J Physiol BiochemDOI 10.1007/s13105-012-0194-7 Dietary behaviors as associated factors for overweightand obesity in a sample of adolescents from Aquitaine,France Caroline Carriere & Coralie Langevin &Thierry Lamireau & Sylvie Maurice & Hélène Thibault Received: 31 January 2012 / Accepted: 22 June 2012 Abstract This study aimed to identify dietary behav- overweight including obesity and obesity alone (adjust- iors that might be considered as associated factors for ment on sex, age, parental SES, and weight status and overweight or obesity among French adolescents. Forty- adolescents' sedentary activity). In addition to parental nine of the 536 middle and high schools in Aquitaine SES and weight status and adolescents' sedentary activ- (southwest of France) were invited to take part in the ity, some dietary behaviors are also independently and study. For each school, participating adolescents were significantly associated with a higher prevalence of selected using stratification by grade. A self-report ques- overweight including obesity: absence (OR 1.43, tionnaire, including information about sex, age, dietary 0.91–2.23) or rare (OR 1.57, 1.23–2.01) breakfast intake behaviors, physical and sedentary activities, and paren- (p<0.01) and absence (OR 5.03, 3.19–7.92) or rare (OR tal socioeconomic status (SES), was filled in by adoles- 1.90, 1.46–2.47) light afternoon meal intake (p<0.001).
cents during class. Overweight and obesity were defined All variables were also significantly and independently according to the age- and sex-specific body mass index associated with obesity alone. This study shows that cutoff points of the International Obesity Task Force.
socioeconomic factors and individual behaviors are as- Multivariate analysis (logistic regression) was used to sociated with overweight or obesity. These results con- identify independent dietary factors associated with firm the importance to carry out multifacetededucational actions among adolescents, by promotingphysical activity and healthy food choices in order to prevent overweight and promote healthy lifestyle Epidémiologie–Biostatistique, Université BordeauxSegalen, ISPED, Centre INSERM U897, Keywords Children . Overweight . Obesity . Factors .
C. Carriere : C. Langevin : S. Maurice : H. Thibault
INSERM, ISPED, Centre INSERM U897–Epidémiologie–Biostatistique,33000 Bordeaux, France T. LamireauService de Pédiatrie Médicale, CHU de Bordeaux,33000 Bordeaux, France During childhood, nutritional intakes must be ade-quate to cover the energy needs for growth and changes in body composition, especially during ado- lescence when a peak of growth and puberty occurs.
33076 Bordeaux, Francee-mail: [email protected] This increase in energy and nutrient requirements [ coincides with other factors that may affect food details of the subjects' selection and method used choices and nutrient intake of adolescents and thus to measure adolescents' weight and height have their nutritional status: progressive acquisition of au- already been described in the first analysis pub- tonomy, opposition to parents, will to experiment and to be accepted by peers, and preoccupation with self- Subjects were selected among adolescents attend- image []. Nutritional deficiencies and poor eating ing public middle and high schools. Schools were habits established during adolescence can have long- selected using a sampling procedure in order to be term consequences, including chronic diseases, hyper- representative of middle and high schools of the Aqui- taine region, by taking into account the district, the During the last decade, several public health actions schools' geographical area, as well as teachers' will- have been implemented in France to improve feeding ingness to participate in the study. Thus, 49 of the 536 behavior of the population. The “French National Pro- middle and high schools in Aquitaine were invited to gram on Nutrition and Health1” was launched by the participate in the study. For each school, adolescents Ministry of Health in 2001 In the region of were selected using stratification by grade, to consti- Aquitaine (southwest of France), the Program “Nutri- tute a panel of middle and high school class students tion, prevention and health of children and teenagers (the distribution of adolescents in the sample within in Aquitaine2” was started in November 2004 and each district was consistent with the distribution of aims at improving dietary behaviors of children and students in middle and high schools in Aquitaine).
adolescents by promoting healthy food consumption The prevalence of overweight and obesity was studied (particularly fruits and vegetables) and physical activ- according to sex, age, physical activity, and sedentary ity. Thereby, it has contributed to the stabilization of childhood overweight prevalence in Aquitaine [In A 99-item self-report questionnaire was completed the framework of this regional program, a study enti- by adolescents during class, under the supervision of tled “Physical activity, lifestyle and dietary behaviors physical education teachers. It included information of adolescents in Aquitaine” was lead in 2004/2005 about sex, age, dietary behaviors, physical and seden- among a sample of adolescents aged 11–18 years. A first analysis, focused on data about physical and Before the beginning of the investigation, an sedentary activities, has shown that gender, age, pa- approval from the local education authority of rental overweight, and socioeconomic status (SES) as Aquitaine was obtained. Prior consent for partici- well as sedentary activity are strong risk factors for pation was obtained from adolescents and their adolescent's overweight and obesity ], which was parents. Then, questionnaires were transmitted without the adolescents identity, thus no ethics To complete these results, a new analysis was carried committee approval was required as the data ana- out to assess if dietary behaviors were also factors associated with overweight and obesity among adoles-cents. This paper describes this second analysis.
Weight and height were measured and recorded foreach adolescent by school nurses, using the same tools and a standardized method. Body mass index (BMI)was calculated as weight/height² (in kilograms per The study was performed among a sample of square meter). The international age- and gender- adolescents from middle and high schools in Aqui- specific child cutoff points of the International Obesity taine region (southwest France) in 2004/2005. The Task Force (IOTF) [] were used to define overweight and obesity. At the age of 18, the IOTF values for “overweight” and “obese” correspond to a BMI of 25 Dietary behaviors as factors for overweight and obesity Parental socioeconomic status (Parental SES) Institute Inc., Cary, NC, USA). Univariate analysis ex-amined the association of variables concerning adoles- The SES of father and mother were assessed according cents or parents with overweight (obesity included) and to their professional occupation. Three work catego- obesity alone as dependent variables, using χ2 tests to ries were defined: “high” (managers, executives, and determine statistical significance. A p value <0.05 was independent professionals); “medium” (craftsmen, considered statistically significant. Variables found to be tradesmen, shopkeepers, proprietary business owners, significant at the univariate stage at p value <0.25 were office workers, employees, farmers, and landholders); then included into a multivariate analysis (logistic re- and “low” (manual workers, retired, unemployed, gression) using the same dependent variables.
etc.). The SES of the household was assessed bycombining both parents' status: high if at least oneparent had a high status; medium if at least one had a medium status and none had a high status; and low ifboth parents had a low status.
Out of the 49 middle and high schools invited to takepart in the study, 6 declined to participate (response rate 88 %). Questionnaires were filled in by 2,533students. In order to have homogeneous age groups, Data collected on dietary behaviors tended to focus on 148 (5.8 %) adolescents aged less than 11 or more than the rhythms of meals and not on their composition.
18 years old were excluded: 2,385 adolescents aged Indeed, collected information concerned breakfast in- 11–18 years (1,213 boys and 1,172 girls) were includ- take (everyday/not everyday/never), light afternoon ed. Characteristics of adolescents, parental SES and meal intake (always/sometimes or often/never), and weight status, and adolescents' sedentary activity and nibbling (never/sometimes/often or always).
dietary behaviors are described in Table Accordingto the IOTF references, 325 adolescents (13.6 %) were overweight including obesity: 280 (11.7 %) were over-weight and 45 (1.9 %) were obese.
Sedentary activity was estimated by weekly time ofscreen viewing. The adolescents were asked to report Factors associated with overweight (including obesity) separately how many hours they spent watching tele-vision, using a computer, and playing video games on a usual school day and a usual weekend day. Usualweekly time of screen viewing was calculated and All variables included in the univariate analysis were summed to create a total cumulative weekly time spent significantly associated (p<0.05) with higher risk of on screen viewing that we called “sedentary behavior.” overweight (including obesity): male gender, low or Then, sedentary activity level was divided into two medium parental SES, absence (never) or rare (not classes using the median of the sample: “<22 h/week” everyday) breakfast intake, absence (never) or rare (sometimes/often) light afternoon meal intake, a highlevel of sedentary activity (≥22 h/week), younger age (11–14 years), and having at least one overweight parent(Table Frequent (often/always) nibbling was associ- This item was filled in by adolescents themselves and ated with a slight decrease of overweight prevalence.
was formulated as follows: “Does your father have anoverweight problem?” (yes/no) and “Does your moth- er have an overweight problem?” (yes/no).
All variables included in the univariate analysis were included in the multivariate complete model (Table After performing the logistic regression among ado- Data were analyzed using the Statistical Analysis Sys- lescents who had no missing data for all these varia- tems (SAS) software package version 9.1 (SAS bles (N02,211), the association between overweight Table 1 Characteristics of a sample of adolescents (N02,385) everyday) breakfast intake, absence (never) or rare from middle and high schools in the Aquitaine region, France (sometimes/often) light afternoon meal intake, high level of sedentary activity (≥22 h/week), and havingat least one overweight parent (Table ).
In addition to variables significantly associated with overweight in the univariate analysis (p<0.05), varia- bles with a p value <0.25 were included in the multi- variate complete model: gender and the SES of the household (Table ). After performing the logistic regression among adolescents who had no missing data for all these variables (N02,221), a higher preva- lence of obesity was still associated with absence (never) or rare (not everyday) breakfast intake, absence (never) or rare (sometimes/often) light afternoon meal intake, high level of sedentary activity (≥22 h/week), and having at least one overweight parent.
This study shows that parental SES and weight status and adolescents' sedentary activity are variables asso- ciated with overweight and obesity, confirming the results previously reported by Thibault et al. ]. In addition, we found that some dietary behaviors, i.e.
absence or rare breakfast and light afternoon meal intake, are also independently and significantly asso- ciated with a higher prevalence of overweight or obe- sity. These results highlight the importance of the breakfast and also the light afternoon meal to provideadequate and balanced nutritional amounts during Adolescents having breakfast everyday have a lower risk to be overweight or obese than those who have breakfast not everyday or even never. It is now recog- nized that regular breakfast consumption may have po-tential impact on the composition of the overall diet and (including obesity) and all variables remains signifi- contribute to reduce the risk of overweight and obesity, but also of other chronic diseases [, , , ].
An original finding of this study is the influence of light afternoon meal on corpulence. We found thatadolescents who never or sometimes have a light afternoon meal have a significantly higher risk ofbecoming overweight or obese. The protective effect Variables significantly associated with a higher preva- of this meal has already been described [], but, to our lence of obesity were: absence (never) or rare (not knowledge, no other study previously showed an Dietary behaviors as factors for overweight and obesity Table 2 Prevalence and factors associated with overweight (including obesity) and obesity in a sample of adolescents (N02,385) inAquitaine (France)—univariate logistic regression analysis independent association between afternoon meal and The light afternoon meal should provide 10 % of total daily energy intake. It is recommended to According to school timetables in France, the consume fruits (low glycemic index), dairy prod- experts of the French National Program on Nutrition ucts or complex carbohydrates (bread), and to limit and Health recommend that children and adolescents should have a light afternoon meal. Indeed, in France, children and adolescents, the light afternoon meal school usually starts at 8 a.m. and ends at 5 p.m., with should be considered as a fourth meal (with break- a lunch break between noon and 1 p.m. Therefore, a fast, lunch, and dinner) and should not be con- light meal intake after school (around 5 p.m.) reduces fused with snacking or nibbling, which are time between lunch and dinner and thus allows a better unstructured and non-recommended intake.
distribution of caloric intake and limits nibbling before The association between the absence or a rare light dinner ]. The protective effect of the light after- afternoon meal intake and a higher risk of overweight noon meal could be linked to the growing evidence or obesity found in our study confirms the relevance of relating that a high meal frequency is inversely asso- French recommendations, spread by the French Na- tional Program on Nutrition and Health ] and the Table 3 Factors associated with overweight (obesity included) and obesity in a sample of adolescents in Aquitaine (France)—multivariate logistic regression analysis Program Nutrition, Prevention and health of children answer the questionnaire and decreased the recogni- tion of nibbling by overweight adolescents.
The unexpected association between the absence of A limitation of this study is that our results do not nibbling and overweight in the univariate analysis allow us to conclude about causality between some does not persist after adjusting data on adolescent's factors and overweight or obesity prevalence. Howev- characteristics and their dietary behaviors (multivari- er, it seems reasonable to think that some environmen- ate analysis). It may also be surprising to find no tal factors such as parental SES are risk factors of association between nibbling and the risk of being overweight and obesity and not consequences. More- overweight or obese. This could be the consequence over, because of the absence of data about meal com- of previous interventions aiming at limiting snacking position, results could not be adjusted for total energy and suppressing or improving the composition of food intake, and thus, the apparently protective effect of supply at school. Overweight or obese adolescents are breakfast and light afternoon meal should be inter- now aware of nutritional recommendations and of the negative effects of nibbling between the four recom- Several studies have shown that French adolescents mended meals. This may have changed the way to have a low fruit and vegetable consumption, an Dietary behaviors as factors for overweight and obesity unbalanced distribution of energy intake (too much fat Turck D, van Goudoever J (2011) Role of dietary factorsand food habits in the development of childhood obesity: a and protein, not enough complex carbohydrates), and commentary by the ESPGHAN Committee on Nutrition. J an excessive consumption of sweet products Indeed, adolescence is a transition period between 2. Bellisle F, Rolland-Cachera MF, Deheeger M, Guilloud- childhood and adulthood and is a risk period Bataille M (1988) Obesity and food intake in children:evidence for a role of metabolic and/or behavioral daily concerning dietary habits: meals or intake rhythms may become irregular, with low quality composition, 3. Bertais S, Castetbon K, Deheeger M, Deschamps V, Hercberg and eating disorders (anorexia nervosa, bulimia, etc.) S, Rolland-Cachera MF, Savanovitch C (2005) Situation et may appear [These behaviors may induce adverse évolution des apports alimentaires de la population en France,1997-2003. InVs, Paris nutritional conditions. Although nutritional problems 4. Bibbins-Domingo K, Coxson P, Pletcher MJ, Lightwood J, at adolescence do not appear to be more severe than at Goldman L (2007) Adolescent overweight and future adult other ages, they may have a strong deleterious impact coronary heart disease. N Engl J Med 357:2371–2379 5. Briefel RR, Crepinsek MK, Cabili C, Wilson A, Gleason PM (2009) School food environments and practices affect Our findings highlight the importance of imple- dietary behaviors of US public school children. J Am Diet menting educational program, such as the French Na- tional Program on Nutrition and Health and the 6. Castebon K, Vernay M, Deschamps M, Salanave B, Malonet Aquitaine program. Indeed, it seems necessary to car- A, Hercberg S (2006) National Nutrition and Health Survey(ENNS), 2006: nutritional situation in France in 2006 accord- ry out multifaceted educational actions among adoles- ing to objective indicators and guidelines of the National cents, by promoting physical activity and healthy food Nutrition and Health Program. InVs, Paris choices (such as breakfast intake, fruit and vegetable 7. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH (2000) Estab- consumption, and limiting consumption of sweet and lishing a standard definition for child overweight and obe-sity worldwide: international survey. BMJ 320:1240–1243 fatty food) in order to prevent overweight and promote 8. Driskell MM, Dyment S, Mauriello L, Castle P, Sherman K healthy lifestyle behaviors [, , ]. These education- (2008) Relationships among multiple behaviors for childhood al actions might be implemented in early childhood in and adolescent obesity prevention. Prev Med 46:209–215 order to reduce the emergence of unhealthy eating 9. Dupuy M, Godeau E, Vignes C, Ahluwalia N (2011) Socio- demographic and lifestyle factors associated with over- behaviors. These could be effective measures to stop weight in a representative sample of 11-15 year olds in or even reverse the present increase of overweight France: results from the WHO-Collaborative Health Behav- prevalence , At the same time, prevention of iour in School-aged Children (HBSC) cross-sectional study.
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