Current Pediatric Research

Abstract

Background: Childhood obesity is a serious public health issues worldwide in the 21st century and the prevalence has been increasing in all countries. Objectives: To estimate the prevalence of overweight and obesity among primary school students in AL-Nasiriya city and their correlation with the eating habits, socioeconomic and lifestyle factors. Methods: A cross-sectional study conducted on 357 (177 girls and 180 boys) sample of pupils aged 6-12 years selected randomly from students who attended public primary schools during the period from1st of December 2018 to the end of May 2019 in AL-Nasiriya city. The Body Mass Index (BMI) was measured and used as indicator for overweight/obesity. Results: The overall prevalence of obesity and overweight among primary school children in ALNasiriya city was 28% (17.9% were obese and 10.1% were overweight). A significant positive association between excessive body weight and snacks No./day (p-value=0.004, odd ratio=3.112), and fruits intake (p-value=0.014, odd ratio=2.767) was found in this study. While, there was a significant negative association of student's BMI with the physical activities (p-value=0.049, odd ratio=0.566). Conclusion: The prevalence of overweight and obesity is relatively high among primary school students in AL-Nasiriya city. Preventive approaches by the families and the schools should be considered. Keywords: Overweight,

Keywords:

Overweight, Obesity, Primary schools, Nasiriya.

Introduction

In recent decades, childhood obesity has become more prevalent and predicted to become a major health problem by 2020 according to World Health Organization [1]. The WHO reports show that, childhood obesityis one of the most serious public healthchallenges of the 21st century, which issteadily expanding in many low income and middle-incomecountries, especially in urban areas [2]. According to recent global estimates of WHO, the worldwide obesity prevalence tripled between 1975 and 2016 [3]. Under the age of 5 years, 38 million children were overweight or obese in 2019. Half of these children lived in Asia [3,4]. In 2016, among children and adolescents aged 5-19 years, 340 million were overweight or obese [3,5]. The prevalence of overweight and obesity among those aged 5-19 has been increase dramatically from 4% in 1975 to over 18 % in 2016. This increment has occurred equally among boys and girls [3].

The prevalence of overweightand obesity in high socioeconomic statuschildren in India were 16.75% and 5.59% in boys,and 19% and 5% in girls, respectively [6]. In Jordan a study was conducted among school children at 2006 revealed that 19.4% wereoverweight and 5.6% were obese [7]. In Kuwait at 2010, the prevalence of overweight and obesity among male students aged 6-10 years were 20.2% and 16.8%, respectively [8]. In Iraq, a study was done among primary school students in Basrah city at 2011 was found that 13.6% were overweight and 10.5% were obese [9]. While in Baghdad a study was done at 2013 revealed that 16.7% were overweight and 16.2% were obese [10].

Overweight and obesity defined by using the Body Mass Index (BMI) which calculates as person's weight in Kilograms (kg) divided by square of his height in (meters) [11]. Obesity results from an imbalance between calories consumed and energy expended. The socioeconomic status and family lifestyles have a major impact on the dietary and behavioral choices of children [12]. Bad eating habits like consumption of unhealthy high energy food rich in fat, sugar and salt with low nutritional value, drinking of sweetened beverages and outdoor eating coupled with decline in physical activity and sedentary behaviors like spent more time with screens (televisions, smartphones, and computers) results in excess adiposity and dramatic rise in overweight and obesity prevalence [13]. Inadequate sleep is a risk for weight gain through association with decreased leptin levels and increased ghrelin levels, with increased hunger and appetite [11,14].

Excessive adiposity is a major risk factor for emergence of non-communicable diseases later on such as heart disease, osteoarthritis, and some types of cancers [15,16]. In addition, obese children complain from sleep apnea, high blood pressure, insulin resistance, hyperlipidemia and phycological problems like depression [3,9]. Excessive body weight and it is associated comorbidities are preventable. Life style modifications like decrease consumption of high energy fast food, choosing healthy diet, engorge regular daily exercise, and limit time spent in sedentary activities are the main steps in the prevention and treatment of this serious health problem [17].

Aim of the study

This study was carried out to estimate the prevalence of overweight and obesity among primary school children in AL-Nasiriya city and their correlation with the eating habits, socioeconomic and lifestyle factors.

Subjects and Methods

Subjects

This cross-sectional study was carried out on 357 (177 girls and 180 boys) sample of students aged 6 years-12 years selected randomly from students who attended the public primary schools during the period from 1st of December 2018 to the end of May 2019 in AL-Nasiriya city. Four primary schools were recruited for the study, including two schools for boys and two schools for girls. The students selected were healthy with no chronic disease. Children who had diarrhea and children who took steroid drug were excluded from the study.

The data were obtained through a questionnaire designed for this study and include: age of student, sex, parental education that considered as low (primary school or less) and high (secondary schooling or higher), and parental employment [9]. Other questions about dietary habits including number of meals per day 1, 2, 3, eating between meals (snacks) (none, 1, ≥ 2), and eating while watching TV were recorded. In addition, fruits, dairy products (including cheese, milk, ice cream, yogurt, and butter), soft drinks, chocolate and sweets intake were recorded as number of servings per day.

Other variables that were collected included physical activity (sport in and outside school like football, running, and cycling), way of going to school (by bus or on foot), and sedentary behaviors including sleeping time per day, the number of hours watching TV and playing with smart devices. Screen time for >2 hours per day was considered a risk factor for overweight and obesity [18].

Methods

Weight was measured in kilograms with a well-calibrated digital scale. All pupils were wearing light clothes and were barefooted. Height was measured in centimeters without shoes using a standard measuring tape with an accepted error of 0.1 cm.

For all pupils, the Body Mass Index (BMI) was calculated from the equation: (weight (kg)/height (m2)). According to the BMI, the child determined to be: Obese if ≥ 95th percentile, overweight if ≥ 85th percentile to <95th, normal if ≥ 5th percentile to <85th percentile, underweight if <5th percentile [19].

Body Mass Index (BMI) percentile, was determined using the 2000 “Centers for Disease Control and Prevention” (CDC) Growth Charts for the United States [19].

Ethical aspects

An informed consent was obtained from all students participate in this study and from the school’s managers. An ethical approval was obtained from scientific committee of medical college/university of Thi-Qar, and Thi-Qar health directorate.

Results

This study was carried out on 357 primary school students aged 6-12 years. One hundred seventy-seven (49.6%) were girls with mean age 9.4181 and Std. Deviation 1.60709, and 180 (50.4%) were boys with mean age 9.5861 and Std. Deviation 1.66112 (Table 1).

Table 1. Distribution of age and some growth parameters according to gender.

Figure 1 shows that 64 (17.9%) of students were obese, 36 (10.1%) were overweight, while 231(64.7%) had normal nutritional status.

Figure 1: Distribution of primary school children according to BMI.

The prevalence of obesity was higher (20.9%) among girls compared to 15% in boys, while the prevalence of overweight was higher 12.2% in boys compared to 7.9% in girls. These results were statistically insignificant, p-value=0.269. Increase in father educational level associated with excessive body weight among their children (19.4% were obese, and 12% were overweight) but this result was statistically not significant, p-value 0.540. Also, there was no significant association between mother educational level and pupils’ BMI. No significant association was found between parents’ occupation and body weight categories (p=0.913 and p=0.234 for fathers’ and mothers’ occupation respectively) (Table 2).

Table 2. Association of nutritional status with different socio-demographic characteristics of pupils. a: Age.

The prevalence of overweight and obesity significantly increased with the increase in number of meals and snacks/day (p=0.048 and p=0.002 respectively). A significant positive association of BMI with the fruits consumption per day was found, p value=0.045. No association was found between dairy products, soft drinks and sweet intake per day with the pupils’ BMI, p-value >0.05 (Table 3).

Table 3. Association of BMI with the dietary habits of primary school children. a: Age.

The prevalence of overweight among pupils watching TV>2 hrs/day was higher (12.9%) compared to 6.5% among those watching TV<2 hrs. While obesity was more prevalent among those are watching TV<2 hrs. This association was statistically significant, p=0.007. No correlation was found between sleeping time, playing with smart devices, eating while watching TV, and way of going to school with excessive body weight, p-value>0.05 (Table 4).

Table 4. Relationship of BMI with the behavioral habits of pupils. a: Age.

A significant negative association was found between physical activity and high BMI among primary school students, p-value=0.026 (Figure 2).

Figure 2: Correlation of nutritional status with the physical exercise. Pearson Chi-Square=18.943a P value=0.026.

Regression analysis of independent variables with overweight and obesity has revealed that there was a significant positive association of excessive body weight with snacks no./day (p-value=0.004, odd ratio=3.112), and fruits intake (p-value=0.014, odd ratio=2.767). While, there was a significant negative association of student's BMI with the physical activities (p-value=0.049, odd ratio=0.566) (Table 5).

Table 5. Logistic regression analysis of independent variables with the nutritional status of the students.

Discussion

This study was conducted on a sample of children who attended the public primary schools in AL-Nasiriya city and was founded that the overall prevalence of obesity and overweight was 28% (17.9% were obese and 10.1% were overweight). In comparison with the results of studies done in other cities of Iraq, the overall prevalence in the current study (28%) was higher than the results of Basrah and Kirkuk studies (24.1%), while it was lower than the results of studies done in Baghdad and Diyala (32.9% and 33.6% respectively) [9,10,20,21]. The prevalence in the current study was lower than that reported in several neighboring high income Arabic countries like Kingdom of Saudi Arabia, 45% (18.0% were overweight and 27.0% were obese), and Kuwait 37% (16.8% for obese and 20.2% for overweight) [8,22]. In the present study, the prevalence of overweight and obesity (28%) was nearly similar to that reported in Iran 29% (21.1% were overweight and 7.9% were obese) [23]. The higher prevalence of overweight and obesity in some countries in comparison to others was attributed to the differences in the lifestyles, cultural, environmental, and genetic factors.

 In the current study, although the girls were more obese than boys, and the boys were more overweight than girls, these results were statistically not significant (p-value=0.269). This result was in agreement with that reported in another Iraqi study by Lafta et al. [24]. While in Togo study, overweight prevalence among girls was two times higher than in the boys [13]. Others showed that male gender was a risk factor for obesity with a higher rate of obesity and overweight than females [12,25].

The present study showed that overweight and obesity had no significant association with the educational level of the parents. This result was in agreement with that reported by Bhuiyan et al. in Bangladesh, but does not agree with the results of the Italian study and Iranian study [12,26,27]. Both studies revealed that low educational level of the parents are associated with greater risk of overweight and obesity among their children. On the other hand, in Basrah study and Nablus study, high student's BMI associated with increase in parental education [9,25].

No correlation was found in this study between student's BMI and mother's employment and father's occupation. This result is similar to the results of Nablus study in which mother’s profession was not having significant association with pupils' BMI, while others found that children of working mothers and fathers were most likely to be obese compared to those whose parents were unemployed [9,22,25]. In the current study, a highly significant association of overweight and obesity with the number of snacks consumed per day was demonstrated. This is in agreement with the results of other study done by Sun et al. in China reported that snacks are considered a major cause of overweight and obesity [28]. Increase snack consumption leading to excess energy intake and weight gain.

This study also demonstrated that increase consumption of fruits was associated with increase in the student's BMI and this correlation was statistically significant. This result is consistent with that reported by Sharma et al. [29]. Fruit contains large amounts of simple sugars (glucose, fructose, sucrose, etc.). These simple sugars, such as glucose and fructose, are thought to be the main source for generating fatty acids by hepatic de novo lipogenesis, which may increase the levels of hepatic and circulatory triglycerides, very-low- and low-density lipoproteins, thereby resulting in increases in adipose tissue and obesity [29,30]. Thus, the consumption of certain types of fruits that are rich in simple sugars is the most likely mechanism for the association between obesity and fruit intake. On the other hand, the beneficial effects of the fruits on the health are well established and many studies showed a negative relationship between daily fruit intake and weight gain [13,31].

The present study didn’t reveal a significant correlation for excess body weigh with number of meals, dairy products, soft drinks and sweet intake per day. These results disagree with those reported in other studies [25,29,32,33]. In this study, although the prevalence of overweight was higher among students watching TV less than 2 hr/day compared to those watching TV less than 2 hrs/day, it was statistically not significant. Also, no significant correlation was demonstrated in the current study between high BMI and playing with smart device, eating while watching TV, and sleeping time, which does not coincide with other studies in which significant association was reported. Lack of activity and sedentary behaviors are major risk factors for overweight and obesity in children [7,11,13,27].

Small sample size or cross suctional nature of this study may attribute to the lack of association in the present study. With respect to physical activity, this study was found a significant negative association between student's BMI and their activity in and outside their schools and revealed that obesity was less prevalent among physically active students compared to inactive ones. This result was in consistent with the results of a study conducted by Sulaiman et al. in Erbil and Bhuiyan et al. in Bangladesh [26,33-35]. Both studies reported that physical activity was a protective factor from excess body weight. Physical activity increases total energy expenditure, which can help them stay in energy balance and maintain a healthy body weight.[36]

Conclusion

From this study we conclude that the prevalence of overweight and obesity among primary school children was relatively high in Al Nasiriya city. Snacks and fruits intakewere independent risk factors for high BMI. Our study also revealed that physical activitywas a protective factor from excess body weight.

Recommendations

Due to the rapid increases in obesity prevalence and the serious public healthconsequences, we need urgent preventive interventions to reduce the health burden of the childhood obesity pandemic. The hallmark of prevention and treatment of obesity includes lifestyle modification (healthy eating habits, increased physical activity, and decrease sedentary behaviors). Parents must play their role in these interventions.

Nutrition and physical activity lessons can be introducing into the school curriculum to learn the students how can choose and maintain healthy lifestyles. Schools can provide healthy food choices and limit marketing of unhealthy foods like sugar-sweetened beverages in the cafeteria. Annual measurement of weight, height and BMI for each student in the school and inform the results to their families. This would help parents to become aware of any weight abnormality and early intervention.

References

1. World Health Organization. Obesity: Preventing and managing the global epidemic. Geneva: WHO Technical report series 894 World Health Organization, Geneva, Switzerland. 2000.
2. Mehravar F, Majdzadeh R, Honarvar M, et al. Effect of socioeconomic inequality on overweight and obesity in children: A review of systematic reviews. J Clin Basic Res 2019; 3(4): 23-30.
3. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
4. Sun Y, Hu X, Huang Y, et al. Spatial Patterns of Childhood Obesity Prevalence in Relation to Socioeconomic Factors across England. Int J Geo-Inf 2020; 9(10): 599.
5. Koletzko B, Fishbein M, Lee WS, et al. Prevention of childhood obesity: A position paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN). J Pediatr Gastroenterol Nutr 2020; 70(5): 702-10.
6. Marwaha RK, Tandon N, Singh Y, et al. A study of growth parameters and prevalence and obesity in school children from Delhi. Indian Pediatr 2006; 43(11): 943-52.
7. Khader Y, Irshaidat O, Khasawneh M, et al. Overweight and obesity among school children in Jordan: Prevalence and associated factors. Matern Child Health J 2009; 13(3): 424-31.
8. Al-Isa AN, Campbell J, Desapriya E. Factors Associated with overweight and obesity among Kuwaiti elementary male school children aged 6-10 years. Int J Pediatr 2010; 2010: 459261.
9. Salman MA, Ajeel NA. Prevalence of overweight and obesity among public primary school children in Basrah city. Iraqi J Comm Med. 2013; (2): 103-8.
10. Al-Daboony SJ. Prevalence of overweight and obesity among primary school children in Baghdad/Al-Karkh city. Iraqi Med J 2014; 60(2): 143-8.
11. GahaganSh, Behrman RE, Kliegman RM, et al. Overweight and obesity. Nelson Textbook of Pediatrics, 21st edn. Elsevier Saunders, Philadelphia. 2019.
12. Prevalence and determinants of overweight and obesity among public primary school students in AL- Nasiriya City at 2018-2019.
13. Lazzeri G, Giacchi MV, Spinelli A, et al. Overweight among students aged 11-15 years and its relationship with breakfast, area of residence and parents’ education: results from the Italian HBSC 2010 cross-sectional study. Nutr J 2014; 13:69.
14. Sagbo H, Ekouevi DK, Niangoran S, et al. Prevalence and factors associated with overweight and obesity among children from primary schools in urban areas of Lomé, Togo. Public Health Nutr 2018; 21(6): 1048-56.
15. Hanlon EC, Dumin M, Pannain S. Sleep and Obesity in Children and Adolescents. Global Perspectives on Childhood Obesity (2nd edn.) Science Direct, IL, United States. 2019.
16. http://www.who.int/entity/dietphpsicalactivity/en/2011
17. Kopelman P. Health risks associated with overweight and obesity. Obes Rev 2007; 8 (Suppl 1): 13-7.
18. Matson KL, Fallon RM. Treatment of obesity in children and adolescents. J Pediatr Pharmacol Ther 2012; 17(1): 45-57.
19. Bhuiyan MU, Zaman S, Ahmed T. Risk factors associated with overweight and obesity among urban school children and adolescents in Bangladesh: A case-control study. BMC Pediatr 2013; 13: 72.
20. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: Methods and development. Vital Health Stat 11 2002; (246):1-190.
21. Shakoor JA, Muhe Al-deen AL. Prevalence of obesity and overweight among public primary school students in Kirkuk city. J Nat Sci Res 2015; 5(24):59-66.
22. Muhammad AJ, Obaid KA, Ghassan H, et al. Prevalence of overweight and obesity in primary-school children in Alkhaliscity, Diyala Governorate, Iraq. Int J Adv Res Biol Sci 2018; 5(1): 79-83.
23. Al-Sharif MSA. Risk factors associated with obesity in children age 6-12 years in nutritional clinic at security forces hospital in Riyadh city. King Saudi University, 2008.
24. Jazayeri S. Overweight and obesity among school-aged children of metropolitan Tehran, Iran. Pak J Nutr 2005; 4(5): 342-4.
25. Lafta RK, Kadhim MJ. Childhood obesity in Iraq: Prevalence and possible risk factors. Ann Saudi Med 2005; 25(5): 389-93.
26. Isbaih MA. Prevalence of overweight and obesity among school-age children in Nablus city. An-Najah National University, Nablus, Palestine 2009.
27. Bhuiyan MU, Zaman S, Ahmed T. Risk factors associated with overweight and obesity among urban school children and adolescents in Bangladesh: A case-control study. BMC Pediatr 2013; 13: 72.
28. Mozaffari H, Nabaei B. Obesity and related risk factors. Indian J Pediatr 2007; 74:  265-7.
29. Tahmasebi S, Qasim MT, Krivenkova MV, et al. The effects of oxygen-ozone therapy on regulatory T‐cell responses in multiple sclerosis patients. Cell Biol Int 2021; 45(7): 1498-1509.
30. Sun M, Hu X, Li F, et al. Eating habits and their association with weight status in Chinese school-age children: A cross-sectional study. Int J Environ Res Public Health 2020; 17(10): 3571.
31. Sharma SP, Chung HJ, Kim HJ, et al. Paradoxical effects of fruit on obesity. Nutrients. 2016; 8(10): 633.
32. Tappy L, Lê KA. Metabolic effects of fructose and the worldwide increase in obesity. Physiol Rev 2010; 90(1): 23-46.
33. Lin BH, Morrison RM. Higher fruit consumption linked with lower body mass index. Food Rev 2002; 25(3): 28-32. 
34. Al-Asadi GM. Extent of overweight and obesity among children aged (6-60) months in Al-Nasiriya at 2015-2016. Thi-Qar Med J 2018; 15(1): 58-71.
35. Sulaiman SJ, AlAni MH. Prevalence of obesity and physical activity among primary school children in Erbil City/Iraq. Mosul j nurs 2020; 8(1): 6-17.
36. Shabgah AG, Qasim MT, Mostafavi SM, et al. CXC chemokine ligand 16: A Swiss army knife chemokine in cancer. Expert Rev Mol Med 2021; 23.