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Keywords:

  • BMI;
  • childhood adiposity;
  • migration;
  • overweight

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Objective  The objective of the study was to analyse prevalence of overweight and obesity among migrant girls in Vienna, Austria, starting at the age of 6 years up to the age of 15 years.

Design  In a longitudinal study, the prevalence of overweight and obesity among migrant girls from Turkey and former Yugoslavia was documented and compared with that among Austrian girls in Vienna.

Setting  Medical investigation of medical school authority in Viennese schools.

Sample  Seven hundred and ninety girls of low socio-economic status were included in the study.

Methods  Anthropometric data were collected at the age of 6, 10 and 15 years. Body mass was estimated by means of the body mass index (BMI), and percentile curves were used for determining the weight status.

Main outcome measure  Stature, body weight, BMI, weight status.

Results  The prevalence of overweight and obesity was significantly higher among migrant girls at all age groups. The highest percentage of overweight was found among 10-year-old girls from Yugoslavia (nearly 35%) and the lowest percentage of overweight was exhibited in 6-year-old Austrian girls (20%). Being overweight or obese at the age of 6 years increased the risk of being overweight at 10 and 15 years significantly (P < 0.001). Among migrants, this risk was significantly higher than among Austrian girls (P < 0.001). Only 64.8% of Austrian girls, who were overweight/obese at the age of 6 years, were still classified as overweight at the age of 15 years. Among migrant girls, who were overweight at the age of 6 years, 72.0% (Turkish girls) and 78.3% (Yugoslavian girls) remained overweight until the age of 15 years.

Conclusions  Especially girls from former Yugoslavia but also Turkish girls exhibited high rates of overweight and obesity. Prevention should start as early as possible since overweight tends to persist from childhood into adolescence.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The incidence of obesity has been rapidly increasing during the past decades and poses a significant health problem in nearly all industrialised countries. Unfortunately, obesity begins long before adulthood and results in social stigmatisation of obese children and may have deleterious social and economic consequences.1,2 Childhood obesity is also acknowledged to be an increasingly strong predictor of adult obesity. Approximately one-third of obese adolescents are predicted to be obese as adults.3 There are also implications for long-term health and longevity: childhood obesity is one of the most important risk factors not only for hypertension, diabetes mellitus or abnormal lipid profiles4,5 but also for psychic and emotional morbidity in later life.2 The Harvard Growth study, for example yielded an increased risk of coronary heart disease, colon cancer and arthritis among men and women who had been overweight adolescents.6 Among female adolescents, obesity is also discussed to have an impact on gynaecological health during adulthood.7 Therefore, it is of special interest to define causes and risk factors of this dramatic rise in overweight and obesity in industrialised countries. Besides genetic factors,8 obesity seems to be largely caused by an environment that promotes excessive food intake and discourages physical activity.9 However, the impact of sociocultural parameters should not be underestimated. From a social point of view, minority group status, low socio-economic status or to be a migrant seem to be important risk factors to develop overweight or obesity during childhood, resulting in all long-term consequences mentioned above.10 Therefore, the aim of this longitudinal study was to analyse prevalence of overweight and obesity among migrant girls in Vienna, Austria, starting at the age of 6 years up to the age of 15 years.

Materials and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Data set

Data collection took place in strong co-operation with the Viennese school medical authority. Forty-six public schools of Vienna (two from each of the 23 districts of Vienna) were randomly selected from the Viennese school authority to participate in the present project. In Austria, it is obligatory that besides medical data, data regarding stature height and body weight of all school children were collected by special educated personal of the medical school authority. Stature was measured with an anthropometer to the nearest millimetre. Weight was recorded with a scale precise to ±100 g. The children and adolescents were measured without shoes and wearing only underwear. The first examination takes place at the age of 6 years before the child starts with school. The second examination takes place 4 years later, when primary school is finished at the age of 10 years. The third and last examination takes place at the age of 15 years, short before the school attendance ends. The data files including all information concerning stature and body weight but also some socio-economic data are stored by the Viennese school medical officers. We were allowed to use these data of the Viennese school medical office. We decided to include only complete data sets and exclude all children, whose data sets are incomplete from the analyses. Altogether, we got data sets of 790 girls, all of them started with school in 1994. The birth year of all of them was 1988.

Ethnicity and migrant status

It is very difficult to define migrant status because different definitions to identify a migrant are used.11 In the present study, only children of the first-generation or second-generation immigrants were included. Both parents had to be born in their origin country. All subjects started with school in Austria, although some of them had immigrated to Austria after their birth. The data set was divided into three subsets according to the ethnicity of the subjects. Group 1 comprised 339 girls from Austria. All of them were born in Austria and were Austrian citizens, this was also true of their parents. Group 2 comprised 191 girls from Turkey. Although the majority of them were born in Austria, all of them lived in traditional Turkish immigrant families of the first or second generation. The third group comprised 260 girls who originated from countries of former Yugoslavia (Serbia, Bosnia-Herzegovina, Croatia and Macedonia). More than half of this children were born in Austria; however, all families had still immigrant status. Only migrant girls from Turkey and former Yugoslavia were included in the analyses because the great majority of migrants in Austria originated from these countries. Therefore, all probands were Caucasians, so no major population differences between the proband groups exists. This fact is of special importance for the further analyses because the same body mass index (BMI) classification criteria were used for all probands.

Socio-economic status of the probands

Social status was estimated by educational level of the girls, parental educational level, parental employment status and family size. Only girls visiting public secondary schools in Vienna were included in the present analyses. The attendance to a public secondary school (Hauptschule) is a main indicator for a low socio-economic status and a low educational level of the parents in Vienna (Viennese school authority, pers comm). This information was corroborated by the present data. Regarding parental educational level, it turned out that none of the parents had more than 12 years of education. Only 2.3% of the parents had more than 9 years of education. The great majority of parents worked as unskilled workers (80.2%). The percentage of unemployed fathers depending on government assistance was extraordinary high with 15.6%. Only 34.3% of Austrian and Yugoslavian mothers were unemployed. This was true for 74.1% of the Turkish mothers. Household size varied between 2 and 12 persons. Unfortunately, it is not possible to collect any data regarding family income from Austrian pupils because such kind of data collection is forbidden by Austrian school authority. Nevertheless, from the data collected for this study, it can be assumed that all subjects belong to the same social class, the lower social strata of Vienna. Unfortunately, it was not possible to get comparable data from Austrian and immigrant children with a higher socio-economic status.

Classification of the weight status

Weight status was determined using the BMI (kg/m2). Although the BMI is increasingly used for the diagnosis of obesity, overweight and underweight in childhood and adolescence, up to now, there is a lack of European standards.12 For optimal weight status monitoring, up-to-date reference data on representative samples from the population are necessary. In a city with a high percentage of immigrants like Vienna, the dilemma is whether one should use BMI references derived from a representative sample from the whole multi-ethnic population or use a BMI reference for the ethnic Austrian and appropriate reference data on the largest ethnic groups living in Vienna. Unfortunately, appropriate BMI reference data exist neither for the Austrian population of Vienna nor for immigrant one. Since all three subsamples of the present study comprised only Caucasians living in Central Europe, the authors decided to use the percentiles of the BMI published by Kromeyer-Hauschild et al.13 for Central Europe. The authors are aware that the optimum BMI for any population is that associated with the lowest mortality rate and the use of the BMI curves published by Kromeyer-Hauschild et al. may be interpreted as incorrectness. However, we assume that the recommendations by Kromeyer-Hauschild et al.13 and the European Childhood obesity group14 to use the 10th percentile was used as cutoff for underweight, the 90th percentile as cutoff for overweight and the 97th percentile as cutoff for obesity, may fit to all Caucasian children and adolescents living in Central Europe.

Statistical analyses

Statistical analyses were carried out by means of SPSS (program version 11.0; SPSS Inc., Chicago, IL, USA). Since the Kolmogoroff–Smirnov test indicated that a normal distribution of the data could be assumed, for statistical analyses, parametric tests were applied. After computing descriptive statistics (mean, SD, range), group differences were tested with regard to their statistical significance using one-way analysis of variances (Duncan analyses) and chi-square test (crosstabs). Furthermore, odds ratios and 95% confidence intervals were calculated. Additionally, binary logistic regression analyses were performed.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Anthropometrics

As shown in Table 1, significant ethnic differences in stature, body weight and BMI were observed for each age class. Especially girls from former Yugoslavia were taller and heavier at all age groups than their counterparts from Austria and Turkey. Regarding the BMI, Yugoslavian girls surpassed Austrian and Turkish girls at the age of 6 and 10 years; at the age of 15, however, Turkish girls exhibited the highest BMI.

Table 1.  Stature, body weight and BMI according to age and ethnicity
 AustriaTurkeyFormer YugoslaviaSignificant P value
Mean (SD)Mean (SD)Mean (SD)
Stature (cm)
6 years119.8 (6.2)119.9 (6.7)121.8 (6.8)<0.01
10 years141.4 (7.9)141.2 (7.8)143.5 (7.9)<0.01
15 years162.3 (7.1)159.7 (6.4)162.3 (6.1)<0.001
Body weight (kg)
6 years23.3 (4.9)23.9 (4.7)25.4 (6.9)<0.001
10 years37.9 (9.9)38.4 (9.1)40.9 (12.3)<0.01
15 years58.2 (12.7)57.3 (10.8)59.2 (13.1)n.s.
BMI (kg/m2)
6 years16.12 (2.52)16.54 (2.09)16.93 (3.21)<0.01
10 years18.78 (3.88)19.11 (3.46)19.64 (4.57)<0.05
15 years22.01 (4.32)22.42 (3.86)22.41 (4.44)n.s.

Weight status

Regarding the weight status, marked ethnic differences were observable: immigrant girls in every age group showed higher percentages of overweight and/or obesity in comparison with their Austrian counterparts (Table 2). At the age of 6 and 15, the differences were of statistical significance (chi-square = 12.67, P < 0.05 and chi-square = 12.55, P < 0.05, respectively). Even the Austrian children showed high levels of overweight and obesity. At the age of 6 years, 20% of the girls correspond to the definitions of overweight or obesity (BMI above the 90th percentile). At the age of 10 and 15 years, this was true for nearly 25% of the Austrian girls. Although the percentage of overweight and obesity is generally high even in the Austrian part of present sample, the risk to be overweight or obese is higher among Turkish or Yugoslavian girls.

Table 2.  Weight status (BMI percentiles) according to age, sex and ethnicity
 AustriaTurkeyFormer Yugoslavia
6 years
Underweight (%)10.13.15.1
Normal weight (%)69.872.068.0
Overweight (%)9.312.510.9
Obese (%)10.812.416.0
10 years
Underweight (%)8.15.55.5
Normal weight (%)66.064.659.9
Overweight (%)15.416.515.4
Obese (%)10.413.419.2
15 years
Underweight (%)6.83.15.0
Normal weight (%)69.370.266.9
Overweight (%)15.314.214.6
Obese (%)8.612.513.5

Socio-economic parameters and weight status

As to be expected, parental educational level and parental employment status had no significant impact on the weight status of the girls in the present sample because the socio-economic situation of the whole sample was homogeneous. This was also true of the household size.

Longitudinal observations

As shown in Figures 1–3, weight status at the age of 6 years had a marked impact on the weight status at the age of 10 and 15 years (P < 0.001). Only 64.8% of Austrian girls, who were overweight/obese at the age of 6 years, were still classified as overweight at the age of 15 years. Among migrant girls, who were overweight at the age of 6 years, 72.0% (Turkish girls) and 78.3% (Yugoslavian girls) remained overweight until the age of 15. Overweight or obesity at the age of 6 years represented a special risk to be overweight or obese at the age of 10. At the age of 15 years, this effect was lower than at the age of 10 years; however, childhood obesity was still an important risk factor for the maintenance of obesity. This trend was true for all three ethnic groups (Table 3). The binary logistic regression analyses corroborated these results. Weight status at the age of 10 years was influenced significantly by the weight status at 6 years and ethnicity. Weight status at 15 years was influenced by the weight status at 6 years, the weight status at 10 years and ethnicity (Table 4).

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Figure 1. Weight status changes in the Austrian sample.

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Figure 2. Weight status changes in the Turkish sample.

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Figure 3. Weight status changes in the Yugoslavian sample.

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Table 3.  Relative risk to be overweight at the age of 10 and 15 years of overweight children at the age of 6 years in comparison with children of normal weight at the age of 6 years
Age (years)Austrian girlsTurkish girlsYugoslavian girls
OR (95% CI)OR (95% CI)OR (95% CI)
103.42 (1.69–6.91)4.78 (2.72–8.36)6.04 (2.86–12.77)
152.49 (1.73–3.59)2.87 (1.52–5.43)3.93 (2.26–6.83)
Table 4.  Binary logistic regression analyses (1 = normal weight; 2 = overweight)
 CoefficientSignificance (P value)95% CI
Weight status at the age of 10 years
Weight status at the age of 6 years3.340.00116.38–48.64
Ethnicity0.290.051.01–1.75
Weight status at the age of 15 years
Weight status at the age of 6 years1.580.0011.66–8.81
Weight status at the age of 10 years2.290.015.62–17.24
Ethnicity0.280.050.93–1.69

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Migration within Europe is an continuing social phenomenon of large scale, which affects the health of the individual migrants and also that of the populations.15 Although Austria cannot be considered as a typical country of immigration, such as the USA or Canada, since the 1960s, thousands of people have migrated to Austria.16 The vast majority of these immigrants came from Turkey and former Yugoslavia. Up to now, migrants are a minority, often with a lower social status than the host population.16 This low socio-economic position and minority status are frequently associated with increased chronic distress, a higher morbidity and an increased mortality rate.11,17,18 As special health problem of migrants, a high prevalence rate of overweight and obesity, especially among women and children or adolescents, was documented.11,16,19 Although overweight and obesity are becoming increasingly prevalent nearly all over the industrialised world at the beginning of the third millenium,20 to be migrant seems to represent a special risk factor for developing overweight or obesity, especially during childhood and adolescence.11,21–24 In Central and Northern Europe, a high prevalence of childhood and adolescence obesity was mainly found among migrants originating from Mediterranean countries, such as Italy, Turkey or Morocco.11,22,24 The results of the present study corroborate these observations: the percentages of overweight and/or obesity were significantly higher among migrant girls at all age groups. Especially girls from former Yugoslavia showed a high prevalence of overweight. At the age of 10 years, nearly 35% of the Yugoslavian girls were classified as overweight or obese. Although the percentage of overweight or obese Austrian girls was also extraordinary high ranging from 20% at the age of 6 up to 25% at the age of 10 years, the prevalence of overweight and obesity was markedly higher among the migrant group. Instead of ethnicity-associated differences in social status, no marked differences in the socio-economic situation was observable between the three ethnic groups considered in the present study. The educational level of children and their parents was rather low. The great majority of parents were classified as unskilled workers and more than 15% of the fathers were unemployed and depended on governmental assistance. No significant differences in paternal educational level and employment status was documented between the three ethnic groups. Therefore, socio-economic factors cannot be assumed to be responsible for these differences between the ethnic groups because all children belonged to the lower socio-economic stratum of Vienna. Within the present sample, household size, parental educational level and paternal employment status had no impact on weight status. This may be explained by the fact that socio-economic differences within the whole sample were minimal. Recently, a low social or socio-economic status are declared to be among the major risk factors for developing overweight during childhood.10,25 Ethnicity seems to be an independent risk factor for developing overweight because cultural factors seems to play an important role in its aetiology. Nutritional habits and activity patterns are highly influenced by culture and religious components.23,26–28 High-energy diet on the one hand and reduced physical activity characterised by long-time watching of TV29 on the other hand seemed to be the main reason for the high levels of overweight and obesity among migrant children observed in several European countries.11,22,24 The especially high levels of overweight and obesity among migrant girls documented in the present study are in accordance with the observations described in the studies above. Obesity among adolescent girls has also a profound impact on gynaecological health and fertility.30,31 Obesity and especially increased abdominal body fat are frequently associated with infertility, hyperandrogenism, menstrual disorders and ovulatory dysfunction.32 Especially the polycystic ovary syndrome (PCOS), the most frequent endocrine cause of infertility, is found predominantly among overweight females, even during adolescence.33,34 Therefore, overweight during adolescence is also discussed as one important cause for ovulatory dysfunction and infertility during adolescence and adulthood.35 On the other hand, childhood obesity often predicts obesity during adulthood. In the present sample, overweight or obesity at the age of 69 years increased the risk to remain overweight or obese during adolescence. This was especially true for migrant girls. During adulthood, obesity is an important risk factor during pregnancy and birth.36,37 It is well documented that maternal obesity is associated with higher rates of maternal complications, pre-eclampsia, caesarean delivery and neonatal complications because obese women suffer higher rates of type II diabetes and gestational diabetes and tend to deliver macrosome offspring.38 These obesity-associated fertility disorders and pregnancy complications may lead to various psychosocial problems especially for migrant women from Islamic societies such as Turkey. The social pressure to have children shortly after marriage is high, even among migrants in Austria.39 Involuntary childlessness leads to psychic disturbances, negative self-perception and various psychosomatic problems. Being a mother is essential for the female sex role and childlessness is regarded a disgrace.39 In case of PCOS, a weight reduction of at least 10% can improve the hormonal profile and clinical manifestations of PCOS; however, weight loss is difficult to achieve and even more difficult to maintain, especially among migrant girls and women. Postmenarcheal migrant girls often underlie strict cultural and religious pressures, characterised by extremely low physical activity outside the household. Ethnicity has a profound impact on weight status development between the age of 6 and 15 years. While only 64.8% of the overweight Austrian girls remain overweight until the age of 15 years, this was true for 72.0% of the Turkish girls and for 78.3% of the Yugoslavian girls. One special problem is the fact that neither the migrant children and adolescents by themselves nor their parents are worried about their high weight status. This may be due to the fact that up to now, overweight in Turkey or former Yugoslavia is a phenomenon predominantly found in social middle and high-income class.40 This leads to a culturally positive interpretation of overweight, which is not seen as an important long-time health risk. Overweight and obesity are therefore not only medical problemsbut are also biosocial and cultural problems. In the future, health professional should consider these biosocial and cultural factors in their concepts and prevention should start as early as possible41 because overweight seems to persist from childhood up to adolescence.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The authors are gratefully indebted to the Viennese school medical authority (Dr Lucius and her team) for their kind co-operations and help.

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  2. Abstract
  3. Introduction
  4. Materials and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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