Discriminating Bangladeshi Children and Adolescents of Affluent Families by Level of Obesity

Child obesity is a condition where excess body fat negatively affects a child’s health or well-being and creates a state of chronic calorie imbalance [1]. Trends in obesity are causing serious public health problem throughout the world [2]. It is a threat to the viability of basic health care delivery. It is an independent risk factor for many non-communicable diseases like diabetes, non-alcoholic fatty liver disease, cardiovascular disease risk, osteoarthritis and cancer. A global epidemic of pediatric obesity occurred in recent years, and prevalence of obesity is continuing to rise [3]. In the developed world obesity is now the most common disease of childhood and adolescence. In Bangladesh also, the increasing prevalence of overweight and obesity among children (0-12 years) and adolescents (13-19years) have emerged as a major public health problem [4] and it was observed that the prevalence of overweight and obesity among children and adolescents varied from 1.0% to 20.6% and 0.35 to 25.6%, respectively. The pooled prevalence rates of overweight and obesity were 7.0% and 6.0%, respectively. However, it is in increasing trend. Approximately, 43 million pre-school aged children throughout the world have been estimated to be overweight and obese and 92 million are at risk of overweight [5]. Children who are obese are at a significantly elevated risk for adverse health outcomes including both medical and psychological problems [6]. The most common medical co-morbidities associated with obesity include metabolic risk factors for type ІІ diabetes (T2D) including high blood pressure, high cholesterol, impaired glucose tolerance and metabolic syndrome [7,8]. Behavioral factors have significant effects on metabolic risk. It has been observed in some research findings that youth who do not meet guidelines for dietary behavior, physical activity and sedentary behavior have greater insulin resistance than those who do meet guidelines [9].

factors including genetics, environment, metabolism, behavior, personal history of obesity, culture and socio-economic status [9]. The origins of obesity can be traced to early adiposity rebound, which refers to the time at which BMI of young children begins to increase after reaching their lowest level of fat. Children in whom adiposity rebound begins at age of three years tend to have an increased mean BMI from age 3 to adolescence, which often extends into adulthood [14,15]. Children born to overweight or obese mothers are more likely to be overweight by the age of four years old even if their BMI is within the average range at the age of two years [16].
Other aspects of family environment are also highly influential [1].
Parents' knowledge about nutrition and physical activity have also been found to be very strong predictors of children's weight status [17]. In a study [18], among school-aged children it was observed that parental behavior and BMI have stronger impact on children's BMI. Features of the built environment, including excess to parks, supermarkets, and convenient store hours, have been found to moderate treatment effects of obesity intervention [19].
Proximity of a person's home to fast food restaurants has been associated with increased obesity rates [20]. Living in low-income neighborhoods has also been associated with more sedentary behavior and less physical activity [21]. School activity affects physical activity in youth. It has observed that children in higher socioeconomic schools have more excess to regular physical education classes than children attending low socioeconomic schools [22]. iii) to discriminate the children and youth according to the level of obesity and to identify the factors responsible for the discrimination.

Methodology
The present analysis was based on 662 responses observed from 560 randomly selected affluent [23,24] families of students  Table 1. Obese and severe group of children and adolescents were 9.1%. This finding is almost like that observed in another study [4]. It was seen that among the male children 77.4 percent were underweight. The corresponding figure among females is 60.3 percent. The differential in obesity by gender were significant [χ 2 = 44.03, p-value= 0.00].  The information of 72.5% children were reported from urban area. The corresponding percentages of rural and semi-urban chil-  The investigated children and youths were classified into three classes by their age levels. These three groups of children were again classified by their level of obesity. The classified results were shown in Table 3. It was seen that 72.5% children and youths of age group 10 years and above were underweight. The proportions of underweight children of other two groups were lesser than the percentages of overall underweight group of children. The higher percentage of overweight group was observed among the children of age less than 5 years. This differential in proportions of level of obesity according to age groups was highly significant as calculated χ2= 38.94 with p-value = 0.00. Amongst the investigated children and youth 22.8% were diabetic [ Table 4]. The corresponding percentage among obese and severe obese group together was 31.7%.
Diabetes was less prevalent among overweight group (16.8%). The differences in proportions of diabetic group among children with different levels of obesity were significant [χ 2 = 8.75 with p-value = 0.033].       Family environment is one of the correlates of obesity among children [19]. It seemed that family environment is influenced by parents' education and occupation. Let us investigate how fathers' and mothers' education were associated with children and adolescent's obesity. It was seen that [ Table 9] the fathers of 77.9 % children were highly educated and 75%  (Table 11) were also observed [χ 2 = 186.02 with p-value = 0.00]. But mother's occupation was not an influencing factor for the changes in the levels of obesity of children [ Table 11, χ 2 = 10. 50 with p-value = 0.572] (Table 12).

Results of Discriminant Analysis
The children and adolescents were classified by their level of obesity. There are 4 groups of respondents and for these 4 groups the variables age of the children, food habit of children, utilization of time by the children, father's education, mother's education, fa-ther's occupation, mother's occupation and family income were different and most of them were associated with the level of obesity.
Therefore, these variables were included to discriminate the children. For 4 groups of children 3 Fisher's linear discriminant functions were available. The coefficients of these functions for different variables are shown in Table 13.

Discussion
In a cross-sectional study, it was observed that 81.4% students of the university under study [24] were living in urban area and fathers of around 46% students were highly educated. Almost similar was the case with mother's education (90%). In respect of parent's education and family income, the families of the students could be considered affluent. The present study was done using the data collected from similar type of affluent families. The data were collected from 560 randomly selected families. In these selected families, there were 662 children and youth These children were privileged group compared to the general children of the country. Our objective was to study the level of obesity among the children and adolescents of affluent families.
The study result showed that around 6.3% children were obese and 2.8% belonged to severe obese group. In a separate study [4] it was observed that the proportions of overweight were 2%, 11% and 15% among children of age under 15 years, 5-9 years and 10-18 years respectively in the Indian sub-continent [Bangladesh, India and Pakistan], the pooled estimate of obesity was around 6%.
But these results were observed among all the children in the country The same percentage in Bangladesh was 7 [5]. The pooled estimate of proportion of obese and severe obese group of children and youth of affluent families was 9.1%. It indicated that among females among children of affluent families was an alarming problem.
Fathers of most of the children and youth were engaged in respectable profession and higher proportion of them belonged to higher income group. Majority of the investigated children were males and higher proportion of them were underweight compared to the underweight group among female. As these children and ad-olescents belonged to affluent families, they had the scope to go to high socioeconomic school in which the expected facilities of physical education exist. But majority of the children were engaged in watching T.V. Very few children were involved in games and sports.
Among the urban children risk of obesity was more compared to rural children. The percentage of obese children were lesser in rural area. This is an environmental effect on obesity as urban children spent less time for physical activity. Similar findings were observed in other studies. [18,21]. This study also indicated that the overweight and obesity were in increasing trend as rates of overweight were less in 2014 [5].
In a separate study [19] it was reported that the increasing trend of obesity was associated with fast food from restaurant. The present findings were also similar in respect of association of obesity and fast food from restaurants and visiting the fast food shops was associated with parent's social status and family income. The offspring from affluent families visited fast food restaurants every now and then and obesity and severe obesity were particularly observed among them. Upward trend in parent's education and family income were responsible factors for the children's physical inactivity and their tendencies to watch T.V. and for visiting fast food shops.
Discriminant analysis also showed that fathers' occupation was the most responsible factor for obesity and overweight of children and youth followed by mothers' education and fathers' education. As a result, children of affluent families were becoming obese and finally were affected by diabetes. These are grave health hazards with significantly elevated risk of medical and psychological problems [9]. Thus, obesity and diabetes are interrelated phenomena, which can start at any time of life. In many instances' obesity starts dur-ing childhood, unless proper care is not taken for the health of the children and youth.

Conclusion
The study was conducted among the children and adolescents of some randomly selected affluent [23,24] families of students of American International University, Bangladesh. Most of the children and adolescents were the city dwellers and parents of them were mostly highly educated and were in better economic and social conditions. The study indicated that obesity and severe obesity were significantly associated with parental social and economic status. Again, obesity and severe obesity were related to diabetes and many other non-communicable diseases [25,26]. These diseases are the major health burden in both developed and developing countries. In a separate study [2], it was reported that most of the NCDs affected people were suffering from diabetes. This is true for both children and adults. In this study also the prevalence rate of diabetes among the obese and severe obese groups of children and youth were observed higher (31.7%). This percentage was 21.9 among the underweight and overweight groups of children.
This is a problem for both parents and health planners. Parents can take care of foods of their offspring. They can choose school for their kids where there are enough facilities for child's physical education. Government can introduce some regulations so that physical education is a compulsory co-curricular activity of the school.
Urban parents should find time to accompany their kids to parks and playgrounds at least for some hours in a week. The urban children should be advised to go to the nearby school on foot accompanied by either of the parents or any of the family member. The school authority can encourage the children to take healthy foods which are available nearby school or they may be advised to bring healthy foods to take it during school hours. There should be prohibited regulations not to advertise fast food and candy for their children. Fresh and healthy foods along with physical activities may decrease the rate of obese children.