Nutritional status and nutrient intake adequacy of Students of Nursing and Midwifery Training College, Bole, Ghana

Study design

A cross-sectional design was used to carry out this study at one of the Nursing and Midwifery Training Colleges in the Savanna region of Ghana. The study concentrated on the nutritional status of students and nutrient intake adequacy as well as the dietary diversity of meals consumed. The Kwame Nkrumah University of Science and Technology, Kumasi's Committee on Human Research, Publications, and Ethics (CHRPE) granted its clearance for the study (Reference: CHRPE/AP/113/21). Additionally, permission was obtained from the Nursing and Midwifery Training College, Bole, management. Before conducting any evaluation or interview, each responder (staff or students) gave their written agreement. The informed consent form was explained to and signed by every participant who was chosen to participate in the study. Since the study document did not list the names of the participants, the anonymity of the data gathered was guaranteed. Participation in the study was entirely voluntary, and there were no financial incentives.

Population and sampling

The study population included Registered Nurse Assistant Preventive (RNAP) students, Post-NAP/NAC (PNNM) midwives, and Registered Community Nursing (RCN) students. A sample size of 231 was estimated using Yamane’s formula¹⁰ for determining sample size as follows: $\mathrm{n}=\frac{\mathrm{N}}{(1+{\mathrm{Ne}}^2)}$ , Where n = sample size, N = population size = 423, and e = margin of error or required precision (5%) = 0.05. To cater for errors and missing data capture, an additional 10% contingency was applied. Based on the overall population of each class, a probability proportionate to size methodology was used to obtain the 231 numbers needed for the investigation. Each class was stratified according to sex, and the respective proportions were estimated ( Table 1). To get the proportion to be represented in the sample, Microsoft Excel was used to generate random numbers from the sampling frame of each class as shown in Table 2.

Data collection and measurements

Semi-structured questionnaires were used to collect quantitative data for one month and two weeks (19th March 2021 to 3rd May 2021). Before collecting data, the field interviewers/anthropometrists underwent extensive training in questionnaire administration, anthropometric evaluations, and nutrition evaluation. The interviewers/anthropometrists were Diploma graduates in Community Nursing. The principal researcher continuously monitored the work of the field workers while collecting data, checking the questionnaire on the ground to guarantee that incomplete questionnaires and measurement errors were fixed the same day.

Anthropometric measurements

Recommended practices were used to measure the students’ weight, height, waist, and hip circumferences.¹¹ A microtoise (Bodymetre 208; Seca GmbH) was used to measure height to the nearest 0.1 cm, and an electronic scale (Uniscale; Seca GmbH) was used to measure weight to the nearest 0.1 kg. The scale was calibrated to measure a known mass (10 kg) every day. A tape measure was used to measure the waist and hip circumferences to the nearest 0.1 cm. All measurements were averaged over two measurements. The students' ages were calculated using their measurement dates and birth dates. To ensure that each participant had enough privacy, all physical assessments were carried out in an isolated location. The following procedures were used.

Height measurement using microtoise

Procedures

Weight measurement using a Uniscale

Set up requirements

The scale was positioned on a firm, level surface and turned on to show 0.0.

Procedures

Waist circumference measurement

Procedure

Hip circumference measurement

Procedure

Measurement of haemoglobin concentration

A HemoCue1 Hb 201+ was used to collect venous blood of about 1 ml to determine the haemoglobin concentration of the students. The blood sample was drawn from the fingertip of each participant into a pre-treated cuvette. The haemoglobin concentration value was displayed within 30 seconds on the device’s screen.

Procedure

Weighed food record

The school’s three (3) main meals were weighed every day from Sunday to Saturday for a total of one (1) week to assess the food and nutrient intakes. Using a digital electronic scale (MC-1001) to randomly weigh five (5) served meals at each meal time, the average was recorded down to the nearest 1g. All of the meal’s primary components were weighed and recorded separately throughout the weighing process, along with a description of the brands and information about how the food was prepared. The following procedure was used in weighing:

Dietary diversity assessment

Using a semi-structured Food Frequency Questionnaire (FFQ), the college’s weekly menu was assessed, and a list of the ingredients needed to prepare it during a typical week was documented. Based on the FAO minimum dietary diversity index, the food products were divided into 10 groups.¹² Eight (8) frequency of intake categories, ranging from none (0) to seven (7) times per week, were available for each dietary item.

Statistical analysis

Data collected first went through cleaning daily during the data collection period to check for missing data. In case of missing data, the respective respondent was revisited. Data entry and analysis were done using SPSS version 23.0 (SPSS, Inc.) (http://www.ibm.com/analytics/us/en/technology/predictive-analytics/#ibm-spss-stats-modeler-trials). Continuous data distribution was checked by visual examination of normal-curved fitted histograms. The test of normality was done using the Kolmogorov-Smirnov test. Descriptive statistics were computed for the background characteristics of students. One sample t-test was used to test the differences in the nutrient content of foods served and actual requirements. The mean Adequacy Ratio was determined for some nutrients of interest using their nutrient adequacy ratios. A chi-square test of independence was performed to examine the relation between the background characteristics and nutritional status. An outcome with a p < 0.05 was considered statistically significant for all analyses.

Demographic characteristics of the students

The respondents’ mean age was 24.24±3.2 years ( Table 3). Approximately 13% of the interviewees said they were married, while 1.8% said they were engaged. The findings revealed that the majority (75.3%) of the students were females. Similarly, most (77%) of the students pursued a Nurse Assistant Preventive program and 59.6% were in their first year of study.

Body mass index

The mean weight, height, and BMI of students were 62.49 ± 11.1 kg, 1.6 ± 0.1 m, and 23.45 ± 4.1 kg/m² respectively. Out of the 223 students who were investigated, 152 (68.2%) had BMIs within the range for an acceptable body weight, whereas 4% and 27.8%, respectively, were underweight or overweight, as shown in Figure 1. Table 4 shows that females were more likely than males to be overweight and obese. Likewise, students studying Post-NAP/NAC Midwifery (PNNM) were more prone to be overweight and obese whilst the risk of being underweight was significant among students in the Registered Nurse Assistant Preventive (RNAP) program (χ² = 37.978, p < .001). Furthermore, the prevalence of underweight and overweight among first-year students was 4.5% and 18.6%, respectively, with 74.5% of them having a normal body weight and 7.5% being obese. Third-year students had lower odds of obesity and underweight than first-year students did (χ² = 13.912, p < .05).

Figure 1. Nutritional Status of Respondents.

Waist-to-hip Ratio (WHR)

From the study, 74.9 ± 13.9 cm was the mean waist circumference and a mean WHR of 0.8 ± 0.9. Table 5 shows that the majority (81.6%) of students had a normal waist-to-hip ratio. However, the waist-to-hip ratio was larger in 22 per cent of females than in 7.3 per cent of males. (χ² (1) = 6.086, p < .05). Additionally, 15.2 per cent of first-year students and 25.3 per cent of second-year students, respectively, exhibited high waist-to-hip ratios (χ² (2) = 5.124, p < .077) ( Table 5).

Anaemia status

The mean haemoglobin level, shown in Table 6, among students in the study, was 13.5 ± 2.1 g/dL. About 22 per cent of the 223 students who were studied were anaemic. Females were more likely than males to have anaemia (χ² (1) = 8.779, p = .003). Additionally, 17.3% of first-year students had anaemia, compared to 30.1% of second-year students, who also had anaemia. Third-year students were at a lower risk than first-year and second-year students due to the large difference in prevalence (χ² (2) = 6.960, p < .05). A highly significant association was identified between anaemia and the program of study. In comparison to 3.0% of students in the Registered Community Nursing (RCN) program and none (0.0%) in the Post NAP/NAC Midwifery (PNNM) program, students in the Registered Nurse Assistant Preventive (RNAP) program had a higher chance of developing anaemia (27.3%) (χ² = 15.046, p = .001).

Meals served to students in the school

The major ingredients of the meals provided to students by the school were corn, cassava, beans, and rice. Some of the meals provided were millet porridge, Tuo Zaafi (TZ) with dry okra soup, Banku with groundnut soup, Gari and beans, and plain rice with tomato stew. Details are displayed in Table 7.

Comparison of mean nutrient intakes with RDAs

Table 8 contains the mean daily consumption of various nutrients in seven days matched with the Recommended Dietary Allowance (RDA). The mean energy in the form of calories provided by the school meals was 1951.77 ± 331.12 and those of protein, fat, carbohydrate, and fibre were 51.06 ± 17.09, 59.20 ± 28.45, 310.46 ± 31.14, and 25.62 ± 7.26 respectively. The percentages of two of the macronutrients, protein, and carbohydrates, provided in the school’s meals exceeded 100% of the daily requirements (RDA). The amount of cholesterol (M = 46.41, SD = 81.37) and fat (M = 59.20, SD = 28.45) met through the school diet was 15% and 61% respectively, whilst the total energy and fibre provided were 85% and 67% of the Recommended Dietary Allowance.

More than 100% of the Recommended Dietary Allowance (RDA) for Ascorbic Acid (212%), Thiamine (102%), Vitamin B₆ (128%), and Folate were provided by the school meals (121 per cent). The percentages of the RDA for riboflavin, vitamin B₁₂, vitamin A, and vitamin K, on the other hand, were less than 66 per cent, while those for niacin and vitamin E were 84 and 92 per cent, respectively.

In addition, while magnesium, sodium, and selenium provided over 100 per cent of the RDA, the amounts of calcium (M = 248.25, SD = 104.55), iron (M = 12.96, SD = 5.42), potassium (M = 2254.72, SD = 895.55), and zinc (M = 8.78, SD = 2.36) obtained from the meals contributed less than 66 per cent of the RDA.

Additionally, the study found that the RDA for each essential amino acid was exceeded by more than 100%. In comparison to normal population means, the mean levels of tryptophan, threonine, leucine, phenylalanine, histidine, valine, and methionine in school meals were greater, t (6) = 3.158, p < .05; t (6) = 3.316, p < .05; t (6) = 3.710, p < .05; t (6) = 4.998, p < .005; t (6) = 3.677, p < .05; t (6) = 6.648, p < .005; t (6) = 4.478, p < .005.

Mean Adequacy Ratio (MAR) of nutrients and dietary diversity of meals

Figure 2 shows the Mean Adequacy Ratio (MAR) of several nutrients from the study. The macronutrient MAR was 1.2 and the micronutrient MAR was 1.3. The study's findings showed that the most often consumed food groups were grains, white roots and tubers, plantains, and other vegetables (every day of the week). Pulses were eaten four times as opposed to twice per week for dairy, meat, fish, and leafy green vegetables. There were no (0) fruits of any sort served on any day of the week, and dark green leafy vegetables earned a score of two on the nutritional scale. Meat, poultry, and fish had a score of 2 for dietary diversity. A total dietary diversity score of 28 was recorded for the meals in the school as shown in Table 9.

Figure 2. Mean Nutrient Adequacy Ratio of Macronutrients and Micronutrients.

Anthropometric status

The current study found that the obesity prevalence was 7.2%, the overweight prevalence was 20.6%, and the undernutrition prevalence was 4% which were all in contrast to other research works.^13,14 The reason for these variations in malnutrition prevalence may be because, in contrast to the current study, where the majority of participants were young adults in their twenties, their study populations focused on teenagers, a group at a stage with higher nutritional demands. However, the high prevalence of overweight and obesity among the Post-NAP/NAC Midwifery (PNNM) program could be because students pursuing that program are gainfully employed which may play a role in how and what they consume. The research also revealed that 25.1% of students had waist circumferences that were excessive for their respective genders.¹⁵ This shows that roughly 25 out of every 100 research participants have an increased chance of having metabolic issues and non-communicable diseases linked to fat (NCDs).

From the findings, metabolic issues are significantly more likely to emerge in 18.4% of students, with females being more at risk than males. The study's greater proportion of female participants who were overweight or obese may have contributed to their higher risk of developing metabolic problems than did their male counterparts.

The majority of students with a high waist-to-hip ratio were second-year students, females, and students in the Post-NAP/NAC Midwifery (PNNM) program. The second-year students at the school might not participate in daily tasks like cleaning and maintenance. As a result, they become less active while eating the same amount of food as they did in the first year. Consequently, an increase in body fat will likely result from a decrease in activity. More specifically, the Post-NAP/NAC Midwifery (PNNM) program is mostly for females, and the program also has a greater prevalence of overweight among all the programs examined, which may be associated with the high prevalence of waist-to-hip ratio among females.

Prevalence of anaemia

Males were less likely to be anaemic than females contrast to a study in which more than 50 per cent of females were anaemic.¹⁶ This may be because women lose more iron through menstruation regularly than men and since the majority of the study's participants were females, their need for iron is also higher. It might also be that most of the overweight and obese women in the study are females, and total body fat has been linked to anaemia.¹⁷ Additionally, students enrolled in the Registered Nurse Assistant Preventive (RNAP) program had higher rates of anaemia. This may be the case given that the majority of RNAP participants have just graduated from high school and are in the transitional period between adolescence and early adulthood. Similar to this, a higher percentage of second-year students who were mostly female and of reproductive age had anaemia. The higher prevalence might be due to increased demand or loss, poor absorption, or parasitic infections¹⁸ as well as other things, like a bad combination of foods rich in iron and foods high in nutrients that restrict growth (high calcium, phytates, and others).

Nutrient Adequacy and Dietary Diversity of Meals

According to the mean adequacy ratios, the amount of macronutrients and amino acids in school meals is generally sufficient for students’ needs, but the amount of minerals and vitamins is not. The micronutrient inadequacy could be ascribed to the limited provision of green leafy vegetables and the lack of fruits in the school’s meals.¹⁹ However, the MAR for both macronutrients and a combined MAR for micronutrients (vitamins and minerals) in the college is adequate.

The study findings revealed that the dietary diversity score of the meals served in the school is 28. This implies that the school’s meals served to students are not diversified,¹² thus reflecting micronutrient inadequacy.^20,21 Hence, it is not surprising that the study discovered that the meals served at the school lacked sufficient amounts of vitamins and minerals.