Analysis of Factors Affecting the Body Mass Index in a National Sample of Iranian Children and Adolescents: Bootstrapping Regression

Authors

1 Department of Biostatistics and Epidemiology, School of Public Health, Isfahan University of Medical Sciences, Isfahan, Iran

2 Department of Pediatrics, Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

Background: This study aims to evaluate the effect of some factors, including birth weight, sex, age, waist circumference, family history of obesity, as well as some lifestyle factors as frequency of breakfast days and physical activity, on the body mass index among a nationally representative sample of Iranian children and adolescents by using bootstrapping regression. Materials and Methods: This study was conducted as the third survey of a school-based surveillance system (CASPIAN-III study). Total participants were 5570 school students, aged 10-18 years, selected by multistage random cluster sampling from urban and rural areas of 27 provinces of Iran. Multiple linear regressions was used to evaluate the effect of various factors on obesity, but in our data the assumptions of this model violated, and possible solutions were not appropriate, therefore the bootstrapping regression based on the observations and errors resampling approaches was used as an alternative. Results: The tests of significance showed that the effects of sex, age, waist circumference, family history obesity and frequency of breakfast days were clearly significant (P < 0.001). The effect of vigorous level of physical activity was significant in comparison to mild physical activity (P = 0.01). In comparison to low birth weight, medium and high birth weight had significant effect on obesity. Conclusions: Bootstrap method is preferable in linear regression because of some theoretical properties like having any distributional assumptions on the residuals and hence allows for inference even if the errors do not follow normal distribution or constant error variance.

Keywords

1.
Sharma M. International school-based interventions for preventing obesity in children. Obes Rev 2007;8:155-67.  Back to cited text no. 1
[PUBMED]    
2.
Kelishadi R. Childhood overweight, obesity, and the metabolic syndrome in developing countries. Epidemiol Rev 2007;29:62-76.  Back to cited text no. 2
[PUBMED]    
3.
Sinaiko AR, Jacobs Jr DR, Steinberger J, Moran A, Luepker R, Rocchini AP, et al. Insulin resistance syndrome in childhood: Associations of the euglycemic insulin clamp and fasting insulin with fatness and other risk factors. J Pediatr 2001;139:700-7.  Back to cited text no. 3
    
4.
Rippe JM, Angelopoulos TJ. Obesity: Prevention and Treatment. United States: CRC Press; 2012.  Back to cited text no. 4
    
5.
Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: The Bogalusa Heart Study. J pediatr 2007;150:12-7.e2.  Back to cited text no. 5
    
6.
Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991. Arch Pediatr Adolesc Med 1995;149:1085-91.  Back to cited text no. 6
[PUBMED]    
7.
Chen X, Beydoun MA, Wang Y. Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Obesity 2008;16:265-74.  Back to cited text no. 7
[PUBMED]    
8.
Story M, Sallis JF, Orleans CT. Adolescent obesity: Towards evidence-based policy and environmental solutions. J Adolesc Health 2009;45:S1-5.  Back to cited text no. 8
[PUBMED]    
9.
Resnicow K, Yaroch AL, Davis A, Wang DT, Carter S, Slaughter L, et al. GO GIRLS!: Results from a nutrition and physical activity program for low-income, overweight African American adolescent females. Health Educ Behav 2000;27:616-31.  Back to cited text no. 9
[PUBMED]    
10.
Reilly JJ, Jackson D, Montgomery C, Kelly L, Slater C, Grant S, et al. Total energy expenditure and physical activity in young Scottish children: Mixed longitudinal study. Lancet 2004;363:211-2.  Back to cited text no. 10
    
11.
French SA, Story M, Jeffery RW. Environmental influences on eating and physical activity. Annu Rev Public Health 2001;22:309-35.  Back to cited text no. 11
[PUBMED]    
12.
Sheikholeslam R, Mohamad A, Mohammad K, Vaseghi S. Non communicable disease risk factors in Iran. Asia Pacific journal of clinical nutrition 2004;2:13.  Back to cited text no. 12
    
13.
Kelishadi R, Sadri G, Tavasoli AA, Kahbazi M, Roohafza HR, Sadeghi M, et al. Cumulative prevalence of risk factors for atherosclerotic cardiovascular diseases in Iranian adolescents: IHHP-HHPC. J Pediatr 2005;81:447-53.  Back to cited text no. 13
    
14.
Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, et al. Obesity and cardiovascular disease pathophysiology, evaluation, and effect of weight loss. Arterioscler Thromb Vasc Biol 2006;26:968-76.  Back to cited text no. 14
[PUBMED]    
15.
Epstein LH, Gordy CC, Raynor HA, Beddome M, Kilanowski CK, Paluch R. Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity. Obes Res 2001;9:171-8.  Back to cited text no. 15
[PUBMED]    
16.
Organization WH. Global strategy for non-communicable disease prevention and control (Draft). Geneva: WHO; 1997.  Back to cited text no. 16
    
17.
Monteiro CA, Conde WL, Lu B, Popkin BM. Obesity and inequities in health in the developing world. Int J Obes Relat Metab Disord 2004;28:1181-6.  Back to cited text no. 17
[PUBMED]    
18.
Kelishadi R, Pour MH, Zadegan NS, Kahbazi M, Sadry G, Amani A, et al. Dietary fat intake and lipid profiles of Iranian adolescents: Isfahan Healthy Heart Program–heart health promotion from childhood. Prev Med 2004;39:760-6.  Back to cited text no. 18
[PUBMED]    
19.
Kelishadi R, Hashemi Pour M, Sarraf-Zadegan N, Ansari R, Alikhassy H, Bashardoust N. Obesity and associated modifiable environmental factors in Iranian adolescents: Isfahan Healthy Heart Program − Heart Health Promotion from Childhood. Pediatr Int 2003;45:435-42.  Back to cited text no. 19
    
20.
Beyerlein A, Fahrmeir L, Mansmann U, Toschke AM. Alternative regression models to assess increase in childhood BMI. BMC Med Res Methodol 2008;8:59.  Back to cited text no. 20
[PUBMED]    
21.
Sahinler S, Topuz D. Bootstrap and jackknife resampling algorithms for estimation of regression parameters. J Appl Quant Methods 2007;2:188-99.  Back to cited text no. 21
    
22.
Šaltytė Benth J, Dahl F, Mitic S. Can linear regression model give reliable conclusions about the postoperative recovery? Bootstrap for case study in Mitic et al. 2007. Clin Otolaryngol 2008;33:287-9.  Back to cited text no. 22
    
23.
Kelishadi R, Heshmat R, Motlagh ME, Majdzadeh R, Keramatian K, Qorbani M, et al. Methodology and early findings of the third survey of CASPIAN study: A national school-based surveillance of students' high risk behaviors. Int J Prev Med 2012;3:394.  Back to cited text no. 23
[PUBMED]    
24.
Khashayar P, Heshmat R, Qorbani M, Motlagh ME, Aminaee T, Ardalan G, et al. Metabolic syndrome and cardiovascular risk factors in a national sample of adolescent population in the middle east and north Africa: The CASPIAN III study. Int J Endocrinol 2013;2013:702095.  Back to cited text no. 24
[PUBMED]    
25.
Kelishadi R, Motlagh ME, Roomizadeh P, Abtahi SH, Qorbani M, Taslimi M, et al. First report on path analysis for cardiometabolic components in a nationally representative sample of pediatric population in the Middle East and North Africa (MENA): The CASPIAN-III Study. Ann Nutr Metab 2013;62:257-65.  Back to cited text no. 25
[PUBMED]    
26.
Wehrens R, Putter H, Buydens L. The bootstrap: A tutorial. Chemometrics and Intelligent Lab Syst 2000;54:35-52.  Back to cited text no. 26
    
27.
Fox J. Bootstrapping regression models. An R and S-PLUS Companion to Applied Regression: A Web Appendix to the Book Sage, Thousand Oaks, CA. Available from: http://www.cran r-project org/doc/contrib/Fox-Companion/appendix-bootstrapping pdf. [Last accessed on 2014 Jan 10].  Back to cited text no. 27
    
28.
Haukoos JS, Lewis RJ. Advanced statistics: Bootstrapping confidence intervals for statistics with “difficult” distributions. Acad Emerg Med 2005;12:360-5.  Back to cited text no. 28
[PUBMED]    
29.
Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med 1997;337:869-73.  Back to cited text no. 29
[PUBMED]    
30.
Wirfält E, Hedblad B, Gullberg B, Mattisson I, Andrén C, Rosander U, et al. Food patterns and components of the metabolic syndrome in men and women: A cross-sectional study within the Malmö Diet and Cancer cohort. Am J Epidemiol 2001;154:1150-9.  Back to cited text no. 30
    
31.
Liu S, Manson JE. Dietary carbohydrates, physical inactivity, obesity, and the 'metabolic syndrome'as predictors of coronary heart disease. Curr Opin Lipidol 2001;12:395-404.  Back to cited text no. 31
[PUBMED]    
32.
Chu N. Prevalence and trends of obesity among school children in Taiwan-the Taipei Children Heart Study. Int J Obes Relat Metab Disord 2001;25:170-6.  Back to cited text no. 32
    
33.
Mohammadpour-Ahranjani B, Rashidi A, Karandish M, Eshraghian M, Kalantari N. Prevalence of overweight and obesity in adolescent Tehrani students, 2000–2001: An epidemic health problem. Public Health Nutr 2004;7:645-8.  Back to cited text no. 33
    
34.
Whelton H, Harrington J, Crowley E, Kelleher V, Cronin M, Perry IJ. Prevalence of overweight and obesity on the island of Ireland: Results from the North South Survey of Children's Height, Weight and Body Mass Index, 2002. BMC Public Health 2007;7:187.  Back to cited text no. 34
[PUBMED]    
35.
Silva DA, Pelegrini A, Silva JM, Petroski EL. Epidemiology of abdominal obesity among adolescents from a Brazilian State Capital. J Korean Med Sci 2011;26:78-84.  Back to cited text no. 35
[PUBMED]    
36.
Janssen I, Katzmarzyk PT, Boyce WF, King MA, Pickett W. Overweight and obesity in Canadian adolescents and their associations with dietary habits and physical activity patterns. J Adolesc Health 2004;35:360-7.  Back to cited text no. 36
[PUBMED]    
37.
Olds T, Wake M, Patton G, Ridley K, Waters E, Williams J, et al. How do school-day activity patterns differ with age and gender across adolescence? J Adolesc Health 2009;44:64-72.  Back to cited text no. 37
[PUBMED]    
38.
Salazar-Martinez E, Allen B, Fernandez-Ortega C, Torres-Mejia G, Galal O, Lazcano-Ponce E. Overweight and obesity status among adolescents from Mexico and Egypt. Arch Med Res 2006;37:535-42.  Back to cited text no. 38
[PUBMED]    
39.
Forshee RA, Anderson PA, Storey ML. The role of beverage consumption, physical activity, sedentary behavior, and demographics on body mass index of adolescents. Int J Food Sci Nutr 2004;55:463-78.  Back to cited text no. 39
[PUBMED]    
40.
Storey ML, Forshee RA, Weaver AR, Sansalone WR. Demographic and lifestyle factors associated with body mass index among children and adolescents. Int J Food Sci Nutr 2003;54:491-503.  Back to cited text no. 40
[PUBMED]    
41.
Euser AM, Finken MJ, Keijzer-Veen MG, Hille ET, Wit JM, Dekker FW. Associations between prenatal and infancy weight gain and BMI, fat mass, and fat distribution in young adulthood: A prospective cohort study in males and females born very preterm. Am J Clin Nutr 2005;81:480-7.  Back to cited text no. 41
    
42.
Pietiläinen KH, Kaprio J, Räsänen M, Winter T, Rissanen A, Rose RJ. Tracking of body size from birth to late adolescence: Contributions of birth length, birth weight, duration of gestation, parents' body size, and twinship. Am J Epidemiol 2001;154:21-9.  Back to cited text no. 42
    
43.
Sørensen HT, Sabroe S, Rothman KJ, Gillman M, Fischer P, Sørensen TI. Relation between weight and length at birth and body mass index in young adulthood: Cohort study. BMJ 1997;315:1137.  Back to cited text no. 43
    
44.
Gibson LY, Byrne SM, Davis EA, Blair E, Jacoby P, Zubrick SR. The role of family and maternal factors in childhood obesity. Med J Aust 2007;186:591-5.  Back to cited text no. 44
[PUBMED]    
45.
Wang Z, Patterson CM, Hills AP. Association between overweight or obesity and household income and parental body mass index in Australian youth: Analysis of the Australian National Nutrition Survey, 1995. Asia Pac J Clin Nutr 2002;11:200-5.  Back to cited text no. 45
[PUBMED]    
46.
Kimm S, Glynn NW, Obarzanek E, Kriska AM, Daniels SR, Barton BA, et al. Relation between the changes in physical activity and body-mass index during adolescence: A multicentre longitudinal study. Lancet 2005;366:301-7.  Back to cited text no. 46
    
47.
Berkey CS, Rockett HR, Field AE, Gillman MW, Frazier AL, Camargo CA, et al. Activity, dietary intake, and weight changes in a longitudinal study of preadolescent and adolescent boys and girls. Pediatrics 2000;105:e56-e.  Back to cited text no. 47
    
48.
Berkey CS, Rockett HR, Gillman MW, Colditz GA. One-year changes in activity and in inactivity among 10-to 15-year-old boys and girls: Relationship to change in body mass index. Pediatrics 2003;111:836-43.  Back to cited text no. 48
[PUBMED]    
49.
Must A, Tybor DJ. Physical activity and sedentary behavior: A review of longitudinal studies of weight and adiposity in youth. Int J Obes (Lond) 2005;29(Suppl 2):S84-96.  Back to cited text no. 49
[PUBMED]    
50.
Barba G, Troiano E, Russo P, Siani A; ARCA Project Study group. Total fat, fat distribution and blood pressure according to eating frequency in children living in southern Italy. Int J Obes (Lond) 2006;30:1166-9.  Back to cited text no. 50
[PUBMED]    
51.
Sandercock G, Voss C, Dye L. Associations between habitual school-day breakfast consumption, body mass index, physical activity and cardiorespiratory fitness in English schoolchildren. Eur J Clin Nutr 2010;64:1086-92.  Back to cited text no. 51
    
52.
Siega-Riz AM, Popkin BM, Carson T. Trends in breakfast consumption for children in the United States from 1965-1991. Am J Clin Nutr 1998;67:748S-56.  Back to cited text no. 52
[PUBMED]    
53.
Keski-Rahkonen A, Kaprio J, Rissanen A, Virkkunen M, Rose RJ. Breakfast skipping and health-compromising behaviors in adolescents and adults. Eur J Clin Nutr 2003;57:842-53.  Back to cited text no. 53
[PUBMED]    
54.
Niemeier HM, Raynor HA, Lloyd-Richardson EE, Rogers ML, Wing RR. Fast food consumption and breakfast skipping: Predictors of weight gain from adolescence to adulthood in a nationally representative sample. J Adolesc Health 2006;39:842-9.  Back to cited text no. 54
[PUBMED]    
55.
Barton BA, Eldridge AL, Thompson D, Affenito SG, Striegel-Moore RH, Franko DL, et al. The relationship of breakfast and cereal consumption to nutrient intake and body mass index: The National Heart, Lung, and Blood Institute Growth and Health Study. J Am Diet Assoc 2005;105:1383-9.  Back to cited text no. 55
[PUBMED]    
56.
Berkey CS, Rockett H, Gillman MW, Field A, Colditz G. Longitudinal study of skipping breakfast and weight change in adolescents. Int J Obes 2003;27:1258-66.  Back to cited text no. 56
    
57.
Karlis D, editor. An introduction to bootstrap methods. 17th conference of Greek Ststistical Society; 2004.  Back to cited text no. 57
    
58.
Fox J. Applied regression analysis, linear models, and related methods. United States: Sage Publications Inc; 1997.  Back to cited text no. 58