ORCP-348; No. of Pages 9
ARTICLE IN PRESS
Obesity Research & Clinical Practice (2013) xxx, xxx.e1—xxx.e9
ORIGINAL ARTICLE
Overweight and obesity prevalence and trends in children and adolescents in Cyprus 2000—2010 Savvas C. Savva a,∗, Yiannis A. Kourides a, Charalampos Hadjigeorgiou a, Michael J. Tornaritis a,b a
Research and Education Institute of Child Health, 138, Limassol Avenue, 2015 Strovolos, Cyprus b Pedagogical Institute of Cyprus, 40, Macedonia Avenue, 2238 Latsia, Cyprus Received 5 September 2013 ; received in revised form 12 November 2013; accepted 14 November 2013
KEYWORDS Adolescent; Child; Obesity; Overweight
∗
Summary Objectives: To estimate the prevalence of overweight and obesity in 2010 and examine prevalence trends between 2000 and 2010 among school-aged children and adolescents in Cyprus. Methods: A representative cross-sectional study was undertaken in 2010. Anthropometric data were taken using standard methods from 3090 children. The IOTF cut-offs were used to define overweight and obese participants, and prevalence was compared with a previous representative study performed in 2000. Prevalences with 95% confidence intervals (95% CI) were calculated and logistic regression models were used to estimate 10-year trends. Results: The overall prevalence of obesity was higher in 2010 (8.1% [95%CI: 7.1, 9.1]) compared to 2000 (5.9% [95%CI: 5.0, 6.8]), p = 0.002. The overall prevalence of overweight was also higher in 2010 (20.1% [95%CI: 18.7, 21.5]) compared to 2000 (16.5% [95%CI: 15.0, 18.0]), p < 0.001. The prevalence of obesity increased at a greater rate in school-aged boys (p = 0.017), and in rural areas (p = 0.001). In rural areas, high maternal education background is associated with a decreased odds for obesity; odds ratio 0.35 (95% CI: 0.17, 0.69), p = 0.003. Conclusions: The prevalence of obesity and overweight in children and adolescents in Cyprus has increased substantially over a decade, mainly in rural areas and in school-aged boys. © 2013 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Corresponding author. Tel.: +357 22 510310; fax: +357 22 510903. E-mail addresses: [email protected], [email protected] (S.C. Savva).
1871-403X/$ — see front matter © 2013 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.orcp.2013.11.005
Please cite this article in press as: Savva SC, et al. Overweight and obesity prevalence and trends in children and adolescents in Cyprus 2000—2010. Obes Res Clin Pract (2013), http://dx.doi.org/10.1016/j.orcp.2013.11.005
ORCP-348; No. of Pages 9
ARTICLE IN PRESS
xxx.e2
Introduction Obesity has been one of the most challenging public health issues in the past decades affecting not only developed countries [1,2] but also developing ones [2,3] who suffer from the double burden of disease linked to both under- and over-nutrition. The prevalence of obesity among children and adolescents has been increasing during the past decades though there have been reports for a leveling off trend in some developed regions [4—8]. Cyprus is a European Union member state in the eastern Mediterranean Sea. The prevalence of obesity in Cyprus has been estimated in a representative sample of school-aged children and adolescents for the first time in 2000 [9] and in preschool-aged children in 2004 [10]. In particular, the prevalence of obesity was relatively low in 2—5 year olds being 3% [10] but was much higher in school-aged children reaching 10% at the age of 10—11 y and then decreased to around 4% by the age of 15—17 y [9]. Those results ranked Cyprus among the European countries with the highest prevalences of obesity and overweight at that time [11]. Moreover, there has been evidence that the prevalence of obesity among school-aged children increased substantially within a period of 6 years [12]. Monitoring obesity prevalence is a crucial step in defining national needs and priorities, and evaluating progress of undertaken efforts against obesity. The aim of the present study was to report the 10year change in the prevalence of overweight and obesity in school-aged children and adolescents in Cyprus.
Methods A school based study was performed between October 2009 and May 2010 in order to collect anthropometric data to estimate the prevalence of overweight and obesity in a representative sample of school-aged children and adolescents in Cyprus, and compare this prevalence with similar data collected by our Institute 10 years earlier [9]. The survey took place in elementary and secondary schools all over the freely-accessible areas of Cyprus, but in contrary to the previous study [9], not only public but also private schools were included, because the proportion of students in private schools increased from 7% in 1999 to 13% in 2009 [13]. The study was approved by the Ministry of Education and Culture, and written consent was obtained from the parents/legal guardians of the
S.C. Savva et al. participants. Moreover, invited participants were included in the study only if they stated that they wished to participate.
Sample selection A similar sampling procedure was utilized for this study as in the 1999—00 study [9]. A nationally representative sample was selected with a school class being the sampling unit. School classes were randomly selected stratifying for age, gender, district, and area of living (urban/rural areas). Classes were selected in order to include 200 participants in every 1-year age-interval for each gender. Thus 4800 children and adolescents were randomly selected to participate. This sample was almost double compared to the 1999—00 sample, because increased proportions of invited participants were expected to refuse participation in comparison to the 1999—00 study.
Body measurements Four groups of trained researchers performed body measurements. Briefly, weight (kg) was measured after breakfast with a portable scale, with the child in light clothing and without shoes. Height (0.1 cm) was measured with a portable stadiometer at the standing position without shoes. The portable scale and stadiometer were calibrated daily. Body mass index (BMI) was calculated as weight/height2 (kg/m2 ).
Mother’s education level Socioeconomic status in the 1999—00 study was determined as a composite measure of the family’s net income, household’s size, and maternal education level. Family’s net income was not available in the 2009—10 study, as this question was removed from the questionnaire, because in many of our studies undertaken in the past decade has been a source of skepticism from the participants and/or left unanswered. Therefore, mother’s education level was used as a proxy of socioeconomic status.
Definitions The International Obesity Task Force’s (IOTF) recommended cut-offs based on the age and sex specific values of BMI extrapolated to the adult values of 25 kg/m2 and 30 kg/m2 have been used for the definition of overweight children (BMI > 25 kg/m2 and BMI ≤ 30 kg/m2 ), obese children (BMI > 30 kg/m2 ), and overweight including
Please cite this article in press as: Savva SC, et al. Overweight and obesity prevalence and trends in children and adolescents in Cyprus 2000—2010. Obes Res Clin Pract (2013), http://dx.doi.org/10.1016/j.orcp.2013.11.005
ORCP-348; No. of Pages 9
ARTICLE IN PRESS
Childhood obesity trends in Cyprus obese children [14]. The lmsGrowth module for Microsoft Excel (available on the web, http://www. ceb.cuhk.edu.hk/growth download.htm) which converts BMI to an ordered grade by interpolating to the child’s exact age was used to classify children [15]. The module codes normal weight as 0 and overweight (between 25 and
ARTICLE IN PRESS
Obesity Research & Clinical Practice (2013) xxx, xxx.e1—xxx.e9
ORIGINAL ARTICLE
Overweight and obesity prevalence and trends in children and adolescents in Cyprus 2000—2010 Savvas C. Savva a,∗, Yiannis A. Kourides a, Charalampos Hadjigeorgiou a, Michael J. Tornaritis a,b a
Research and Education Institute of Child Health, 138, Limassol Avenue, 2015 Strovolos, Cyprus b Pedagogical Institute of Cyprus, 40, Macedonia Avenue, 2238 Latsia, Cyprus Received 5 September 2013 ; received in revised form 12 November 2013; accepted 14 November 2013
KEYWORDS Adolescent; Child; Obesity; Overweight
∗
Summary Objectives: To estimate the prevalence of overweight and obesity in 2010 and examine prevalence trends between 2000 and 2010 among school-aged children and adolescents in Cyprus. Methods: A representative cross-sectional study was undertaken in 2010. Anthropometric data were taken using standard methods from 3090 children. The IOTF cut-offs were used to define overweight and obese participants, and prevalence was compared with a previous representative study performed in 2000. Prevalences with 95% confidence intervals (95% CI) were calculated and logistic regression models were used to estimate 10-year trends. Results: The overall prevalence of obesity was higher in 2010 (8.1% [95%CI: 7.1, 9.1]) compared to 2000 (5.9% [95%CI: 5.0, 6.8]), p = 0.002. The overall prevalence of overweight was also higher in 2010 (20.1% [95%CI: 18.7, 21.5]) compared to 2000 (16.5% [95%CI: 15.0, 18.0]), p < 0.001. The prevalence of obesity increased at a greater rate in school-aged boys (p = 0.017), and in rural areas (p = 0.001). In rural areas, high maternal education background is associated with a decreased odds for obesity; odds ratio 0.35 (95% CI: 0.17, 0.69), p = 0.003. Conclusions: The prevalence of obesity and overweight in children and adolescents in Cyprus has increased substantially over a decade, mainly in rural areas and in school-aged boys. © 2013 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Corresponding author. Tel.: +357 22 510310; fax: +357 22 510903. E-mail addresses: [email protected], [email protected] (S.C. Savva).
1871-403X/$ — see front matter © 2013 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.orcp.2013.11.005
Please cite this article in press as: Savva SC, et al. Overweight and obesity prevalence and trends in children and adolescents in Cyprus 2000—2010. Obes Res Clin Pract (2013), http://dx.doi.org/10.1016/j.orcp.2013.11.005
ORCP-348; No. of Pages 9
ARTICLE IN PRESS
xxx.e2
Introduction Obesity has been one of the most challenging public health issues in the past decades affecting not only developed countries [1,2] but also developing ones [2,3] who suffer from the double burden of disease linked to both under- and over-nutrition. The prevalence of obesity among children and adolescents has been increasing during the past decades though there have been reports for a leveling off trend in some developed regions [4—8]. Cyprus is a European Union member state in the eastern Mediterranean Sea. The prevalence of obesity in Cyprus has been estimated in a representative sample of school-aged children and adolescents for the first time in 2000 [9] and in preschool-aged children in 2004 [10]. In particular, the prevalence of obesity was relatively low in 2—5 year olds being 3% [10] but was much higher in school-aged children reaching 10% at the age of 10—11 y and then decreased to around 4% by the age of 15—17 y [9]. Those results ranked Cyprus among the European countries with the highest prevalences of obesity and overweight at that time [11]. Moreover, there has been evidence that the prevalence of obesity among school-aged children increased substantially within a period of 6 years [12]. Monitoring obesity prevalence is a crucial step in defining national needs and priorities, and evaluating progress of undertaken efforts against obesity. The aim of the present study was to report the 10year change in the prevalence of overweight and obesity in school-aged children and adolescents in Cyprus.
Methods A school based study was performed between October 2009 and May 2010 in order to collect anthropometric data to estimate the prevalence of overweight and obesity in a representative sample of school-aged children and adolescents in Cyprus, and compare this prevalence with similar data collected by our Institute 10 years earlier [9]. The survey took place in elementary and secondary schools all over the freely-accessible areas of Cyprus, but in contrary to the previous study [9], not only public but also private schools were included, because the proportion of students in private schools increased from 7% in 1999 to 13% in 2009 [13]. The study was approved by the Ministry of Education and Culture, and written consent was obtained from the parents/legal guardians of the
S.C. Savva et al. participants. Moreover, invited participants were included in the study only if they stated that they wished to participate.
Sample selection A similar sampling procedure was utilized for this study as in the 1999—00 study [9]. A nationally representative sample was selected with a school class being the sampling unit. School classes were randomly selected stratifying for age, gender, district, and area of living (urban/rural areas). Classes were selected in order to include 200 participants in every 1-year age-interval for each gender. Thus 4800 children and adolescents were randomly selected to participate. This sample was almost double compared to the 1999—00 sample, because increased proportions of invited participants were expected to refuse participation in comparison to the 1999—00 study.
Body measurements Four groups of trained researchers performed body measurements. Briefly, weight (kg) was measured after breakfast with a portable scale, with the child in light clothing and without shoes. Height (0.1 cm) was measured with a portable stadiometer at the standing position without shoes. The portable scale and stadiometer were calibrated daily. Body mass index (BMI) was calculated as weight/height2 (kg/m2 ).
Mother’s education level Socioeconomic status in the 1999—00 study was determined as a composite measure of the family’s net income, household’s size, and maternal education level. Family’s net income was not available in the 2009—10 study, as this question was removed from the questionnaire, because in many of our studies undertaken in the past decade has been a source of skepticism from the participants and/or left unanswered. Therefore, mother’s education level was used as a proxy of socioeconomic status.
Definitions The International Obesity Task Force’s (IOTF) recommended cut-offs based on the age and sex specific values of BMI extrapolated to the adult values of 25 kg/m2 and 30 kg/m2 have been used for the definition of overweight children (BMI > 25 kg/m2 and BMI ≤ 30 kg/m2 ), obese children (BMI > 30 kg/m2 ), and overweight including
Please cite this article in press as: Savva SC, et al. Overweight and obesity prevalence and trends in children and adolescents in Cyprus 2000—2010. Obes Res Clin Pract (2013), http://dx.doi.org/10.1016/j.orcp.2013.11.005
ORCP-348; No. of Pages 9
ARTICLE IN PRESS
Childhood obesity trends in Cyprus obese children [14]. The lmsGrowth module for Microsoft Excel (available on the web, http://www. ceb.cuhk.edu.hk/growth download.htm) which converts BMI to an ordered grade by interpolating to the child’s exact age was used to classify children [15]. The module codes normal weight as 0 and overweight (between 25 and
