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Abstract Back ground: The prevalence of childhood obesity is increasing rapidly in industrialized nations. Childhood obesity can create many complications at the cardiovascular, endocrine, pulmonary, musculoskeletal and gastrointestinal levels, as well as possible psycho-social consequences (poor self-esteem, depression, eating disorders). On contrary malnutrition is the most prevalent causes of children mortality and morbidity in developing country. For this reason, recent studies have focused on the possible causes and risk factors associated with obesity and malnutrition in pediatric ages. Objective: To identify the potential independent predictors for BIM from Jimma infant survival data Method: Longitudinal case control study was done on 7865 infants of Jimma zone, south west Ethiopia. Result: The coefficient of simple linear regression shows that there is a significant difference among the regression coefficients values. Family size 0.19, but here it is 0.04.family income 0.247, but here 0.191, arm circumference o.630 and here is 0.029 and for education it was 0.183. Conclusion: Educational status has direct relationship with educational status of the mother. It explains the model around 0.6% of the BMI variability. Family income, family size and arm circumference are significantly (P< 0.001) associated with BMI which also supported by other studies (WHO, 1998). We concluded that relatively family income, family size and arm circumference are potential covariates that can predict the BMI of infants in the general population

Key words: Arm circumference, Body mass index, Family income, Educational status

2.1. Introduction

Body Mass Index (BMI) was calculated as weight in kilogram divided by height in meter square. Underweight was defined as having a BMI lower than 5th percentile of age- and sex-specific BMI (Center for Disease Control and Prevention(CDC) 2000); normal weight was defined as BMI between 5th and 85th percentiles; at risk for overweight and overweight were defined as BMI between 85th and 95th and greater than 95th percentile, respectively (1).Obesity is a multifactorial disorder stemming from the interaction between genetic and metabolic factors on the one hand, and nutritional lifestyles and physical activity on the other, both of which are, in turn, conditioned by social, behavioral and cultural factors. It constitutes a major and increasing public health problem worldwide (1). Linear Regression analysis is used for the analysis of continuous outcome (dependent) variable. Simple Linear regression estimates the coefficients of the linear equation, involving one dependent outcome whereas multiple linear regressions involves two and more independent variables, that best predict the value of the dependent variable.

The prevalence of childhood obesity is increasing rapidly in industrialized nations. Childhood obesity can create many complications at the cardiovascular, endocrine, pulmonary, musculoskeletal and gastrointestinal levels, as well as possible psycho-social consequences (poor self-esteem, depression, eating disorders). For this reason, recent studies have focused on the possible causes and risk factors associated with obesity in pediatric ages (2, 1). Numerous studies have shown that the risk of becoming obese is higher in children of obese parents (2). Parents are responsible not only for the genetic structure of their children, but also for passing onto them their behaviors and attitudes toward life. The lifestyle of the family plays an important role in the nutritional and behavioral choices of the child and this can be the result of both social and economic factors, such as the place of residence; the parents cultural level; the economic assets of the family; and their income.(3). Obesity was strongly associated with age and a lower educational level. Overweight and obesity were more frequent in women with a lower educational level; indeed, prevalence of obesity in the two categories with a lower educational level exceeded 20 %.( 3, 2). The prevalence of obese children increased along the parents BMI category: from 1.4% for underweight mothers to 30.3% for obese mothers and from 4% for under-normal-weight fathers to 23.9% for obese fathers (p <0.001). An inverse relationship was observed between the parents educational level and child obesity, the lowest educational level corresponding to the highest prevalence of obese children: 9.3% for mothers with a low educational level compared to 5.8% for mothers with a high educational level (p = 0.15); similarly, the corresponding prevalence for fathers was 9.5% compared to 4.5% (p = 0.03).(4)

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2.3. Objective

2.3.1 General objective

To identify the potential independent predictors for BIM from Jimma infant survival data

To identify the relationship between maternal educational status and BMI of infants To assess the relationship between family income and BMI of infants To identify the relationship between family size and BMI of infants To predict the relationship between arm circumference and BMI of infants

2.4. Methodology

We identify the potential independent variables which can more predict the BMI by applying simple scatter plot followed by determining the regression coefficient at p-value <0.05.Then each independent variable that relatively fits the model is selected based on the comparison coefficient of determination (R2 ) . Following this we state our hypothesis as null hypothesis there is no relationship between BMI and selected covariates (Arm circumference, Family income, Family size and Educational status of mother) and alternative hypothesis sated as BMI is related with( Arm circumference, Family income, Family size and Educational status of mother).Then we set p-value < 0.05 to reject the null hypothesis. We subsequently enter the independent variable to develop the model by applying different methods i.e. Enter, Forward, Stepwise and Back ward.

2.5 Result

From the analysis of simple linear regression, the results of each covariate with respective coefficient of determination, regression coefficient and p-value as displayed in the following tables. Educational level and BMI The model equation based on the above SPSS output table 2.1: BMI=12.749 +0.183(Educational level) R2 = SSB/SST= 152.822/26818.985= 0.006= (SSB: the sum square between) (SST: sum square of total) This means the model explains the dependent variable only 0.6%

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Table 2.1. ANOVA table for the relationship between the BMI and educational level.

df 1 7863 7864

F 45.062

Sig. .000a

a. Predictors: (Constant), Educational level b. Dependent Variable: BMI Table 2.2 Coefficients for educational level and BMI Standardized Coefficients Beta t 495.456 .075 6.713 Sig. .000 .000

Unstandardized Coefficients Model (Constant) Educational level Dependent Variable: BMI B 12.749 .183 Std. Error .026 .027

1. Family income with BMI The scatter plot below shows relationship between BMI and family income which shows relatively direct linear relationship as indicated below.

Fig 2.1 The scatter plot for BMI and family income

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a

df2 7401

Table 2.4 Coefficientsa of the family income with BMI. Unstandardized Coefficients Model 1 (Constant) B 12.438 Std. Error .040 .020 .141 Standardized Coefficients Beta t 309.099 12.253 Sig. .000 .000

Family income .247 a. Dependent Variable: BMI a. Predictors: (Constant), Family income b. Dependent Variable: BMI

From table 2.4, we develop the model equation as follow. BMI=12.438+0.247(Family income) R2 = SSB/SST =502.541/25275.874 =0.02=2%, which indicates that this model describes the BMI by 2% of the variability. 3. Family Size with BMI

Figure 2.2 the scatter plot for the family income and BMI

Table 2.5 ANOVAb table for the family size and BMI Model 1 Regression Residual Sum of Squares Df 279.387 26566.728 1 7871 7872 Mean Square 279.387 3.375 F 82.775 Sig. .000a

Table 2.6 Coefficientsa family size with BMI Unstandardized Coefficients Model 1 (Constant) B 12.390 Std. Error .055 .021 .102 Standardized Coefficients Beta t 225.961 9.098 Sig. .000 .000

From table 2.6 and 2.5 we develop the model as follow. BMI=12.390+0.190(Family size) R2 = SSB/SST = 279.387/ 26846.114 =0.01=1% The model explains the BMI of the infants by 1%. 4.0 Arm circumference and BMI

Table 2.7 ANOVAb output for BMI and arm circumference Model 1 Regression Residual Sum of Squares Df 4072.465 22765.957 1 7870 Mean Square 4072.465 2.893 F 1407.817 Sig. .000a

Total 26838.422 7871 a. Predictors: (Constant), Arm circumference b. Dependent Variable: BMI

Table 2.8 Coefficientsa of arm circumference and BMI Standardized Unstandardized Coefficients Coefficients Model 1 (Constant) B 6.010 Std. Error .183 .017 .390 Beta t 32.784 37.521 Sig. .000 .000

From the above table 2.8 the model equation for BMI predication based on arm circumference: BMI= 6.010 +0.639(arm circumference) R2=SSB/SST=4072.465/ 26838.422 =0.15=15% , which means that the model explains about 15% of the variability of BMI due to arm circumference. 2.4.2 Analysis by multiple regressions 1. Regression by Enter method: All the predictor variables are enter all at a time and analyzed jointly as shown on the following tables.

Table 2.9 Variables Entered/Removedb through enter method Model Variables Entered 1 Arm circumference, Educational level, Family Size, Family . income Variables Removed Method

Enter

Table 2.10 Coefficientsa Unstandardized Coefficients Model 1 (Constant) Family Size Family income Educational level Arm circumference a. Dependent Variable: BMI B 5.665 .042 .172 .048 .619 Std. Error .192 .010 .023 .031 .018 .048 .098 .020 .377 Standardized Coefficients Beta t 29.576 4.417 7.552 1.530 35.322 Sig. .000 .000 .000 .126 .000

From this output result table we developed the model that holds the potential covariates as follow: BMI=5.665+0.042(Family size) +0.172(Family income) +0.048(Educational levee) +0.619 (Arm circumference) 2. Regression by Step wise method During this method of variable enter each variable is evaluated at each stage and if found unfit in relative to the other it is removed and replaced by other variables that best fits.

Table 2.12 Coefficientsa Table 2.11 Variables Entered/Removeda Variables Unstandardized Coefficients Removed Method B Std. Error 6.014 .638 . 5.794 .626 .205 . 5.664 . .620 .191 .040 .190 Standardized Coefficients Beta t 31.695 Sig. .000

Model Model 1 1

.018 Stepwise (Criteria: Probability-of-F-to-enter <= .050, .388 36.251 .000 Probability-of-F-to-remove >= .100). .189 .017 .381 30.610 35.792 .000 .000

(Constant) Arm circumference Family income 2 Family income (Constant) Family Size Arm circumference Family income Family Size

.019 Stepwise (Criteria: Probability-of-F-to-enter <= .050, .117 11.012 .000 Probability-of-F-to-remove >= .100). .192 Stepwise (Criteria: Probability-of-F-to-enter <= .050, 29.569 .000 Probability-of-F-to-remove >= .100). .018 .377 35.348 .000 .019 .109 10.092 .000 .009 .046 4.248 .000

3 3

The model is developed as follow based on the output on table 2.12 BMI=5.664+0.629(arm circumference) +0.191(Family income) + 0.04 (Family size) The coefficient of simple linear regression shows that there is a significant difference among the regression coefficients values. Family size 0.19, but here it is 0.04.family income 0.247, but here 0.191, arm circumference o.630 and here is 0.029 and for education it was 0.183 but here it is insignificant which excluded from the model 3. Regression by Backward method It starts from the full model and then variables which are not significantly predict the outcome is removed consequently until significant variables remains in the model. The following tables show this procedure.

2.13. Variables Entered/Removedb Model 1 Variables Entered Arm circumference, Educational level, Family Size, Family incomea . Variables Removed Method

Enter

Table 2.14 Coefficientsa Unstandardized Coefficients Model 1 (Constant) Family Size Family income Educational level Arm circumference 2 (Constant) Family Size Family income B 5.665 .042 .172 .048 .619 5.664 .040 .191 Std. Error .192 .010 .023 .031 .018 .192 .009 .019 .018 .046 .109 .377 .048 .098 .020 .377 Standardized Coefficients Beta t 29.576 4.417 7.552 1.530 35.322 29.569 4.248 10.092 35.348 Sig. .000 .000 .000 .126 .000 .000 .000 .000 .000

BMI=5.665+0.04 (Family Size) +0.191(Family income) +0.620(Arm circumference) 4. Regression by Forward It starts from the null model and proceeds by adding variables provided that added variables show significant different.

Table 2.15 Variables Entered/Removed a by forward method Model 1 2 3 Variables Entered Arm circumference Family income Family Size Variables Removed . . . Method Forward (Criterion: Probability-of-F-to-enter <= .050) Forward (Criterion: Probability-of-F-to-enter <= .050) Forward (Criterion: Probability-of-F-to-enter <= .050) 10

Table 2.15 Variables Entered/Removed a by forward method Model 1 2 3 Variables Entered Arm circumference Family income Family Size Variables Removed . . . Method Forward (Criterion: Probability-of-F-to-enter <= .050) Forward (Criterion: Probability-of-F-to-enter <= .050) Forward (Criterion: Probability-of-F-to-enter <= .050)

Table 2.16 Coefficientsa Unstandardized Coefficients Model 1 2 (Constant) Arm circumference (Constant) Arm circumference Family income 3 (Constant) Arm circumference Family income Family Size a. Dependent Variable: BMI B 6.014 .638 5.794 .626 .205 5.664 .620 .191 .040 Std. Error .190 .018 .189 .017 .019 .192 .018 .019 .009 .377 .109 .046 .381 .117 .388 Standardized Coefficients Beta t 31.695 36.251 30.610 35.792 11.012 29.569 35.348 10.092 4.248 Sig. .000 .000 .000 .000 .000 .000 .000 .000 .000

From the above table we develop the equation that describes the relationship among the three variables and the dependent variable BMI. BMI= 5.664+0.6209arm circumference) +0.191(family income) +0.04(family size) From the above four tables (2.10, 2.12, 2.14 and 2.16) we have seen that the regression coefficient that we found in the linear regression and multiple linear regression are quite different. And also some independent variables become unfit in the model during the multiple linear regression analysis.

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As the research done on relation between BMI and educational level of family in Italy in 2010 there is an inverse relationship was observed between the parents educational level and BMI of the infants (p<0.001), but in our case educational status has direct relationship with educational status of the mother. It explains the model around o.6% of the BMI variability. Family income, family size and arm circumference are significantly (P< 0.001) associated with BMI which also supported by other studies (WHO, 1998). We concluded that relatively family income, family size and arm circumference are potential covariates that can predict the BMI of infants in the general population.

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References

1. Socio-demographic Factors Associated with Body Mass Index of Female Adolescent Students in Semnan City, Iran Doust mohammadian A 1, Dorostymotlagh AR1, Keshavarz A2, Sadrzadehyeganeh H2 & Mohammadpour-Ahrangani 2004 2. WHO/FAO: Joint WHO/FAO Expert Consultation on diet, nutrition and the prevention of chronic diseases, diet, nutrition and the prevention of chronic diseases: report of a joint WHO/FAO expert consultation Geneve: WHO; 2003. 3. Ebbeling CB, Pawlak DB, Ludwig DS: Childhood obesity: public-health crisis,\ common sense cure. Lancet 2002, 360:473-82. 4. Role of educational level in the relationship between Body Mass Index (BMI) and healthrelated quality of life (HRQL) among rural Spanish women, 1998.

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