Variations in Height, Weight and Body Mass Index According to Generation, Place of Residence and Region in Palestinian Territories

Introduction: The relationship between second intifada and risk factors of chronic diseases was not studied before in Palestine Aims: The aims of this study is to describe differences in height , weight and BMI between different generations of Palestinians who were born at different times in the armed conict. Also we wanted to know whether weight and height in West Bank follow any social pattern. Methods: This study was retrospective analysis of pooled data from many previous studies where participants reported their weight, height, place of residence, region in west bank and income. Results: Almost 61% of our study were females. Among female 12.8% were born before rst intifada, 6.4% around rst Intifada and 80.8% were born around second intifada. For males; 12.2% before rst intifada, 5.7% around rst intifada and 82.9% around second intifada. The generation born around second intifada had 12 cm higher height relative to generation before rst intifada, 5 cm more height relative to rst intifada generation (p=0.001), whereas females born before intifada had 20 Kg more weight than the generation of second intifada (p< 0.0001). In multiple regression model done for the second intifada generation weight and height were related to place of residence and income and age signicantly. Conclusion: Political conict


Introduction
Anthropometric measurements are useful tools that can be used by health professionals to assess human body dimensions including height and weight and it can be used to assess energy requirements and predict diseases such as cardiovascular diseases and diabetes mellitus 1 . Average height of large number of humans could be indicative of welfare. Economists usually use human height to evaluate the impact of poor nutrition and health on economics of nations. Earlier keynote lecture by Robert F. Fogel showed that 17.5 centimeter height de cit for Norwegian male meant 71% higher risk of dying in their next period of life 2 . Studies in some European countries reported on regional and generational differences in human height. Much of interest in countries like USA, Japan was given to male heights relative to females and children height. Also, countries differed in height reached by their citizens, for example average height of males from Montenegro was found to be 177 cm and sometimes 3 178 cm which is proclaimed to be the highest in Europe whereas heights of males in Herzegovina which is close to Montenegro is 175-176 cm. A genomic prediction model showed that genomics predictors are responsible for 40% of variation height and that actual height correlation with predicted height based on genomic predictors was 0.65 4 . On other hand, socioeconomic (education, occupation and material health) status plays role in determining height, but this relationship is poorer for women from developing countries 5 . On the other hand, political con icts associated with violence could also impact human height as was shown in other reports 6 . Other factors that predict human height include nutritional factors, health, social inequality, protein quality in diet and total fertility which determines the amount of resources expended on per child and so small family size is important determinant of height 7 .
On the other hand, weight is another important anthropometric measurement that is rapidly changing with obesity pandemic that is present globally 6 . Bodyweight and body mass index (BMI) are anthropometric measurements that re ect human overall nutrition consumption and strictly related to human disease. Humans can be classi ed as underweight, normal weight overweight and obese based on BMI 8 . It is well known that age is associated with increase in weight and BMI. Also, there is clear relationship between SES and obesity and that this relationship is based on gender. Lower SES is associated with higher rates in obesity in females more so than males 9 .
Palestinians in the historical Palestine passed through different periods of political violence with associated stress and changes in nancial resources. First Intifada broke in 1987 followed by Oslo Accords 1993 and then Second Intifada in 2000. All these political changes in the life of Palestinian people represented variation in stress and nancial resources and their impact on Palestinian wellbeing was not compared before 9,10 .
Hence the goals of this study was to 1) To compare the height, weight and BMI of different political Palestinian generations 2) To compare the height, weight and BMI between different regional and places of residence of different social and political environments.

Methods
Data for this work was pooled from different studies including Food label study, Two parts nutrition literacy studies and Education MyPlate for Palestinian young students. Information on self-reported height, self-reported weight, BMI, place of residence (Refugee Camp, Village, City, Israeli citizens) or region ( North and Middle Areas (including Nablus, Qalqilya, Tulkarem, Salfeet, Jenin along with following villages and refugee camps), Southern Area (Hebron and Bethlehem), Ramallah, Jerusalem and Israeli Arabs. Sometimes data was combined to increase number of participants. Different Generations was de ned those who were before First Intifada (Group 1), those who were born between two Intifadas, those who were born at the time of Second Intifada.

Statistics.
Height, Weight and BMI were compared according to generation, region or place of residence using one way ANOVA. Comparisons were done based on gender and repeated for the generation who were born at time of second intifada.
Percent of people more than certain height values were calculated for different height cutoff points for each gender separately. The same calculations was done for Second Intifada generation. Also, BMI categories prevalence was calculated for males and females and repeated for second Intifada generation. Mixed model regression analysis was used to study correlates of height, weight and BMI.
Data was analyzed utilizing SPSS 21.

Results
We included 523 participants in this study, among them we had only 123 male participants. Table 1 provides demographic variables for the study group.

Height
In table 2 we report signi cant height differences between Palestinian age groups. The group 1 who re ected people born around second Intifada is 12.1 cm taller than the group born before rst Intifada and slightly less than 5 cm taller than the group who was born around rst Intifada. Females height was not signi cantly different between age groups. In the generation of second intifada (less than 25 y), height was signi cantly different according to place of residence. Males form city were 10 cm shorter than ones from refugee camps, Refugee camp group was almost 5 cm higher than ones from villages, whereas no signi cant difference was found between females (Table 3). Also, the group that reported higher income had 7 cm increase in height, whereas in females less than 25 y there were no relationships to place, region or income. Table 4 shows the percent of participants higher than certain height cutoff values of note is that we had 117 female less than 150 cm in height, and that the trend of height was not different for group of 25 y and less than total sample. Although not signi cant, women with Israeli citizenship were the shortest and ones from Jerusalem were the tallest.
Multiple regression model for the generation of second intifada shows that increased age, being from city was associated with lower height in males, other variables such as income and region were not signi cantly related to height in nal models. In females only income was signi cant predictor of height as low income was associated with lower height (Table 4) Weight and BMI Males were not signi cantly different in weight across age groups, but BMI was different, the highest BMI was for oldest generation and the lowest was for youngest (Table 2). For females, weight and BMI followed age trend, with women more than 34 y having almost 20 kilogram more than women of 25 or less y (Table 2).
In males less than 25 y there was no signi cant trend according to place of residence region, but males from refugee camp or from Ramallah and Jerusalem (combined) tended to be more overweight (Table 3).
For females, being from village was associated with lower weight and BMI, whereas refugee and women with Israeli citizenship had higher BMI and weight, whereas region was not related to weight and BMI. (Table 3). No differences were reported according to region and income. In multiple regression model being from city was related to lower weight in males, whereas in females lower income was associated with increase in BMI (Table 4).  11 . One study found that con ict related stress was associated with decrease in birth-weight. Many Palestinian women of reproduction age were not consuming enough meat, dairy, poultry at height of con ict. Imposing curfew was also associated with restricted access to healthcare 11 . In a longitudinal analysis that was performed on Palestinian population living in Occupied Palestinian territories, con ict did not show effect on access to health service among mothers and infants across socioeconomic conditions. However, in South and Central parts of West Bank intensity of con ict had negative impact on access to healthcare which provides evidence to regional differences in healthcare in Palestinian territories affected by con ict 12 .

Discussion
On the other hand, regional differences could be in fact related to patriarchy differences in different regions of West Bank. Patriarchy is well-known determinant of womens' health including women of childbearing age, particularly health seeking behavior and income that may affect food intake [13][14][15] .
Females and Males in refugee camps had gap in terms of weight and height with others from city and villages. Refugees represent 45.6% of Palestinian people. In the period from 2005-2010, mortality rates was the highest for refugees in Opt. (23.7 for refugees relative to 18.8 for West Bank) in 1000 childbirth.
Which indicates deteriorating health conditions among refugees. However, Palestinians who are refugees tend to have education degree more than the rest of society (10.7% versus 10.4%) . However, economy of West Bank refugees yet better than other refugee in diaspora is rather fragile and unstable.
Also, refugee camps employment is different according to the city, for example Jalazoun refugee camp which near Ramallah has high employment for Palestinian authority, while further refugee camps are not the same 16 .
Arabs in Jerusalem and Israel may have higher income and access to health care relative to West Bank, but also they have high rate of unemployment and crime rate. Although Arab Israeli males and Jerusalemite were taller, counterparts females were more obese or had higher BMI 17 The percent of males above 190 cm height was 3% which less that what was reported previously in European populations who went under con it (5% in Kosovo), but this value is higher than in France (1%) 6 . However, 5.8% of our study males were under 160 cm which is unlike study from Kosovo, where no male was less than 160 cm. With regards to females, we have one female of 190 cm and 8 (2%) who are over 180 cm, whereas in Kosovo study no female was higher than 190 cm and only 1.2% of females were higher than 180 cm in Kosovo 6 . However we have 6 females less than 140 cm and 117 below 150 cm which strikingly different than Kosvo where no female was less than 150 cm 6 . At the same time, we have high rate of underweight women (52 females or 13%) whether those females were born with low birhtweight needs investigation.
In this study we show that age especially in females was associated with large weight gap between the three generation ( + 20 Kg) between the generation before inti da and the one who were born around second intifada. The weight gain with age showed dependence on gender, race and socioeconomic status in Cardia study 18 . Exposure to war trauma is associated with posttraumatic stress (PTSD) and emotional disorders in adults and children 19 . The generation who were born before rst intifada were exposed to political trauma in their adult life, past year PTSD was associated with higher obesity risk (OR 1.51, 95% CI 1.18, 1.95), but this was not different between males and females. 20 . The relationship between PTSD and obesity was supported by systematic review done by Bartoli et al 21 . It is well-known that weight gain with years is associated with higher risk for CVD. 22 It is not well understood why the group from refugee camp had higher height than cities and villages. It is assumed that refugee camps during second intifada drew the attention of medical aid organizations more so than other regions in Palestine, due to concentration of ghts in these spots. This could partially explain the provision of more healthcare for pregnant Palestinian women and their infants in refugee camp which could have been translated into have higher heights. Another explanation is that the group of students who came refugee camp may represent some social section of the population in refugee camp who care about education and can afford it, not the rest of population and hence this could be a bias in representation. This need further studies, but may re ect complex relationship between socioeconomic status and chronic human nutrition. This is consistent with our nding that males who have higher income where in fact higher than the rest of the sample among the second intifada generation. This is consistent with previous literature which supports that socioeconomic status in fact affect growth standards which itself could affect education attaiment. 23 This study is not without limitation including the use of self-reported height and weight. However, selfreported height and weight are highly correlated with measured height and weight and one study. Minor under-estimation of body weight is present that may lead to some study bias 24 . Also, this study is cross sectional in its design with pooling of data from many studies, which may lead to minor discrepancies in categorizing data.
In summary, in large sample of Palestinians, we report 12 cm difference in height between different generations of Palestinians who were born during different times of political con ict, this was for males, but females who endured the trauma of second intifada as young adults had extra 20 Kg weight relative to younger generation who were infants or children during the second intifada. Also, we report differences in height, weight, BMI according to place of living and socioeconomic status. More studies are needed to understand the impact of second intifada on generations of Palestinians and their risk for diseases.

Declarations
Ethical Approval and Consent to participate: The research was conducted in accordance with Declaration of Helsinki and approval from the IRB at An Najah National University was obtained before conducting the study. Informed consent was obtained from participants.

Consent for publication
All the study authors read and approved the manuscript for publication Data Availability and material The datasets generated and/or analyzed during the current study are not publicly available due [being kept con dential for future work] but are available from the corresponding author on reasonable request.