ORIGINAL ARTICLE

Factors associated with overweight and obesity in preschool

children
Amira Kurspahić-Mujčić1, Amra Mujčić2

Department of Social Medicine, School of Medicine, University of Sarajevo, 2Secondary Medical School; Sarajevo, Bosnia and Herzegovina
1

ABSTRACT

Aim To determine factors associated with overweight/obesity in

preschool children.

Methods This cross-sectional study was carried out in paediatric

outpatient departments of the Public Institution Primary Health
Care Centre of Canton Sarajevo, Bosnia and Herzegovina. The
study included 300 preschool children who were divided into two
groups: normal weight (n=150) and overweight/obese (n=150).
Children were weighed and measured and body mass index was
calculated. Data concerning potential childhood overweight/obe-
sity risk factors (sociodemographic characteristics of child and
mother, physical activity and sedentary behaviour of the child)
were collected using a designed questionnaire filled in by the
mothers. Logistic regression analysis was used to estimate the
association between potential risk factors and overweight/obesity
Corresponding author:
in preschool children.
Amira Kurspahić-Mujčić
School of Medicine, Results Male gender of the children (p=0.043) and maternal
University of Sarajevo overweight (p=0.000) were positively associated with child
overweight/obesity. Male children were 1.6 times more likely to
Čekaluša 90, 71000 Sarajevo,
be overweight/obese than female (95% CI: 1.01-2.53). Children of
Bosnia and Herzegovina
overweight mothers were 3.34 times more likely to be overweight/
Phone: +387 33 202 051; obese than children with mothers of normal weight (95% CI: 1.77-
Fax: +387 33 202 051; 6.28). Physical activity <60 minutes/day ) (p=0.014), screen time
Email: amira.kurspahic@mf.unsa.ba >180 minutes/day (p=0.020), regular snacking while watching
ORCID ID: http://www.orcid.org/0000- television, using computer/tablet/ mobile phones (p=0.000) were
associated with overweight/obesity status of the preschool chil-
0002-0741-5490
dren.

Conclusion Public health programs that aim to reduce overweight/

Original submission: obesity in preschool children should mainly help mothers under-
stand the serious risk of childhood obesity and the importance of
01 April 2020;
them creating a healthy lifestyle in childhood.
Accepted:
05 May 2020 Key words: paediatric obesity, screen time, exercise, mothers
doi: 10.17392/1175-20

Med Glas (Zenica) 2020; 17(2): 538-543

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 Kurspahić-Mujčić et al. Overweight /obesity in preschoolers

INTRODUCTION The aim of this study was to determine factors

associated with overweight/obesity in preschool
The obesity epidemic in preschool children is
children in Sarajevo Canton.
on the rise and represents a serious public health
challenge (1). Recent evidence suggests that in EXAMINEES AND METHODS
obese children most of their excess weight is gai-
ned before the age of five years (2). Studies have Examinees and study design
indicated that childhood obesity is associated This cross-sectional study was carried out at the
with the development of noninsulin-dependent Paediatric Outpatient Department of the Public
diabetes at an early age (3). Obese children are Institution Primary Health Care Centre of Canton
more likely to suffer mental health issues and Sarajevo, Bosnia and Herzegovina (B&H) in the
psychosocial problems and even discrimination period March – July 2019.
(4). Childhood obesity predicts obesity in adult-
The study included preschool children. According
hood (5) and later cardiovascular disease (6).
to Kail (19), preschoolers are defined as children
Studies have shown that many factors can po- between 4 and 6 years of age. A total of 300 chil-
tentially be associated with overweight/obesity dren (150 of normal weight and 150 overweight/
in preschool children (7,8). From this, factors obese) were selected from patients who used
which are on the maternal side were marital sta- health care services at the Primary Health Care
tus, level of education, employment and weight Centre during the study period. It was combined
status (9). Some previous studies found that overweight and obese children, based on pre-
maternal characteristics had a stronger effect on vious research suggesting that children who are
children’s weight status than paternal characte- overweight are at risk of becoming obese (20).
ristics (10). This effect is mainly accounted for
The inclusion criteria were children aged 4-6
by a combination of genetic and behavioural
years who had a medical record in the Primary
factors, as mother has a strong influence on their
Health Care Centre of the Sarajevo Canton, wit-
children’s eating and drinking habits, as well as
hout contraindications for physical activity. The
on their activity levels (11).
exclusion criteria were children younger than 4
One of the factors related to overweight and obe- or older than 6 years, children who did not have
sity in preschool children is insufficient physical medical records at the Primary Health Care Cen-
activity (12). Today, young children are sedentary tre of the Sarajevo Canton, known contraindica-
for a significant portion of the day (13). Most tions for physical activity.
studies focused on screen time as an indicator of
The Ethics Committee of the School of Medici-
sedentary behaviour (14). There is solid eviden-
ne, University of Sarajevo, approved the study.
ce that increased screen time has been associated
For this research, a written consent of the Gene-
with overweight, obesity in preschool children
ral Director of the Primary Health Care Centre of
within multiple cohorts and studies (15,16).
the Sarajevo Canton was obtained. An informed
Marsh et al. reported that there was strong evi-
consent for participation in the study was taken
dence that screen time in the absence of food ad-
from all mothers.
vertising was associated with increased dietary
intake compared with non-screen behaviour (17). Methods
Considering the rapid rise in prevalence of early- A questionnaire was administered to mothers
onset obesity in preschool children, and its links accompanying their children to the Primary He-
to later childhood and adult obesity, particular alth Care Centre. The questionnaires were given
attention should be paid to identifying the early to mothers while they were waiting for the appo-
life risk factors for overweight /obesity. intment. The sociodemography section requested
No studies examined the factors associated with information on the child and mother. There were
overweight and obesity (sociodemographic cha- two items about the child (age, gender) and three
racteristics of child and mother, physical activity items concerning the mother: marital status (li-
and sedentary behaviour of child) in preschool ving with a spouse/co-habiting subject), single,
children in Bosnia and Herzegovina, but only divorced and widowed), level of education (in-
those which examined obesity in elementary and complete elementary school, completed elemen-
secondary school students (18). tary school, completed secondary school, com-

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pleted high school/university) and employment between normal weight and overweight/obese
status based on mothers’ stated employment du- group was performed by χ2 test.
ring an interview (employed or not employed). The individual effects of potential childhood
The mothers reported average minutes that the- overweight/obesity risk factors on the presence of
ir child spent in moderate to vigorous intensity child overweigh/obesity were obtained by logistic
physical activity (that makes him/her out of bre- regression analysis through the calculation of the
ath or warmer than usual) daily. According to the odds ratio (OR). The level of significance was set
World Health Organization (WHO) physical acti- at p<0.05, and the confidence level of 95%.
vity guidelines, preschool children who are physi-
cally active for at least 60 minutes of moderate-to RESULTS
vigorous intensity physical activity (MVPA) da- The study evaluated 300 children in two groups
ily were considered as compliant with the WHO of 150 each (i.e. normal weight and overweight/
physical activity recommendations (21). obese).
The mothers reported average minutes per day their More male children were in the overweight/obe-
child sat and watched television, and also the time se than in the normal weight group, 82 (55.0%)
the child used a computer/ tablet/ mobile phones. and 65 (43.3%). More female children were in
The specific questions asked were, ''Over the past the normal weight group than in the overweight/
30 days, for how many minutes on average per day obese, 85 (56.7%) and 67 (45.0%).
did the child sit and watch TV?“ and ''Over the past Most of the children in the normal weight and
30 days, for how many minutes on average per day overweight/obese group, 124 and 123 (82.7% and
did the child use a computer/tablet/mobile phone?" 82.0%, respectively) resided in 2-parent househol-
We summed up average minutes of television and ds, with both their biological mother and father.
computers/ tablet/ mobile phones to estimate "scre-
Maternal education level in the normal weight
en time." We defined high screen time as greater
and overweight/obese group was not significantly
than 120 minutes (2 hours) per day (22).
different (p=0.448). Maternal education level
Variables “snacks in front of TV” and “snacks in included mainly high school/ university educati-
front of computers/tablet/mobile phones ” were on, 86 (57.3%) in the normal weight group and
grouped in “snacks in front of screens”, with 92 (61.3%) in the overweight/ obese group.
three options of answers: never, sometimes, and
Maternal employment in the normal weight and
always eats snacks in front of screens.
overweight/obese group was not significantly
The mothers were asked to indicate their own height different (p=0.803). Slightly more children of
and weight. Maternal body mass index (BMI) was employed mothers were in the overweight/obese
calculated as underweight (BMI <18.5), normal- group than in the normal weight, 105 (70.0) and
weight (18.5< BMI <24.9), overweight (BMI ≥25- 102 (68.0), respectively.
29.9), and obese (BMI ≥30). Children were weighed
Among normal weight children, 16 (10.7%) li-
and measured, and BMI was calculated. Weight was
ved with an overweight mother, and five (3.3%)
measured with the child in light clothing, to the ne-
lived with a mother who was obese. Among
arest 0.1 kg. Standing height was recorded without
overweight/obese children, 43 (28.7%) lived
shoes to the nearest 0.1 cm. The BMI was calculated
with an overweight mother, and six (4.0%) lived
as weight (kg) divided by height in square meters
with a mother who was obese.
(m2). The BMI categories were defined according
to the WHO reference curves for different age and A total of 87 (58.0%) children in the normal weight
gender groups (23): normal weight (BMI between group and 65 (43.3%) in the overweight/obese gro-
5th-85thpercentiles), overweight (BMI between up spent at least 60 minutes each day in MVPA.
85th-95th percentiles), and obese (BMI ≥85th-95th A total of 14 (9.3%) children in the normal weight
percentiles). The mothers were also asked to report group and eight (5.3%) in the overweight/obese
their weight and height. group achieved screen time recommendations
(<2 hr per day).
Statistical analysis
Four times more children with regular snacking
Testing of the difference in the distribution of po- while watching television, using computer/tablet/
tential childhood overweight/obesity risk factors mobile phones was in the overweight/obese gro-

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 Kurspahić-Mujčić et al. Overweight /obesity in preschoolers

Table 1. Distribution and association of risk factors and overweight/obesity in preschool children
No (%) of children Logistic regression analysis
Potential risk factor
p
Normal weight Overweight / obese OR (95% CI) p
Child gender
Female 85 (56.7) 67 (45.0) 0.049 1
Male 65 (43.3) 82 (55.0) 1.6 (1.01-2.53) 0.043
Family status
Two-parent family (married) 124 (82.7) 123 (82.0) 0.582 1
Single parent family (divorced) 25 (16.7) 27 (18.0) 1.09 (0.59-1.98) 0.780
Single parent family (single) 1 (0.7) 0 (0.0) 0.34 (0.01-8.33) 0.505
Maternal education level
Completed high school /university 86 (57.3) 92 (61.3) 0.448 1
Completed secondary school 64 (42.7) 57 (38.0) 1.2 (0.46-1.91) 0.437
Incomplete/completed elementary school 0 (0.0) 1 (0.7) 0.36 (0.01-8.87) 0.529
Maternal employment
Yes 102 (68.0) 105 (70.0) 0.803 1
No 48 (32.0) 45 (30.0) 1.09 (0.68-1.79) 0.7081
Maternal body mass index status
Normal weight 123 (82.0) 99 (66.0) 0.001 1
Underweight 6 (4.0) 2 (1.3) 0.41 (0.08-2.09) 0.286
Overweight 16 (10.7) 43 (28.7) 3.34 (1.77-6.28) 0.000
Obese 5 (3.3) 6 (4.0) 1.49 (0.44-5.03) 0.519
Physical activity (minutes/day)
≥60 87 (58.0) 65 (43.3) 0.039 1
30-59 59 (39.3) 79 (52.7) 1.79 (1.12-2.86) 0.014
< 30 4 (2.7) 6 (4.0) 2.01 (0.54-7.41) 0.295
Sedentary behaviour
Screen time (minutes/day)
< 120 14 (9.3) 8 (5.3) 0.022 1
120-180 118 (78.7) 107 (71.3) 1.59 (0.64-3.93) 0.318
> 180 18 (12.0) 35 (23.3) 3.40 (1.20-9.61) 0.020
Snacks in front of screens
Never 49 (32.7) 14 (9.3) 0.000 1
Always 14 (9.3) 56 (37.3) 3.22 (1.65-6.27) 0.000
Sometimes 87 (58.0) 80 (53.3) 1.14 (0.49-2.63) 0.753
OR, odds ratio; CI, confidence interval

up, 56 (37.3%), than in the normal weight group, DISCUSSION

14 (9.3) (Table 1). This study investigated the factors associated with
Male gender of the children (p=0.043) and mater- overweight/obesity in preschool children in Sa-
nal overweight (p=0.000) were positively asso- rajevo Canton. The results of this study showed
ciated with child overweight/obesity. Male chil- that maternal overweight had a significant asso-
dren were 1.6 times more likely to be overweight/ ciation with child overweight/obesity. Similar to
obese as female (95% CI: 1.01-2.53). Children our finding, Janjua et al. found that children of
of overweight mothers were 3.34 times more li- overweight and obese mothers were more likely
kely to be overweight/obese than children with to be obese and overweight at the age of 5 (24).
mothers of normal weight (95% CI: 1.77-6.28). Those results match previous studies and suggest
Family status, maternal education level and ma- that maternal excess weight has an important role
ternal employment were not significantly asso- on child’s BMI (25,26). This relationship can be
ciated with overweight/obesity status of the pres- explained through both genetic and lifestyle fac-
chool children. tors passed on from mothers to their children (27).
Physical activity <60 minutes/day ) (p=0.014), In this study, male children are found more likely
screen time >180 minutes/day (p=0.020), regular than female to be overweight/obese. Overweight
snacking while watching television, using com- and obesity rates in preschool children in the Eu-
puter/tablet/mobile phones (p=0.000) were asso- ropean Union are generally higher in boys than in
ciated with overweight/obesity status of the pres- girls (28). This may be attributable to different body
chool children. Regular snacking in front of the standards for boys and girls. For example, mothers
screens is a practice that triples children’s risk of may think that boys should eat more to grow faster,
becoming obese (95% CI: 1.65-6.27). (Table 1). which encourages overeating and can lead to obe-
sity. In addition, the prevalence of overweight and

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obesity in Turkish children aged less than 7 years related to consumption of unhealthy food thro-
was without gender difference (29). ughout the day (40). Studies have revealed that
Research on relationship between maternal edu- children consume a large proportion of their daily
cation level and overweight /obesity in prescho- calories and meals while watching screen media
ol children has not provided a definite answer. (41). In this study, regular snacking in front of
Some studies, as well as this one, have not found screens is a practice that triples children’s risk for
a statistically significant relationship (30). Pre- becoming obese.
vious studies across 11 European countries have This study aimed to focus on the role of sociode-
indicated that low maternal education could yield mographic characteristics of child and mother,
a substantial risk of early childhood obesity (31). physical activity and sedentary behaviour of the
Interestingly, the association between maternal child, but many other factors of the family envi-
education and children’s weight status in China ronment might influence children’ obesity. The-
is different from that in western countries. In refore, future research is needed to explore other
China, the obesity rate among children with high potential factors associated with overweight/obe-
maternal education is higher than that of lower sity in preschool children that were not included
maternal education (32). in the present study.
A growing research literature has explored the In conclusion, this study demonstrated a signi-
relationship between maternal employment and ficant association between maternal overweight
children’s body mass index (BMI) (33,34). A syste- and children’s weight status. This suggests that
matic review using six studies from the United Sta- early interventions for childhood obesity sho-
tes of America, the United Kingdom, Germany and uld focus on children of overweight or obese
Japan, concludes that maternal employment is asso- mothers. In addition, factors including screen
ciated with an increased risk of overweight /obe- time viewing and physical activity are also asso-
sity for children (35). The employed mothers spent ciated with children’s weight status. Educating
less time on meal preparation and healthy weight parents, specially mothers on the screen-use re-
management than unemployed mothers as docu- commendations and the negative health risks of
mented by Savage et al. (36). In this study maternal excessive screen use, as well recommendations
employment was not significantly associated with for physical activity may improve parental awa-
overweight/obesity status of the preschool children. reness and monitoring of their children’s seden-
Regarding other risk factors for overweight / tary behaviour and physical activity.
obesity, our results fit into known patterns; as in
FUNDING
other studies, screen time viewing was positively
(37,38), whereas physical activity was inversely No funding was received for this study.
associated with childhood overweight or obesity
in preschool age children (39). TRANSPARENCY DECLARATION

The number of hours in front of TV is directly Competing interests: None to declare.

6. Nadeau KJ, Maahs DM, Daniels SR, Eckel RH.
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