Socioeconomic status, perceptions and obesity among adolescents in Jordan

Introduction Prevalence of obesity among adolescents constitutes a serious public health problem. We aimed to investigate the association between socioeconomic factors and obesity perceptions, and prevalence of overweight and obesity among school adolescents. Methods A cross-sectional study that included students 12 to 17 years old participating from six schools that were randomly selected in Northern Jordan. Body mass index (BMI) measurements and interview questions were completed by trained researchers. A total of 701 were successfully involved in the analysis. Results Students involved were 53.6% males and 46.4% females. Students with normal BMI had a mean BMI of 21.45 (+1.76). Those who were obese, or overweight were 202 (28.8%) students and had a BMI of 29.1 (+4.05). Family monthly income, mother's education and working status among other socioeconomic status factors were significantly associated with children’s overweight or obesity. Perceptions about obesity including meal choices, interest in self body weight, considering someone in family as obese and instructions at school were statistically significant as well. Conclusion Family factors, adolescents' pocket money and perceptions about obesity were significant predictors of obesity among adolescents in Jordan. Effective intervention strategies should be implemented in schools and other primary care settings to reduce the relatively high prevalence of adolescent's obesity observed in this study.


Introduction
At the individual level, childhood obesity is defined as "a result of an imbalance between the calories a child consumes as fat foods and beverages and the calories a child uses to maintain normal growth, metabolism, and physical activities" [1]. Overweight and obesity are increasing dramatically and rapidly in both children and adults. Many health professionals are sounding the alarm about the problems of obesity-related disability and death as well as the socioeconomic burden on health care systems [2]. Studies have reported that the prevalence of obesity has been associated with age [1], gender [3], physical activity [4], dietary patterns [5], and socioeconomic status since families with less monthly household income suffer from an increase in overweight and obesity [6]. Several international and regional studies indicate that factors causing obesity are multifactorial in nature. These factors may include genetic, behavioral, environmental, cultural, and socioeconomic factors [5][6][7][8]. Low socioeconomic status (SES) of individuals or families usually accompanies living in poor settings which offers an environment that allows easy access to unhealthy food and encourages physical inactivity. Families that have a history of low SES often provides information of unhealthy behavior, poor preferences of food selection, shopping, cooking, and exercising [5,7,9,10]. Another important social factor that is related to obesity is individuals' self-image and perceptions about health. Children behave in a certain way to reflect special patterns of thoughts and behaviors that are shared with other groups [11][12][13]. For this reason, peers have positive and negative influences on the children's behavior. Many children and adolescents spend their time with peers in fast-food restaurants. Most of meals that are offered in these restaurants are high in calories and fats.
Studies found that peers have an influence on the behavior of overweight and obese children or those at risk of being overweight or obese because children pick up on the behaviors of their peers which could include lack of exercise, eating unhealthy foods, and not taking care of health and body image [14,15]. Further, the ability of children to achieve the recommended action, such as doing regular exercise instead of eating high-calorie foods, seems to be related to selfefficacy "beliefs of people in their ability to perform the recommended action" [16]. Consequently, the presence of delicious high calorie foods at home or school may not help children to make the correct decision and can lead to negative impacts, particularly on the children who have low self-efficacy. Although this chronic disease is multifactorial in origin, investigating related factors and working on reducing them in a systematic way will progress toward reducing the burden of disease. In addition, studies that estimated the prevalence of obesity among Jordanian adolescents and factors associated with it are lacking. Therefore, this study aimed at estimating the prevalence rate of overweight and obesity among adolescents in Irbid Governorate, North Jordan and in examining its relation to SES and individuals' perceptions on health. Study population and sample: all students in the age group 12 to 17 years in six participating schools were considered as the target population, giving a total of 2,803 students. In this study, 836 successfully completed the study survey, with a response rate of 96.1% (836 out of 870 students who were approached to participate in the study). After analyzing the raw data, the researcher excluded 99 students because they were underweight. Thirty-seven other students were excluded because they did not answer all the items of the questionnaire. The final number of students who completed the questionnaire and were included in the final analysis was seven hundred and one. The participating schools vary in their nature, type and region. It includes public versus private schools, girls versus boys, and urban versus rural areas. The study population was selected in multistage five steps sampling procedure: determining the number of schools in Irbid Governorate, selecting the schools purposefully taking into consideration the schools which have classes from the 7 th -11 th grade, determining the number of classes in each grade, randomly selecting more than one class from each grade, randomly selecting half of the students from classes that were chosen randomly.

Methods
Study instrument and pilot testing: after reviewing the related literature, the researcher modified a version of a survey that was designed as an instrument published in 2008; entitled "Obesity and related factors among students grade 7-12 in Phuttha Monthon District, Nakhon Pathom Province, Thailand" [18]. The survey was translated from English to Arabic that was used in data collection of this study. For the purposes of the current study, an easy understood Arabic language questionnaire was distributed to the participating students. The study survey includes general information about the students' socio-demographic characteristics. Before starting the data collection process, a pilot test was carried out in one of public schools' classes. Some appropriate modifications were made mainly in editing.
Some questions were joined in a box to separate them from others.
Some of instructions were written and the type and size of font were changed to make the questions easier to read and understand.
Measurements and data collection: a consent sheet was distributed to students to ask their parents' approval. Research assistants were trained on how to take weight and height and to compute body mass index (BMI). BMI was calculated as body weight divided by height squared (kg/m²) and classified according to the Ministry of Health. The classification is indicated in the following (Table 1). The research team had to visit the schools more than one time to take the BMI measures of the whole sample since it was difficult to take them all at once.

Results
Descriptive statistics were used to report socio-demographic data. The whole study was conducted in the first directorate of Irbid in Jordan.

Discussion
Obesity is a growing public health problem of epidemic proportions in both developed and developing countries. Among children and adolescents, obesity is becoming a big concern in for its link with many in which a higher frequency of obesity were found among males [19].
The differences in the gender-based distribution of obesity between the two studies could be a result of differences in the age range of the population of each respective study. Another study by Zhang et al. (2018) found that boys had higher odds for overweight or obesity than girls [13]. On the other hand, our findings are consistent with the results of Whitaker and Orzol (2006), which did not report a genderbased difference in the prevalence of obesity among school children [20]. Another important factor that was significantly associated with obesity among adolescents was the employment status of the mother. There was a significant difference between children of working mothers and non-working ones. These findings are consistent with several other reports from various geographical regions/ethnicities including studies in developed or developing countries; the uniformity of these findings could indicate a possible global trend [19,21,22]. Several reasons could explain this observation among Jordanian school children; firstly, maternal employment may be associated with a shorter time the mother or her partner spends on meal preparation. Accordingly, households of working mothers may more likely depend on restaurants for providing meals which tend to be of more calorie dense than meals prepared at home. Secondly, children of working mothers are more likely to spend time under the supervision of others, including teachers and peers at school, which might have a positive or negative impact in terms of children perceptions and behaviors [11]. However, the higher prevalence of obesity among children of working mothers were not consistent across all studies [23,24].
The main reason that influenced the status of children BMI was the parents' economic status; another predictor explored in this study.
There was a positive association between income (total family or daily pocket) and being overweight/obese in our study. Findings suggest that family income may modify total calorie intake, dietary behaviour or physical activity of school children [25]. School children that are raised within families of higher total income have a wider range of food choices including food served at restaurants. Meals prepared and served at restaurants are usually more calorie dense and are higher in fat and sodium content. Moreover, a higher daily pocket income of the child could result in less strict control of children dietary behaviour by the parents; a factor that may lead to a higher consumption of calorie dense "fast" food [6,13,20]. Another determinant of childhood obesity in our report was the rank of the child in a big family size, with children belonging to larger families more likely of being overweight/obese. The exact reason of this finding warrants further investigation but could be related to children of larger families receiving less instruction from their parents regarding their food choices. Moreover, parents of fewer children regardless of the child's rank among siblings could be more educated and could spare more time to supervise their children. Accordingly, parents of smaller families may well be more attentive of their children's dietary behaviour and physical activity [12,25,26]. All these SES could affect the child's perception about eating habits, physical activity and health in general, mainly affected by parental weight status, their views about health and obesity, and maternal education [27,28].
Perceptions of school-age children in this study were found to be a significant determinant of obesity/overweight prevalence. In this regard, perceptions of family members viewed as obese, perception and interest in own weight, meal amount, preference in vegetables in meals, and the harmful effect of eating junk food were significantly related to obesity/overweight prevalence. Similar results were reported by other studies [27,28]. These factors are related to SES and/or mother's education level. Nonetheless, a working mother who is educated or from a high SES might not have enough time to educate or direct her child toward healthy food, and thus, the child's perception towards eating habits will be affected by the social environment. • Obesity among children were explored in the school-age 6-12.

What this study adds
• Obesity among children were explored in the school-age 13-17; • The effect of perceptions of children about the meals and obesity; • The effect of the money allowance the child has in school. Table 1: the classification of the body mass index   Equal or more than 30