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��ࡱ�>��	�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������c�)��0z�bjbjZ�Z�	4�8�b\8�b\�}�������j	j	������������8.Dr<�(/0�����"""k.m.m.m.m.m.m.$X0�3<�.Q�"""""�.����H�.�*�*�*" ����k.�*"k.�*�*,�,����������������B%*�,W.�.0(/�,,J3l&0J3�,J3��,�""�*"""""�.�.�*"""(/""""��������������������������������������������������������������������J3"""""""""j	>�:	)Prevalence of Underweight and Overweight/Obesity in a Sample of Iranian Children Aged 3-6 Years: Relationship between Some Socio-Economic Variables


Abstract
Despite the growing prevalence of overweight/obesity trends in recent years, underweight is still reported within a wide range of Iranian children. The results of studies conducted in this domain to determine socio-economic variables affecting these two disorders are not also endowed with a homogeneous pattern, so that it is not even possible to indicate the proportion of each of the variables affecting children�s weight and develop a comprehensive theory on this issue. Taking the insignificant evidence in this regard into account, the purpose of this study was to determine the prevalence of overweight/obesity and underweight in a sample of Iranian pre-school children as well as family-related socio-economic variables. To this end, 1224 pre-school children living in the city of Arak in one of the provinces in center of Iran participated in this study. One of the intricate and multiple relationships examined was associated with family-related variables such as age, birthplace, occupation status, native or non-native parents, birth order, family size in both genders, as well as their effects on the prevalence of weight disorders using statistical approaches for data analysis. Based on the results of multilevel logistic analysis in this study, each of the maternal socio-economic variables could have an impact on underweight and overweight/obesity with different levels and trends compared with paternal ones and also the given effects were reported different between both genders.
Keywords: Underweight, Overweight, Obesity, Socio-Economic Variables, Parents, Children Aged 3-6 Years

Introduction
Over the past thirty years, the prevalence of overweight/obesity in pre-school children living in developing countries has been rising (1-3); so, in recent years, prevalence rates have doubled (4). However, in developing countries such as Iran, both growth disorders (underweight and overweight/obesity) have been reported (5-8) and also accompanied by significant complications for an individual�s survival, incidence of acute and chronic illnesses, as well as associated socio-economic costs during early years of life (9).
According to the reports released by international organizations; the prevalence rate of underweight in children under 5 years of age, between 1990 and 2011, has dropped by 25% from 40% and it has reached 25% of the population of children aged less than 5 years (10). In 1996, the first national survey in Iran also revealed that the prevalence rate of underweight in children under 5 years of age was 6.16% and this value reached 4.08% after fifteen years in 2011 (11). It should be noted that, in spite of this downward trend, the given rate in deprived areas of Iran is still high and several times higher than the nationwide average.

So far, studies conducted in this domain have been limited to growth disorders in pre-school children; so that 30-50% of these disorders have not been diagnosed until school age (12,13). It should be noted that underweight or overweight/obesity among pre-school children can be affected by numerous variables such as race/ethnicity (14,15), education, income, occupation status, and parent's place of residence. In this respect, researchers have considered mutual and complicated effects of socio-economic and political variables involved in weight-related disorders, especially underweight, due to inequalities in social sub-groups (16).
Nowadays, numerous studies have been carried out on the impact of determinants of overweight/obesity but their results have not been endowed with a homogeneous pattern; for example, the highest prevalence rate of obesity was seen among white people in South Africa while the highest prevalence rate of obesity in developed countries had occurred in individuals with low socio-economic status, especially if those individuals belonged to a certain race or an ethnic group (17). The relationship between socio-economic status and disorders such as overweight/obesity can also change over time and the given relationship is changing with the transition of economic growth. Therefore, today, overweight/obesity in developed countries such as the United States, Australia, France, Britain, Sweden, and Spain is correlated with low socio-economic conditions; while, at the same time, it is directly related to high socio-economic status in developing countries such as Brazil, Cameroon, Jordan, and Madagascar (18). It should be noted that as a country goes through economic recession within its economic development; the prevalence rate of obesity can be reduced; for example, it was observed in some Eastern European countries and Russia in the late 1980s and early 1990s (19). As long as the economic situation is improved; for instance, in West Germany (in schoolchildren) or Croatia (among pre-school children), the prevalence rate of obesity can have an increasing trend (20,21) while economic inequalities are considered as strong variables affecting low prevalence of underweight and, of course, underweight has always been aligned with low socio-economic status.
Although there is no general consensus regarding the age at which the effects of socio-economic inequalities on physical status can be seen, some evidence suggests that such impacts can be investigated at pre-school age (22,23). Accordingly, child care professionals reflect on pre-school age as the main age for the development of growth disorders such as overweight/obesity (24-26). Thus, attempts made to learn more about the variables affecting these disorders in this stage of life are of utmost importance in terms of prevention and treatment of underweight/obesity.
The main challenge in examining growth in children is lack of comprehensive information from different countries as well as diversity of research results. Moreover, the complexity of this issue has not led to an accurate estimate of the impact of these variables, especially in developing countries such as Iran, so that determining the proportion of each of the important and effective variables in a very organized classification pattern is not possible.
Thus, this study aimed to determine the power of some family-related socio-economic variables such as education, age, occupation status, parents� birthplace, birth order, and family size on the prevalence of underweight and overweight/obesity in pre-school children (3-6 years old) in the city of Arak in Iran in order to compare the most important variables affecting weight disorders at the age of 3-6 years in both genders.

Methods
Arak is the capital city of one of the central provinces of Iran called Markazi Province. This province is known as the industrial hub of the region, so a wide range of people belonging to different ethnic groups in Iran from all over the country have been immigrating to this area for a long time.
To this end; using a survey method via questionnaire (a list of questions with a guide), this study was conducted by determining the sample size based on similar studies within this age (27) and 1224 children (600 boys and 624 girls) aged 3-6 years were randomly selected from 20 pre-school centers (30 boys and 30 girls from each center) in the city of Arak.
After the approval of the research project (with the ethics code of 13951) and obtaining necessary permits, the methods of filling in the questionnaires were taught to the investigators (paramedical students). As well, weight (with a precision of 0.1kg) and height (with a precision of 0.1cm) were measured for children and they were recorded in combination with other data considering the anonymity of children.
Body mass index (BMI) was also calculated based on the formula of weight/height squared (kg/m2). According to the standard charts of the Centers for Disease Control and Prevention (CDC) 2000, children�s BMI were divided into two groups: the first group included children with a BMI equal to or above the 85th percentile standard (overweight/obese) and the control group that were not overweight/obese (the latter group included children with normal and low weight). Besides, the second group was comprised of children with a BMI below the 5th percentile standard (underweight) and the control group included children who were not underweight or normal but overweight/obese.
The data obtained were entered into the SPSS Software (Version 18) and two analyses were conducted: 1) initial descriptive analysis and 2) multilevel logistic regression analysis. The multilevel logistic regression analysis was employed to rank the variables in several levels; thereby, to correct the standard errors of cluster calculations of the variables so that accurate confidence intervals and significance levels could be established (28). In this study, multilevel logistic regression analysis (adjusted) was also used to investigate the relationship between overweight/obese children (the dependent variable) and age, education, birthplace, parent's occupation status, and family size (independent variables) in terms of gender. The same analysis was similarly performed for the variable of underweight. Furthermore, the results of the logistic regression analysis in the form of odds ratio (OR) were shown with the corresponding 95% confidence intervals (95% CI). Positive deviation from zero also implied the additive interaction.

Results
The findings revealed that 1224 children (49.01% boys and 51.99% girls) aged 3-6 years had participated in this study. The total prevalence rate of underweight was 12.6% and the results revealed that the female participants were more affected with underweight than the male ones. Besides, the total prevalence of overweight/obesity was reported by 19.2% and the boys were suffering more from overweight/obesity than girls. The highest rates of underweight and overweight/obesity were also observed in 4-year-old (18.2%) and 6-year-old children, respectively.
In this regard, Table (1) illustrated the prevalence rate of disorders in Iranian children aged 3-6 years considering gender and age; and Table (2) showed the distribution of parental socio-economic variables affecting overweight/obesity and underweight groups. Moreover, the prevalence rate and the risk of overweight/obesity due to parental socio-economic variables in terms of gender were presented in Table (3) and the prevalence rate as well as the risk and the odds ratio of underweight in parental socio-economic variables, separately by gender, were delineated in Table (4).

Discussion
In recent years, the Middle East and North Africa region (MENA) has been encountered by the crisis of weight disorders in both sides of population distribution (29,30). In this respect, some evidence has reported the existence of underweight/obesity together in the same family (with low socio-economic status) (31).
In this study, less than 20% of children aged 3-6 years were in the physical status of overweight/obesity (with a slightly greater prevalence which was not significantly correlated in boys). Consistent with these results; Netay and Kelishadi et al. in a nationwide study on children aged 6 years reported the prevalence of overweight/obesity by 19.4% in which the highest prevalence rate of obesity were observed in children living in the city of Tehran as well as Iran�s Northern regions and the lowest prevalence rate was seen in the cities located in Western Iran (32). The prevalence rate of overweight/obesity in pre-school children has been also reported in various rates in cities and provinces of Iran (20-33%) (33,34,5). For example, Jafar Adl et al., in an investigation reviewing related articles between 2005 and 2014 reported the prevalence rate of obesity highly various in Iran due to the multi-ethnicity of Iran as well as the cultural, social and economic differences of its provinces (35). Another study on children aged 0-5 years in Eastern Mediterranean countries similarly showed that the prevalence rate of overweight in children living in rich Persian Gulf countries was relatively low (from 1.9% to 9.4%); however, in countries such as Djibouti (12.3%) and Syria (21.9%), the given rates were reported to be high (36).
In this study, the prevalence rate of underweight children aged 3-6 years was 12.6%, which was much higher than the nationwide investigation conducted in Iran in 2011, but close to the results of another study by Kelishadi et al (32). As well, Sharifzadeh et al. reported the prevalence of underweight children less than 6 years of age at moderate to severe rates in urban and rural areas of Eastern Iran due to the recent drought in the region (12.9%) and shed light on the effective variables including place of residence, mother�s occupation, as well as parental education. Similar to the results of the present study, girls were much more underweight than boys and also children living in villages were more affected with underweight than those residing in urban areas (37). In a study in 2011, Motlagh et al. examined 6-year-old Iranian children in terms of their underweight and obesity together and found genetic factors and differences in economic status of provinces as well as ethnic differences as important variables in this domain (7). Thus, some Iranian researchers suggested a pattern of underweight and overweight/obesity specific to sub-ethnic groups in Iran due to ethnic differences in Iranian children�s growth (38).
In the present study, the prevalence of underweight in children was lower than that of overweight/obesity. Some other evidence also revealed that, in recent years, overweight/obesity has been alarming despite the fact that underweight was taken into account as a major problem in children�s health status in Iran a few years ago (39). Moreover, the prevalence of underweight in some low-income Asian countries is still high (40,41,23).
The place of residence for all the participants in this study and their parents was urban areas, but the birthplace of respectively 3.3% and 2.8% of fathers and mothers examined was rural areas. In this case, the impact of parental birthplace on the risk of underweight and overweight/obesity was different. So, mothers from urban areas could lower the likelihood of underweight and increase the chance of obesity, while fathers form urban areas could multiply both the risk of underweight and overweight/obesity in children. In fact, the strongest risk variable for obesity in these children was their parents� birthplace. Some other studies also indicated that urbanization in Iran was much more effective than other demographic and socio-economic variables determining obesity (42,43).
The adjusted analyses in this study also demonstrated that education i.e. high school diploma and higher degrees among mothers could have a generally negligible impact on underweight in children; however, examining differences in the effects of these variables on gender revealed that high levels of maternal education could have a rising effect on underweight in girls and a decreasing impact on underweight in boys which was likely to be related to gender preference (as pointed out in some sources) (44-46). Besides, higher levels of education in mothers could augment the likelihood of overweight/obesity in all children by 1.5 times, but it did not have any effects on the chance of obesity in boys; while it could double obesity in girls. In total, higher education levels in mothers had increased the probability of both weight disorders in girls, while the effect of paternal education was opposed to maternal one with a less power, so that high school diploma and higher education in fathers could insignificantly add to the incidence of obesity and underweight in boys implying the different effects of maternal and paternal variables on both genders. It should be noted that education is considered as an indicator that can be reviewed and compared more than occupation and income. Besides, the use of education is more useful for measuring socio-economic status of a person in empirical studies (47). In this respect, Maddah and Javaheri also assessed that the relationship between parental higher education levels and overweight was positive (48,49).
Moreover, housekeeper mothers had doubled overweight/obesity especially in boys, but they had led to an increase in underweight in girls that showed the effect of gender difference in terms of maternal education. The results of the present study also revealed that occupation status in mothers, following parental birthplace and maternal education level was a strong variable affecting the incidence of obesity in pre-school children. Examining the impact of father�s occupation on weight disorders correspondingly showed that employed and unemployed fathers could increase obesity in boys and underweight in girls; respectively. Moreover, Tchicaya did not find any relationship between parental occupation and childhood obesity but Hungarian researchers reported a correlation between paternal occupation and physical status in girls (18,50). Studying BMI by some researchers in Japan in children aged 3-6 years also indicated that children who had to live with others such as grandfathers or grandmothers due to their mothers� occupation were likely to be affected with an increased risk of obesity (51). In the present study, the possibility of examining the impact of grandparents on the weight disorders of these children was not provided due to the fact that all employed mothers had put their children in pre-school centers.
The results of this study showed that the larger the family size (4 members or so), the higher the likelihood of obesity in girls, but birth order (first-born) had augmented the risk of underweight, especially in boys, while it had no effect on overweight/obesity. Furthermore, Dorosti et al. (2012) studying children in one of the central provinces of Iran (Isfahan) did not find any relationships between obesity and birth order (52).
In this study, younger mothers had reduced the probability of obesity among all their children, while younger fathers had increased risk factors for overweight/obesity in children especially in girls. Contrary to these results, the effect of parental age on underweight was obtained. Maternal age (e"30 years) was also considered as the strongest variable affecting underweight in this study while paternal age had lowering impacts on underweight.
However, interaction between various family-related socio-economic variables can change according to parent-child�s gender, or it may not be possible to distinguish such a difference between both genders. Despite all this diversity, evidence suggests that the effect of parental variables depends on child�s age as well as their gender so that it is more likely to be seen in early childhood than in adolescence and this issue can justify variation in the results of studies on different age groups (53).
Research has also demonstrated that maternal variables are considered as important ones determining obesity in pre-school children (54). Considering that variables such as parental birthplace (urban areas), mother�s occupation (housekeeper), father�s occupation (employee) as well as parental education had positive effects on the prevalence rates of overweight/obesity in the present study, it seemed that high socio-economic status in this community had an increasing impact on the prevalence of overweight/obesity in children aged 3-6 years . Although, in almost all cases, the effect on both genders was different, research studies by Lamerz in Germany showed that the prevalence rate of childhood obesity was three times considering low socio-economic status (55); while in countries located in the Eastern Mediterranean region, the prevalence rate of overweight children aged 0-5 years in low- and middle-income countries was higher than high-income ones (47). Moreover, investigations by Kelishadi on 6-year-old Iranian children in different provinces revealed that prevalence of overweight/obesity along with low rates of underweight was similar to high prevalence of overweight/obesity in children and adults in provinces with economically low status (32).

Among the variables studied, being first-born and having a younger mother had increased the risk of underweight in children aged 3-6 years more than other ones. In addition to these two variables, some variables such as unemployed fathers and housekeeper mothers had added to underweight only in girls that could be related to the effects of gender preferences. At the same time, underweight in these children would be due to other variables such as low birth weight, parental weight, and related genetic factors or child�s growth status during childhood although there was no possibility to examine them in this research.

Advantages and Disadvantages
The advantage of cross-sectional studies like the present one was the availability of a large population of children aged 3-6 years as a sensitive and important age group in both genders which could provide a various pattern of socio-economic indicators although such inherent associations were cross-sectional and affected by other variables in terms of their orientation.
Such information are disseminated nationally every few years in developed countries and they are not also available in developing countries such as Iran; thus, the standard charts of CDC 2000 were used as a reference to determine overweight/obesity and underweight in children in which genetic, geographical, or regional variables affecting growth in Iranian children would not be included although their effect on the results of this study was unlikely.

Acknowledgments
This article was based on the results of the research project approved by the Islamic Azad University of Arak with the code number of 1219508020025. We, hereby, express our gratitude to the Vice-Chancellor�s Office for Research for their cooperation to fulfill this study.














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