Prevalence of Overweight/Obesity and Associated Factors Among Under-Five Children in Ethiopia: Evidence From the 2019 Ethiopia Mini Demographic and Health Survey (Emdhs); A Multilevel Analysis

Background: Childhood overweight and obesity are emerging public health challenges of the 14 21 st century. There was a 24% increase in the number of overweight children under the age of 15 five years in low-income countries. Despite the significant risk of childhood 16 overweight/obesity for non-communicable diseases, premature death, disability, and 17 reproductive disorders in their adult life, little attention has been given. Therefore, we aimed 18 to assess the prevalence of overweight/obesity and associated factors among under-five 19 children. 20 Methods: This study was conducted using data from a nationally representative sample of the 21 2019 Ethiopia Mini Demographic and Health Survey (EMDHS). The Mini EDHS was a 22 community-based cross-sectional study that covered all the administrative regions of Ethiopia. 23 The data collection was conducted between March 21, 2019, to June 28, 2019. Both descriptive and analytic findings were produced using STATA version 14. For associated factors, a 25 multilevel binary logistic regression model was fitted to account for the hierarchical nature of 26 the data. Adjusted odds ratio (aOR) with 95% confidence interval (CI) was reported to show 27 the strength of association and statistical significance. 28 Results: A total 5,164 under-five children were included in this study. The overall prevalence 29 of overweight/obesity was 2.14 % (95% CI; 1.74-2.53) (more than two standard deviations 30 (+2SD) above the median of the reference population) based on the body mass index (BMI) Z- 31 score. The odds of overweight/obesity was higher among children aged less than 6 months 32 (aOR= 5.19; 95%CI: 2.98-9.04), 6-24 months (aOR = 1.97; 95%CI: 1.18-3.29), delivered by 33 caesarean section (aOR = 1.75; 95% CI: 1.84-3.65), living in Addis Ababa city (aOR = 2.16; 34 95%CI: 1.59-7.81), Oromia region (aOR = 1.93; 95CI: 1.71-5.24), having mothers with the age 35 40-49 years (aOR = 3.91; 95%CI: 1.90-16.92), uses traditional contraceptive methods (aOR = 36 2.63; 95%CI: 1.66-10.47), and households headed by male (aOR = 1.71; 95%CI: 1.84-3.48). 37 Conclusion: This study showed that childhood overweight/obesity is the problem in Ethiopia. There was an interplay of several factors that affect childhood obesity including child factors, maternal socio-demography, and healthcare utilization, and geography of residence. Therefore, strategies to reduce childhood overweight and obesity should consider a multitude of 41 contributing factors.

and analytic findings were produced using STATA version 14. For associated factors, a 25 multilevel binary logistic regression model was fitted to account for the hierarchical nature of 26 the data. Adjusted odds ratio (aOR) with 95% confidence interval (CI) was reported to show 27 the strength of association and statistical significance.

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Results: A total 5,164 under-five children were included in this study. The overall prevalence 29 of overweight/obesity was 2.14 % (95% CI; 1.74-2.53) (more than two standard deviations 30 (+2SD) above the median of the reference population) based on the body mass index (BMI) Z-31 score. The odds of overweight/obesity was higher among children aged less than 6 months 32 (aOR= 5.19; 95%CI: 2.98-9.04), 6-24 months (aOR = 1.97; 95%CI: 1.18-3.29), delivered by  Conclusion: This study showed that childhood overweight/obesity is the problem in Ethiopia. 38 There was an interplay of several factors that affect childhood obesity including child factors, 39 maternal socio-demography, and healthcare utilization, and geography of residence. Therefore, 40 strategies to reduce childhood overweight and obesity should consider a multitude of 41 contributing factors.
3 respectively (1). Although childhood overweight and obesity have been considered the 48 problems of high-income countries, are now on the rise in low-and middle-income countries. 49 While these countries continue to deal with the problems of infectious diseases and 50 undernutrition, childhood overweight and obesity are "double burdens" and the most serious within the age group of 0-59 months was reported 6.8% (4). Different studies suggest that 57 childhood overweight and obesity in sub-Saharan Africa (SSA) is likely to be worsened by the 58 current transition in nutrition and physical activity that is characterized by increased use of 59 energy-saving devices, availability of cheap high calorie-dense foods, and limited participation 60 in physical activity generally (5).

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In low-income Sub-Saharan countries including Ethiopia, childhood obesity is not yet 62 perceived as an emerging health issue and receives little attention. According to the annual 63 report of UNICEF in 2017, there was an overall increment of the prevalence of overweight 64 among children from 1.7 to 3.6% in Ethiopia (6). According to 26 Demographic and Health Childhood overweight and obesity are linked to more deaths than underweight and are 72 associated with a higher chance of breathing difficulties, increased risk of fractures, 73 hypertension, early markers of cardiovascular disease, insulin resistance, psychological effects, 74 and adulthood obesity, premature death, and disability and resulting in an increased risk of non-75 communicable diseases and reproductive disorders later in their life(1, 10).

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Previous studies have reported many factors that were associated with overweight and 77 obesity in under the age of five children. These are socioeconomic status, maternal education 78 level, marital status, smoking during pregnancy, sex of the child, birth weight and the child's 79 birth rank, residence, age of the child, body mass index (BMI) of parents, high dietary diversity, 80 consumption of sweet food, time spent in watching television>2hr/day, living in the grass field 81 area, religion (7, 11-13).

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Despite the rising of childhood overweight and obesity in Ethiopia, there is a paucity of 83 information with robust statistical analysis. Therefore, this study aimed to assess the prevalence    The outcome variable for this study was overweight/obesity in under-five children and it was 122 coded as "1", whereas those children who were categorized as underweight, and normal were 123 coded as "0". The independent variables were: Individual-level factors such as child age, child 124 sex, birth order, twin child, delivered by caesarean section, mother's education status, current 125 age, marital status, child ever born, age of mother at first birth, number of household members, 126 sex of head of households, water source, toilet facility, wealth index, and contraceptive use.

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The community-level factors such as residence, region, and the altitude of clusters. those children whose BMI z-scores were missing or were recorded as out of plausible limits" 132 or "Flagged cases", as their values were unusable. These data were recorded in the database 133 under special codes which corresponded either to responses that were considered inconsistent 134 with other responses in the questionnaire and thought to be probably an error or to responses 135 whose value was "Don't know" (12, 16).

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Both descriptive such as frequencies and proportions and analytic statistics were computed.

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A weighted analysis was done to compensate for the unequal probability of selection between 138 the strata due to the non-proportional allocation of samples to different regions, places of 139 residence, and non-response rate among study participants (15). Since demographic and health  (Table 1).  (Table 3). Dar town which was 6.9 % (17). The current finding was lower than the findings of the study 229 in different settings; 13.8% in Gondar (7), the combined prevalence was 10.7 % in Hawassa 230 with 7.3 % overweight and 3.4% obesity (9) and 7% the global prevalence (18).

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The prevalence of overweight/obesity in this study was also lower than a study conducted in In the current study, the age of the child was significantly associated with childhood 243 overweight/obesity. The odds of overweight and obesity was 5.19 times higher among children 244 whose age group fewer than six months as compared to those children in the age group of 25- increases and children get thinner. This study report suggests that age-specific nutritional 255 counselling programs and strategies during childhood are necessary.

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The present study showed that maternal age was significantly associated with the overweight 257 and obesity of under-five children. The odds of under-five children overweight and obesity was 258 3.91 times higher among children whose maternal age was 40-49 years as compared to those 259 children whose maternal age from 15-19 years. The possible explanation might be as the age The study used a large survey and nationally representative data including regional variation, 308 factors at individual and community levels. However, there were some limitations to this study.

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The cross-sectional nature of the data prevents causality from being inferred between the 310 independent and dependent variables. This study only focused on the specific factors of 311 overweight and obesity but did not include missed variables such as dietary intake, feeding 312 habits of the children, maternal nutritional status, and the weight of the child at birth these The author(s) received no funding for this work.