Prevalence of overweight and obesity and associated factors among adolescentc aged 15 to 19 years old in phonghong districh, vientiane province, lao pdr in 2019

AND MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH HANOI UNIVERSITY OF PUBLIC HEALTH SOMPHONE SOUKHAVONG PREVALENCE OF OVERWEIGHT AND OBESITY AND ASSOCIATED FACTORS AMONG ADOL

AND MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH

HANOI UNIVERSITY OF PUBLIC HEALTH

SOMPHONE SOUKHAVONG

PREVALENCE OF OVERWEIGHT AND OBESITY AND ASSOCIATED FACTORS AMONG ADOLESCENTS AGED 15 TO 19 YEARS OLD IN PHONHONG DISTRICT, VIENTIANE PROVINCE, LAO PDR 2019

MASTER OF PUBLIC HEALTH

CODE: 8720701

HANOI, 2020 HUPH

MINISTRY OF HEALTH UNIVERSITY OF HEALTH SCIENCES, FACULTY OF PUBLIC HEALTH

AND MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF HEALTH

HANOI UNIVERSITY OF PUBLIC HEALTH

SOMPHONE SOUKHAVONG

PREVALENCE OF OVERWEIGHT AND OBESITY AND ASSOCIATED FACTORS AMONG ADOLESCENTS AGED 15 TO 19 YEARS OLD IN PHONHONG DISTRICT, VIENTIANE PROVINCE, LAO PDR 2019

MASTER OF PUBLIC HEALTH CODE: 8720701

SUPERVISORS:

HANOI, 2020

DR CHANDAVONE PHOXAY

DIRECTOR, NUTRITION CENTER

MINISTRY OF HEALTH, LAO PDR

ASSOC PROF LE THI THANH HUONG

HEAD, FACULTY OF ENVIRONMENTAL AND OCCUPATIONAL HEALTH

HANOI UNIVERSITY OF PUBLIC HEALTH

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of Health and Assoc Prof Le Thi Thanh Huong, Head of the Faculty of Environmental and Occupational Health, Hanoi University of Public Health, who steered me in the right direction whenever they thought I needed it

I would also like to acknowledge the valuable comments and encouragement from the examination chair of my Independent Study Committee and also wish to thank the external members of the committee

I am most grateful to the directors of the Vientiane Provincial Health Department as well as to the facilitators, heads of villages and the research team in Phonhong District, Vientiane Province, who kindly agreed to help and participate in this research This study could not have been completed without their generous assistance

I am grateful as well to all the lecturers, teachers and staff of the UHS, TPHI and HUPH for their continuous assistance and helpful advice

Lao-I would like to thank Dr Somphou Outensackda, Miss Ammala Phommachack and my classmates for their kindness during the period of my studies

at UHS and HUPH

Finally, I would like to thank my family for their love, understanding, support, and encouragement during the time I was studying in Laos and Vietnam

Mrs Somphone SOUKHAVONG

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ABBREVIATIONS

BMI Body Mass Index

GSHS Global School Based Health Survey

Lao-TPHI Lao Tropical and Public Health Institute

LSIS Lao Social Indicators Survey

MOES Ministry of Education and Sports

MOH Ministry of Health

NIDDK National Institute of Diabetes and Digestive and Kidney Diseases NIOPH National Institute of Public Health

UNICEF United Nations Children‟s Fund

UNFPA United Nations Fund for Population Assistance

WHO World Health Oganization

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CONTENTS

ACKNOWLEDGEMENTS i

ABBREVIATIONS ii

LIST OF TABLES v

SUMMARY vi

INTRODUCTION 1

RESEARCH OBJECTIVES 3

CHAPTER 1 4

REVIEW OF LITERATURE 4

1.1 Concept of overweight and obesity 4

1.2 Concept of adolescents 4

1.3 Causes of overweight and obesity 5

1.4 Consequences of overweight and obesity 5

1.5 Classification and assessment of overweight and obesity 6

1.6 Overweight and obesity situation among adolescents 7

1.6.1 Overweight and obesity situation among adolescents at global level 7

1.6.2 Overweight and obesity situation among adolescents in Laos 9

1.6.3 Overweight and obesity situation among adolescents in Vientiane Province 10

1.7 Factors associated with overweight and obesity among adolescents 10

1.7.1 Individual factors 10

1.7.2 Family factors 13

1.7.3 Eating habits among adolescents 16

1.7.4 Physical activities among adolescents 17

1.8 Conceptual Framework 18

1.9 Study setting 19

CHAPTER 2 20

METHODOLOGY 20

2.1 Study population 20

2.2 Study site and duration of data collection 20

2.3 Study design 20

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2.4 Sample size 21

2.5 Sampling method 21

2.6 Data collection 22

2.7 Variables of the study 24

2.8 Assessment criteria 26

2.9 Data analysis 27

2.10 Ethical considerations 28

CHAPTER 3 29

RESULTS 29

3.1 Demographic characteristics 29

3.2 Overweight and obesity statuses among adolescents 31

3.3 Factors associated with overweight and obesity statuses among adolescents 32

3.4 Multiple logistic regression analysis of the factors associated with overweight and obesity 52

CHAPTER 4 55

DISCUSSION 55

CONCLUSION 67

RECOMMENDATIONS 68

REFERENCES 69

ANNEXES 75

Annex 1: Table of definition and measurement of variables in the study 75

Annex 2: Table 3.6 Frequency of eating particular food items of adolescent (n=403) 78

Annex 3: Questionnaires 81

Annex 4: BMI for age growth charts for boys and girls 5-19 years old 90

Annex 5: Certificate of approval 92

Annex 6: Participant Information Sheet 94

Annex 7: Informed Consent Form 96

Annex 8: Thesis comment 97

Annex 9: Minutes of explanation after thesis defence 104

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LIST OF TABLES

Table 3.1 Demographic characteristics of adolescent aged 15-19 years old 30 Table 3.2 Overweight and obesity statuses of adolescents aged 15-19 years old 31 Table 3.3 Overweight and obesity statuses by gender among adolescents aged 15-19 years old 31 Table 3.4 Overweight and obesity statuses by age among adolescents aged 15-19 years old 32 Table 3.5 Family factors contributing to occurrence of overweight and obesity

statuses of adolescents 33 Table 3.6 Frequency of eating particular food items of adolescents aged 15-19 years old 36 Table 3.7 Eating habits among adolescents aged 15-19 years old 37 Table 3.8 Physical activity and sedentary behavior among adolescents 38 Table 3.9 Association between individual factors and adolescents‟ overweight and obesity statuses 42 Table 3.10 Association between family factors and overweight and obesity statuses among adolescents aged 15-19 years old 44 Table 3.11 Association between eating habits of adolescents and their overweight and obesity statuses 48 Table 3.12 Association between physical activities of adolescents and their

overweight and obesity statuses 49 Table 3.13 Multiple logistic regression analysis of the factors associated with

overweight 53 Table 3.14 Multiple logistic regression analysis of the factors associated with

obesity 54

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SUMMARY

Overweight and obesity in adolescents is increasing worldwide Malnutrition has become a challenge to public health in developing countries Childhood obesity increases the risk of chronic disease in adulthood Information about childhood overweight and obesity, however, is scarce in Laos The researcher was therefore keen to explore the prevalence of overweight and obesity and their associated factors among adolescents aged

15 to 19 years in Phonhong District, Vientiane Province, Lao PDR in 2019

A cross-sectional descriptive study was conducted in Phonhong District from 20thAugust to 10th September, 2019 using a cluster sampling method with 403 adolescents aged 15 to19 A face to face interview technique and anthropometric measurements were used to collect data, with the help of six well trained research assistants Overweight and obesity were determined when BMI for age = 23.0 – 24.9 kg/m2 and BMI for age ≥ 25 kg/m2, respectively Data were processed and entered into the EpiData software and exported into the STATA application for data analysis Univariate and multivariate logistic regressions were carried out to identify the factors associated with overweight and obesity

Sixty-one percent of those studied were women, and the prevalence of overweight and obesity were 13% and 11% respectively High monthly family income and family eating outside the home or eating fast food were statistically significant in overweight

among adolescents, with (AOR=4.9, p-value <0.001) and (AOR=2.3, p-value =0.013)

respectively Male adolescents were more positively correlated with obesity than female

adolescents (AOR= 5.2, value <0.001), while high family monthly income (AOR=9.1, value <0.001) and a higher number of obese persons in the family (AOR=3.2, p-value

p-=0.004) had a statistically significant association with the adolescents‟ obesity

The prevalence of overweight and obesity in adolescents is alarming in the study area (Phonhong District) Gender, family monthly income, number of obese persons in the family, eating outside the home and eating fast food were important determinants impacting the risk factors of overweight and obesity in adolescents Based on the results of this study, the policymakers should concentrate on overweight and obesity in parallel with under nutrition and to improve adolescents‟ nutritional status There is a need to include nutrition and physical education programs in schools and the community and to raise awareness among families and the community of the health benefits of proper dietary behaviors and physically active lifestyles

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The 2016 Global Nutrition Report highlights an important issue: “Worldwide, millions of kids are eating too much of unhealthy foods, while millions more are not getting enough of foods to let them grow and thrive” The epidemic of obesity in developed countries is commonly associated with poor dietary habits and a sedentary lifestyle However, other determinants, including education background and family income, may contribute to the problem, especially in developing countries Significant differences were found between BMI categories and gender, parents‟ occupation and educational level, household income and size, and socio-

economic status (Ahmad et al., 2018)

Recent studies conducted across the world have indicated that nutrition education interventions on school children have significantly improved their eating habits and informed their food choices In East Asia and South East Asia, rapid urbanization and socio-economic development combined with changes in eating habits and in physical activities have led to an increase in obesity in adults and in children as well (WHO, 2014) Overweight and obesity are among the five leading causes of death

in the world Since overweight and obesity are major risk factors of

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communicable diseases in later life (WHO, 2020), it is important to understand the potential factors associated with body weight in adolescents

In the context of Laos, there is limited information available on the nutritional status

of adolescents in general, and especially in Vientiane Province According to the Lao Social Indicators Survey 2017, children in the province below five years of age are 33% stunted, 9% wasting, 21% underweight, and 3.5% overweight or obese (Lao Statistical Bureau, MOH, UNFPA & UNICEF, 2017) The Global School Based Health Survey in Laos reported that 13% of students aged 13 to 17 years were overweight or obese (WHO & NIOPH 2015) Existing data show that there is

an increasing prevalence of overweight and obesity among adolescents, together with unhealthy eating, drinking and inappropriate physical activity (Phouapanya,

2015, Keolangsy, 2017)

Phonhong District is the major city of Vientiane Province, but it is less advanced than Vientiane Municipality To date, there is no empirical study on the nutritional status of adolescents in this district Hence, there was a need for this exploration of the prevalence of overweight and obesity and their associated factors among adolescents aged 15 to 19 years in the district

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RESEARCH OBJECTIVES

This research aimed to explore issues of adolescent nutrition in the province outside

of Vientiane Capital The focus was:

1 To estimate the prevalence of overweight and obesity among adolescents aged

15 to 19 years old in Phonhong District, Vientiane Province, Lao PDR in 2019

2 To identify factors associated with overweight and obesity among adolescents aged 15 to 19 years in Phonhong District, Vientiane Province, Lao PDR in

2019

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CHAPTER 1

REVIEW OF LITERATURE

1.1 Concept of overweight and obesity

Overweight, as defined by the World Health Organization (WHO), is a condition in

an individual in which they weigh more than they should in relation to their height Overweight is generally due to extra body fat However, overweight may also be due to extra muscle, bone, or water Obesity, on the other hand, is a condition of excessive and abnormal fat accumulation in one body area or the whole body to a level that affects health People who are obese usually have too much body fat (WHO, 2000 & 2003) Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health The terms “overweight” and

“obesity” refer to body weight that is greater than what is considered normal or healthy for a certain height (WHO, 2018)

1.2 Concept of adolescents

The manifest gulf in experience that separates younger and older adolescents makes

it useful to consider this second decade of life in two parts: early adolescence (10 to

14 years) and late adolescence (15 to 19 years) Early adolescence might be broadly considered to stretch between the ages of 10 and 14 Late adolescence encompasses the latter part of the teenage years, broadly between the ages of 15 and 19 It is a time of opportunity, idealism and promise It is in these years that adolescents make their way into the world of work or further education, settle on their own identity

and world view and start to engage actively in shaping the world around them

(UNICEF, 2011)

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1.3 Causes of overweight and obesity

The fundamental cause of overweight and obesity is an energy imbalance between calories consumed and calories expended Globally, there has been an increased intake of energy-dense foods that are high in fat and an increase in physical inactivity due to the increasingly sedentary nature of many forms of work, changing modes of transportation and increasing urbanization (WHO, 2018)

Childhood obesity causes various problems centering on an imbalance between energy in (calories obtained from food) and energy out (calories expended in the basal metabolic rate and physical activity) Childhood obesity most likely results from an interaction of nutritional, psychological, familial and physiological factors (Aisbitt, 2008)

1.4 Consequences of overweight and obesity

An estimated 97 million adults in the United States are overweight or obese As a major contributor to preventable deaths in the United States today, overweight and obesity pose a major public health challenge (Ng, 2014) Most people who are overweight and have one or more factors that raise their chances of heart disease should lose weight These factors include diabetes, pre-diabetes, high blood pressure, dyslipidemia or high levels of LDL cholesterol, low levels of HDL cholesterol, or high levels of triglycerides (WHO, 2014) Overweight and obesity are risk factors and when present in childhood can lead to serious adult medical conditions like heart disease, heart failure, and stroke (Smith, 2000)

A study conducted by Kelly et al in 2013 revealed that children with a BMI ≥ 95th percentile, 70%, 39%, and 18% had at least 1, 2, or 3 cardiovascular disease (CVD) risk factors, respectively In contrast, among those with a BMI ≥ 99th percentile, which was used to identify severe obesity in the study, 84%, 59%, and 33% had at

least 1, 2, or 3 CVD risk factors, respectively (Kelly et al, 2013)

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1.5 Classification and assessment of overweight and obesity

According to the WHO‟s nutritional status based on BMI for age (WHO, 2007), overweight and obesity is defined and classified by using body mass index (BMI) and calculated based on height and body weight The formula for calculating BMI

is the child's body weight (in kg) divided by the square of their height (in meters):

BMI = Weight (kg) / Height2 (m)

In children (between 5 and 19 years old), height changes, while using the BMI threshold for adults is not recommended Hence, BMI in children has to be calculated according to the age and gender of the child and using the WHO 2007 reference population with the following threshold points to assess the nutritional status of the adolescents

 BMI for age classification

o Underweight BMI for age < 18.5 kg/m2

o Normal nutrition BMI for age = 18.5 - 22.9 kg/m2

o Overweight BMI for age ≥ 23.0 - 24.9 kg/m2

o Obese I BMI for age ≥ 25.0 - 29.9 kg/m2

o Obese II BMI for age ≥ 30 kg/m2

 BMI z-score classification

o BMI z-score < -2 SD: Underweight

o BMI z-score - 2 SD to +1 SD: Normal

o BMI z-score > +1SD to +2SD: Overweight

o BMI z-score > +2SD: Obese

 BMI Percentile classification

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1.6 Overweight and obesity situation among adolescents

1.6.1 Overweight and obesity situation among adolescents at global level

Globally, most of the world's population live in countries where overweight and obesity kills more people than underweight The increasing prevalence of overweight and obesity among adolescents began to nearly triple between 1975 and

2016 in low- and middle-income countries The prevalence of overweight and obesity was now causing a "double burden" of disease among children and adolescents aged 5 to 19 (WHO, 2016)

The rise has occurred similarly among both boys and girls (10 to 18 years old): In

2016 18% of girls and 19% of boys were overweight Once considered a income country problem, overweight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings (WHO, 2016) In Saikia‟s study in India, of the total number of adolescents, 46% were girls The prevalence

high-of overweight and obesity overall was 22.5% and 9.7% respectively and was higher

in girls (p-value <0.05) and among the younger ages (p-value<0.05), with dietary

behavior and physical activity significantly affecting the weight of adolescents (Saikia et al., 2016)

The epidemic of obesity in developed countries is commonly associated with poor dietary habits and a sedentary lifestyle However, other determinants, including educational background and family income may contribute towards the problem especially in these countries Significant differences have been found between BMI categories and gender, parents‟ occupational and educational levels, household income and size, and socio-economic status (Ahmad et al., 2018)

In other recent studies, attention has focused on the cardiovascular health risks associated with severe pediatric obesity, with emphasis on how the immediate and long-term risks in this subgroup differ from less extreme forms of obesity Of children with a BMI ≥ 95th percentile, 70%, 39%, and 18% had at least 1, 2, or 3 CVD risk factors, respectively In contrast, among those with a BMI ≥ 99th

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percentile, which was used to identify severe obesity in the study, 84%, 59%, and 33% had at least 1, 2, or 3 CVD risk factors, respectively Results from this study suggest a high level of cardiovascular risk in severely obese children and adolescents (Kelly et al., 2013)

Since overweight and obesity are the major risk factors of non-communicable disease in later life, it is important to understand the factors associated with body weight in adolescents In the study by Zarei, et al., body weight was found to be

significantly (p-value <0.05) associated with age, gender and grade (Zarei et al.,

2014) Wake and Reeves studied cultural and lifestyle related factors that affect obesity in school-aged children living in England and France Their study found

that there was a significant impact on obesity (p-value <0.01) in the levels of

out-of-school physical activity undertaken by both the French children and the English children (Wake & Reeves, 2012)

The 2011 Youth Risk Behavior survey from the United States reported high rates of overweight and obesity among high-school students The survey found 15.2% of students were obese and 13% were overweight Similar prevalence has been recorded among Australian adolescents (Hayward et al., 2014) The proportion of overweight and obese individuals is plateauing in the US, but it is continuing to rise around the world Obesity is a significant health concern because it predisposes individuals to several comorbidities, including hypertension, dyslipidemia, coronary heart disease, Type 2 diabetes, stroke, cancer and osteoarthritis and a shortened life expectancy while impairing the quality of life (Greenway, 2015)

In East Asia and South East Asia, rapid urbanization and socio-economic development combined with changes in eating habits and in physical activity have led to an increase in obesity in adults and in children as well The prevalence of overweight and obesity was 17.8% and 3.2%, respectively among children aged 11

to 14 years, and children living in wealthier families were more overweight and obese than those living in less wealthy families (Nguyen et al., 2013)

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1.6.2 Overweight and obesity situation among adolescents in Laos

In the context of Laos, the WHO in 2014 estimated that 48% of population deaths in Laos was associated with non-communicable diseases, of which overweight and obesity are major risk factors Of this 48%, 22% were due to cardio-vascular disease and 11% were due to cancer (WHO, 2014) There is limited data available

on the nutritional status of adolescents in general According to the Lao Social Indicators Survey, 2017, 33% of children below five years of age are stunted, 9% are wasting, 21% are underweight and 3.5% are overweight or obese (Lao Statistical Bureau, MOH, UNFPA & UNFPA, 2017) The Global School-based Health Survey (GSHS) in Laos reported that among students aged 13 to 15 years, 13.6% are overweight and obese while among those aged 16 to 17 years, 12.3% are overweight and obese The percentage of students who usually drink carbonated soft drinks one or more times per day during the 30 days before the survey were 58.1% in the 13 to 15 year age group and 45% in the 16 to 17 year age group (WHO

& NIOPH, 2015) Another study in Xinxay Secondary School, Vientiane Capital, found that 6.2% were overweight and 12.3% were obese and that factors

significantly associated (p-value<0.05) with overweight were gender, knowledge on

nutrition, household income and eating behavior (Bounheung, 2015)

In a recent study conducted by Vathsana Phouapanya, among adolescents aged 15

to 19 years reporting the prevalence of nutritional status based on BMI for age, and there were 12.8% overweight or obese (Phouapanya, 2015) Among the 300 adolescents aged 15 to 19 years studied, 23.3% were overweight 67.0% of these adolescents had a poor eating habit, despite the fact that 78.0% of them had a good knowledge of nutrition Factors significantly associated with overweight and obesity were low-level physical activity and adolescents living with their parents (Keolangsy, 2017)

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1.6.3 Overweight and obesity situation among adolescents in Vientiane Province

There is limited information available on the nutritional status of adolescents aged

15 to 19 years in Vientiane Province The Lao Social Indicators Survey 2017 reported that among children below five years of age in Vientiane Province, 33% are stunted, 9% are wasting, 21% are underweight and 3.5% are overweight or obese (Lao Statistical Bureau, MOH, UNFPA & UNFPA, 2017) Phonhong District

is one of the more advanced districts in Vientiane province As people have higher income and restaurants are on the increase, this together makes for higher and easier access and consumption of fast food and soft drink However, as there had been no empirical study on the nutritional status of adolescents aged 15 to 19 in this district, this study was undertaken, focusing on overweight and obesity and their associated factors among 15 to 19 year olds in this district in 2019

1.7 Factors associated with overweight and obesity among adolescents

1.7.1 Individual factors

 Gender: The WHO reports in Thailand that a significantly higher proportion

of males than females were overweight (WHO 2018) A study on nutrition among adolescents found that 16.4% of female students were overweight compared to 12.7% in males There was a significant association between

gender and BMI (p-value <0.01) Significantly more females were overweight than males (p-value <0.05) (Maryam, 2014) Cruz Estrada et al

(2017) found that females have a higher overweight rate than males (3:1) Sardinha et al (2011) reported that by using IOTF cut‐offs the prevalence of

overweight was 17.0 in girls, and 17.7 in boys, respectively (p-value <0.001

for overweight)

In Thailand, it is reported that 5.8% of adolescents were obese, with the prevalence of obesity significantly higher among male (8.9%) than female (3.2%) adolescents (WHO, 2018) In contrast, Zarei et al (2014) in their

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study on the nutritional status of adolescents found that there was a

significant association between gender and BMI (p-value <0.01) and significantly more females were obese than males (p-value <0.05)

 Age: Findings in Laos have revealed that 13.6% of students aged 13-15 years and 12.3% of students aged 16 to 17 years were overweight, respectively (WHO & NIOPH, 2015) The study of Keolangsy in Vientiane Capital has also found that adolescents aged 18 to 19 years were positively correlated with overweight, indicating that the older aged adolescents are more likely to develop overweight The prevalence of overweight was higher among adolescents 10 to 18 years of age (13%) than children 5 to 9 years of age

(9.4%) (p-value <0.001) and was highest (23.1%) at age 15 years

(Ene-Obong et al., 2012)

WHO & NIOPH, 2015 and Keolangsy, 2017 revealed that 12.3% of adolescents aged 16 to 17 years were obese It was also found that adolescents aged 18 to 19 years were 1.4 times more likely to be obese than those who are 15 to 17 years old, indicating that older aged adolescents are more likely to develop obesity With the WHO cut‐offs, a lower prevalence

of obesity was observed at the higher ages in boys, while in girls, the prevalence of obesity increased from 10 to 12 years of age and decreased from the age of 13 to 18 years (Sardinha et al., 2011)

 Level of education: The study of the factors affecting the nutritional status of adolescents attending the Iranian Secondary School found that there was a

significant association between body weight status and level of education

(p-value < 0.05) (Zarei, 2014)

 Number of siblings and number of household members: Respondents who had one to two siblings were 1.3 times more likely to be overweight than those who had more than two siblings, and adolescents from households of two to four members were 1.2 times more likely to be overweight or obese

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than those who had at least five members (Keolangsy, 2017) Meller et al.,

2018 reported in their meta-analysis that the number of siblings was associated with overweight A higher risk of overweight was consistently found among adolescents with one sibling than among those with two or more siblings

For obesity, the study by Keolangsy (2017) found that adolescents who had one to two siblings were also 1.3 times more likely to be obese than those who had more than two siblings, and adolescents from households of two to four members were also 1.2 times more likely to be obese than those who had at least five members Meller et al 2018 reported in their meta-analysis that number of siblings was also associated with obesity That is, a higher risk of obesity was consistently found among adolescents with one sibling than among those with two or more siblings

 Birth order: A study by Min (2017) in China reported that being the first child meant that adolescents were about four times more likely to be overweight than those who were the second child The association became stronger over time Adolescents who were the first or second child in the family were 1.3 times more likely to be overweight than those who were the third and later child (Keolangsy, 2017) A systematic review to evaluate the effects of birth order and number of siblings on the risk of overweight by Meller et al (2018) found that lower (vs higher) birth order was associated with overweight, with ORs of 1.47 Generally, there was a higher risk of overweight among firstborns Both lower birth order and lower number of siblings are associated with risk of overweight, which suggests that only children are at a slightly increased risk of overweight The study of Ochiai et

al (2012) found that having a larger number of younger siblings was negatively associated with overweight For the prevalence of obesity, the studies by Min (2017), Keolangsy (2017) and Meller et al., (2018) found that birth order was statistically also a factor associated with obesity

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1.7.2 Family factors

 Living arrangements: The influence of caregivers was found to be significantly associated with the participants‟ nutritional status Students who lived with their parents were more than 3.5 times more likely to be overweight or obese than those who did not live with their parents (Keolangsy, 2017)

 Parents‟ education and occupation: Significant differences were found between BMI categories and gender, parents‟ occupational and educational

level, household income and size, and socio-economic status (Ahmad et al.,

2018) The occupations of parents or guardians were not associated with the

nutritional status of adolescents aged 15-19 years old (p-value >0.05)

However, according to the results, adolescents whose parents or guardians were unemployed were more likely to be overweight and obese than those whose parents or guardians had a job (Keolangsy, 2017)

The obesity index was higher in adolescents of highly educated parents

(p-value >0.05) (Hasan, 2018) For obesity, significant differences were also found between BMI categories and gender, parents‟ occupational and educational level, household income and size, and socio-economic status (Ahmad et al., 2018)

 Monthly income of the family: Family income may contribute towards the nutrition problem, especially in developing countries Respondents from a family whose total monthly household income was US$251 to US$400 or more were about 2.66 to 4 times more likely to develop overweight compared to students from families whose monthly income was less than 100 USD (Anteneh et al., 2015) A recent study of Lao adolescents of secondary school age showed that those from households with monthly incomes that were more than 5,000,000 LAK (about US$550) had a higher risk of developing overweight than those from households with incomes less than

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5,000,000 LAK (Bounheung, 2015) A higher proportion of male (30.7%) than female (27.4%) children were overweight The BMI of the children was

significantly related to family income (p-value <0.001) (Shafaghi et al.,

2014)

Adolescents living in wealthier families were more obese than those living in less wealthy families (Nguyen, 2013) This indicates that households of higher income are able to provide more than good food or even snacks for their children As with overweight, a higher proportion of male (30.7%) than female (27.4%) children were obese The BMI of the children was also

significantly related to family income (p-value <0.001) (Shafaghi et al.,

2014) A study to estimate incidence and risk of childhood obesity according

to socio-economic status in Peruvian and Vietnamese school-aged children in

2015 demonstrated that the incidence of obesity was higher for children of families at the top wealth indices in all samples (Jaime & Bernabé-Ortiz, 2015)

 Family history of obesity: The recent study by Bounheung among 308 secondary school aged Lao students found that children in households with obese family members had a higher risk of developing overweight than those

in households that did not have obese family members (p-value <0.001)

(Bounheung, 2015) In another study, a cross-sectional study in Southwest France in 2004-2005 to determine the association of overweight and obesity and age and gender in French adolescents, parental overweight was a strong risk factor for their adolescent children‟s overweight, and parents‟ active lifestyles were associated with a lower risk of overweight in their adolescents (Thibault et al., 2010) The study of Bahreynian et al (2017) found that environmental factors including parental overweight, shared family lifestyle, dietary habits, and socio-economic status were linked to adolescent overweight

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In Thibault‟s study, parental overweight was also a strong risk factor for adolescent obesity (Thibault et al., 2010) The study by Bahreynian et al (2017) also found that adolescents from families with obese parents were at a significantly higher risk of obesity The study of Jiang et al (2013) found that maternal BMI had a strong influence on obesity prevalence in adolescents

 Family eating behavior: Adolescents and children who join in fewer family meals consume unhealthier food There is a positive relation between frequent family meals and greater consumption of healthy foods (i.e., fruits, vegetables, and calcium-rich foodstuffs) Nutrient and caloric intake at family meals depends on the foods served and providing fast food and takeout food items at family meals may negate the nutritional benefits usually associated with home-cooked family meals Parents who are overweight, who have problems controlling their own food intake or who are concerned about their children‟s risk for overweight may adopt controlling child-feeding practices in an attempt to prevent their children from becoming overweight too (Scaglioni et al 2018) With regard to eating habits, the study

of Bahreynian et al (2017) likewise found that environmental factors including shared family lifestyle and dietary habits were linked to adolescent overweight Bounheung (2015) found that households that were consuming meat regularly had a higher risk of developing overweight than those

households that did not do so (AOR = 2.2, 95% CI = 1.1-4.4, p-value

<0.001)

Similarly, in studies on obesity, adolescents and children who join in fewer family meals consume unhealthier food and there is a positive relationship between frequent family meals and greater consumption of healthy foods (i.e., fruits, vegetables and calcium-rich foodstuffs) Dietary habits are shaped at a young age and maintained during later life with tracking over time Although eating behaviors and child weight are difficult to modify

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directly, parental feeding practices are potentially a good target for interventions to prevent unhealthy eating patterns and developing excess weight in children (Ng, 2014)

1.7.3 Eating habits among adolescents

The research of Keolangsy (2017) found that poor eating habits are one of the key factors of a healthy lifestyle More than half of the subjects did not have an appropriate eating behavior and had poor eating habits Consequently, respondents with poor eating habits had a higher percentage of overweight The relationship

between eating habits and nutritional status was significant (p-value <0.05)

Unhealthy eating patterns were observed, considering that 45.4% of males and 40.2% of females reported consuming fried food Fast food consumption occurred more than three times a week in 36.9% of males but only in 19.2% of females Although the majority of males (82.4%) and females (83.2%) seemed to be equally aware of the long-term effects of dietary behavior on health status, more female

students (p-value <0.05) are trying to obtain information about the nutrient value of

what they consume by reading nutrient labels Eating behavior established in childhood persists, with implications such as fussiness and poor dietary variety or high responsiveness to fast food increasing obesity risk (Ng, 2014)

Soutisad (2015) focused on research on the factors correlated with the incidence of obesity among children in primary schools in Kamphaengphet district and found that there was a significant association between food behaviors towards obesity among children In the research of Keolangsy (2017), poor eating habits was also one of the key factors affecting obesity More than half of the subjects did not have

an appropriate eating behavior and had poor eating habits, and, as a result, respondents with poor eating habits had a higher percentage of obesity The

relationship between the eating habits and nutritional status was significant (p-value

<0.05) In another study by Washi, poor eating habits was particularly relevant for obesity in adolescents (Washi, 2010)

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1.7.4 Physical activities among adolescents

The study by Desalew et al (2017) found that adolescents who had not engaged in regular physical exercise were significantly associated with overweight A study by Hanley et al (2018) reported that respondents who did not do vigorous physical activity were more than four times more likely to develop overweight compared to those who did vigorous physical activity Moreover, who did vigorous physical activity less than three times a week were more than four times more likely to develop overweight compared to those who did vigorous physical activity more than six times a week (Hanley et al., 2018) The study by Thibault et al (2010) found that adolescents' sedentary behavior is a strong risk factor for adolescent overweight

The study by Desalew et al (2017) and the study by Hanley et al (2018) reported that adolescents who did not do physical exercise were significantly associated with obesity, and Thibault et al (2010) found that adolescents' sedentary behavior has strong risk factors for adolescent obesity

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1.8 Conceptual Framework

The conceptual framework for this study is based on two previous studies, those by Phouapanya (2015) and Keolangsy (2018), as well as on some independent variables based on literature reviews in five papers (Ahmad et al., 2018; WHO, 2014; Silangwe, 2013; Nguyen et al., 2013; Zarei et al., 2014)

Individual factors: Gender, Age, Level of

education, Number of household

members, Number of siblings in family,

Birth order

Eating habit factors: food consumption

patterns and frequency

Physical activity factors: daily activities,

travel and recreational activities

Overweight (BMI = 23 24.9 kg/m2)

-Obesity (BMI ≥ 25 kg/m2)

Family factors: Living arrangement,

monthly income of the family, Parental

education, Parental occupation, family

history of obesity, family eating behavior

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1.9 Study setting

Vientiane Province is located in the mid north-west of Laos There are eleven districts spread over a total land area of 15,927 km2 (See map below.) The population is approximately 419,090 as of the March 1, 2015 census The province borders Luang Prabang Province to the north, Xiangkhoung Province to the northeast, Bolikhamxai Province to the east, Vientiane Prefecture and Thailand to the south, and Xaignabouli Province to the west Vientiane Province was the third richest province in Laos (Lao Statistical Bureau, MOH, UNFPA & UNICEF, 2017) The principal town is Phonhong District, which has a higher economic status than other districts At the same time, when people have higher incomes and restaurants increase, there is easier access to and consumption of fast food and soft drinks, especially among adolescents (Lao National Census, 2015) As classified by the Education and Sports Service of Vientiane Province, there are 59 villages, divided into six village groups based on the distance from the Phonhong District Office: Phonhong (10 villages), Phonsi (11 villages), Sakar (12 villages), Nalow (7 villages), Phonxay (10 villages) and Nalao (9 villages), which are 1 km, 10 km, 12

km, 6 km, 24 km, 18 km away respectively (ESD report, 2018)

The province is made up of the following 11 districts:

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o Adolescents who were pregnant or married

2.2 Study site and duration of data collection

The study was conducted in communities in Phonhong District, Vientiane Province The data collection took up four weeks after obtaining ethical approval from the Hanoi University of Public Health (HUPH) and the UHS ethics committee

2.3 Study design

This study was designed as a cross-sectional study to assess overweight and obesity and its associated factors among adolescents aged 15 to 19 in Phonhong District, Vientiane Province, Laos

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2.4 Sample size

The study samples were selected from one district (Phonhong) There were 59 villages The sample size was estimated and calculated by using the following formula, adapted from Daniel (1999),

where

n is minimum sample size required,

p was the partial percentage of 13% of overweight and obesity among high school students in Xaysettha District, Vientiane Capital Laos (Phouapanya, 2015),

z is the confidence level (with 95% confidence, then z = 1.96), and

d is the absolute precision (d=0.05 used in this study)

Thus,

n = 174 adolescents aged 15-19 The sample size of this study is multiplied by 2 (because of the design effect), which is equal to 348 adolescents, plus 10% of refusals or dropouts Finally, 403 adolescents were obtained from the calculation and recruited into the study as the study respondents

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 Group 1 Phonhong (10 villages), 1 km from Phonhong Administrative Office;

 Group 2 Nalow (7 villages), 6 km from Phonhong Administrative Office;

 Group 3 Phonsi (11 villages), 10 km from Phonhong Administrative Office;

 Group 4 Sakar (12 villages), 12 km from Phonhong Administrative Office;

 Group 5 Nalao (9 villages), 18 km from Phonhong Administrative Office; and

 Group 6 Phonxay (10 villages), 24 km from Phonhong Administrative Office

In total, 18 villages were selected, from which 403 adolescents 15 to 19 years of age who were willing to participate in the study were recruited

2.6 Data collection

After obtaining approval from the community authorities and the signatures of the adolescents‟ parents or guardians (for adolescents younger than 18 years old), data collection proceeded on separate questionnaires All respondents were given an identity number, and then their name, age and their anthropometric measurements were recorded and coded to facilitate entry of data into the computer

Body mass and stature were measured by using weight scales (SECA) to the nearest 0.1 kg and height was measured by Microtoise in meters to the nearest 0.1 cm Data

on height, weight, gender, and age were used to compute the BMI-for-age by using the WHO AnthroPlus software

The survey was conducted by interviews with questionnaires The questionnaire was translated into Lao and pre-tested prior to real data collection

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2.6.1 Questionnaire

A face-to-face interview with a questionnaire was employed for data collection since it was presumed to be the best method for getting answers from young adults having no experience in participating in the research on the one hand and a way to make the respondents feel proud to be approached by the researchers on the other hand Initially, the questionnaire was prepared in English, and then it was translated into Lao and pre-tested prior to real data collection to see if the actual respondents

might have difficulties understanding the wording used in the interview The

questionnaire mostly included multiple choice questions and comprised a total of 56

questions divided into four parts:

 Part 1 Demographic characteristics: This part contained six questions dealing with gender, age, level of education, number of household

members, number of siblings in family and birth order

 Part 2 Family factors: This part consisted of questions on living arrangement, father‟s education and occupation, mother‟s education and occupation, relatives‟ education and occupation (male and female), monthly income, obese family member(s), relationship of obese person(s), family eating habits (focusing on fast food), kind of food eaten

in family, and eating meals with family

 Part 3 Eating habits among adolescents: This part of the questionnaire on eating habits contained 20 items that asked about the action of the

individuals that could affect their nutrition such as their eating and

drinking patterns Nutrient estimates in the questions were from the Food

Frequency Questionnaire The data was calculated by using the sum method (Liu et al., 2013) Means and standard deviations (SD) were calculated for nutrient intakes assessed by the semi-FFQs The scores of eating habits were classified into two groups based on Means (Shulz,

product-2005)

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 Part 4 Physical activities: The physical activities part of the questionnaire contained 16 items that asked about the respondents‟ physical activity (PA) and their sedentary behavior in three settings (or domains), namely, their activities at schools and in communities, their traveling to places and their recreational activities, using the Global Physical Activities Questionnaire (GPAQ) (WHO, 2009)

2.7 Variables of the study

 Dependent variables: These consisted of the overweight and obesity levels of adolescents aged 15 to 19

 Independent Variables: These consisted of the general characteristics of adolescents aged 15 to 19 (level of education, gender, age, birth order, number of siblings, number of household members), family factors (covering parents, father, mother, relatives), family income per month (the income of parents, father, mother, relatives) and education and occupation (of parents, father, mother, relatives) Eating habits were classified into two levels (poor and good eating habits) and physical activities

The definitions and measurements of the variables in the study are described in

Annex 1

2.7.1 Operational definitions of the variables

 Dependent variables – Overweight and obesity levels:

o Overweight: Overweight is a condition in which the individual weighs more than their "should have" weight compared to their height, overweight with BMI for age ≥ 23.0 - 24.9 kg/m2

o Obesity: Obesity is a condition of excessive and abnormal fat

accumulation in one body area or the whole body to a level that affects health, obese with BMI for age ≥ 25.0 kg/m2

 Independent variables

- Part 1 Demographic factors

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o Gender: Whether the adolescents are male or female

o Age: The age in years of the participants at the time of the

interview

o Level of education: The highest educational level attained of the adolescents or if they had never been to school

o Number of household members: Number of people living together

in the same house

o Number of siblings: Number of brothers or sisters living in the same house

o Birth Order: Position of the respondent among their siblings in the

family

- Part 2 Family factors

o Living arrangement: Whether the adolescent is living with and

cared for by both parents, only the father or mother or others

o Parents‟ or relatives‟ education: The highest educational level of the respondent‟s father, mother or relative

o Parents‟ or relatives‟ occupation: Main job of father, mother or relative as reported by the respondent

o Monthly income of the family: Average total income per month of the earning members of the family

o Family history of overweight and obesity: Cases of overweight and obesity among grandparents, parents and siblings

o Family eating behavior: Daily dietary patterns of the family

- Part 3 Eating habits

The actions of the individuals that could affect their nutrition, such as eating patterns and frequency (classified as good eating habits and poor eating habits)

- Part 4 Physical activity

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The individuals‟ participation in activities, travel and recreational activities (classified into vigorous intensity and moderate intensity)

2.8 Assessment criteria

The respondents were assessed for their levels of overweight and obesity based on their nutrition and eating habits

2.8.1 Nutritional status based on BMI for age

The nutritional status of respondents was considered in terms of BMI for age using the Body Mass Index (BMI) for children graph (aged 5 to 19 years) from WHO to

obtain the z-score The BMI for age classification was as follows:

- Underweight: BMI for age < 18.5 kg/m2

- Normal nutrition: BMI for age = 18.5 - 22.9 kg/m2

- Overweight: BMI for age ≥ 23.0 - 24.9 kg/m2

- Obese: BMI for age ≥ 25.0 kg/m2

(WHO, 2007)

2.8.2 Eating habits in relation to nutrition

As mentioned, this part of the questionnaire contained 20 items that asked about the actions of individuals that could affect their nutrition such as their eating and

drinking patterns Nutrient estimates from the Frequency Food Questionnaire data

were calculated by using the product-sum method (Liu, et al., 2013)

 Items 3, 6, 9, 7, 11 and 13 were the positive questions in the questionnaire Each of these gave the respondent nine choices, with their corresponding number of points as follows:

“Never” = 1 point

“1-3 times per month” = 2 points

“1 time per week” = 3 points

“2-4 times per week” = 4 points

“5-6 times per week” = 5 points

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“1 time per day” = 6 points

“2-3 times per day” = 7 points

“4-5 times per day” = 8 points

“6 or more times per day” = 9 points

 Items 1, 2, 4, 5, 8, 10, 12, 14, 15, 16, 17, 18, 19, and 20 were the negative questions in the questionnaire Each of these gave the respondent the same nine choices, but with their corresponding number of points reversed as follows:

“Never” = 9 points

“1-3 times per month” = 8 points

“1 time per week” = 7 points

“2-4 times per week” = 6 points

“5-6 times per week” = 5 points

“1 time per day” = 4 points

“2-3 times per day” = 3 points

“4-5 times per day” = 2 points

“6 or more times per day” = 1 point Median was calculated for nutrient intakes assessed by the semi-FFQs The scores of eating habits were classified into two groups based on Median (Shulz, 2005)

 Score ≤ Median: Poor eating habits

 Score > Median: Good eating habits

2.9 Data analysis

2.9.1 Data entry: The data obtained were coded, entered into Epidata software

version 3.1 and analyzed in STATA software

2.9.2 Statistical techniques: After completion of data collection and data entry,

analysis was undertaken in the following steps:

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 Descriptive statistics was used to describe the demographic characteristics of

the subjects Categorical variables were presented as frequency and percentages while continuous variables were presented in means and standard deviations

 Univariate analysis was used to compare individual characteristics and

overweight and obesity

 The variables in the univariate analysis were significant at p-value <0.05, and

then were entered into a multivariable logistic regression model In the multivariate analysis, standard techniques were employed Variables having

p-value <0.05 in the multivariate analysis were taken as significant

predictors Crude and adjusted odds ratios with 95% confidence intervals were calculated and presented in texts and tables

2.10 Ethical considerations

Data collection began after obtaining ethical clearance from the University of Health Sciences No 188/19, dated 5th August 2019 and the Hanoi University of Public Health ethical committee No 441/2019/YTCC-HD3, dated 20th September

2019

This study was conducted according to the rules and principles of human research ethics This study was completely voluntary and informed consent was obtained before data collection, respecting the rights of the study respondents Participants also had the right to end their participation in the research at any time and when under any conditions that they may have felt uncomfortable with

To protect the privacy of participants, their names were not included in all the questionnaires, and information collected from them was kept confidential The research objectives, methodology and potential risks were made known to each respondent before the interview Informed consent was obtained from adolescents wishing to participate in the research Young adults who agreed to take part in the interview were considered as consenting voluntarily

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Table 3.1 Demographic characteristics of adolescents aged 15 to 19 years (n=403)

Grades of schooling

Grade 10 (M5) or lower Grade 11 (M6) or upper

184

219

45.7 54.3

Table 3.1 shows the general characteristics of the adolescents aged 15 to 19 years old, a total of 403 persons Sixty-one percent of these were female Those respondents who were 15 to 16 years old accounted for 58% When classified by grade, over 50% of the students were in Grade 11 or M5 Over 50% of the adolescents came from households having fewer than five persons, whereas more than 40% came from families having two siblings With regard to birth order, over 55% were the second child of the family (with Median = 2, Min = 1, Max = 6)

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3.2 Overweight and obesity statuses among adolescents

Table 3 2 Overweight and obesity statuses among adolescents aged 15 to 19

Table 3.2 shows the nutritional status of the adolescents It includes the BMI

of underweight, normal weight, overweight and obese respondents Of the 403 adolescents, 192 (47.6%) had normal weight with a BMI of 18.5 – 22.9 Kg/m2, 114 (28.3%) were underweight with a BMI of < 18.5 Kg/m2, over 13% were overweight with a BMI of ≥ 23.0 – 24.9 Kg/m2, and almost 11% were obese with a BMI of ≥ 25 Kg/m2

Table 3 3 Overweight, obesity statuses by gender among adolescent aged 15 to 19

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Table 3 4 Overweight, obesity statuses by age among adolescent aged 15to 19

adolescents in the 15 to 17 age group were obese

3.3 Factors associated with overweight and obesity statuses among adolescents

3.3.1 Family factors contributing to occurrence of overweight and obesity statuses

Family factors is one of the independent variables and is composed of the living arrangement of the adolescents, their father‟s education, father‟s occupation, mother‟s education, mother‟s occupation, relatives‟ education, relatives‟ occupation, monthly income of the family, whether or not there are obese persons in the family, the number of these obese persons and family eating habits like the types of food prepared for daily consumption and the frequency of meals eaten