CORRELATION OF BODY MASS INDEX AND LIFESTYLE PATTERNSWITH ACADEMIC ACHIEVEMENT AMONG FEMALE HIGH SCHOOL STUDENTS IN AL MADINAH, KSA: A POPULATION-BASED STUDY

1. Assistant Professor Of Community Medicine, Faculty of Medicine, Taibah University, Madinah, KSA. 2. Associate Professor Of Community Medicine, Faculty of Medicine, Cairo University, Egypt. 3. General Practitioner, Madinah, KSA. 4. Obstetrics And Gynecology Resident, King Fahad Medical City, Ryiadh, KSA. 5. Opthalmology Resident, Eastern Province Program, Eastern Province, KSA. 6. Pediatric Resident, Maternity and Children Hospital, Madinah, KSA. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 10 July 2020 Final Accepted: 14 August 2020 Published: September 2020


Introduction:-
Unhealthy lifestyle among students is a major concern worldwide. There is evidence of a direct link between unhealthy lifestyle and decreased academic achievement and cognitive functions among children and adolescents (1).Healthy lifestyle plays a major role in determining students' attention, learning abilities and school attendance therefore their academic achievement and these factors including physical activity, diet, sleep duration and pattern and video games addiction (2).
Obesity in particular is a major medical concern worldwide. According to the World Health Organization (WHO), almost at least 2.8 million die from obesity annually (3). In Saudi population, obesity increased strongly in the last two decades by alarming rates. Saudi women reportedly are suffering from overweight by 75%, and 44% are obese (4). It is reported that Saudi Arabia ranks 29 upon the fattest countries in the world on a 2007 list (5). The estimated percent of overweight and obesity among Saudi children are 23.1%, 9.3% respectively (6).
The prevalence of overweight and obesity between children and adolescents has increased extensively worldwide making it one of the most common long-lasting conditions in this age group (7).
It is reported that children who were obese have a lower score of intelligence quotients (IQs) than non-obese controls (8).Body mass index (BMI) was significantlylinked with all students' educational outcomes and obese students were more likely to suffer from school problems, school absences, grade retention, and to belessengaged in school than non-obese children (9). Being obese and eating unhealthy food affects the academic achievement of school children (10).
Physical activity is also reported to be correlated with academic achievement. Physical activity and sports help to improve children academic performance and learning abilities (11). Physical activity especially aerobicswere associated with behavioral, cognition and psychological aspects (12). Another study confirmed that low physical activity contributes to poor academic achievement and poor mental health (13). As regards diet, Children who do eat breakfast regularly have a higher IQ compared to those whodo not, additionally, regular breakfast consumption may have nutritional as well as social benefits (14).
Adequate Sleep duration have an impact on the mental functions and students' academic achievements (15). Sleeping enough can increase positive attitude about life and improve academic accomplishment (16). Sleep quality significantly correlate with school performance among children and adolescents and sleep has an important role in memory consolidation (17,18).

Aim of Work
To appraise the prevalence and the impact of overweight and obesity andother lifestyle patterns onfemale high school student's academic achievement in order to insight policy makers to plan interventions to improve lifestyle behaviors and subsequently, improvestudent'shealth status and their academic performance.
Objectives:-1. To estimate the prevalence of obesityand overweight among female high school students. 2. To assess the pattern of lifestyle behaviors among female high school students. 3. To investigate the relationship ofBMI and lifestyle factorswith academic achievement among female high school students in Al Madinah, KSA.

Study design
This is an analytical cross-sectional study.

Study setting and study period
The study was applied in two randomly selected high schools for females in Al-Madinah, KSA during the period from 1rst of February 2019 to the end of June 2019.

Study participants, sample size and sampling design
A cluster sampling technique was first applied. Two high schools (one governmental and one private) for females were randomly selected from a list of high schools for females in Al-Madinah, KSA. From each high school, a stratified sample was applied, where a list of classes from each school grade was prepared and then a simple random sample of female students was selected from each class.
Sample size was manipulated using OpenEpi online sample size calculator (19). Inputs entered were prevalence of overweight and obesity among Saudi high school female students of 40.9% assuming 18% of overweight students having low academic achievement versus 7% of normal weight students, yielding a risk ratio of 2.57 (20) at a confidence level of 95%, 5% precision and 80% statistical power. This yielded a sample size of at least 276 female students. A total of 205 students agreed to participate in the study (response rate of 74.27%) Inclusion criteria for the participants were; high school female student from grades 10 to grade 12 who completed the first term of the scholastic year 2018-2019 and had received their Grade Point Average (GPA) result.

Data collection
A modified version of the "Trent's Regional Strategic Framework for Health Promotion questionnaire" was given to the students (21). The questionnaire included personal and socio-economic data (academic grade in which the student is currently enrolled, school type whether governmental or private, the transportation method to/from school, family income and parent's education), tobaccosmoking habit (never smoker, X-smoker, current smoker (occasional or daily smoker), Dietary habits (weekly frequency of fast food and soft drinks, vegetable and fruit intake as well as daily breakfast intake), stress:wasmeasured using the Arabic version of Perceived Stress Scale (PSS) which is composed of 14 items and meant to assess the degree to which circumstances in an individual's life are perceived as stressful and how persons found their life erratic, uncontrollable, and burdened.PSS-14 scores scope from 0 to 56 established that the greater the score the higher the stress level (22), Physical activity was measured by using the Allied Dunbar National Fitness Survey "ADNFS" questionnaire which measures the frequency of occasions of vigorous or moderate activity to nil activity measured as levels from Level 5 (12 or more 20-minute occasions of vigorous activity over a four-week period) to Level 0 (no occasions) (23), quality of sleep was measured using the Pittsburgh Sleep Quality Index (PSQI) Arabic version of which is composed of 19 items to evaluate subjects sleep quality over the past month. (24), body Mass Index was calculated by measuring student's weight in Kilograms by using balance beam scale and height measurement by a wall-mounted stadiometer. BMI was then calculated using the equation (BMI= weight in kg/ height in m2), the subjects were categorized as underweight (BMI >18.50 kg/m2), normal weight (BMI18.5-24.99 kg/m2), overweight 25-29.99 kg/m2 and obese <30 kg/m2. Class 1 obesity was classified as BMI of 30 to < 35, class 2 obesity was classified as BMI of 35 to < 40, class 3 obesity was classified as BMI of 40 or higher (25).

Outcome measures
The primary outcome estimated the prevalence of obesity between female high school students in Medina. Also, to determine the relationship of the BMI and lifestyle factors (smoking, dietary habits, stress, physical activity, sleeping patterns), type of school whether private or governmental, parent's education and socioeconomic status with the level students' academic performance.

Statistical Analysis
Data were entered and analyzed using the Statistical Package for Social Scientists (SPSS) software version 21.
Descriptive statistics displayed categorical variables as frequency and percentage. Continuous variables were normally distributed. Correlation of students' GPA with BMI and stress scale score and sleep quality score was performed using Pearson correlation. Correlation of the level of physical exercise with students' GPA was performed using Spearman's correlation. Multivariate analysis using linear regression was performed to investigate for predictors of students' GPA. A P value of less than 0.05 is considered to be statistically significant.

Ethical Approval
An ethical approval was given from Taibah University ethical committee. An administrative approval was obtained from the educational facilities included in the study. An informed consent was obtained from the students' parents. All ethical considerations were followed according to the declaration of Helsinki on ethical values for medical research involving humans were followed (26).    Table 1shows that Students from governmental schools constituted 58.5% of the studied group. As regards parents' educational level, 63.3% of fathers and 49.3% of mothers were university graduates. Nearly 52% of the students claimed their family income is 15000 or more Saudi Riyal (SR). Student who have daily breakfast represent only 22% of the group, while 29.3% never eat breakfast. Those who claimed rarely eating 5 daily servings of vegetable and fruits represented 44.4% of the participants. As regards fast foods, 47.8% eat fast food meals 1-3 times/week and 57.6% reported drinking soft drink rarely while those consuming it on daily basis (at least 1 can/day) represented 10.7% of the participants. Tobacco smokers represented 2.9% of the participants. Only10.2% reported having good quality sleep, and 49.8% of the students reported nil physical activity. The mean (±SD) perceived stress scale score is 29.41± 7.47. As regards the BMI, 53.7% of the students were classified as normal, while 30.2% were classified as being underweight. Only 4.9% of the students were obese (2.9% class 1 obesity, 2% class 2 obesity). The mean (±SD) overall GPA for all students were 3.46±0.8. Nearly 63% of the students had an excellent grade at the last term. Table 2 shows a negative correlation between BMI (r = -.002), Perceived stress scale score (r =-.073), and Sleep quality score (r =-.071)with students' GPA and a positive correlation between physical exercise level and students' GPA (r=.068). However, these factors were statistically insignificant. Table 3 displays the predictors of student's GPA. It showed that being in a governmental school (p=0.041) and tobaccosmokers(p=0.004) were statistically significant predictors of lowered students' GPA. All other socioeconomic and lifestyle factors were statistically insignificant.

Disussion:-
This study demonstrates that 53.7% of the female students have normal weight and only 4.9% are obese, while underweight is prevalent among them (30.2%).These figures are close to those reported by Sabra, 2014 who investigated nutritional problems among female intermediate nursing schools in Dammam, KSA and reported 51.5% had normal weight, and only 3.8% were obesewhile 19.2% were underweight, a figure that is lower than that reported in the current study (27).
As regards body mass index, a study in Hail, Saudi Arabia documented a mean BMI of 23.5±5.28 kg/m2among Saudi teenagers (12-16 years), which is close to current study's findings of a mean BMI 21.38±4.68 among female high school students (28).
Concerning tobacco smoking, a study in Dammam City, KSA enrolled 1020 female non-medical college students reported that 8.6% are tobacco smokers, a figure that is higher than that reported in the current study (2.9%). This may be due to population differences as the current study enrolled high school students while the Dammam study enrolled older college students (29).
Sleep quality was reported as poor by most of the participants in this study (89.9%). This agrees with a study done in Riyadh including Al-Mareefa college students which reported thatapproximately 71% of the students experienced tiredness in most days and had a day time sleepiness (30). Also, in accordance with the present study, a study by AlZamil et al, 2019, who investigated lifestyle patterns among female college students and reported that 95% of females had insufficient sleep (<8 h/night). They also reported that approximately50% of the participated females were inactive, a finding agreed with the current study results which reported 49.8% of the participants being physically inactive (31).
As regards predictors of lowered academic performance, the current study revealed that smoking is significantly independently related with lower GPA (P = 0.004). This outcome is consistent a review including 28 studies, concludingthat all researches found an inverse relationship between tobacco use and academic accomplishments and stated that studentswith good academic achievement have good cognitive ability to decide being away from unhealthy behavior (32).
A positive correlation was found in previous studies between academic achievements and family income (33). However, family income and GPA showed insignificant correlation (p=0.66) in the current study.
Parents' educational level wasinsignificantly correlated to student's GPA. This finding is inagreement with many other studies (34,35),all documented no significant relationship between parents' level of education and academic performance among College students.
The current study also shows that being in a public school is a predictor of lower GPA. This is in line with a studywhich reported that academic achievement of private school students is higher than those in public schools (36).
In the current study, obesity was not a predictor of student's GPA. A study conducted in Taif, Saudi Arabia, reported a similar finding but noted that obese students got lower grades in physics specifically compared to normal weight students (37).
Across-sectional study found that students who eat breakfast regularly, fruits, vegetables, and milk products contributed to high school achievements (38). In the current study, results showed that fast food consumption, breakfast, soft drinks and physical activity is not a predictor of students' GPA (P<0.05). As regards to physical activity, the finding of the current study is consistent with a study conducted in Japanreporting no significant relation between overall grade point average of junior high school girlsand fitness score (39).As regards diet, Ruthiget al, 2011 found that diet and academic performance are not related to each other (40).However, other studies showed that unhealthy dietary habits such as increasing fast food consumption, skipping breakfast and drinking beverages is associated with decreased academic performance (41,42,43,44). This controversy may be due to methodological differences as the current study is a cross sectional one.
Many studies found a investigate stress and its impact on students academically. Students afraid of failure at school, difficult exams, too many requirements, and tasks, their parental expectations and their fear about the future career (45). However, the results of present study showed an insignificant correlation between perceived stress scale scores and students' GPA (P-value =0.300). In accordance with the findings of the current study, Shah et al, 2010showedthat perceived stress and medical student's academic achievement were insignificantly correlated (46).Shalaby et al, 2017 also found that among critical care nursing students, the academic achievement is not significantly correlated with the students' perceived stressors (47).
Low school achievement by students was studied to be associated with inadequate sleep duration or poor-quality sleep. It is reported that inadequate sleep can result in increased daytime sleepiness and, therefore, lead to problems with attention, concentration and cognitive functioning (48). In the current study there was no significant association between poor sleep quality and decreased academic performance.This is compatible with Howell et al, 2004, who reported no correlation betweensleep quality scores and GPA scores for 414 college students using Pittsburgh Sleep Quality Index (49).
Coordinated efforts of school health programs and primary care services can help students attain full academic potential and healthy life. School health program can provide students with the skills, social support, and environmental reinforcement they need to adopt long-term, healthy lifestyle behaviors. While, Primary care physicians are capable of preventing and treating nutritional problems in children and improving lifestyle behaviors by coordinating efforts within the primary care setting and resources within the community settings by adopting interventions such as healthy lifestyle promotion, weight assessment and monitoring, community health education and policy advocacy.

Conclusion:-
There is low prevalence of obesity among female high school students in Al-Madinah, while underweight is a noticeable nutritional problem among them. Never eating breakfast or daily vegetables and fruits, nil physical exercise and poor sleep qualityare prevalent lifestyle problems among them. BMIis not correlated with students' GPA as indicator of academic achievement. Only tobacco smoking and being in a governmental school are predictors of poor academic performanceamongst female students in high school in Al-Madinah.An awareness program is required to improve dietary habits and lifestyle patterns of female students. Provision of school meals for the students as a component of the school health service program would be of value in controlling for malnutrition problems among them. Further research is needed to investigate underlying factors for underweight and unhealthy life styles among these students.