The Relation Between Stress Level and Nutritional Status Among Primary School Pupils in Mosul City

Background and Aim : Stress is now considered a common problem in children, it has been liked with both increased and decreased dietary intake. The study aimed to identify the relationship between stress level and nutritional status among primary school pupils in Mosul City. Materials and Methods : A cross-sectional study has been designed for a sample of children consist of (200) pupils from the primary schools in Mosul City, aged (10-13) years old. The study has been conducted from 1 st of January to 30 th of April 2019. Data were collected through the interview of the children which included the height and weight measurement which done in the classroom and then the questionnaire about demographic characteristics, stress level and dietary intake were distributed for them to be answered by the one of child's parents. The data were analyzed through the application of descriptive statistical analysis that included frequency, percentage and Chi square . Results : The study indicated that the 78.5% of the children were 10-12 years old, 44.5% of them from moderate economic status , also show there are significant relationship between stress level and increase of weight, costumed saturated oils, meat, carbohydrate, low fruit and low vegetable intake at P-value=0.05. Conclusion : This study found consistent association between stress level and unhealthy dietary intake. Pupils with higher stress had higher consumption of fat and sugar which lead to obesity . Recommendations : Pay attention to the child by the family and school, reduce the psychological stress, he has by addressing his social problems and enhancing his selfconfidence .


Introduction
Stress is defined as the body's physiological response as a result of pressures and events that overwhelm it and threaten and shake the person's ability to maintion balance (Torres and Nowson, 2007) .
Stress in the early stage of life has a negative impact on the development of the child, structure and function of the brain (Nelson, 2013;Charmandavi et al., 2003). Also its effect on physical activity, health behaviours, dietary intake and increasing risk of obesity (Nader et al., 2006 ;Telma et al., 2014) . Short -term stress can cause a people to lose their appetite, while longterm stress can lead to comfort eating which often involves the overeating of food that are rich of calories such as high fat and carbohydrates in an attempt to make them feel better (Sally, 2018;Honor, 2017) . Long time stress affects body functions and plays an important role in most of psychiatric disorders and indirect health behavior changes (Dohrenwend, 2006), One of the behavioral changes is food choice that affects health as a result of changes in appetite and dietary intake (Steptoe etal., 1998). Many people do not think about healthy eating at the time of stress, they often skip some meals especially the breakfast or eat fast food outside the home which can leads to more emotional strain and adversely affect their health (Canfield, 2011).
School-age children need a wellbalanced diet per day that is required to meet growth needs, as the child size increases (Edelman and Mandle, 1998), Over nutrition refers to an excessive intake of one or more nutrients which causes a stress on bodily function. Stress has been linked with high or low dietary intake (Geliebter and Aversa, 2003).
Obesity was considered a disease of stress (Tsenkova etal., 2013) . Excess of body weight is associated with many health problems such as heart disease, liver disease, high blood pressure, sleep apnea, gall bladder disease, depression, diabetes and endocrine disorders (Hurt, 2011).  Giuglianib, 2005). Higher consumption of carbohydrate is associated with higher calories intake, it has been estimated that every additional glass of a sweetened beverage drink per day by children increases becoming obese by 60% (Barnfather, 2004). The study aimed to identify the relation between stress level and nutritional status among primary school pupils in Mosul City . The purpose of this study was firstly, to find the relationship between the level of stress and the body mass index (BMI) for school pupils, second, to identify the association between stress level and dietary intake in the study sample.   This table shows that the most of the sample were (10-12) years old, they accounted 78.5 .

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.5 from study sample were normal weight , 44.5 of sample had an moderate economic level.   (2011); Koski and Naukkarinen (2017) and Honor (2017) have found that stress can causes and fuel and raise obesity risk. Nader et al., (2006) found that children which living in low-income housing are more likely to become obese due to early life stress. Moore and Cunningham (2012) pointed out that higher stress is associated with less healthy eating behavior, higher body weight and poor nutritional status. Evelyn et al., (2008) noted that obese children may be more prone to mental illness such as depression and self-impairment than non obese children.
Our study results in table (3) revealed that the majority of pupils 93% ate grains, 63% of them ate carbohydrate, while the lowest number of them ate fruits 34%.
The study of Yahya et al., (2005) reported that 60% of the pupils low consumption of fruits and vegetable and excess sweet intake in 25%. Gillis and Bar, (2003) compared the eating habits of obese to non-obese children, found that obese children consumed significantly more fast foods than the non-obese children. Chacar and Salameh (2011) found that the children who consumed very high of fried food, soft drinks and chocolate have been linked to higher energy intakes which may increase the risk of developing obesity . In this study high significant relationship was observed at table (4) between stress level and pupils who consumed food high of saturated fat p=0.021, meat p=0.000, carbohydrate p=0.01, and low consumed of fruit p=0.000 and low vegetables p=0.03 at p-value=0.05.
The results is agreed with the study of Honor, (2017) which noted that stress has been linked with the consumption of food high in fat and sugar. Both Zellner et al. (2007) and Oliver and Wardle (1999) Pollard et al., (1995) said that there are studies did not find any difference in food compensation as a result of different level of stress .
Most literature has indicated that point to positive associations between the consumption of foods rich in fats and carbohydrates and stress level are common . In the time of stress food choices are redirected to higher palatability food especially those high in sugar and fat (such as sweets) with reduce in the consumption of fresh food such as fruits and vegetables (Zellner et al., 2006;Mikolajczyk et al., 2009 andEl-Ansari et al., 2014).

Conclusions
We believe our study is both necessary and important for children, where we have shown that there is a strong relationship between level of stress and unhealthy dietary intake.
children with higher stress level had higher consumption of fast food and snacks which containing a high calories.

Recommendations
We must pay attention to the child by the family and school, reduce the physiological stress he has by addressing his social problems and enhancing his self-confidence. Families should take a positive approach to eating , eating more fruits and vegetables and reduce the consumption of high energy dense foods especially fast foods and sweets. Children should get at least one hour of physical activity every day with the possibility of participating in school sports activities according of their wishes.