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Background: Existing evidence on the association between food insecurity and childhood obesity is mixed. In addition, literature from developing countries in general and Ethiopia in particular on the nexus and impact of household and child food insecurity on childhood obesity in the context of urbanization remains limited. The objective of this study was to explore the association between household and child food insecurity and childhood obesity in an urban setting of Ethiopia. Methods: An observational population based cross-sectional study was conducted in five sub-cities of Addis Ababa. Multi-stage sampling techniques were employed to identify the study unit from the selected sub-cities. Multivariable logistic regression models with robust estimation of standard errors were utilized to determine the associations. Interactions by age and sex in the associations explored were tested. Results: A total of 632 children and adolescents-parent dyads were included in the study. About 29.4% of those in food secure households and 25% of those in food insecure households were overweight/obese. Similarly, 29.8% of food secure children and 22% of food insecure children were overweight/obese. Household and child food insecurity status were not significantly associated with child and adolescent overweight or obesity in the final adjusted models. Conclusions: Household and childhood food insecurity status were not associated with child and adolescent overweight/obesity in the study setting. Interventions aimed at combating overweight and obesity in the study setting should target children and adolescents irrespective of their food security status.
The study was an observational population based cross-sectional study conducted in representative samples of mother and child pairs in Addis Ababa city administration. The study was carried out in selected sub-cities in Addis Ababa, Ethiopia; namely, Bole, Gulele, Kolfe Keranio, Nifasilk Lafto and Yeka. The source population was mother-child pairs at household level living in each sub-city during the study period. The study population was paired sampled school aged children with their mothers in the selected sub-cities. In this study, the following inclusion criteria were used to recruit participants: those children who are living with their mothers, those children who are in school aged (5 to 18 years old), mothers who can respond to the interviewer and school age children who lived in each of the sub-cities for at least 5 years. The exclusion criteria were: children who were permanently ill and the caregiver/mothers in a morbid state, severely ill (i.e. not able to provide the necessary information) and difficult to conduct or take any physical measurement (i.e. scoliosis and kyphotic deformities). The sample size was calculated using single proportions sample size formula by using Epi Info statistical package (Centers for Disease Control and Prevention, Atlanta, U.S.A., 2010). The following parameters were used to calculate the sample size: proportion of children who were overweight in the population (P) is 9.5% [17], 95% CI(α = 0.05)[Z-The standard normal value at (100% − α) confidence level], d- 3% of Margin of error for sampling and 80%(β = 0.20) power. This gave a sample size of 367. So, by adding 15% for non-response rate and design effect of 1.5, total sample size was 634.. Multi-stage sampling technique were conducted to identify the study unit from selected sub-cites. From each sub-city, proportion to population sampling was applied to obtain the sample size. Simple random sampling method was applied to select districts and Kebeles (smallest administrative unit in government structure) in each sub-city. One child was selected from single-child households, and in some instance random selection of one child was done when the number of children in household more than one. In this case, a child was selected randomly using lottery method. In case of non-attendance of a qualified child in selected household, the next household was considered. In this study, data were collected by a structured questionnaire originally developed in English. The content of the questionnaire included: socio-demographic characteristics (age and sex of child, age of mother, educational and occupational status of mother) and socio-economic indicators as well as household and child food security level. The tools were translated into Amharic and retranslated back to English by another expert to check and maintain its consistency. Data was collected by trained data collectors at home using standardized, structured and pre-tested tools. The quantitative study was conducted by interviewing mother-child dyads pair during data collection process. A team of data collectors with health professional background were recruited from the health facilities. Each team of interviewer was assigned in each selected sub-city, which consisted of one team supervisor, two females and two male interviewers. The supervisors oversaw the coordination aspect of data collection in sub-cities. One male and female interviewer was allocated per each household. Overall, 5 supervisors, 10 females and 10 male interviewers participated in the data collection process. Objective height and weight measurements were conducted. Weight measurements were obtained using lightweight, SECA mother-infant scales with a digital screen designed and manufactured under the guidance of The United Nations Children’s Fund (UNICEF). Height measurements were carried out using a measuring board in standing position. Weight and height of each child were measured after calibrating to the nearest 0.1 kg and 0.1 cm. In this study, height and weight measurements of children were converted into Z-scores based on WHO reference population considering their age and sex. The outcome variable used for analysis in this study was childhood overweight/obesity as a binary variable and defined as more than 1 SD above the median based on WHO growth reference [18]. Household food security was measured using the Household Food Insecurity Access Scale of the Food and Nutrition Technical Assistance Project (HFIAS/FANTA)/US Agency for International Development (USAID), which offers information on behaviour and insights linked to household food insecurity status – anxiety and depression, inadequate diet quality and insufficient food intake or reducing quantity of food consumed. The HFIAS is a continuous measure of the degree of food insecurity mostly related to access in the household. The 10 questions/items which assess the dietary status were asked for a 30-days period preceding the survey. The households were categorized into three groups: food secure, mildly and moderately food insecure and severely food insecure [19]. Children’s Food Security status was measured by 8 items in the Children’s Food Security Scale survey module. The module developed by adjusting questions from the household food security survey module for direct administration to children. If the response to the affirmative to question with a row score of ≥2 then it is categorized as child food insecure otherwise food secure [20]. Because numerous demographic and socioeconomic characteristics of child and parent are often related to children’s overweight/obesity status and can also be related to food security status, a priori defined potential confounders based on biological and statistical considerations, were included. These variables were: socio-economic status/wealth index(poorest, poorer, middle, richer and richest), household asset index, age group of the children and adolescents in year (5–9, 10–14 and 15–18); sex of children and adolescents (male and female); sex of household head (male and female); age group of the household head in years (< 40 and ≥ 40); maternal education (no-formal education (are those who are Illiterate) and formal education (those who were literate)); maternal occupation (unemployed, private business and employed); marital status of the mother (married, divorced, widowed and separated); household size (numbers) (< 5 and ≥ 5) and type of school the child attends (private and public). The age- and sex-specific body mass index z-scores (BMIZ) among children and adolescents were calculated using the World Health Organization (WHO) 2007 reference data. In this study, descriptive analyses were used to characterize the variables under investigation. Chi-square test was used to explore the association between overweight/obesity and child and maternal characteristics. Explanatory variables that showed an association at p < 0.2 in bivariate analysis were included in the final models. Multivariable logistic regression model with robust estimation of standard errors, accounting for the clustering at the level of sub-city, were fitted to determine associations. Interaction of age and sex in the associations explored was checked. Statistical significance was defined as P < 0.05. Data was entered by SPSS Version 21 and analysis carried out by Stata 15.0 (Stata Corporation, College Station, TX) and WHO Anthro Plus software v1.02 (WHO, Geneva, Switzerland). This study was conducted in accordance with the Declaration of Helsinki and all procedures involving human subjects were approved by the Institutional Review Boards of Departmental Higher Degrees Committee of the Department of Health Studies University of South Africa Ethical Clearance Committee for Research on Human Subjects (HSHDC/ 575/2016) and Addis Ababa City Administration Health Bureau (A/A/H/B/3542/227). Also, support letter was written from the University of South Africa Addis Ababa Regional Office to Addis Ababa City Administration Health Bureau. Official letters of co-operation from the above organizations were given to the respective sub-city and district administrator. Verbal informed consent was approved by the ethics committee of Departmental Higher Degrees Committee of the Department of Health Studies University of South Africa Ethical Clearance Committee for Research on Human Subjects and Addis Ababa City Administration Health Bureau. As well, verbal Informed consent was also obtained from each participant and confidentiality was assured. Additionally, for those children under the age of 18 years, verbal informed consent was obtained from their parents or caregivers. Assent was obtained from each participant.
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