Food Insecurity in Obese Adolescent Females in Tehran Schools : An Examination of Anthropometric and Socio-Economic Factors

Background Obesity and its complications affect much of the population of the world today. In addition to physical complications, psychological complications also increase with increasing obesity. It has always been important to pay attention to the growing trend of childhood obesity, which is a factor in adulthood obesity and future chronic illnesses. Today, one of the factors that has been identified as effective in weight gain and obesity in urban communities is food insecurity, which is not merely a lack of food, but also includes related factors such as upbringing, behavior, psychosocial adaptation, and physical activity. Therefore, the purpose of this study was to investigate the effects of food insecurity on anthropometric indicators and other relevant factors in obese girls aged 11 to 14 years. Method In this study 452 obese female students aged 11 to 14 years, who had BMI more than 2SD above the WHO 2007 reference point, were randomly selected from several schools in three areas of Tehran. After obtaining written consent, demographic information and food security information were collected using a General and the United States Department of Agriculture (USDA) questionnaire. Anthropometric indices and fat percentage were also measured, based on skin fold and by calipers. Finally, the data were analyzed using SPSS software. Current Research in Nutrition and Food Science www.foodandnutritionjournal.org ISSN: 2347-467X, Vol. 07, No. (1) 2019, Pg. 280-286 CONTACT Nayere Esmaeil Kaboli nekaboli@yahoo.com Nutrition Sciences, Tehran University of Medical Sciences, Tehran, Iran. © 2019 The Author(s). Published by Enviro Research Publishers. This is an Open Access article licensed under a Creative Commons license: Attribution 4.0 International (CC-BY). Doi: doi.org/10.12944/CRNFSJ.7.1.28 Article History Received: 3 September 2018 Accepted: 15 April 2019


Introduction
According to current statistics, the prevalence of obesity (BMI > 2SD) in children is increasing.In Iran, which, like other developing countries, faces the phenomena of urbanization and industrialization, the prevalence of obesity and overweight is increasing.According to statistics, at least 10 percent of the world's children are overweight or obese. 1 The prevalence of obesity in Iranian children aged 7 to 12 has been reported at 5 -10 %. 2 Additionally, obesity increases the risk of chronic diseases such as type 2 diabetes, insulin resistance, increased blood pressure, increased cardiovascular disease, some cancers, and even premature death.It also causes psychosocial problems. 3Childhood obesity not only causes obesity in adulthood, but also causes physical and psychological problems at an early age. 4 Therefore, the prevention of obesity is a vital World Health Organization (WHO) goal. 5e of the factors that is known today to be an effective factor in weight gain and obesity in urban communities is food insecurity. 6According to the United Nations in 1986, food security exists when all members, at all times, have access to enough food for an active, healthy life.According to this definition, the availability of food, access to food and the stability of food intake are the three most important elements.The final report of the 1996 states that food security "exists when all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life". 7od insecurity has drawn the attention of many health professionals and politicians as one of the most serious problems facing the international community over the past two decades.More than 852 million people globally suffer from food insecurity, of whom a large part live in developing countries. 8The prevalence of food insecurity in Iran in 2016 was reported as 49 %, with the highest prevalence rate being among preschool children (67 %), then the elderly (67 %), mothers (61 %), and adolescents 11-16 years old (49 %). 9 Given this general view, food insecurity is assumed to lead to lower food intake and changes in the type of food consumed, due to underlying reasons such as low economic status.Therefore, food diversity is reduced and the consumption of high-caloric and poor quality nutritional foods is increased.These dietary patterns are the basis for the development of obesity and overweight and associated risks.In general, food insecurity is associated not only with food deficiency, but also with various factors such as child education, behavior, and the psychosocial, physical and motor factors (10 -12), which overall form the lifestyle of the child and the household.

Materials and Methods
In this study 452 obese female students aged 11 to 14 years with similar general characteristics who had BMI greater than 2SD above the defined WHO level were randomly selected from several schools in three areas of Tehran (south, south -east, south -west).After obtaining written consent, a general information questionnaire was completed.Student's height and weight information was accurately recorded by trained experts.Body weight was measured to the nearest 0.1 kg using a Seca scale with subjects wearing light clothing (i.e.no sweaters, jackets, or belts) and no shoes.Height was measured to the nearest 0.1 centimeter using a Seca stadiometer, in a standing position and with shoes removed.Body mass index (BMI) was calculated from the height and weight data; BMI = kg/m 2 .
Obese people with z score > 2 were selected using standard BMI curves determined by the WHO.To determine the percentage of body fat, the skin fold was measured by calipers in the triceps of the arm.Skinfold calipers are used in the measurement of skinfold thickness and the estimation of total body fat.Skinfold measurements are generally taken at specific sites on the right side of the body.The tester pinches the skin at the location site and pulls the fold of skin away from the underlying muscle so only the skin and fat tissue are being held.Special skinfold calipers are then used to measure the skinfold thickness in millimeters.
To determine the household food score, the USDA Food Security Questionnaire (18 items) was used, which was carried out by trained experts who obtained the data from the students' mothers.The USDA household food security questionnaire, which was used in this study, has been evaluated and validated in a study on households in Isfahan 13 and, in another study on households in Shiraz, has been moderated. 14This questionnaire examines household food security over the past 12 months.The questionnaire has two parts: the first part is for all households, and the second part is for families with children under the age of 18.The scoring of this questionnaire, according to Bickel et al., 15 is that for options of "often correct", "sometimes correct", "almost every month", "some months," and "yes", a score of 1 is awarded, whereas the answers "not true," "only 1 or 2 months," and "no" are awarded a score of 0. The maximum score of this questionnaire, when completed in both parts, is 18.To determine the state of food security, households are ranked into food secure, food insecure without hunger, food insecure with moderate hunger, and severe starvation.

Statistical Analysis
After data collection, data were analyzed using SPSS 17 software.Comparison within groups was done using independent t-test.By using a covariance test, confounders effects were examined and eliminated as far as possible.Before performing the above analyses, the normal distribution of variables was examined.If variables were nonnormal, a nonparametric test was used (School Grade, Head of the Family, Father's Occupation, Mother's Occupation, Father's Education, Mother's Education, Residential Region, Economic Status, House Ownership, House Type).Results with pvalue < 0.05 were considered significant.

Results
Based on the findings of this study, the samples were divided into two groups of food secure and food insecure.As shown in Table 1, there was a significant correlation between father's level of education (p = 0.004), mother's level of education (p < 0.001), household economic status (p < 0.001) and house ownership (p < 0.001) between the two groups, based on the chi -square test.In another analysis conducted within the context of food security, samples were divided into four categories: secure food group, insecure food group without hunger, insecure food group with mild hunger, and severe hunger.The association of these four groups with all quantitative and qualitative features was analyzed statistically.According to the independent t test, there was a significant difference in height (p = 0.02) and weight (p = 0.03) between the two groups.According to Table 2, the only significant differences were observed in father's job (p=0.004),father's education (p=0.001),mother's education (p < 0.001), family economic status (p < 0.001) and home ownership (p < 0.001) between all four groups, based on the chi-square test.However, no significant difference was observed between anthropometric indices and the 4 groups of food security, according to the ANOVA test.

Discussion
In the present study, there was a significant relationship between the education level of parents and the state of food insecurity, while in a study by Simon et al, the level of education in people with food insecurity was lower.Alson et al. (1996) found in their study that those who experienced food insecurity had lower levels of literacy.Other studies conducted in Iran have also shown a significant relationship between food insecurity and education level (Ramesh et   18 These studies are consistent with the present results.
Significant relationships can be attributed to the fact that higher education increases the chances of earning more paid jobs and improving the nutritional attitude of parents in relation to food needs and, as a result, reducing the level of household insecurity.
In this study, there was also a significant relationship between household economic status and food insecurity.Other studies have similarly shown that food insecurity has a meaningful relationship with economic status. 19In the studies by Ghasemi et al. 20 and Dastgiri et al., 17 food insecurity showed an inversely significant relation with income.The prevalence of food insecurity in US, Canadian, Malaysian, Mongolian and Georgian households had an inversely significant relationship with high income levels. 18The results of these studies are consistent with the present study.Income is a crucial determinant of food security, and is a critical factor in access to food in the community.Higher-income households and better economic conditions have wider food choices and can spend more on their food.
In a study by Andy Bukasa et al., there was a significant relationship between "overweight" children, based on "weight for height" in terms of the Household Food Insecurity Access Scale (HFIAS).Also, in this study, there was a significant relationship between "height " and "mild family food insecurity".On the other hand, "weight for age" and "weight for height" were not statistically related to HFIAS categories.The relationship between anthropometric indices, in particular "overweight", "height for age" and "weight for height" on the one hand, and poverty and HFIAS indicators on the other, shows that anthropometric indices of children can be good indicators of household food security.However, their measurements should be combined with other indicators.In the present study, a significant relationship was only observed in the weight and height of children with food security.

Conclusion
Today, food insecurity is a major public health problem, and food security is considered as a household and individual health indicator.Food insecurity and hunger can have adverse social and psychological effects in addition to their health effects.In this study, factors such as father's occupation and education, mother's education, and household economic status had a significant relationship with the level of food security.Also, from anthropometric indices in this study, only the height and weight of children showed a relationship with household food security.

Table 1 : Quantitative and Qualitative Characteristics of Participants Based on Food Insecurity a .
17., Mohammadzadeh et al., Danesh et al.).16According to the results of this study, there was a significant relationship between food insecurity and the employment status of the participant's father.In the studies of Mohammadzadeh et al. and Dastgiri et al.,17there was a meaningful relationship between employment status and food ** presented as Mean (SD) for quantitative variables and frequency (%) for qualitative variables ** calculated by Chi-Square or one-way ANOVA test; Significant at the 0.05 level