Weight control practices and its associated factors among high school female-adolescents’ in Hawassa town, Ethiopia

Abstract

Adolescence, especially for females, is a period of ongoing risk behavior that triggers the development of adverse health outcomes during adulthood. This study aimed to investigate the weight control practice and its associated factors among high school female-adolescents in Hawassa town, Ethiopia. A school-based mixed cross-sectional study was conducted on 552 female-adolescents in Hawassa town, between December 2020 and January 2021. SPSS version 26 was used to perform bivariable and multivariable regression. Chi-square and Odds ratio were used to see the association in addition to Descriptive statistics of the data collected using a structured and semi-structured mixed questionnaire. BMI was calculated after taking the weight and height using a digital weight scale and stadiometer respectively of adolescent female participants. The focus group discussion was collected using an open-ended questionnaire. Among the total female-adolescents, 38.6% [95% CI = 34.5–42.8%] had experienced any of the weight control practices. The study also revealed that 25.9%, 20.5% and 7.8% of female-adolescents had experienced unhealthy, healthy and both weight control practices respectively. The multivariate regression analysis revealed that being at late adolescent age [AOR = 1.98; 95% CI = 1.33–2.95], living in a household at middle wealth status [AOR = 2.72; 95% CI = 1.60–4.63] and high wealth status [AOR = 5.69; 95% CI = 3.43–9.46], having a normal BMI [AOR = 2.36; 95% CI = 1.18–4.71] and being an overweight adolescent [AOR = 2.45; 95% CI = 1.13–5.28], having a mild depression [AOR = 1.72; 95% CI = 1.12–2.66], being dissatisfied with own mid-torso body image [AOR = 2.68; 95% CI = 1.52–4.73] were associated with exercising weight control practice. This study indicates that nearly forty percent of female-adolescents exercise weight control behaviors, of which a significant proportion of them were involved in unhealthy weight control behaviors. Factors that were associated with weight control behaviors among female adolescents should be also considered in designing healthy weight control interventions in urban settings of Ethiopia.

Keywords:

• Female-adolescents
• high school
• overweight
• weight control practice
• ethiopia

Reviewing Editor:

• M. Luisa Escudero-Gilete, Universidad de Sevilla, Spain

Subjects:

• Allied Health
• Specialist Community Public Health Nursing
• Allied Health

Introduction

WHO defines adolescence as the age between 10 and 19 years of age and it is further divided into early adolescence (10–14 years) and late adolescence (15–19 years) (World Health Organization [WHO], 2017, 2014). It is the second decade of life where physical and psychological changes are profound, in addition to the development of behavioral and social perceptions (De Onis and Onyango, 2014). The adolescent period is a special time in the human life cycle because it is characterized by rapid physical, cognitive, social, emotional, and sexual developments (WHO, 2017). It also encompasses elements of biological growth and major social role transitions, in which development patterns vary across time and place (Sawyer et al., 2018).

Weight control practice is a mechanism to lose, gain, or maintain weight. Weight control practice has become a concern of those wishing to avoid adverse health outcomes in adulthood in developing countries (Raphael, 2013; Tuffa et al., 2020). According to different studies, body weight control is classified as healthy and unhealthy (Ferraro et al., 2015; Park et al., 2019; Vander Wal, 2012). Healthy body weight control practice includes physical activity and healthy eating choices like a low-fat diet and consumption of fruits and vegetables (Neumark-Sztainer et al., 2012). Whereas, unhealthy weight control behaviors include specific behaviors that are not typically recommended for weight management and these include long hours of fasting, eating very little food, using a food substitute (powder or a special drink), skipping meals, smoking more cigarettes, taking dietary pills, self-induced vomiting, using laxatives and also diuretics (Davila et al., 2014; Ferraro et al., 2015; Neumark-Sztainer et al., 2012). However, most of the efforts for tackling overweight have been focused on controlling and preventing behavioral risk factors such as tobacco and excessive alcohol use, sexual and injury-related behaviors, and engaging in good physical exercise and dietary habits. Moreover, adolescence is a period, where these behaviors are usually established and continued as an ongoing risk behavior for developing adverse health outcomes during adulthood (Raphael, 2013). Furthermore, a study conducted in Portland, Oregon showed that females are more prone to perceiving themselves as overweight and obese even though they had a healthy BMI which led them to engage heavily in healthy or unhealthy weight loss management practices (Haley et al., 2010).

Recently, Ethiopia has been challenged by the double burden of communicable and non-communicable diseases (Ethiopia, 2020; Misganaw et al., 2017). Lower respiratory infections, diarrheal diseases, tuberculosis, and HIV/AIDS are still large drivers of premature mortality in Ethiopia. The country’s performance in reducing cardiovascular diseases, diabetes, cancer, and other non-communicable diseases has been minimal, causing some non-communicable diseases to become leading causes of death (Misganaw et al., 2017). A couple of systematic review and meta-analysis studies also reported a prevalence of 2–5% of diabetes and 9.3–30.3% of hypertension in Ethiopia (Bishu et al., 2019; Kibret and Mesfin, 2015; Legese and Tadiwos, 2020). A systematic review in Ethiopia also reported a high pooled prevalence of overweight and obesity among the adult population (24.4%) (Kassie et al., 2020). Studies in the same country have also shown that being female and living in urban areas, are among the positively associated factors with overweight/obesity (Anteneh et al., 2015; Gebrie et al., 2018; Teshome et al., 2013). Furthermore, this problem persists and similar findings are also reported in Ethiopian adults (Darebo et al., 2019; Mekonnen et al., 2018).

As adolescence is a transition period between childhood and adulthood, they are also victims of a high prevalence of obesity and overweight in Ethiopia (Gali et al., 2017). Unlike adults, adolescents, especially females usually engage in different weight control practices due to various reasons, but a majority of them practice unhealthy weight-control mechanisms (Bojorquez et al., 2018; Haley et al., 2010; Liou et al., 2012; Vander Wal, 2012). Among the individual reasons for practicing unhealthy weight control practices, body image dissatisfaction, body weight perception issues, and depressive symptoms are mentionable (Johnson et al., 2016; Philippi and Publica, 2018; Shin, 2017; Vander Wal, 2012). Whereas socio-cultural factors such as family, friends, and media influence adolescent girls’ weight control practices either positively or negatively (Philippi and Publica, 2018). A recent study conducted in Addis Ababa, a capital city of Ethiopia confirmed the perception of being overweight was among the factors associated with exercising unhealthy weight control practices by female adolescents (Tuffa et al., 2020).

Since adolescents who are engaged in unhealthy weight control practices are looking for a ‘quick fix’, as a result, they would be at risk of nutrient deficiency within a short period. However, a 10-year follow-up study conducted on middle and high school adolescents in the USA revealed that those adolescents who were exercising dieting, and unhealthy weight control/s including skipping meals and disclosed reduced meal portion size, use of food substitutes and dietary pill use reported a significant weight gain over time (Neumark-Sztainer et al., 2012).

Despite these, pieces of evidence are generated related to weight control practiced by Ethiopian adolescents, and even with a scope of unhealthy weight control practices in adolescents of Addis Ababa, the capital city of the country. Therefore, this study aimed to assess the level of unhealthy and healthy weight control practices and also look at groups practicing both weight control methods, and identify the potential factors associated with exercising weight control practices among female adolescents of Hawassa town, in Ethiopia, where high adolescent (30.4%) and adult overweight and obesity prevalence (28.2%) have been reported (Darebo et al., 2019; Teshome et al., 2013).

Methods and materials

Study area

Hawassa town is 273 km from Addis Ababa, the capital city of Ethiopia, and according to the Ethiopian Central Statistics Agency (CSA), the total population of the town was projected to be 351,469 in 2015 (Statistical C, 2012). According to the Sidama region education bureau, there were 33 secondary schools in Hawassa city, of which 12 were private and the rest 21 were public schools in 2019 G.C. The total number of females in these 33 schools was 12789. Among the 33 schools, only 10 schools were 9–12 grade of which, 3 were public and 7 were private schools.

Study design and period

An institution-based mixed cross-sectional study was conducted between December 2020 and January 2021, among female adolescents who were attending both private and public secondary schools at Hawassa town, Sidama regional state, Ethiopia.

Source and study population

The source population was all adolescent female high school students who were attending their high school in a regular program in Hawassa town and the study population included randomly selected adolescent female high school students who were attending their high schools in selected private and government schools of Hawassa city in the 2020 academic year. However, those female adolescent students who were not willing to participate in the study were excluded from the study.

Sample size determination and sampling technique

The total sample size was calculated using a single population proportion formula followed by correcting using the finite population correction formula since the total female population was less than 10,000. For this, we used a prevalence of 50% for weight control practice since no study was conducted on the overall weight control practice in Ethiopia, with a margin of error of 5%, a 95% confidence level, and a design effect of 1.5. Therefore, the total sample size was 537. An additional 10% of the total sample size was considered for the non-response rate so the final sample size for the study was 591.

The respondents were selected by a multi-stage sampling procedure. For this, first, we identified the number of high schools with 10–12 grades in Hawassa town, which was then categorized into two: private (n = 7) and government (n = 3). Then, randomly two high schools were included in this study, each from the private and government category. Following this, the total sample size calculated for this study (n = 591) was proportionally distributed to the two private and two government high schools included considering their population size. Next, the sampling frame was prepared for the two categories separately, based on the grade levels, and again proportion to the three grades (grades 10, 11, and 12), thus a systematic random sampling technique was implemented to identify the study subjects (Figure 1).

Data collection

Six nurses, who had completed at least a diploma and above were recruited for data collection and they were monitored by two supervisors. A mixed structured and semi-structured questionnaire was first prepared in English and later translated into Amharic. An open-ended questionnaire was used to collect qualitative data. Before conducting the data collection, two days of training on the basics of the data collection techniques, the purpose of the study with practical demonstration, coupled with pre-testing of the questionnaire in female adolescent students from high school who were not included in this study were conducted.

Socio-demographic, economic, socio-cultural, and individual factors were collected using the self-administered method. Anthropometric measurements of the study participants were measured in triplicate following standard methods (WHO, 2004), using a height measuring board and a digital weight balance scale. The height and weight values were rounded off to the nearest 0.1 cm and 0.1 kg respectively.

Body weight perception was assessed using a five scale from very underweight to obese (Christoph et al., 2018; Han and Kim, 2019; Ojala et al., 2012; Yan et al., 2018). The body part satisfaction scale was used to assess the level of satisfaction of different body regions with a scale ranging from extremely satisfied to extremely unsatisfied (Feng and Abebe, 2017; Tuffa et al., 2020). Depressive mood status was evaluated using the PHQ-9 questionnaire which contains 9 questions each having a score ranging from 0 (not at all) to 3 (nearly every day) on how frequently they exhibit the questions listed one to nine (Negeri et al., 2021). Regarding weight control practice, participants were asked how frequently they use/practice the listed ways of methods of weight control practices. The frequency of practice ranges from never practice to daily practice (Han and Kim, 2019; Tuffa et al., 2020). Influence for engaging in weight control practice was assessed by whether they were pressured to practice weight control by the listed potential triggers (Balantekin et al., 2018).

For the qualitative data, focus group discussion (FGDs) was conducted using open-ended leading questions. A total of four questions were asked and each question was further followed with a probing question. The questions focused on their general understanding of weight control practice, the reason for their engagement, specific and personal ways they use weight control, and finally, what got them into the practices. Four FGDs were conducted, each in the selected high schools, comprising six study participants in each session. The FGDs were recorded with a tape recorder and important remarks were written down by the facilitators (principal investigator and one more MSc nutrition student). The FGD was transcribed manually for accurate transcription and important remarks were properly highlighted and pointed out. Finally, responses and conversations were used to support the statistical findings and interpretations.

Data management and analysis

Data were checked for completeness and consistency; data entry was performed by the principal investigator to ensure the quality of the data. After that, the data was coded and entered into Epi-data version 4.6 and then exported to SPSS version 26 for analysis. WHO-Anthro plus software was used to classify BMI for age Z-score (WHO, 2004; 2007). The Wealth index was extrapolated by principal component analysis (PCA) inside SPSS using variables that included fixed house assets and housing condition of study participants that were adapted from the Ethiopian Demographic and Health Survey (EDHS) 2016 questionnaire (DHS, 2016) after categorizing the response into 1 and 0. Finally, the composite index was categorized into three tiles/classes under the rank parameter of the factor analysis giving us low, middle, and high-income groups.

Further, the factors associated with weight control practices were identified by entering the dependent and independent variables in the binary logistic regression model. The independent variables with a p-value of = <0.25 in bivariate analysis (screening) were further entered together in the multivariate regression model. Therefore, those variables with p = < 0.05 in the final model were declared as the associated factors with weight control practices. In addition, model fitness was checked by Hosmer-Lemeshow which was 0.13 and fitted. Variance inflation factor (VIF) was used to check for multicollinearity where a maximum of 3.6 was found showing a low correlation.

Operational definitions

Weight control practices are the techniques and underlying physiological processes that contribute to a person’s ability to attain and maintain a certain weight.

Unhealthy weight control practice (UWCP) is the adoption of one of the following weight control practices which include self-induced vomiting, using diet pills, smoking cigarettes, long hours fasting and fasting more than 24 h, skipping meals, use of laxatives and diuretics, taking diet pills, fasting and excessive training or doing vigorous exercise, eating less amount of food than the usual, taking other food substitutes and eating only one type of diet. Therefore study participants who answered yes to one of the listed measures are subjected to UWCP.

Healthy weight control practice (HWCP) is the adoption of weight control practice which includes regular physical exercise and healthy eating habits which include a low-fat diet, low sugar/sugar-free diet, avoiding processed foods, and regular consumption of fruits and vegetables. Therefore study participants who answered regular engagement to one of the above measures are classified as a person with a healthy weight control practice.

Bodyweight misperception is a mismatch between an individual’s measured weight status based on BMI and self-reported weight status.

Body image dissatisfaction is defined as the negative perceptions and feelings a person has about their body and is influenced by factors such as body shape and appearance, attitudes towards weight gain, and cultural norms about an ideal body.

Results

Socio-demographic and economic characteristics by weight control practice

A total of 552 female adolescents participated out of the initial 591, resulting in a 93.4% response rate. Among those participants who were engaged in weight control practice, about two-thirds (63.4%) were 18–19 years old adolescents, and the rest (36.3%) were aged between 14 and 17 years old. Among those who were engaged in weight control practice, a higher proportion participated from grade 10 compared to grade 11 and grade 12. Slightly higher than half (53.1%) of female adolescents who practiced weight control were living in households at higher wealth status, followed by the adolescents from households at middle (29.6%) and low (17.4%) wealth statuses, respectively (Table 1).

Table 1. Weight control practice in female adolescent students by selected socio-demographic and economic characteristics.

Variables	Categories	Weight control practice		x^2p-value
		Yes (n = 213) (%)	No (n = 339) (%)
Age	Middle adolescent (14–17)	78 (36.6)	165 (48.7)	.005
	Late adolescent (18–19)	135 (63.4)	174 (51.3)
Grade	Grade 10	82 (38.5)	133 (39.2)	.984
	Grade 11	74 (34.7)	117 (34.5)
	Grade 12	57 (26.8)	89 (26.3)
School type	Private	58 (27.2)	85 (25.1)	.573
	Governmental	155 (72.8)	254 (74.9)
Father’s education	No formal education	27 (12.7)	50 (14.7)	.964
	Can read and write	35 (16.4)	48 (14.2)
	Primary school	22 (10.3)	36 (10.6)
	Secondary school	44 (20.7)	70 (20.6)
	Some college or technical school	45 (21.1)	66 (19.5)
	College graduate or above	21 (9.9)	33 (9.7)
	Other	19 (8.9)	36 (10.6)
Mother’s education	No formal education	31 (14.6)	54 (15.9)	.996
	Can read and write	47 (22.1)	75 (22.1)
	Primary school	35 (16.4)	59 (17.4)
	Secondary school	44 (20.7)	68 (20.1)
	Some college or technical school	22 (10.3)	31 (9.1)
	College graduate or above	15 (7.0)	21 (6.2)
	Other	19 (8.9)	31 (9.1)
Wealth	Low	37 (17.4)	145 (42.8)	.000
	Middle	63 (29.6)	93 (27.4)
	High	113 (53.1)	101 (29.8)

Weight perception, weight preference and body part satisfaction and WCP

Almost all (98.6%) adolescent students, perceived that they had normal weight or were overweight or obese. More than half (53.1%) of those female adolescents who were engaged in weight control practices wanted to maintain their weight status during the study period while 46.9% of the participants wanted to lose their body weight. In the case of body satisfaction, most (86.9%) of study participants who practiced weight control were satisfied with their facial structure. Similarly, among those female adolescents who practiced weight control, 69% were satisfied with their upper torso, while 62.9% and 60.1% were satisfied with their lower torso and muscle tone respectively (Table 2).

Table 2. Perception, preference, and satisfaction on body weight and body parts related with WCP in selected High schools, Hawassa, Sidama regional state (December 2020).

		WCP
Variables	Response	Yes (n = 213) (%)	No (n = 339) (%)	x^2p-value
Weight perception	Very underweight	2 (0.9)	6 (1.8)	.095
	Underweight	4 (0.5)	19 (5.6)
	Normal weight	159 (58.2)	259 (76.4)
	Overweight	40 (31.0)	47 (13.9)
	Obese	8 (9.4)	8 (2.4)
Weight preference	Gain weight	0 (0)	27 (8)	.426
	Lose weight	100 (46.9)	71 (20.9)
	Maintain current weight	113 (53.1)	241 (71.1)
Body part satisfaction
Face	Satisfied	185 (86.9)	305 (90)	.259
	Not satisfied	28 (13.1)	34 (10)
Upper torso	Satisfied	134 (69)	281 (82.9)	.000
	Not satisfied	79 (31)	58 (17.1)
Mid torso	Satisfied	90 (42.3)	239 (70.5)	.000
	Not satisfied	123 (57.7)	100 (29.5)
Lower torso	Satisfied	134 (62.9)	269 (79.4)	.000
	Not satisfied	79 (37.1)	70 (20.6)
Muscle tone	Satisfied	128 (60.1)	268 (79.1)	.000
	Not satisfied	85 (39.9)	71 (20.9)
Weight	Satisfied	133 (62.4)	272 (80.2)	.000
	Not satisfied	80 (37.6)	67 (19.8)

Social factors and weight control practice

The majority of female adolescent students (76.5%) who practiced weight control were due to their peer influence. Likewise, 165 (77.5%) and 98 (46%) of adolescent students who practiced weight control were influenced by the information provided through social media and mass media, respectively. Among the least influential in practicing wealth control, school teachers (14.6%) and dating partners (16%) were mentionable (Table 3).

Table 3. BMI for age, social factors, and depression related with WCP groups in selected High schools, Hawassa, Sidama regional state, Ethiopia (December 2020).

		WCP
Variable	Categories	Yes (n = 213) (%)	No (n = 339) (%)	x^2p-value
BMI for age	Underweight	15 (7)	45 (13.3)
	Normal	117 (54.9)	209 (61.7)	.002
	Overweight	70 (32.9)	79 (23.3)
	Obese type 1	11 (5.2)	6 (1.8)
Peer influence	Yes	163 (76.5)	33 (73.3)
	No	50 (23.5)	12 (26.7)	0.649
Family influence	Yes	63 (29.6)	15 (33.3)
	No	150 (70.4)	30 (66.7)	0.618
Dating partner	Yes	34 (16)	9 (20)
	No	179 (84)	36 (80)	0.509
School teachers	Yes	31 (14.6)	7 (15.6)
	No	182 (85.4)	38 (84.4)	0.863
Mass media	Yes	98 (46)	19 (42.2)
	No	115 (54)	26 (57.8)	0.643
Social media	Yes	165 (77.5)	34 (75.6)
	No	48 (22.5)	11 (24.4)	0.782
Depression	Not depressed	72 (33.8)	160 (47.2)
	Mild depression	120 (56.3)	129 (38.1)	0.000
	Moderate depression	21 (9.9)	50 (14.7)

FGDs also revealed that female adolescents were pressured and made conscious of their weight status and general physique often by friends at school and neighborhood, family members usually brother or sister, and close relatives. A student stated ‘… sometimes my friends jokingly say something about my weight or call me names and it would bother me for real even though I don’t say anything to them….’ similarly, another student said ‘….my brother and two sisters joke around about my weight when we are together. I know their intentions were not to make me feel bad but it bothers me.’ Another student said, ‘…I regularly go for a run with my dad in the morning which I picked up on after my dad motivated me …’.

In addition, they would get compelled to try tips and steps to lose weight and or work a certain type of workout for a specific part of their body part. One student disclosed ‘…I would see different types of abdominal workouts when I open YouTube and Tik Tok videos and also I see different videos recommending foods and drinks to avoid and consume for weight loss and I would try them for myself…’.

BMI for age and weight control practice

Of the total female students who practiced weight control, 7%, 32.9% and 5.2% were underweight, overweight, and obese, respectively, while 54.9% of female adolescents from the weight control practicing group had normal BMI for age (Table 3). During FGDs, information on why adolescents control their weight was asked of the participants and the common answer was ‘I want to have a nice overall physique’. The point of having a healthy life and health benefits was secondary to most participants in the FGDs. The repeated answer from the students was they prefer to have a flat stomach with a slim arm and face. In one of the schools, one female student sarcastically answered ‘…to have a shape like the number 8…’.

Depression status and WCP

Of the total participants in this study, 232 (42%), 249 (45.1%), and 71 (12.9%) were non-depressed, mildly depressed, and moderately depressed respectively. However, among those who practiced weight control, 72 (33.8%), 120 (56.3%) and 21 (9.9%) were categorized as non-depressed, mildly depressed and moderately depressed respectively (Table 3).

Magnitude of weight control practice

In the current study, the magnitude of weight control practice among study participants was 38.6% [95% CI = 34.5–42.8%]. Furthermore, the proportion of healthy weight control practice was 12.7% while that of unhealthy weight control practice was 18.1% and around 7.8% were engaged in both practices (Figure 2). Furthermore, in the HWCP group, a higher proportion of respondents 77 (36.2%) said that they regularly had less sweet food eating practices, followed by fewer soda drinks 59 (30%) and less high-fat foods 60 (28.2%) drinking and eating practices (Table 4).

Figure 1. Sampling procedure for selecting schools and adolescent students (December 2020).

Figure 2. Distribution of female adolescent students by weight control practices in selected high schools, Hawassa, Sidama regional state, Ethiopia (n = 552).

Table 4. HWCPs within the WCP group by frequency of practices in selected High schools, Hawassa, Sidama regional state, Ethiopia (December 2020).

HWCP (n = 113)	Never	Rarely	Sometimes	Regularly
Exercise	122 (57.3%)	58 (27.2%)	18 (8.5%)	15 (7.0%)
Eating more fruits and vegetables	38 (17.8%)	124 (58.2%)	37 (17.4%)	14 (6.6%)
Eating less high-fat	17 (8.0%)	78 (36.6%)	58 (27.2%)	60 (28.2%)
Eating less sweet	5 (2.3%)	63 (29.6%)	68 (31.9%)	77 (36.2%)
Drinking less soda	6 (2.8%)	60 (28.2%)	83 (39%)	59 (30%)
Watch portion size	120 (56.3%)	44 (20.7%)	35 (16.4%)	14 (6.6%)

Qualitative information from FGDs revealed that fatty foods, sweet foods, and soft drinks were disclosed as bad for weight, and for that reason, the adolescents were cautious in their consumption of them. A student responded ‘…I struggle to not eat cakes and soft drinks when I am with my friends and we are at a café. If I did that I almost immediately feel guilty afterward…’.

When asked if they do physical exercise regularly, a common response was it was hard to do and easily get fatigued and bored. One student said ‘……I plan to jump rope in the morning but every time I just can’t put myself through it……’ another student responded, ‘….I courageously prepare and start to do my exercise but a few minutes into it I get unmotivated to keep going and just finish my session short…’.

In the UWCP group, more than half 136 (63.8%) of the female adolescents who participated in this study had been eating less food followed by skipping meal 123 (57.7%) and prolonged fasting and or fasting for more than 24 h 48 (22.5%) (Table 5).

Table 5. UWCPs within the WCP group by frequency of practices in selected High schools, Hawassa, Sidama regional state, Ethiopia (December 2020).

UWCP (n = 143)	Yes	No
Skipping meal	123 (57.7%)	90 (42.3%)
Prolonged fasting and fasting for >24 hr	48 (22.5%)	165 (77.5%)
Eating less food than usual	136 (63.8%)	77 (36.2%)
Taking laxatives or diuretics	0 (0%)	213 (100%)
Self-induced vomiting	8 (3.8%)	205 (96.2%)
Taking slimming drinks or diet pill	11 (5.2%)	202 (94.8%)
Taking food substitute	6 (2.8%)	207 (97.2%)
Smoking cigarettes	0 (0%)	213 (100%)

Qualitative information obtained from FGD reflected that almost all participants responded that they tend to rely on skipping a meal and restricting their food intake which they said was the best and most efficient way to lose weight and not gain weight.

Asked to give specific examples, one student said ‘…I will eat breakfast and after, I’ll go the rest of the day without another meal’ and another student said ‘…I will eat one meal in the afternoon and skip breakfast and dinner…’ another student responded, ‘…I like to drink lemon water and ginger tea on regular basis…’.

Factors associated with weight control practice

In the current study, age, BMI for age, wealth index, body part dissatisfaction, and depression were included in the bivariate model and adolescent age, BMI, depression, wealth index, and body part dissatisfaction were found to have a significant association with WCP in the bivariate model. However, after adjusting for confounders in the multivariate logistic regression, age, BMI, depression, wealth index, and mid-torso dissatisfaction showed statistically significant association with weight control practice, therefore, they were found to be final predictors for weight control practice.

The odds of engaging in WCP were 1.98 times higher among late adolescents than those of middle adolescent age groups [AOR = 1.98; 95% CI = 1.33–2.95]. Female adolescent students who were from middle and high wealth categories had 2.72 times higher odds [AOR = 2.72; 95% CI = 1.60–4.63] and 5.69 times higher odds [AOR = 5.69; 95% CI = 3.43–9.46] for practicing WCP respectively compared to those female adolescents from low wealth status households. Similarly, the odds for being in normal weight for age and also overweight female adolescent students who practice WCP were 2.36 times [AOR = 2.36; 95% CI = 1.18–4.471] and 2.45 times [AOR = 2.45; 95% CI = 1.13–5.28] compared to female adolescent students who were underweight respectively. Likewise, female adolescent students with mild depression had 1.72 odds [AOR = 1.72; 95% CI = 1.12–2.66] to practice WCP compared to those female adolescent students who had no depression. Furthermore, those female adolescent students who were not satisfied by their body part, more specifically mid-torso had 2.68 higher odds for practicing WCP [AOR = 2.68; 95% CI = 1.52–4.73] compared to those satisfied with their mid-torso (Table 6).

Table 6. Factors associated with WCP among female high school adolescents, Hawassa, Sidama regional state, Ethiopia (December 2020).

Variables	Category	WCP		AOR	p-Value
		Yes (n = 213)	No (n = 339)
Adolescent age group	Middle (14–17)	78	165
	Late (18–19)	135	174	1.978 [1.327–2.946]	.001**
BMI class	Underweight	15	45
	Normal	117	209	2.362 [1.183–4.714]	.015**
	Overweight	70	79	2.448 [1.134–5.282]	.023**
	Obese type 1	11	6	3.310 [.907–12.083]	.070
Depression	None	72	160
	Mild	120	129	1.723 [1.118–2.657]	.014**
	Moderate	21	50	.568 [.285–1.132]	.108
Wealth	Low	37	145
	Middle	63	93	2.723 [1.602–4.629]	.000**
	High	113	101	5.694 [3.428–9.460]	.000**
Body part satisfaction
Upper torso	Yes	147	281
	No	66	58	.748 [.366–1.530]	.462
Mid torso	Yes	90	239
	No	123	100	2.683 [1.520–4.734]	.001**
Lower torso	Yes	134	269
	No	79	70	1.080 [.492–2.371]	.848
Muscle tone	Yes	128	268
	No	85	71	1.430 [.704–2.905]	.322
Weight	Yes	133	272
	No	80	67	.911 [.461–1.798]	.788

* p-Value < 0.25 was used to screen candidate variables in bivariate analysis, COR: Crude Odds Ratio; **p-Value < 0.05, AOR: Adjusted Odds Ratio; WCP: Weight control practice.

Discussion

The overall aim of the current study was to assess the magnitude and factors associated with weight control practices in Hawassa town. Accordingly, the magnitude of weight control practice in female adolescent students in Hawassa town was 38.6% [95% CI = 34.5–42.8%], of them, 20.5%, 25.9%, and 7.8% had healthy weight control and unhealthy weight control practice and those practicing both unhealthy and healthy weight practices, respectively. A study conducted in Addis Ababa 6 shows that the prevalence of UWCP was 30.8% in female adolescents, which was higher than what was found in our present study. This might be because the influence of globalization might affect people living in towns like Addis Ababa compared to Hawassa, in which thin body images in females are taken as a sign of beauty.

In our present study, the older age group or late adolescents were more engaged in weight control practice. This finding was in line with a study conducted in Boston Massachusetts, USA (Calzo et al., 2012). On the contrary, a study that looked at survey data of 8–15 years old children from the National Health and Nutrition Examination Survey (NHANES) found that almost half (49.1%) of the children were engaged in weight control practices, which was much higher than the current study (Masler et al., 2021). Though the study didn’t include late adolescents, the higher proportion could be explained by how children from well-developed countries are overweight and obese at an early age. Furthermore, they are exposed to external influences like access to private smartphones plus internet access, social media, and mainstream media, and these are countries where unrealistic physical perfections are over-emphasized. This might cause body part dissatisfaction, misperception, and low self-esteem among the children leading them to engage with weight control practice early.

Students in the middle and upper economic class were found to have a significant association with weight control practice. A study conducted in Addis Ababa found that the higher SES group had higher odds of engaging in weight control practice (Tuffa et al., 2020). Also, a study from Israel found that high SES had a significant association with unhealthy weight control practices (Tur-Sinai et al., 2020). In addition, a study from Britain (Johnston and Lordan, 2014) and the US (Seward, 2014) found that participants from the high-income bracket were more prone to engage in weight control practice and likely to be concerned about their physical and health status. This might be because study participants from higher SES backgrounds have modern dietary habits which consist of packed and processed food full of sugar and high calorie leading to weight gain. Moreover, they have more access to resources and information when it comes to weight control practice and in addition, they are more likely to follow current health trends and socially considered ‘acceptable’ physique. In contrast, being from a middle SES was not found to be associated with weight control practice in the above studies (Seward, 2014; Tuffa et al., 2020; Tur-Sinai et al., 2020). The association of adolescents from middle-income families with WCP in the current could be that older age participants might be more from the middle class.

The finding of this study showed that 10.9%, 27.0%, and 3.1% of all the participants were underweight, overweight, and obese respectively. This finding was consistent for overweight and obesity with the study conducted on the prevalence of overweight and obesity among high school adolescents in the study area, Hawassa, Ethiopia (Teshome et al., 2013). Regarding BMI class, the normal weight and overweight group had a significant association with weight control practice. Supporting this finding, a study conducted among US adolescents reported that the overweight group of adolescents had 3.61 times higher odds of engaging in WCP but in contrast, normal BMI groups were not found to be associated with weight control practice among the adolescents (Yang et al., 2014). This might be due to overweight female adolescents being more likely to receive comments about their weight status and are encouraged to engage in weight control practice from their surroundings and more likely to be thinking and comparing their physical appearance to their friends and family members. During the FGD, adolescents disclosed that they frequently get comments both negative and positive from friends and family members about their weight status and general appearance and a number of them added that they became aware of their weight status and started thinking about engaging in WCP.

One of the main discussion points in multiple studies (Duong, 2016; Pedro et al., 2016) was the relationship between weight perception and actual BMI and these findings show that female adolescents tend to misperceive their actual weight status. Similarly, the current study found that 9.5% were normal weight but perceived themselves as overweight which can explain the association of weight control practice to normal BMI for age of adolescents in the current study. One study conducted in Mauritius found that 88.5% of students perceived themselves as overweight even though only 19.2% were overweight (Bhurtun and Jeewon, 2013). In another study from Nigeria, 87.4% of the adolescents wrongly perceived their actual body size were the majority of females with normal weight perceived themselves as overweight (Oyewole et al., 2018).

This study also found that female students with mild depression had a significant association with weight control practice. This is similar to the finding of a survey study, where lower depressive symptom was associated with a higher likelihood of healthy weight control practice among adolescents (Lampard et al., 2016). In contrast, the study from Addis Ababa 6 found that being severely depressed was significantly associated with WCP and those students were 4 times more likely to engage in WCP. A possible explanation for this could be that depressed individuals are usually insecure about themselves. Most depressed individuals have other psychological challenges such as eating disorders, and body dysmorphic disorder. Moreover, depression could be secondary to overweight and obesity which can explain the association.

The study also found that adolescent females who were dissatisfied with their mid-torso body parts were found to engage in the WCP. In line with the current finding, a study conducted in Sao Paulo reported that body part dissatisfaction was significantly associated with WCP, and of all more than half (63.7%) of female adolescents answered they were dissatisfied with their stomach area (Philippi and Publica, 2018). This was also observed during the FGD where the adolescents had a specific preference for how certain parts of their bodies should look and that they were unsatisfied with their current physique.

In the current study, social factors which include family, peer influence, mainstream media, and social media, and socio-demographic factors of mother’s education were not associated with WCP. The study from Addis Ababa was in line with the current study (Tuffa et al., 2020). But a study conducted in Mexico found that adolescent mothers’ education was found to be a significant predictor of WCP (Bojorquez et al., 2018). Furthermore, a study conducted in Switzerland reported that family function, peers, and media sensitivity are associated with WCP among adolescents (Balantekin et al., 2018). It might be related to current mainstream content not provoking and influencing and social media exposure depends on the accessibility of the internet and owning smartphones which usually happens in late adolescence. Perhaps, the advertisement, music, and film industries are showing changes in their content and the current easiness of internet access in the country can influence the coming generation of adolescent females. In regards to family influence, it might be that most Ethiopian parents are happy and never comment on their children when they gain weight as it is seen as comfort.

Limitations of the study

A cross-sectional study only looks at one point in time and also cannot look for cause and effect relationships where it falls under the ‘chicken-egg’ dilemma. Similarly, it is also affected by recall and non-response bias. Furthermore, the current study was not able to include grade nine students since the national exam for high school entry was delayed and late result annunciations and this could alter the result in the current study.

Conclusion

In conclusion, the overall magnitude of weight control practice was found to be 38.6% among female high school adolescents in Hawassa, Ethiopia. Unhealthy weight control practice was proportionally higher than that of healthy weight control practice. The result from multivariate regression analysis showed that being older age female adolescents, living in households at medium and high-income status, with high and normal BMI for age, mild depression as well and mid-torso dissatisfaction were significant predictors of weight control practice. Therefore, all responsible bodies should be aware of this public health issue and take the associated factors into account when designing interventions for promoting healthy WCP and prevention of UWCP among female adolescents in urban settings of Ethiopia.

Ethical approval

Ethical clearance was obtained from the Institutional Review Board at Hawassa University (IRB/039/13 25/11/2020). Also, permission letters were obtained from the responsible bodies of the selected schools included in this study.

Informed consent

Informed consent was collected after a detailed explanation of the purpose and benefit of the study right before the individual data was collected. The participants were also told to opt from their participation in the course of data collection at any time. Besides, participants were informed that the data collection procedure was entirely accomplished anonymously together with observance of the necessary confidentiality of already solicited information. The advantages of their honest response to the successful completion of the study were briefed to the participants to get quality information.

Acknowledgments

We would like to thank Hawassa University, School of Applied Human Nutrition for giving us a chance to commence this research. We could not have completed this work without the help of our data collectors and the understanding and kind contribution of the study participants. Finally, we would like to extend our gratitude to the principals and assigned officials of schools for facilitating and helping us during data collection.

Disclosure statement

The authors report no competing interests in this work and the work is self-funded.

Data availability statement

The data used to support the findings of this study are included in the article. Further data will be provided upon request from the corresponding author.

Additional information

Notes on contributors

Gelana Mulu Waktola

Gelana Mulu Waktola did masters in Public Health and Applied Human Nutrition, at Hawassa University. Currently he is working as Public Health Specialist in one of the health facilities under the Sidama Health Bureau.

Beruk Berhanu Desalegn

Dr. Beruk is currently working as an Associate Professor of Human Nutrition and Food Science, at Hawassa University.

Tagel Alemu Tafese

Mr. Tagel Alemu is lecturer of Food Science and Technology, at Hawassa University.