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THE EFFECT OF SOCIO - ECONOM IC CONDITIONS ON GROW TH , DEVELOPMENT A N D OBESITY A M O N G

ADOLESCENTS IN TURKEY

Ass. Prof. Bike AKSU KOCAOĞLU*/Prof. Dr. Orhan KÖKSAL** Tlıis study is designed to assess various factors

suclı as socio - econom ic status, cultural level, jnutri- tional stiatus, age and sex on developm ent of obe- sity during adolescence. Tw o groups o f adolescent children betvveen the ages o f 11 and 15 with d if- ferent socio-econom is and cultural background were studied. The first group is from a private junior high sclıool in Ankara where children of high so­ cio - econom ic status attend. T he second group is from a public junior high school of a semi urban area, 40 kilometres from Ankara. The descriptive analysis o f subjects from these two differen t socio - econom ic backgrounds revealed m a jör differences between the education and incom e levels o f fam ilies o f subjects studied. The evaluation o f height m ea- surements fo r age have shown 10 cins differen ce on the average between two socio - econom ic groups at ali ages. The assessment o f lobesity, rnade by using weight fo r height tables was m ade. 15.9 % of children from high socio - econ om ic group and 22,5 % o f children from low gocio - econom ic group were classified as overweight and obese respecti- vely.

Children of high socîo - econom ic status were found to be m ore active physically than children from Jow socio - econom ic group. Availability of well progtrammed sports activities w ith adequate facilities enabled these children to get involved in sports and exercise. Food consum ption patterns of these two groups were ^ssessed by frequency use o f foods techniques. Children from high socio - econom ic group were found to be consum ing a more varied diet rich in anim al proteins and fats. W h e- reas, the typical diet o f children fro m low socio - econom ic group consisted m ainly o f cereals, sugars and vegetables w ith insignificant am ounts o f <dairy Products. The num,ber of meals consum ed ateo

sig-* Boğaziçi University.

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26 Kocaoğlu, Aksu B., Köksal, O. n ifica n tly differen t. Children from high socio - eco-

nom ic group had proper 3 meals with more than one snack daily. T he results of this study have cle- arly dem onstrated the effects of socio - econom ic and cultural status on the developm ent of obesity during adolescence. Type of diet, inadequate physi- cal activity are strongly influenced by socio - e co ­ n om ic status. Short stature attained especially am ong girls of Iow socio - econom ic group raises the question w hether children show ing a tendency tovvards obesity during adolescence, may become obese w om en after frequent pregnancies should also be studied.

INTRODUCTION

Ö ver the past two decades, obesity is b ecom in g an im portant public health prob lem in Turkey. A cco rd in g to «Nationvvide Health and N utrition Su rvey» ca rried ou t in 1974, the p revalen ce o f obesity was fo u n d to be 26.8 % a m on g vvomen an d 7.6 %

a m on g m en ö v e r 20 yea rs o f age (1). M ore recen t bu t sm aller studies also sh ow sim ilar rates fo r w o m e n o f rural areas. G ü ­ neyli (2) reported a v ery h igh p rev a len ce o f 58.4 % fo r adult rural w om en livin g in villages a rou n d A n kara. H ow ever, the rate o f obesity was fo u n d to b e m u ch less fo r ed u ca ted y ou n g er vvomen vvho w ork as p rofession als in u rb a n areas (3) ■

These studies h ave relied u p o n h eig h t a n d vveight relati- onships in assessing the p rev a len ce o f obesity. The criteria accepted fo r obesity and overvveight are 25 % a n d m ore a n d 15 % - 25 % o f the desired Standard w eigh t fo r h eigh t respectively.

This h ig h p rev a len ce ob serv ed a m o n g adu lt vvomen raised the n e e d to id en tify som e o f the a etiolog ica l fa cto rs re g a rd in g the causes a n d the tim e o f on set o f obesity to su ggest m ean s by vvhich p rev en tion m a y be p ra ctice d at com m u n ity level.

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two critical periods in adipose tissue developm ent; the flrst occu rs prior to ıthe age o f 2 years, and the secon d is associated with puberty. Salans and Cushm an (4) have su ggested that the adipose celi n u m ber in adult obese hum ans is related to the age o f onset o f obesity. A dults w h o b ecom e obese in childh ood tend to have h igh er celi num bers than those w ho becom e obese as adults.

D ifficulties involved in studying the very y o u n g children led us to concentrate on adolescents regard in g the time o f onset o f obesity. A lthou gh the effects o f the fin a l grow th spurt on developm ent o f obesiıty is not very clearly known, two form s o f obesity du rin g adolescence has been described. First, the fat child w ho com es into adolescence and becom es increasingly obese, and the second, the adolescent w h o becom es obese.

This study is designed to assess various factors su ch as socio - econ om ic status, culture level, nutritional status, age and sex on developm ent o f obesity d u rin g

adolescence-METHOD AN D MATERIALS

The study w hich is presented in the follow in g was carried out in two ju n ior h igh schools fro m tw o differen t socio - econ o­ m ic areas, cross - sectionally.

The first sch ool «A n k ara C ollege» is a private ju n ior high sch ool studied in A nkara, the capital city- C hildren w h o attend this sch ool are from fam ilies o f h igh er s o c i o - econ om ic classes. This sch ool has g o o d sport facilities and other social activities. 507 children, 248 boys and 259 girls betw een the ages o f 11 and 15 are selected ran dom ly from a total population o f 3200 ch ild ­ ren.

The secon d high school, «Ç ubuk Junior H igh School» is a p u blic ju n ior h igh sch ool in a sem i - urban area 40 kilom etres fro m A nkara. C hildren w h o attend this sch ool are partly from rural villages, partly from sem i - u rban settlem ent o f Çubuk. 448 children 287 boys and 161 girls w ere in clu d ed in the study.

The study was carried out at schools. The study team com - posed o f a m edical doctor, a nutritionist and a dietician visited each sch ool fo r 2 w eeks each. The m ed ical d o c to r ca rrie d out

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28 Kocaoğlu, Aksu B., Koksal, O. the clin ical exam inations. A n th ropom etric m easurem ents w ere taken b y the nutritionist and the dietician u n dertook the ques- tionnaires.

Height, weight, skin fold thicknesses from biceps, triceps, su bscapular and suprailiac sites w ere collected fo r a n th rop o­ m etric evaluation. The m easurem ents w ere m ade a ccord in g to the techniques suggested b y Jelliffe (5).

A Standard bath room scale (Şalter) w ith 140 k g capacity, reading to the nearest 0.5 k g was used fo r w eigh ing. A sim ple w ooden stadiom eter m easurin g to the nearest 0.5 cm fo r height m easurem ents and H oltain Skinfold ca lip er w ere used fo r skin­ fold m easurem ents.

The cov era g e rates fo r A n k a ra C ollege and Ç ubuk Junior High S ch ool w ere 99.2 % and 98-3 %. T o assess the socio - de- m ograph ic characteristics and fo o d con su m ption a pre - coded, pre - tested and self adm inistered questionn aire w as p repared by the au th or and con d u cted un der the su pervision o f dietician in each classroom . F ood consu m ption in form a tion w as collected

by a 24 h ou r recall m ethod.

For the evalu tion o f w eigh t fo r h eigh t values, translated and extended values o f B a ld w in -W o o d Tables w ere used (5).

By u sin g parents o ccu p a tion and ed u cation status w eigh ed scores w ere d evelop ed fo r the classification o f so cio - e co n o m ic classes.

RESULTS

T able I, show s the distribution o f adolescents studied b y sex and schools. There w ere 535 m ale a n d 420 fem a le children. 53.1 % and 46 9 % o f children are fro m A n k a ra C ollege CA.C.) a n d Ç u bu k Ju n ior H igh S ch ool (ÇHS) respectively. T here is a sig n ifica n t d iffe re n ce betw een th e n u m b er o f girls aged 14 and 15 years. In Turkey, this is quite co m m o n fo r ru ral areas, fo r parents -vvith rural b a ck g rou n d s p re fe r n ot to educate th eir y o - u n g dau gh ters. T h erefore on ly 35.9 % o f ÇHS ch ildren were girls.

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Table 1 : Distribution o f Children by ıSchool and Sex

Male Female Total

Schools n % n % n % Ankara College 248 48.9 259 51.1 507 53.1 Çubuk Junior High School 287 64.1 161 35.9 448 46.9 Total 535 100.0 420 100.0 955 100.0 X= = 22.149 SD = 1 p < 0 .0 1 Table 2 •: Distribution of Children by A ge and School

Age - Groups 11 12 13 14 15 Total Schools n % n % n % n % n % n % Ankara College 14 2.8 126 24.9 130 25.6 142 28.0 95 18.7 507 100.0 Çubuk J. H. S. 54 121 136 30,4 147 32.8 93 20.7 18 4.0 448 100.0 Total 68 7.2 262 27.4 277 29.0 235 24.6 113 11.8 955 100.0 In Table 2, the age distribuıtion o f adolescents is given by age and school. In order to assess ages correctly, the birth dates asked were cross checked w ith sch ool records. The n u m ber of 11 ye ar old children from A nkara C ollege is sign ifican tly less than the ones in Ç ubuk because o f the p reparatory class o f

A n kara College. ^

Table 3 gives the educational status o f parents o f the study group s. 63-5 % and 29.8 % o f fathers o f adolescents attending A n kara C ollege are university and h igh sch ool graduates res- pectively. These rates are m uch above the a verage rates fo r Turkey in general. O n the other hand, as it is typical fo r rural areas in Turkey, on ly 8.0 % and 12.7 % o f fath ers o f a d o ­

lescents attending Ç ubuk High S ch ool are u n iversity and high sch ool graduates. A lth ou gh prim ary sch ool ed u ca tion is com - pulsory, the rate o f illiterate m others o f Ç u b u k group w ith 40.6 % significantly differs from A n k a ra C ollege group.

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Kocaoğlu, Aksu B., Koksal, O.

Table 3 : Educational Status of Parents by Schools

E ducational Status Ankara College Father Moîlher Çubuk Junior High School Father Mother Total ■ Father Mother Illiterate n 1 15 41 182 42 197 % 0.2 3.0 9.2 40.6 4.4 20,6 Llterate n 0 6 15 8 15 14 % — 1.2 3.3 1.8 1.6 1.5

Prim ary School n 16 26 246 218 262 244

% 3.2 5.1 55.0 48.7 27.4 25.5 Junior high n 17 80 53 29 70 109 school % 3.4 15.8 11.8 6.5 7.3 114 High School n 151 208 57 10 208 218 % 29.8 41.0 12.7 2.2 21,8 22.8 Higher educa- n 322 172 36 1 358 173 tion % 63.5 34.0 8.0 0.2 37.5 18.1 Total n 507 507 448 448 955 955 % 100.0 100.0 100.0 100.0 100.0 100.0

Table 4 : Distribution o f Children by Schools and Socio - Econom ic Status

Weighed Socio - Economic Ankara High

Score Status College School Total

3 1 — 40 High n 341 9 350 % 67.2 2.1 36.7 30 — 21 Middle n 157 122 279 % 31.0 27.2 29.2 11— 20 Lower - middle n 8 83 91 % 1.6 63.1 9.5 0 — 11 Low n 1 34 35 °/o 0.2 7.6 3.7 Total n 507 448 955 °/o 100.0 100.0 100.0

Table 4 gives the socio - econ om ic status classification o f two groups a ccord in g to the w eigh ed scorin g m eth od d eveloped by usin g parents occu pa tion and edu cational status. A s expec- ted, there are sign ifican t d ifferen ces betw een the tw o groups. 70.7 % o f adolescents are fro m low er and low er m iddle classes.

H ow ever on ly 1.8 % o f A n k a ra C ollege g rou p are fro m low er

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A nthropom etric evaluation :

A verage heights, weights and skinfold thickness m easure- ments along with their Standard deviations w ere calcu lated separately fo r boys and girls fo r each age group. Because o f rapid and changing growth patterns during adolescence, no h e ­ ight and w eight by age Standard seem ed applicable. W eigh t fo r height standards are used fo r the assessment o f overw eight and obese children. Table 5 gives the m ean heights o f boys by age and school- A lthough the cross sectional nature o f our data seems insufficient to com e to definite conclusions, there is on the average 6 cm d ifference in height fo r L l-12-13 years and the increase in height reaches to 9 cm betw een the ages

13 to 14 years A n kara College boys w h o b elon g to h igher socio - econom ic classes. H ow ever fo r Çubuk boys, the average incre- m ent in height is 3 cm fo r 11-12-13-14 yeaxs. The d ifferen ce of 12 cm s betvveen 14 and 15 years m ay indicate the grow th spurt, w hich seems to occu r a year later than the A n k a ra College boys. There are considerable significant d ifferen ces between the m ean heights of boys from tw o groups. A n k a ra C ollege boys are 4 to 14 cm s taller than Çubuk boys.

Table 5 : Average Height of Boys by Age and School

Age 11 12 13 14 15 n 12 61 58 59 58 Ankara X 147.2 153.6 159.9 168.8 171.8 College s D 6.64 7.61 8.59 8.15 6.94 1.74 0,97 1.11 1.06 0.91 n 39 81 91 64 12 Çubuk Junior X 139.2 142.1 147.8 154.6 167.5 High School SD 5.79 6.68 8.56 9.69 5.45 Se 0.92 7.68 0.89 1.21 1.57 t 4.051 9.396 8.47 8.88 2.38 P < 0.001 < 0.001 < 0.01 < 0.01 < 0.05

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32 Kocaoğlu, Aksu B., Köksal, 0. Table 6 : Average W eight of Boys by Age and Schools

Age 11 12 13 14 15 n 12 61 58 59 58 • Schools X 32.25 41.81 47.0 52.0 55.8 Ankara SD 10.04 8.44 10.03 8.46 8.06 College 2.89 1.08 1.31 1.10 1.05 n 39 81 91 64 12 Çubuk Junior X 32.6 34.3 37.5 42.2 54.2 H igh School SD 7.06 5.40 6.65 8.03 6.15 »E 1.13 0.60 0.69 1.00 1.77 t 0.855 6.097 6.40 6.613 0.780 P < 0.05 < 0,001 < 0.001 < 0.001 > 0.05 The m ean w eights o f boys are show n in Table 6. Parallel to m ean heights, the m ean w eigh t gained by tw o groups show sign ificant d ifferen ces fo r 12, 13 and 14 years. O n the average A n k a ra C ollege boys are 7 to 10 k g h eavier than Ç ubuk boys, betw een the ages 12 and 14 years. H ow ever the w eight d ifferen ce is only 2 k g fo r 15 y e a r olds.

Tables 7 and 8 give the m ean heights and weights fo r girls. There are sign ifican t differen ces betw een the tw o groups fo r 12, 13 and 14 years fo r height. The differen ces are betw een 8 - 1 0 cms. O n the oth er h an d the d ifferen ces betw een w eights seem to d ecrease fo r 14 and 15 years. These findings m ay indicate that the girls fro m low er socio econ om ic classes do n ot reach the exp ected h eight .of girls fro m h igher socio econ om ic classes but gain w eigh t alm ost as m u ch as th© girls from u pper classes and b ecom e hea vier fo r their heights.

Table 7 : Average Heights of Girls by Age and Schools

Age 11 12 13 14 15 Schools n 2 65 58 83 37 Ankara X 151.5 155.3 159.9 161.4 162.3 College s D 8.50 7.79 6.26 5.82 7.07 s E 0.35 0.96 0.73 0.63 1.16 n 15 55 56 29 6 Çubuk Junior X 141.0 144.6 149.9 155.5 153.5 Heigh S ch ool s D 6.46 0.74 7.72 5.52 4.11 SE 1.66 1.03 1.03 1.01 1.67 t 7.59 7.62 4.92 p < 0.001 < 0.001 < 0.001

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Table 8 : Average W eights o f Girls by Age and Schools Age 11 12 13 14 15 Schools n 2 65 72 83 37 Ankara X 35.0 41.7 47.1 49.7 53.6 College SD 1.00 7.75 7.03 6.9 9.04 SE 0.70 0.96 0.82 0.76 1.48 Çubuk n 15 55 56 29 6 Junior X 31.7 35.9 39.7 47.1 52.1 Heigh school SD 4.89 6.90 7.77 8.65 5.17 SE 1.26 0.93 1.03 1.60 2.11 t 4.34 5.611 1.47 p < 0.001 < 0.001 > 0.05

The distribution o f abdolescents by expected percent weight fo r height Standard is given in Table 9. The rates o f children who are classified as obese and overw eight are m ore in Çubuk grou p with 4.18 % obese, 13.2 ,% ovenveigh t fo r boys and 11.18

% and 15.5 % fo r girls respectively. There seem s to be a tendency

fo r low er socio econ om ic groups to b ecom e shorter but heavier children.

Table 9>: Distribution of Boys and Girls by Percent W eight for Height Schools Percent W eight fo r Height

120 - 119-110 109 - 105 104 - 100 9 9 -9 5 94 -9 0 89 - Total Ankara College n 7 26 20 41 31 38 85 248 % B 2.8 10.4 8.1 16.5 12.5 15.3 34.3 100 n 12 36 22 39 32 40 78 259 % G 4.6 13.8 8.5 15.1 12.4 15.4 30.1 100 Çubuk Junior High School n 12 38 24 80 48 40 45 287 % B 4.18 13.2 8.5 27.8 16.7 13.9 15.6 100 n 18 25 19 25 22 21 31 161 11.6 15.5 11.8 15.5 13.7 13.0 19.6 100 Total n 19 64 44 121 79 78 130 535 % B 3.5 11.9 8.2 22.5 14.7 14.5 24.1 100 n 30 61 41 64 54 61 109 420 % G 7.1 14.5 9.8 15.2 12.9 14.5 25.9 955 B: boys G : girls

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34

Kocaoğlu, Aksu B., Koksal, O.

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A ccordin g to food consum ption data collected b y 24 hour recall and history o f eating patterns m ethod, it is fou n d that there were differences betw een the groups in the nu m ber o f meals consum ed each day. 2 % o f Ç ubuk h igh sch ool children had only one m eal a day whereas in A n k a ra C ollege ali ch ild­ ren had at least 2 meals a day. O n the other h an d children w ho could consum e 4 m eals a day in A n k a ra C ollege is 41.4 %

in com parison w ith 6.9 % fo r Ç ubuk group. The freq u en cy use o f m ilk and products, m eat and poultry was m u ch less fo r the low er socio econom ic Ç ubuk adolescents. AIso- the type and freq u en cy o f eating snacks also d iffered betw een the groups- W ealthy children o f A n kara C ollege n ot on ly h a d the m oney to b u y snacks and sandwiches to consum e betw een the m eals but also ali these food s were available fo r them. O n the other hand, purchase and consum ption o f snacks b y Çubuk group was limited.

DISCUSSION

The rate o f puberta! grow th and m aturation is a com plex set o f interrelationships between genetic en dow m en t and its surrounding environment. The influence o f environm ental con - ditions especially the nutritional status on grow th and develop- m ent during infancy and childh ood is v ery w ell docum ented. There has been reports on the secular trend in grow th du rin g adolescence in the W e ste m Countries (6). D reizen et. al. (7) have show n that ch ron ic u n dem u trition du rin g the entire grow th period resulted in slow ed skeletal grow th and m atu ra­ tion, delayed m enarche and a p rolon ged growth. Frisch and R avelle (8) have suggested the use o f m ean age o f m axim um increm ent in grow th o f height o r w eigh t o f adolescent boys as a usefu l index o f nutritional status o f a region o r country.

C hildren from Çubuk high sch ool show ed d ela yed grow th, especially fo r height. The height attainm ent fro m 11 years to 14 years is fou n d to be m u ch slow er than th eir coun terparts in A n k a ra College- A ccord in g to our fo o d con su m ption data, the diet consum ed in this sem i urban area m eets the requirem ents but insufficienit in protein both qualitatively a n d quantitatively. One o f the m ajör causes o f slow grow th is p ro b a b ly protein inadequacy. The average height attained, esp ecia lly b y girls

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36 Kocaoğlu, Aksu B., KfJksal, O. at fifte e n years o f a g e is 153 cm. This value is in accordan ce w ith the n ation al average h eigh t f o r w om en. However, w eigh t in crem en t continues despite the very slow grow th in height. W h e n the w eigh ts o f these adolescents are evaluated b y w eight fo r h eigh t standards, there seem s to b e m a n y children w h o are overw eigh t an d obese. In reality, w e p rob ab ly have «insu ffici- en tly n ou rished obese» adolescents in ou r hands. Bearing in m in d the v e ry h igh p revalen ce o f obesity am on g w om en in Turkey, w e assum e that these relatively fa t adolescent girls tu m in to fa t w om en w h en fa ce d w ith conditions w h ich leads to obesity : these ca n be sum m arised as freq u en t pregnancies, la ck o f ph ysical activity and con su m ption o f food s rich in carbohydrajties. A li these fa ctors lead m ajority o f w om en in T urkey to obesity w h en they are 35 - 40 years old.

ÖZET

SO SY O - EKONOM İK KOŞULLARIN AD ÖLESAN LARDA BÜYÜME GELİŞME VE ŞİŞM ANLIK ÜZERİNE ETKİSİ

K ocaoğlu , Aksu, B., Koksal, O. Bu çalışm anın am acı, adölesanlarda, bü yüm e ve şişm anlık olu şu m u ü zerine sosy o - ekon om ik, kü ltü rel ve beslenm e k oşu l­ ların ın etkisini saptam aktadır. A raştırm a örneklem ini, iki d e ­ ğişik sosyo - ek on om ik ve kü ltü rel d ü zeydek i 1 1 -1 5 yaşlar ara­ sındaki a d ölesa n la r oluşturm uştur. B irinci grupta, A n k a ra ’da sosyo - ek on om ik k o ş u lla n yöiksek özel b ir ortaokul, ikinci g ru p ­ ta ise A n k a ra ’y a 40 k m u zak lıktaki Ç u bu k’ta bu lun an düşük sosyo - ek on om ik d ü zeydek i orta ok u l öğren cileri y e r alm ıştır. G ru plar arasın da ailelerin eğiıtim ve g elir dü zeyleri arasında ön em li fa rk lılık la r saptanm ıştır. T üm yaşlarda, iki g ru b u n b o y u zu n lu ğu arası fa r k ise 10 cm dir. Ş işm an lığın saptanm asın da b o y a g ö r e ağırlık standardı ku llanılm ıştır. Y ü k sek sosy o - e k o ­ n om ik dü zeydek i çocu k la rın % 15.9 u ve dü şü k sosyo - e k o n o ­ m ik d ü zeydek i ço cu k la rın % 22-5 i h a fif şişm an ve şişm an b u ­

lunm uştur. Y ü k sek sosyo - e k o n o m ik d ü zey d ek i ço cu k la r a ra ­ sın da iyi progra m la n m ış sp or aktivitesi n ed en iyle ç o k a k tif ç o ­ cu k ora n ı yüksektir. Y ü k sek sosy o - ek on om ik d ü zeydek i ç o ­ cu k la rın diyeti h a y v an sa l p ro te in v e y a ğ d a n zen gin , d ü şü k sos­ y o - ek on om ik d ü zey d ek i ço cu k la rın diyeti ise tahıl, şeker ve sebzelere d aya lı bulun m u ştur. Bu gru p, özellik le süt ü rü n lerin i

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yetersiz tüketm ektedirler. Y üksek sosyo - ekon om ik düzeydeki çocu klar 3 ana ve en az bir ara öğü n alırken, düşük sosyo - ek o­ nom ik grupta öğün atlayanlar daha çoktur. Bu araştırm anuı so ­ n u çlan , adölesanlarda, şişm anlığın oluşum unda sosyo - ekon o­ m ik ve kültürel koşulların etkisini açıkça gösterm ektedir. Diyet tipi ve elverişsiz fiziksel aktivite, sosyo - ekonom ik ve kültürel düzeyle ilgilidir. Kısa b oy özellikle kızlar arasında, düşük sosy o­ ekonom ik grupta şişm anlığa eğilim i vurgulam aktadır ve ileri yaşlarda sık gebeliklerin etkisi ile de şişman yetişkin olasılığı artmaktadır.

REFERENCES

1. Nutrition in Turkey : 1974 Nutrition and Health Survey Report, Ed : Orhan Koksal, Hacettepe Üniv., Ankara, 1978

2. Güneyli, U „ Ankara - Çubuk İlçe Merkezi ve K öylerinde Ailelerin Bes­ lenme Durumlarını Saptamada Kullanılan Değişik Araştırma Y öntem ­ lerinin Değerlendirilmesi, Hacettepe Üniv. Sağlık Tek. Yük. Okulu Bes­ lenme ve Diyetetik Bölümü, D oçentlik Tezi, Ankara, 1977.

3. Arslan, P., Çalışan Yetişkin K adınların E nerji Gereksinmelerinin De­ ğerlendirilmesi Üzerine Bir Araştırma, H acettepe Üniv. D oçentlik Tezi, Ankara, 1982.

4. Salans, L. B „ Cushman, S. W., W eismann, R. E’ : Studies of Human Adipose Tissue. Adipose Celi Size and Number in Nonobese and Obese Patients. J. Clin. Invest. 52 : 529, 1973.

5 Jelliffe, D.B., The Assessment of the Nutritional Status of The Community, WHO M onograph Series, No : 53, Geneva, 1966

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