*3.2.7 Familial factors*

The family has a significant role to play in the development of childhood obesity. The influence starts even before the child is born. The first reported causal association of intra-uterine undernutrition resulting in obesity in the offspring later in life was from the observation of children born to women who were pregnant during the Dutch famine [45]. Intra-uterine malnutrition may lead to a higher susceptibility to excess weight gain due to increased fat stores, short stature and a preference for foods high in fats [46]. This is the 'mismatch' effect alluded to earlier. A phenomenon known as 'mirror imaging' between the mother and her baby is observed in India. The baby's birth size is predicted by the mother's size before pregnancy. Despite this, birth weight has been found to be a poor indicator of adiposity in the

foetus. In Caucasian populations, birth weight is related to lean mass rather than to fat mass; whereas, in India, babies have more fat mass as compared to Europoid babies at every ponderal index. Babies with both low- and high-birth weights have a high risk of obesity in later life in India [47].

Maternal and paternal heights are independent predictors of childhood obesity. The highest adiposity is seen in children who exceed mid-parental height. Parental height may serve as a composite indicator of genetic factors, nutrition and growth during childhood [47, 48]. Many studies in India have shown that the mother's BMI correlates with the child's weight. This may be due to genetic factors and environmental factors such as shared diets and eating habits [31, 49]. Raskind et al. found that every overweight child had an overweight mother. The combination of overweight mother and child formed 11% of their study population which was one of the highest in Asian countries [50]. Rebecca Kuriyan studied the role of familial and sibling factors on abdominal adiposity in children in an urban location in South India. Multiple regression models showed that overweight status of father or mother was associated with the younger sibling having abdominal obesity (OR = 1.45 and 1.81, respectively). If both parents were overweight, the OR for the younger sibling having abdominal obesity was 1.63 (95% CI: 1.33–2.99). If the older sibling had abdominal obesity, then the OR for the younger sibling to have the same was 3.22 (95% CI: 2.30–4.50). When siblings were of the same sex, the odds were higher (OR 3.55, 95% CI 2.24–5.65) than if the siblings were of different sexes (OR 2.73, 95% CI: 1.67–4.46). The association was stronger among male sibling pairs (OR 4.18, 95% CI: 2.21–7.93) than female sibling pairs (OR 2.85, 95% CI 1.42–5.72). All the above findings were statistically significant (p < 0.01). These effects are probably due to behaviour modelling among siblings and this is strongest in same sex siblings. The younger child is likely to follow the elder sibling in a number of behavioural traits like academic engagement, smoking, alcohol use, substance abuse and sexual behaviour [48]. Not only are dietary habits of children modelled on those of their parents and peers, but they also pick up food preferences, intake and willingness to try new foods from them. The key to good dietary preferences is the availability and repeated exposure to a variety of healthy foods. Authoritative feeding refers to parents who determine what foods are offered and then allowing children to choose. This leads to a positive attitude to healthy eating. However, authoritarian restriction of 'junk foods' works in the opposite way. It increases the children's desire for these foods and leads to weight gain. It is also known that families that eat together consume healthier foods. There is a greater tendency to consume fast foods in single parent families or where both parents work. Eating out regularly and 'TV dinners' are both associated with higher intake of dietary fats [51, 52].

Peer support at school, supervision of studies by parents, parental connect with children and bonding have all been studied. Pengpid and Peltzer founds that odds for overweight/obesity correlated with peer support at school (OR1.28, 95%CI 1.08–1.53, p < 0.01), parental support (OR 1.33, 95%CI 1.13–1.58, p < 0.001) and parental bonding (OR 1.31, 05%CI 1.12–1.54, p < 0.001) [11].

#### *3.2.8 Socio-economic factors*

There are many commonalities in socio-economic factors associated with childhood obesity from studies across India. Urban background has the strongest association. Familial economic status, educational levels of parents and job profile of parents are other important factors. The type of school that children study in also is an important determinant. Strangely, data on religious denominations is conflicting.

**225**

p = 0.05) [39].

*Obesity in School Children in India*

children and leads to fat gain.

proportionately decreased [54].

*DOI: http://dx.doi.org/10.5772/intechopen.89602*

Urbanisation is the strongest risk factor for obesity in India. Obesity is three times commoner in cities as compared to rural areas. Development of good roads and satellite television have blurred the divide between cities and villages. Youth migrating from villages to metros to study and work take back urban food habits and norms back to their villages. Thus, Indian villages are getting urbanised in their habits. This phenomenon is referred to as rubanisation or urbanisation in situ [47]. Bharathi et al. reported that the OR for obesity in school children from urban areas as compared to rural areas was 3.046 (95% CI: 1.662–5.582) [17]. Rapid urbanisation has led to 'McDonaldisation' of society in terms of an increase in the culture of eating out and eating fast foods. An important contributory factor to this change has been increasing financial independence of women, who are now spending less time in their kitchens. Such households often pack energy-dense convenient food in school tuck boxes and also offer the same as snacks between meals. This results in excess consumption of calories by the

Higher socio-economic status is another risk factor. The GDB Collaborator Group found prevalence of obesity to be higher in countries with higher sociodemographic index (SDI). A relative increase of 20% was found in the prevalence of obesity in children of both sexes between 1980 and 2015 in low SDI countries. The increase was greatest in countries with middle SDI [5]. An American study compared school children from two neighbouring communities, the first with a median household income of US\$ 28610 and the second with US\$ 46299. The prevalence of obesity was 22.2 and 12.6%, respectively (p = 0.01) [53]. Chhatwal et al. found a direct correlation between socio-economic status and overweight/ obesity in children from three different schools in Ludhiana, Punjab. Prevalence of obesity was 15.5% in children from socio-economic class I (highest income group), 2.7% in children from class IV and 0% in children from class V (lowest income group.) [28]. Eagle et al. observed that as the average American household income decreased, frequency of consumption of fried food and TV or video time/week increased. Consumption of vegetables and moderate/vigorous physical exercise also

Kaur et al. reported three times higher number of overweight children (15.3%)

and obese children (6.8%) in high-income schools as compared to children in lower-income schools [55]. Prevalence of overweight/obesity in children aged 14–17 years from urban Delhi was 29% in private schools and 11.3% in governmentfunded schools [15]. In Udupi, the percentage of children with BMI in overweight/ obese range were 6.9%, 10.9% and 31.2% for government, aided and unaided/ private schools, respectively (p < 0.001) [16]. Ramachandran et al. reported an overweight/obesity prevalence of 4.5% in low-income schools and 22% in better-off schools in Chennai [25]. Another interesting factor related to schools is the provision of free lunches or mid-day meals (in India). Govindan et al. reported that regular consumption of school lunches was associated with obesity in both boys and girls (boys OR 1.29, 95% CI 1.01–1.64, p = 0.04, and girls OR 1.27, 95%CI 1.00–1.62,

The effect of religion on childhood obesity is varied. In Udupi, the odds of overweight/obesity in children from Muslim or Christian homes was significantly higher (for Muslims the AOR was 2.26, and for Christians it was 1.60) in comparison to children from Hindu homes [16]. The authors attributed this to a focus on vegetables in the Hindu diet and a lack of meat [16]. In Wardha, however, the OR for obesity was 1.730 (p = 0.036) for Hindu children when compared to children from other communities [17]. Here, it probably was influenced by greater affluence

of Hindus in comparison to Muslims and Christians.

#### *Obesity in School Children in India DOI: http://dx.doi.org/10.5772/intechopen.89602*

*Public Health in Developing Countries - Challenges and Opportunities*

are both associated with higher intake of dietary fats [51, 52].

parental bonding (OR 1.31, 05%CI 1.12–1.54, p < 0.001) [11].

Peer support at school, supervision of studies by parents, parental connect with children and bonding have all been studied. Pengpid and Peltzer founds that odds for overweight/obesity correlated with peer support at school (OR1.28, 95%CI 1.08–1.53, p < 0.01), parental support (OR 1.33, 95%CI 1.13–1.58, p < 0.001) and

There are many commonalities in socio-economic factors associated with childhood obesity from studies across India. Urban background has the strongest association. Familial economic status, educational levels of parents and job profile of parents are other important factors. The type of school that children study in also is an important determinant. Strangely, data on religious denominations is

high risk of obesity in later life in India [47].

foetus. In Caucasian populations, birth weight is related to lean mass rather than to fat mass; whereas, in India, babies have more fat mass as compared to Europoid babies at every ponderal index. Babies with both low- and high-birth weights have a

Maternal and paternal heights are independent predictors of childhood obesity. The highest adiposity is seen in children who exceed mid-parental height. Parental height may serve as a composite indicator of genetic factors, nutrition and growth during childhood [47, 48]. Many studies in India have shown that the mother's BMI correlates with the child's weight. This may be due to genetic factors and environmental factors such as shared diets and eating habits [31, 49]. Raskind et al. found that every overweight child had an overweight mother. The combination of overweight mother and child formed 11% of their study population which was one of the highest in Asian countries [50]. Rebecca Kuriyan studied the role of familial and sibling factors on abdominal adiposity in children in an urban location in South India. Multiple regression models showed that overweight status of father or mother was associated with the younger sibling having abdominal obesity (OR = 1.45 and 1.81, respectively). If both parents were overweight, the OR for the younger sibling having abdominal obesity was 1.63 (95% CI: 1.33–2.99). If the older sibling had abdominal obesity, then the OR for the younger sibling to have the same was 3.22 (95% CI: 2.30–4.50). When siblings were of the same sex, the odds were higher (OR 3.55, 95% CI 2.24–5.65) than if the siblings were of different sexes (OR 2.73, 95% CI: 1.67–4.46). The association was stronger among male sibling pairs (OR 4.18, 95% CI: 2.21–7.93) than female sibling pairs (OR 2.85, 95% CI 1.42–5.72). All the above findings were statistically significant (p < 0.01). These effects are probably due to behaviour modelling among siblings and this is strongest in same sex siblings. The younger child is likely to follow the elder sibling in a number of behavioural traits like academic engagement, smoking, alcohol use, substance abuse and sexual behaviour [48]. Not only are dietary habits of children modelled on those of their parents and peers, but they also pick up food preferences, intake and willingness to try new foods from them. The key to good dietary preferences is the availability and repeated exposure to a variety of healthy foods. Authoritative feeding refers to parents who determine what foods are offered and then allowing children to choose. This leads to a positive attitude to healthy eating. However, authoritarian restriction of 'junk foods' works in the opposite way. It increases the children's desire for these foods and leads to weight gain. It is also known that families that eat together consume healthier foods. There is a greater tendency to consume fast foods in single parent families or where both parents work. Eating out regularly and 'TV dinners'

**224**

conflicting.

*3.2.8 Socio-economic factors*

Urbanisation is the strongest risk factor for obesity in India. Obesity is three times commoner in cities as compared to rural areas. Development of good roads and satellite television have blurred the divide between cities and villages. Youth migrating from villages to metros to study and work take back urban food habits and norms back to their villages. Thus, Indian villages are getting urbanised in their habits. This phenomenon is referred to as rubanisation or urbanisation in situ [47]. Bharathi et al. reported that the OR for obesity in school children from urban areas as compared to rural areas was 3.046 (95% CI: 1.662–5.582) [17]. Rapid urbanisation has led to 'McDonaldisation' of society in terms of an increase in the culture of eating out and eating fast foods. An important contributory factor to this change has been increasing financial independence of women, who are now spending less time in their kitchens. Such households often pack energy-dense convenient food in school tuck boxes and also offer the same as snacks between meals. This results in excess consumption of calories by the children and leads to fat gain.

Higher socio-economic status is another risk factor. The GDB Collaborator Group found prevalence of obesity to be higher in countries with higher sociodemographic index (SDI). A relative increase of 20% was found in the prevalence of obesity in children of both sexes between 1980 and 2015 in low SDI countries. The increase was greatest in countries with middle SDI [5]. An American study compared school children from two neighbouring communities, the first with a median household income of US\$ 28610 and the second with US\$ 46299. The prevalence of obesity was 22.2 and 12.6%, respectively (p = 0.01) [53]. Chhatwal et al. found a direct correlation between socio-economic status and overweight/ obesity in children from three different schools in Ludhiana, Punjab. Prevalence of obesity was 15.5% in children from socio-economic class I (highest income group), 2.7% in children from class IV and 0% in children from class V (lowest income group.) [28]. Eagle et al. observed that as the average American household income decreased, frequency of consumption of fried food and TV or video time/week increased. Consumption of vegetables and moderate/vigorous physical exercise also proportionately decreased [54].

Kaur et al. reported three times higher number of overweight children (15.3%) and obese children (6.8%) in high-income schools as compared to children in lower-income schools [55]. Prevalence of overweight/obesity in children aged 14–17 years from urban Delhi was 29% in private schools and 11.3% in governmentfunded schools [15]. In Udupi, the percentage of children with BMI in overweight/ obese range were 6.9%, 10.9% and 31.2% for government, aided and unaided/ private schools, respectively (p < 0.001) [16]. Ramachandran et al. reported an overweight/obesity prevalence of 4.5% in low-income schools and 22% in better-off schools in Chennai [25]. Another interesting factor related to schools is the provision of free lunches or mid-day meals (in India). Govindan et al. reported that regular consumption of school lunches was associated with obesity in both boys and girls (boys OR 1.29, 95% CI 1.01–1.64, p = 0.04, and girls OR 1.27, 95%CI 1.00–1.62, p = 0.05) [39].

The effect of religion on childhood obesity is varied. In Udupi, the odds of overweight/obesity in children from Muslim or Christian homes was significantly higher (for Muslims the AOR was 2.26, and for Christians it was 1.60) in comparison to children from Hindu homes [16]. The authors attributed this to a focus on vegetables in the Hindu diet and a lack of meat [16]. In Wardha, however, the OR for obesity was 1.730 (p = 0.036) for Hindu children when compared to children from other communities [17]. Here, it probably was influenced by greater affluence of Hindus in comparison to Muslims and Christians.


#### **Table 1.**

*Some common myths in India society related to obesity in school children.*
