Obesity is the accumulation of body fat which has a negative effect on person’s health. A person is considered obese if his/her body weight is 20 % higher than normal( Reference Musaiger 1 ). Growth charts have been constructed by observing the growth of large numbers of normal children over time( Reference Patterson, Risby and Chan 2 ). The height, weight and head circumference of a child can be compared with the expected parameters of children of the same age and sex to determine whether the child is growing appropriately( Reference Dehghan, Akhtar-Danesh and Merchant 3 ).
Childhood overweight and obesity is a health problem that needs effective approaches. Its prevalence is becoming a threat to public health worldwide, affecting both developed and developing nations. Overweight and obesity represent a rapidly growing risk to the health of people in an increasing number of countries( 4 ). For many developing countries, obesity and its consequences have become a challenge like hunger and undernutrition( Reference Keding, Msuya and Maass 5 ).
Recently, there has been an increase in prevalence of childhood obesity (5–19 years) due to rapid change in dietary practices and adoption of sedentary lifestyles in developing countries( Reference Gupta, Goel and Shah 6 ). Prevalence of childhood overweight and obesity worldwide has increased from 4·2 % in 1990 to 6·7 % in 2010( Reference De Onis, Blössner and Borghi 7 ). The trend is anticipated to reach 9·1 % in 2020. The estimated prevalence of childhood overweight and obesity in Africa in 2010 was 8·5 % and is expected to reach 12·7 % in 2020( Reference De Onis, Blössner and Borghi 7 ).
Overweight and obesity in children and adolescents is progressively being observed alongside improved access to technology that is associated with varying lifestyle of families due to increased purchasing power, luxurious living, increasing hours of inactivity due to increased watching of television (TV) and use of video games and computers, which seem to substitute for outdoor games and other social activities( Reference Abdul-Rasoul 8 , Reference Singh and Sharma 9 ). The trend of overweight and obesity is rising with urbanization, changes in lifestyle and social economic transition. Social economic transition is considered to be among the causes of overweight and obesity, in which residing in cities provides greater access to more fast foods and the emergence of people with high economic income who can afford these fast foods with high glycaemic index( Reference Mosha and Fungo 10 , Reference Wang and Lobstein 11 ). Children’s physical and psychological health is highly affected by overweight and obesity. The mechanism of overweight and obesity is not well understood but is believed to be disorder of multiple causes. It is assumed to be a result of increasing intakes of energy and fat. According to experimental and observational studies, both diet and physical activity have a positive effect on decreasing obesity and controlling body weight( Reference Dehghan, Akhtar-Danesh and Merchant 3 ).
Obesity and/or overweight are major risk factors for chronic diseases and play a central role in insulin resistance as well as the metabolic syndrome, which includes hyperinsulinaemia, hypertension, hyperlipidaemia and type 2 diabetes mellitus( Reference Kelishadi 12 ). Obesity also correlates strongly with increased risk of atherosclerotic CVD, stroke, sleep apnoea syndrome and some forms of cancer( Reference Kelishadi 12 – 15 ). However, little is known about the prevalence of childhood obesity and the paediatric metabolic syndrome in developing countries because of the limited number of studies, the variety of definitions and cut-offs used and the different age groups studied, which makes comparisons difficult( Reference Kelishadi 12 ). Among developing countries, the prevalence of childhood obesity is highest in the Middle East and Central and Eastern Europe( Reference James 16 ). Due to a lack of statistics for overweight/obesity among schoolchildren in Jordan, the present study was conducted to assess the prevalence of overweight and obesity in Jordanian children and adolescents and to investigate the level of maternal nutritional knowledge and dietary information.
Methods
Study approval
Approval of the Institutional Review Boards of the Medical School of Jordan University of Science and Technology and King Abdullah University Hospital, Irbid, was obtained first before the study was initiated.
Participants
The study was of analytical cross-sectional design and conducted in autumn 2016. A convenience sample of 516 children and adolescents aged 6–18 years was recruited. The sample was selected randomly from four public and four private schools in different areas of Irbid city in the north of Jordan.
Procedures
The researcher met with school administrations to provide all details about the study and to explain its objectives. Random classes from elementary, secondary and high schools were selected to guarantee the participation of all age groups. Based on the school administration’s preference, a specific time was chosen to let the researcher meet with all students and explain all the questions in the questionnaire. The researcher also mentioned the importance of the study and the privacy of the information to be collected. All participants were given a consent form and information sheet explaining the general background of the study and received a brief verbal explanation regarding the research objectives. All participants had the right to drop out during the study period.
Measures
Questionnaire
A trained researcher helped all students from all different age groups to fill out a pre-designed and pre-tested questionnaire; all questions were explained clearly to the students to guarantee understanding and accurate answers. The questionnaire was designed and circulated to three faculty members to review and it was modified based on their suggestions. Feedback comments were done to validate the questionnaire. The questionnaire had five sections. The first three concerned sociodemographic characteristics, general health and eating behaviours, which focused mainly on the number of meals taken daily, number of snacks, amount of water consumption and frequency of eating fast foods. The fourth section asked about lifestyle practices such as sleeping patterns, parental smoking habits, parents’ weight and height, electronic devices and watching TV. The last section of the questionnaire focused on physical activity level. The parents’ weight and height were recorded and then parental BMI was calculated to categorize them based on their BMI.
Anthropometric assessment
At the beginning of each class meeting, the researcher measured each student’s body weight, height and waist circumference (WC). Body height was measured to the nearest 0·1 cm using a stadiometer and weight was measured to the nearest 0·1 kg using a standard weighing scale, with the child wearing light clothes and barefoot. WC was measured to the nearest centimetre using a non-stretchable circumference-measuring tape (SECA 203, Germany). The site of tape placement was determined according to the WHO’s description of midway between the iliac crest and the lower rib border( 4 ). According to the WHO, there are no cut-off points for WC in children. Three measurements were recorded, and the average was taken. BMI was calculated as body weight in kilograms divided by the square of height in metres (kg/m2). Age-specific cut-off points of BMI (with the age ranging from 2 to 18 years) for the diagnosis of overweight and obesity were used. Those between the 85th percentile and 95th percentile on the growth chart were considered overweight, while underweight was set to be ≤5th percentile( Reference Cole, Flegal and Nicholls 17 , Reference Addo and Himes 18 ).
Nutritional knowledge of mothers
To examine the nutritional knowledge of parents, especially mothers, a quiz specifically developed for this purpose was circulated to three faculty members who were professionals in this domain to guarantee the simplicity, accuracy and validity. Modifications were done to the quiz based on the reviewers’ comments and suggestions. Six questions were included in the quiz. The questions focused mainly on the number of cups of water children need to consume, best fat/oil choices, which food items may cause obesity, healthy snack choices, the number of meals children need and foods rich in vitamins and minerals.
The students were encouraged to bring back the quiz the next day. Students were told that they would be given a prize when they brought back the quiz from their mothers/guardians. The prize was a set comprising a pencil, eraser, sharpener and notebook. Parents who answered four or more questions correctly out of the six (more than half of the questions) were considered to have adequate dietary information, while those who answered three or fewer questions correctly were considered to have a low level of dietary knowledge. The children demonstrated that mostly their mothers had answered the quiz questions (95 %), while fathers answered the quiz in 5 % of the cases only.
Statistical analysis
Collected data were entered in a data sheet and analysed using the statistical software package IBM SPSS Statistics version 19. Data were initially examined by performing descriptive statistics for all categorical and continuous variables. Characteristics of the participants were expressed as number and percentage using frequency distribution for categorical variables. Means and standard deviations were used for continuous variables after a Shapiro–Wilk test was performed to check normality. Data were normally distributed and ANOVA was used to examine the impact of age, gender, sociodemographic status, eating behaviour and lifestyle characteristics on participants’ BMI and WC. P<0·05 was considered significant.
Results
The sociodemographic and health characteristics of the students included in the study are presented in Table 1, which shows that about two-thirds of the population were females while only one-third were males (68 % v. 32 %). Age of the students ranged from 9 to 17 years; 46 % of male students were in the age group ≥15 years while 40 % of female students fell in that age group. Fifty-six per cent belonged to an extended family and about half of the participants had at least one working parent. Moreover, most of the students did not have any health problem except 19 % of them had allergy, and 58 % had healthy-weight parents.
Sociodemographic and health characteristics of the children and adolescents (n 516) by gender, Irbid, north Jordan, autumn 2016
* Values are significantly different between genders by the least significant difference test if P<0·05.
Table 2 shows that most of the study population considered lunch as the main meal (86 %). Nearly all of them (93·8 %) got fewer than three snacks per day. Eighty per cent of the participants worried about the quality of food they eat and 81 % revealed that they usually eat homemade food only. Seventy-four per cent revealed they take fewer than four cups of water daily. About 57 % of males and 70 % of females slept more than 8 h/d.
Lifestyle characteristics of the children and adolescents (n 516) by gender, Irbid, north Jordan, autumn 2016
TV, television.
* Values are significantly different between genders by the least significant difference test if P<0·05.
Regarding lifestyle characteristics, the study showed that 88·6 % of the students had an electronic device at home, as shown in Table 2. Among the 516 students, 39 % of them were eating while watching TV. Only 44 % of the participants reported that they consider themselves physically active (incorporate about 60 min of moderate exercising daily). Nearly 30 % of the study sample was overweight/obese (overall prevalence among the study group=29·5 %) and thus obesity seems to be a common problem among children in north Jordan. On the other hand, 59 % of the participants had normal weight and almost 11 % were underweight.
Children and adolescents in the present study were divided into three groups based on their age as follows: the first group included children aged ≤10 years, the second group included adolescents aged 11–14 years old and the third group included adolescents aged ≥15 years. The children’s and adolescents’ anthropometric characteristics based on their age group showed that there was a significant increase in mean BMI, WC, height and weight in general, as shown in Table 3. This increase in BMI and WC is expected because children grow fast during this stage of their lives.
Anthropometric characteristics of the children and adolescents (n 516) by age group, Irbid, north Jordan, autumn 2016
WC, waist circumference.
* Values are significantly different between age groups by the least significant difference test if P<0·05.
Examination of the means of BMI and WC according to gender, age, place of living and eating while watching TV showed that there was a significant difference (P<0·05) by BMI and gender among all age groups (Table 4). Males tended to have a higher BMI than females (P<0·05) in all age groups except the ≥15 years group, where females had a higher BMI mean than males (22·73 (sd 7·30) v. 22·57 (sd 5·56) kg/m2, respectively; P<0·05). A similar trend was also observed concerning WC between males and females, where males had a significantly higher mean WC compared with females in the age groups ≤10 years and ≥15 years (P<0·05). Mean BMI and WC among children and adolescents according to urban or rural residency showed that children living in urban areas had significantly a higher mean BMI than those living in rural areas in all three age groups (P<0·05). Likewise, mean WC for urban children aged ≤10 years and ≥15 years was significantly higher than that of their counterparts living in rural areas (P<0·05). Both mean BMI and WC were significantly higher in children who ate in front of the TV compared with those who did not eat while watching TV, except in the group of children aged ≤10 years (P=0·46).
Mean BMI and waist circumference of the children and adolescents (n 516) by age, gender, place of living and eating in front of the television, Irbid, north Jordan, autumn 2016
WC, waist circumference; TV, television.
* Values are significantly different between genders, living places and eating in front of the TV or not by the least significant difference test if P<0·05.
Table 5 shows that half of the parents knew the minimum water requirements for their children. However, about 80 % of those parents did not know the best oil to be consumed. Among the 516 participants, only 39 % of the parents know nutrients and food items that could contribute to obesity. Nearly 57 % of them realized that salad is a healthy food choice and about 60 % of mothers revealed that they mostly gave unhealthy options to their children when they are hungry as snacks. On the other hand, half of the mothers knew that fruits and vegetables are high in vitamins and minerals.
Parent’s answers to the nutritional knowledge quiz (n 516), Irbid, north Jordan, autumn 2016
* Values are significantly different between correct and incorrect answers by the least significant difference test if P<0·05.
Table 6 shows that 40 % of the mothers answered four or more questions correctly out of six, which indicates a sufficient level of nutritional knowledge, while 20 % of the mothers were considered to have a moderate level of nutritional knowledge (three out of six questions answered correctly) and 40 % had a low level of nutritional knowledge (fewer than three of the six questions answered correctly). We found a significantly decreased mean WC in the children and adolescents whose mothers had a moderate and high level of nutritional knowledge, compared with those whose mothers had a low level of nutritional knowledge.
Mean BMI and waist circumference of children and adolescents (n 516) by their mothers’ level of nutritional knowledge, Irbid, north Jordan, autumn 2016
WC, waist circumference.
a,bMean values within a column with unlike superscript letters were significantly different by the least significant difference test (P<0·05).
Discussion
The purpose of the present study was to estimate the prevalence of overweight and obesity among children and adolescents in north Jordan and to explore the risk factors associated with such crucial phenomena. The major finding of the study was that overweight and obesity are serious health problems that may be common in all age groups including children and adolescents in both genders. The prevalence of overweight/obesity was 29·5 %, while about 11 % of the study population was underweight. Our findings are similar to those of Mahajan et al.( Reference Mahajan, Purty and Singh 19 ) in India, who found that the prevalence of childhood overweight and obesity ranged from 3 to 29 % and indicated that the prevalence was higher in urban than in rural areas among children aged 6–12 years. A similar trend was also reported in Taiwan based on a cross-sectional study conducted among schoolchildren. In that survey of 1366 school-aged Taiwanese children, it was found that the prevalence of obesity has steadily increased from 1980 to 1994, from 12·4 to 16·4 % for boys and from 10·1 to 11·1 % for girls( Reference Chu 20 ).
Underweight has also been reported among schoolchildren (6–11 years) and adolescents (12–18 years) in many Arab countries. Studies in Egypt, Lebanon, Tunisia, Jordan, Yemen and Arab Gulf countries showed that the prevalence of underweight ranged from 10 to 35 % among schoolchildren and from 5 to 25 % among adolescents. Despite the fact that most of these studies were not national baselines, they give a good indicator that a high percentage of underweight exists in these age groups in the region. Unhealthy dietary habits such as skipping breakfast, low intake of nutritious foods (such as milk, fruits and vegetables), high intake of ‘empty-calorie’ foods (such as soft drinks and some sweets) and lack of nutritional knowledge are the main factors for the high proportion of underweight among schoolchildren and adolescents in the majority of Arab countries( Reference Musaiger 21 ).
In the present study, a significant difference (P<0·05) in BMI was found between boys and girls in the age groups ≤10 years and 11–14 years, with higher BMI in males than females. This agrees with Jeffry and Voss( Reference Jeffry and Voss 22 ) who found in 2015 that parents of obese boys were not aware about the weight of their children; on the other hand, girls and their parents were under more cultural pressure about their perfect body shape. Our findings are also in agreement with Geer and Shen( Reference Geer and Shen 23 ) who found that male children have larger WC because they have more abdominal fat than female children, which distributed in an apple shape. However, our study findings revealed that females at age ≥15 years had higher BMI than males of the same age. This could be due to hormonal changes, which are considered the main cause of weight changes at this age, and is in concordance with Waters et al. ( Reference Waters, de Silva Sanigorski and Hall 24 ), who found that women tend to crave foods high in fat and carbohydrate during specific phases of the menstrual cycle. Women also tend to have higher energy intake during their period and/or during premenstrual syndrome. Women with premenstrual syndrome suffer from any of a complex of symptoms including emotional tension and fluid retention in the days immediately before menstruation. Those symptoms change females’ appetite and energy-rich food craving, which contributes to weight gain.
We also evaluated BMI in children and adolescents living in urban and rural settlements. Those living in a city had a higher BMI compared with those who lived in villages. Children who live in a village are known to be more active and tend to play more with their peers in the neighbourhood. Children also practise outdoor play and sports, which have been substituted by video games, TV, computers and mobile devices by children who live in a city, which makes urban children at higher risk of becoming overweight and obese( Reference Kelishadi 12 ). Furthermore, children who live in a village spend less time at school and walk to school, instead of using school buses or private cars, that makes them less obese than city children( Reference Itoi, Yamada and Watanabe 25 ). On the other hand, frequent walking or cycling to school makes city children more active than those children who are living in villages and less likely to be overweight/obese( Reference Van Sluijs, Fearne and Mattocks 26 ).
The WHO( 27 ) reported that several environmental factors, including low air quality, pollution and high-density traffic, lack of parks and sidewalks, violence and absence of recreational facilities due to increased urbanization, might discourage participation in physical activity in both adults and children, thus increasing the rate of overweight and obesity( Reference Birch and Fisher 28 ).
Our results confirmed that children older than 11 years who eat in front of the TV tend to have higher BMI and higher WC. These findings agree with a study conducted on 523 children who ate in front of the TV, which found that 49 % of these children were obese( Reference Larson and Story 29 ). Commercials and mass media have a significant effect on eating habits. The amount of time spent in front of the TV and the content watched can be a reason for developing obesity. TV not only contributes to physical inactivity, but also commercials and other programmes encourage viewers to eat more( Reference Musaiger 1 ). In addition, watching TV goes hand in hand with eating snacks, most of which contain a large amount of energy. In the current study, among children aged ≤10 years, those who ate in front of the TV did not have a significantly different BMI or WC compared with those who did not tend to eat while watching TV. This is likely explained because most hormonal changes occur at about 15 years of age, which may make the older group more susceptible to obesity than younger children( Reference Cadogan, Blumsohn and Barker 30 ). Also, younger children tend to be more physically active and interested in playing more than older children and adolescents.
Parental nutritional knowledge level was generally low in the present study, as most of the mothers (60 %) did not answer an adequate number of questions correctly. Also, children of mothers having a high/moderate level of knowledge tended to have a decreased WC compared with children of mothers having a low level of nutritional knowledge. This may indicate that mothers or parents may pass on wrong behaviours and information to their children, which may affect their choices and dietary practices later in life and in turn affect their weight and health in adulthood.
Conclusion
The current study revealed that obesity is a growing health problem in child and adolescent school students in Irbid city, which requires an appropriate intervention, especially considering the alarming rates of obesity and its associated co-morbidities among Jordanian schoolchildren. Public health efforts in Jordan should be directed towards the creation of new prevention programmes at the individual, family and community level to promote schoolchildren’s health.
More research is required on the behavioural and biological causes of overweight and obesity, and on the prevalence among different regions, ages and settings. Appropriate health policies are urgently needed to prevent or reduce the obesity problem. Parents should learn more about proper nutrition and should be advised to monitor the dietary habits of their children and to correct any unhealthy habits as early as possible. Moreover, parents should play an important role in motivating their children to practise different sports in- and outside home. It is recommended that schoolteachers must be engaged in healthy nutrition training workshops to emphasize the importance of balanced nutrition for all school students in the north of Jordan.
Acknowledgements
Acknowledgements: The authors wish to thank the public and private schools of Irbid District for their help in conducting this research. Financial support: The work was supported by the Deanship of Research of Jordan University of Science and Technology (grant number 195/2016). The funder had no role in the design, analysis or writing of this article. Conflict of interest: There is no conflict of interest for any author regarding this manuscript. Authorship: H.S.S. conceived of and designed the study, conducted the analysis and interpretation of the data, and wrote the manuscript. Y.A.-S. conducted the research, collected the data and helped in drafting the manuscript. H.B. helped in drafting the manuscript. N.A.-B. carried out critical revision of the manuscript. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Institutional Review Boards of the Medical School of Jordan University of Science and Technology and King Abdullah University Hospital, Irbid. Written informed consent was obtained from all subjects.
