Double burden of malnutrition and associated factors among adolescent in Ethiopia: A systematic review and meta-analysis

Aragaw Gezaw; Wolde Melese; Bekalu Getachew; Tefera Belachew

doi:10.1371/journal.pone.0282240

. 2023 Apr 12;18(4):e0282240. doi: 10.1371/journal.pone.0282240

Double burden of malnutrition and associated factors among adolescent in Ethiopia: A systematic review and meta-analysis

Aragaw Gezaw ^1,^*, Wolde Melese ¹, Bekalu Getachew ¹, Tefera Belachew ²

Editor: Solveig A Cunningham³

PMCID: PMC10096189 PMID: 37043492

Abstract

Background

As adolescence is a transition period from childhood to adulthood malnutrition occurring at this age resonates through generations. Although there were many individual studies in Ethiopia about different form of malnutrition among adolescent, their results are inconclusive indicating the need for generating a pooled estimate of adolescent nutritional status and associated factors. This review and meta-analyses aimed at estimating the pooled prevalence of different forms of malnutrition and associated factors among adolescents in Ethiopia.

Method and materials

We searched data bases from Pub Med, Cochrane Library, Health Inter Network Access to Research Initiative (HINARI), Science Direct and search engines; Google and Google Scholar and other sources; Reference of References and expert contact which were used to select the studies. Joanna Briggs Institute (JBI) quality appraisal tool was applied to identify eligible studies. STATA/SE V.14 was used to analyze the data. Effect size with 95% Confidence Interval (CI) and heterogeneity were estimated. Heterogeneity of studies was quantified with I² statistic >50% used as an indicator of heterogeneity. Potential publication bias was assessed using Funnel plots and Egger’s regression test. Trim and fill analysis was also performed. The presences of a statistical association between independent and dependent variables were declared at P <0.05. The PROSPERO registration number for the review is CRD42020159734.

Results

The pooled prevalence of overweight/obesity, stunting and thinness were 10.63% (95% CI: 8.86, 12.40), 20.06% (95% CI: 15.61, 24.51) and 21.68% (95% CI: 9.56, 33.81), respectively. Being female (OR: 2.02, CI: 1.22–3.34), low dietary diversity score (OR: 2.26 CI: 1.28–3.99) and high physical activity (OR: 0.36, 95%CI: 0.14–0.88) were significantly associated with adolescent overweight/obesity. Urban residence (OR: 0.82, 95%CI: 0.68–0.99), protected drinking water source (OR: 0.50, CI: 0.27–0.90) and having family size<5 people (OR: 0.54, CI: 0.44–0.66) were independent predictors of adolescent stunting. Early adolescent age (10–14 years) (OR: 2.38, CI: 1.70–3.34), protected water source for drinking (OR: 0.36, CI: 0.21–0.61), low wealth index (OR: 1.80, CI: 1.01–3.19) and family size <5 people (OR: 0.50, CI: 0.28–0.89) were significantly (P < 0.05) associated with adolescent thinness.

Conclusion

The prevalence of overweight/obesity, stunting and thinness are high in Ethiopian adolescents indicating the upcoming challenge of double burden of malnutrition. The results imply the presence of double burden of malnutrition among adolescents which heralds the need for programmatic and policy response in terms of addressing modifiable risk factors including: dietary practices, physical activity, water source and economic status of these adolescents.

Introduction

Adolescence period is characterized by physical, biological, psychological and social maturation signifying the transition to adulthood. According to World Health Organization (WHO) adolescents represent in the age group of 10–19 years [1]. Adolescents represent almost 20% of the world population and approximately 84% are living in developing countries. Sub- Saharan African adolescents make 23% of the population. In Ethiopia they represent 20–26% of the population [1–7]. According to WHO, interest and focus on adolescent health and nutrition is relatively recent. Conversely, the rate of growth during adolescence is the second fastest next to growth that occurs in the first 1000 days of life implying the need for direct nutrition intervention for this age-group. Although adolescents need a continuum care from childhood through adolescent, they are often ignored [1,8–10].

Previously the focus of nutrition agenda in low and middle-income countries has been on under-nutrition. Rapid economic development and urbanization have given rise to a nutrition transition, where energy-dense foods replace traditional foods and sedentary lifestyles prevail leading to an increase in obesity and diet-related chronic non-communicable diseases. Coexistence of under nutrition and over nutrition poses a public health challenge [11–14]. Therefore, it is imperative to find ways to eliminate under-nutrition and its associated morbidity and mortality, without contributing to obesity and risk of nutrition-related chronic diseases.

Malnutrition is deviations from the optimum body needs (it can be undernutrition or overnutrition). It is mainly caused by unbalanced, inadequate, or excessive intake of nutrients. Undernutrition refers to insufficient intake of dietary energy and nutrients that fulfill the body’s demand for optimum function. Undernutrition manifests in the form of stunting or wasting/thinness. Stunting is a chronic form of undernutrition which is caused by inadequate nutrition over a long period that fails to attain optimum growth while wasting/thinness is an acute form of undernutrition that indicates a recent food shortage and/or infectious diseases that leads to rapid and severe weight loss [15–19]. Overnutrition include overweight and obesity which is abnormal or excessive accumulation of fat that may result in health impairment [18–20].

To assess the nutrition status of adolescents, the WHO currently recommends using BMI-for-age and height-for-age. Thinness (low body-mass-index (BMI)-for-age (BAZ)) z-score is below minus 2 (-2.0) standard deviations (SD) and stunting (low height-for-age (HAZ)) z-score is below minus 2 (-2.0) standard deviations (SD). Overweight is (high Body Mass Index (BMI)-for-age)) greater than plus 1 standard deviation; and obesity is greater than plus 2 standard deviations above the WHO Growth Reference median [17–19,21].

Optimal nutrition during adolescence is a prerequisite for proper physical, mental, and social development. During adolescence; boys can achieve a linear growth of 9.5 cm/year while girls can increase 8.3 cm per year [22–25]. They can also increase in weight as much as half of their adult body weight. This rapid growth can be taken as a window of opportunity compensating for early childhood growth failure. Adolescent period is not only a time for tremendous growth, but also time of considerable risk. Suboptimal nutrition during adolescence results in delayed pubertal development, delayed sexual maturation, low lean body mass accretion, slower linear growth and future adverse health outcomes (adult physique and sense of self-esteem, metabolic and cardiovascular problems) and productivity [1,8,26–28].

Ethiopia has been implementing different strategies and programs to ensure food and nutrition security, as part of its national development agenda such as the Food Security Strategy, National Nutrition Strategy, National Nutrition Program, the Seqota Declaration roadmap, Nutrition Sensitive Agriculture Strategy, School Health and Nutrition Strategy and the Productive Safety Net Program through multi-sectoral nutrition coordination and integration [29,30]. However, health services in Ethiopia are not meeting the need of adolescents, instead focusing on preschool children and pregnant women, which resulted in lack of attention to adolescents and left several questions unanswered. Absolute nutrient requirements are higher during adolescence compared to childhood due to increased growth and body size [31]. Adolescent boys have greater requirements for most nutrients compared to girls due to differences in growth and development [20].

There is also lack of consistent information regarding factors associated with adolescent nutritional status; the difference in sex, age, residence, household wealth index, and lifestyle including alcohol and tobacco use, eating habits, level of physical activity, parent educational status, family size and sanitation.

Quantifying the double burden of malnutrition among adolescents and examining the associated factors across the country are important for policymakers to support actions for achievement of the Sustainable Development Goal (SDG) of ending malnutrition in all its forms by 2030. Nutrition is an indispensable cog without which the SDG machine cannot function smoothly [32–34]. Health care providers should have up-to-date and state-of-the-art evidence on adolescent malnutrition and associated factors to provide integrated nutrition services. Therefore, this study aimed at determining the pooled prevalence malnutruition and associated factors among Ethiopian adolescents.

Materials and methods

This study followed the recommended statement of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [35]. The procedures of screening and selection of eligible studies were presented using the PRISMA flow diagram [36]. The protocol for this systematic review and meta-analysis was registered at the international prospective register of systematic review and meta-analysis (PROSPERO) with a registration ID of CRD42020159734.

Eligibility criteria

Inclusion criteria

All studies reported on malnutrition and associated factors among adolescents in Ethiopia (both male and female between 10–19 years), observational studies including descriptive cross-sectional, analytical cross-sectional, case–control and cohort studies were included, all articles regardless of publication status but reported only in the English language were included. All forms of overnutrition (overweight/obesity) or undernutrition (stunting and thinness) with their prevalence and associated factors done in Ethiopia were also considered without time restriction.

Exclusion criteria

Studies conducted among special population (such as adolescents living with HIV/AIDS, tuberculosis) and mental disorders were excluded.

Information sources and search strategy

PROSPERO registrations as well as databases were explored to confirm whether previous systematic review and/or meta-analysis exist in order to avoid duplicates. To access published primary studies, PubMed/Medline, Cochran library, Science Direct and Health Inter Network Access to Research Initiative (HINARI) databases were used. Grey literature was retrieved using Google and Google Scholar searching engines. The reference lists of the retrieved studies were probed through contact relevant experts and organization’s website to collect articles that were not accessible through databases and search engines.

The search was restricted to only ‘human studies’ and ‘English language’ to suppress the number of irrelevant studies in the advanced search. The following were the key search terms: “nutritional status”, “overnutrition”, “overweight”, “obesity”, “undernutrition”, “stunting”, “thinness”, “wasting”, “malnutrition”, “determinants*”, “associated factors”, “adolescents” and “Ethiopia”. In the advanced search of databases, ‘Medical Subject Headings (MeSH)’ terms and to linking ‘All fields’ “AND” and “OR” Boolean operator and “*” truncation was used as appropriate (Table 1).

Table 1. Search strategies of adolescent malnutrition and associated factors in Ethiopia.

Data bases	Search strategy
Pubmed	(((("nutritional status"[Mesh] OR "malnutrition"[Mesh] OR "under nutrition"[Mesh] OR “over nutrition”[Mesh] OR stunting[Mesh] OR thinness[Mesh] OR overweight[Mesh] OR obesity[Mesh] OR nutrition[tiab]))) AND ((Adolescent[Mesh] OR youth[Mesh] OR teenager[Mesh] OR adolescen(tiab) OR youth(tiab) OR teen(tiab)))) AND ((“Ethiopia”[MeSH Terms] OR “Ethiopia”[All Fields]))
HINNARI	(((("nutritional status"[Mesh] OR "malnutrition"[Mesh] OR "under nutrition"[Mesh] OR “over nutrition”[Mesh] OR stunting[Mesh] OR OR thinness[Mesh] OR overweight[Mesh] OR obesity[Mesh] OR nutrition[tiab]))) AND ((Adolescent[Mesh] OR youth[Mesh] OR teenager[Mesh] OR adolescen(tiab) OR youth(tiab) OR teen(tiab)))) AND ((“Ethiopia”[MeSH Terms] OR “Ethiopia”[All Fields]))
Cochrane library	((((((((((("nutritional status") OR undernutrition) OR thinness) OR stunting) OR overweight) OR obesity) OR overnutrition) OR malnutrition) AND AND adolescent) AND Ethiopia
Science direct	“Nutritional status”[Mesh] OR undernutrition OR stunting OR wasting OR overnutrition OR overweight OR obesity OR malnutrition
Search engines
Google	(((("nutritional status"[Mesh] OR "malnutrition"[Mesh] OR "under nutrition"[Mesh] OR “over nutrition”[Mesh] OR stunting[Mesh] OR thinness[Mesh] OR overweight[Mesh] OR obesity[Mesh] OR nutrition[tiab]))) AND ((Adolescent[Mesh] OR youth[Mesh] OR teenager[Mesh] OR adolescen(tiab) OR youth(tiab) OR teen(tiab)))) AND ((“Ethiopia”[MeSH Terms] OR “Ethiopia”[All Fields]))
Google scholar	(((("nutritional status"[Mesh] OR "malnutrition"[Mesh] OR "under nutrition"[Mesh] OR “over nutrition”[Mesh] OR stunting[Mesh] OR thinness[Mesh] OR overweight[Mesh] OR obesity[Mesh] OR nutrition[tiab]))) AND ((Adolescent[Mesh] OR youth[Mesh] OR teenager[Mesh] OR adolescen(tiab) OR youth(tiab) OR teen(tiab)))) AND ((“Ethiopia”[MeSH Terms] OR “Ethiopia”[All Fields]))

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Study selection

Articles gathered from different sources were exported to Endnote X7, and duplicates were identified and removed. The remaining articles were evaluated in the context of the topic, study participants, language and study area. The independent reviewers screened the title and abstract of each study. Agreement between the two reviewers were accepted when Cohen’s kappa coefficient was>0.6. The screening was repeated when the kappa value is <0.6 [37]. After reaching good agreement, a full-text review was performed. When there was disagreement the review resolved through discussion.

Data collection process

After eligible studies were identified, two independent reviewer (AG and WM) extract the relevant data using a standardized data extraction format, which was adopted from the JBI data extraction format prepared on Microsoft Excel spreadsheet [38] and edited by(TB). Pilot test was conducted for all data extraction forms using a representative sample of the studies to be reviewed and the form was corrected based on pilot test finding. Finally, the two reviewers independently extracted the full texts of the name of the first author, year of publication, region, residence, study design, sex, age, sample size, number of nutritional status(overweight/obesity, stunted and thinness/ wasted), response rate, study quality score and raw data of associated factors on a 2x2 table using the structured data extraction format.

Quality appraisal and risk of bias in individual studies

The quality assessment was performed by two independent reviewers (AG and WM). The quality of each article was assessed using the standardized Joanna Briggs Institute(JBI) critical appraisal tool prepared for case–control, analytical cross-sectional and descriptive cross-sectional studies each with 10, 8 and 9 question items was assessed respectively [38]. All tools have ‘Yes’ and ‘No’ types of questions and scores were given 1 for ‘Yes’ and 0 for ‘No’ responses. Scores were sum up and transformed into percentage. Only studies that scored ≥50% were considered for both systematic review and meta-analysis of prevalence [39]. For any scoring disagreements, which were happening between the assessors, the source of discrepancy was investigated through making a thorough revision and disagreements were resolved through discussion. The quality results of primary studies were placed in a separate column of the data extraction format.

Operational definition

Overweight is BMI for age Z-score of more than +1 standard deviations (SD) from the median of the reference population and obesity is BMI-for-age Z-score of more than +2 SD. Adolescents whose height-for-age Z-score is below minus two (-2 SD) from the median of the reference population are considered short for their age (stunted). Underweight `is weight for age z-score < -2SD.

Summary measures

Effect measures were calculated for each study. Since, the data are dichotomous, effect size was calculated for prevalence and odds ratio (OR). The values of ratio measure, odds ratio underwent log transformations before being analyzed. The log transformed values made the scale symmetric to perform the analyses, and then converted the results back to ratio values for interpretation. Summary effect was different in the two models. In the fixed-effect analysis we assumed that the true effect size was the same in all studies, and the summary effect was our estimate of this common effect size. In the random-effects analysis we assume that the true effect size varies from one study to the next, and that the studies in our analysis represent a random sample of effect sizes that could have been observed. The summary effect is our estimate of the mean of these effects. The precision which encompassed three formal statistics, the variance, standard error, and confidence interval that addresses the accuracy of the summary effect as an estimate of the true effect were determined.

Synthesis of results

The extracted data were exported to STATA/SE V.14 for further analysis. The data were synthesized based on nutritional status (both over and under nutrition). The existence of heterogeneity among studies was examined by Forest plot, Cochran’s Q statistics (X² test) and the size of I². The I² values of 25%, 50% and 75% were interpreted as the presence of low, medium and high heterogeneity, respectively [40]. A pooled estimate of the prevalence was generated for the different form of malnutrition (overweight/obesity, stunting and thinness) separately among adolescents. Potential cause of heterogeneity was explored by meta-regression analysis, sensitivity analysis and subgroup analyses.

Results were presented in narratives, tables and forest plots. All statistical interpretation was reported based on p-value and 95% CI. The presence of a statistical association between independent and dependent variables was declared based on p-value of <0.05. Finally, the findings of the qualitative studies were combined, and an integrative approach of quantitative–qualitative meta-synthesis was carried out.

Risk of bias across studies

Publication bias was assessed using funnel plot subjectively and Egger’s test objectively (35, 36). Publication bias was adjusted by trim (remove unmatched observation) and fill (imputing values for missed studies) methods of analysis.

Ethics and dissemination

Ethical clearance was obtained from School of Public Health, College of Medicine and Health Sciences, Wollo University. Even if ethical clearance was not required for this review as primary data were not collected, Ethical clearance was given for corresponding author(s) via mail and other means of communication for articles with full texts that were hard to access. The copy of this systematic review and meta-analysis was given to Wollo University.

Results

Study selection

In the initial search, a total of 1289 records were found from different electronic search databases, search engine and other sources: Pub Med (38), Cochrane Library (56), HINARI (1090), Science Direct (85) and search engines; Google (5), Google Scholar (1), other sources; cross references (13) and expert contact (1). From these, 114 duplicate records were removed and 1112 records were excluded after screening by title and abstracts. We assessed the full texts of 63 remaining records for eligibility, and 30 records were further excluded by the exclusion criteria. Finally, 33 studies were considered for the final review and meta-analysis [1,4,41–71] (Fig 1). Of the 33 studies, 14 studies for overweight/obesity, 25 studies for stunting, and 25 studies for thinness were used to estimate the pooled prevalence of adolescent nutritional status (Fig 1).

Characteristics of the studies and systematic review

The studies included in this systematic review and meta-analysis were 30 descriptive cross-sectional studies, 2 comparative cross sectional studies and one case control study. A total of 25,172 adolescents were included in the analysis. The included studies reported sample size ranging from 174 [65] to 2733 [41]. All included studies were conducted among female participants [1,4,41–71], but for overweight/obesity 12 studies were conducted among both male and female [4,43,46,48,51,53–56,65,70], for thinness 13 studies were conducted among both male and female [1,4,42,45,46,48,49,53,54,56,68,70,71] and for stunting 12 studies were conducted among both male and female participants[1,42,45,48,49,54,56–58,67,68,71]. The pooled estimate of overweight/obesity was high among females, while thinness was high among male participants which were 13% and 28%, respectively (Table 2). Eighteen (54.5%) of the included studies were conducted in both urban and rural areas [1,4,41,44–49,52,56–58,62,65,67,71]. Among all included studies, two were conducted in Addis Ababa[43,54], one at the national level [41], one in Afar Region [59], 6 in Amhara Region [44,49,62,66,67,71], 11 in Oromia Region [45,48,51,56–58,60,63,65,69,70], 5 in SNNP [4,46,55,61,64], 2 in Somalia Region [42,50] and 5 in Tigray Region [1,47,52,53,68] (Table 3).

Table 2. Summary of extracted studies subgroup by sex in the analysis of prevalence and associated factors of adolescent’s malnutrition in Ethiopia.

S.No	Author	Publication year	Region	Female obese	Total Female	Male obese	Total male	stunted female	Total female	Stunted male	Total male	Female Thin	Total Female	Male Thin	Total male
1	Abate B, et al	2020	Ethiopia	NR	NR	NR	NR	380	2733	NR	NR	NR	NR	NR	NR
2	Abdulkadir A et al	206	Somalia	NR	NR	NR	NR	29	347	46	308	78	308	72	347
3	Alemu E, et al	2014	AA	12	211	63	589	NR	NR	NR	NR	NR	NR	NR	NR
4	Arage G. et al	2019	Amhara	NR	NR	NR	NR	59	362	NR	NR	105	362	NR	NR
5	Assefa et al	2015	Oromo	NR	NR	NR	NR	103	942	210	1014	839	941	738	1010
6	Berbada, D et al	2017	SNNP	31	324	36	276	NR	NR	NR	NR	52	324	66	276
7	Berhe, K.et al	2020	Tigray	NR	NR	NR	NR	133	398	NR	NR	128	398	NR	NR
8	Damie, T et al	2015	Oromo	11	106	1	185	11	106	10	185	11	106	60	185
9	Demilew, Y et al	2018	Amhara	NR	NR	NR	NR	33	219	68	188	3	165	26	242
10	Engidaw, M. et al	2019	Somalia	NR	NR	NR	NR	45	415	NR	NR	63	415	NR	NR
11	Gali, N.et al	2017	Oromo	53	303	15	207	NR	NR	NR	NR	NR	NR	NR	NR
12	Gebregyorgis, T.et al	2016	Tigray	NR	NR	NR	NR	99	814	NR	NR	174	814	NR	NR
13	Gebremariam, H et al	2015	Tigray	7	290	6	265	NR	NR	NR	NR	78	290	132	265
14	Gebreyohannes, Y et al	2014	AA	57	503	30	521	34	503	40	521	13	503	51	521
15	Geta, M et al	2017	SNNP	57	171	43	129	NR	NR	NR	NR	NR	NR	NR	NR
16	Hassen, K. Etal	2017	Oromo	28	312	11	238	50	312	36	238	34	312	30	238
17	Irenso, A.et al	2020	Oromo	NR	NR	NR	NR	224	982	317	1028	NR	NR	NR	NR
18	Jikamo, B. et al	2019	Oromo	NR	NR	NR	NR	330	985	214	973	NR	NR	NR	NR
19	Kahssay, M. et al	2020	Afar	NR	NR	NR	NR	78	340	NR	NR	30	310	NR	NR
20	Kt, Roba et al	2016	Oromo	28	700	NR	NR	109	700	NR	NR	149	700	NR	NR
21	melaku, Y. A.et al	2015	Tigray	NR	NR	NR	NR	58	154	41	194	41	194	50	154
22	Roba, A. C.et al	2015	SNNP	26	188	NR	NR	58	188	NR	NR	3	185	NR	NR
23	Tariku, A. et al	2019	Amhara	NR	NR	NR	NR	734	1150	NR	NR	NR	NR	NR	NR
24	Teferi, D. et al	2018	SNNP	31	315	3	340	34	655	NR	NR	7	315	25	340
25	Tegegne, M, etal	2016	Oromo	NR	NR	NR	NR	71	598	NR	NR	125	473	NR	NR
26	Teshome, T et al	2013	SNNP	55	274	16	280	NR	NR	NR	NR	NR	NR	NR	NR
27	Wakayo, T et al	2016	Oromo	16	99	2	75	NR	NR	NR	NR	NR	NR	NR	NR
28	Wassie, M et al	2015	Amhara	NR	NR	NR	NR	404	1281	NR	NR	170	1252	NR	NR
29	Woday, A et al	2018	Amhara	NR	NR	NR	NR	33	277	47	238	NR	NR	NR	NR
30	Yebyo H et al	2015	Tigray	NR	NR	NR	NR	45	208	60	203	70	208	111	203
31	Yemaneh, Y et al	2012	Oromo	NR	NR	NR	NR	130	642	NR	NR	95	642	NR	NR
32	Yetubie, M.et al	2010	Oromo	9	183	9	242	NR	NR	NR	NR	45	183	72	242
33	Zemene, M et al	2019	Amhara	NR	NR	NR	NR	32	167	17	160	11	167	5	160

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NR = Not Reported.

Table 3. Summary of extracted studies in the analysis of prevalence and associated factors of adolescent’s malnutrition in Ethiopia.

S.No.	Author	Publication Year	Region	Residence	Study Design	Sex	Age	Sample size	Response Rate	Overweight/Obesity	Stunting	Thinness	Quality Score
S.No.	Author	Publication Year	Region	Residence	Study Design	Sex	Age	Sample size	(%)	(%)	(%)	(%)	(%)
1	Abate B, et al	2020	Ethiopia	Both	CS	Female	15–19	2733	78	NR	15	NR	89
2	Abdulkadir A et al	2016	Somalia	Unclass.	CCS	Both	10–19	655	100	NR	11.45	22.90	88
3	Alemu E, et al	2014	AA	Urban	CS	Both	15–19	800	100	9.38	NR	NR	100
4	Arage G. et al	2019	Amhara	Both	CS	Female	10–19	362	100	NR	16.30	29.01	89
5	Assefa et al	2015	Oromo	Both	CS	Both	10–19	1956	93.8	NR	16.00	80.62	100
6	Berbada, D et al	2017	SNNP	Both	CS	Both	10–19	600	94.6	11.17	NR	19.67	100
7	Berhe, K.et al	2020	Tigray	Both	CS	Female	10–19	398	100	32.16	32.16	32.16	89
8	Damie, T et al	2015	Oromo	Both	CS	Both	10–19	291	91.2	4.12	5.84	24.40	100
9	Demilew, Y et al	2018	Amhara	Both	CS	Both	15–19	407	95.9	NR	24.82	7.13	100
10	Engidaw, M. et al	2019	Somalia	Unclass.	CS	Female	10–19	415	98.1	NR	10.84	15.18	100
11	Gali, N.et al	2017	Oromo	Unclass.	CS	Both	10–19	510	93.4	13.33	NR	NR	100
12	Gebregyorgis, T.et al	2016	Tigray	Both	CS	Female	10–19	814	98.9	NR	12.16	21.38	100
13	Gebremariam, H et al	2015	Tigray	Unclass.	CS	Both	10–19	555	97	2.34	NR	37.84	100
14	Gebreyohannes, Y et al	2014	AA	Unclass.	CCS	Both	13–19	1024	100	8.50	7.23	6.15	100
15	Geta, M et al	2017	SNNP	Unclass.	CC	Both	12–15	300	100	33.33	NR	NR	80
16	Hassen, K. Etal	2017	Oromo	Both	CS	Both	10–19	550	96	7.09	15.64	11.64	100
17	Irenso, A.et al	2020	Oromo	Both	CS	Both	10–19	2010	100	NR	2.69	NR	100
18	Jikamo, B. et al	2019	Oromo	Both	CS	Both	13–17	2084	100	NR	26.10	25.29	100
19	Kahssay, M. et al	2020	Afar	Unclass.	CS	Female	10–19	340	97.7	NR	22.94	8.82	100
20	Kt, Roba et al	2016	Oromo	Urban	CS	Female	13–19	700	97.2	3.00	15.57	21.29	89
21	melaku, Y. A.et al	2015	Tigray	Both	CS	Both	10–19	348	100	NR	28.45	26.15	100
22	Roba, A. C.et al	2015	SNNP	Unclass.	CS	Female	15–19	188	100	13.83	30.85	1.60	89
23	Tariku, A. et al	2019	Amhara	Both	CS	Female	10–19	1550	100	NR	47.35	NR	100
24	Teferi, D. et al	2018	SNNP	Both	CS	Both	10–19	655	95.2	5.19	5.19	4.89	100
25	Tegegne, M, etal	2016	Oromo	Both	CS	Female	10–19	598	96.9	NR	20.90	11.87	100
26	Teshome, T et al	2013	SNNP	Urban	CS	Both	10–19	554	93	15.52	NR	NR	100
27	Wakayo, T et al	2016	Oromo	Both	CS	Both	11–18	174	98	10.92	NR	18.97	100
28	Wassie, M et al	2015	Amhara	Rural	CS	Female	10–19	1281	97.2	NR	31.54	13.27	100
29	Woday, A et al	2018	Amhara	Both	CS	Both	10–19	515	96.26	NR	15.53	NR	100
30	Yebyo H et al	2015	Tigray	Unclass.	CS	Both	10–19	411	100	NR	26.28	44.04	100
31	Yemaneh, Y et al	2012	Oromo	Rural	CS	Female	10–19	642	94	NR	20.25	14.80	100
32	Yetubie, M.et al	2010	Oromo	Rural	CS	Both	10–19	425	100	4.24	NR	27.53	100
33	Zemene, M et al	2019	Amhara	Both	CS	Both	15–19	327	93.69	NR	14.98	4.89	100
TOTAL								25172

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CS = Cross-sectional

CCS = Comparative Cross-sectional

CC = Case Control

unclass. = unclassified

NR = Not Reported.

Quality appraisal was performed for 33 studies using JBI critical appraisal tool. The quality score ranged from 80–100% and all of them were included. Regarding the respective study design; quality score ranged from 89–100% for 30 descriptive cross-sectional studies, for two comparative cross-sectional studies quality score was 89 and 100%, while for case control studies a quality score of 80% was observed (S1 Table).

Prevalence of adolescent double burden of malnutrition

Thirteen studies were included to estimate the pooled prevalence of overweight/obesity [4,43,46,48,51,53,54,56,60,61,64,65,70]. Heterogeneity among the studies was used to estimate the pooled prevalence of adolescent overweight/ obesity was low (I² = 31.4%, P = 0.132). Using fixed-effects model (Mantel-Haenszel), the pooled prevalence of adolescent overweight/obesity was 10.6% (95% CI: 8.86, 12.40) (Fig 2). Twenty five studies were included in the analysis to estimate the pooled prevalence of adolescent stunting [1,4,41,42,44,45,47–50,52,54,56–63,66–69,71]. The heterogeneity among the 25 studies used to estimate the pooled prevalence of adolescent stunting was high (I² = 97.0%, P < 0.001). Using the random-effects model, the overall pooled prevalence of adolescent stunting was 20.1% (95% CI: 15.61, 24.51) (Fig 3).

Twenty-five studies were included to estimate the pooled prevalence of thinness [1,4,42,44–50,52–54,56,58–61,63,65,66,68–71]. Heterogeneity among the studies used to estimate the pooled prevalence of adolescent thinness was high (I² = 99.7%, P < 0.001). The pooled prevalence of adolescent thinness was 21.7% (95% CI: 9.56, 33.81) using random-effects model (Fig 4).

Subgroup analysis for prevalence of adolescent double burden of malnutrition

Since there was high heterogeneity on the pooled effect of studies conducted on stunting and thinness, subgroup analysis were performed to identify the possible source of heterogeneity. The pooled prevalence estimated for adolescent stunting was high in Amhara Region (25.2%, 95% CI: 13.24, 37.11) and Tigray Region (25.4%, 95% CI: 18.36, 32.40), and the least was in Somalia (11.2% (95%CI: 7.24, 15.07). Heterogeneity was high except in Somalia Region (88.8–99.1%). Subgroup analysis by gender showed that comparable pooled estimate of stunting were (19.9%, 95%CI: 14.81–25.66) and (20.2% 95% CI: 12.47–27.96) among males and females, respectively. Heterogeneity was high (92.9%) among both sexes. High heterogeneity was also observed in other subgroups; residence, age, study design and sample size (Table 4).

Table 4. Subgroup analysis of double burden of malnutrition among adolescent in Ethiopia.

Sub-group	Variables	Number of studies	Prevalence (95% CI)	Heterogeneity
Sub-group	Variables	Number of studies	Prevalence (95% CI)	I²%	P
Overweight/Obesity
Region	Adis Ababa	2	8.96(4.54–13.38)	0.0	0.846
	SNNP	4	12.88(10.18–15.59)	40.4	0.169
	Oromo	6	9.26(6.44–12.09)	24.9	0.248
	Overall	13	10.63(8.86,12.40)	31.4	0.132
Sex	Female	13	13.23(11.65–14.80)	67.2	<0.001
Sex	Male	11	8.06(5.57–10.54)	0.0	0.541
	Overall	13	11.75(10.42,13.08)	59.9	<0.001
Stunting
Region	Other	3	15.49(7.02–23.95)	88.8	<0.001
	Somalia	2	11.16(7.24–15.07)	0.0	0.879
	Amhara	6	25.18(13.24–37.11)	98.7	<0.001
	Oromo	8	19.02(15.02–23.02)	86.7	<0.001
	Tigray	4	25.38(18.36–32.40)	99.1	<0.001
	SNNP	2	18.33(-6.81–43.47)	95.0	<0.001
	Overall	25	20.69(15.11–26.28)	97.5	<0.001
Sex	Female	25	20.21(12.47–27.96)	99.1	<0.001
Sex	Male	12	19.90(14.81–25.66)	95.0	<0.001
	Overall	25	20.03(14.41,24.99)	98.8	<0.001
Age	15–19	7	19.59(13.87–25.30)	92.9	<0.001
Age	10–19	18	20.69(15.11–26.28)	97.5	<0.001
	Overall	25	20.06(15.61,24.51)	97.0	<0.001
Study design	DCS	23	21.29(16.84–25.73)	97.0	<0.001
Study design	CCS	2	9.86(5.56–14.17)	0.0	0.352
	Overall	25	20.06(15.61,24.51)	97.0	<0.001
Residence	Urban and rural	16	20.58(14.42–26.74)	97.4	<0.001
	Unclassified	6	18.66(11.56–25.76)	94.2	<0.001
	Urban	1	15.57(11.01–20.14)	-	-
	Rural	2	25.97(14.91–37.03)	95.2	<0.001
	Overall	25	20.06(15.61,24.51)	97.0	<0.001
Sample size	≥384	19	20.33(14.89–25.77)	97.4	<0.001
Sample size	<384	6	20.53(14.23–26.83)	93.5	<0.001
	Overall	25	20.06(15.61,24.51)	97.0	<0.001
Thinness
Region	Somalia	2	19.18(11.62–26.74)	85.0	0.010
	Amhara	4	13.99(1.69–26.31)	95.2	<0.001
	Oromo	9	27.15(2.30–52.00)	99.8	<0.001
	SNNP	3	9.93(-2.60–22.47)	84.6	0.002
	Tigray	5	32.40(24.63–40.16)	97.4	<0.001
	Other	2	7.74(2.88–12.61)	0.0	0.597
	Overall	25	21.68(9.56,33.81)	99.7	<0.001
Sex	Female	23	19.94(2.86–37.02)	99.8	<0.001
Sex	Male	13	27.93(15.33–40.52)	99.6	<0.001
	Overall	25	22.84(12.16,33.51)	99.7	<0.001
Age	15–19	6	12.19(4.29–20.09)	90.3	<0.001
Age	10–19	19	24.53(10.48–38.60)	99.8	<0.001
	Overall	25	21.68(9.56,33.81)	99.7	<0.001
Study design	CCS	2	14.88(-1.52–31.28)	93.4	<0.001
Study design	DCS	23	21.96(9.18–34.74)	99.7	<0.001
	Overall	25	21.68(9.56,33.81)	99.7	<0.001
Residence	Unclassified	7	20.31(25.94–31.28)	98.1	0.001
	Urban and rural	14	22.79(4.04–41.54)	99.8	<0.001
	Urban	1	21.29(17.52–25.06)	-	-
	Rural	3	18.68(8.87–28.49)	93.7	<0.001
	Overall	25	21.68(9.56,33.81)	99.7	<0.001
Sample size	≥384	18	23.27(8.35–38.19)	99.8	<0.001
Sample size	<384	7	18.09(12.25–23.94	91.0	<0.001
	Overall	25	21.68(9.56,33.81)	99.7	<0.001

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The pooled estimate of adolescent thinness was high in Tigray Region (32.4, 95%CI: 24.63, 40.16) and least in Addis Ababa and Afar (7.7, 95%CI: 2.88, 12.61). Heterogeneity was high except in Addis Ababa and Afar Region 84.6–99.8%. Another subgroup analysis showed that adolescent thinness was high in sample size of ≥384 (23.3%, 95%CI: 8.35, 38.19). Subgroup analysis by gender showed that pooled estimate of thinness was high among males (27.9% 95% CI: 15.33–40.52). Heterogeneity was high among other subgroups; sex, age, residence, study design and sample size which was 90.3–99.8% (Table 4).

Even if subgroup analysis was performed, source of heterogeneity was not detected. Therefore sensitivity analysis and meta-regression were considered to identify the source of heterogeneity.

Sensitivity analysis for prevalence of adolescent double burden of malnutrition

Sensitivity analyses were performed for effect sizes of all of the studies on stunting and thinness to identify the possible source of heterogeneity and to single out the effect of one study on the overall estimate. However none of studies were found to be neither showed a statistically significant source of heterogeneity nor a significant influence in all the analysis (Figs 5 and 6).

Meta-regression for prevalence of adolescent double burden of malnutrition

Meta regression was done for each variable to identify the possible source of heterogeneity in the pooled estimate of stunting and thinness. Univariate meta-regression analysis was done by taking publication year of the studies and the sample size to detect the potential source(s) of variation. Sample size for studies on thinness was significant (p = 0.031) indicating that sample size is the source of heterogeneity. Binary meta-regression was undertaken for other binary variables, but none of them were found to be statistically significant source of heterogeneity (Table 5).

Table 5. Meta-regression for factors related to heterogeneity of adolescent malnutrition in Ethiopia.

Stunting			Thinness
Variables	Coefficients	P	Variables	Coefficients	P
Publication year	0.6113396	0.522	Publication year	-1.149887	0.376
Sample size	0.0015933	0.609	Sample size	0.015184	0.031
Region			Region
Amhara	14.151	0.093	Amhara	-5.266813	0.703
Oromo	7.595355	0.341	Oromo	7.38093	0.553
Others*	4.162138	0.648	Others*	-11.55734	0.553
SNNP	7.908809	0.434	SNNP	0–9.764877	0.509
Tigray	14.0995	0.112	Tigray	13.28234	0.322
Somalia	Reference	1	Somalia	Reference	1
Residence			Residence
Rural	10.37073	0.416	Unclassified	1.517998	0.901
Unclassified	10.37073	0.790	Urban	2.717691	0.894
Both	5.110404	0.633	Both	4.400977	0.696
Urban	Reference	1	Rural	Reference	1
Age			Age
10–19	1.350945	0.764	10–19	13.16494	0.094
15–19	Reference	1	15–19	Reference	1
Sex			Sex
Both	-5.592236	0.159	Both	7.205115	0.295
Female	Reference	1	Female	Reference	1
Study Design			Study Design
Comparative cross sectional	-11.96162	0.107	Comparative cross sectional	-7.49505	0.549
Descriptive cross sectional	Reference	1	Descriptive cross sectional	Reference	1
Sample size			Sample size
≥384	6.653005	0.380	<384	-8.788739	0.224
<384	Reference	1	≥384	Reference	1

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Publication bias for prevalence of adolescent double burden of malnutrition

Possible publication bias was subjectively examined using funnel plot and objectively determined using Egger’s test at 5% significant level. The funnel plots were asymmetrical and Eggers’ regression test (p<0.001) were significant. Both funnel plot and Eggers’ test results showed that there is a significant publication bias (Figs 7–9). Therefore, the final effect size was determined by applying Trim and Fill analysis. However, there was no change in effect size (Figs10–12).

Factors associated with double burden of adolescent malnutrition

Eight factors were identified for overweight/obesity that could be used in the quantitative meta-analysis. Weights were calculated using the random-effects analysis since heterogeneity was observed among all factors. Statistical association were not observed among adolescent age, residence, wealth index, meal frequency and family size <5. Female adolescents had almost 2 times higher odds of being overweight/ obese compared males (OR: 2.02, CI: 1.22–3.34). Adolescents who had low DDS were 2 times more likely to be overweight/obese (OR: 2.26 CI: 1.28–3.99).Adolescents with high physical activity had 64% lower odds of being overweight/obese (OR: 0.36, 95%CI: 0.14–0.88) (Fig 13).

For stunting, six associated factors were used in the quantitative analysis. Although heterogeneity was not observed in family size and residence, it was observed among adolescent age, sex, meal frequency and protected drinking water source. Weights were calculated using the random-effects analysis. Adolescent age, sex, and meal frequency were not statistically significant factors for stunting. Urban adolescences had 18% lower odds of being stunted (OR: 0.82, 95%CI: 0.68–0.99). Adolescents having protected water source for drinking had 50% lower likelihood of stunting (OR: 0.50, CI: 0.27–0.90). Households with family size of < 5 were 46% less likely to be stunted than those with family size of ≥5 (OR: 0.54, CI: 0.44–0.66) (Fig 14).

Heterogeneity was observed in all the seven factors associated with thinness included in the analysis. Thus, weights were calculated using the random-effects analysis. Sex, residence, meal frequency and DDS were not statistically significant. Early adolescents (age 10-14years) were 2 times more likely to be thin than late adolescent (OR: 2.38, CI: 1.70–3.34). Adolescents with protected water source were 64% less likely to be thin than those adolescents had unprotected water source (OR: 0.36, CI: 0.21–0.61). Likewise, households with a family size of <5 were 50% less likely to be thin than those who had family size of ≥5 (OR: 0.50, CI: 0.28–0.89). Adolescents in the households with lower wealth index were almost 2 times more likely to be thin than those in high wealth index (OR: 1.80, CI: 1.01–3.19) (Fig 15).

Subgroup analysis of factors associated with double burden of adolescent malnutrition

Among factors associated with nutritional status (overweight/obesity, stunting and thinness) high heterogeneity was observed in pooled effect of most factors. Subgroup analysis was conducted to explore the possible source of heterogeneity on the overall odds ratio of each factors associated with nutritional status among adolescent by considering potentially important factors. The heterogeneity still persisted in the subgroups of factors associated with respective nutritional status (Table 6). Then, further sensitivity analysis and meta-regression analysis were performed to identify source of heterogeneity.

Table 6. Subgroup analysis of factors associated with adolescent malnutrition in Ethiopia.

Sub-group		Variables	Number of studies	OR (95% CI)	Heterogeneity
Sub-group		Variables	Number of studies	OR (95% CI)	I²%	P
Overweight/Obesity
Sex		Overall	12	2.02(1.22–3.34)	82.6	<0.001
	Region	Adis Ababa	2	1.04(0.26, 4.22)	92.0	<0.001
		SNNP	4	2.22(0.78, 6.32)	91.3	<0.001
		Oromo	5	2.82(1.51, 5.27)	50.2	0.091
		Tigray	1	1.07(0.35, 3.22)	-	-
	Study design	Cross-sectional	9	2.29(1.09, 4.80)	85.4	<0.001
		Other	2	1.45(0.70, 2.99)	78.6	<0.001
		Overall	11	1.98(1.15, 3,42)	83.1	<0.001
	Sample size	> = 384	8	1.72(0.92, 3.21)	84.6	<0.001
	Sample size	<384	3	4.46(0.61, 32.35)	85.5	0.001
Physical activity		Overall	5	0.36(0.14–0.88)	93.3	<0.001
	Region	AA	2	0.83(0.28, 2.48)	90.9	0.001
		Oromo	1	0.11(0.06, 0.19)	-	-
		SNNP	2	027(0.14, 0.54)	63.7	0.097
	Study design	Cross-sectional	3	0.22(0.09, 0.52)	87.6	<0.001
	Study design	Other	2	0.75(0.20, 2.78)	92.2	<0.001
	Sample size	> = 384	4	0.35(0.11, 1.10)	95.0	<0.001
		<384	1	0.38(0.22, 0.68)	-	-
		Overall	5	0.36(0.14, 0.88)	93.3	<0.001
Stunting
Residence		Overall	11	0.82(0.68–0.99)	61.2	0.004
	Region	Other	3	0.79(0.52, 1.18)	63.2	0.066
		Amhara	4	0.82(0.52, 1.27)	70.9	0.016
		Oromo	4	0.83(0.60, 1.15)	66.8	0.029
	Study Design	Cross-sectional	10	0.82(0.68, 0.99)	61.2	0.004
		Overall	10	0.82(0.68, 0.99)	61.2	0.004
	Sample size	> = 384	8	0.82(0.68, 0.99)	60.4	0.014
		<384	4	0.80(0.36, 1.81)	75.4	0.017
		Overall	12	0.82(0.68, 0.99)	61.2	0.004
Safe water		Overall	6	0.50(0.27–0.90)	85.3	<0.001
	Region	Others	4	0.55(0.24,1.27)	86.9	<0.001
		Tigray	3	0.39(0.24,0.90)	26.4	0.244
	Study design	Descriptive Cross-sectional	5	0.57(0.31, 1.05)	81.3	<0.001
	Study design	Comparative Cross-sectional	1	0.27(0.16, 0.46)	-	-
		Overall	6	0.49(0.27, 0.90)	85.3	<0.001
	Sample size	≥384	5	0.49(0.24, 1.00)	88.1	<0.001
	Sample size	<384	1	0.53(0.27, 1.03)	-
		Overall	6	0.50(0.27, 0.90)	85.3	<0.001
Thinness
Age		Overall	11	2.38(1.70–3.34)	75.4	<0.001
	Region	Amhara	2	4.22(3.02,5.89)	0.0	0.0.836
		Tigray	3	1.74(1.11,2.72)	66.3	0.051
		Oromo	3	2.63(1.41,4.87)	75.9	0.016
		Somalia	2	1.76(0.99,3.14)	-	-
		Overall	10	2.38(1.70,3.34)	75.4	<0.001
	Study design	Cross-sectional	10	2.38(1.70, 3.34)	75.4	<0.001
		Overall	10	2.38(1.70, 3.34)	75.4	<0.001
	Sample size	> = 384	7	2.42(1.66, 3.53)	78.4	<0.001
		<384	2	2.36(0.76, 7.32)	70.8	0.064
		Overall	9	2.38(1.69, 3.34)	75.4	<0.001
Wealth (low)		Overall	4	1.80(1.01–3.19)	85.9	<0.001
	Region	Other	2	3.05(2.18, 4.25)	3.7	0.308
	Region	Tigray	2	1.17(0.89, 1.53)	0.0	0.368
	Study design	Cross-sectional	4	1.80(1.01, 3.19)	85.9	<0.001
		Overall	4	1.80(1.01, 3.19)	85.9	<0.001
	Sample size	> = 384	4	1.80(1.01, 3.19)	85.9	<0.001
	Sample size	Overall	4	1.80(1.01, 3.19)	85.9	<0.001
Family size		Overall	4	0.50(0.28–0.89)	79.6	0.002
	Region	Tigray	3	0.59(0.31, 1.11)	83.2	0.003
	Region	Amhara	1	0.23(0.09, 0.57)	-	-
	Study design	Cross-sectional	4	0.50(0.28, 0.89)	79.6	0.002
	Study design	Overall	4	0.50(0.28, 0.89)	79.6	0.002
	Sample size	> = 384	2	0.49(0.23, 1.07)	85.9	0.008
		<384	2	0.47(0.13, 1.78)	84.0	0.012
		Overall		0.50(0.28, 0.89)	79.6	0.002

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Sensitivity analysis of factors associated with double burden of adolescent malnutrition

Sensitivity analysis was performed for included factors to identify source of heterogeneity on overall odds ratio of factors associated with nutritional status (overweight, stunting and thinness). But there was no study that showed a significant influence in all the analysis (Figs 16–18).

Meta-regression of factors associated with double burden of malnutrition

Due to the presence of high heterogeneity on pooled odds ratio of factors associated with respective nutritional status, (overweight / obesity, stunting and thinness) of adolescent, meta-regression was conducted to identify the possible cause of heterogeneity in factors associated with nutritional status (overweight/obesity, stunting and thinness). But none of the included variables showed a statistically significant source of heterogeneity in all the analysis (Table 7).

Table 7. Meta-regression to identify heterogeneity among factors associated with adolescent malnutrition in Ethiopia.

Variables	Coefficients	P
Overweight/obesity
Publication year	0.0159467	0.871
Sample size	0.0004868	0.547
Age(10–14)	-0.6196052	0.819
DDs(low)	0.6712044	0.843
Family size (<5)	0.0391229	0.989
Physical activity(high)	-0.9172185	0.735
Sex(female)	3.131227	0.197
Wealth(low)	-0.8022954	0.767
Residence(urban)	Reference	1
Stunting
Publication year	0.0139177	0.827
Sample size	-0.0000627	0.711
Age(10–14)	1.010321	0.042
Family size (<5)	-0.0254711	0.964
Residence (urban)	0.2860214	0.567
Sex (female)	0.6528639	0.194
Protected water	Reference	1
Thinness
Publication year	-0.0331687	0.561
Sample size	0.0002983	0.294
Age(10–14)	1.095686	0.050
Residence(urban)	0.3036364	0.783
Protected water	-0.1338743	0.918
Sex(female)	1.155758	0.274
Wealth(low)	1.498451	0.250
Family size(<5)	Reference	1

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Publication bias for factors associated with double burden of adolescent malnutrition

Potential publication bias among factors associated with nutritional status was examined subjectively (Funnel plot) and objectively (Eggers’ test) which showed symmetrical funnel plot and non-significant Egger’s test result. Therefore no publication bias was detected among factors associated with nutritional status (overweight/obesity, stunting and thinness) (Figs 19–21).

Discussion

Malnutrition affects adolescent’s sexual maturation and growth, increases the risk of poor obstetric outcomes, affects ability to learn and work with maximum productivity, prevents the attainment of normal bone and teeth strength, increase the risk of chronic disease resonating through generations [25]. Overweight/obesity is an emerging nutritional problem in developing countries, which increases the burden of nutrition-linked non-communicable diseases and has far-reaching consequences on economic growth of countries over time [25,72]. Contrary to previous concerns that mainly focused on the difficulty of undernutrition, over nutrition is currently becoming and emerging nutrition related public health problem. The problem is a double whammy debilitating low income communities in different parts of Africa most importantly in Ethiopia [73]. This systematic review and meta-analysis was conducted to estimate the pooled prevalence and associated factors of adolescent nutritional status in Ethiopia.

The result of this meta-analysis showed that the combined overall prevalence of overweight/obesity was 10.63% (95% CI: 8.86, 12.40%) among adolescents in the country which was higher than overweight/obesity estimated in EDHS; 2005, 2011 and 2016 which was 3, 2.8 and 4%, respectively [74–76]. Although it was cross-sectional study, it serves as a baseline for the country level policies and recommendations. The result was also higher than the study conducted among African school learner adolescent(7%) [77]. The possible reason for this discrepancy might be due to difference in nutritional pattern and physical activities and socio-cultural reasons indicating the increase in overweight/obesity over time. The prevalence of overweight/obesity in this study was less than the finding reported among adolescents in Asia(15%) [78]. The prevalence of overweight/obesity was also lower than the study conducted in America (30%), Europe (22%–25%) and Italy(17.9%), Oceania, Australia(23.2%) and New Zealand (34.2%) [79]. This discrepancy could be due to variation in socioeconomic status, the life style consuming energy dense diet and sedentary lifestyles.

Factors associated with overweight/obesity among adolescents were reviewed and meta-analyzed. Females had higher odds of developing overweight/obesity compared to males. Gender differences were not observed in a study conducted in African school learner adolescent [77]. This study is in line with studies conducted in four of twenty five countries in the world [79]. But, it is contrary to studies conducted on seventeen of twenty five countries in the world [79]. This may be explained by biological differences in energy need and body composition between males and females in relation to rate of growth and timing of sexual maturation [25]. Males are also more physically active than females. In developing countries including Ethiopia, girls usually stay at home due to cultural influence not to move from place to place than boys which results in physical inactivity and ultimately lead to overweight and obesity.

Adolescents with low DDS had two times higher odds of being overweight / obese compared to those with higher DDS. Low DDS reflects monotonous dietary intake which can result in overweight/obesity. The reason could be that adolescents have a greater preference to sweet food products which are calorie rich and leading to a positive energy balance. Adolescents with high physical activity had 64% lower odds of being overweight/obese. Physical activities are important for burning fat tissues and increase muscular tissue [77].

The pooled prevalence of adolescent stunting was 20.06% (95% CI: 15.61–24.51). The prevalence of stunting in this study was within the range of the prevalence reported from Latin America and Caribbean countries (6.5–42.7%) [80]. The stunting prevalence of this study was higher than the result reported from studies conducted in 57 low and middle-income countries (10.2%) [81]. The difference could be due to variation in sampling and study period, cultural and dietary practices, access and utilization of health services.

In this analysis, adolescents in the urban areas had 18% lower odds of stunting. This may due to the inequalities in socio-economic status, access to medical services and health information in urban and rural settings. Adolescents from household with protected water source for drinking had 50% lower odds of stunting. Protected source of drinking water is a mechanism to prevent intestinal parasites and other communicable diseases which causes poor nutritional status. Unprotected water source results in repeated infections, depressed immunity increasing the severity and duration of diseases. This finding was similar with study conducted in sub-Sahara African countries [82]. Adolescents in the households with family size of < 5 were 46% less likely to be stunted than those living in the households with family size of ≥5. This might be due to the fact that small family size is usually found in educated parents who are more likely to be aware of dietary diversity and have good dietary consumption practice [48]. There is also enough food among the small household members for adequate consumption.

In this study, the pooled prevalence of adolescent thinness was 21.68% (95% CI: 9.56–33.81).This finding was consistent with EDHS 2005 (32.5%) and 2016 (29%) (78, 80). This result was in line with the finding of review on seven African countries(12.6–31.9%) [83] and Latin America and Caribbean countries (3.1–21.6%) [80]. However, prevalence of thinness was higher compared to studies conducted in 57 low and middle-income countries (5.5%) [81]. The possible explanation for this difference could be due variations in socioeconomic status, study period and access to and utilization of health care services.

The effect size of factors associated with adolescent thinness was also estimated. Adolescent in the households with protected water source had 64% less odds of being thin than those who had unprotected water source. This can be explained by the fact that protecting source of drinking water is a mechanism for preventing intestinal parasites and other communicable diseases which causes poor nutritional status. Unprotected water source could lead to higher frequencies of infections, depressed immunity and making the severity and duration of diseases [41].

Thinness was identified in early adolescents (10-14years) was 2 times higher than late adolescents. There is faster growth and development in the early age of adolescents (10–14 years) as compared to late adolescents (15–19years) [25].When the requirement nutrient for achieving their maximum need for growth and development is not fulfilled, adolescents would be affected by thinness. Adolescent thinness with lower wealth index family income was almost 2 times higher than high wealth index. It might be due to inability to afford food items for consumption and inadequate dietary intake which can result in thinness.

The study has practical implications. Despite methodological differences, nutritional patterns and the availability of recreational facilities, the findings of this analyses clearly indicates that nutrition transition (overweight/ obesity) is becoming a public health problem with the existing undernutrition creating a double burden. This affects educational status, productivity, health status of the community and economic growth of the country at large. Although, there is heterogeneity among the regions, malnutrition in adolescents has taken the status of double burden, which calls for programs and policies to consider this in addressing the nutritional status of this segment of population. For researchers there is a need for surveillance of the problem to track the trend and risk factors for nutritional status among adolescents in Ethiopia.

This study did a comprehensive review of studies which assessed nutritional status (overweight/obesity, stunting and thinness) and the effect of gender on nutritional status of adolescents. The use of multiple reputable databases, reproducible and pretested extraction formats and inclusion of studies from different regions of the country can are some of the strengths of the study. However, we acknowledge limitations inclosing use of mostly cross-sectional studies could affect the temporal relationship between the assessed determinant factors and outcome variables. Most of the studies were institution/school based may not represent spume pout of school adolescents although they are few as over 90% adolescents are in school. The numbers of studies for estimation of the effect size of associated factors were small which could affect the generalization of the findings. Study participants were not proportional in sex (female participants were higher in number).The study was restricted to articles only published in English language. Heterogeneity was high, despite the use of random effects models to accommodate this variability. Even if trim and fill analysis was done, the funnel plots reported high publication bias. Therefore, findings of this review and meta-analysis should be interpreted with caution in the context of the inherent limitations of both the original studies and the present review and meta-analysis.

Conclusion

Adolescent nutritional status remains one of the most important public health problems in Ethiopia. The pooled estimate of overweight/obesity showed high increase, with the existing high burden of stunting and thinness. Female sex, DDS and physical activity were factors significantly associated with adolescent overweight/obesity. Urban residence, family size < 5 family and protected drinking water source were predictors of adolescent stunting. Being early adolescent (10–14 years), wealth index, protected water source and family size < 5 members were significantly associated with adolescent thinness.

The results imply the need for giving more emphasis on design and implementation of preventive policies to reduce stunting and thinness and the high prevalence of overweight/obesity among adolescent in Ethiopia. It is imperative to design interventions that address the emerging dual burden of malnutrition through providing comprehensive and routine nutritional assessment and counseling services at health facility, school and community levels.

Supporting information

S1 Checklist. PRISMA 2009 checklist.

(DOC)

Click here for additional data file.^{(61.5KB, doc)}

S1 Table. JBI critical appraisal checklist for studies included in systematic review and meta-analysis of adolescent nutritional status in Ethiopia.

(DOCX)

Click here for additional data file.^{(33.2KB, docx)}

S1 File

(DOC)

Click here for additional data file.^{(55.5KB, doc)}

Acknowledgments

We would like to extend our gratitude to the authors of the primary papers, study participants and the data collectors.

Abbreviations

BMI: Body Mass Index
CI: Confidence Interval
DDS: Dietary Diversity Score
JBI: Joanna Briggs Institution
MeSH: Medical Subject Headings
OR: Odds Ratio
PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analysis
SDG: Sustainable Development Goal
SE: Standard Error
WHO: World Health Organization

Data Availability

All relevant data are within the paper.

Funding Statement

The author(s) received no specific funding for this work.

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PONE-D-21-00351Double burden of malnutrition and Associated Factors among Adolescent in Ethiopia: A Systematic Review and Meta AnalysisPLOS ONE

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Reviewer #1: - There were not the tables 1 to 4 in the file and I couldn’t see the list of studies and their score of critical appraisals.

- One of the most important of restrictions of this study is that it was restricted to only ‘English language’ which can lead to language bias and unreal estimation. It is recommended to include all published studies of Ethiopia adolescents regardless of the language of the articles

- Other weakness of study is that it included all studies without time restriction, while the malnutrition is a time depended issue and in order to get a true picture of the current state of society, it is better to apply a time restriction or do a cumulative meta-analysis to observe the changes in the index over time.

- It is recommended to use the random-effects model even if the heterogeneity is low, so it is recommended to use the random model for overweight/ obesity in this study as well.

- Have studies whose reports are not based on Z- Score been deleted?

Reviewer #2: Dear Editor,

Thank you, for giving me the opportunity to review this manuscript, which sets out to assess the prevalence and the associated factors of the double burden of malnutrition in Ethiopia, using meta-analysis and systematic review approach. The paper is interesting and largely well presented. However, there are shortfalls that need to be addressed before it can be publishable. Please, find details of my review below:

Abstract:

• Indicate the direction of effects of the independent variables on the dependent variable. Or better still, present the results in the context of ORs.

Introduction:

• The referencing throughout this section needs to be reworked on. All substantial claims should be referenced. E.g., reference is needed in the first part of the second paragraph etc. etc.

• What is the research question(s) the study addresses? SR/MA usually starts by identifying research questions to be addressed

Methods:

• There are so many sub-headings in this section and some of the text overlaps. A critical review of the entire section may be required

• The “data collection process” could be changed to “data extraction process”

• Including the initials of researchers who undertake various assignments is unnecessary…this should be captured under the ‘authors contribution’ section.

• “Operational definition” could be changed to “outcome variables”

• The sub-heading “summary measures” appears misleading as the text that follows does not reflect the heading. Consider revising.

• “Since the data are dichotomous, effect size was calculated for prevalence” What does this mean. Is it suggesting that the only reason for computing the effect size is the dichotomous nature of the data? Clarify.

• No ethical approval was obtained before the conduct of the study, therefore indicating that ethical clearance was given by School of Public Health is misleading. The school granting you access to full articles does not constitute ethics approval. Consider revising the statement.

Results

• The study selection processes may be suitable in the method section than the results section. Consider incorporating part of the text in the method section

• This section is unnecessarily long and difficult to follow. This is probably because of the authors attempt to present all results. I will suggest they present only the striking findings

• Similarly, the authors attempt to explain how the analysis was done to obtain the results has also made the section difficult to read. This should be done in the method section. The results section is meant for the presentation of the findings obtained in the study

• The presentation of the results should be as concise as possible

• The several sub-sections contained in the results section is unnecessary. As I indicated earlier, not all results need to be presented. Consider revising

Discussion

• The presentation of the discussion section is a bit disjointed, thereby making it difficult read. A lot more work is needed to make it flow coherently. The section needs a complete overhaul

• The first paragraph needs to be revised. This paragraph should summarise the main findings but not the literature as has been done

• Restating the results (e.g., CI, ORs etc) is unnecessary. This style has made the section to look more like the results section…take out all CIORs etc and minimise the use of statistics in this section

• Also avoid causal words such as “affecting”

• Further, avoid comparing the prevalence obtained in your study to others in the literature. There are no bases for doing that. Discuss your findings and relate the same to the existing literature

Tables:

• The tables are too many. Not all of them are necessary. The authors should include only those they consider critical

• The Y-axis of tables 13-15 are a bit messy. If the authors want to include the same, they should consider enhancing their readability.

Verdict: The manuscript has the potential to be a good piece of work. However, a lot more effort is needed to bring it to that state. The authors should therefore revise the manuscript critically, and ensure that unnecessarily details etc etc. are minimised. There are also a lot of grammatically issues that need the attention of the authors.

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Reviewer #1: Yes: Maryam Zamanian

Reviewer #2: Yes: Dr Dickson A Amugsi

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PLoS One. 2023 Apr 12;18(4):e0282240. doi: 10.1371/journal.pone.0282240.r002

Author response to Decision Letter 0

23 Feb 2022

1. We have correctly cited all the tables and figures. Each figure caption appear directly after the paragraph in which they are first cited

2. Language restriction is due to interpretation purpose and almost all studies in Ethiopia published in English language. So language bias is less likely.

3. The protocol of this study was assuming that malnutrition is time dependent and plan to do cumulative meta-analysis, but all the studies done in Ethiopia were recent and we conceder no change among those studies over time.

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PLoS One. doi: 10.1371/journal.pone.0282240.r003

Decision Letter 1

Solveig A Cunningham

7 Nov 2022

PONE-D-21-00351R1Double burden of malnutrition and associated factors among adolescent in Ethiopia: A systematic review and meta-analysisPLOS ONE

Dear Dr. Gezaw,

Please be sure to address the important recommendations provided by the two expert reviewers. Reviewer 3 especially has provided detailed guidance that will improve the quality and the impact of the manuscript. As reviewer 4 notes, please also carefully review the grammar and orthography of the manuscript.

Please submit your revised manuscript by Dec 22 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Solveig A. Cunningham, Ph.D.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear authors,

Thank you for the re-submission of your paper after having addressed reviewer comments. The paper has been additionally reviewed by two expert reviewers who have provided excellent and detailed recommendations for further improving the quality and impact of the paper. Please address the comments from the two reviewers.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Partly

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: I Don't Know

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: (No Response)

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Reviewer #3: Thank you for the opportunity to review this manuscript on the important topic of adolescent nutrition in Ethiopia. The authors conducted a systematic review and meta-analysis to estimate the pooled prevalence of 3 forms of malnutrition (overweight/obesity, stunting, thinness) and the association between select factors and each of these forms of malnutrition. The topic of the paper is of high interest to the journal’s readership. Congratulations to the authors for completing this work. It’s clear that the authors were thoughtful in their approach and took steps to conduct a high-quality review and meta-analysis – for example, by searching both the peer-reviewed literature and gray literature, assessing publication bias using funnel plots and Egger’s regression test, and conducting sensitivity analyses.

To help strengthen the manuscript, I’m sharing comments and suggested revision for the authors to consider.

Abstract

1. The authors state: “Although there were many individual studies in Ethiopia, their results are inconclusive…” It would be helpful for the authors to specify what the studies are about – e.g., “studies in Ethiopia about [specify here – e.g., nutritional status among adolescents]” in order to improve clarity.

2. The authors write, “The prevalence of overweight/obesity, stunting and thinness are higher in Ethiopian adolescents…” The authors could consider instead writing that the prevalence was “high,” since the authors do not compare the prevalence of these forms of malnutrition in Ethiopian adolescents to the prevalence in another population.

Introduction

3. It would strengthen the paper for the authors to define the double burden of malnutrition, given the many definitions in the literature. It would also be useful for the authors to explicitly state the level at which they are assessing the double burden of malnutrition, since the double burden can occur at the country, household, or individual levels.

4. Suggest re-wording the last sentence in the first paragraph for clarity. I believe the authors are referring to the idea that a continuum of care from childhood through adolescence is needed.

Methods

5. In the information sources and search strategy section, the authors state that “the reference lists of the retrieved studies were probed to collect articles that were not accessible through databases and search engines.” Were they accessible but just not picked up by the search strategy?

6. In the study selection section, the authors seem to describe how level of agreement was assessed for the title and abstract screening. I suggest they also describe how agreement was achieved for the full-text review.

7. In the study selection section, I suggest the authors describe how disagreements were resolved – e.g., through discussion.

8. In the data collection process, the authors mention that a “pilot test was conducted for all forms of using a representative sample of the studies to be reviewed…” What does it mean for the sample to be representative?

9. In the data collection process, the authors write that the study quality score was extracted from the full texts. Suggest deleting “study quality score” in the list of info that was extracted from the studies, since a study quality score cannot be extracted from the studies. It’s clear later on in the discussion section that the study quality scores were included in the extraction sheet.

10. I suggest the authors revise the quality appraisal and risk of bias section for clarity – e.g., the authors write that “the source of discrepancy was investigated through making a thorough revision.” Did the authors mean that disagreements were resolved through discussion?

Results

11. The first sentence states that there were a total of 1289 records, while the figure indicates that there were a total of 1269 records. Is this a typo?

12. Suggest Table 3 includes “(n)” at the top of the columns that report n’s.

13. The authors may want to consider moving some of the tables and/or figures to the supplementary materials section.

14. Figures 16, 17, and 18 are difficult to read. They may need to be re-formatted.

Discussion Conclusion

15. It would be helpful for the authors to discuss the quality of the studies in the discussion section.

16. Is the prevalence of overweight and obesity among Ethiopian adolescents increasingly rapidly? If so, what do the authors think about generating a pooled prevalence estimate based on studies conducted between 2010 – 2020?

17. The authors could consider moving the first paragraph of the discussion section to the introduction, as it describes the problem of malnutrition.

18. The authors compare their findings to results from other LMICs and high-income countries. The authors could consider also describing how the results compare to those from other countries in the region.

19. The authors write “The pooled estimates of overweight/obesity showed high increase” and then later refer to the “rising prevalence of overweight/obesity.” Since trends were not evaluated in this study, I suggest not using words that indicate an increasing trend in order to ensure that the findings support the conclusions.

20. The authors argue that surveillance of nutritional status is needed. Specifically, what would the authors recommend for improved surveillance? Some specific examples of recommendations could strengthen the manuscript.

Overall

21. I suggest proofreading the entire manuscript as there are some typos and sentences that could be revised for clarity.

22. References for some of the statements made, particularly in the introduction and discussion sections, are needed.

For example:

• “According to WHO, interest and focus on adolescent health and nutrition is relatively recent.”

• “They can also increase in weight as much as half of their adult body weight.”

• “Males are also more physically active than females.”

• “In developing countries including Ethiopia, girls usually stay at home due to cultural influence not to move from place to place than boys which results in physical inactivity and ultimately lead to overweight and obesity.”

• “Protected source of drinking water is a mechanism to prevent intestinal parasites and other communicable diseases which causes poor nutritional status.”

• “Unprotected water source results in repeated infections, depressed immunity increasing the severity and duration of diseases.”

23. The authors may want to reference some of the latest articles on the double burden of malnutrition published in the 2019 Lancet series on the double burden of malnutrition: https://www.thelancet.com/series/double-burden-malnutrition#:~:text=The%20double%20burden%20of%20malnutrition%20is%20the%20coexistence%20of%20overnutrition,community%2C%20household%2C%20and%20individual.

24. Since micronutrient deficiencies and associated morbidity and mortality are a persisting challenge in Ethiopia, it may strengthen the paper for the authors to discuss micronutrient deficiencies (even if briefly) in the paper (e.g., in the discussion section, the authors could consider noting that there are other indicators of nutritional status that are important to measure and address).

Reviewer #4: Dear Editor

My apologies for the delay in submitting my recommendation for this paper. Also, I wish to thank you for providing me this opportunity to review this paper which aims to evaluate the important issue of double burden of malnutrition in a developing nation like Ethiopia. Please find below my suggestions:

Introduction

In second paragraph, authors can give statistical figures suggesting how nutrition transition is increasing overnutrition in Ethiopia alongwith existing issue of undernutrition.

Spelling and grammatical recheck needs to be done e.g. in last paragraph 'this study aimed at determining the pooled prevalence malnutruition and associated factors among Ethiopian adolescents'.

Methods

Exclusion/Inclusion criteria should include the year of studies that were selected for the present manuscript.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

Reviewer #4: No

**********

PLoS One. 2023 Apr 12;18(4):e0282240. doi: 10.1371/journal.pone.0282240.r004

Author response to Decision Letter 1

24 Dec 2022

We have addressed all comments given by the editors in abstract introduction, methods, result, discussion and conclusion part point by point.

Attachment

Submitted filename: Response to reviewers.docx

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PLoS One. doi: 10.1371/journal.pone.0282240.r005

Decision Letter 2

Solveig A Cunningham

13 Feb 2023

Double burden of malnutrition and associated factors among adolescent in Ethiopia: A systematic review and meta-analysis

PONE-D-21-00351R2

Dear Dr. Gezaw,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

This manuscript has improved much across the revisions.

A final important component that I encourage you to add before final publication is to consider the time component. You are pooling data from across a couple of decades, over which the prevalence of unhealthy weight is likely to have changed. It would be very important to provide some information on whether/how unhealthy weight has changed over time. Indeed, in the abstract you use the word "increase" but it's not clear over what period an increase has occurred. Please add an analysis of time trends.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Solveig A. Cunningham, Ph.D.

Academic Editor

PLOS ONE

PLoS One. doi: 10.1371/journal.pone.0282240.r006

Acceptance letter

Solveig A Cunningham

17 Feb 2023

PONE-D-21-00351R2

Double burden of malnutrition and associated factors among adolescent in Ethiopia: A systematic review and meta-analysis

Dear Dr. Gezaw:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. PLOS Manuscript Reassignment

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PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. PRISMA 2009 checklist.

(DOC)

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S1 Table. JBI critical appraisal checklist for studies included in systematic review and meta-analysis of adolescent nutritional status in Ethiopia.

(DOCX)

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S1 File

(DOC)

Click here for additional data file.^{(55.5KB, doc)}

Attachment

Submitted filename: comments.docx

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Attachment

Submitted filename: response to reviewers.docx

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Attachment

Submitted filename: Response to reviewers.docx

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Data Availability Statement

All relevant data are within the paper.

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PERMALINK

Double burden of malnutrition and associated factors among adolescent in Ethiopia: A systematic review and meta-analysis

Aragaw Gezaw

Wolde Melese

Bekalu Getachew

Tefera Belachew

Roles

Abstract

Background

Method and materials

Results

Conclusion

Introduction

Materials and methods

Eligibility criteria

Inclusion criteria

Exclusion criteria

Information sources and search strategy

Table 1. Search strategies of adolescent malnutrition and associated factors in Ethiopia.

Study selection

Data collection process

Quality appraisal and risk of bias in individual studies

Operational definition

Summary measures

Synthesis of results

Risk of bias across studies

Ethics and dissemination

Results

Study selection

Fig 1. PRISMA 2009 flow diagram of study selection of adolescent double burden of malnutrition in Ethiopia.

Characteristics of the studies and systematic review

Table 2. Summary of extracted studies subgroup by sex in the analysis of prevalence and associated factors of adolescent’s malnutrition in Ethiopia.

Table 3. Summary of extracted studies in the analysis of prevalence and associated factors of adolescent’s malnutrition in Ethiopia.

Prevalence of adolescent double burden of malnutrition

Fig 2. Forest plot of the pooled prevalence of adolescent overweight/obesity in Ethiopia.

Fig 3. Forest plot of the pooled prevalence of adolescent stunting in Ethiopia.

Fig 4. Forest plot of the pooled prevalence of adolescent thinness in Ethiopia.

Subgroup analysis for prevalence of adolescent double burden of malnutrition

Table 4. Subgroup analysis of double burden of malnutrition among adolescent in Ethiopia.

Sensitivity analysis for prevalence of adolescent double burden of malnutrition

Fig 5. Sensitivity analysis of stunting among adolescents in Ethiopia.

Fig 6. Sensitivity analysis of thinness among adolescents in Ethiopia.

Meta-regression for prevalence of adolescent double burden of malnutrition

Table 5. Meta-regression for factors related to heterogeneity of adolescent malnutrition in Ethiopia.

Publication bias for prevalence of adolescent double burden of malnutrition

Fig 7. Funnel plot and Eggers’ test to assess publication bias for adolescent overweight/obesity in Ethiopia.

Fig 9. Funnel plot and Eggers’ test to assess publication bias for adolescent thinness in Ethiopia.

Fig 10. Trim and fill analysis for overweight/obesity among adolescent in Ethiopia.

Fig 12. Trim and fill analysis for thinness among adolescent in Ethiopia.

Fig 8. Funnel plot and Eggers’ test to assess publication bias for adolescent stunting in Ethiopia.

Fig 11. Trim and fill analysis for stunting among adolescent in Ethiopia.

Factors associated with double burden of adolescent malnutrition

Fig 13. Pooled Odds Ratios of factors associated with overweight/obesity among adolescent in Ethiopia.

Fig 14. Pooled Odds Ratio of factors associated with stunting among adolescent in Ethiopia.

Fig 15. Pooled Odds Ratio of factors associated with thinness among adolescent in Ethiopia.

Subgroup analysis of factors associated with double burden of adolescent malnutrition

Table 6. Subgroup analysis of factors associated with adolescent malnutrition in Ethiopia.

Sensitivity analysis of factors associated with double burden of adolescent malnutrition

Fig 16. Sensitivity analysis of factors associated with overweight/obesity in Ethiopia.

Fig 18. Sensitivity analysis of factors associated with thinness in Ethiopia.

Fig 17. Sensitivity analysis of factors associated with stunting in Ethiopia.

Meta-regression of factors associated with double burden of malnutrition

Table 7. Meta-regression to identify heterogeneity among factors associated with adolescent malnutrition in Ethiopia.

Publication bias for factors associated with double burden of adolescent malnutrition

Fig 19. Funnel plot and Eggers’ test to assess publication bias for factor associated with adolescent overweight/obesity in Ethiopia.

Fig 21. Funnel plot and Eggers’ test to assess publication bias for factor associated with adolescent thinness in Ethiopia.

Fig 20. Funnel plot and Eggers’ test to assess publication bias for factor associated with adolescent stunting in Ethiopia.

Discussion

Conclusion

Supporting information

Acknowledgments

Abbreviations

Data Availability

Funding Statement

References

Decision Letter 0

Avanti Dey

Roles

Transfer Alert

Author response to Decision Letter 0