Path Analysis on Life Course Factors Affecting Overweight and Obesity in Children Aged 2 to 5 Years Old in Surakarta


  • Uyunun Nudhira Masters Program in Public Health, Sebelas Maret University
  • Cri SP Wekadigunawan Faculty of Medicine, Sebelas Maret University
  • Bhisma Murti Masters Program in Public Health, Sebelas Maret University


Background: Globally, prevalence of obesity in children under 5 years old has been increasing from 32 million in 1990 to 42 million in 2014. Indonesia ranks highest in the number of obesity cases in South East Asia with prevalence of 11.5% in 2013. However, child overweight and obesity have not been the focus of health problems in Indonesia. Early intervention and prevention of child obesity can reduce long-term risk of chronic diseases in adulthood. This study aimed to analyze the life course factors affecting overweight and obesity in children aged 2 to 5 years old in Surakarta.

Subjects and Method: This was an analytic observational study with case control design. The study was conducted in 5 community health centers, Surakarta, from September to October, 2017. A total sample of 150 children aged 2 to 5 years old was selected using fixed disease sampling. The dependent variable was overweight or obesity. The independent variables were nutrition intake, exclusive breastfeeding, starting age of complementary feeding, physical activity, birthweight, age of gestation, sectio cesarea labor, maternal body mass index, and maternal job. Physical activity data was measured using Pre PAQ questionnaire. Other data were collected using a set of questionnaire and maternal and child health monitoring book. The data were analyzed by path analysis.

Results: Overweight and obesity in children aged 2 to 5 years old were positively affected by over nutrition intake (b= 1.9; 95% CI= 0.15 to 3.60; p=0.033), high maternal body mass index (b= 2.0; 95% CI= 0.51 to 3.42; p=0.008), and sectio cesarean birth (b= 2.1; 95% CI= 0.56 to 3.73; p=0.008). Overweight and obesity in children aged 2 to 5 years old were negatively affected by normal birthweight (b= -2.2; 95% CI=  -4.28 to -0.19; p=0.032), exclusive breastfeeding (b= -2.0; 95% CI= -3.60 to -0.39; p=0.015), timely starting age of complementary feeding (b= -1.3; 95% CI= -2.80 to 0.11; p=0.072), and high physical activity (b= -3.0; 95% CI= -4.63 to -1.37; p=0.001). Birthweight was positively affected by age of gestation (b= 4.2; 95% CI= 1.99 to 6.32; p=0.001) and was negatively affected by maternal body mass index (b= -1.1; 95% CI= -2.11 to -0.13; p=0.025). Exclusive breastfeeding was negatively affected by working outside the house (b= -1.4; 95% CI= -2.10 to -0.72; p= 0.001).

Conclusion: Overweight and obesity in children aged 2 to 5 years old are positively affected by over nutrition intake, high maternal body mass index, and sectio cesarean birth. Overweight and obesity in children aged 2 to 5 years old are negatively affected by normal birthweight, exclusive breastfeeding, timely starting age of complementary feeding, and  high physical activity.

Keyword: life course factors, overweight, obesity, path analysis.

Correspondence: Uyunun Nudhira. Masters Program in Public Health, Sebelas Maret University, Jl. Ir. Sutami 36 A, Surakarta 57126, Central Java. Email: Mobile: +6285253781714

Journal of Epidemiology and Public Health (2017), 2(3): 267-283 


Asian Depelopment Bank (ADB) (2016). Key Indicators for Asia and the Pacific 2016. Philippines. ADB. ISBN: 9789292576301.

Andrade AC, Machado MMT, Kenner C, Lindsay AC (2015). Prematurity, Overweight and Obesity: A Problem That Merits Increased Recognition by Healthcare Practitioners and Researchers’, Newborn and Infant Nursing Reviews. Elsevier BV, 15(4): 174–176. doi: 10.1053/j.nainr.2015.09.002.

Bammann K, Peplies J, De Henauw S, Hunsberger M, Molnar D, Moreno LA, Tornaritis M, et al. (2014). Early life course risk factors for childhood obesity: The IDEFICS case control study. PLoS ONE, 9(2): 1–7. doi: 10.1371/journal.pone.0086914.

Barker DJP (2004). The Developmental Origins of Adult Disease. Journal of the American College of Nutrition, 23 (588S–595S).

Binns C, Lee M, Low WY (2016). The Long Term Public Health Benefits of Breastfeeding. Asia Pacific Journal of Public Health, 28(1): 7–14. doi: 10.1177/1010539515624964.

Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, Ezzati M, et al. (2013). Maternal and child undernutrition and overweight in lowincome and middleincome countries. The Lancet, 382(9890): 427–451. doi: 10.1016/S01406736(13)60937X.

Blake Lamb TL, Locks LM, Perkins ME, Woo Baidal JA, Cheng ER, Taveras EM (2016). Interventions for Childhood Obesity in the First 1,000 Days A Systematic Review. American Journal of Preventive Medicine. Elsevier, 50(6): 780–789. doi:10.1016/j.amepre.2015.11.010.

Bronstein JM (2016). Preterm Birth in the United States. doi: 10.1007/9783319327150.

Burtonjeangros C, Editors DB, Howe LD, Firestone R, Tilling K and Lawlor DA. (2015). A Life Course Perspective on Health Trajectories and Transitions. Springer. doi: 10.1007/978-3-319-20484-0.

Calkins K, Devaskar SU and Angeles L. (2011). Fetal Origins of Adult Disease. Curr Probl Pediatr Adolesc Health Care, 41(6): 158–176. doi: 10.1016/j.cppeds.2011.01.001.Fetal.

Campbell KJ, Hesketh KD, McNaughton SA, Ball K, McCallum Z, Lynch J, Crawford DA (2016). The extended Infant Feeding, Activity and Nutrition Trial (InFANT Extend) Program: A cluster randomized controlled trial of an early intervention to prevent childhood obesity Energy balancerelated behaviors. BMC Public Health. BMC Public Health, 16(1): 1–10. doi: 10.1186/s12889-016-2836-0.

Choukem SP, KamdeuChedeu J, Leary SD, Mboue Djieka Y, Nebongo DN, Akazong C, Mapoure YN, et al (2017). Overweight and obesity in children aged 3–13 years in urban Cameroon: a cross sectional study of prevalence and association with socioeconomic status. BMC Obesity. BMC Obesity, 4(1): 7. doi: 10.1186/s40608-017-0146-4.

Cnattingius S, Villamor E, Johansson S, Bonamy A-KE, Persson M, Wikström AK, and Granath F (2013). Maternal Obesity and Risk of Preterm Delivery. Jama, 309(22): 2362. doi: 10.1001/jama.2013.6295.

Colley RC, Garriguet D, Adamo KB, Carson V, Janssen I, Timmons BW, and Tremblay MS (2013). Physical activity and sedentary behavior during the early years in Canada: a crosssectional study. International Journal of Behavioral Nutrition & Physical Activity, 10(54–62). doi: 10.1186/14-79-5868-10-54.

Daniels LA, Mallan KM, Nicholson JM, Thorpe K, Nambiar S, Mauch CE, Magarey A. (2015). An Early Feeding Practices Intervention for Obesity Prevention. Pediatrics, 136(1): e40–e49. doi: 10.1542/peds.2014-4108.

Debasis B (2011) Global Perspectives on Childhood Obesity Current Status, Consequences and Prevention. first edit. London UK: Elsevier Inc.

Dinas Kesehatan Provinsi jawa Tengah (2016). Profil Kesehatan Triwulan 2 tahun 2016. Dinas Kesehatan Provinsi Jawa Tengah. 3511351(24)174.

Flemming K, Woolcott CG, Allen AC, Veugelers PJ, Kuhle S (2013). The association between caesarean section and childhood obesity revisited: A cohort study. Archives of Disease in Childhood, 98(7): 526–532. doi: 10.1136/archdischild-2012-303459.

Godfrey KM, Reynolds RM, Prescott SL, Nyirenda M, Jaddoe VWV, Eriksson JG, Broekman BFP (2017). Influence of maternal obesity on the longterm health of offspring. The Lancet Diabetes & Endocrinology, 5(1): 53–64. doi: 10.1016/S2213-8587(16)301-07-3.

Green MJ and Popham F. (2017). Life course models: Improving interpretation by consideration of total effects. International Journal of Epidemiology, 46(3)1057–1062. doi: 10.1093/ije/dyw329.

Guendelman S, Kosa JL, Pearl M, Graham S, Goodman J, Kharrazi M. (2009). Juggling Work and Breastfeeding: Effects of Maternity Leave and Occupational Characteristics. Pediatrics, 123(1): e38–e46. doi: 10.1542/peds.2008-2244.

Han JC, Lawlor DA, Kimm SYS (2017). Childhood obesity. The Lancet. 375 (1737-1748).

Han TS, Hart CL, Haig C, Logue J, Upton MN, Watt GCM, Lean MEJ (2015). Contributions of maternal and paternal adiposity and smoking to adult offspring adiposity and cardiovascular risk: The Midspan Family Study. BMJ Open, 5(11). doi: 10.1136/bmjopen2015-007682.

Hardy R (2015). A life course approach to cardiovascular disease prevention. Future cardiology, 10(2): S20–S31. doi: 10.1016/S1474-5151(11)00113-7.

Herman DR, TaylorBaer M, Adams E, Cunningham Sabo L, Duran N, Johnson DB, Yakes E (2014). Life course perspective: Evidence for the role of nutrition. Maternal and Child Health Journal, 18(2): 450–461. doi: 10.10-07/s10995-013-1280-3.

Hirko KA, Kantor ED, Cohen SS, Blot WJ, Stampfer MJ, Signorello LB (2015). Body mass index in young adulthood, obesity trajectory, and premature mortality. American Journal of Epidemiology, 182(5): 441–450.

Hirschmugl B, Desoye G, Catalano P, Klymiuk I, Scharnagl H, Payr S, Kitzinger E, et al. (2017). Maternal obesity modulates intracellular lipid turnover in the human term placenta. International Journal of Obesity. Nature Publishing Group, 41(2): 317–323. doi: 10.1038/ijo.2016.188.

Howie EK, Brewer A, Brown WH, Pfeiffer KA, Saunders RP, Pate RR (2014). The 3 year evolution of a preschool physical activity intervention through a collaborative partnership between research interventionists and pre school teachers. Health Education Research, 29(3): 491–502.

Isgor Z, Powell L, Rimkus L, Chaloupka F (2016). Associations between retail food store exterior advertisements and community demographic and socioeconomic composition. Health and Place. Elsevier, 39(43–50). doi: 10.1016/j.healthplace.2016.02.008.

Jornayvaz FR, Vollenweider P, Bochud M, Mooser V, Waeber G and Marques Vidal P. (2016). Low birth weight leads to obesity, diabetes and increased leptin levels in adults: The CoLaus study. Cardiovascular Diabetology. BioMed Central, 15(1)1–10. doi: 10.1186/s12933-016-0389-2.

Kementerian Kesehatan (2015). Profil Kesehatan Indonesia 2014. Jakarta: Kemenkes.

Koletzko B, Brands B, Chourdakis M, Cramer S, Grote V, Hellmuth C, Kirchberg F, et al. (2014). The power of programming and the earlynutrition project: Opportunities for health promotion by nutrition during the first thousand days of life and beyond. Annals of Nutrition and Metabolism, 64(3–4)187–19. doi: 10.1159/000365017.

Dinas Kesehatan Kota Surakarta. (2014). Profil Kesehatan Kota Surakarta 2014. Surakarta : Dinkes Surakarta.

Kuhle S, Tong OS and Woolcott CG. (2015). Association between caesarean section and childhood obesity: A systematic review and metaanalysis. Obesity Reviews, 16(4) 295–303.

Labresh KA. (2016). Improving outcomes for Noncommunicable Diseases in low and middleincome countries.

Laurson KR, Lee JA, Gentile DA, Walsh DA, Eisenmann JC (2014). Concurrent Associations between Physical Activity, Screen Time, and Sleep Duration with Childhood Obesity, ISRN Obesity, 1–6. doi: 10.1155/2014/204540.

Lewis RM, Demmelmair H, Gaillard R, Godfrey KM, Hauguel De MS, Huppertz B, Larque E, et al. (2013). The placental exposome: Placental determinants of fetal adiposity and postnatal body composition. Annals of Nutrition and Metabolism, 63(3): 208–215. doi: 10.1159/000355222.

Mamun AA, Mannan M, Doi SAR (2014). Gestational weight gain in relation to offspring obesity over the life course: A systematic review and bias adjusted metaanalysis. Obesity Reviews, 15 (4): 338–347. doi: 10.1111/obr.12132.

Martin RM, Kramer MS, Patel R, Rifas Shiman SL, Thompson J, Yang S, Vilchuck K, et al. (2017). Effects of promoting long term, exclusive breastfeeding on adolescent adiposity, blood pressure, and growth trajectories: A secondary analysis of a randomized clinical trial. JAMA Pediatrics, 171(7): e170698. doi: 10.1001/jamapediatrics.2017.0698.

McDonald SD, Han Z, Mulla S, Beyene J (2010). Overweight and obesity in mothers and risk of preterm birth and low birth weight infants: systematic review and metaanalyses. Bmj, 341(201): c3428c3428. doi:10.1136/bmj.c3428.

Mirkovic KR, Perrine CG, Scanlon KS, Grummer Strawn LM (2014). In the united states, a mother’s plans for infant feeding are associated with her plans for employment. Journal of Human Lactation, 30(3): 292–297. doi: 10.1177/0890334414535665.

Nkrumah J (2017). Maternal work and exclusive breastfeeding practice: A community based cross sectional study in Efutu Municipal, Ghana. International Breastfeeding Journal. 12(1): 1–9. doi: 10.1186/s13006-017-0100-6.

O’Reilly JR, Reynolds RM (2013). The risk of maternal obesity to the longterm health of the offspring, Clinical Endocrinology, 78(1): 9–16. doi: 10.1111/cen.12055.

Ogbuanu C, Glover S, Probst J, Liu J, Hussey J (2011). The Effect of Maternity Leave Length and Time of Return to Work on Breastfeeding. Pediatrics, 127(6): e1414–e1427. doi: 10.1542/peds.20100459.

Paes VM, Ong KK, Lakshman R (2015). Factors influencing obesogenic dietary intake in young children (0-6 years): Systematic review of qualitative evidence. BMJ Open, 5(9): 1–10. doi: 10.1136/bmjopen-2014-007-396.

Pérezescamilla R, Kac G (2013). Childhood obesity prevention: a lifecourse framework Childhood obesity prevention: a lifecourse framework. 2–5. doi: 10.1038/ijosup.2013.2.

Pluymen LPM, Smit HA, Wijga AH, Gehring U, De Jongste JC, Van Rossem L (2016). Cesarean Delivery, Overweight throughout Childhood, and Blood Pressure in Adolescence, Journal of Pediatrics. Elsevier Inc., 179: 111–117.e3. doi: 10.1016/j.jpeds.2016.08.059.

Poston L (2012). Best Practice & Research Clinical Endocrinology & Metabolism Maternal obesity , gestational weight gain and diet as determinants of off spring long term health, Best Practice & Research Clinical Endocrinology & Metabolism. Elsevier Ltd, 26(5): 627–639. doi: 10.1016/j.beem.2012.03.010.

Qiao Y, Zhang T, Liu H, Katzmarzyk PT, Chaput JP, Fogelholm M, Johnson WD, et al. (2017). Joint association of birth weight and physical activity/ sedentary behavior with obesity in children ages 9-11 years from 12 countries. Obesity, 25(6): 1091–1097. doi: 10.1002/oby.21792.

Ramírez A, Bernal O, Rodríguez J, Pinzón JD (2016). Morbidity Due to Obesity, Hypertension and Diabetes II Attributable to NonBreastfeeding and Low Birth Weight during the 1000 Days of Life: Estimation of the Population Attributable Fraction. Health, 8(386-401). doi:10.4236/health.201-6.85041.

Redsell SA, Edmonds B, Swift JA, Siriwardena AN, Weng S, Nathan D, Glazebrook C (2016). Review Article Systematic review of randomised controlled trials of interventions that aim to reduce the risk, either directly or indirectly, of overweight and obesity in infancy and early childhood, 24–38. doi: 10.1111/mcn.12184.

Ahima RS (2014). Childhood Obesity Prevalence, Prevalence, Pathophysiology, and Prevention. Toronto New Jarsey: Apple Academic press.

Robinson M, Crozier SR, Harvey NC, Barton BD, Law CM, Godfrey KM, Cooper C, et al. (2015). Modifiable earlylife risk factors for childhood adiposity and overweight: an analysis of their combined impact and potential for prevention. The American Journal of Clinical Nutrition. 101 (368–375). doi: 10.3945/ajcn.114.-094268.Am.

Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, Piwoz EG, et al. (2016). Why invest, and what it will take to improve breastfeeding practices?. The Lancet. Elsevier Ltd, 387(10017): 491–504. doi: 10.1016/S0140-6736(15)01044-2.

Rutayisire E, Wu X, Huang K, Tao S, Chen Y, Tao F (2016). Cesarean section may increase the risk of both overweight and obesity in preschool children. BMC Pregnancy and Childbirth. BMC Pregnancy and Childbirth.16(1)1–8. doi: 10.1186/s12884-016-1131-5.

Small L, Aplasca A (2016). Child Obesity and Mental Health. A Complex Interaction. Child and Adolescent Psychiatric Clinics of North America. Elsevier Inc, 25(2)269–282. doi: 10.1016/j.chc.2015.11.008.

Sutharsan R, Mannan M, Doi SA, Mamun AA (2015). Caesarean delivery and the risk of offspring overweight and obesity over the life course: a systematic review and biasdjusted meta-analysis.13(293–301).

UNICEF, WHO, Word Bank (2014). Levels and Trends in Child malnutrition. Midwifery. 4(96): 90067-4. doi: 10.-1016/S02666138.

Wang L, Collins C, Ratliff M, Xie B, Wang Y (2017). Breastfeeding Reduces Childhood Obesity Risks. Childhood Obesity. 13(3): 197–204. doi: 10.1089/chi.2016.0210.

Ward LC, Poston L, Godfrey KM, Koletzko B (2013). Assessing early growth and adiposity: Report from an early nutrition academy workshop on behalf of the earlynutrition academy. Annals of Nutrition and Metabolism. 63(1–2): 120–130. doi: 10.1159/000-350702.

Weng SF, Redsell SA, Nathan D, Swift JA, Yang M (2014). Estimating Over weight Risk in Childhood From Predictors During Infancy. Pediatrics 132: e414. doi: 10.1542/peds.2012-3858.

Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP (2012). Systematic review and metaanalyses of risk factors for childhood overweight identifiable during infancy. Archives of Disease in Childhood. 97(12): 1019–1026. doi: 10.1136/archdischild-2012-302263.

Wijnhoven TM, vanRaaij JM, Spinelli A, Yngve A, Lissner L, Spiroski I, Farrugia SV, et al. (2016). WHO European Childhood Obesity Surveillance Initiative: Impact of Type of Clothing Worn during Anthropometric Measurements and Timing of the Survey on Weight and Body Mass Index Outcome Measures in 6–9-Year-Old Children. Epidemiology Research International. 2016 (1–16).

WooBaidal JA, Locks LM, Cheng ER, Blake Lamb TL, Perkins ME, Taveras EM. (2016). Risk Factors for Childhood Obesity in the First 1,000 Days. American Journal of Preventive Medicine. Elsevier, 50(6): 761–779. doi: 10.1016/j.amepre.2015.11.012.

World Health Organization (WHO) (2016). World Health Statistics SDGs. Geneva: WHO.

_____ (WHO). (2016b). Consideration of the evidence on childhood obesity for the Commission on Ending Childhood Obesity: Report of the Ad hoc Working Group on Science and Evidence for Ending Childhood Obesity. World Health Organization. (1–30). doi: ISBN 978 92 4 151006 6.

_____ (2014). Report of the First Meeting of the Ad hoc Working Group on Science and Evidence for Ending Childhood Obesity. World Health Organization. doi: ISBN 978924 1510066.

Yang Z, Huffman SL (2013). Nutrition in pregnancy and early childhood and associations with obesity in developing countries. Maternal and Child Nutrition. 9(1): 105–119. doi: 10.1111/mcn.12010.

Zamzani M, Hadi H, Astiti D (2016). Aktifitas fisik berhubungan dengan kejadian obesitas pada anak sekolah dasar. Jurnal Gizi dan Dietik Indonesia. 4(3): 123-128. doi: 10.21927/ijnd.2016.4(3).123-128.

Zheng JS, Liu H, Zhao YM, Li J, Chen Y, Zhu S, Chen H, et al. (2015). Complementary feeding and childhood adiposity in preschoolaged children in a large Chinese cohort. Journal of Pediatrics. Elsevier Inc, 166(2): 326–331.e2.doi: 10.1016/j.jpeds.2014.11.010.




How to Cite

Nudhira, U., Wekadigunawan, C. S., & Murti, B. (2018). Path Analysis on Life Course Factors Affecting Overweight and Obesity in Children Aged 2 to 5 Years Old in Surakarta. Journal of Epidemiology and Public Health, 2(3), 267–283. Retrieved from




Most read articles by the same author(s)

1 2 3 4 5 6 7 8 9 10 11 12 13 > >>