD-related death in Nigeria and other low-income and middle-income countries

(Onwubere et al., 2011). Leading risk factors for heart disease and stroke are high blood
pressure, high low-density lipoprotein (LDL) cholesterol, diabetes, smoking and secondhand

smoke exposure, obesity, unhealthy diet, and physical inactivity (Ike and Onyema, 2020).

2.3.1. High blood pressure:

High blood pressure is a leading cause of heart disease and stroke because it damages the

lining of the arteries, making them more susceptible to the buildup of plaque, which narrows

the arteries leading to the heart and brain (Shakeri et al., 2012). About 116 million US adults

(nearly 1 in 2) have high blood pressure, defined as 130/80 mm Hg or higher. Only about 1 in

4 of these people have their high blood pressure under control. About 7 in 10 people who

have a first heart attack and 8 in 10 people who have a first stroke have high blood pressure

(Shakeri et al., 2012). Eating too much sodium can lead to high blood pressure. Americans

aged 2 years or older consume an average of about 3,400 mg of sodium each day, well over

the 2,300 mg recommended by the Dietary Guidelines for Americans. More than 70% of the

sodium Americans consume is added outside the home (before purchase), not added as salt at

the table or during home cooking (CDC, 2021).

2.3.2. High LDL cholesterol:

can double a person’s risk of heart disease. That’s because excess cholesterol can build up in

the walls of arteries and limit blood flow to a person’s heart, brain, kidneys, other organs, and

legs. Although nearly 86 million US adults could benefit from taking medicine to manage

their high LDL cholesterol, only about half (55%) are doing so (Akinremi et al., 2013).

People can improve their blood pressure and cholesterol levels by eating a healthy diet that is

low in sodium, being physically active, maintaining a healthy weight, and taking medicines

as recommended (WHO, 2019).

2.3.3. Diabetes

The term diabetes mellitus describes a metabolic disorder of multiple aetiology characterized

by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism

resulting from defects in insulin secretion, insulin action, or both. The effects of diabetes

mellitus include long–term damage, dysfunction and failure of various organs (Zubery et al.,

2021).

Diabetes mellitus may present with characteristic symptoms such as thirst, polyuria, blurring

of vision, and weight loss. In its most severe forms, ketoacidosis or a non–ketotic

hyperosmolar state may develop and lead to stupor, coma and, in absence of effective

treatment, death. Often symptoms are not severe, or may be absent, and consequently

hyperglycaemia sufficient to cause pathological and functional changes may be present for a

long time before the diagnosis is made. The long–term effects of diabetes mellitus include

progressive development of the specific complications of retinopathy with potential

blindness, nephropathy that may lead to renal failure, and/or neuropathy with risk of foot

ulcers, amputation, Charcot joints, and features of autonomic dysfunction, including sexual

dysfunction. People with diabetes are at increased risk of cardiovascular, peripheral vascular

and cerebrovascular disease (Chan et al., 1994; Tanzania Diabetes, Metabolic Syndrome and

Obesity, 2021).

2.3.4. Obesity

Obesity also called corpulence or fatness, excessive accumulation of body fat, usually caused

by the consumption of more calories than the body can use. The excess calories are then

stored as fat, or adipose tissue. Obesity can also be said to be a complex disease involving an

excessive amount of body fat. Obesity isn't just a cosmetic concern. It's a medical problem
that increases the risk of other diseases and health problems, such as heart disease, diabetes,

high blood pressure and certain cancers (Hashmi et al., 2019).

Obesity was traditionally defined as an increase in body weight that was greater than 20

percent of an individual’s ideal body weight—the weight associated with the lowest risk of

death, as determined by certain factors, such as age, height, and gender. Based on these

factors, overweight could then be defined as a 15–20 percent increase over ideal body weight

(Mykkänen, et al., 1993).

2.4. Nutritional needs of adolescence

Adolescence is the period of transition between childhood and adulthood, and it is

characterized by intense body changes resulting from puberty and by impulses of emotional,

mental, and social development (UNICEF, 2018). All these changes are part of a continuous

and dynamic process that starts with the fetal life, changes during childhood, with favorable

or unfavorable influences from the setting and from the social context, and end with the

complete physical growth and sexual maturation, personality consolidation, economic

independence, and integration of the individual within his/ her social group (WHO, 2005.).

In adolescence, the need for marking new positions or becoming unattached from the family

may also be expressed by affective matters or conflicts concerning sexuality that are

transferred to the dietary process (Dona, 2005).

2.4.1. Energy requirement

Caloric requirements may be estimated in kcal/cm of height, varying according to age and

sex and adding extra expenditures with daily activities. The maximum consumption of

calories for females should be estimated around 2,500 kcal in the menarche period, on
average between 12 and 12.6 years of age, decreasing progressively to 2,200 kcal after that

(Skiba et al., 1997). For males, the caloric intake requirements increase to up to 3,400 kcal

around 15 to 16years of age, due to the pubertal spurt, and decrease to 2,800kcal until the end

of the growth period.

 CHAPTER THREE

RESEARCH METHODOLOGY

Study Location

The study will be conducted among adolescence in doko metropolis Niger State.

Study design:

The design that will be adopted for this research work will be descriptive and cross-sectional

study.

Target population:

The target population will be adolescence doko area of Niger State.

3.3. Ethical Approval

Letter of approval will be obtained from the Head of Department of Nutrition and Dietetics in

Federal Polytechnic Bida and submitted to the authority’s concern.

3.4. Sampling techniques

A multi-stage sampling technique will be used

Stage 1 simple random balloting will be used to select participant

Stage 2 purposive selection of a LGA govt of which lavun will be selected

Stage 3 purposive selection of a rural community in the selected LG

Stage 4 simple random technique will be used to select community used in the selected town
3.5 Sampling Size;

Sample Size

The sample size will be obtained from the formula described by Yamane Taro, (1967) and

Glenn, (1992):

N
n=
1  N (e) 2

Where;

n = minimum Sample size

N = total population
e= The desired level of precision at 5%
1= Constant

Informed consent;

A verbal consent will be obtained from each response before the questionnaire.

Data collection;

A modified WHO STEP-wise survey questionnaire will be administered to obtain

information on the following:

Socio economic and demographic characteristics of the respondent

Dietary intake was obtained using food habit and food frequency questionnaire

Anthropometric indices using (MUAC) and Clinical Features (BMI, Waist-hip Ratio and

body fat percentage and Blood pressure).

The physical activity level of the response

Data Analysis

Data will be analyzed using frequency percentage and mean and standard deviation.

Correlation test will be used to determine the relationship between variables used. All

statistical analysis was carried out using IBM SPSS statistical version 25.0.
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