Path Analysis on Life Course Factors Affecting Overweight and Obesity in Children Aged 2 to 5 Years Old in Surakarta
Path Analysis on Life Course Factors Affecting Overweight and Obesity in Children Aged 2 to 5 Years Old in Surakarta
Uyunun Nudhira 1) , Cri SP Wekadigunawan 2) , Bhisma Murti 1)
1) Masters Program in Public Health, Universitas Sebelas Maret 2) Faculty of Medicine, Universitas Sebelas Maret
ABSTRACT
Background: Globally, prevalence of obesity in children under 5 years old has been increasing from 32 million in 1990 to 42 million in 2014. Indonesia ranks highest in the number of obesity cases in South East Asia with prevalence of 11.5% in 2013. However, child overweight and obesity have not been the focus of health problems in Indonesia. Early intervention and prevention of child obesity can reduce long-term risk of chronic diseases in adulthood. This study aimed to analyze the life course factors affecting overweight and obesity in children aged 2 to 5 years old in Surakarta. Subjects and Method: This was an analytic observational study with case control design. The study was conducted in 5 community health centers, Surakarta, from September to October, 2017.
A total sample of 150 children aged 2 to 5 years old was selected using fixed disease sampling. The dependent variable was overweight or obesity. The independent variables were nutrition intake, exclusive breastfeeding, starting age of complementary feeding, physical activity, birthweight, age of gestation, sectio cesarea labor, maternal body mass index, and maternal job. Physical activity data was measured using Pre PAQ questionnaire. Other data were collected using a set of questionnaire and maternal and child health monitoring book. The data were analyzed by path analysis. Results: Overweight and obesity in children aged 2 to 5 years old were positively affected by over nutrition intake (b= 1.9; 95% CI= 0.15 to 3.60; p=0.033), high maternal body mass index (b= 2.0; 95% CI= 0.51 to 3.42; p=0.008), and sectio cesarean birth (b= 2.1; 95% CI= 0.56 to 3.73; p=0.008). Overweight and obesity in children aged 2 to 5 years old were negatively affected by normal birthweight (b= -2.2; 95% CI= -4.28 to -0.19; p=0.032), exclusive breastfeeding (b= -2.0; 95% CI= -3.60 to -0.39; p=0.015), timely starting age of complementary feeding (b= -1.3; 95% CI= -2.80 to 0.11; p=0.072), and high physical activity (b= -3.0; 95% CI= -4.63 to -1.37; p=0.001). Birthweight was positively affected by age of gestation (b= 4.2; 95% CI= 1.99 to 6.32; p=0.001) and was negatively affected by maternal body mass index (b= -1.1; 95% CI= -2.11 to -0.13; p=0.025). Exclusive breastfeeding was negatively affected by working outside the house (b= -1.4; 95% CI= -
2.10 to -0.72; p= 0.001). Conclusion: Overweight and obesity in children aged 2 to 5 years old are positively affected by over nutrition intake, high maternal body mass index, and sectio cesarean birth. Overweight and obesity in children aged 2 to 5 years old are negatively affected by normal birthweight, exclusive breastfeeding, timely starting age of complementary feeding, and high physical activity.
Keyword: life course factors, overweight, obesity, path analysis.
Correspondence:
Uyunun Nudhira. Masters Program in Public Health, Sebelas Maret University, Jl. Ir. Sutami 36 A, Surakarta 57126, Central Java. Email: uyununnudhira14@gmail.com. Mobile: +6285253781714
(UNICEF, WHO and World Bank, 2014; Nutritional problems in ASIA become
BACKGROUND
Black et al., 2013). Currently, all countries doubel burden in which on one side,
in the world are facing problems of wasting and stunting is still high, on the
epidemiological transition of diseases other hand obesity is also increasing
which are not infectious in both developed
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and developing countries. Risk factors that
2 diabetes, heart disease, certain types of increase the potential for non-infectious
cancer development, insomnia and sleep diseases include overweight and obesity
disorders (Ahima, 2014; Debasis, 2011; (WHO, 2016). As described in NCDs,
Godfrey et al., 2017; Ramírez et al. , 2016). overweight and obesity cause 55% of deaths
Obesity can cause negative impacts on from non-infectious diseases (WHO,
children's mental and social health, low 2016b).
self-esteem and depression (Small and Overweight and children under 5
Aplasca, 2016). Therefore, efforts to obesity have increased globally from 32
prevent overweight and obesity need to be million in 1990 to 41 million by 2014
done early (Blake-Lamb et al., 2016). (WHO, 2016b). All over the world,
Factors that affect obesity include, genetic overweight and obesity in infants and
history, obese parents, smoking, low and children are predicted to increase to 70
over birth weight, not receiving exclusive million by 2025. With the increase in the
breastfeeding and rapid duration, the proportion of obesity cases at different
quality of child's sleep, unbalanced diet ages, it has become one of the nine targets
which is high in calories and fat, less of the global monitoring program frame-
physical activity, and at a higher level it work for non-infectious diseases (WHO,
may be affected by circumstances in 2014; Wijnhoven et al., 2016).
communities, environments, and demo- The number of overweight and
graphic factors (Bam-mann et al., 2014; children obesity cases in Asia continues to
Poston, 2012). The influence of other increase. In 2013, the highest number of
factors such as genetic, biological, socio- overweight and children obesity in Azer-
cultural, psychological and environmental baijan was 13.0% and the lowest one was at
factors is a risk factor for obesity (Herman Vannatu (4.6%). In Southeast Asia, the
et al., 2014; Isgor et al., 2016). highest overweight and children obesity is
Early detection of overweight and in Indonesia which was 11.5% and the
obesity cases is a way of preventing and lowest one was in the Philippines for about
reducing risk factors that will occur in the 5.0% (ADB, 2016).
future (Redsell et al., 2016; Weng et al., Obesity and its association with
2012). Health programs that focus on various comorbidities have posed a serious
addressing these nutritional problems are threat to the global health (Han, et al.,
the first thousand days of life nutrition to 2017). Obesity is a major cause of
ensure that children grow well as they cardiovascular disease (Hardy, 2015). Over-
progress. Good growth and development in weight and obesity are the main risks of
the first 1000 days of life will determine the serious chronic diseases (Labresh, 2016)
future child development (Blake-Lamb et Overweight and obesity in children increase
al., 2016; Woo Baidal et al., 2016). the risk of death 40-90% higher in their
Overweight and obesity status are also adulthood than normal children do (Hirko
associated with lifelong epidemiology from et al., 2015).
gestation to adult children (Bammann et Overweight and obesity in childhood
al., 2014). A growing theory explains that lead to morbidity and mortality in
the lifelong exposure relationship to adult adulthood (Redsell et al., 2016). Obesity
disease is a life course epidemiology (Green that continues into adulthood can lead to
and Popham, 2017; Pérez-escamilla and chronic diseases, such as hypertension, type
Kac, 2013).
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Based on Indonesia's 2015 health profile, the classification of energy levels and characteristics is found that the largest overweight and obesity rate in Indonesia is between the ages of 5-12 and 10.2%, of it occurs in various regions both urban and rural. The incidence rate in urban areas is 6.9% and in rural area id 5.8% (Ministry of Health, 2015). Obesity in Central Java in 2016 was 1.867 (3.1%) and was included in five major non-infectious diseases (Central Java Provincial Health Office, 2016). The prevalence of overweight and obesity in the age group of 2-5 years was 5.4% overweight and 1.7% for obesity. One area with an increased prevalence of overweight and obese children aged 2-5 years was Sura- karta district, in 2014, for about 3.7% increase from the previous year which was only 1.45% (Surakarta Health Office, 2014).
Although in Surakarta it has not become a major problem but overweight and obesity in children 2-5 years need to get more attention considering the increase of health problems caused by it. A pre- liminary study conducted at the Surakarta health office shows that 1530 infants were overweight and obese. The purpose of this study is to know the influence of path analysis of factors throughout life on overweight and obesity of children under five in Surakarta.
SUBJECTS AND METHOD
1. Study design
This was an analytic observasional study with a case control design, by determining the group which was exposed first and then identifying the cause or risk factors of the disease. The study was conducted at Ngoresan, Gilingan, Stabelan, Nusukan, and Penumping community health centers, Surakarta, Central Java, from September 2 to November 28, 2016.
2. Population and sample
The target population was Toddlers aged 2-
5 years who live in Surakarta. The source population were underweight (2-5 years old) toddlers living in the area of Ngoresan, Gilingan,
Stabelan, Nusukan and Penumping Public Health Centers which were overweight and obese and normal (under-five) toddlers for about 150 subjects with the comparison of 1: 2. The case group consisted of 50 subjects and the control one consisted of 100 subjects.
The sampling technique used in this study was fixed disease sampling by choosing the subjects based on the data of overweight and obese children and normal children at the public health centers, then the data collection process was conducted at integrated health service. The selection of subjects was done randomly according to the sample size required by the researcher. There were ten variables in this study. The dependent variable is overweight and obesity toddlers. The independent variables were maternal body index, gestational age, cesarean delivery, birth weight, exclusive breastfeeding, breastfeeding feeding age, physical activity, diet, and maternal occupation.
3. Operational of variables
Overweight or obese in children under five was define by calculated bodyweight/ body height and compared with Z-score. The measurement scale was continuous, but for the purpose of data analysis, it was transformed into dichotomous, coded 0 for normoweigth and 1 for overweight/ obesity.
The history of the mother with over- weight / obesity was determined based on maternal BMI during pregnancy and recorded in the maternal and child moni- toring book. Gestational age was defined as the length of time that begins from the time of ovulation to the birth, the duration of distal birth (<37 weeks), and term delivery
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( ≥37 weeks). Sectio caesarean was defined ≥0.22 and Cronbach Alpha ≥0.77, on the as the expenditure of conception with an
physical activity variables r arithmetic incision on the maternal abdomen.
≥0.21 and Cronbach Alpha ≥0.91, so that all Exclusive breastfeeding was defined
questions/items were stated as reliable. as only breastmilk consumed by infants
5. Data analysis
until the first 6 months of age. The age at This study used path analysis. This analysis complementary feeding was defined as the
can calculate the magnitude of the direct first age of children introduced with solid
and indirect effects of any independent foods.
variable on the dependent variable. Steps to Physical activity was defined as the
perform path analysis included model movement that generates the measured
specifications, model identification, model energy with the children which is inter-
conformity, parameter estimation, and mittent and is interrupted by breaks and
model respesification.
were measured by the Pre-PAQ question-
6. Research ethics
naire. The diet pattern includes the type, The research ethical clearance was obtained amount and frequency consumed each day.
from the Research Ethics Committee at Dr. Maternal occupation was defined an act
Moewardi Hospital, Surakarta, Central done to earn wages.
Java, Indonesia. Research ethics included
issues such as informed consent, anoni- The data collection used questionnaires and
4. Study instrument
mity, confidentiality, and ethical clearance. KIA books. The instruments that were tested for reliability were dietary and
RESULTS
physical activity questionnaires. Based on
1. Sample Characteristics
the results of the correlation reliability test The characteristics of subjects in this study item-total dietary variables were r count
are presented in Table 1.
Table 1. The Distribution of study subjects
Normoweight (control) Characteristics
Obesity (case)
% Gender
Male 26 52 53 53 Female
Maternal age (year)
Children age (months)
Number of children
Maternal education
Low (<Senior high schol) 10 20 36 36 High (≥Senior high school)
Family Income
< Rp 2,000,000 18 36 53 53 ≥ Rp 2,000,000
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Table 1 shows the characteristics of the application with SEM (Structural Equation study subjects from 150 of them, 26 were
Modeling) program. Path analysis explains male (52%) and 53 control (53%). The
the direct and indirect effects of overweight number of ,others who were <35 years old
and obesity causes in infants. The degree of was 29 (58%) cases and 72 (72%) for the
freedom (df) = 35 value is over-identified so control one. There were 31 (62%) under-
that path analysis can be done. This study five children who were over 36 months. As
has been in accordance with the sample many as 40 (80%) mothers had education
data shown by the saturation model and ≥Senior high school.
also the regression coefficient which is
more than zero and statistically significant, Figure 1 shows the structural model after
2. Path Analysis
so there is no need to re-create the path estimating data processing using STATA 13
analysis model.
Figure 1. Structural model of path analysis
Table 2 shows that there is an association of (<2,500 g) (b = -2.2; 95% CI = -4.28 to - Maternal BMI with an overweight increase
0.19; p = 0.032).
and obese infant which was statistically There was a relationship between a significant. Overweight/ obese mothers had
cesarean delivery and the increase of overweight and overweight children's
overweight and obesity in children and was obesity scores of 2 units higher than normal
statistically significant. Cesarean delivery body mass index mothers (b = 2.0; 95% CI
had overweight and overweight children's = 0.51 to 3.42; p = 0.008).
obesity scores of 2.1 units higher than There was a relationship between
mothers with normal delivery (b = 2.1; 95% birth weight and the decrease of overweight
CI = 0.56 to 3.73; p = 0.008). or obesity in children which was statis-
There was a relationship between tically significant. Normal birth weight has
exclusive breastfeeding and a decrease of overweight logit score and obesity of
overweight and obesity in children under underweight of 2.2 units lower than under-
five and was stastically significant. Exclu- weight children with low birth weight
sive breastfeeding had an overweight logit score and under-five obesity of 2 units
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lower than toddlers who do not get exclu- overweight logit score and underweight sive breastfeeding (b = -2.0; 95% CI = -3.60
obesity of 3 units lower than under-five to -0.39; p = 0.015).
children with inactive physical activity (b = There a correlation between age at
-3.0; 95% CI = -4.63 to -1.37; p = 0.001). complementary feeding and the decrease of
There was a significant relationship overweight and obesity in under-five
between diet with overweight and under- children and was statistically significant.
weight obesity. A diet high in carbohydrates Age at complementary feeding more than 6
and fats had overweight and overweight months had overweight logit score and
children's obesity scores of 2 units higher childhood obesity of 1.3 units lower than
than low-carbohydrate and fat diets (b = under-five children given breastfeeding MP
1.9; 95% CI = 0.15 to 3.60; p = 0.033). less than 6 months (b = -1.3; 95% CI = -
There was a statistically significant
2.80 to 0.11; p = 0.072). relationship between gestational age and There was a relationship between
birth weight gain. Gestational age (<37 physical activity and the decrease of
weeks) had a low birth weight logit score of overweight and obesity in under-five
4.2 units higher than gestational age ( ≥37 children and was stated as statistically
weeks) (b = 4.2; 95% CI = 1.99 to 6.32; p = significant. Active physical activity had
Table 2. Results of pathway analysis of lifetime overweight and obese factors in children
95% CI Dependent
Path
Upper p Variable
Independent Variable
Lower
Coefficient
Limit Direct Effect
Limit
Overweight/ Mothers
index Birth weight
-0.19 0.032 Caesarean section
2.1 0.56 3.73 0.008 Exclusive breastfeeding
-0.39 0.015 The first age at
complementary feeding Physical activity
-1.37 0.001 Dietary pattern
Indirect Effect
Birth weight Gestational age
4.2 1.99 6.32 0.001 Mothers body mass
Asi Eksklusif Occupation
-0.72 0.001 Log Likelihood= -175.82
There was a statistically significant There was a statistically significant relationship between maternal body mass
correlation between maternal employment index and weight loss. Mothers with normal
status and the decrease of exclusive body mass index had a lower birth weight
breastfeeding. The working mother had a logit score of 1.1 units lower than that of
logit score of 1.4 units lower than that of the overweight mothers / obese (b = -1.1; 95%
housewife (b = -1.4; 95% CI = -2.10 to - CI = -2.11 to -0.13; p = 0.025).
0.72; p = 0.001).
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DISCUSSION
2. The effect of birthweight with
1. The effect of maternal body mass overweight or obesity in children index (BMI) with overwight or
under five
obesity in children under five
The result of this study showed that there The result of this study showed that there
was a negative and significant effect was a positive and significant effect
between birthweight with overweight and between maternal body mass index and
obesity in toddlers. Babies with normal overweight and obesity in children.
birthweight decrease the risk of over- Mothers with overweight/obesity were
weight/ obesity in toddlers compared to more likely to have overweight/obesity
babies with low birthweight. infants compared to mothers with normal
Low birth weight was associated with weight.
increased coronary heart disease, stroke, Obesity in pregnant women is
hypertension, obesity, insulin resistance associated with excessive amounts of
and type 2 diabetes. The association is nutrients to the fetus in the form of fatty
considered to be a consequence from the acids, increased fetal blood pressure and
development of different genotypical plasti- the accumulation of babies ’ body fat. The
city in both physiological and environ- enhancement of body weight and body fat
mental morphologies during the develop- will increase the risk of obesity to children
ment (Barker, 2004; Robinson et al., 2015). in the future. Pregnant women with obesity
Low birthweight infants have higher lead to trans-generational thus increasing
plasma levels than normal-weight infants. the risk of disease in their babies (Koletzko
The enhancement of leptin and the fat mass et al., 2014).
ratio are also associated with nutrient The overweight during pregnancy will
intake during childhood resulting in the continue until postpartum. The evidence-
enhancement of leptin production by body based cycle of heredity suggests that
fat units. In low birth-weight children, the newborns
leptin levels increase with the growth rate pregnancies are more likely to store
from
overweight/obese
in childhood, therefore, the chidlren will excessive body fat from the earliest period
have a higher risk of overweight and obesity in life (Pérez-escamilla and Kac, 2013).
(Jornayvaz et al., 2016).
A study conducted by Yang and the risk of overweight in children by 1.38
The history of obese parents increased
Huffman (2013) shows that birth weight times compared to parents with normal
less than 2,500 g has a risk of metabolic body weight (Mamun, et al., 2014).
syndrome and has central obesity in adult- The study of Bammann et al. (2014)
hood, compared to normal birthweight. found that parental body weight before
Other studies explain that children with low high pregnancy was associated with obesity
birth weight and low physical activity in children by 1.02 times than mothers with
showed 5.18 times more likely to become normal body weight. Children with obese
obese (Qiao et al., 2017). parents have 10.25 times risk to be obese
3. The effect of sectio cesarean birth
and 3.03 times to have metabolic syndrome
with overweight or obesity in
compared with parents without obesity
children under five
(Han et al., 2015). The result showed that section cesarean birth has positive effect on overweight/ obesity in toddlers which is statistically
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significant. Cesarean section increased the body's internal energy response in recog- risk of overweight/obesity in toddlers. The
nizing satiety rather than formula-fed intestinal flora of children born from
children (Binns et al., 2016; Martin et al., cesarean birth has low levels of bifido-
2017). the concentration of leptin (a bacteria. In children who born from cesa-
hormone that works to inhibit appetite and rean section, there is lack of good bacteria
regulate fat in the body) was found with a from mothers found in birth canal, while
more balanced concentration in children the enhancement of bad bacteria can harm
who were breastfed rather than formula-fed the child's immune system, this affects the
(Daniels et al., 2015).
child's susceptibility to overweight and Non-exclusive breastfeeding causes obesity (Sutharsan et al., 2015). The
obesity of 29.9% higher than exclusive exposure of gut microbiota in children with
breastfeeding up to 2 years old. In addition, cesarean delivery section can increase the
infants who are not breastfed have risk of potential of biological mechanisms of
type 2 diabetes mellitus(Ramírez et al., obesity in the development of infants and
children (Kuhle, et al., 2015). Giving exclusive breastfeeding for less The results of a study on pre-school
than six months increases the risk of children aged 3-6 years old, 67.3% have a
obesity than giving exclusive breastfeeding history of sectio cesarean birth and 15.7%
for more than six months (Daniels et al., are obese. Cesarean delivery increases over-
2015; Woo Baidal et al., 2016). Infants with weight by 1.7 times and obesity by 1.29
formula milk before 4 months old will times than normal-born children (Ruta-
increase the risk of obesity in toddlers after yisire et al., 2016).
3 years old (Bammann et al., 2014). Breast- The study of Pluymen et al. (2016)
feeding is a way of protecting children from suggests that 236 or 8.9% of children born
obesity risk factors later in life, especially from cesarean section had a 1.52 times
breastfeeding in the first year of life (Weng higher risk of overweight and obesity than
et al., 2014).
children with prevaginam delivery. Similar
5. The effect of first age at comple-
study also explained that 70% of children
mentary feeding with overweight or
with sectio cesarean birth have 1.49 times
obesity in children under five
higher risk of obesity than children with The result of this study showed that the normal birth delivery (Flemming et al.,
timely starting age of complementary feed- 2013).
ing has an effect on overweight/obesity in
4. The effect of exclusive breast-
toddlers which is statistically significant.
feeding with overweight or obesity in
Infants with first age of complementary
children under five
food more than 6 months decrease the risk The result showed that exclusive breast-
for overweight/obesity in toddlers. feeding has an effect on overweight/obesity
Exclusive breastfeeding and timely in toddlers which is statistically significant.
introduction of complementary foods is a Infants with formula milk as the food
prevention of obesity in the future. Comple- sources have a higher and longer insulin
mentary foods and high protein intake from response than breast-fed children, there-
an early age was associated with the fore, it stimulates more fat tissue deposition
enhancement of fat mass and obesity in and resulting in weight gain. Breast-fed
adulthood (Yang and Huffman, 2013). children have the ability to regulate the
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Based on a study by Zheng et al. in which children who rarely follow (2015), from 40,510 children, 3.18% have
physical activities are 3.1 times more likely excess body weight and 64.8% were given
in boys and 2.5 times in girls to have complementary foods before 3 months old.
overweight and obese than children who Complementary feeding before the age of 3
regularly follow physical activity guidelines. months is associated to the risk enhance-
Other study explained that physical activity ment by 11% for overweight or 1.11 times
in children for less than 1 hour increase higher risk for overweight/obesity or
overweight and obesity in children by 5.69 increased z-score than complementary
times greater than in children who perform feeding at 6 months old.
physical activity more than 1 hour per day Research with systematic review and
(Zamzani, et al., 2016).
meta-analysis showed an association
7. The effect of dietary pattern with
between complementary feeding under 4
overweight/obesity
months old, including 4-6 months old The result of this study showed that a diet increase the risk of overweight with a
high in fats and carbohydrates increased relative risk of 1.18 and obesity with a
energy intake which will further impact on relative risk of 1.33 higher for the over-
obesity with positive relationships which is weight and obese in toddlers compared to
statistically significant so that these complementary feeding at 6 months old
findings are reliable.
(Wang et al., 2017). Obesity is caused by an imbalance
6. The effect of physical activity with
between the amount of energy that enters
overweight or obesity in children
and the needs of the body for various
under five
biological functions such as physical The result of this study showed that
growth, development, activity, health main- children with high physical activities
tenance. If this condition persists conti- decreased the risk of obesity (negative
nuously (positive energy balance) in long- relationship). The result was statistically
term period, then it can lead to obesity significant so that the findings are
(Ahima, 2014; Burton-jeangros et al., 2015; influential and reliable.
Laurson et al., 2014).
Physical activity is needed in burning Obesity in the early period of life is the calories in the body. Excessive energy
influenced by the promotion of dietary intake and not balanced by adequate
habit and healthy eating habits, sedentary physical activity will increase the risk for
and physical activity. Increased prevalence overweight (Colley et al., 2013). The
of adipocytes can be known in an early life, standard practice of recommended physical
family and environmental parenting will activity in toddlers is not too heavy but
increase the chances of children to become encourages the children to always actively
obese since early stage. The implemen- move, as an intervention and reduce the
tation of the dietary habit and healthy living risk of daily habits of children who are lazy
in children is an early intervention for the to move, therefore, they will be easily to
occurrence of obesity (Campbell et al., have overweight or obesity (Howie et al.,
2014). Studies show that high-carbohydrate
A study by Laurson et al. (2014) and fat dietary compounds have higher risk explained about weight gain of children
of obesity by 1.18 times than low-fat diets who follow the physical activity guidelines,
and carbohydrate consumption patterns,
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balanced by lack of physical activity, and the psychological risks caused by premature daily habits that can lead to obesity such as
(Andrade et al., 2015).
watching TV and playing games (Choukem
A study by McDonald et al. (2010) et al., 2017).
using systematic review and meta-analysis Family habits with wrong dietary
in developing countries shows that habit such as, family modeling, lack of
gestational age has an effect on low nutritional knowledge, eating time, giving
birthweight and overweight/obesity. Lower food as a gift, affordability and constraints
gestational age with low birth weight of good food access and environmental
(<2,500 g) was found to be the highest in factors also affect children's dietary habit
women with overweight and obesity, with a and increase food intake, such as on food
relative risk of 1.30 times higher than availability,
normal mothers. Overweight and maternal influences and babysitters. All these factors
advertising,
socio-cultural
obesity also increases the risk for can be the cause of obesity in children
premature birth (37 weeks) due to medical associated with dietary habit (Paes, et al.,
indications with a relative risk of 1.24 times 2015).
higher. The highest incidence rate in
8. The effect of maternal gestational
developing countries with a relative risk of
age with overweight or obesity
0.58 higher than developed countries.
through birthweight
9. The effect of maternal BMI with The result of this study showed that
overweight/ obesty through birth-
mothers with gestational age (<37 weeks)
weight
had an effect on overweight/obesity of The result of this study showed that children through birthweight. Mothers with
mothers with overweight/obesity increase less gestational age increase the risk of low
the risk of low birthweight which continued birthweight, which furthermore becomes
to be more risky for overweight/obesity, more risky for overweight / obesity in
and it is statistically significant. infants.
Obese mothers significantly modified Pre-term gestational age (premature)
bolus gene expression associated with is a very important perinatal and public
neutral lipid transport and storage. health issue, not only because of high rates
Increased regulation of CGI-58, regulator of of neonatal morbidity and mortality and
TG hydrolysis system, contributes to intra- low birth weight, but also an impact on
cellular lipid turnover in placenta of obese quality throughout the life of the population
women, and it is strictly regulated by (Bronstein, 2016; Calkins, et al., 2011). maternal metabolic factors (Hirschmugl et
Premature birth is associated with
al., 2017).
changes in nutritional status and and the The function of the placenta can affect need for normal weight return. Births with
fetal adiposity tissue at the primary very low birthweight, metabolic enhance-
nutritional level. High plasma levels of ment, combined with dietary habit, pers-
certain nutrients of obese mothers are pectives on nutritional improvement, child-
considered important as a nutrient transfer hood eating habits, environmental and
link to the fetus resulting in fat accretion cultural social determinants, increase the
that poses a higher risk of fetal weight or risk in this population. A variety of factors
low birthweight, due to differences in the increase the risk of nutritional status to
differential bolus transfer nutrition settings become overweight and chronic illness to
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required for fetal growth (Lewis et al., as fatigue, practicality, lack of breastfeeding 2013).
time, and the intensity of meeting with Mothers with obesity are associated
infants (Rollins et al., 2016). with adverse long-term effects on children's
Mothers who plan to return to work health such as an increased risk of low
on the day off of less than 6 weeks increase birthweight, obesity, metabolic regulation
the risk by four times to stop the leading to the enhancement of insulin
breastfeeding in an early time, it also deals resistance, hypertension, heart and asthma
with maternal psychological stress, unco- risk. The complex relationship between
operative workplaces and the constraints in maternal and fetal metabolic as well as
giving the breastmilk (Guendelman et al., environmental influences and postpartum
lifestyle increases the risk of overweight/ Another study explains that mothers obesity of children from pregnancy to birth
who return to work when the infant is less (O’Reilly and Reynolds, 2013).
than 12 weeks reduce exclusive breast- The results of the study in Sweden
feeding rate by 0.68 times compared to showed that the risk of preterm delivery
mothers with longer day off (Mirkovic et increased at less gestational age of
al., 2014) . According to Ogbuanu et al., overweight and obese mothers, a mother
(2011) mothers with long day off and with a body mass index (BMI) of 25 to less
housewives increase the chances of than 30 increases the risk by 1.26 times,
exclusive breastfeeding in infants compared BMI 30 to less than 35 increases the risk by
to mothers with short day off.
A study in Ghana showed that the risk by 2.1 times and BMI more than 40
1.58 times, BMI 35 to less than 40 increases
housewives increase exclusive breast- increase the risk by 2.99 times. The
feeding by (84%) and formal working enhancement of maternal BMI will increase
mothers by (16%). Housewives (informal the incidence of premature in toddlers.
employment) provide greater opportunities Spontaneous preterm birth occurs in
(91%) for frequent breastfeeding of more mothers with BMI 30 and prematurely as a
than eight times compared to mothers who result of medical indications increase in
work in the formal sector (9%). Most mothers between overweight and obesity
mothers who work in the formal sector do (Cnattingius et al., 2013). not bring their babies to work, and do not
10. The effect of maternal employ-
pump their breast milk, therefore, it
ment status with overweight or
increases the risk of problems in breast-
obesity through exclusive breast-
feeding (Ward et al., 2013; Binns, 2016;
feeding
Nkrumah, 2017).
The result of this study showed that maternal employment status has an effect
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