Elsevier

Clinical Nutrition

Volume 38, Issue 1, February 2019, Pages 310-316
Clinical Nutrition

Original article
The relationship between behavioral factors, weight status and a dietary pattern in primary school aged children: The GRECO study

https://doi.org/10.1016/j.clnu.2018.01.015Get rights and content

Summary

Background & aims

Numerous factors have been associated with the increase in childhood overweight and obesity, including environmental, dietary and behavioral. The latter have been associated with unhealthy eating behaviors but studies of their relation to dietary patterns are limited. Dietary patterns serve as a better means to evaluate children's diet and risk of obesity and therefore the aim of the study was to examine the relationship of behavioral factors with a specific dietary pattern developed for children (child derived Food Index (cdFI)), and to assess how behavioral and diet are related to children's weight status when addressed together in a model.

Methods

Study included school-aged children (n = 4434) from the Greek Childhood Obesity study (GRECO), a cross-sectional survey. Participants self-reported behavioral habits and dietary intake, using a semi-quantitative food-frequency questionnaire (FFQ). A high dietary pattern-cdFI is related to a healthier dietary pattern. Anthropometric data were measured. Multiple linear and logistic regressions were performed, adjusting for age and gender.

Results

The dietary pattern was positively associated with sleep, family meals and study hours, and was inversely associated with total screen time, frequency of eating out and eating while on some screen. Overweight and obese children were more likely to have a lower cdFI score (2%), sleep less (8%) and report more study hours (6%).

Conclusion

In order to reduce and prevent child overweight and obesity, interventions probably need to address specific behavioral and dietary patterns together.

Introduction

Numerous factors have been associated with the increase in childhood overweight and obesity, including environmental, dietary and behavioral [1], [2]. For this reason, these factors have been termed as “obesogenic” and it is unlikely that they exert their effects individually.

Obesogenic factors that have been associated to the increase of child overweight & obesity include sleep [3], [4], sedentary lifestyle and various eating behaviors. The latter encompass frequency of eating during the day (meal frequency), frequency of having family meals, frequency of eating while watching TV, and frequency of eating or ordering from a restaurant [5], [6]. Television-viewing has been used as a proxy measure to sedentary lifestyle and is the behavioral variable most examined, linked to poor health outcomes and unhealthy weight gain [6], [7], [8]. The effect of total screen time (TV and other media types) on weight status, which is also related to sedentary lifestyle and is an increasing trend among children [9], is limited. Total study hours, has recently been suggested [10], [11] as an additional factor adding to total sedentary time in school aged children, but has not been adequately investigated to date.

Diet & unhealthy eating patterns have been associated with childhood weight status [11], [12] and short sleep duration has been found to increase risk of childhood obesity by 58%–89% [3], [4].

The association of these behavioral factors on children's dietary preferences has also been investigated. Sleep duration and TV-viewing and screen time [13], [14], [15], [16], [17] have been associated with unhealthier food intakes, including high fat & sugary foods and low fruit & vegetable intake. An overall assessment of children's food choices based on individual intakes has been found highly heterogenic [18], which makes it difficult to provide an evidence-based association between Body Mass Index (BMI) status, diet and child-behaviors. The use of dietary patterns, has been shown to decrease heterogeneity since all dietary patterns are assessed based on the same standards. The use of a previously validated dietary pattern, such as the child derived Food Index (cdFI), designed to predict child overweight and obesity, can account for diet heterogeneity and help provide stronger associations. Studies examining the relationship between obesogenic behavioral factors on a dietary pattern as a whole are limited.

Therefore, the aim of the present study was firstly, to examine the association of specific childhood obesogenic behavioral factors, with a specific dietary pattern, the child derived Food Index (cdFI) and secondly, to assess how these behavioral factors and total cdFI score are related to children's weight status, in total and by gender, when addressed together in a model.

Section snippets

Procedure

The study was carried out from October 2008 to May 2009, from the whole district of Greece, via stratified sampling scheme weighted by age, sex, and region, according to the population distribution (National Statistical Services, 2001 census). Precise details on the stratification scheme have been previously published [19]. The number of children required to increase the power of the study to 85% (5% type I error) was considered prior to the study with odds ratio (OR) evaluated to equal 1.10,

Results

The basic total and gender specific characteristics of the study population are shown in Table 1. Mean values along with their standard deviation (SD) are depicted for continuous variables, and frequencies with percentages presented for, categorical variables. Statistically significant gender differences in anthropometric measurements were found in the mean values for height, age, waist-circumference and BMI. BMI categories, as per IOTF standards, did not significantly differ (p = 0.091).

Gender

Discussion

The present study investigated the relationship between a child derived food pattern with behaviors linked to the obesity epidemic, including sleep duration, total screen time, and other eating behaviors. Study time, a factor that adds to sedentary time in school aged children and has not been extensively studied, was also examined. The result of each on children's weight status, in univariate and multivariate analysis was examined, accounting for residual confounding by these already known

Future research

The results of this study may form the basis for implementing public health policies but most importantly for designing intervention studies addressing children's dietary habits (either school oriented or specific overweight group targeted), most of which to date have no or very small effect. It must be recognized that in order to prevent or decrease childhood obesity interventions may need to target behavioral factors, specific dietary patterns and eating habits, in a reasonable time span.

Statement of authorship

The GRECO study started and was conducted from the Agricultural University of Athens. Responsibilities of A.Z., D.B.P., G.R. and P.F. included study design and field work supervision. Statistical analysis was performed and overall write up was performed by E.M., and D.B.P., E.M., and A.Z. interpreted the data. Data management and database preparation was performed by all authors, All authors participated in writing the final version of the submitted paper. The authors have no competing

Sources of funding

The study was funded by the General Secretariat of Consumers-Greek Ministry of Development, Hellenic Association of Food and Beverage Companies, FAGE S.A., Coca Cola Hellas, Coca Cola Hellenic Bottling Company, Cereal Partners Hellas, Unilever Hellas, Nestle Hellas, Kraft Foods Hellas. The European Union (European Social Fund – ESF) has co-financed the research as well as the Greek national funds through the Operational Program “Education and Lifelong Learning” of the National Strategic

Conflicts of interest

The authors declare that they have no conflicts of interest.

Compliance with ethical standards

Ethical Standards The Agricultural University of Athens research committee approved procedures as well as the Hellenic Ministry of Education (Department of Primary Education) as the law provides in Greece for any studies conducted at school during formal working hours. Data protection regulations were observed in the survey. Signed informed consent was obtained from main caregiver prior to enrolling the children in the study.

References (33)

  • J. Falbe et al.

    Adiposity and different types of screen time

    Pediatrics

    (2013)
  • P. Farajian et al.

    Hierarchical analysis of dietary, lifestyle and family environment risk factors for childhood obesity: the GRECO study

    Eur J Clin Nutr

    (2014)
  • E. Magriplis et al.

    Newly derived children-based food index. An index that may detect childhood overweight and obesity

    Int J Food Sci Nutr

    (2015)
  • C. Kleiser et al.

    HuSKY: a healthy nutrition score based on food intake of children and adolescents in Germany

    Br J Nutr

    (2009)
  • C. Lazarou et al.

    Children's physical activity, TV watching and obesity in Cyprus: the CYKIDS study

    Eur J Public Health

    (2010)
  • R.K. Golley et al.

    Sleep duration or bedtime? Exploring the association between sleep timing behaviour, diet and BMI in children and adolescents

    Int J Obes

    (2013)
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