INTRODUCTION:

Obesity is a major and rapidlygrowing global public health concern and is associated with significant morbidity and mortality in the past three decades⁽¹⁾. The last two decades have witnessed an increase in health care costs due to obesity and related issues among children and adolescents.

The world Health Organization (WHO) describe an escalating global epidemic of overweight and obesity “globosity” that is taking over many parts of world “if immediate action is not take, million will suffer from a serious health disorder.⁽²⁾

The rise in obesity has led to wide spread calls for regular monitoring of changes in overweight and obesity prevalence in all populations.

Childhood obesity is a global phenomenon affecting all socio-economic groups, irrespective of age, sex or ethnicity⁽³⁾. About 23.9 million children ages 2 to 19 are overweight or obese; 33.0% of boys and 30.4% of girls. Of these children, 12.7 million are obese; 18.6% of boys and 15.0% of girls⁽⁴⁾.

Obesity is now so common within the world’s population that it is beginning to replace under nutrition and infectious diseases as the most significant contributor to ill health. In particular, obesity is associated with diabetes mellitus, coronary heart disease, hyperlipidemia, certain forms of cancer, asthma, sleep-breathing disorders and osteoarthritis.

The global epidemic of obesity results from a combination of genetic susceptibility, increased availability of high-energy foods and decreased requirement for physical activity in modern society. Obesity should no longer be regarded simply as a cosmetic problem affecting certain individuals, but an epidemic that threatens global well being⁽⁵⁾. There is no single cause of all overweight and obesity. There is nosingle approach that can help prevent or treat overweight andobesity. Treatment may include a mix of behavioral treatment,diet, exercise, and sometimes weight-loss drugs. In some cases ofextreme obesity, weight-loss surgery may be an option⁽⁶⁾. The present study aims to Assess knowledge, attitude and practices about obesity among sample of students in secondary school in Baghdad city/Al-Karkhdistrict.

METHOD:

A cross sectional study involving 456secondary school students in Baghdad city/Al-Karkh district.The study was carried out at 6secondary schools (3 schools for each males and females) during the period of 1^st of January to the 30th of April, 2015. The study sample was adolescents between the ages of 16 to 19 years. A sample of classes from each school from 4^th to 6^th class were chosen. All the students within each class were enrolled (convenient sample). The questionnaire forms were distributed to the 456 secondary school pupils. The instructions were given by the investigator and the way of filling the questionnaire forms was unified. The pupils themselves completed filling the questionnaire form. After completion of filling the questionnaire, each pupil handed it over to the investigator who then measured the weight (by a wheel type scale), (buerer GS 205 sequence ,with 150 kg capacity ,made in Germany) the pupil stands with minimal movement with hands by their side. Shoes and excess clothing removed, and height (by a tape measure) of each pupil in turn and wrote it on the pupil's own questionnaire form. The weight scale was standardized after each weighing process to the zero score and after each school visit with a standard weight scale. By using the equation of BMI [ weight (kg) height (m²)] and according to the WHO growth charts⁽⁷⁾, the students were classified into underweight, normal weight, overweight and obese .Inclusion criteria of present study were adolescents aged 16-19 years from 4^th to 6^th secondary classes who were attending the schools involved in this study, and Exclusion criteria were adolescents who have history of chronic diseases (heart diseases, diabetes mellitus, asthma, and epilepsy) and students whose their age less than 16 years and more than 19 years were excluded from the study. The questionnaire assesses knowledge, attitude and practice among secondary school students toward obesity; it included 4 partswhich are socio- demographic characteristic, 16 questions about knowledge, 3 questions about attitude and 11 questions about practice. Knowledge questions and score were detected by each correct answer is given a mark , total score for maximum correct answers was (16). The students were asked about sources of information about obesity they heard from (internet/TV- doctors /health workers– friends / families).

Practice questions and score:

the accumulative score for the positive practice in threequestions of themis one mark for each correct answer and the other eight questions about practiceare given double marks as maximum score, total score for maximum correct answers is (19). The statistical analysis of this cross sectional study performed with the statistical package for social sciences (SPSS) 21.0 and Microsoft Excel 2013. Categorical data formulated as count and percentage. Chi-square test used to describe the association of these data. Numerical data were described as Median, mean, standard error of mean and standard deviation. Mann-Whitney test used for comparison between two groups. The lower level of accepted statistical significant difference is or equal to below0.05.

RESULTS:

The results show that 456 adolescents were includedin this study,distribusions of the students according to the genderandthe level of class are shown in figure1 and 2 respectively.

Figure 1:Distribution of the students according to gender .

Figure 2:Distribution of the students according to level of class .

Table (1) shows the distribution of gender according to BMI groups. 33.3% of females were overweight and 33.8% of males were over-weightwhile 11.9% of females and 15.6% of males were obese, with significant difference (p=0.006)

Table 1:Distribution of the students according to the BMI and gender.

		Underweight	Normal	Over weight	Obese	Total
Gender	Female	9	111	73	26	219
	%	4.1%	50.7%	33.3%	11.9%	100.0%
	Male	27	93	80	37	237
	%	11.4%	39.2%	33.8%	15.6%	100.0%
Total	Total	36	204	153	63	456
Total	%	7.9%	44.7%	33.6%	13.8%	100.0%
P value		0.006

Table (2) shows thedistribution of the students according to the body weight and class with significant association ( p=<0.001) being that , about (58 %) of the forth class students were overweight and obese while about (32 %) of the sixth class students were overweight and obese.

Table 2: Distribution of the students according to the BMI and class.

		Underweight	Normal	Over weight	Obese	Total
Class	4^th	23	50	76	25	174
	%	13.2%	28.7%	43.7%	14.4%	100.0%
	5^th	9	73	41	33	156
	%	5.8%	46.8%	26.3%	21.2%	100.0%
	6^th	4	81	36	5	126
	%	3.2%	64.3%	28.6%	4.0%	100.0%
Total	Total	36	204	153	63	456
Total	%	7.9%	44.7%	33.6%	13.8%	100.0%
P value		<0.001

The students perception about obesity was that; 376 (82.46%) students believed that obesity is a disease, 402 (88.16%) thought that obesity lead to negative effect on health, while 332 (72.81%) students thought that there is a difference between overweight and obesity, 437 (95.83% ) students thought that people with overweight should loss their weight and 271 (59.43%) students believed that only obese people should loss their weight as shown in ( table 3) .

Table 3: Response of the student to the interview item regarding general knowledge about obesity.

Response	No.	%
Normal weight is important	426	93.42%
Obesity is a disease?	376	82.46%
There is a difference between overweight and obesity?	332	72.81%
People with overweight should loss their weight?	437	95.83%
Only obese people should loss their weight?	271	59.43%
Obesity leads to negative effect on your health?	402	88.16%
Obesity causes psychological upset and awkwardness with friends, family and colleagues?	305	66.89%

Regarding the methods of diagnosis of obesity and overweight , 306 (67.1 %) students mentioned that , they must depend on the weight and height , while 131(28.7 5) students thought that ,they could diagnose obesity and overweight by depending only on weight without reference to height and only 19 (4.2 %) students mentioned that they could diagnose obesity and overweight by depending only on appearance , as shown in (table 4) .

Table 4: Method for diagnosis of obesity and overweight.

Response By depending on	No.=456	100%
height and weight	306	67.1%
weight without reference to height	131	28.7%
Appearance	19	4.2%

As regarding the causes of obesity and overweight; eat too much fat was mentioned by 414 (90.8 %) students, 314 (68.9 %) eat too much sweet, 315 (69.1%) insufficient physical activity while only 65 (14.3%) students mentioned that eat too much fruit and vegetable can cause obesity, as in ( table 5).

Table 5: Causes of obesity and overweight.

response	No.	%
Eat too much fat?	414	90.8%
Eat too much sweet?	314	68.9%
Eat too much fruit and vegetable?	65	14.3%
Psychological upset?	238	52.2%
Insufficient physical activity?	315	69.1%
Drugs and disease?	109	23.9%

In ( table 6), 305 (66. 9%) students preferredeating inside home while 151 (33.1%) students preferred eating outside home and 60 (39.7 %) of those who preferred eating outside were because it is something enjoyable with friends, 52 (34.4 %) its convenient for them, 29 (19.2%) students mentioned that it test better ,while 10 (6.6%) students mentioned that their families not cock much or well .

Table 6: Attitude of student accordingto preference of place of eating .

Response	NO.=456	100%
Inside home	305	66.9%
Outside home	151	33.1%
Outside home		No=151	100%
What influence your decision to eat outside	it’s usually something enjoyable with friends.	60	39.7%
	It’s convenient for me.	52	34.4%
	my parent don’t cock much or well.	10	6.6%
	it taste better than anything at home.	29	19.2%

About half of the participants showed a good practice regarding vegetable and fruits consumptions, 229 (50.2 %) adolescents ate vegetable and fruit more than 3 times in the last week ,regarding sugary drinks consumption 306 (67.1%) students drank more than 3 times in the last week, while no one didn’t drink any type of sugary drinks at all in the last week. About 30 % of the total sample never ate their breakfast in the last week, as in (table 7).

In (table No. 8), 72(15.8%) students did exercises more than 3 times in the last week, 201 (44.1%) students did exercises 3 times and less in the last week and of those who exercised 163 (59.7%) students did exercises for less than 30 minutes and 110 (40.3 %) students did exercises more 30 minutes.

In this study the mean knowledge score for the students was 11.55 of 16 with minimum = 5 and maximum =16 while the mean practice score was 12.39 of 19 with minimum =3 and maximum = 19 as shown in( table 9).

The students in the 6^th class were significantly had a good knowledge regarding obesity and overweight more than the other classes also the practice had a significant variation and the highest score (13.26 ) was in the 5^th class , as shown in ( table 10).

Knowledge score has significant variation with gender (0.004) while Practice score has a significant variation with gender (0.003) as shown in table 11.

Table 7: Practice of student according to some dietary habit .

Response	More than 3 times	%	3 times and less	%	Never	%
How much time you eat your breakfast in the last week?	138	30.3%	182	39.9%	136	29.8%
How many times you eat your dinner in the last week?	275	60.3%	168	36.8%	13	2.9%
How many times you eat vegetable and fruit in the last week?	229	50.2%	193	42.3%	34	7.5%
How many times you drink *sugary drinks in the last week ?	306	67.1%	150	32.9%	0	0

*Sugary drinks; all beverage drinks including carbonated soft drinks .

Table 8:Response of the students according to exercise .

Response	More than 3 times	%	3 times and less	%	Never	%
How many times you exercised in the last week?	72	15.8%	201	44.1%	183	40.1%
And for how long?	Less than 30 min			More than 30 min
And for how long?	163	59.7%		110	40.3%

Table 9:Knowledge and practice scores for the students about obesity .

	Minimum	Maximum	Mean	Standard Deviation	Median	Percentile 05	Percentile 95
Knowledge	5	16	11.55	2.16	12	7	14
Practice	3	19	12.39	2.80	13	7	16

Table 10:Knowledge and practice scores of the students about obesity according level of the class.

	Level of class	Min.	Max.	Mean	SD.	Median	Per. 05	Per. 95	P value
Knowledge	4^th class	5	16	11.32	2.29	12	6	14	0.003
	5^th class	6	15	11.41	2.15	11	7	14
	6^th class	5	15	12.12	1.83	12	9	15
Practice	4^th class	6	18	11.62	2.63	12	6	15	<0.001
	5^th class	7	19	13.26	2.85	14	8	18
	6^th class	6	18	12.51	2.41	13	7	16

Table 11:Knowledgeand practice scores of the students about obesity according to gender.

Knowledge	Gender	Min.	Max.	Mean	SD.	Median	Per. 05	Per. 95	P value
	Female	6	15	11.85	2.03	12	7	14	0.004
	Male	5	16	11.27	2.24	11	7	15	0.004
practice	Female	6	18	11.98	3.01	12	6	16	0.003
practice	Male	3	19	12.76	2.53	13	9	17	0.003

DISCUSSION:

In this study, and according to WHO categorization overweight and obesity were identified using the growth chart for BMI of children and adolescent 5-19 years accordingly, approximately 47.4% of the studied subjects were overweight and obese, 33.5%were overweight, while in a study in Erbil ⁽⁸⁾ , the percentage of overweight was 21.4%. While in Musaiger study⁽⁹⁾ done in middle east the prevalence of overweight reported in Bahrain was (38.5%), Kuwait, with a rate of 31.8%,and the prevalence of overweight reported from the Islamic Republic of Iran was (27.7%). These results were approximately agree with result of our study . The rate of obesity in our study was 13.75% this frequency was much higher than what had be found in Erbil in which 6.5 % of the adolescents were obese⁽¹⁰⁾.

In our study the percentage of obesity is higher among males than females (male 15.6% female 11.9 %) this agrees with the results of Erbil study in which the rate of obesity for males was (7.6 %) while for females was (5.6% )⁽¹⁰⁾ , this may reflect that the female especially in this age group take care for their body shape more than male .

The highest percentage of obesity in this study is noticed in 5^th class (21.2%), while in the 4^th class was (14.4%) and the less was the 6^th class which was (4%) , there is no another study that classify the obesity according to the classes.

Regarding the knowledge of the study participants about obesity, the current data showed that (82.4%) of the students considered obesity as a disease, (88.1%) of the students mentioned that ;obesity could have a negative effect on health, (66.8%) students considered obesity a cause for psychological problems and awkwardness with friends and family ,this agree with Rehman et al study in which 90% of the adolescents knew that being overweight and obese was harmful to health and lead to psychological and social complications⁽¹¹⁾.

Regarding the causes of obesity about (90%) of students agreed that eating excessive fat can lead to obesity and about (69%) of students mentioned that eating excessive sweet and insufficient physical activity can lead to obesity while for psychological upset and for drugs and disease , students responded by about (52%) and (24%) for each cause respectively ,only (14.3%) of students wrongly agreed that fruit and vegetable can lead to obesity, regarding insufficient physical activity (70%) and eating excessive fruit and vegetable (17%) and also agreed with Brenda Gable study⁽¹²⁾ in Jordan in 2014 regarding psychological upset (54 %) .In Rehman et al study⁽¹¹⁾only (77 %) of students mentioned that excessive fat eating can lead to obesity and for drugs and disease (59%). About (33%) of the students prefered eating outside home this frequency was much higher than what found in Carmen studywhich was about only (6.5%) of students⁽¹³⁾. This discrepancy in the results may be due to delivery home service of fast food so not necessary to eat outside home,and when the students were asked about the causes that influence their decision to prefer eating outside , (39.7%) of them mentioned that ; it’s usually something enjoyable to do with their friends, ( 34.4%) responded that It’s convenient for them, (19.2%) said it taste better than anything at homeand only (6.6%) their parents don’t cock much or well .

As regard practices related to obesity, the present results showed that about (40%) of the students were never practicing exercise while in Penny study about (33%) of African American adolescent were never practicing ⁽¹⁴⁾ .More than (15%) exercised regularly (3 times and more per week) these result disagrees with result of Mosleh et al which was (37.2%) students doing exercise regularly more than 3 times a week⁽¹⁵⁾, the reasons for this mismatch in the results between these studies may be due to that, few parks or open areas that are free for student to be physically active , neighbourhood is not safe, the students parent or family don’t exercise and their school doesn’t offer physical educational class.

From those who exercised, (59.7%) students exercised for less than 30 minutes and (40.3%) exercised more than 30 minutes per day while in Rachael study in Australia (2015) found that; (82%) were engaging in less than 30 minutes of physical activity per day⁽¹⁶⁾and in Hae-Jeung et al study (36.5%) adolescent did regular exercises >30 min for more than 3 days per week⁽¹⁷⁾, observed data from adolescent that have looked at the importance of total physical activity show a generally consisted finding that total physical activity decrease the risk of overweight and obesity .There is also evidence of dose response effect and more often report on inverse association between total physical activity and weight gain⁽¹⁸⁾. As regards to frequency of some dietary habit the data shows that, students who having breakfast more than 3 times per week were (30.3%) , having dinner more than 3 times per week ( 60.3%) ,eating vegetable and fruit were (50.2%), while in Carmen studyin Romania (2014) was (75 %) of adolescent drink soft drinks daily⁽¹³⁾ this give us a good interpretation about practice of the student in secondary school, this percentage (67%) may reflect that a high amount of sugary drinks were consumed by the students ,increase in the consumption of sugary soft drinks was significantly associated with greater weight gain and greater risk of obesity over time in both children and adults. Vasantiet al study⁽¹⁹⁾found significant associations between the intake of sugar-sweetened beverages and weight gain,consumption of sugar-sweetened beverages, particularly carbonated soft drinks, may be a key contributor to the epidemic of overweight and obesity. About (70%) of the students either never or less than 3 times per week they take their breakfast , Deshmukhet al study⁽²⁰⁾ shows that Skipping breakfast was associated with a significantly higher risk of obesity and energy intakes by frequent snacking tended to be greater on days when subjects reported skipping breakfast. In general the mean of knowledge of the students about obesity was (11.55 ) where the mean of practice of the students was (12.39 ).

Relation of knowledge and practice score to gender and class level:

Knowledge test score mean of the students in the study has significant variation with level of the class , the highest score was for 6^th class and then for 5^th class ,the least score was for the 4^th class this may be due to increase information about obesity and its effect on health with progration of level of the class , knowledge test score mean of the students in the study has significant variation with the gender ,the highest for the female this may indicate that female take more care of their body shape , general look and more concerned about fashion and design by giving more attention to the information from her friends and her relatives and family internets. Also practice score significantly varied (0.003) regarding gender that highest score was for male this may be the boys spent more time outside home doing more activity than girls like going to gym or playing football .In conclusion The students had a good knowledge and practice regarding obesity and overweight, with significant variation with gender and level of the classes, so we recommend that the primary health centre, including doctors and health staff should take more active role in education of pupils to increase their knowledge in all domains of obesity related knowledge and to improve their attitudes, and Make legislations that empower the school health program staff about the quality of food in the cafeteria of school, with limitation of unhealthy food and beverage .

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Received on 27.09.2017 Modified on 09.01.2018

Research J. Pharm. and Tech 2018; 11(4): 1649-1654.

DOI: 10.5958/0974-360X.2018.00307.4