BMC Public Health 2009, 9:485 http://www.biomedcentral.com/1471-2458/9/485 Background Malnutrition during adolescence has important short and long-term health implications. Adolescent obesity has been associated with adverse cardiovascular [1], meta- bolic [2] and psychological outcomes [3]. Tracking of obesity from adolescence to adulthood has been shown to be high [4], and obesity in adulthood is associated with chronic diseases and increased mortality [5]. At the same time, undernutrition during childhood has been linked to higher risk of obesity and chronic diseases in adulthood [6]. The rise in obesity and chronic diseases worldwide has been linked to urbanization, which entails nutrition tran- sition and sedentary lifestyle [7]. Compared to western societies, Middle Eastern countries experienced a later but faster-paced nutrition transition [8]. Palestinian society has also been undergoing nutrition transition [9], where studies have shown nutrition-related chronic diseases and their risk factors such as heart diseases, hypertension, dia- betes, cancer, smoking, sedentary lifestyle and obesity to be prevalent among Palestinians [9]. One study among adults estimated combined prevalence of overweight and obesity to be 58.7% among men and 71.3% among women [9]. At the same time, stunting which is associated with chronic undernutrition, has been increasing among Palestinian children younger than 5 years of age from 7.2% in 1996 to 10.2% in 2006 [10]. Studying various aspects of the nutritional status of Pales- tinian adolescents (10-19 years) is important as they rep- resent about one-quarter of the Palestinian population [11]. Studies exploring nutrition-related aspects of Pales- tinian adolescents in the West Bank are few. One national study which was part of the Health Behaviour in School aged Children Survey (HBSC) was conducted in the West Bank and the Gaza Strip in 2003/2004. In that survey, prevalence of overweight/obesity (using International Obesity Task Force (IOTF) criteria) was estimated at 20.4% for boys and 13.0% for girls [12]. However, calcu- lation of body mass index (BMI) in that survey was based on self reported weights and heights rather than on actual measurements. Moreover, undernutrition (stunting and underweight) was not assessed. To our knowledge, no population based studies have reported actual measured anthropometric data for underweight, overweight, obesity and stunting among adolescents in the West Bank. There- fore, there is a need to conduct such studies to be able to identify the vulnerable groups and plan proper interven- tion programs. The West Bank in the occupied Palestinian territory (oPt) is an area of 5655 square Km with 2 350 583 inhabitants and is composed of 11 governorates (governorate is offi- cial administrative division of the oPt) [11]. This study was conducted in two main governorates in the West Bank (Ramallah and Hebron governorates) chosen for their contrasting demographic and lifestyle features and for their importance in terms of economic status and popula- tion size. Ramallah governorate is located in the middle of the West Bank with 279,730 inhabitants in 2007 [11]. It has 6 urban and 69 rural localities with 34.1% and 59.5% of the population, respectively [13]. Ramallah city is a cul- tural, political, and administrative center of the Palestin- ian Authority. Hebron, which is the largest governorate in terms of population size, is located in the southern part with 552,164 inhabitants in 2007 [11]. It has 10 urban and 144 rural localities, with 67.0% and 30.2% of the population, respectively [13]. In a comparison of demo- graphic and lifestyle characteristics such as fertility levels, age of women at marriage, education levels, types of employment, and the availability of modern household amenities, Ramallah and Hebron cities represented two distinctive modes of urban life with Ramallah being more modernized and having a higher standard of living [14]. Corresponding rural areas showed similar pattern with those of Ramallah having better indicators than those of Hebron. The differences between the cities and their rural areas in these indicators were more pronounced in Ram- allah than in Hebron [14]. The objective of this article was to assess the prevalence of stunting, underweight, overweight, and obesity using actual measured weights and heights among school-based adolescents (13-15 years) in 2 major governorates (Ram- allah and Hebron) in the West Bank in the oPt. It also aimed to study the associations between these anthropo- metric measurements and selected sociodemographic characteristics such as residential factors (region, urban- rural), age, gender, educational level of the parents, aspects of household economic situation, and food avail- ability. Methods Study Sample A list of all the students attending the 8th and 9th grades in 2004-2005 was provided by the Palestinian Ministry of Education and Higher Education (which included number of students per classroom). The school enroll- ment rate for Palestinian children in the West Bank in 2007/2008 was 84.5% in the basic education stage (1st to the 9th grade) [15]. The total number of 8th and 9th grade students was 13011 in Ramallah and 26681 in Hebron. The classes were divided into nine strata using school gen- der category (single sex-boy, single sex-girl and co-educa- tional) and school ownership type (public, United Nation Relief and Works Agency (UNRWA), or private). The sam- ple was selected using single stage probability propor- tional-to-size sampling procedure from each of the nine strata, using the class as the primary sampling unit. Page 2 of 12 (page number not for citation purposes)