Journal Information
Vol. 101. Issue 1.
Pages 3-13 (1 July 2024)
Visits
199
Vol. 101. Issue 1.
Pages 3-13 (1 July 2024)
Original Article
Full text access
Prevalence of obesity and related factors in schoolchildren aged 3 to 4 years
Prevalencia de obesidad y factores relacionados en escolares de 3 a 4 años
Visits
199
Gemma Serrala,b,c,
Corresponding author
gserral@aspb.cat

Corresponding author.
, Catalina Londoño-Cañolaa,d, Xavier Continentea,b,c, Silvia Bruguerasa,c, Francesca Sanchez-Martíneza,c, Carlos Arizaa,b,c
a Agència de Salut Pública de Barcelona, Barcelona, Spain
b Ciber de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
c Institut d’Investigació Biomédica Sant Pau (IIB Sant Pau), Barcelona, Spain
d Departament de Ciències Experimentals i de la Salut (DCEXS), Universitat Pompeu Fabra, Barcelona, Spain
This item has received
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Tables (5)
Table 1. Distribution of weight category based on sex, socioeconomic level of school district and type of school (n = 2936). POIBIN, Barcelona (2017).
Table 2. Distribution of weight category based on sociodemographic characteristics. Data from self-report family questionnaire (n = 1613). POIBIN, Barcelona (2017).
Table 3. Distribution of weight category based on eating behaviours and food intake frequency (n = 1613). POIBIN, Barcelona (2017).
Table 4. Distribution of weight category based on physical activity, hours of sleep and screen time (n = 1613). POIBIN, Barcelona (2017).
Table 5. Distribution of weight category based on perception of family of the child’s weight and diet (n = 1613). POIBIN, Barcelona (2017).
Show moreShow less
Figures (1)
Abstract
Objective

To describe the prevalence of obesity and analyse possible differences in it according to sociodemographic characteristics, diet, physical activity, screen use and family perception of the weight and dietary habits of schoolchildren aged 3 to 4 years in Barcelona.

Methods

We conducted a cross-sectional study in a representative sample of schools selected based on the socioeconomic status (SES) of the corresponding neighbourhood and school ownership. We selected 101 schools in Barcelona and recruited pupils aged 3 to 4 years during the 2016–17 academic year (n = 2936 children). Anthropometric measurements were taken in each participant. Family members completed a questionnaire on eating habits, physical activity, sleeping hours, screen use and the family’s perception of the child’s weight and diet. The primary variable was the body mass index (BMI) for age and sex, subsequently categorised as normal weight, overweight or obese.

Results

Approximately 7.0% of girls and 7.1% of boys aged 3 to 4 years presented obesity. The prevalence of obesity (8.3%) was higher in neighbourhoods of lower SES compared to those of higher SES (5.2%; p = .004). Parents of children with obesity reported that the child had some excess weight or excess weight in 46.9% of cases, 3.9% indicated the child’s weight was appropriate and 0.9% that the child was a little underweight or underweight (p < .001).

Discussion

The prevalence of obesity in children aged 3 to 4 years is high. There are social and geographical inequalities, and obesity was more prevalent in areas of lower SES. A large percentage of the families of children with obesity do not consider that the child’s weight is excessive.

Keywords:
Childhood obesity
Social inequalities
Weight perception
Resumen
Objetivo

Describir la prevalencia de obesidad y analizar posibles diferencias según características sociodemográficas, alimentación, actividad física, visionado de pantallas y percepción familiar sobre el peso y alimentación de sus hijos/as en escolares de 3 a 4 años de Barcelona.

Método

Estudio transversal a una muestra representativa de escuelas según nivel socioeconómico (NSE) del barrio y titularidad. Se seleccionaron 101 escuelas de Barcelona y se reclutó al alumnado de 3 a 4 años en el curso 2016-17 (N = 2.936 niños/as). Se tomaron medidas antropométricas. Los familiares respondieron a un cuestionario de hábitos sobre alimentación, actividad física, horas de sueño, visionado de pantallas y percepción familiar sobre el peso y la alimentación de su hijo/a. La variable principal fue el Índice de Masa Corporal (IMC), calculado por edad y sexo, y categorizado en: normopeso, sobrepeso u obesidad.

Resultados

El 7,0% de las niñas y el 7,1% de los niños de 3-4 años presentaron obesidad. En los distritos de NSE desfavorecido hubo mayor obesidad (8,3%) que en los más favorecidos (5,2%; p = 0,004). Los padres/madres de niños/as cuyo peso fue de obesidad declararon que el peso de su hijo/a era un poco excesivo o excesivo en un 46,9%, en un 3,9% indicaron que era adecuado y el 0,9% que era un poco bajo o bajo (p < 0,001).

Discusión

La prevalencia de obesidad en niños y niñas de 3 a 4 años es elevada. Existen desigualdades sociales siendo superior en áreas de NSE más desfavorecidas. Un elevado porcentaje de familias de niños/as con obesidad no consideran que el peso de sus hijos/as sea excesivo.

Palabras clave:
Obesidad infantil
Desigualdades sociales
Percepción del peso
Full Text
Introduction

Obesity is a chronic, non-communicable, complex and multifactorial disease usually with onset in childhood and/or adolescence.1 In the past 25 to 30 years, the prevalence of obesity has increased significantly worldwide.2 According to the report of the Organization for Economic Cooperation and Development (OECD) for year 2019, Spain, is among the countries with the highest rates of childhood obesity in the world, ranking fourth in Europe.3 The nationwide Thao cohort study conducted in 2014 highlighted the problem of excess weight in Spain, as it found a prevalence of overweight of 20% in children aged 3 to 5 years.4 In 2017, more than 1 in 10 children (10.3% in the group aged 2 to 17 years) had obesity in Spain, with a similar prevalence in boys (10.2%) and girls (10.4%).5

The prevention of childhood obesity should begin in the early stages of life, and some experts even argue that the problem should be addressed from the period of gestation.6 The family plays a key role, so the main modifiable determinants of the risk factors for overweight and obesity in the first years of life concern the family milieu. Parents make decisions regarding food choices, meal structure and the dietary pattern in the home and contribute to shaping physical activity and sedentary habits in the child (especially screen use).7 Another factor to consider is socioeconomic status (SES). The prevalence of childhood obesity exhibits a heterogeneous distribution based on SES in societies at the global level. In developed countries, the prevalence of overweight and of obesity tends to be higher in socioeconomically disadvantaged groups.8

In addition, children of obese parents (mother, father or both) are at increased risk to develop obesity.9 One of the potential factors at play in childhood obesity is the inaccurate perception of parents of the severity of excess weight in their children. A nationwide study in children of both sexes with excess weight aged 3 to 16 years found that approximately two thirds of parents did not perceive the weight of their children as problematic. Furthermore, even if parents are aware of the overweight or obesity of their children,10 they may not make any changes to improve dietary, physical activity or screen use habits.11–13

Few studies have been conducted in Spain analysing the prevalence of childhood obesity in representative samples in children aged less than 6 years.14,15 In addition, knowledge on how families perceive their children’s weight and dietary habits is essential to be able to develop interventions at different levels with the ultimate goal of reducing the prevalence of childhood obesity at younger ages.16,17 The aim of our study was to describe the prevalence of obesity and analyse possible differences based on sociodemographic characteristics, diet, physical activity, screen use and how the family perceives the weight and the diet of children aged 3 to 4 years in Barcelona.

Methods

We conducted a cross-sectional study in a representative sample based on the SES of the district where the early childhood education centre was located (socioeconomic [SE] advantage/disadvantage) and the type of centre (public/private or mixed [private centre receiving public funding]) in pupils aged 3 to 4 years in the city of Barcelona during academic year 2016–2017. In the framework of the project for the Prevention of Childhood Obesity in Barcelona in Early Childhood Education (known as POIBIN, for its acronym in Spanish),18 we selected 101 schools and selected the entire P3 class cohort (year 1 of early childhood education, starting from age 3 years: N = 3631 children born in 2013). The study adhered to the principles of the Declaration of Helsinki and was approved by the Clinical Research Ethics Committee of Parc de Salut Mar (file 2016/6711/I). Anthropometric measurements (weight and height) were obtained for 2936 pupils aged 3 to 4 years whose families provided informed consent to participation (81%). Of this total, 55% of families completed a questionnaire on dietary habits, physical activity, hours of sleep, screen use and perception in the family of the child’s weight and dietary intake. Thus, we obtained complete data for 1613 children, including the objective information collected through anthropometric measurement and the self-reported information provided by the parents regarding health care-related habits and beliefs.

The primary outcome of the study was the body mass index (BMI) z score for age and sex, using the World Health Organization (WHO) child growth standards for reference.19 We classified BMI values as normal weight, overweight (BMI z > 1) or obesity (BMI z > 2). The school-related variables were: socioeconomic level of the school district based on household disposable income data (HDI, data from 2016)20 categorised as SE advantage (HDI ≥ 85) vs SE disadvantage (HDI < 85) and the type of school based on ownership (public vs private/mixed). Through the self-report questionnaire, we collected data on sociodemographic variables, including the country of origin (Spain vs foreign country), the SES of the family based on the Family Affluence Scale (FAS)21 (categorised as high, medium or low) and educational attainment (recording the highest educational attainment in the household, categorised as university, secondary or primary education). We also collected data on the weight and height of the mother and father (as self-reported) and then categorised them as normal weight, overweight or obesity based on the WHO standards. The dietary habits and intake variables, based on current dietary recommendations, were the following: adequate breakfast including fruit, cereal and dairy; eating in the school canteen; screen use during supper; going to fast food restaurants; drinking water during meals; consumption of fruit and/or vegetables (≥ 5 servings a day); consumption of dairy (twice or more a day); consumption of meat (twice or fewer times a week); consumption of fish (≥ 3 times a week); consumption of sugary drinks (≤ 3 times a month); consumption of pastries/baked goods (≤ 3 times a month); consumption of sweets (≤ 3 times a month); all classified as yes/no. The variables used to assess physical activity, sleep duration and screen time were as follows: participation in extracurricular athletic activities (yes/no), performance of physical activity as a family (never or seldom, some or all weekends, some or nearly every day of the week), means of transport used to commute to and back from school (walking, public transport, car/motorcycle; bicycle), hours of sleep on school nights (< 10 hours vs ≥ 10 hours) screen time (< 2 hours vs ≥ 2 hours) on weekdays and on the weekend.22

The questionnaire also collected data regarding the perception by the family of the child’s weight and nutrition through 14 items taken from the Child Feeding Questionnaire.23 These items assess aspects concerning the perception of the child’s weight and beliefs regarding the imposition or restriction of dietary habits and eating behaviours in their children. For the purposes of this study, we grouped responses in 3 categories: strongly disagree or disagree, neither agree nor disagree, agree or strongly agree.

We conducted a descriptive bivariate analysis to assess the correlation between the objective BMI measure in the child and the independent study outcomes (n = 2936). We compared percentages by means of the χ2 test, calculating the corresponding 95% confidence intervals (significance: P < .05). In the case of variables related to nutrition (n = 1613, data from questionnaire completed by families), we calculated a global indicator that encompassed behavioural aspects (adequate breakfast including fruit, cereal and dairy; eating in the school canteen; screen use during supper and/or going to fast food restaurants) and aspects concerning adherence to dietary guidelines22 (drinking water during meals; consumption of fruit and/or vegetables; consumption of dairy; consumption of meat; consumption of fish; consumption of sugary drinks; consumption of pastries/baked goods; consumption of sweets). We analysed the prevalence of adherence to recommended habits, classified as inadequate (≤ 1 behaviour) vs adequate (> 1 behaviour) and adherence to recommended food intake frequency, classified as inadequate (appropriate for ≤ 2 recommendations) vs adequate (appropriate for > 2 recommendations). We set cut-off points at the intermediate value, both for habits and food frequency. The statistical analysis was performed with the statistical package Stata/SE, version 15.1.

Results

The prevalence of obesity in children aged 3 to 4 years was 7.0% in girls and 7.1% in boys. There was a statistically significant difference in weight status based on sex (P = .019), with a greater prevalence of overweight in girls (19.1%) compared to boys (15.2%). In districts with a lower HDI, there was a higher prevalence of obesity compared to districts with a higher HDI (8.3% vs 5.2%; P = .004) (Table 1).

Table 1.

Distribution of weight category based on sex, socioeconomic level of school district and type of school (n = 2936). POIBIN, Barcelona (2017).

  Child’s weight status
  Normal weightOverweightObesityTotal   
    P 
Child’s sex
Male  1176  77.7  230  15.2  107  7.1  1513  .019 
Female  1052  73.9  272  19.1  99  7.0  1423   
Socioeconomic level of school (HDI)
SE advantage  938  76.9  218  17.9  63  5.2  1219  .004 
SE disadvantage  1290  75.1  284  16.6  143  8.3  1717   
Type of school
Private/mixed  1100  75.6  264  18.2  90  6.2  1454  .095 
Public  1128  76.1  238  16.1  116  7.8  1482   

HDI, household disposable income; SE, socioeconomic.

Statistical significance set at P < .05.

Table 2 presents the distribution of weight status in boys and girls based on sociodemographic variables. Children whose mother was born in a country other than Spain were more likely to be obese compared to those with mothers born in Spain, a difference that was statistically significant (9.3% vs 4.2%, p < .001). Of the mothers who reported being obese themselves, 15.9% had children with obesity; in the case of fathers with obesity, the proportion of children with obesity was 14.5%. In families with SE disadvantage, there was a higher percentage of children with overweight (21.3%) or obesity (10.1%) (p < .001).

Table 2.

Distribution of weight category based on sociodemographic characteristics. Data from self-report family questionnaire (n = 1613). POIBIN, Barcelona (2017).

  Child’s weight status
  Normal weightOverweightObesityTotal   
    P 
Child’s country of birth
Spain  1169  76.8  265  17.4  89  5.8  1523  .471 
Other  53  71.6  17  23.0  5.4  74   
NA  13  81.2  12.5  6.3  16   
Mother’s country of birth
Spain  855  78.5  188  17.3  46  4.2  1089  < .001 
Other  373  72.6  93  18.1  48  9.3  514   
NA  70.0  30.0  0.0  10   
Father’s country of birth
Spain  826  78.2  185  17.5  45  4.3  1056  .002 
Other  353  72.6  91  18.7  42  8.7  486   
NA  56  78.9  11.2  9.9  71   
Maternal weight status
Normal weight  854  81.5  159  15.2  35  3.3  1048  < .001 
Overweight  234  68.2  79  23.0  30  8.8  343   
Obesity  71  62.8  24  21.3  18  15.9  113   
NA  76  69.7  22  20.2  11  10.1  109   
Paternal weight status
Normal weight  530  81.8  100  15.4  18  2.8  648  < .001 
Overweight  449  75.8  108  18.3  35  5.9  592   
Obesity  84  60.9  34  24.6  20  14.5  138   
NA  172  73.2  42  17.9  21  8.9  235   
Socioeconomic level of household (FAS)
High  483  78.8  104  17.0  26  4.2  613  < .001 
Medium  461  80.2  89  15.5  25  4.3  575   
Low  271  68.6  84  21.3  40  10.1  395   
NA  20  66.7  23.3  10.0  30   
Educational attainment (highest in mother/father)
University  816  78.0  189  18.1  41  3.9  1046  .001 
Secondary  320  73.1  76  17.3  42  9.6  438   
Primary  34  77.3  18.2  4.5  44   
NA  65  76.5  11  12.9  10.6  85   

NA, no answer FAS, Family Affluence Scale.

P value calculated with self-reported data in the subset of the sample that answered the item (excluding unanswered items [NA]). Statistical significance set at P < .05.

Table 3 presents data on eating behaviours and food group intake frequency. We found a statistically significant difference in the intake of fish, with a higher prevalence of obesity among children who consumed less fish than recommended (P = .021). On the other hand, when it came to the consumption of meat, the prevalence of obesity was greater in children who consumed the amount recommended (8.4%) compared to children who did not adhere to meat intake recommendations (5.0%). We did not find significant differences in any other eating behaviours or dietary habits based on weight status categories.

Table 3.

Distribution of weight category based on eating behaviours and food intake frequency (n = 1613). POIBIN, Barcelona (2017).

  Child’s weight status
  Normal weightOverweightObesityTotal   
    P 
Adequate breakfast (fruit, cereal and dairy)
Yes  120  77.9  27  17.5  4.6  154  .790 
No  1079  76.5  249  17.6  83  5.9  1411   
NA  36  75.0  16.7  8.3  48   
Eating in school canteen
Yes  1000  76.6  236  18.1  70  5.3  1306  .374 
No  231  77.3  47  15.7  21  7.0  299   
NA  50.0  12.5  37.5   
Screen use during meals
Never/sometimes  842  76.3  199  18.1  62  5.6  1103  .839 
Often/always  387  77.6  84  16.8  28  5.6  499   
NA  54.5  9.1  36.4  11   
Fast food restaurants
Never/sometimes  1177  76.3  277  17.9  89  5.8  1543  .130 
Once or twice a week  45  88.2  7.9  3.9  51   
NA  13  68.4  15.8  15.8  19   
Global dietary indicatora
Adequate habits (> 1 habit)  1129  76.4  267  18.1  82  5.5  1478  .103 
Inadequate habits (≤1 habit)  106  78.5  17  12.6  12  8.9  135   
Drinking water with meals
Yes  997  77.5  221  17.2  69  5.3  1287  .220 
No  227  73.0  62  19.9  22  7.1  311   
NA  11  73.3  6.7  20.0  15   
Consumption of fruits/vegetables (5 or more servings/day)
Yes  93  79.5  17  14.5  6.0  117  .641 
No  1129  76.3  266  18.0  84  5.7  1479   
NA  13  76.5  5.9  17.6  17   
Consumption of dairy (twice or more a day)
Yes  700  75.8  175  18.9  49  5.3  924  .250 
No  521  77.7  107  16.0  42  6.3  670   
NA  14  73.7  10.5  15.8  19   
Consumption of meat (Twice or less a week)
Yes  243  72.5  64  19.1  28  8.4  335  .034 
No  973  77.6  218  17.4  62  5.0  1253   
NA  19  76.0  8.0  16.0  25   
Consumption of fish (≥ 3 times a week)
Yes  414  75.8  111  20.3  21  3.9  546  .021 
No  803  77.1  171  16.4  68  6.5  1042   
NA  18  72.0  8.0  20.0  25   
Consumption of sugary drinks (≤ 3 times a month)
Yes  1091  77.4  238  16.9  80  5.7  1409  .071 
No  121  69.9  41  23.7  11  6.4  173   
NA  23  74.2  16.1  9.7  31   
Consumption of pastries (≤ 3 times a month)
Yes  347  73.7  91  19.3  33  7.0  471  .153 
No  866  77.8  190  17.1  57  5.1  1113   
NA  22  75.9  10.3  13.8  29   
Consumption of sweets (≤ 3 times a month)
Yes  635  76.5  144  17.4  51  6.1  830  .709 
No  584  76.6  138  18.1  40  5.3  762   
NA  16  76.2  9.5  14.3  21   
Global food frequency indicatorb
Adequate intake (> 2 food groups)  1012  76.5  238  18.0  72  5.5  1322  .289 
Inadequate intake (≤ 2 food groups)  223  76.6  46  15.8  22  7.6  291   

P value calculated with self-reported data in the subset of the sample that answered the item (excluding unanswered items [NA]). Statistical significance set at P < .05.

a

Habits: adequate breakfast, eating in school canteen, use of screens during meals, dining in fast food restaurants.

b

Food intake frequency: drinking water with meals, consumption of fruit/vegetables, consumption of dairy, consumption of meat, consumption of fish, consumption of sugary drinks, consumption of pastries, consumption of sweets.

As can be seen in Table 4, the proportion of children with obesity was lesser among children with screen times of less than 2 hours a day compared to children with screen times of 2 hours or greater on weekdays (4.3% vs 8.6%) or on weekends (3.2% vs 7.1%), differences that were statistically significant.

Table 4.

Distribution of weight category based on physical activity, hours of sleep and screen time (n = 1613). POIBIN, Barcelona (2017).

  Child’s weight status
  Normal weightOverweightObesityTotal   
    P 
Extracurricular physical activity
Yes  199  71.6  59  21.2  20  7.2  278  .088 
No  1017  77.7  222  17.0  70  5.4  1309   
NA  19  73.1  11.5  15.4  26   
Physical activity as a family
Never or seldom  30  75.0  22.5  2.5  40  .396 
Some or all weekends  706  75.5  174  18.6  55  5.9  935   
Some or every day of the week  481  78.9  94  15.4  35  5.7  610   
NA  18  64.3  25.0  10.7  28   
Commute to school from home
Walking  853  76.6  194  17.4  67  6.0  1114  .187 
Public transport  161  76.3  33  15.6  17  8.1  211   
Car/motorcycle  178  76.4  48  20.6  3.0  233   
Bicycle  23  85.2  14.8  0.0  27   
NA  20  71.4  17.9  10.7  28   
Commute home from school
Walking  904  76.9  205  17.4  67  5.7  1176  .208 
Public transport  157  73.0  40  18.6  18  8.4  215   
Car/motorcycle  134  77.5  33  19.1  3.5  173   
Bicycle  18  94.7  5.3  0.0  19   
NA  22  73.3  16.7  10.0  30   
Sleep duration (school nights)
< 10 hours  224  75.4  49  16.5  24  8.1  297  .146 
≥ 10 hours  972  77.2  222  17.6  65  5.2  1259   
NA  39  68.4  13  22.8  8.8  57   
Screen time (weekdays)
< 2 hours  826  78.2  185  17.5  45  4.3  1056  .002 
≥ 2 hours  392  73.6  95  17.8  46  8.6  533   
NA  17  70.8  16.7  12.5  24   
Screen time (weekend)
< 2 hours  458  80.4  94  16.5  18  3.2  570  .002 
≥ 2 hours  751  74.6  185  18.4  71  7.1  1007   
NA  26  72.2  13.9  13.9  36   

P value calculated with self-reported data in the subset of the sample that answered the item (excluding unanswered items [NA]). Statistical significance set at P < .05.

Table 5 summarises the data on the perception of families about the child’s weight and eating by child weight status. Of the parents whose children’s weight was in the obesity range, 46.9% reported that their child’s weight was slightly excessive or excessive, 3.9% that their weight was average and 0.9%, that their weight was slightly low or low (P < .001). When it came to parental control of the child’s diet, 5.2% of the parents of children with obesity agreed with the statement “If I did not guide or regulate my child’s eating, he/she would eat much less than he/she should”, while 7.0% disagreed. Furthermore, 5.4% of parents of children with obesity agreed with the statement “I have to be especially careful to make sure my child eats enough” while 7.4% disagreed (P < .001). As regards restricting intake, 7.4% of parents of children with obesity expressed agreement with the statement “If I did not guide or regulate my child’s eating, he/she would eat too many junk foods”, while 3.2% expressed disagreement (P = .047).

Table 5.

Distribution of weight category based on perception of family of the child’s weight and diet (n = 1613). POIBIN, Barcelona (2017).

  Child’s weight status
  Normal weightOverweightObesityTotal  P 
   
Your child’s weight is…
Average  971  76.6  248  19.6  49  3.9  1268  < .001 
Slightly excessive/excessive  19  23.5  24  29.6  38  46.9  81   
Slightly low/low  222  96.1  3.0  0.9  231   
NA  23  69.7  15.2  15.2  33   
How concerned are you about your child eating too much when you are not around him/her?
Unconcerned/slightly unconcerned  767  79.6  144  15.0  52  5.4  963  .001 
Concerned/slightly concerned  437  71.8  135  22.2  37  6.1  609   
NA  31  75.6  12.2  12.2  41   
How concerned are you about your child having to diet to maintain a desirable weight?
Unconcerned/slightly unconcerned  436  76.2  98  17.1  38  6.6  572  .376 
Concerned/slightly concerned  772  77.0  180  18.0  50  5.0  1002   
NA  27  69.2  15.4  15.4  39   
How concerned are you about your child becoming overweight?
Unconcerned/slightly unconcerned  422  74.6  115  20.3  29  5.1  566  .124 
Concerned/slightly concerned  786  77.7  165  16.3  60  5.9  1011   
NA  27  75.0  11.1  13.9  36   
If I did not guide or regulate my child’s eating, he/she would eat much less than he/she should.
Disagree/strongly disagree  399  70.2  129  22.7  40  7.0  568  < .001 
Neither agree nor disagree  267  75.2  71  20.0  17  4.8  355   
Agree/strongly agree  534  83.7  71  11.1  33  5.2  638   
NA  35  67.3  13  25.0  7.7  52   
I have to be especially careful to make sure my child eats enough.
Disagree/strongly disagree  300  69.1  102  23.5  32  7.4  434  < .001 
Neither agree nor disagree  193  75.7  50  19.6  12  4.7  255   
Agree/strongly agree  720  80.5  126  14.1  48  5.4  894   
NA  22  73.3  20.0  6.7  30   
If my child says I’m not hungry, I try to get him/her to eat anyway
Disagree/strongly disagree  362  72.5  107  21.4  30  6.0  499  .028 
Neither agree nor disagree  240  75.7  59  18.6  18  5.7  317   
Agree/strongly agree  612  79.9  111  14.5  43  5.6  766   
NA  21  67.7  22.6  9.7  31   
My child should always eat all of the food on his/her plate
Disagree/strongly disagree  360  77.8  88  19.0  15  3.2  463  .057 
Neither agree nor disagree  270  75.2  61  17.0  28  7.8  359   
Agree/strongly agree  583  76.6  129  17.0  49  6.4  761   
NA  22  73.3  20.0  6.7  30   
I intentionally keep some foods out of my child’s reach
Disagree/strongly disagree  467  79.3  95  16.1  27  4.6  589  .037 
Neither agree nor disagree  198  78.9  35  13.9  18  7.2  251   
Agree/strongly agree  540  73.4  151  20.5  45  6.1  736   
NA  30  81.1  8.1  10.8  37   
I offer my child his/her favourite foods in exchange for good behaviour
Disagree/strongly disagree  512  79.4  102  15.8  31  4.8  645  .072 
Neither agree nor disagree  324  77.1  72  17.1  24  5.7  420   
Agree/strongly agree  370  72.1  108  21.1  35  6.8  513   
NA  29  82.9  5.7  11.4  35   
If I did not guide or regulate my child’s eating, he/she would eat too many junk foods
Disagree/strongly disagree  377  80.7  75  16.1  15  3.2  467  .047 
Neither agree nor disagree  227  77.2  50  17.0  17  5.8  294   
Agree/strongly agree  601  74.2  149  18.4  60  7.4  810   
NA  30  71.4  10  23.8  4.8  42   
I offer sweets to my child as a reward for good behaviour
Disagree/strongly disagree  647  78.6  139  16.9  37  4.5  823  .132 
Neither agree nor disagree  272  75.3  66  18.3  23  6.4  361   
Agree/strongly agree  287  73.0  76  19.3  30  7.6  393   
NA  29  80.6  8.3  11.1  36   
If I did not guide or regulate my child’s eating, he/she would eat too much of his/her favourite foods
Disagree/strongly disagree  190  78.2  46  18.9  2.9  243  .307 
Neither agree nor disagree  191  77.3  42  17.0  14  5.7  247   
Agree/strongly agree  832  76.4  187  17.2  70  6.4  1089   
NA  22  64.7  26.5  8.8  34   
I think my child eats well
Disagree/strongly disagree  99  84.6  13  11.1  4.3  117  .192 
Neither agree nor disagree  165  78.9  32  15.3  12  5.7  209   
Agree/strongly agree  948  75.4  235  18.7  74  5.9  1257   
NA  23  76.7  13.3  10.0  30   

NA, no answer.

Data from self-report family questionnaire (n = 1613).

P value calculated with self-reported data in the subset of the sample that answered the item (excluding unanswered items [NA]). Statistical significance set at P < .05.

Discussion

Our study found a prevalence of obesity of 7% in children aged 3 to 4 years in the city of Barcelona, with a higher prevalence in schools in neighbourhoods with lower SES. In families of children with obesity, there was a greater proportion of parental obesity, of parents of foreign origin, of low SES and of a maximum household educational attainment of secondary or primary education. When it came to dietary habits, a greater prevalence of obesity was associated with a fish intake below recommendations. In addition, a screen time of 2 hours a day or greater was also associated with a higher prevalence of obesity. When it came to the perception of families, nearly half of families of children with obesity perceived that the weight of their children was slightly excessive or excessive.

The prevalence of childhood obesity observed in our study had increased compared to previously reported data in this age group.4 This increasing in the frequency of childhood obesity is consistent with the reports of the national health survey of Spain, which have shown a progressive increase in the prevalence of childhood obesity between 2003 and 2017.5 Few studies offer data on the prevalence of obesity in children under 5 years.14,15,24 In our study, we found a high prevalence of obesity in early childhood.2,25

In general, countries with a higher prevalence of childhood obesity are those in which there is greater social inequality.26 In our study, we found that more disadvantaged areas had a higher prevalence of childhood obesity. Thus, factors like parental foreign origin (mother and/or father), low household SES or a highest educational attainment of primary or secondary school in the parents were associated with a greater proportion of excess weight in the children, as previously described in the domestic and international literature.27,28

Our study identified inadequate dietary habits in young children that are associated with weight problems. Nine in ten children did not have an adequate breakfast. A breakfast including dairy, fruit and cereal is a key factor that contributes to a healthy diet.29 The literature shows that the consumption of healthy foods in school is associated with a decreased prevalence of obesity and overweight. In agreement with these findings, the results of our study were similar to those of the ALADINO study conducted in Spain in 2011,30 in which the meals offered by schools adhered to Spanish dietary guidelines for healthy nutrition. This suggests that adherence to dietary recommendations may be associated with a reduction in the frequency of obesity and overweight in the preschoolers and schoolchildren. Other analysed aspects, such as using screens during mealtimes or consuming fast food, are associated with an increased risk of weight problems.31 However, our study did not yield evidence of these associations. We ought to highlight that there is little evidence of a direct association between the prevalence of obesity in the age group under study and the exposure to fast food restaurants. In our study, we found significant differences in the consumption of meat and fish. Specifically, we found that consumption of fish seemed to have a protective effect while the results for meat were contradictory. We found an increased prevalence of obesity in children who consumed meat with appropriate frequency.22 A possible explanation is that even if the frequency of meat intake adhered to recommendations, other components of the diet could be unhealthy or foods could be eaten in excessive amounts.32–34

The WHO recommends moderate consumption of red meat due to its association with chronic degenerative diseases found in epidemiological studies.35

As regards screen use, the increasing trend in screen time has led to a decrease in the time devoted to healthier activities. According to the WHO guidelines, screen time (television, mobile phones, computers, gaming consoles etc.) should not exceed 2 hours a day.36 The data showed that a high percentage of children of either sex aged 3 to 4 years spent more than 2 hours using screens on weekdays (1 in 3) and weekends (2 in 3). In our study, we found that the prevalence of obesity doubled in children with screen times greater than 2 hours. The use of screens is associated with a decrease in the time spent resting and/or engaging in physical activity.37

The findings of our study were consistent with those of the previous literature, as most parents of children with obesity underestimated the weight of their children.38 Similarly, a study conducted in Portugal between 2013 and 2014 identified different factors associated with the frequency of underestimating weight status in families based on the weight status of the child. Families were more likely to underestimate weight in children of either sex who were overweight.39

The limitations of the study included those intrinsic to cross-sectional designs, which preclude the establishment of causality. Another limitation was the collection of data through a self-report questionnaire, which carries a risk of information bias.

Among the strengths of the study, we should highlight that it is the first to collect data on childhood overweight and obesity in very young children for the city of Barcelona. The sample size was large enough to estimate the population prevalence of overweight and obesity. Lastly, we collected information on how families perceived the weight of their children in a representative sample in the city of Barcelona.

In conclusion, the prevalence of obesity is very high in children of both sexes aged 3 to 4 years, and there are social and geographical inequalities, with a higher prevalence in socioeconomically disadvantaged areas. In addition, the sociodemographic characteristics of the household, parental nutritional status and screen time were determinants associated with weight in children.

Funding

This research did not receive any external funding.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
M. Rivero Urgell, L.A. Moreno Aznar, J. Dalmau Serra, J.M. Moreno Villares, A. Aliaga Pérez, A. García Perea, et al.
Libro Blanco de La Nutrición Infantil en España.
2015th ed., Prensas de la Universidad de Zaragoza, (2015),
[2]
J. Bentham, M. Di Cesare, V. Bilano, H. Bixby, B. Zhou, G.A. Stevens, et al.
Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128•9 million children, adolescents, and adults.
Lancet, 390 (2017), pp. 2627-2642
[3]
Ministerio de Sanidad, Consumo y Bienestar Social; Agencia Española de Seguridad Alimentaria y Nutrición. Prevalencia de Sobrepeso y Obesidad En España En El Informe “The Heavy Burden of Obesity” (OCDE 2019) y En Otras Fuentes de Datos. Observatorio de la Nutrición y de Estudio de la Obesidad 2019.
[4]
S. Felipe, G. Santos, R.E. Santiago, N. Palacios Gil-Antuñano, M. Rosaura, L. Trabazo, et al.
Thao-child health programme: community based intervention for healthy lifestyles promotion to children and families: results of a cohort study.
Nutr Hosp, 32 (2015), pp. 2584-2587
[5]
Ministerio de Sanidad - Portal Estadístico Del SNS - Encuesta Nacional de Salud de España 2017. Available from: https://www.sanidad.gob.es/estadEstudios/estadisticas/encuestaNacional/encuesta2017.htm. (Accessed on 7 May 2023).
[6]
H. Dutton, S.J. Borengasser, L.M. Gaudet, L.A. Barbour, E.J. Keely.
Obesity in pregnancy: optimizing outcomes for mom and baby.
Med Clin North Am, 102 (2018), pp. 87-106
[7]
A.C. Lindsay, K.M. Sussner, J. Kim, S. Gortmaker.
The role of parents in preventing childhood obesity.
Future Child, 16 (2006), pp. 169-186
[8]
F Sánchez-Martínez, P Torres Capcha, G Serral Cano, S Valmayor Safont, C Castell Abat, C Ariza Cardenal, Grupo de Evaluación del Proyecto POIBA.
Factores Asociados al Sobrepeso y La Obesidad En Escolares de 8 a 9 Años de Barcelona.
Rev Esp Salud Publica, 90 (2016), pp. 1-11
[9]
RC Whitaker, JA Wright, MS Pepe, KD Seidel, WH Dietz.
Predicting obesity in young adulthood from childhood and parental obesity.
N Engl J Med, 337 (1997), pp. 204
[10]
O. Zamudio-Solorio, R.M. Muñoz-Arenillas.
Percepción de Los Padres Respecto al Sobrepeso y Obesidad de Sus Hijos.
Rev Enferm Inst Mex Seguro Soc, 24 (2016), pp. 61-64
[11]
K.I. Gauthier, B. Gance-Cleveland.
Hispanic parental perceptions of child weight in preschool-aged children: an integrated review.
Child Obes, 11 (2015), pp. 549-559
[12]
K.I. Gauthier, B. Gance-Cleveland.
Hispanic parents’ perceptions of their preschool children’s weight status.
J Spec Pediatr Nurs, 21 (2016), pp. 84-93
[13]
Rodríguez Martín A, Novalbos Ruiz JP, Villagran Pérez S, Martínez Nieto JM, Lechuga Campoy JL. La Percepción Del Sobrepeso y La Obesidad Infantil Por Parte de Los Progenitores. Available from: https://scielo.isciii.es/scielo.php?script=sci_arttextπd=S1135-57272012000500003. (Accessed on 20 March 2023).
[14]
J.J. Lasarte-Velillas, M.T. Hernández-Aguilar, T. Martínez-Boyero, G. Soria-Cabeza, D. Soria-Ruiz, J.C. Bastarós-García, et al.
Overweight and obesity prevalence estimates in a population from Zaragoza by using different growth references.
An Pediatr (Barc), 82 (2015), pp. 152-158
[15]
J.J. Lasarte-Velillas, I. Lamiquiz-Moneo, I. Lasarte-Sanz, L. Sala-Fernández, M. Marín-Andrés, P. Rubio-Sánchez, et al.
Prevalencia de Sobrepeso y Obesidad En Aragón y Variaciones Según Condicionantes de Salud.
An Pediatr (Engl Ed), 98 (2023), pp. 157-164
[16]
C. Ariza, E. Ortega-Rodríguez, F. Sánchez-Martínez, S. Valmayor, O. Juárez, M.I. Pasarín.
La Prevención de La Obesidad Infantil Desde Una Perspectiva Comunitaria.
Aten Primaria, 47 (2015), pp. 246
[17]
A. Ek, K. Sorjonen, K. Eli, L. Lindberg, J. Nyman, C. Marcus, et al.
Associations between parental concerns about preschoolers’ weight and eating and parental feeding practices: results from analyses of the child eating behavior questionnaire, the child feeding questionnaire, and the lifestyle behavior checklist.
[18]
G Serral, F. Sánchez, C. Ariza.
Programa de Prevenció de l’Obesitat Infantil de Barcelona (Projecte POIBIN).
Agència de Salut Pública de Barcelona, (2019),
[19]
World Health Organization. Body Mass Inder-for-Age (BMI-for-Age) Available from: https://www.who.int/toolkits/child-growth-standards/standards/body-mass-index-for-age-bmi-for-age. (Accessed on 20 March 2023).
[20]
Gabinet Tècnic de Programació. Ajuntament de Barcelona. Distribució territorial de la renda familiar disponible per càpita a Barcelona (2016). Available from: https://www.idescat.cat/serveis/biblioteca/docs/bib/pec/paae2017/a07882016.pdf.
[21]
C. Currie, M. Molcho, W. Boyce, B. Holstein, T. Torsheim, M. Richter.
Researching health inequalities in adolescents: the development of the health behaviour in school-aged children (HBSC) family affluence scale.
Soc Sci Med, 66 (2008), pp. 1429-1436
[22]
J.A. Bartrina, V. Arija Val, E. Maíz Aldalur, E. Martínez De Victoria Muñoz, R.M. Ortega Anta, C. Pérez-Rodrigo, et al.
Guías Alimentarias Para La Población Española (SENC, Diciembre 2016); La Nueva Pirámide de La Alimentación Saludable.
Nutr Hosp, 33 (2016),
[23]
L.L. Birch, J.O. Fisher, K. Grimm-Thomas, C.N. Markey, R. Sawyer, S.L. Johnson.
Confirmatory factor analysis of the child feeding questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness.
Appetite, 36 (2001), pp. 201-210
[24]
L. Serra Majem, L. Ribas Barba, C. Pérez Rodrigo, B. Roman Viñas, J. Aranceta Bartrina.
Hábitos Alimentarios y Consumo de Alimentos En La Población Infantil y Juvenil Española (1998-2000): Variables Socioeconómicas y Geográficas.
Med Clin (Barc), 121 (2003), pp. 126-131
[25]
World Health Organization. Tenfold Increase in Childhood and Adolescent Obesity in Four Decades: New Study by Imperial College London and WHO. Available from: https://www.who.int/es/news/item/11-10-2017-tenfold-increase-in-childhood-and-adolescent-obesity-in-four-decades-new-study-by-imperial-college-london-and-who. (Accessed on 21 March 2023).
[26]
T. Mekonnen, H.H. Havdal, N. Lien, S.A. O’Halloran, O.A. Arah, E. Papadopoulou, et al.
Mediators of socioeconomic inequalities in dietary behaviours among youth: a systematic review.
[27]
K. Bammann, W. Gwozdz, A. Lanfer, G Barba, S. De Henauw, G. Eiben, et al.
Socioeconomic factors and childhood overweight in Europe: results from the multi-centre IDEFICS study.
[28]
S. Newton, D. Braithwaite, T.F. Akinyemiju.
Socio-economic status over the life course and obesity: systematic review and meta-analysis.
[29]
Health Sponsorship Council (HSC).
Encouraging Children to Eat Breakfast.
The Health Sponsorship Council’s Breakfast-Eaters Promotion, (2011),
[30]
Estudio ALADINO: Estudio de Vigilancia Del Crecimiento, Alimentación, Actividad Física, Desarrollo Infantil y Obesidad En España 2011. Agencia Española de Seguridad Alimentaria y Nutrición, Ministerio de Sanidad, Servicios Sociales e Igualdad, (2013),
[31]
A. Avery, C. Anderson, F. McCullough.
Associations between children’s diet quality and watching television during meal or snack consumption: a systematic review.
Matern Child Nutr, 13 (2017),
[32]
P. Mascarenhas, J.M. Furtado, S.M. Almeida, M.E. Ferraz, F.P. Ferraz, P. Oliveira.
Pediatric overweight, fatness and risk for dyslipidemia are related to diet: a cross-sectional study in 9-year-old children.
Nutrients, 15 (2023), pp. 329
[33]
T. Alzate Yepes, T. Alzate Yepes.
Consumo de Carnes Rojas y Procesadas. La Controversia Está Servida.
Perspect Nutric Humana, 21 (2019), pp. 137-142
[34]
WHO European Childhood Obesity Surveillance Initiative (COSI): Report on the Fourth Round of Data Collection 2015-2017, (2021),
[35]
A. Pan, Q. Sun, A.M. Bernstein, M.B. Schulze, J.A.E. Manson, M.J. Stampfer, et al.
Red meat consumption and mortality: results from 2 prospective cohort studies.
Arch Intern Med, 172 (2012), pp. 555-563
[36]
World Health Organization.
Guidelines on Physical Activity, Sedentary Behaviour and Sleep for Children under 5 Years of Age.
World Health Organization, (2019),
[37]
À. Cartanyà-Hueso, C. Lidón-Moyano, J.C. Martín-Sánchez, A. González-Marrón, H. Pérez-Martín, J.M. Martínez-Sánchez.
Association between recreational screen time and excess weight and obesity assessed with three sets of criteria in Spanish residents aged 2–14 years.
An Pediatr (Engl Ed), 97 (2022), pp. 333-341
[38]
M.D. Esteban-Vasallo, I. Galán, M.A. Ortiz-Pinto, A. Astray San Martín, E.M. Cabrero López, M.T. Morales San José, et al.
Accuracy of anthropometric measurements and weight status perceptions reported by parents of 4-year-old children.
Public Health Nutr, 23 (2020), pp. 589-598
[39]
D. Rodrigues, A.M. Machado-Rodrigues, C. Padez.
Parental misperception of their child’s weight status and how weight underestimation is associated with childhood obesity.
Am J Hum Biol, 32 (2020),
Copyright © 2024. Asociación Española de Pediatría
Idiomas
Anales de Pediatría (English Edition)
Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?