In this study we aimed to evaluate the epidemiology of obesity and hypertension among a sample of children from military families. To the best of the authors’ knowledge, this is the largest report among school-age children of military families from the Middle East, which provides invaluable information.
Overall, 9.9 and 5% of the population were overweight and obese, respectively. This is comparable with a study by Mirmohammadi et al.  who reported on a large population of children between 7 and 18 years old. They found that 9.2 and 3.2% of individuals were overweight and obese, respectively. In a systematic review, Fakhri and colleagues , found that among a total of 93 studies, the rate of obesity and overweight in the pediatric population in Iran was 7 and 12%, respectively. In another systematic review by Kelishadi and colleagues , among a total of 27 studies from 2005 to 2010, authors reported the prevalence of obesity and overweight to be 7 and 11% among 7–11 year old children. Compared to the aforementioned reports from the normal population, school-age children in military families do not seem to have higher rates of obesity, although do have higher rates of overweight individuals. In another study from the US, among military families , authors evaluated a large number of children between 2 and 18 years old and compared them to their civilian counterparts. Accordingly, in their study the rate of overweight and obesity was 27 and 11.6%. They found that children from military families had lower rates of individuals who were overweight and obese compared to the normal population.
In a systematic review, Akbari et al.  evaluated hypertension among children between 3 and 18 years old. Among a total of seventeen relevant studies, they reported the prevalence of hypertension to be 8.9%. Compared to that of our population, we recorded higher rates of individuals with risk of hypertension (12.7% vs. 8.9%). In a similar study in the US , authors evaluated children between 4 to 17 years old from a large military academic center. Among a total of 3941 individuals, they found that 17% were obese. They also found 31% of obese children to have hypertension. To this regard, their results were similar to that ours. On the other hand, in the same study their obesity rates were higher compared to that of our population (5% vs. 17%).
A reason for the higher rates of individuals with risk of hypertension and individuals who were overweight in our population compared to other reports from the general population maybe attributed to a higher stress level among military families [9, 10], which has been linked to higher rates of metabolic disease [6, 11]. Although this would require validation by future studies. Furthermore, the stress and mental strain on military families maybe more pronounced in the Middle East region due to ongoing regional conflicts and war.
Another factor may be attributed to the high rate of obesity and overweight among adults in the military (parents of the children in military families). As one study  found a higher rate of obesity and overweight in military personnel compared to the general population in our region and this may be affecting children in these families, considering that studies have found that obesity in parents is related to obesity/overweight in children [26, 27].
Other factors which may have contributed to this, such as differences in dietary intake between children in military families and their counterparts from non-military families, require further studies in the future.
Interestingly in our study, out of the 12.7% that either had stage 1 or 2 hypertension, only 0.8% were previously diagnosed with high BP. This shows that only one in every fifteen individuals among school-age children in military families is aware of their existing hypertension. This calls for an urgent need to increase and expand screening programs in this specific population.
We found that age is associated with risk of hypertension, in other words older children had higher rates of hypertension. This could be attributed to the increase in obesity rates with increasing age. Obesity and physical activity were other factors associated with hypertension which are already known factors.
One interesting factor we found to be associated with risk of hypertension in our study, was a positive history of hypertension in the mother. This finding was similar to that reported in the study by Pang et al. , in which they studied 1288 school-aged children, and found that a positive family history of hypertension was significantly associated with hypertension among children (OR = 1.96, 95%: 1.16—3.32).
Low birth weight was also associated with risk of hypertension among school-age children. In one study, authors evaluated 45,319 children between the ages of 6 and 18 years old . Similar to that of our study, authors found low birth weight to be significantly associated with hypertension (OR = 1.29, 95%: 1.02—1.64) among girls.
With regard to obesity, we found that with increasing age, rates of obesity also increase. This is compatible with the report by the CDC as they found an increasing trend in childhood obesity with age .
History of obesity in both the mother and father was also associated with obesity in the child. This finding was similar to that reported in the study by Bahreynian et al. , in which boys (OR = 2.79, 95% CI: 2.44–3.20) and girls (OR = 3.46, 95% CI: 3.03–3.94) with obese parents had higher chances of being obese, compared to those with normal parents. As expected, physical activity was protective against childhood obesity. Although we did not find a significant relationship between high intensity physical activity and obesity and only normal level physical activity was associated with obesity in our study. This may be due to multiple reasons, first is the qualitative measure of physical activity which may have had an observer bias as parents were answering the questions regarding their children’s level of physical activity. Second is that some of these children may have had diseases such as ADHD (which was not diagnosed as part of our study) and some studies have shown that ADHD may be associated with obesity and overweight [30, 31].
As a large number of those who join the military in the future are children of military families, a high rate of metabolic disease will eventually have a negative impact on the recruitment of these individuals, accordingly early detection and treatment is of vital importance in this specific population.
This study was not without limitations. First was the ongoing pandemic related to COVID-19 which made patient visitation difficult during the study period. The study was conducted among a military population, thus access to more specific data was limited due to the nature of the study. We could not assess military rank as a factor in our multivariate models, considering that some studies have shown that military rank may affect childhood obesity . We assessed physical activity using a qualitative approach and by direct questioning of the parents which is not an accurate measure compared to a quantitative tool of assessment. Although for large scale epidemiological studies, a self-report tool is usually used for assessment of physical activity which may be associated with bias due to reasons such as the sporadic short burst nature of activity among children (which makes the assessment of physical activity more difficult among children) . Blood pressure measurement was done using a sphygmomanometer and although this has long been considered the gold standard method of BP measurement for epidemiologic studies , more accurate methods such as the 24-hour ambulatory blood pressure monitoring (ABPM) do exist. From another point of view, using an ABPM for epidemiologic studies with large sample sizes is difficult, especially in countries with limited resources.
Moreover, some studies have shown that BP when using a sphygmomanometer is usually higher compared to a ABPM and this should be considered when interpreting our results .
From another aspect, this limitation would not have affected our comparison with reports within the region, as most of the studies in our region  have used a sphygmomanometer for the measurement of BP.
On the other hand, this is the largest report on the metabolic status of school-age children from military families from our region.