|Year : 2014 | Volume
| Issue : 5 | Page : 23-28
Prevalence of overweight and obesity in urban school going adolescents in Shimla city
Anjali Mahajan1, Prakash Chand Negi2
1 Department of Community Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
2 Department of Cardiology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
|Date of Web Publication||19-Dec-2014|
Department of Community Medicine, Indira Gandhi Medical College, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: To study the prevalence of overweight and obesity among school going adolescents in Shimla city in Himachal Pradesh. Materials and Methods: A school based cross-sectional study was carried out to determine the prevalence of overweight and obesity among urban school-going adolescents (10 to 19 years) of both sexes studying from fifth to twelfth classes in various government and private schools of Shimla city in Himachal Pradesh. Results: A sample of 3385 students comprising 1665 females (49.2%) and 1720 (50.8%) males was formed for the purpose of the study. It was observed that 39.8% subjects were underweight, 3.0% were overweight, and 0.9% obese. 5.7% adolescents were found to be centrally obese taking ninety-fifth percentile of waist circumference for age and sex as the cut off. In transition from the higher to lower socioeconomic status, there was an increase in prevalence of underweight and decrease in prevalence of overweight and obesity. Prevalence of overweight and obesity was more in females of the higher socioeconomic class. Conclusions: It is indeed ironic that a problem of 'plenty,' namely, childhood overweight and obesity has emerged, even as we are still fighting malnutrition and infectious disease. As such, conflict in public health messages is a distinct possibility and must be avoided at all cost.
Keywords: Adolescent, obesity, underweight, overweight
|How to cite this article:|
Mahajan A, Negi PC. Prevalence of overweight and obesity in urban school going adolescents in Shimla city. Int J Nutr Pharmacol Neurol Dis 2014;4, Suppl S1:23-8
|How to cite this URL:|
Mahajan A, Negi PC. Prevalence of overweight and obesity in urban school going adolescents in Shimla city. Int J Nutr Pharmacol Neurol Dis [serial online] 2014 [cited 2020 Jul 8];4, Suppl S1:23-8. Available from: http://www.ijnpnd.com/text.asp?2014/4/5/23/147461
| Introduction|| |
Obesity can now be seen as the first wave of a defined cluster of non-communicable diseases (NCD) in both developing and developed countries. This has been called the 'New World Syndrome' and is already creating an enormous socioeconomic and public health burden in poorer countries.  Obesity in adults is a well-recognized risk factor for several NCDs such as, non-insulin dependent diabetes mellitus (NIDDM), cardiovascular disease (CVD), hypertension, some cancers (such as endometrial, breast, ovarian in women, and prostate in men), and premature death. It is also associated with increased risk of dyslipidemias, gall bladder disease (GBD), and osteoarthritis. The most significant long-term consequence of obesity in childhood is that it predisposes to later obesity and thus increases the risk of NCD and premature death in adulthood. [2-6]
Childhood obesity is one of the most serious public health challenges of the twenty-first century. The proportion of children in the general population who are overweight and obese has doubled over the past two decades in both developed and developing countries, including India.  There has been a remarkable increase in the prevalence of overweight and obese children in both developed and developing countries. However, in countries with developing economies, such as India, the problem of obesity is emerging at a time when malnutrition remains a significant problem. Among Indian children, various studies report a varying magnitude of overweight and obesity. ,,, To the best of our knowledge no such study has been conducted in this area earlier; therefore, this pilot study was conducted to determine the magnitude of this upcoming problem in adolescent school children in Shimla city, in Himachal Pradesh, India.
| Materials and Methods|| |
In India, there is a paucity of data on the prevalence of childhood obesity, because little attention is paid to this serious emerging public health challenge. As we are still struggling to curb malnutrition and infectious diseases in children, problems such as childhood overweight and obesity take a backseat. As no data on childhood obesity and overweight was available from this part of the country, this study was undertaken to estimate the magnitude of childhood obesity and overweight in Shimla city. The sample size to be studied was therefore worked calculated to be 3385 students (assuming prevalence of obesity in children as 5%, with a permissible error of 15%). The sample size was used with a forethought that it would prove to be an asset to support the study findings.
We conducted a population-based, cross-sectional study from January 1, 2006 to September 30, 2006, in the urban schools of Shimla city. To start with, all primary, middle, and senior secondary schools in Shimla City from both the government and private sectors were enlisted. In the study area, there were a total of 57 number primary, middle, and senior secondary schools (28 number Government and 29 private) with a total student strength (source population) of 26,872 in the age group of 10 to 19 years, with the eligible population being 3,425. The schools to be included in the study from each sector were selected by the simple random sampling technique (Lottery Method). As per the calculated sample size, an almost proportionate number of students were selected for examination from each sector.
The examination of these students was done in a nonrandom manner in the serial order of the allotted roll numbers in their respective classes, that is, from fifth to twelfth standards. Prior permission from the concerned school authorities was sought for this study. The purpose and process of the study was explained to all the students and teachers. There was 100% response from the children of all selected schools in this study. Only children without history of any active disease or significant past medical history were included in the study. All the students from fifth to twelfth standards in these selected schools were examined as per a predetermined criterion, wherein, only those children above 10 years of age formed the subjects of the study. For the purpose of participating in the study, the students were given consent forms in advance to secure consent from their respective parents/guardians. In case a student was 18 years or above, his or her own consent sufficed. Information regarding age was obtained from the students and also verified from the school records. Other information such as sex, family size, history of hypertension in the family, and socioeconomic status was also obtained. Data collection was done during normal school hours. A pretested, structured, and self-prepared questionnaire was administered to the study subjects in advance of the day of examination. Students with the help of their parents/guardians filled the questionnaire. The pretest was carried out in one of the schools of Shimla city, which was not included in the study sample. Appropriate changes were made in the schedule, taking into consideration the experiences of the pretest. The students were called in groups of 15 in a separate room and their weight was noted with the help of a standardized weighing machine after removal of shoes, jackets, heavier clothing, and pocket contents. The weighing machine was tested daily for accuracy and calibrated against a set of standard weights. Their height was recorded with the help of a calibrated bar. For this, the child was made to stand upright, with heels together, and the weight borne evenly on both feet. Heels, buttocks, and back were brought in contact with the vertical surface. The head was so positioned that the child faced forward with the Frankfurt plane (the line joining floor of external auditory meatus to the lower margin of orbit) and the biauricular plane being horizontal. Height was measured on bare feet. The body mass index (BMI) was calculated as weight (Kg) divided by height (m²) and was then used to find the corresponding BMI-for-age percentile for the child's age and sex.
Waist circumference was measured using a flexible but inelastic (nonstretchable) graduated tape, which snuggled against the skin, but did not compress the soft tissue. It was measured midway between the inferior margin of the last rib and the crest of the ilium in a horizontal plane at the end of normal expiration.
A child was labeled as underweight when BMI was less than or equal to the fifth percentile for that age and sex.
A child was labeled as overweight when BMI exceeded the eighty-fifth percentile for that age and sex.
A child was labeled as obese when BMI exceeded the ninety-fifth percentile for that age and sex.
For labeling a child as underweight, normal, overweight or obese, the frequencies of BMI cut offs relative to the National Center for Health Statistics (NCHS)/World Health Organization (WHO) reference data (CDC Charts)  were used. Waist circumference cut offs for labeling a child as centrally obese do not exist. The ninety-fifth percentile of waist circumference of the study population was used as a cut off. The Modified Prasad Classification was followed for the assessment of the socioeconomic status of the study subjects.
Data collected was entered into the computer using a customized application with Sybase SQL Anywhere 5 at the back end of the relational database management system (RDBMS). Simultaneously, the data was cleaned for errors and omissions before transporting to MS Access 2000 DBMS and MS Excel spreadsheet 2000. Statistical analyses were performed using Healthwatch pro version 2.1 and statistical package SPSS version 10.0.1.
Both descriptive and inferential statistics were used to analyze the data. Chi Square, Analysis of Variance (ANOVA), and Correlation Coefficient analysis were carried out to test for proportions, association, and significant differences.
| Results|| |
A sample of 3385 students comprising of 1665 females (49.2%) and 1720 (50.8%) males was chosen for the purpose of the study. Of the total 1665 females, 661 (19.5% of total students) and 1004 (29.7% of total students) were from government and private schools, respectively. Similarly, of a total of 1720 males, 916 (27.1% of total students) and 804 (23.8% of total students) were from government and private schools, [Table 1] respectively. In the present study, the mean BMI of both the genders showed a significant increase with age. Between genders females had higher mean BMI values within each age group. In the 10 to18 year age groups, mean BMI increased from 14.7 to 20.6 in females and from 14.2 to 18.5 in males.
In the present study, variance in mean BMI was significant with variance in socioeconomic status in both the genders. Between the highest and the lowest socioeconomic class there was a reduction in mean BMI values in both the genders. At the overall level, BMI showed a significant increase with increase in the per capita family income of the students [Table 2].
|Table 2: Overweight and obesity in students based on socioeconomic class |
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In the present study, 86 (85%) of the total 101 overweight and 31 (100%) of the total 31 obese subjects were from the private schools. On the contrary, 62% of the total underweight subjects were from the government schools [Table 1]. The overall prevalence of overweight and obesity was higher in females than in males. In our study it was also observed that although differing between the sexes, the waist circumference was strongly associated with age. In the present study, 5.7% subjects were found to be centrally obese taking sex specific ninety-fifth percentile of waist circumference as the cut off.
| Discussion|| |
In the present study, mean BMI in both the genders showed a significant increase with age. Between genders, females had higher mean BMI values within each age group. In the 10 to18 year age groups, mean BMI increased from 14.7 to 20.6 in females and from 14.2 to 18.5 in males. The reason for this finding may be attributed to the fact that in children, BMI changes physiologically (substantially) with age and sex. The crucial periods for persistence of obesity appear to be the gestational period, the adiposity rebound age (5 to 7 years) and the adolescent age. Adolescence is a period of increased autonomy, which often results in irregular meals, changed food habits and spells of inactivity during leisure hours. This compounded by physiological changes, particularly in females, causes relatively higher fat deposition in them, thus leading to their relatively higher BMI values in relation to their counterparts.
In the present study, variance in mean BMI was significant with variance in socioeconomic status in both the genders. Between the highest and the lowest socioeconomic class, there was a reduction in mean BMI values in both the genders. At the overall level, BMI showed a significant increase with increase in the per capita family income of the students. The lower mean BMI value observed in students of lower socioeconomic classes was because of their inability to secure adequate food, yet remaining engaged in moderate to heavy manual work. It has been observed that as the per capita family income increases, the nature of diet in traditional societies and the role of physical activity tend to change in a pervasive manner. This increase in income, therefore, results in increased consumption of high calorie/high fat food items at or away from home and/or reduced physical activity. However, the overall effect tends to lead to obesity.
The prevalence of obesity (globally) has nearly tripled since the 1970s and has become a global public health challenge.  Increasing rates of overweight and obesity has reached epidemic proportions in developed countries and is rapidly increasing in many middle-income and less-developed countries. However, in countries with developing economies such as India, even as we are grappling with the problem of malnutrition, the emerging evil face of obesity is staring at us right in our face. This is clearly evident in our study.
In the present study, it was observed that 39.8% subjects were underweight, 3.0% overweight and 0.9% obese [Table 3]. The most likely explanation for such low prevalence of overweight and obesity and high prevalence of underweight is the high level of natural physical exertion associated with residing in hilly terrains hereafter referred to as the 'hill factor'. Approximately 72% students reported walking to school a variable included in the study only to confirm the effect of this hill factor. The hill factor playing an isolated role in the above observation does not seem very plausible and other factors such as imbalanced diets; genetics, and so on may also simultaneously be playing a complementary role in the etiology of underweight, overweight or obesity. These need further study. In a study conducted on 1630 students in Mangalore city, 82 children (5.03%) were found to be undernourished, 37 (2.3%) were overweight, and 16 (1%) were obese. 
Nitzan Kaluski et al., found 12.9% overweight and 5.6% obese in MABAT Youth Survey in the age group of 11 to 19 years in Israel.  El Mouzan et al., in a household survey in Saudi Arabia reported 17.9% overweight and 7.0% obese adolescents in the age group of 13 to 18 years.  In National Survey of Children's Health (NSCH) in United States, Singh et al., reported 15.2% overweight and 16.4% obese adolescents in the US. 
Oner et al.,  in a study on Turkish adolescents reported an underweight prevalence of 11.9% in females and 14.4% in males; overweight of 10.6% in females and 11.3% in males; obesity as of 2.1% in females and 1.6% in males. The coexistence of thinness and overweight adolescents has also been reported in a study in Nigeria. 
Kapil et al.,  reported the prevalence of obesity in adolescent school-going children of affluent Indian families to the tune of 7.4% and overweight 23.1%.
High incidence of overweight and obesity reported by Kapil et al.,  is probably because of selection of different populations (affluent family children). In the present study, 86 (85%) of the total 101 overweight and 31 (100%) of the total 31 obese subjects were from the private schools. On the contrary, 62% of the total underweight subjects were from the government schools.
Ramachandran et al.,  have reported similar finding. This is because of the rich poor divide and therefore, children studying in government schools are economically not very sound and mostly belong to a poor socioeconomic background.
The change of lifestyle and the use of new technologies (such as satellites, e-games, cell phones, and the Internet) may predispose children to new types of problems, such as obesity and antisocial behavior (such as violence, delinquency, and illegal sexual relationships). Hence it is strongly recommended that children be supervised properly when they are engaged in such activities to avoid their exposure to 'bad' games, films, websites, and the like, and at the same time to encourage them to practice regular physical exercise and to adopt a healthy lifestyle to prevent development of obesity and promote both physical and mental health. 
In the present study, the overall prevalence of overweight and obesity was higher in females than in males. Studies in humans and animals indicate that females exhibit a stronger preference for carbohydrates before puberty whereas, males prefer protein. However, after puberty, both males and females display a marked increase in appetite for fat in response to changes in the gonadal steroid levels. This rise in fat appetite occurs much earlier and to a greater extent in females. Females have a tendency to channel extra energy into fat storage whereas, males use more of this energy for protein synthesis. This pattern of energy usage or 'nutrition partitioning' in females contributes to further positive energy balance and fat deposition. Differences of prevalence of overweight and obesity between genders have been related to geopolitical and cultural conditions.  However, a study conducted in Delhi  among affluent adolescent school children, found a higher prevalence of obesity in males in comparison to females. In another study in Ludhiana,  no significant difference in the prevalence of overweight and obesity was found between the two genders.
Frank obesity may not be as high in India as in the west, but the body composition and metabolism of Indians (Asians in general) makes them especially prone to adiposity and its consequences. South Asians have at least 3 to 5% higher body fat for the same BMI as compared to Caucasians.  The fat is typically located centrally, and around visceral organs where it is metabolically more dangerous than peripheral fat. As in adults centralized or upper body fat is correlated with less favorable patterns of serum lipoprotein concentration and BP.
Our difficulty with this area of research is that despite increasing interest in measurement of regional fat deposition, commonly accepted cut offs for classifying subjects with central adiposity do not exist to date.
As in adults, centralized or upper body fat carries an increased risk for metabolic complications in children and adolescents Waist circumference correlates closely with BMI and waist-to-hip ratio (WHR) is an approximate index of the intra abdominal fat mass and total body fat. 5.7% adolescents were found to be centrally obese taking ninety-fifth percentile of waist circumference for age and sex as the cut off.
As waist circumference representing central fatness is an important correlate of concentrations of lipids and insulin among children and adolescents its measurement may therefore, help to identify children and adolescents with adverse concentrations of lipids and other risk factors.
| Acknowledgment|| |
The authors would like to extend special thanks to all the students who were the study subjects of this study and their parents. Without their consent and participation, this study would not have been possible.
| References|| |
Gracey M. New World syndrome in Western Australian aborigines. Clin Exp Pharmacol Physiol 1995;22:220-5.
Kemp MW, Kallapur SG, Jobe AH, Newnham JP. Obesity and the developmental origins of health and disease. J Paediatr Child Health 2012;48:86-90.
Must A. Morbidity and mortality associated with elevated body weight in children and adolescents. Am J Clin Nutr 1996;63 Suppl 3:445-7S.
Obesity: Preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:i-xii, 1-253.
Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents: A follow-up of the Harvard Growth Study of 1922 to1935. N Engl J Med 1992;327:1350-5.
Nader PR, O'Brien M, Houts R, Bradley R, Belsky J, Crosnoe R, et al.
National Institute of Child Health and Human Development Early Child Care Research Network. Identifying risk for obesity in early childhood. Pediatrics 2006;118:e594-601.
Raj M, Sundaram KR, Paul M, Deepa AS, Kumar RK. Obesity in Indian children: Time trends and relationship with hypertension. Natl Med J India 2007;20:288-93.
Kamath R, Kumar M, Pattanshetty S, Kamath A. Nutritional status assessment of school children in Mangalore city using the multicenter growth reference study WHO 2007 Z-scores. Int J Nutr Pharmacol Neurol Dis 2012;2:233-6.
Kapil U, Singh P, Pathak P, Dwivedi SN, Bhasin S. Prevalence of obesity among affluent adolescent school children in Delhi. Indian Pediatr 2002;39:449-52.
Sidhu S, Kaur N, Kaur R. Overweight and obesity in affluent school children of Punjab. Ann Hum Biol 2006;33:255-9.
Chhatwal J, Verma M, Riar SK. Obesity among pre-adolescent and adolescents of a developing country (India). Asia Pac J Clin Nutr 2004;13:231-5.
Mohan B, Kumar N, Aslam N, Rangbulla A, Kumbkarni S, Sood NK, et al.
Prevalence of sustained hypertension and obesity in urban and rural school going children in Ludhiana. Indian Heart J 2004;56:310-4.
Nitzan Kaluski D, Demem Mazengia G, Shimony T, Goldsmith R, Berry EM. Prevalence and determinants of physical activity and lifestyle in relation to obesity among schoolchildren in Israel. Public Health Nutr 2009;12:774-82.
El Mouzan MI, Foster PJ, Al Herbish AS, Al Salloum AA, Al Omer AA, Qurachi MM, et al.
Prevalence of overweight and obesity in Saudi children and adolescents. Ann Saudi Med 2010;30:203-8.
Singh GK, Kogan MD, van Dyck PC. Changes in state-specific childhood obesity and overweight prevalence in the United States from 2003 to 2007. Arch Pediatr Adolesc Med 2010;164:598-607.
Oner N, Vatansever U, Sari A, Ekuklu E, Güzel A, Karasalihoðlu S, et al.
Prevalence of underweight, overweight and obesity in Turkish adolescents. Swiss Med Wkly 2004;134:529-33.
Ejike CE, Onyemairo JN, Onukogu IA. Co-existence of child and adolescent obesity and thinness in a city in Nigeria: Comparison of results derived from different reference standards. Int J Nutr Pharmacol Neurol Dis 2013;3:276-81.
Ramachandran A, Snehalatha C, Vinitha R, Thayyil M, Kumar CK, Sheeba L, et al.
Prevalence of overweight in urban Indian adolescent school children. Diabetes Res Clin Pract 2002;57:185-90.
Al-Sharbati M. The emergence of behavioral disorders in children and adolescents. Int J Nutr Pharmacol Neurol Dis 2012;2:1-2.
de Moraes AC, Fadoni RP, Ricardi LM, Souza TC, Rosaneli CF, Nakashima AT, et al.
Prevalence of abdominal obesity in adolescents: A systematic review. Obes Rev 2011;12:69-77.
Deurenberg P, Deurenberg-Yap M, Guricci S. Asians are different from Caucasians and from each other in their body mass index/body fat percent relationship. Obes Rev 2002;3:141-6.
[Table 1], [Table 2], [Table 3]