Stunting and thinness among adolescents residing in Jazan City, Saudi Arabia: a school-based cross-sectional study using WHO AnthroPlus

Abstract

BACKGROUND:

Adolescence is a critical period of growth and development during which nutritional deficiencies may adversely affect health outcomes throughout adulthood.

OBJECTIVES:

To determine the prevalence of stunting and thinness among adolescents in Jazan city, Saudi Arabia, using the WHO AnthroPlus growth reference, and to identify associated sociodemographic factors.

DESIGN:

School-based cross-sectional study

SETTING:

Governmental intermediate schools in Jazan city, Saudi Arabia, between January and May 2023

PATIENTS AND METHODS:

A total of 324 adolescents aged 13–16 years were enrolled using a multistage cluster sampling technique. Sociodemographic data were collected using a data collection form. Anthropometric measurements, including height and weight, were obtained according to standardized World Health Organization (WHO) protocols. Height-for-age z-scores (HAZ) and body mass index-for-age z-scores (BMIZ) were calculated using WHO AnthroPlus software. Binary logistic regression analyses were performed to identify factors associated with stunting and thinness.

MAIN OUTCOME MEASURES:

Prevalence of stunting (HAZ <−2 standard deviations, SD), severe stunting (HAZ <−3 SD), and thinness (BMIZ <−2 SD), and their associations with sociodemographic characteristics.

SAMPLE SIZE:

A total of 324 adolescents were included in the final analysis.

RESULTS:

The mean HAZ for the study population was −0.74±1.08. Stunting (HAZ <−2 SD) was identified in 40 adolescents (12.3%; 95% CI: 9.0%–16.0%), including 6 adolescents with severe stunting (1.9%; 95% CI: 0.6%–3.4%). The mean BMIZ was 0.69±1.30, and thinness (BMIZ <−2 SD) was observed in 14 adolescents (4.3%; 95% CI: 2.2%–6.5%). Increasing age was independently associated with higher odds of stunting (AOR 1.61, 95% CI 1.12–2.30; P=.010).

CONCLUSIONS:

Stunting remains a significant public health concern among adolescents in Jazan city despite the relatively low prevalence of thinness. Increasing age was independently associated with higher odds of stunting.

LIMITATIONS:

The cross-sectional design precludes causal inference. The study included only governmental schools from Jazan city, which may limit generalizability.

INTRODUCTION

Adolescence is a critical period of rapid physical growth, when nutrition and health strongly influence adult height, body composition, and future disease risk.¹ Stunting (low height-for-age) reflects long-term nutritional and health deprivation, while thinness (low body mass index, (BMI)-for-age) indicates more acute undernutrition.²

Stunting is defined as height-for-age z-scores (HAZ) more than two standard deviations (SD) below World Health Organization (WHO) standards and is a key marker of chronic malnutrition, social inequality, and impaired development.³ Thinness is usually assessed using body mass index-for-age z-scores (BMIZ) and reflects insufficient recent energy intake.^4,5 Studies from Middle East and North Africa (MENA) and South Asia show substantial stunting and thinness among adolescents, with rural residence and lower socioeconomic status as important correlates.^6-8

The WHO 2007 Growth Reference and AnthroPlus software provide standardized age- and sex-specific BMI-for-age and height-for-age z-scores for 5–19-year-olds.^9,10 Using adult BMI cutoffs in adolescents can markedly overestimate thinness and obscure true patterns of stunting and overweight.¹¹ Studies from India, Pakistan, Brazil, and Saudi Arabia have successfully applied AnthroPlus to describe adolescent nutritional profiles and to reveal coexistence of undernutrition with overweight and obesity.^12-15

Although thinness is relatively uncommon in Saudi Arabia, the prevalence of overweight and obesity has risen substantially in recent years.¹⁶ Meanwhile, stunting and micronutrient deficiencies remain present in certain regions, highlighting the complex nutritional challenges facing children and adolescents in the country.^16-18 Evidence from Saudi adolescents is concentrated in Riyadh, Hail, Aseer, and selected girls' cohorts, with little data specific to Jazan.^19-21 Given the unique sociodemographic and geographic characteristics of Jazan, region-specific data are needed to better understand the nutritional challenges facing adolescents. Therefore, this study aimed to assess the nutritional status of adolescents in the Jazan city using the WHO AnthroPlus growth reference by determining the prevalence of stunting and thinness and examining their associations with age, sex, and selected sociodemographic characteristics.

METHODS

Study design and setting

A school-based cross-sectional study was conducted among adolescents attending governmental intermediate schools in Jazan City, Saudi Arabia, between January and May 2023. Jazan City is the administrative capital of the Jazan Region, located in the southwestern part of the Kingdom of Saudi Arabia. The study was approved by the Standing Committee for Scientific Research, Jazan University, Saudi Arabia (HAPO-10-Z-001), under approval No. REC-44/02/299, on September 15, 2022. The study was approved by the Standing Committee for Scientific Research, Jazan University, Saudi Arabia (HAPO-10-Z-001), under approval No. REC-44/02/299, on September 15, 2022.

Study population, sample size, and sampling procedure

The study population consisted of male and female adolescents aged 13–16 years who were enrolled in governmental intermediate schools in Jazan City, Saudi Arabia. The minimum required sample size was calculated using the single-population proportion formula:

$$\mathrm{n}={\mathrm{Z}}^2\mathrm{P}(1-\mathrm{P})/{\mathrm{d}}^2$$

where n is the required sample size, Z is the standard normal deviate corresponding to the desired confidence level, P is the estimated prevalence of the outcome of interest, and d is the margin of error. In the absence of recent local estimates, a prevalence (P) of 30% was adopted from studies conducted in comparable adolescent populations in the region.^22,23 At a 95% confidence level (Z=1.96), and a margin of error (d) of 5%, the minimum required sample size was estimated to be 323 participants. In total, 324 adolescents provided complete questionnaire and anthropometric data and were therefore included in the final analysis.

A multistage cluster sampling technique was employed. Initially, a list of all governmental intermediate schools was obtained from the Jazan Education Directorate. Schools were grouped according to educational sectors, and two schools were randomly selected from each sector using a simple random sampling method. Subsequently, three classes were randomly selected from each participating school. Within selected classes, students were recruited using systematic random sampling until the required sample size was achieved.

Eligible participants were adolescents aged 13–16 years enrolled in the selected schools whose parents or guardians provided written informed consent. Students who declined participation, were outside the eligible age range, had acute illness at the time of data collection, or had physical conditions that could interfere with accurate anthropometric measurements were excluded.

Data collection

Data collection was carried out after obtaining ethical approval from Jazan University, followed by administrative approval from the Jazan Education Directorate and the participating schools. School visits were arranged in coordination with school principals, and all data were collected by trained research personnel using standardized protocols.

Sociodemographic data were obtained using a data collection form. The collected information included the adolescent's age, sex, grade level, place of residence, parental education, parental occupation, and monthly household income in Saudi Arabian Riyals (SAR). Parental educational attainment was categorized as higher versus below secondary education, while parental occupation was classified as employed or unemployed.

Anthropometric measurements

Measurements were obtained using standardized procedures in accordance with WHO recommendations. Height (cm) was measured without shoes using a portable stadiometer, with participants standing upright, heels together, and the head positioned in the Frankfurt plane. Measurements were recorded to the nearest 0.5 cm. Body weight (kg) was measured using a calibrated digital scale, with participants wearing light clothing and no shoes, and was recorded to the nearest 0.1 kg. Anthropometric indices were generated using WHO AnthroPlus software version 1.0.4 based on the WHO Growth Reference 2007 for children and adolescents aged 5–19 years. HAZ and BMIZ were calculated for all participants. Participants' age, sex, weight, and height were entered into the WHO AnthroPlus software. The software automatically calculated age- and sex-specific height-for-age Z-scores (HAZ) and BMI-for-age Z-scores (BMIZ) according to the WHO 2007 growth reference. Nutritional status was classified as follows:

$$\begin{array}{l}\text{Stunting: HAZ}<-2\text{ standard deviations (SD)}\\ \text{Severe stunting: HAZ}<-3\text{ SD}\\ \text{Thinness: BMIZ}<-2\text{ SD}\end{array}$$

Statistical analysis

Data was analyzed using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA). The distribution of continuous variables was assessed using the Shapiro–Wilk test, histograms, and Q–Q plots. Normally distributed variables were presented as mean ± standard deviation (SD), while non-normally distributed variables were summarized as median and interquartile range (IQR). Categorical variables were described using frequencies and percentages.

The prevalence of stunting, severe stunting, and thinness were calculated with 95% confidence intervals (CIs). Continuous variables were compared between groups using the independent-samples t-test for normally distributed data and the Mann–Whitney U test for non-normally distributed data. Associations between categorical variables were assessed using the chi-square test or Fisher's exact test, as appropriate. Factors associated with stunting and thinness were first examined using univariable logistic regression analysis. Prior to multivariable logistic regression, multicollinearity among the candidate predictors included in the final model was assessed using variance inflation factors (VIFs) and tolerance statistics. No evidence of problematic multicollinearity was identified (VIFs 1.006–1.014; tolerance values 0.986–0.994). Variables with a P value <.20 were then entered into multivariable logistic regression models. The results were presented as odds ratios (ORs) and adjusted odds ratios (AORs) with 95% confidence intervals. A two-sided P value <.05 was considered statistically significant.

RESULTS

Sociodemographic characteristics

As shown in Table 1, a total of 324 adolescents aged 13–16 years were included in the study. Males accounted for 73.5% (n=238) of participants, while females represented 26.5% (n=86). The most common age was 13 years (45.7%, n=148), followed by 14 years (29.3%, n=95), 15 years (20.7%, n=67), and 16 years (4.3%, n=14). Most participants were Saudi nationals (72.5%, n=235). Most fathers (99.7%, n=323) and mothers (97.5%, n=316) were aged 40 years or older. Most mothers (71.0%, n=230) and fathers (78.7%, n=255) had attained at least secondary-level education. Regarding occupation, 83.3% (n=270) of fathers were employed, whereas 39.5% (n=128) of mothers were employed. Regarding family income, 52.2% (n=169) of participants had a monthly family income below 5000 SAR, 18.8% (n=61) had an income of 5000–10 000 SAR, and 29.0% (n=94) had an income above 10 000 SAR.

Table 1.

Sociodemographic characteristics of the study participants (n=324).

Characteristic		n (%)
Sex	Male	238 (73.5)
	Female	86 (26.5)
Age (years)	13	148 (45.7)
	14	95 (29.3)
	15	67 (20.7)
	16	14 (4.3)
Nationality	Saudi	235 (72.5)
	Non-Saudi	89 (27.5)
Father's age (year)	<40	1 (0.3)
	≥40	323 (99.7)
Mother's age (year)	<40	8 (2.5)
	≥40	316 (97.5)
Mother's education	≥Secondary level	230 (71.0)
	<Secondary level	94 (29.0)
Father's education	≥Secondary level	255 (78.7)
	<Secondary level	69 (21.3)
Father's occupation	Working	270 (83.3)
	Not working	54 (16.7)
Mother's occupation	Working	128 (39.5)
	Not working	196 (60.5)
Family income (Saudi Riyal/month)	<5000	169 (52.2)
	5000–10 000	61 (18.8)
	>10 000	94 (29.0)

Prevalence of stunting and thinness among adolescents

The mean HAZ for the study population was −0.74 ± 1.08. Stunting (HAZ<−2 SD) was identified in 40 adolescents (12.3%; 95% CI: 9.0%–16.0%), including 6 adolescents with severe stunting (1.9%; 95% CI: 0.6%–3.4%). The mean BMIZ was 0.69±1.30, and thinness (BMIZ <−2 SD) was observed in 14 adolescents (4.3%; 95% CI: 2.2%–6.5%) as shown in Table 2.

Table 2.

Nutritional status of adolescents aged 13–16 years according to sex-based on WHO AnthroPlus Growth Reference.

Variable	Total (n=324)	Males (n=238)	Females (n=86)	P value
Mean HAZ±SD	-0.74±1.08	-0.8±1.1	-0.5±1.0	.030
Stunting (HAZ <–2 SD), n (%)	40 (12.3% CI: 9.0%–16.0%)	32 (13.4)	8 (9.4)	.338
Severe stunting (HAZ <–3 SD), n (%)	6 (1.9% CI: 0.6%–3.4%)	6 (2.5)	0 (0.0)	.140
Mean BMIZ±SD	0.7±1.3	0.7±1.3	0.6±1.4	.752
Thinness (BMIZ <–2 SD), n (%)	14 (4.3% CI: 2.2%–6.5%)	11 (4.6)	3 (3.5)	.676

BMIZ, body mass index-for-age z-score; HAZ, height-for-age z-score; SD, standard deviation. Nutritional indicators were derived using WHO AnthroPlus according to the WHO 2007 Growth Reference for children and adolescents aged 5–19 years.

As illustrated in Figure 1, the distribution of HAZ values was shifted to the left of the WHO 2007 Growth Reference, indicating lower height-for-age values among the study participants. In contrast, Figure 2 demonstrates a slight rightward shift in the BMIZ distribution relative to the WHO reference.

Figure 1.

Distribution of height-for-age z-scores (HAZ) among adolescents in Jazan City, Saudi Arabia, compared with the WHO 2007 Growth Reference.

Figure 2.

Distribution of BMI-for-Age z-scores (BMIZ) among Adolescents in Jazan City, Saudi Arabia, Compared with the WHO 2007 Growth Reference. The figure was generated automatically using WHO AnthroPlus software (version 1.0.4). The software-generated graph displays 323 participants, whereas all statistical analyses in this study were conducted using the complete dataset of 324 participants.

Male adolescents had significantly lower mean HAZ values than females (−0.83±1.09 vs. −0.52±1.04, P=.030). However, the prevalence of stunting did not differ significantly between males and females (13.4% vs. 9.4%, P=.338). Similarly, severe stunting was observed only among males (2.5%), although this difference did not reach statistical significance (P=.140). No significant sex differences were observed in mean BMIZ (0.71±1.26 vs. 0.63±1.41, P=.752) or in the prevalence of thinness (4.6% vs. 3.5%, P=.676).

Factors associated with stunting

In univariable logistic regression analysis, increasing age was significantly associated with stunting (OR=1.56, 95% CI: 1.10–2.21, P=.013). This association remained significant after adjustment for maternal occupation and monthly household income (AOR=1.61, 95% CI: 1.12–2.30, P=.010).

Household income was independently associated with stunting. Compared with adolescents from households with a monthly family income exceeding 10 000 SAR, those from households earning <5000 SAR (AOR=0.28, 95% CI: 0.13–0.60) and 5000–10 000 SAR (AOR=0.25, 95% CI: 0.08–0.77) had significantly lower odds of stunting.

Maternal employment demonstrated a borderline association with stunting in the adjusted model (AOR=0.52, 95% CI: 0.26–1.05, P=.067). No significant associations were observed between stunting and sex, nationality, parental age, parental educational level, paternal occupation, or maternal occupation (P>.05) as shown in Table 3.

Table 3.

Univariate and multivariate binary analysis of the factors associated with stunting among participants.

Variables	Adolescents with stunting (number=40)	Adolescents without stunting (number=284)	Univariate binary analysis			Multivariate binary analysis
			OR	95% CI	P	AOR	95% CI	P
Age, years (median, interquartile range)	14.0 (13.0–16.0)	14.0 (13.0–16.0)	1.56	1.10–2.21	.013	1.61	1.12–2.30	.010
Sex (%)
Male	32 (80.0)	206 (72.5)	0.66	0.29–1.50	.444
Female	8 (20.0)	78 (27.5)	Reference
Nationality (%)
Saudi	27 (67.5)	208 (73.2)	1.32	0.65–2.69	.446
Non-Saudi	13 (32.5)	76 (26.8)	Reference
Mother's age (years) (%)
<40	2 (5.0)	6 (2.1%)	0.41	0.08–2.11	.271
≥40	38 (95.5)	278 (97.9)	Reference
Father's age (years) (%)
<40	0	1 (0.4)	NE	-	-
≥40	40 (100)	283 (99.6)	Reference
Mother's education (%)
≥Secondary level	27 (67.5)	203 (71.5)	1.21	0.59–2.45	.604
<Secondary level	13 (32.5)	81 (28.5)	Reference
Father's education (%)
≥Secondary level	32 (80.0)	223 (78.5)	0.91	0.40–2.09	.831
<Secondary level	8 (20.0)	61 (21.5)	Reference
Mother's occupation (%)
Working	20 (50.0)	108 (38.0)	0.61	0.32–1.19	.147	0.52	0.26–1.05	.067
Non-working	20 (50.0)	176 (62.0)	Reference
Father's occupation (%)
Working	34 (85.0)	236 (83.1)	0.87	0.35–2.18	.763
Non-working	6 (15.0)	48 (16.9)	Reference
Monthly income (SAR/month)
<5000	15 (37.5)	154 (54.2)	0.24	0.08–0.75	.014	0.28	0.13–0.60	.016
5000–10 000	4 (10.0)	57 (20.1)	0.34	0.17–0.70	.003	0.25	0.08–0.77	.001
>10 000	21 (52.5)	73 (25.7)	Reference

AOR, adjusted odds ratio; CI, confidence interval; NE, not estimable; OR, odds ratio; SAR, Saudi Arabian Riyal. Values are presented as n (%). Variables with P<.20 in univariate analysis were included in the multivariable logistic regression model. Reference categories are indicated. Statistical significance was set at P<.05.

Factors associated with thinness

As shown in Table 4, only 14 (4.3%) were classified as thin and 310 (95.7%) had normal BMI-for-age. Univariate logistic regression analysis showed no significant associations between thinness and age, sex, nationality, parental age, parental educational level, parental occupation, or household income (P>.05). Maternal educational level (OR=0.18, 95% CI: 0.02–1.39, P=.065) and maternal employment (OR=0.35, 95% CI: 0.11–1.06, P=.053) demonstrated borderline associations with thinness but did not reach statistical significance.

Table 4.

Univariate binary analysis of the factors associated with thinness among participants.

Variables	Adolescents with thinness (number=14)	Adolescents without thinness (number=310)	Univariate binary analysis
			OR	95% CI	P
Age, years (median, interquartile range)	13.0 (13.0–16.0)	14.0 (13.0–16.0)	0.76	0.40–1.46	.414
Sex (%)
Male	11 (78.6)	227 (73.2)	0.75	0.20–2.74
Female	3 (21.4)	83 (26.8)	Reference
Nationality (%)
Saudi	10 (71.4)	225 (72.6)	1.06	0.32–3.47	.658
Non-Saudi	4 (28.6)	85 (27.4)	Reference
Mother's age (years) (%)
<40	0	8 (2.6)	NE	-	-
≥40	14 (100)	302 (97.4)	Reference
Father's age (years) (%)
<40	0	1 (0.4)	NE	-	-
≥40	14 (100)	309 (99.7)	Reference
Mother's education (%)
≥Secondary level	13 (92.9)	217 (70.0)	0.18	0.02–1.39	.065
<Secondary level	1 (7.1)	93 (30.0)	Reference
Father's education (%)
≥Secondary level	11 (78.6)	244 (78.7)	1.01	0.27–3.72	.990
<Secondary level	3 (21.4)	66 (21.3)	Reference
Mother's occupation (%)
Working	9 (64.3)	119 (38.4)	0.35	0.11–1.06	.053
Non-working	5 (35.7)	191 (61.6)	Reference
Father's occupation (%)
Working	12 (85.7)	258 (83.2)	0.83	0.18–3.81	.807
Non-working	2 (14.3)	52 (16.8)	Reference
Monthly income (SAR/month)
<5000	5 (35.7)	164 (52.9)	0.42	0.09–2.10	.291
5000–10 000	2 (14.3)	59 (19.0)	0.38	0.12–1.23	.106
>10 000	7 (50.0)	87 (28.1)	Reference

CI, confidence interval; NE, not estimable; OR, odds ratio; SAR, Saudi Arabian Riyal. Values are presented as median (interquartile range) or n (%). Odds ratios were estimated using univariate binary logistic regression with the indicated reference categories. Statistical significance was set at P<.05.

DISCUSSION

This study assessed the prevalence of impaired linear growth (stunting) and thinness among adolescents in Jazan City using the WHO AnthroPlus growth reference. Approximately one in eight adolescents was classified as stunted, whereas thinness affected a relatively small proportion of participants.

The prevalence of stunting (12.3%) indicates that impaired linear growth remains relatively common among adolescents in Jazan City. Although HAZ is widely used as a population-level indicator of chronic undernutrition, linear growth is influenced by multiple factors, including genetics, early-life health, pubertal development, chronic disease, socioeconomic conditions, and environmental exposures.²⁴ Therefore, the observed prevalence should not be interpreted as evidence of nutritional deficiency alone. The prevalence observed in the present study is comparable to that reported in previous Saudi studies, indicating that stunting remains clinically important since stunting reflects cumulative nutritional deprivation and adverse health exposures during childhood.^16,21 Previous studies from the Middle East and South Asia have reported considerable variability in adolescent stunting rates, reflecting differences in socioeconomic conditions, dietary practices, healthcare access, and growth assessment methods.^7,8 The prevalence observed in our study suggests that despite the substantial socioeconomic development achieved in Saudi Arabia, pockets of chronic undernutrition persist in some regions.

In contrast, the prevalence of thinness was relatively low (4.3%), indicating that acute undernutrition is less common than chronic growth restriction among adolescents in Jazan city. Similar findings have been reported in countries undergoing nutritional transition, where improvements in food availability reduce thinness while longstanding determinants of linear growth deficits continue to affect vulnerable populations.^25,26

The coexistence of a relatively higher prevalence of stunting (12.3%) and a much lower prevalence of thinness (4.3%) suggests that impaired linear growth may not primarily reflect current nutritional deprivation during adolescence. Instead, this pattern may represent the cumulative effects of growth restriction originating earlier in life, nutritional transition, socioeconomic influences, constitutional or genetic factors, or other biological determinants of stature. Because dietary intake, micronutrient status, pubertal maturation, and other important determinants were not evaluated, the underlying causes of impaired linear growth cannot be established from the present study.

Male adolescents had significantly lower mean HAZ than females; however, the prevalence of stunting did not differ significantly between sexes. This finding may reflect differences in pubertal timing and growth velocity, as female adolescents generally experience earlier pubertal growth spurts than males.²⁷ Nevertheless, sex was not independently associated with stunting, suggesting that biological differences alone do not explain the observed variation in nutritional status.

Older adolescents in our sample had higher odds of being classified as stunted than younger participants. However, because this was a cross-sectional study, the observed association should not be interpreted as evidence that stunting progresses with age. Height-for-age Z-scores are age-standardized, and the association may reflect differences between age groups related to early-life growth trajectories, pubertal timing, socioeconomic factors, or other unmeasured determinants rather than a true age-related decline in linear growth. Furthermore, pubertal maturation, an important determinant of adolescent height, was not assessed. In addition, the oldest age group represented only a small proportion of the study population, which may have reduced the precision of the estimated association between age and stunting. Similar associations between age and stunting have been reported in adolescent populations from other developing regions, where growth deficits accumulated during childhood persist into later adolescence.^23,28

In the present study, adolescents from households with monthly incomes below 10 000 SAR had significantly lower adjusted odds of stunting than those from households earning more than 10 000 SAR. This finding contrasts with the established evidence that lower socioeconomic status is generally associated with an increased risk of impaired linear growth due to reduced access to adequate nutrition, healthcare, and other essential resources.^29,30 This unexpected finding should be interpreted with caution, as it may reflect residual confounding, the small number of stunting cases in some income categories, or limitations of household income as a sole indicator of socioeconomic status. Further longitudinal studies are warranted to confirm this association.

No significant associations were found between stunting and parental education, parental occupation, nationality, or parental age. Although these factors have been linked to child nutritional status in previous studies,^7,16,31 they may not have shown a significant effect in the present study because most parents had relatively similar educational and socioeconomic backgrounds, resulting in limited variation within the study population.

These findings have practical implications for adolescent health in the Jazan city as schools can play an important role by regularly monitoring students' growth and helping identify those at risk of stunting at an early stage. Using age- and sex-specific growth charts as part of routine school health programs could support timely detection and early intervention. In addition, providing greater support to adolescents from lower-income families may help reduce inequalities in growth and improve overall nutritional outcomes.

This study has several limitations. First, because of its cross-sectional design, causal relationships between sociodemographic factors and nutritional outcomes cannot be established. Second, the study included only adolescents attending governmental intermediate schools in Jazan city, which may limit the generalizability of the findings to private-school students and adolescents living in rural areas. Third, the unequal sex distribution, resulting from lower participation among female students in one of the selected girls' schools, may have reduced the statistical power for sex-specific analyses. Finally, although several sociodemographic variables were considered, important determinants of adolescent growth including pubertal maturation, parental height, birth history, dietary intake, physical activity, sleep duration, chronic medical conditions, endocrine disorders, and micronutrient deficiencies were not assessed. Consequently, residual confounding cannot be excluded and should be considered when interpreting the study findings.

CONCLUSION

Impaired linear growth, reflected by stunting, remained relatively common among adolescents in Jazan city and was more common than thinness. These findings highlight the potential value of school-based growth monitoring and nutritional surveillance for the early identification of adolescents at risk of impaired linear growth. However, given the cross-sectional design and restriction to governmental intermediate schools in Jazan city, the findings should be interpreted with caution and cannot establish causality or be generalized to all adolescent populations. Furthermore, because stunting reflects the cumulative influence of nutritional, biological, socioeconomic, and environmental factors, it should not be interpreted as evidence of nutritional deficiency alone. Further longitudinal studies incorporating dietary, clinical, developmental, and socioeconomic assessments are needed to better define the determinants of impaired linear growth in this population.

Funding Statement

None.

AUTHORS CONTRIBUTION

Ebtihal Eltyeb: conceptualization, methodology, investigation, Data analysis; writing original draft. Ali Al-Makramani: conceptualization, writing, review and editing. All authors have read and approved the final manuscript.