Child Nutrition and Health

In: Child Nutrition and Health ISBN: 978-1-62257-981-5 Editors: G. Cvercko and L. Predovnik © 2013 Nova Science Publishers, Inc. Chapter IV The Breakfast Experience in Low Socioeconomic Families with Overweight Children Simone Pettigrew* and Melanie Pescud† University of Western Australia Abstract Dietitians emphasise the importance of a healthy breakfast as part of a balanced diet. As well as providing energy to fuel physical and mental activity, there is increasing evidence that eating breakfast assists individuals manage their food intake to prevent excessive weight gain. Parents play a critical role in determining if their children eat breakfast and, if so, the kinds of foods that are consumed at this meal. Limited previous research has specifically examined parents’ beliefs and behaviours in relation to this aspect of their children’s diets. Such information is especially important in the context of low socioeconomic families given that disadvantaged children have significantly higher rates of overweight and obesity and poorer academic performance relative to their more advantaged peers. In the present study, parents’ attitudes to breakfast and its role in children’s health were explored. A range of qualitative data collection methods was employed over an extended period (12 months) with low socioeconomic status parents of overweight children. Insights were generated into the barriers, motivators, and facilitators influencing whether parents provide their children with healthy breakfasts. Numerous factors were listed as making it difficult to ensure children eat a healthy breakfast. These included time constraints, children’s taste preferences, a lack of appetite upon waking, and a reluctance among some parents to model recommended breakfast consumption behaviours. The findings indicate that future efforts to improve children’s nutrition could (i) build on parents’ existing belief that breakfast is important and (ii) suggest coping * Professor Simone Pettigrew, Business School, University of Western Australia Ph: +61 8 6488 1437 [email protected]. † Melanie Pescud, Business School, University of Western Australia Ph: +61 8 6488 2972 [email protected].

90 Simone Pettigrew and Melanie Pescud strategies for parents to overcome the identified barriers to selecting and serving healthy breakfast foods. Introduction Child obesity is a common affliction across the developed world (World Health Organization, 2010). In Australia, the context of the present study, one in four children is either overweight or obese (Australian Bureau Statistics (ABS), 2009). The rates vary by socioeconomic status (SES), with one in three low SES children being overweight or obese compared to one in five high SES children (ABS, 2009). Numerous factors that are contributing to the obesity epidemic have been identified. These include escalating food marketing (Nestle, 2006; World Health Organization, 2006; Zimmerman, 2011), more food being consumed outside the home (Burns et al., 2002), the introduction of trans fats and high fructose sugars into the food supply (Lichtenstein et al., 2006), and a growing proportion of two-income households in which there is less time for food preparation (ABS, 2000). Each of these factors places upwards pressure on the amount of energy consumed by individuals. Energy is consumed during meals and when consuming snacks (Nielsen et al., 2002), with snacking in particular being likely to involve highly energy-dense foods (Lipsky, 2009). As a result, considerable previous research has focused on the extent to which snack foods and other high energy density foods are promoted to and consumed by children (Cairns et al., 2009; Piernas and Popkin, 2010). In recent years, other eating occasions have attracted increasing attention in efforts to develop a more comprehensive approach to preventing and treating child obesity. For example, in recognition of the importance of breakfast for children’s nutrient intake (Affenito, 2007; Williams, 2007), various studies have assessed the extent of breakfast skipping among children (e.g., Barton et al., 2005; Cheng et al., 2008; Deshmukh-Taskar et al., 2010; Delva et al., 2006; Dubois et al., 2006; Sampson et al., 1995; Shaw 1998; Tin et al., 2011; Vanelli et al., 2005). These studies have concluded that skipping is quite common, resulting in calls to develop and implement intervention strategies designed to encourage breakfast consumption among children (Dubois et al., 2006; Pearson et al., 2009; Rampersaud et al., 2005). However, there has been a lack of research into the reasons for children’s breakfast skipping behaviours to inform such interventions. The present study seeks to generate insight into Australian children’s breakfast-related behaviours by gathering qualitative data from low socioeconomic parents of overweight children over an extended time period. The rationale for this sample and the methodological approach adopted are explained after the following review of relevant literature. Literature Review Breakfast has long been held by conventional wisdom to be an important part of the overall diet. Hence pioneer nutritionist Adelle Davis’ famous quote, “Eat breakfast like a king, lunch like a prince, and dinner like a pauper” (Rattiner, 2002, p.1). In terms of child obesity, cross-sectional studies usually demonstrate an inverse relationship between

The Breakfast Experience in Low Socioeconomic Families … 91 frequency of breakfast consumption and body mass index (Affenito, 2007; Deshmukh-Taskar et al., 2010; Szajewska and Ruszczynski, 2010; Thompson-McCormick et al., 2010; Tin et al., 2011; Utter et al., 2007; Williams, 2007). Body mass index (BMI) is calculated by dividing weight by height squared (Lobstein et al., 2004), and provides a robust indication of weight status (i.e., whether an individual is underweight, normal weight, overweight, or obese) (Bouchard, 2007). The tendency for breakfast consumption to be associated with lower BMI holds despite a typically higher overall energy intake among those children eating breakfast (Rampersaud et al., 2005). Potential explanations for this result include lower levels of physical activity among breakfast skippers (Kapantaisa et al., 2011; Rampersaud et al., 2005) and higher metabolic rates in breakfast eaters due to more frequent food consumption (Deshmukh-Taskar et al., 2010). Longitudinal studies have yielded inconsistent results, possibly reflecting the more diverse range of factors that contribute to food consumption behaviours as children age (for a review see Affenito, 2007). Aside from implications for weight status, breakfast consumption has other favourable nutritional outcomes. Diet quality overall is better among children who eat breakfast relative to those who do not (Sampson et al., 1995; Utter et al., 2007; Williams 2007), and higher intakes are achieved of specific positive nutrients such as fibre and calcium (Barton et al., 2005). Further advantages can be accrued in the form of cognitive or academic performance (Hoyland et al., 2009). Those children consuming breakfast tend to score better on working memory tests (Cueto, 2001; Mahoney et al., 2005), and there is some evidence that they are better behaved in class (Kleinman et al., 2002). Those who regularly consume breakfast in both childhood and adulthood have been found to have better heart health in later life than those who do not (Smith et al., 2010) Given the importance of the breakfast meal, there is growing research interest in identifying those individuals who are most likely to be at risk of missing breakfast (Keski- Rahkonen et al., 2003; Rampersaud, 2009). As a result, studies to date have mainly focused on determining the prevalence and correlates of breakfast skipping (e.g., Pearson et al., 2009). Estimates of breakfast skipping among children range from 5% to 30%, depending on the particular country and the age of the children studied (Rampersaud et al., 2005; Tin et al., 2011). There is a trend for skipping to become more frequent as children enter their teens and have greater discretion over their food consumption behaviours (Shaw, 1998; Utter et al., 2007). Skipping has also been found to be more common among children from single parent families (Croezen et al., 2009; Deshmukh-Taskar et al., 2010; Pearson et al., 2009), those whose parents do not eat breakfast regularly (Pearson et al., 2009), and those of low SES (Delva et al., 2006; Deshmukh-Taskar et al., 2010; Utter et al., 2007). These contributing factors point to the importance of the family environment in determining children’s breakfast consumption behaviours and highlight the need to view the family as the relevant unit of analysis. While prevalence studies are growing in number, relatively little work has examined children’s motivations for consuming or skipping breakfast and for consuming particular kinds of breakfast foods. The limited existing work on motivations has typically focused on adolescents (Kapantaisa et al., 2011; Miech et al., 2006; Niemeier et al., 2006; Thompson- McCormick et al., 2010; Zullig et al., 2006). Among teenagers, especially girls, skipping breakfast has been found to be used as a means of weight management (Affenito, 2007; Kapantaisa et al., 2011; Zullig et al., 2006). Other identified reasons include tiredness upon waking and a lack of time in the morning for meal preparation and consumption (Affenito,

92 Simone Pettigrew and Melanie Pescud 2007). Given the higher rate of breakfast skipping among adolescents, the focus on this segment of the population is understandable. However, the earlier childhood years are important in establishing taste preferences and food consumptions habits (American Dietetic Association, 2004), making it important to appreciate how breakfast behaviours originate and consolidate during these years. The greater tendency for skipping in low SES families and the higher rates of overweight and obesity among members of this group indicate the need to focus on these families in formative research (Miech et al., 2006). Given the lack of prior work in this area, such information would be of value to policy makers seeking guidance on appropriate means of (1) encouraging breakfast consumption in families at higher risk of breakfast skipping and (2) informing families of the kinds of foods that are most appropriate for consumption at the breakfast meal. The present study provides some preliminary insights into the contextual factors relevant to breakfast consumption behaviours among low SES families in Australia. The findings are useful in depicting the complex and often difficult circumstances in which low SES parents attempt to deliver a healthy diet to their children. Method Ethics clearance was obtained from a university ethics committee. In accordance with the approval requirements, all of the study participants were given information documents and were asked to sign consent forms prior to the commencement of data collection. A longitudinal, qualitative study was undertaken with low SES parents of overweight children. The broad aim of the study was to explore the motivators, facilitators, and barriers relevant to these parents caring for their children’s health. Breakfast was spontaneously raised numerous times as an important but difficult aspect of parenting and hence became a topic of particular focus during data analysis. The study was originally planned as a six-month project involving 50 parents, but ultimately ran for 12 months with a smaller sample. A social research agency used a random digit dialling process to identify potential participants with the following characteristics: at least one child aged five to nine years with a body mass index that placed them in the overweight or obese category (as per Cole et al., 2000); a gross annual household income of less than AU$60,000 (the national average household income was $73,000: Australian Bureau of Statistics, 2008); and no tertiary education qualification. The selection of the five to nine years age range for the children reflects the importance of this developmental stage for the onset of overweight and obesity (American Dietetic Association, 2004). Parents provided their children’s height and weight details to enable calculation of body mass index to determine eligibility to participate in the study. In line with recruitment difficulties encountered in previous research with low SES study participants (Blumenthal et al., 1995; Heinrichs et al., 2005), the research agency experienced considerable difficulty identifying willing parents who fit the eligibility criteria. This was at least partially the result of the high level of participation required by the study. Potential participants were advised that they would be expected to provide fortnightly self- introspections on topics of their choice relating to child health and attend two individual interviews and a focus group. The introspections could be submitted by mail, email, weblog,

The Breakfast Experience in Low Socioeconomic Families … 93 or telephone recorded message and the individual interviews could be undertaken at any location preferred by the participant (most chose their homes). The focus groups were held on a university campus. Table 1. Participant characteristics Category Description Quantity Gender Women 35 Men 2 Family structure Dual-parent families 14 Single-parent families 23 Employment status Working full time 6 Working part time 7 Child gender ‡ Parenting full time 24 Female 25 Male 14 Child weight status ‡ Overweight 20 Obese 19 No. of children in family 1 child 5 2 children 17 3 children 8 4+ children 7 ‡Total adds to more than 37 because some parents had more than one overweight or obese child in the specified age range. Reflecting the level of commitment required by the research, potential participants were advised that they would be paid $75 per month over the course of the study, with proportional payments made to accommodate any reductions in participation relative to expectations. The average monthly payment made to participants was $71. Ultimately, just 37 parents commenced the study, almost all of whom were mothers. Table 1 provides the sample profile. Of note is the relatively high proportion of single parents, which reflects the substantially higher rates of single-parent families among low SES households (Australian Bureau of Statistics, 2007). Given this smaller than anticipated starting sample and the ongoing commitment of the participants once they had become involved in the study, the decision was made at the six-month point to extend the study to a full year. Twenty-seven of the participants were still involved at this stage, 22 of whom agreed to continue for the full 12 months. All data collection episodes were audio recorded or captured online, and subsequently transcribed. The result was 588,734 words of data that were imported into NVivo 9 for coding and analysis. A thematic approach was used to interpret the data and produce findings of relevance to public policy makers attempting to prevent child obesity. Findings Throughout data collection and analysis, it became clear that breakfast is a particularly contentious food consumption occasion for most of the families participating in the study. Almost all of the parents noted the importance of breakfast and expressed a desire for their

94 Simone Pettigrew and Melanie Pescud children to consume a healthy meal in the morning to ensure they could function properly during the day: The children have to have good breakfast in the morning – drink milk, another protein food, such as an egg, cheese, or meat, a slice of white bread or wholemeal toast or a bowl of cereal - so they can have energy and concentration at school. (Adeline, single, four children, handwritten introspection) However, for many of the study participants it was a challenge to make this aim of daily, healthy breakfasts a reality. As noted by one mother, “Breakfast is a really hard meal to get them to have” (Kathryn, single, two children, phone bank message). Breakfast was often spontaneously raised by the parents as a particularly problematic aspect of managing their children’s diets because of the numerous factors that in combination make it a pressured food consumption occasion. While a minority described breakfast in their household as being ‘under control’, many others nominated numerous elements of breakfast organisation, delivery, and consumption as being a source of concern and conflict. These elements are categorised into themes as outlined below. Kids Rule, OK? In line with their views about the importance of breakfast, the majority of the participants reported going to some lengths to ensure their children ate breakfast prior to leaving home in the morning. However, it was clear than in many instances the children had the upper hand in terms of the type of food consumed. Constrained by their desire to ensure their children did not skip breakfast altogether, many parents reported that their children ate sub-optimal breakfast foods because their children’s taste preferences were permitted to determine the food items that were purchased and consumed: At least if they’ve eaten something, you know what I mean? I know it’s high sugar, I know all the wrongs and all that, but it’s just, if they’re going to refuse and not eat anything, it’s like, well, I’d just prefer them to have something in their stomach, anything. Yeah, I mean something else will keep them satisfied longer, of course, but at least, I sort of think, at least it will keep them full for half an hour, you know what I mean? (Natasha, living with partner, two children, interview) A fear of their children refusing to eat at all, combined with a desire to avoid early morning conflict in the home, appeared to often result in some children being able to effectively manipulate their parents into providing foods, despite concern among the parents that the foods were nutritionally inadequate. Natasha went on to explain further as follows: I’m a mean mum if I don’t supply this, the high sugar cereals. I tried them not having anything, and they just wouldn’t have anything. So it’s like, well, what do you do? They just refuse to eat it, so you know what I mean? (Natasha, living with partner, two children, interview)

The Breakfast Experience in Low Socioeconomic Families … 95 For some, this acquiescence in relation to the types of foods consumed constituted a reward for the children complying with the logistics of getting up and ready on time. Especially for working parents, the breakfast plan that worked best was the one that enabled children to make the food selection decisions: I believe it is hard to get kids to eat breakfast. And I do give them whatever they want. Well, see, in the mornings my girls come into work early with me in the morning at 8 o’clock. They come through at the back of the workshop and they pick out a milkshake, or Up & Go. Tabitha always picks the Up & Go and Renee gets the iced coffee, and they walk to school with it. That’s their little reward to come to work with me and get up, and the boss lets them come through and everything. They’ve got like a five minute walk to school, so they’re having a drink, walking, and so I do give them whatever they want for breakfast with the cereals… Yep, I just give them what they want to eat for breakfast. (Veronica, single, four children, interview) Children’s tiredness and their lack of hunger until they had been awake for a period of time were often reported to make children difficult to feed in the morning. While most participants responded to this situation by either allowing their children to eat unhealthy breakfast foods or skip breakfast altogether, the foster mother quoted below had learned over the years to ensure that the children in her care were woken up in time to develop an appetite for breakfast. Everyone has to have breakfast. The boys never would eat breakfast when they came to my care, they refused to eat breakfast. They weren’t hungry when they got out of bed. I learnt to wake them up earlier. (Claudia, single, one child plus foster children, interview) For just a few, the power of the children in the household resulted in the parents being unable to influence their breakfast consumption at all, resulting in breakfast being skipped at the child’s whim: With Jane, she very rarely has breakfast. I always offer it and encourage it, but if she doesn’t want it, she won’t have it. (Tara, single, three children, focus group) This refusal to consume breakfast by the child can have negative outcomes for both the child and the family, as described in the quote below. Despite these undesirable and highly unpleasant consequences, which would presumably act as a strong motivator, these parents were not able to conceptualise and implement strategies to overcome their children’s reluctance to have breakfast: There are, you know, quite regularly days when he doesn’t have breakfast, doesn’t have lunch. He comes home and is absolutely ravenous, obviously, and yells and screams and fights. (Emily, single, three children, interview) A strategy used by some participants to prevent conflict with their children over the types of breakfast foods that were available in the home was to compromise by purchasing foods that were attractive to their children while also having attributes of importance to the parent.

96 Simone Pettigrew and Melanie Pescud As explained in the following quote, there are trade-offs that can be made that result in both the parent and the child being satisfied with the food choice: It’s the good of the devil. You’ve got all these devils and I’m trying to choose the best devil, vitamins sprinkled on top. It’s like with the white bread. If I’m going to have white bread, I’ll try to get something that’s got high fibre in it or low GI. So even though it’s bad, it’s still the better of the bad. (Natasha, living with partner, two children, interview) While many of the participants appeared to experience a lack of control over their children’s food consumption in the mornings, this outcome was not uniform within households. Participants often drew comparisons between their children’s diets to illustrate their variable ability to ensure their children consumed a healthy breakfast. The implication seemed to be that the problem was the specific child rather than their parenting skills. While this may to some extent be the result of different breakfast consumption behaviours that emerge as children grow older (Niemeier et al., 2006; Utter et al., 2007), there were sufficient variations in the age and birth order of the problematic child to indicate that this is an incomplete explanation. Instead, it appeared that different children within families can bring different issues to the breakfast table: My middle child (age 7) has breakfast every morning, cereal every morning. My oldest child (age 9) is difficult – we’re lucky if we can get an apple into her at breakfast time. (Danielle, married, three children, interview) I try not to worry about her because she says she’s not hungry, and she went off this morning without having breakfast. But the other two, Amy (age 8) will always have her Weet- Bix or cereal and Timothy (age 10) will have toast, but Lynda (age 13) won’t. (Isabela, married, six children, interview) James (age 9) always has a very good appetite and he always has his Weet-Bix and then his piece of toast. Anna (age 6) will sometimes eat it, and other times say, ‘I’m not hungry’. (Melina, married, two children, interview) Nutrition Confusion Confounding the control issues referred to above was some confusion relating to the nutritional profile of various breakfast foods. Most participants nominated Weet-Bix and oats (porridge) as being superior breakfast foods: Weet-Bix, yes, healthy, healthy. (Tara, single, three children, focus group) We hardly buy those Coco Pops and stuff like that. We get Cornflakes and porridge and Weet-Bix. (Melinda, single, four children, paired interview) Lately I’ve been buying Nutri-Grain and Honey Puffs and I think they get hungry faster than if they have just Weet-Bix or porridge. Porridge lasts longer. (Naomi, married, three children, interview)

The Breakfast Experience in Low Socioeconomic Families … 97 Breakfast cereals that are high in sugar were generally recognised as being poor choices. Commonly mentioned examples were those that are heavily promoted to children, such as Coco Pops and Froot Loops: I know that all the cereals are bad. A lot of people get tricked with the cereals, like I’ve got Coco Pops and stuff, but I only let them have that on the weekends. (Claire, married, two children, interview) These assessments coincide with those of a major nutritional review of Australian breakfast cereals by CHOICE (2010), the nation’s primary consumer organisation. However, with almost 200 cereals on the market, the participants found themselves struggling to evaluate the relative and absolute healthiness of many other product offerings. None of the participants mentioned referring to the nutrient information panel on cereal packets, instead relying on marketing information located on the front of the pack and contained in advertisements and word-of-mouth communications received from family and friends: I’ve got issues with Cheerios though. I think they’re good - it says good stuff on the package. (Claudia, single, one child plus foster children, interview) My kids love Nutri-Grain, and I always thought Nutri-Grain was good. Then not long ago I got told, ‘No, it’s really bad. It’s like Coco Pops.’ So I won’t let my kids eat Coco Pops or Froot Loops…I think it was my brother who said, ‘Nah’, and he was watching something on the TV and he was like, ‘Nutri-Grain is really bad. You might as well give them Froot Loops.’ Yeah, he said, ‘Nah, it’s really bad for them.’ And then my mum was like, ‘Yeah it’s really high in sugar.’ I didn’t know that. (Marion, single, two children, interview) In their evaluations, participants focused mainly on added sugars, and to a lesser extent fibre. There did not seem to be an appreciation that breakfast products may also be high in salt and fat and that a range of other important nutrients are contained within breakfast foods (e.g., folate, iron, zinc, magnesium, potassium, and vitamins A, B6, B-12, and C: Deshmukh- Taskar et al., 2010). I’m also aware of how bad our cereals are, and the sugar that’s in it. Elise is going to the dentist and they have to do a lot of work on her teeth, and I think it’s just those little incidental things that you don’t think are bad, like your cereal. And because I have Special K and the ad says, ‘It will keep you looking good if you have special K’, and um, and I thought I was doing really good. But when I went to the dentist and that was one on their list to say that it was high in sugar, but when you eat it, I can’t taste sugar in it, so to me it doesn’t taste like there’s sugar in it. So they have Cheerios, which I don’t think are fantastic either way. (Marilyn, married, three children, interview) I like Weet-Bix. To me it’s a good solid, fibre to start off the day with. (Rachel, married, three children, interview) There appeared to be a general belief among participants that there exists a nutritional hierarchy among breakfast foods that has a cooked breakfast at the top, followed by healthy cereals, then less-healthy cereals, then bread. Fruit was also considered to be appropriate breakfast food, although inadequate on its own to constitute a complete breakfast.

98 Simone Pettigrew and Melanie Pescud Ezra is right into having an omelette for breakfast, a one-egg omelette. I think that’s quite healthy, so I’m thinking it’s better than bread. (Natasha, living with partner, two children, interview) Depending on how I go with my shopping, they’re allowed to pick out a special cereal, which usually lasts two days because they will eat it a lot. Like things like Coco Pops. But now I’ve got a bit relaxed with the shopping and they will eat that over eating Weet-Bix and it’s just not sustaining them. They’re still hungry, but they have toast in the morning as well, but they’re still hungry before recess. (Laura, married, four children, interview) The assumption that a cooked breakfast is the ideal way to provide the energy needed by children for their daily activities runs counter to research that has found the consumption of such foods to be more likely to be associated with higher BMI and lower intake of positive nutrients compared to children consuming cereals (Barton et al., 2005; Deshmukh-Taskar et al., 2010; Preziosi et al., 1999). However, the belief among some participants that high-sugar cereals constitute a better alternative to bread products may also be problematic. At 37% sugar, it is unlikely that Coco Pops was a superior choice to bread in the context described in the quote below: He’d generally always just have his two slices of toast in the morning, and by that stage it’s just like, ‘Come on mate you’ve got to have something else.’ I’m thinking, ‘I don’t care if it’s a bowl of Coco Pops you know, you can’t have your two slices of bread in the morning and then have a sandwich, you know, like your two slices of bread for your sandwich.’ And then, depending on what we would have for dinner, he’d have a slice of bread to dip in. And it’s like, ‘That’s too much bread, you’ve got to have cereal.’ So yeah, now he pretty much just gets into his Coco Pops and his Rice Bubbles. (Brenda, single, two children, interview) Related to the hierarchy concept was the perception that more breakfast food is better than less. The overall healthy connotation of the breakfast meal appeared to translate into a desire among parents to get as much food into their children as possible at this meal. This was most notable among those parents who prided themselves on having children who would eat healthy breakfast foods: I pour a bowl for cereal for her the same size as mine, you know, because I just don’t want her to go hungry. But it is the wholegrainy sort of cereals, like porridge and that. (Carey, married, two children, interview) Kaden, a little while ago at 18 months, he’d be having five Weet-Bix to himself, and he’d want more. We were just like, ‘Where does it all go?’ (Laura, married, four children, interview) Compliance Issues Some parents acknowledged that they often skipped breakfast themselves, and that their children were aware of their failure to live by the rules they attempted to apply to the younger members of the family. These participants felt that their own suboptimal breakfast behaviours made it difficult for them to legitimately require their children to consume a healthy breakfast:

The Breakfast Experience in Low Socioeconomic Families … 99 I always tell him, ‘Mate you have to have breakfast before you go to school. You need to be able to concentrate, it will help you concentrate. You have to have breakfast.’ But yeah, I feel like a bit of a fool because I don’t eat breakfast, I don’t eat lunch. (Brenda, single, two children, interview) They have got all my bad habits I think. They won’t eat breakfast. (Yvette, single, three children, interview) The situation can become considerably more complicated where parents are estranged or in a fractious relationship, and hence may not communicate a unified message about the kinds of foods that are most appropriate for breakfast. In the quote below, Claudia explains below that when children spend time with the other parent, it may not be possible to maintain a healthy breakfast routine: The mum needs the dad to come and back it up. They (fathers) just think it’s okay to give them what they want to shut them up. That’s parenting the wrong way, but that’s their prerogative because they’re dad. (Claudia, single, one child plus foster children, interview) Discussion Previous research examining children’s breakfast consumption behaviours has mainly focused on the act of breakfast skipping and its correlates (Barton et al., 2005; Cheng et al., 2008; Deshmukh-Taskar et al., 2010; Delva et al., 2006; Dubois et al., 2006; Sampson et al., 1995; Shaw 1998; Tin et al., 2011; Vanelli et al., 2005). The few studies that have identified the range of characteristics and behaviours associated with breakfast skipping have typically surveyed adolescents (e.g., Kapantaisa et al., 2011; Miech et al., 2006; Niemeier et al., 2006; Thompson-McCormick et al., 2010). There is thus a lack of research relating to younger children and the factors affecting their breakfast consumption behaviours. The present study accessed the lived experiences of low SES parents of overweight children to explore the factors that influence their children’s breakfast-related behaviours. As noted in the literature, it is important to focus on low SES children in this context because of their higher levels of obesity and their less favourable breakfast consumption habits (Miech et al., 2006). The selection of families with younger children reflects the importance of this developmental stage for food-related preferences and habits (American Dietetic Association, 2004). The main themes to emerge from the research were (1) parents’ perceived lack of control over their children’s consumption of unhealthy breakfast foods, (2) inadequate knowledge relating to optimal breakfast foods, and (3) the potential for more consistent parental modelling of breakfast consumption. Given the few previous studies that have explored this issue from the perspective of parents of young children, there is little prior research with which to compare these findings. It appears that this is among the first studies to provide a detailed qualitative analysis of how lower SES parents attempt to cope with the various factors that can impede their efforts to ensure their children consume a healthy breakfast each day.

100 Simone Pettigrew and Melanie Pescud The finding that some parents perceive they must make a trade-off between their children eating sub-optimal breakfast foods and not having breakfast at all suggests that they are not fully appreciating their role of food provider. While children are still young, parents largely have control over the food options available (Birch and Fisher, 1998). Food preferences are determined early in life (American Dietetic Association, 2004), and it often takes repeated samples of foods to foster a liking for them (Birch et al., 1987; Birch and Marlin, 1982). As genetic predisposition makes foods high in sugar, fat, and salt highly palatable, it can take effort to cultivate preferences for healthy foods in the presence of these alternatives (Blass, 2003). This phenomenon has resulted in unhealthy foods being labelled ‘competitive foods’ (Bhatia et al., 2011), as by their very presence they can discourage the consumption of healthy foods. The tendency for parents in this study to frequently purchase high sugar cereals is likely to create an environment in which their children reject healthy options because of the ready availability of ‘tastier’ alternatives. Interventions may be needed that focus on encouraging parents to persevere in developing a preference for healthy breakfast foods in their children from a very early age and to ensure unhealthy options are generally unavailable in the home. Related to this issue of product alternatives is the opportunity to provide parents with clearer information about the nutritional quality of the large number of breakfast cereals on the market. The tendency for the participants to rely on word-of-mouth and marketing communications rather than the detailed, accurate information contained in the nutrition information panel located on the back of food packages highlights the need for nutrition information to be provided in a more user-friendly manner. Numerous studies have demonstrated the efficacy of easy-to-understand front-of-pack nutrition labels in providing consumers with information that they can use to select between competing product offerings (for a review see Grunert et al., 2012). ‘Traffic light’ front-of-pack food labels that indicate whether levels of nutrients such as fat, sugar, and salt are low, medium, or high have been found to be especially effective in conveying nutrition information to low SES consumers who are likely to lack literacy skills (Borgmeier and Westenhoefer, 2009; Gorton et al., 2008; Kelly et al., 2009; Louie et al., 2008). The findings of the present study suggest that efforts to implement a front-of-pack labelling system that is readily comprehensible to low SES parents could assist them in their efforts to navigate the cereal aisle to select products that are appropriate for daily consumption by their children. Finally, the findings highlight the need to address food consumption issues at the family level to ensure that parents are both facilitating a healthy diet for their children and modelling the consumption of this diet. The importance of parental modelling in preventing and treating child obesity is depicted in Golan’s (2006) model of family-based health. This model emphasises the need for parents to have appropriate knowledge and skills to enable them to influence their children’s weight status via two pathways: (1) directly through communication about healthy eating and the setting and enforcement of appropriate household rules and (2) indirectly by modelling the desired behaviours. The findings from the present study indicate that low SES parents can struggle to establish rules relating to appropriate breakfast behaviours and to model compliance with these rules. This suggests that interventions may need to focus on providing parents with the knowledge and skills required to achieve these outcomes. As noted by Niemeier et al. (2006), the specific nature of breakfast consumption behaviours can facilitate the development of targeted interventions that aim to modify the factors influencing these behaviours.

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In: Child Nutrition and Health ISBN: 978-1-62257-981-5 Editors: G. Cvercko and L. Predovnik © 2013 Nova Science Publishers, Inc. Chapter V Early Vitamin D Supplementation, Immune Modulation and Allergy Gian Vincenzo Zuccotti and Valeria Manfredini Department of Pediatrics, Luigi Sacco Hospital, University of Milan, Milan, Italy Abstract A daily Vitamin D (VitD) intake of at least 400 IU/day is recommended nowadays by most updated guidelines during the first year of life. However, it is not known whether such an intake is enough to provide all the health benefits associated with VitD and a consensus is still missing stating the serum vitD levels appropriate for global health and the cutoffs for deficiency in younger individuals. Potent immune-modulating effects of VitD have been reported in vitro and, in particular, its potential ability to influence both innate and adaptive immunity, reducing the inflammatory response associated with Th1 and Th17 cells and skewing the T cell balance towards a Th2-phenotype. VitD immune-modulation activities could thus play a role in controlling infections and reducing inflammatory responses toward viral pathogens in both children and adults. However, the evidence in relation to vitD and allergic diseases is controversial. Most evidence report a protective effect of vitD against allergy. Some studies, however, suggest that VitD supplementation can be a risk factor for asthma and atopic disorders, assuming that VitD could induce sensitization against allergens during infancy. In this chapter, published data on the relationship between vitamin D and asthma and allergy will be discussed, emphasizing the need for controlled, prospective studies on vitamin D supplementation to clarify whether it has a role in the prevention of and treatment for asthma and allergic conditions. Introduction In younger individuals, Vitamin D (VitD, cholecalciferol) deficiency and insufficiency lack a precise definition. The recent guidelines issued by the American Academy of

108 Gian Vincenzo Zuccotti and Valeria Manfredini Pediatrics, the Canadian Pediatric Association and the Institute of Medicine recommend, however, a daily intake of VitD of 400 IU/day during the first year of life to target a serum value for 25(OH)D of at least 50 nmol/L (20 ng/mL)[1-3]. This value is supposed, in facts, to meet the needs of nearly all children and is lower than that recommended by some experts referring to adult population [4], for which there is no consensus either [5]. Owing to the recent evidence regarding its immune-modulatory properties, it has been postulated that VitD can be involved in the pathogenesis of several diseases associated with pathological Th1 phenotypes (multiple sclerosis, juvenile rheumatoid arthritis and type 1 diabetes) or Th2 responses (lupus erythematosus sistemicus) [6-9]. Moreover, VitD immune- modulation activities may also act in controlling infections and reducing inflammatory answers toward viral pathogens in both children and adults [10]. The evidence related to VitD and allergic diseases is, however, controversial. Even if most studies report a protective role, some suggest that VitD supplementation can be a risk factor for asthma and atopic disorders, suggesting a VitD-triggered sensitization against allergens during infancy [11-16]. The industrial revolution has dramatically reduced the daily sun exposure, increasingly moving the everyday life from outdoor to indoor and promoting the growing prevalence of obesity in both adults and children [17]. Altogether, these lifestyle changes have favoured the reduction of VitD plasma levels and led to the growing prevalence of VitD insufficiency and deficiency along with its consequences on bone health [18, 19]. Especially in Western countries, where VitD insufficiency is a surprisingly common finding, the concurrent rising pandemic incidence of allergic diseases has lead some investigators to consider VitD playing a major role in the prevention and treatment of several atopic disorders among which are asthma and skin eczema [20]. Since 1999, conversely, Wjst and Dold have supported the idea that the observed increase in asthma and allergy was the consequence of a widespread VitD supplementation used for rickets prophylaxis, appealing to the immune modulating properties of 25-OH-D possibly driving the Th2 responses and favouring the development of allergic phenotypes [11, 12]. Following such theory, other authors have attributed the initial sensitisation against allergens during the newborn period to undetermined and undefined immunological effects of vitamin D supplements used for rickets prevention [14, 15, 21]. Undoubtedly, Vitamin D plays a complicated role and interacts with the genetic predisposition of each single individual, the modification of the lifestyle habits following the growth of industrialisation and the increasing exposure to pollution in the environment, possibly bridging immune function, inflammatory/infectious and allergic diseases. Vitamin Metabolism and Immune Modulation VitD is a secosteroid that shares a close structural and functional resemblance to steroids and acts on target cells with a similarly hormone-like mechanism, binding a specific nuclear Vitamin D receptor (VDR). The ligand receptor complex derived from this interaction acts on specific DNA sequences called the “vitamin D responsive elements” and allowing the transcription of several molecules, among which are proteins involved in the calcium- phosphate metabolism [22].

Early Vitamin D Supplementation, Immune Modulation and Allergy 109 In humans, VitD is mainly produced from cholesterol in the skin after ultraviolet B exposure and is called cholecalciferol. A lesser amount of the vitamin is directly ingested with vegetables and some fungal sources and is known as ergocalciferol (Vitamin D2). To become active, VitD undergoes a two-step hydroxylation process. Two enzymes are involved, the first located in liver cells and leading to the production of the mono-hydroxilated form, the 25-OH-D, and the second, the 1-α-hydroxylase enzyme, found in kidney proximal renal tubule cells and allowing the conversion of the 25-OH-D to its final bioactive form, the 1, 25(OH)2D. In humans, the 25-OH-D accounts for the major amount of the circulating element [23]. In the text, however, we will refer alternatively to VitD as cholecalciferol, 25-OH-D or 1, 25(OH)2D. For many years, the role of VitD in immune modulation has been postulated observing that infants with rickets underwent respiratory infections more frequently than infants without rickets [24]. Nowadays, this theory has found support in the evidence that the 1-α- hydroxylase enzyme, the key-step of the activation cascade, is present not only in the renal tissue but also in cells of the immune system and that the VDR is similarly found in T cells, B cells, NK cells, and monocytes. Moreover, at least four VitD receptors genes exist as heritable traits, thus possibly making VitD sensitivity a genetically determined individual peculiarity [25]. The activation of the VDR has so called non-classical effects including the modulation of growth, differentiation status and functions of various immune targets, especially playing a role in T and B cell regulation. In particular, over 102 genes have been identified in CD4+ T cells being targeted by the VitD [26]. Cholecalciferol-related anti-inflammatory and immune-regulatory properties have been largely analyzed mainly by studies in vitro. Starting from innate immunity, research has shown that VitD inhibits the expression of the Toll-like receptors (TLRs) on monocytes and reduces the TLRs-mediated inflammatory cascade [27]. In addition, VitD acts hosting the differentiation of macrophages into Dendritic Cells (DCs), promoted by the exposure to antigens part of the microbial surface (e.g. the lipopolysaccharides). This process not only leads to the inhibition of DCs maturation, activation and survival but also determines a reduced stimulatory activity on T cells and a decrease of their inflammatory mediators release [28, 29]. Among all cytokines and chemokines produced by the DCs and inhibited by the interaction with VitD are the IL-12 and IL-23, which are major drivers of the Th1 and Th17 differentiation [30]. Not surprisingly, the pro-inflammatory response associated with Th17 cell phenotype has resulted to be similarly inhibited in both mice and humans supplemented with cholecalciferol [31]. In addition, animal models have shown that VitD enhances the T cell proliferation after antigen exposure and, in particular, the Th2 lymphocyte cytokines (IL-4 and IL-13), possibly skewing the T cell balance towards a Th2-phenotype [32]. Moreover, murine studies have shown that the active vitamin D hormone, the 1, 25(OH)2D, is able to promote an immune response with interleukin IL4- and IL13-driven IgE production in mice genetically non-biased for TH2-type responses [33]. However, information related to this issue are still controversial [34, 35]. Further animal models, in particular, have shown that VitD supplementation is also accompanied by the increase of an anti-inflammatory answer and enhanced regulatory response from driven T cells. This is supported by data showing that cholecalciferol does not solely sustain and modulate the T helper function, but also regulates the T regulatory cell (Treg) activity [36]. To further sustain of this issue, it was shown that VitD stimulates the

110 Gian Vincenzo Zuccotti and Valeria Manfredini DCs to release not only IL-10, which has broad-spectrum anti-inflammatory activities, but also the chemokine MIP-3α, which is involved in the recruitment of CCR4-expressing Treg [37]. Besides DCs, also the antigen-presenting and T-cell stimulatory capacities of monocytes/ macrophages are greatly inhibited by the 1, 25(OH)2D. This is demonstrated by the inhibitory effect of the 1, 25(OH)2D on the surface expression of MHCII and co- stimulatory molecules, such as CD40, CD80, and CD86 on antigen presenting cells [38, 39]. Finally, physiologically relevant concentrations of 1, 25(OH)2D have proven to enhance autophagy in human macrophages, possibly playing a key role also in the defence against opportunistic infections [40]. In summary, the 1, 25(OH)2D indirectly shifts the CD4+ T-cell polarization from an inflammatory Th1 and Th17 to a Th2 and regulatory T-cell phenotype. How the Th2 or the Treg dominance is prevailing during supplementation with cholecalciferol and whether VitD induces or decreases, respectively, the in vivo antigen sensitisation is still an open question. Maternal Vitamin D Supplementation and Allergy Most recent evidence is sustaining the hypothesis that VitD exposure might influence the predisposition to allergies already in utero and soon after birth, during the first developmental phases of the immune system [41]. During pregnancy, the foetus is exposed to vitamin D that crosses the placenta through the cord blood and is entirely dependent on its mother for supply. Thus, reduced concentrations of 25-OH-D and poor maternal intakes during pregnancy may reflect in the infant at birth and decrease VitD stores during the first months of life [42]. An inverse association between maternal 25-OH-D intakes during pregnancy and the risk of childhood wheezing was demonstrated in a well designed longitudinal prospective study performed in Japanese population by Miyake and colleagues. Authors were the first to find that maternal intake of total dairy products, milk, especially full-fat milk, cheese and calcium during pregnancy was independently related to a decreased risk of wheeze in children aged 16 to 24 months. Moreover, they found that children whose mothers had consumed daily 4.309 mcg (≈ 100 IU) or more of vitamin D during pregnancy had a significantly reduced risk of both wheeze and eczema [43]. Later on, a retrospective analysis by Algert and colleagues, including a large birth cohort of 240, 511 singleton infants born during 2001-2003, found a significantly increased risk of asthma in children conceived and born in autumn and winter seasons. To explain such seasonal variations, authors assumed that the prevalence of the disease was inversely related to the lower levels of VitD, resulting from a reduced sun exposure during the first trimester of pregnancy [44]. When cord blood 25-OH-D levels were used to assess the association between VitD status at birth and allergic outcomes, contrasting findings were observed. Rothers and colleagues found that both low (<50 nmol/L) and high (≥ 100 nmol/L) levels of cord VitD were associated with increased total IgE and detectable inhalant allergen-specific IgE up to 5 years of age. Notably, however, the 25-OH-D levels were not significantly related to allergic symptoms such as rhinitis or asthma [45]. Camargo and colleagues similarly found no association between the 25-OH-D cord-blood levels and asthma incidence. However, an

Early Vitamin D Supplementation, Immune Modulation and Allergy 111 inverse relation emerged between recorded vitamin D cord-blood concentrations and the risk of respiratory infection and childhood wheezing. Direct measures of maternal levels of 25-OH-D were taken by Gale and colleagues [46]. The authors showed that 25-OH-D concentrations greater than 75 nmol/L (30ng/mL) during late pregnancy significantly related to a higher risk of atopic eczema at 9 months, and asthma at 9 years in the offsprings. Maternal circulating 25-OH-D concentrations were similarly measured during pregnancy in a population-based study including a large birth cohort of 1724 newborns [47]. One year after delivery, data were collected regarding the incidence of a physician-confirmed history of lower respiratory tract infections or a history of wheezing during the first 12 months of life in their children. The same questions about wheezing were annually repeated thereafter and asthma was defined as parental reporting of doctor’s diagnosis of asthma or receiving treatment at the age of 4 to 6 years or wheezing since the age of 4 years. Results showed that higher maternal circulating cholecalciferol levels were independently associated with a decline in the risk of respiratory tract infections but the same relation was not confirmed for wheezing and asthma. Finally, maternal circulating 25-OH-D levels were more strongly associated with the risk of respiratory tract infection in the offspring born during autumn and winter months, when maternal Vitamin D mean seasonal levels were presumptively lower. Even though such reports suggest that low VitD levels may play a part in the etiopathogenesis of asthma and allergy, it must be noticed that none of the available studies measured VitD directly in newborns, simply looking at maternal intake, season of birth, cord or maternal blood concentrations of cholecalciferol as a proxy for its levels of exposure in the newborns, mostly neglecting the contribution of UV radiation to physiological status. It must be also considered that confounding factors should be taken into account when different populations are studied. Consumption of fish, for example, provides a great amount of n-3 fatty acids but is also a major source of VitD in some population, for example the Japanese [48]. In American women, instead, Vitamin D is mainly ingested through fortified milk that lacks in polyunsaturated fatty acids. Such differences could explain why, in the above mentioned study from Miyake and colleagues, the inverse relation between maternal VitD supplementation during pregnancy and wheeze occurrence in Japanese children was found only after data were adjusted for maternal docosahexaenoic and α-linolenic fat acid intake assumed through fish consumption and contemporarily increasing the VitD intake. Finally, it must be noticed that in most studies a weak relationship was found to exist between VitD levels and asthma in childhood. Whereas, the inverse association found between VitD status and wheezing occurrence was stronger and might be attributed to the immune-modulatory, anti infectious and anti inflammatory properties related to the vitamin and better described in the next paragraph. Vitamin D and Asthma Examining the outcome of an early VitD supplementation on the course of asthma among other allergic diseases in children still produces controversial results. In a birth cohort study from Finland, subjects regularly supplemented during the first year of life with a VitD dose of 200 IU/day, that is lower than that suggested nowadays, have shown to develop a significant

112 Gian Vincenzo Zuccotti and Valeria Manfredini higher risk of asthma, atopy, and allergic rhinitis during adulthood than unsupplemented controls [15]. In the same year, another study analysed data from more than 8000 patients provided by the National Centre for Health Statistics (USA) and similarly found that early VitD supplementation was associated with an increased risk of asthma in black children and food allergies in exclusively formula-fed children [14]. Notably, none of these studies provided VitD concentrations obtained from children’s blood samples. In older children, studies in vivo using VitD as a biomarker mainly attribute to cholecalciferol a protective role and find an inverse relation between VitD plasma concentrations and the incidence of asthma and allergy symptoms, confirming similar reports from the adult population [13]. Brehm and colleagues were the first to analyse the relationship between measured 25- OH-D levels and markers of asthma severity in children selected during a family-based cross- sectional genetic study of asthma in Costa Rica [49]. The authors found that lower cholecalciferol levels, less than 75 nmol/L (30 ng/mL), were more frequent in children with asthma. In these patients, minor VitD concentrations were not only associated with increased asthma severity, but also with total IgE and eosinophil count. The association between vitamin D and serum IgE levels was similarly investigated in a group of asthmatic children and adults compared with healthy controls (HC). Remarkably, although prevalence of low VitD levels, less than 20 ng/mL, was similar in both patients and HC (47.6% versus 56.8%), in paediatric asthma group, VitD measures were inversely related to IgE serum concentration and the daily inhaled corticosteroid dose [50]. The role of 25-OH-D has been also assessed in prospective analysis. Hollams and colleagues, for example, described the results obtained from 989 six-year old and 1,380 fourteen-year old subjects from an unselected community birth-cohort [51]. When VitD levels were assessed as a risk modifier for respiratory and allergic outcomes, authors confirmed that VitD concentrations at age 6 and 14 years were predictive of allergy and asthma outcomes at both ages. More importantly, VitD levels at age 6 resulted predictive of atopy and asthma- associated phenotypes at age 14 years in males. The reduced incidence of asthma exacerbation and gravity observed in vivo may find explanation by virtue of 25-OH-D normal plasma concentrations favouring a better control of infections altogether with the reduction of the inflammatory responses toward pathogens. Through its influence on innate immunity, in fact, it has been demonstrated that VitD favours the expression of the human cathelicidin antimicrobial peptide (CAMP), enhancing monocytes/macrophages’ activity also against the mycobacteria [52]. Beside CAMP, it was also shown in vitro that 1, 25(OH)2D targets the gene of the defensin β2 in a variety of cell types including myeloid cells, keratinocytes, neutrophils and bronchial epithelial cells [53]. This is particularly relevant in providing support to the host defence against respiratory tract pathogens and reducing the impact of asthma exacerbations in affected patients. Moreover, it has been proved that 1, 25(OH)2D modulatory properties on the regulatory T cell function and interleukin-10 production might also enhance the therapeutic response to glucocorticoids in steroid-resistant asthma [54]. Despite data regarding VitD status and its effect on asthma pathophysiology are still lacking, studies in both animals and humans have also been investigating a possible relationship between serum VitD concentrations and lung structure. Data on mice have shown, in fact, that VitD deficiency is related to deficits in lung function, primarily explained by differences in lung volume [55]. Further data in animal models have suggested that 1,

Early Vitamin D Supplementation, Immune Modulation and Allergy 113 25(OH)2D plays as a local paracrine and autocrine effector of fetal lung maturation and affects fibroblast apoptosis. Moreover, both 1, 25(OH)2D and its 3-epimer have been proven to act on interstitial lung lipofibroblasts (LF) and alveolar type II (ATII) cell differentiation, at once stimulating LF and ATII cell proliferation thorough the inhibition of their apoptosis [56]. Studies in vivo from the adult population have similarly confirmed the role of VitD in maintaining and supporting an adequate lung development [57]. In children, Gupta and colleagues have studied VitD levels and different lung function test parameters in a cohort of 86 patients with therapy resistant or moderate asthma, compared with healthy controls [58]. A positive relationship was found between FEV1, FVC and vitamin D concentrations in all subjects. VitD levels were also inversely related with exacerbations and inhaled steroid in both moderate and severe asthma patients. Not surprisingly, an inverse relation was recorded between airway smooth muscle mass obtained through fiberoptic bronchoscopy and the plasma levels of the vitamin. Vitamin D and Allergic Skin Diseases Most of the present data regarding the relation between VitD and food allergy mainly focus on atopic dermatitis (AD) to indirectly assess the impact of VitD on allergic skin diseases. Camargo and colleagues first attempted to investigate the relationship between VitD supplements during pregnancy and AD among other allergic diseases [59]. Authors described a decreased risk of recurrent wheeze in children whose maternal VitD intake was higher during pregnancy. However, they could not prove an inverse relation between VitD concentrations and AD occurrence. Conversely, further analyses performed shortly after demonstrated that higher maternal serum levels as so as greater intakes of VitD during childhood were related to a heightened risk of developing AD, collectively supporting the hypothesis that increased 25-OH-D concentration might take part in the pathogenesis of allergy-related skin disease [46]. A recent observational study was performed to assess the severity of atopic disorders in relation to VitD levels in 37 children aged 8 months to 12 years. In their analyses, authors described a higher prevalence of severe AD in patients with mean 25-OH-D serum levels always below 30 ng/mL [60]. In a recent analysis, Goetz and colleagues investigated the possibility of therapeutic benefits related to the use of VitD to treat idiopathic itch, rash, and urticaria symptoms in 63 patients 3 to 80 years of age [61]. In their results, significantly lower levels of 25-OH-D at baseline were described in responsive patients as compared to subjects unresponsive to VitD supplementation, thus supporting the idea that symptoms may resolve or improve through the correction of a detrimental VitD status. To date, randomised controlled trials investigating the role of VitD supplementation on allergic eczema in children are missing. In adults, randomised-controlled studies have been performed in order to test the benefits of a supplementation with cholecalciferol versus placebo in patients suffering form AD [62, 63]. Collectively, results have shown that VitD supplementation dramatically changes the course of AD in the treatment group, improving symptoms and reducing atopic dermatitis scores used to stage the extension of the disease.

114 Gian Vincenzo Zuccotti and Valeria Manfredini Few studies have investigated the potential relationship between VitD and other allergic skin diseases such as urticaria. Data from the adult population have suggested that significantly reduced values of VitD levels are found in subjects with chronic urticaria as compared to controls [64]. Both enzymes required to convert 25-OH-D in its active dyhidroxilated form are found in keratinocytes of the skin [65]. The VitD produced in-loco acts on the VDR that is expressed in proliferating cells and, in particular, is present on basal keratinocytes. Recent data from studies in vitro have shown that VitD attenuates and timely resolves the inflammatory skin responses induced by external injuries [66]. In mice models, the activation of the VDR in the skin has also been related to the improvement of the allergen-triggered eczema [67]. Data are missing to confirm the same in humans. It can’t be excluded, however, that VitD may favour the reduction of symptoms in atopic eczema through modulation of the antigen oral tolerance. To support such hypothesis, it has been assumed that cholecalciferol could accomplish its immune function in the enhancement of the mucosal defence and thorough modulation of lymphocytes’ function in the local gut microenvironment, thus reducing infective episodes of the gastrointestinal tract. These properties would altogether maintain an healthy microbial ecology and reduce the creation of possible breaches of barrier and violation of other defences that might synergistically promote abnormal allergic responses to food antigens, leading to food allergy in predisposed subjects [68]. A potential explanation to the conflicting connection between VitD and allergic skin diseases might be found in the nonlinear association between 25-OH-D and IgE and a threshold effect with both low and high 25-OH-D levels associated with elevated IgE concentrations [69]. Main limitation to the present available data remain the use of indirect indicator, such as VitD intake during pregnancy or estimated intakes based on dietary questionnaires to test a causal relationship between VitD status and AD in children and the lack of randomised controlled studies in children to prove the efficacy of VitD in preventing and treating allergic skin diseases. Vitamin D and Genetics Genetic factors are undisputed determinants of different, individual response to VitD exposure especially in early life. As effects of VitD are primarily mediated through VDRs, single base variant genes have been investigated as risk factors for allergic diseases. In a cross sectional study, Wjst analysed 13 Single Nucleotide Polymorphisms (SNPs) in the VDRs gene obtained from 951 individuals belonging to 224 different lines of descents with at least 2 asthmatic children and altogether providing 11.383 genotypes [70]. In unaffected siblings, the expression of specific VDR-SNPs was more pronounced, resulting from an “excess of transmission”, demonstrated independently from age. The SNPs prevailing in the unaffected group also showed to be inversely related with a quantitative measure of the bronchial hyper- reactivity, calculated through the analysis of the slope of the dose-response curve in a standardised methacoline challenge protocol. It was thus proposed that the preferential

Early Vitamin D Supplementation, Immune Modulation and Allergy 115 transmission of some particular VDRs variants could possibly be protecting against asthma rather than predisposing to the disease. SNPs were also tested to examine whether well-established genetic variants could modify the relationship between a VitD deficient status (VDD) and food sensitisation (FS). VDD was assessed in cord blood and defined as 25-OH-D < 11 ng/ml, whereas specific IgE ≥ 0.35 kUA/l to any of eight common food allergens in early childhood were used as a cut-off to define FS. SNPs were analysed among 11 genes including: molecules critical to the synthesis and regulation of plasma IgE; genes encoding for the interleukin-4 and interleukin-13 (IL4 and IL13) and their receptors (IL4R and IL13RA1), genes encoding the IgE receptor complex and main genes encoding the molecules essential for 25-OH-D metabolism and regulation. Results showed that VDD was associated with FS only when examined jointly with SNPs and mainly referring to a particular IL4 gene polymorphism (rs2243250) supporting that VDD can increase the risk of FS only among individuals with certain genotypes, and highlighting the gene–vitamin D interaction on FS and athopic eczema [71]. It has been also speculated that common rickets may derive, in the absence of proper endogenous VitD production, from a genetically determined “low sensitivity” form, and allergy from a “high sensitivity” form, in the presence of oral VitD exposure [72]. A preferential transmission of certain VDRs variants in children with allergic phenotype and in unaffected can not be confirmed yet and further studies are needed to clarify this issue. Conclusion Vitamin D is the key element and the gold standard for the prevention and treatment of rickets and osteomalacia. Recent data prove that the spread practice of Vitamin D supplementation in early lives has coincided with the rise of the allergic pandemic [15, 16, 68]. Contemporarily, there’s a growing evidence supporting VitD to exert immune modulatory activities, conceivably conferring protection against airways and gastrointestinal tract infections and providing anti inflammatory benefits in humans. From one side, such virtues have been held up as mechanisms, which possibly confer a VitD related benefit against the allergic march and other allergic diseases. On the other hand, the VitD related Th2 increase observed in vitro has focused the attention on cholecalciferol to be possibly involved in the development of the allergic phenotype in genetically predisposed individuals. However, there’s no univocal statement about this issue. As the impact of rickets on global health has been dramatically reduced by the introduction of VitD supplementation, and being major guidelines established according to bone health outcomes, randomised controlled trials are needed to clarify secondary effects related to VitD supplements. Indeed, the first few months of life seem to be particularly immunologically impressionable and the impact of an early supplementation with VitD on the immune system and allergic phenotype development has not yet been examined. Genetic predisposition and family history along with the entire amount of all possible unknown interfering factors impacting on the individual answer to a standardised intervention need to be further investigated to guarantee benefits other than that proved for bone health and metabolism.

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In: Child Nutrition and Health ISBN: 978-1-62257-981-5 Editors: G. Cvercko and L. Predovnik © 2013 Nova Science Publishers, Inc. Chapter VI Factors Associated with Overweight and Obesity among Kuwaiti Young Children A. N. Al-Isa1, Nadeeja Wijesekara2, Ediriweera Desapriya3 and Yamesha Ranatunga4 1Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, University of Kuwait, Kuwait City, Kuwait 2Department of Medical Genetics, Centre for Molecular Medicine, and Therapeutics, Child and Family Research Institute, University of British Columbia, Vancouver, British Columbia, Canada 3Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada 4Department of Food Nutrition and Health, University of British Columbia, Vancouver, British Columbia, Canada Abstract Background. Childhood obesity is becoming a global epidemic which may result in increased morbidity and mortality during young adulthood. Objectives. To identify common factors associated with overweight and obesity among Kuwaiti intermediate school children aged 10-14 years to support Kuwaiti obesity prevention policy making. Methods. Weights and heights of 343 female and 340 male students were collected to obtain body mass index (BMI). Results. The prevalence of overweight and obesity were 21.9 and 6.4% among females and 22.9 and 7.6% among males, respectively. Risk factors for obesity in males and females vary considerably and also differ between age groups. Conclusion. Health education programs focused on reducing obesity in Kuwait must be multifactorial in nature and should be defined by gender and age group.  Correspondence should be addressed to Ediriweera Desapriya [email protected] T. 604 875 2000 Ext.6707, F. 604 875 3569.

122 A. N. Al-Isa, N. Wijesekara, E. Desapriya et al. 1. Introduction The widespread increase in the prevalence of overweight and obesity is a matter of great concern. The serious health, social and economic impacts of this major public health issue led the World Health Organization to recommend the continued surveillance of the population's prevalence of obesity, using body mass index (BMI) as the indicator [1]. The fundamental cause of weight gain is energy intake that persistently exceeds energy expenditure. However, obesity is considered to be the result of a heterogeneous group of conditions, including physical, social and behavioral elements [1]. Current prevalence and time trends in obesity seem to reflect changing lifestyles in a changing environment. To further this, it has been assumed that easy access to highly palatable foods induced excess consumption and that obesity is due to lack of food avoidance by affected subjects [2, 3]. Regardless of cause, obesity is a major public health concern primarily due to its well-recognized association with important chronic disease conditions, including heart disease, stroke, diabetes, hypertension, elevated blood lipids, osteoarthritis, and cancer [1]. Childhood obesity, defined as BMI greater than or equal to the 95th percentile is currently on the rise in its prevalence world-wide. Same risk factors apply here, although the greatest risk factor is considered as obesity of the parents. The issue of childhood obesity in the Middle East, Kuwait in particular, will be addressed in this paper. Among children, family history of obesity, diet, physical activity and mother’s education have significantly correlated the development of obesity in the United Arab Emirates [4]. A previous study of primary age (6-10 years) males in Kuwait determined that there were a variety of additional factors associated with overweight and obesity; however, having one or more obese brothers, an unemployed father or a high (>11) number of persons living at home were significantly associated with higher risk of overweight and obesity. Increased age and school level as well as having a chronic disease were associated with risk of overweight in primary age males [5]. The purpose of this study was to explore the specific factors that are associated with overweight and obesity among Kuwaiti intermediate school children aged 10-14 years to determine if similar factors can be identified between males and females. The results will also be compared to those of the primary age group to determine implications for obesity prevention policy. 2. Methods 2.1. Sample The sample comprised of 343 female and 340 male intermediate school pupils aged 10- 14 years drawn from their respective schools. Each student was provided with an informed consent form to be filled out by his/her parents and/or guardians. This form explained the non-invasive nature of the study and detailed the procedures. Only students whose caregivers provided informed consent were included in this study.

Factors Associated with Overweight and Obesity among Kuwaiti Young Children 123 2.2. Measurements The three primary measurements taken for this study were age, weight and height. Age was ascertained to the nearest month from the pupil’s civil identification card which was obtained from the school files containing the student’s date of birth. Weight was measured by the author, with the student standing and wearing light clothes to the nearest 0.1 kg, using a precalibrated digital SECA scale which was recalibrated between measurements. Height was measured while the subject was standing without shoes to the nearest 0.1 cm, using a specially designed portable stadiometer with a spirit level to ensure that it was parallel to the flat hard floor during measurement. The BMI, which is the weight in kilograms divided by the height in meters squared (kg/m2), was used as the index of adiposity. 2.3. Data analysis The Statistical Programme for the Social Sciences (SPSS) version 17, PC Windows was used for data analysis. In addition to descriptive statistics, the 2 test was used to assess the association between categorical variables. Logistic regression analysis was carried out using a binary variable: non-obese (BMI <25kg/m2) or overweight [(BMI >25kg/m2)/obese (BMI >30 kg/m2)] as a dependent variable and a number of other variables as independent variables. The merit of the logistic regression approach is that it leads to the adjusted odd ratios (estimated relative risk or RR) of the independent variables in relation to a reference group. A p-value of <0.05 was the criterion of statistical significance. 2.4. Associated Factors Age was divided into five categories 10, 11, 12, 13 and 14. The following domains were broken into sub factors. 2.4.1. Dieting and nutrition Number of major meals into three: 1,2,3; eating between meals into three: yes, no, sometimes; dieting into three: yes, no, was; number of times dieted into four: none, low (1-2), medium (3-4), high (≥5); dieting practice into five: on my own, through a consultant, relatives and friends, through the mass media, does not apply; own nutritional knowledge into three: weak, good, excellent; needing special diet to lose weight into three: yes, no, do not know. 2.4.2. Activities and Interests Practice sports (months per year) into three: 1 (< month), 2 (1-3 months), 3 (>9 months); sport involvement (hours per week) into four: high (≥5), medium (3-4), low (≤2), none; exercising into two: yes, no; countries preferred for visiting into four: western, eastern, both, neither.

124 A. N. Al-Isa, N. Wijesekara, E. Desapriya et al. 2.4.3. Socioeconomics Type of housing into three: rent, government, private; number of rooms in the house into three: low (1-2), medium (3-4) and high (≥5); number of those living at home into four: none (0), low (1-2), medium (3-5), high (≥6); number of servants at home into four: none (0), low (1-2), medium (3-5), high (≥6); family income per month into three: low (< 1500 $), medium ($1500 - $3000), high (>$3000). 2.4.4. Family Number of brothers, sisters and total siblings into four: none (0), low (1-3), medium (4- 7), high (≥8); birth order into three: first, middle, last; number of obese brothers/sisters into four: none (0), low (1-2), medium (3-4), high (≥5); obesity among first degree relatives into four: none (0), low (1-2), medium (3-4), high (≥5); parental obesity into four: neither, father, mother, both; parental education into three: low (illiterate or elementary), medium (intermediate or secondary), high (college or higher); father’s employment status into two: working, not working; relation between parents into three: first cousin, there is, there is not. 2.4.5. Academics Current grade point average (GPA) into three: high (excellent and very good); medium (good), low (low pass and failure); level of education into four: first, second, third, and fourth year; high school studies into two: science, non-science; highest desired degree into three: high school, college, higher. 2.4.6. Health Dental status into three: healthy, treated by dentist, unhealthy; suffering from a chronic disease into two: yes, no; last dental or physical check-up into four: do not remember, more than two years, a year ago, a month ago; describe your health into three: bad, good, excellent; feeling tired often into two: yes, no. 3. Results The prevalence of being overweight and obese were 21.9 and 6.4% among females and 22.9 and 7.6% among males, respectively. Table 1 and 2 show the factors associated with being overweight (BMI>25-30 Kg/m²) and with obesity (BMI>30 Kg/m²) among Kuwaiti intermediate school children aged 10-14 years from a chi-squared analysis of female and male data. For females these factors were age (p<0.05), number of brothers (p<0.01), number of obese brothers (p<0.01), number of meals per day (p<0.05), number of persons living at home (p<0.01), number of servants (p<0.01), monthly family income (p<0.05), sport involvement (hours per week) (p<0.05), high school subjects (p<0.05), dieting (p<0.05), level of intermediate education (p<0.01), number of times dieted (p<0.01) and diet consultation (p<0.001). For males these factors included number of obese brothers (p<0.01), parental obesity (p<0.05), current GPA (p<0.05), last health check- up (p<0.05), dieting (p<0.01), level of intermediate education (p<0.01), self-reported health (p<0.05), number of times dieted (p<0.001), diet consultation (p<0.05) and needing special nutrition program. Table 2 and 3 show the risk factors associated with being overweight

Factors Associated with Overweight and Obesity among Kuwaiti Young Children 125 (BMI>25-30 Kg/m²) and with obesity (BMI>30 Kg/m²) among the same group of students from logistic regression. In the female cohort, the risk of being overweight increased with having no brothers (p<0.05, OR=7.0) in comparison with the reference group who had the most number (≥5) of brothers, decreased among those who did not diet (p<0.05, OR=0.47) in comparison with those in the reference group who dieted, decreased among those in the third (p<0.01, OR=0.34) and fourth level of intermediate education (p<0.05, OR=0.42) in comparison with the reference group in the first level, increased among those with low (1) number of obese sisters (p<0.01, OR=2.75) in comparison with those in the reference group who had none, and decreased among those who did not need a special nutrition program in Table 1. Factors associated with overweight (BMI>25-30 kg/m2) and obesity (BMI>30 kg/m2) among Kuwaiti intermediate female school children aged 10-14 years (n=343) from chi-squared analysis Factor Non-obese Overweight Obese p- value Age group (years) n (%) n (%) n (%) 10 <0.05† 11 48 (19.5) 13 (17.3) 6 (27.3) 12 46 (18.7) 13 (17.3) 7 (31.8) 13 48 (19.5) 20 (26.7) 5 (22.7) 14 74 (30.1) 25 (33.4) 2 (9.1) 30 (12.2) 4 (5.3) 2 (9.1) Number of brothers High (>5) 0.01 Medium (3-4) 14 95.7) 1 (1.3) 1 (4.5) 57 (23.2) 13 (17.3) 10 (45.5) Low (1-2) n (%) n (%) n (%) None 157 (63.8) 47 (62.7) 7 (31.8) 18 (7.3) 14 (18.7) 4 (18.2) Number of obese brothers None <0.01† Low (1) 187 (76.0) 52 (69.3) 11 (50.0) Medium (2) 35 (14.2) 15 (20.0) 5 (22.7) High (3) 21 (8.5) 6 (8.0) 5 (22.7) 3 (1.2) 2 (2.7) 1 (4.5) Number of meals per day 1 <0.05 2 19 (7.7) 4 (5.3) 1 (4.5) 3 71 (28.9) 20 (26.7) 1 (4.5) 156 (63.4) 51 (68.0) 20 (90.9) Number of persons living at 0.01 home 91 (37.0) 37 (49.3) 2 (9.1) Low (<6) 125 (50.8) 33 (44.0) 18 (81.8) Medium (7-10) 30 (12.2) 5 (6.7) 2 (9.1) High (>11)

126 A. N. Al-Isa, N. Wijesekara, E. Desapriya et al. Table 1. (Continued) Factor Non-obese Overweight Obese p- value Number of servants n (%) n (%) n (%) <0.01 None Low (1) 8 (3.3) 5 (6.7) 0 (0) <0.05 Medium (2) 87 (35.8) 23 (30.7) 5 (22.7) High (>3) 97 (39.4) 25 (33.3) 4 (18.2) 53 (21.5) 22 (29.3) 13 (59.1) Monthly family income Low (< 700 KD) 27 (11.0) 8 (10.7) 0 (0) Medium (KD 700- 155 (63.0) 41 (54.7) 12 (54.5) 1500) 64 (26.0) 26 (34.7) 10 (45.5) High (KD >1500) Practice sports (hours/week) <0.05 None 21 (8.5) 8 (10.7) 0 (0) 1-2 hours/week 16 (6.5) 8 (10.7) 1 (4.5) 3-4 hours/week 119 (48.4) 37 (49.3) 16 (72.8) 5-6 hours/week 66 (26.8) 18 (24.0) 5 (22.7) >6 hours/week 24 (9.8) 4 (5.3) 0 (0) High school subjects <0.05 Science 157 (63.8) 58 (77.3) 10 (45.5) Non-science 89 (36.2) 17 (22.7) 12 (54.5) Dieting <0.05 37 (15.0) 19 (25.3) 5 (22.7) Yes 189 (76.8) 43 (57.3) 15 (68.2) No 20 (8.1) 13 (17.3) 2 (9.1) I was Level of intermediate studies <0.01 1 55 (22.4) 27 (36.0) 6 (27.3) 2 55 (22.4) 25 (33.3) 8 (36.4) 3 73 (29.7) 10 (13.3) 5 (22.7) 4 63 (25.6) 13 (17.3) 3 (13.6) Number of times dieted <0.01 None 173 (70.3) 38 (50.7) 11 (50.0) Low (1) 29 (11.8) 11 (14.7) 6 (27.3) Medium (2-3) 27 (11.0) 19 (25.3) 3 (13.6) High (>4) 17 (6.9) 7 (9.3) 2 (9.1) Diet consultation <0.001 Personal 153 (62.2) 45 (60.0) 9 (40.9) Professional 26 (10.6) 6 (8.0) 10 (45.5) Friends/Relatives 41 (16.7) 14 (8.7) 3 (13.6) None 26 (10.6) 10 (13.3) 0 (0)

Factors Associated with Overweight and Obesity among Kuwaiti Young Children 127 Table 2. Factors associated with overweight (BMI>25-30 kg/m2) and obesity (BMI>30 kg/m2) among Kuwaiti intermediate male school children aged 10-14 years (n=340) from chi-squared analysis Factor Non-obese Overweight Obese p- n (%) n (%) n (%) value Number of obese brothers None 169 (71.6) 48 (61.5) 14 (53.8) <0.01 Low (1) 43 (18.2) 17 (21.8) 6 (23.1) <0.05 Medium (2) 17 (7.2) 9 (11.5) 3 (11.5) High (>3) 7 (3.0) 4 (5.1) 3 (11.5) Parental obesity 183 (77.5) 66(84.6) 21 (80.8) None 29 (12.3) 3 (3.8) 2 (7.7) Father 22 (9.3) 9 (11.5) 3 (11.5) Mother Both Current GPA 50 (21.2) 23 (29.5) <0.05 High 73 (30.9) 26 (33.3) 10 (38.5) Medium 113 (47.9) 29 (37.2) 6 (23.1) Low 10 (38.5) Last health checkup 34 (14.4) 4 (5.1) <0.05 A month ago 20 (8.5) 5 (6.4) 3 (11.5) 1 year before 19 (8.1) 16 (20.5) 2 (7.7) 2 years before 163 (69.1) 53 (67.9) 4 (15.4) Don’t remember 17 (65.4) 28 (11.9) 16 (20.5) Dieting 190 (80.5) 53 (67.9) <0.01 18 (7.6) 9 (11.5) 9 (34.6) Yes 12 (46.2) No 70 (29.7) 17 (21.8) 5 (19.2) I was 57 (24.2) 21 (26.9) 57 (24.2) 20 (25.6) <0.01 Level of intermediate 52 (22.0) 20 (25.6) education 2 (7.7) 155 (65.7) 42 (53.8) 7 (26.9) 1 73 (30.9) 28 (35.9) 5 (19.2) 2 8 (3.4) 8 (10.3) 12 (27.0) 3 4 <0.05 Health status 11 (42.3) Excellent 11 (42.3) Good 4 (15.4) Poor

128 A. N. Al-Isa, N. Wijesekara, E. Desapriya et al. Table 2. (Continued) Factor Non-obese Overweight Obese p- value Number of times dieted n (%) n (%) n (%) <0.001 High (>4) Medium (2-3) 12 (5.1) 5 (6.4) 4 (15.4) <0.05 Low (1) 11 (4.7) 23 (29.5) 10 (38.5) None 22 (9.3) 10 (12.8) 5 (19.2) <0.001 191 (80.9) 40 (51.3) 7 (26.9) Diet consultation Personal 142 (60.2) 44 (56.4) 14 (53.8) Professional 21 (8.9) 7 (9.0) 6 (23.1) Friends/Relatives 34 (14.4) 17 (21.8) 6 (23.1) None 39 (16.5) 10 (12.8) 0 (0) Needing special diet 56 (23.7) 28 (35.9) 16 (61.5) program 110 (46.6) 30 (38.5) 3 (11.5) 70 (29.7) 20 (25.6) 7 (27.0) Yes No I don’t know comparison with those in the reference group who needed it. The risk of obesity (BMI>30 Kg/m²) decreased among those who were not obese (p<0.001, OR=0.15) in comparison with the reference group who increased among those with medium GPA (p<0.05, OR=2.69) in comparison with those in the reference group with high GPA, increased among those with poor health status (p<0.05, OR=4.98) in comparison with those in the reference group with excellent health status and increased among those seeking consultation for weight loss from professionals (p<0.001, OR=6.87) in comparison with those in the reference group who did it on their own. In the male cohort, the risk of being overweight decreased with those having low current GPA (p<0.05, OR=0.52) in comparison with the reference group with high GPA, decreased in the last health check-up two years before (p<0.01, OR=5.11) in comparison with the reference group who had it a month ago, decreased among those who did not diet (p<0.01, OR=0.38) in comparison with the reference group who dieted, increased among those in the second level of intermediate education (p<0.05, OR=2.08) and in the fourth level (p<0.01, OR=2.60) in comparison with the reference group in the first level, increased among those with poor health status (p<0.01, OR=3.57) in comparison with the reference group who had an excellent health status, increased among those who had attempted dieting a medium number (2-3) of times (p<0.01, OR=4.0) and decreased among those who did not diet at all (p<0.05, OR=0.32) in comparison with the reference group who dieted the most (≥4), decreased among those not needing a special nutrition program (p<0.001, OR=0.35) and those who didn’t know they needed the program (p<0.05,OR=0.49) in comparison with the reference group who needed it.

Factors Associated with Overweight and Obesity among Kuwaiti Young Children 129 Table 3. Risk factors associated with overweight (BMI>25-30 kg/m2) and obesity (BMI>30 kg/m2) among Kuwaiti intermediate female school children aged 10-14 years (n=343) from logistic regression Factors Overweight Obese OR (95% CI) OR (95% CI) # brothers High (>5) (reference) 1.0 1.0 Medium (3-4) 2.83 (0.59-13.42) 2.14 (0.25-18.03) Low (1-2) 2.41 (0.53-10.93) 0.52 (0.06-4.46) None 7.00 (1.39-35.34)* 1.88 (0.00-0.00) Current GPA 1.0 1.0 High (reference) 0.97 (0.58-1.63) 2.69 (1.01-7.1)* Medium 0.57 (0.26-1.22) 2.10 (0.59-7.49) Low Dieting 1.0 1.0 Yes (reference) Overweight Obese OR (95% CI) OR (95% CI) Factors 0.47 (0.26-0.85)* 0.72 (0.25-2.07) 1.16 (0.49-2.68) 0.68 (0.12-3.69) No I was Level of intermediate education 1.0 1.0 1 (reference) 2 1.00 (0.54-1.84) 1.37 (0.45-4.12) 3 4 0.34 (0.16-0.69)** 0.82 (0.24-2.80) 0.42 (0.21-0.85)* 0.54 (0.13-2.23) Health status 1.0 1.0 Excellent (reference) 1.13 (0.68-1.91) 1.05 (0.01-1.18) Good 1.68 (0.53-5.34) 4.98 (0.38-2.84)* Poor Number of obese sisters 1.0 1.0 None (reference) Low (1) 2.75 (1.37-5.52)** 2.63 (0.90-7.65) Medium (2) High (>3) 1.06 (0.33-3.42) 0.00 (0.00-0.00) Diet consultation 1.45 (0.26-8.09) 3.36 (0.37-30.51) Personal (reference) Professional 1.0 1.0 Friends/Relatives 1.74 (0.87-3.49) 0.72 (0.25-2.07) None 1.18 (0.61-2.23) 1.20 (0.31-4.58) 1.09 (0.49-2.40) 0.00 (0.00-0.00) Needing special diet program 1.0 1.0 0.50 (0.28-0.88)* 0.56 (0.21-1.49) Yes (reference) 0.62 (0.34-1.12) 0.51 (0.16-1.58) No I don’t know *<0.05, **<0.01, ***<0.001, OR (Odds Ratio), CI (Confidence Interval).

130 A. N. Al-Isa, N. Wijesekara, E. Desapriya et al. Table 4. Risk factors associated with overweight (BMI>25-30 kg/m2) and obesity (BMI>30 kg/m2) among Kuwaiti intermediate male school children aged 10-14 years (n=340) from logistic regression Factors Overweight Obese OR (95% CI) OR (95% CI) Number of obese brothers 1.0 1.0 None (reference) 1.49 (0.83-2.67) 0.24 (0.05-0.94)* Low (1) 1.97 (0.88-4.35) 0.37 (0.08-1.69) Medium (2) 2.09 (0.69-6.26) 0.42 (0.07-2.43) High (>3) Number of obese relatives 1.0 1.0 None (reference) 1.29 (0.70-2.37) 2.96 (1.14-7.74)* Low (1-2) 1.34 (0.68-2.64) 0.65 (0.13-3.18) Medium (3-4) 1.20 (0.64-2.26) 1.35 (0.42-4.29) High (>5) 1.0 1.0 Current GPA 0.66 (0.32-1.11) 0.44 (0.15-1.27) High (reference) 0.52 (0.29-0.92)* 0.51 (0.20-1.29) Medium Low Number of servants 1.0 1.0 None (reference) 0.56 (0.23-1.14) 0.25 (0.06-0.94)* Low (1) 0.76 (0.30-1.90) 0.35 (0.09-0.94)* Medium (2) 0.64 (0.23-1.73) 0.61 (0.15-2.29) High (>3) Last health checkup 1.0 1.0 A month ago 1.39 (0.41-4.69) 1.01 (0.15-6.50) (reference) 5.11 (1.83-14.28)** 1.45 (0.30-6.92) 1 year before 2 years before 2.04 (0.86-4.83) 0.99 (0.28-3.56) Don’t remember Dieting 1.0 1.0 Yes (reference) 0.38 (0.20-0.69)** 0.24 (0.09-0.61)** No 0.76 (0.31-1.86) 0.90 (0.27-2.98) I was 1.0 1.0 Level of intermediate education 2.08 (1.03-4.17)* 3.90 (0.79-19.35) 1 (reference) 1.86 (0.91-3.77) 2.83 (0.53-14.97) 2 2.60 (1.30-5.18)** 7.25 (1.57-33.45)** 3 4 Health status 1.0 1.0 Excellent (reference) 1.50 (0.91-2.47) 1.95 (0.81-4.65) Good 3.57 (1.40-9.10)** 4.47 (1.27-15.66)* Poor

Factors Associated with Overweight and Obesity among Kuwaiti Young Children 131 Factors Overweight Obese OR (95% CI) OR (95% CI) Number of times dieted High (>4) (reference) 1.0 1.0 Medium (2-3) 4.00 (1.33-12.03)** 1.25 (0.34-4.57) Low (1) 0.81 (0.27-2.41) 0.66 (0.15-2.80) None 0.32 (0.12-0.80)* 0.13 (0.03-0.48)** Diet consultation 1.0 1.0 Personal (reference) 1.55 (0.73-3.31) 2.85 (1.01-8.01)* Professional 1.57 (0.85-2.91) 1.56 (0.52-4.27) Friends/Relatives 0.64 (0.30-1.37) 0.00 (0.00-0.00) None Needing special diet program Yes (reference) 1.0 1.0 No 0.35 (0.20-0.61)*** 0.11 (0.03-0.39)*** (0.16-1.04) I don’t know 0.49 (0.27-0.88)* 0.40 *<0.05, **<0.01, ***<0.001, OR (Odds Ratio), CI (Confidence Interval). The risk of obesity (BMI>30 Kg/m²) decreased among those with low (1) number of obese brothers (p<0.05, OR=0.24) in comparison with the reference group who had none, increased among those with low (1-2) number of obese relatives (p<0.05, OR=2.96) in comparison with the reference group who had none, decreased among those with low (p<0.05, OR=0.25) and medium (p<0.05, OR=0.35) number of servants in comparison with those in the reference group who had none, decreased among those who did not diet (p<0.01, OR=0.24) in comparison with those in the reference group who did, increased among those in the fourth level of intermediate school (p<0.01, OR=7.25) in comparison with the reference group in the first level, increased among those with poor health status (p<0.05, OR=4.47) in comparison with those in the reference group with excellent health status, decreased among those who never dieted (p<0.01, OR=0.13) in comparison with those in the reference group who dieted frequently, increased among those who sought professionals for diet consultation (p<0.05, OR=2.85) in comparison with those in the reference group who did it themselves and decreased among those who did not need a special nutrition program (p<0.001, OR=0.11) in comparison with those in the reference group who needed it. 4. Discussion There is a plethora of factors that has been associated with childhood obesity; however, this study was able to define certain factors that are found in both male and female Kuwaiti groups: number of obese siblings, dieting, health status and level of education. When subjected to logistic regression, among both males and females, those who were not dieting and not requiring a special nutrition program had reduced prevalence of being overweight. For females, the risk of being overweight increased with having no brothers and having obese sisters, while it decreased among those in higher levels of education. In males, while the risk of being overweight increased with higher level of education, poor health status, and number of times they had dieted, the risk of being overweight decreased with low GPA and never dieting. Obesity risk was high among those with a poor health status in both males and

132 A. N. Al-Isa, N. Wijesekara, E. Desapriya et al. females. Lower GPA was also a risk that increased obesity in females. For males, risk of obesity increased with having more obese relatives, higher level of education and among those who consulted professionals for weight management. The prevalence of obesity was lower among male participants with fewer obese brothers, fewer servants, not dieting or never dieted, and those who did not require a special nutrition program. As apparent from our data, it is a common occurrence that obesity runs in the family as it tends to be associated with genetics [6]. However, it is becoming apparent that genetics alone cannot account for the increased prevalence of this pathophysioloigcal condition. In the current study, while higher level of education reduced the risk of being overweight in females, it increased the risk of being overweight and obese in males. Although one may assume that with a higher level of education students become more aware of preventive measures, there is also a likelihood of their studies occupying most of their time in higher grades, thus preventing them from engaging in physical activity and encouraging unhealthy eating habits, such as snacking. It is difficult to judge whether some factors are simply consequences or actual determinants of the risk of overweight/obese. Poor health status may simply prevent students from engaging in physical activity leading to the onset of obesity or may ensue as a consequence of the obesity. As it is difficult to fathom that risk of obesity reduces with not/never dieting, it may be that students at low risk of becoming overweight never had the need to diet. Conversely, students may begin dieting and consulting professionals for weight management only after the onset of obesity and therefore, these are not risk factors for obesity. Some of the associated factors for the 10-14 year old age group were also found in the 6- 10 year old age group of Kuwaiti children, providing a general idea of the common concerns that need to be addressed. These factors include having obese siblings and poor health status. From this study we can see that obesity is indeed multi-factorial in nature and may not be caused by the same factors in each case; there are few consistent patterns for risk of obesity in the studied cohorts. In fact, some of the risks can be conflicting in different groups. Additional studies with larger sample sizes are required to obtain a clearer picture of the factors contributing to obesity and being overweight in this age group. A multitude of cultural factors are associated with detrimental dietary habits and insufficient physical activity levels among Kuwaitis. These variables act as barriers in implementing action plans to combat obesity, and should be taken into account when proceeding with obesity awareness. As an oil rich nation, Kuwait’s rapid economic development and high incomes have facilitated means for sedentary lifestyles. The Kuwaiti population is becoming increasingly dependent on vehicles for transportation, reducing travel by foot. In Kuwaiti households, employment of servants such as maids, cooks, and drivers, minimizes the need to perform daily household tasks. More time is spent watching television and using the internet [7]. These factors associated with wealth and higher standards of living, are conducive to sedentary lifestyles. Several barriers challenge the need for Kuwaitis to engage in regular physical activity. Many Kuwaitis are discouraged by lack of knowledge or faulty assumptions and attitudes concerning exercise [7]. The weather conditions in Kuwait, mainly hot and dry year round, also are unfavorable for outdoor physical activity and unfortunately is encouraging for the consumption of sugar sweetened cold soda beverages.

Factors Associated with Overweight and Obesity among Kuwaiti Young Children 133 Kuwait’s dietary habits are not suitable for sedentary lifestyles that entail low caloric expenditure. Traditional Kuwaiti food is rich; daily diets tend to be high in calories, and high in fat [8]. Meals often consist of large servings of meat such as red meat, chicken, or seafood as well as dairy products like cheese or full fat yogurt [9]. The nature of Kuwaiti dining must also be considered when assessing dietary patterns. In the household, it is common to eat meals together with family and with guests. Social gatherings and celebrations with extended family and friends occur frequently [8]. During these occasions, food is a key focus. A lavish feast offered to guests is an indication of affluence. As generosity is culturally valued, it can be disrespectful to offer a subpar meal [8]. In addition, fast food has become a norm in Kuwaiti society and should be considered as a factor contributing to the high daily caloric intakes [8]. A combination of over consumption and insufficient physical activity means caloric intake will exceed caloric expenditure, resulting in weight gain. Any changes implemented to lifestyle behaviors would become effective only if cultural and religious boundaries are considered. Religious teachings can be used to enforce behaviour change. In the Islamic hadith (reports of the words and deeds of the Prophet Muhammad), good health is considered a blessing. The hadith encourages involvement in sporting activities that promote a healthy lifestyle and encourage family participation and unity. According to Hamid (1993: 40), the Prophet (pbuh) stressed the importance of regular physical activity [10]. Prophet Muhammad encouraged bodily wellness via dietary restrictions. The Prophetic advice to eat only when hungry and to stop eating before becoming fully satiated is valuable advice for today’s society. Early experiences of proper eating and physical activity are important in establishing healthy lifestyle habits later in life. Interestingly, it has been suggested that practices set at infancy are more crucial than those set during school years in preventing obesity [11]. However, pre-adolescent years cannot completely be ignored and preventative measures still need to be set in place. Therefore, schools should consider incorporating diet consultation as well as physical education classes into their curriculum. Clear guidelines should be set on the amount of physical activity requirement for children. Educational programs must be flexible in their approach and ensure that all children are receiving relevant information. Programs may have to be tailored to different age groups, genders and health and physical status of students. Special consideration should be given towards female participation in sports because the agenda is typically set by the boys, and girls may be excluded by their male peers. Furthermore, at this pre-teen stage, a time when girls are starting to display their femininity, there may be some resistance to sports. Schools also have a tendency to favour those who display talent, which could discourage those who are not in high physical form from participation. Interestingly, a study conducted with secondary school students in Ontario, Canada suggests that providing an alternate room for physical activity would be beneficial [12]. Weather conditions in Kuwait should be taken into consideration when designating space for physical activity. There is some belief that home environment is more important than school environment in setting health habits in young children [13]. Reiterating this point, a study has found that children gain more weight during the summer months than during school year [14]. Further, children of overweight parents are at a higher risk of developing obesity as they not only provide the genes, but also the social and behavioral settings, including the diet and should be examined within the context of this study [15]. Therefore, in addition to educating the children, educating the parents of healthy eating habits, importance of exercise and early

134 A. N. Al-Isa, N. Wijesekara, E. Desapriya et al. signs for recognition of weight gain and obesity is of vital importance. Recognizing obesity as necessitating treatment could lead to early implementation of improved health habits. Pediatricians should be encouraged to routinely discuss these issues with visiting parents. They should work with schools and the community to decrease the availability of foods and beverages with little nutritional value [16]. Parents should be encouraged to provide their children more nutritious foods such as fruits vegetables and whole grains, and to limit sugar sweetened beverages and fried fast food. Further, parents should allow for the development of the child’s innate ability to regulate food intake from very early on, therefore, children become aware of when they have consumed enough food. Family meal times should be encouraged as this would allow parents to enforce healthy eating habits on children, while preventing consumption of food from fast food restaurants. Interestingly, studies have found direct links to fast food advertising and childhood obesity, such that food advertising to children has been banned in a number of countries [17]. In addition, a study has found decreasing media use (i.e. television) without specifically encouraging more active behaviors results in significantly lower BMI in children [18]. Therefore, limiting television viewing in young children may be beneficial in reducing obesity. An exploration into these areas in Kuwaiti children would be highly useful. Prioritization of academics over physical activity is becoming common; however, parents should take care to encourage their children to engage in play activities in addition to walking to school and engaging in chores at home. In summary, focus should be placed on raising awareness of childhood obesity, implementing healthy eating habits, reducing sedentary lifestyle and encouraging physical activity, and monitoring weight gain in children, which would lead to early intervention. In Kuwait, continuing to develop a National Physical Activity Plan [19] is the first step towards integrating obesity awareness into society, but it is important to incorporate cultural and demographic variables as has been shown in a study discussing adherence to lifestyle measures in Kuwait [20, 21]. In light of the variations in risk factors and the demonstrated strengths and weaknesses of intervention programs, we encourage the Kuwaiti government and private organizations to pursue obesity programming that incorporates a variety of approaches to best serve the needs of Kuwaiti children. References [1] World Health Organization (2000). Technical Report Series.; 894:i-xii, 1-253. Obesity: preventing and managing the global epidemic. Report of a WHO consultation, No authors listed. [2] Rubenstein AH (2005). Obesity: a modern epidemic. Trans. Am. Clin. Climatol. Assoc., 116:103-111. [3] Jackson RT, Al-Mousa Z, Al-Raqua M, et al. (2001) Prevalence of coronary risk factors in healthy adult Kuwaitis. International Journals of Food Sciences and Nutrition, 52:301-311. [4] Moussa MA, Skaik MB, Selanes SB, Yaghy OY and Bin-Othman SA. (1994) Factors associated with obesity in schoolchildren. International Journal of obesity and Related

Factors Associated with Overweight and Obesity among Kuwaiti Young Children 135 Metabolic Disorders. Journal of the International Association or the study of obesity, 18(7):513-5. [5] Al-Isa A, Campbell J, Desapriya E. (2011) Factors associated with overweight and obesity among Kuwaiti elementary male school children aged 6-10 years. International Journal of Pediatrics, In press. [6] Bell CG, Walley AJ, Froguel P. The genetics of human obesity. Nat Rev Genet 2005;6:221-34. [7] Ramadan J, Vuori I, Lankenau B, Schmid T, and Pratt M. (2010) Developing a national physical activity plan: the Kuwait example. Global Health Promotion, 17:52. [8] Serour M, Alqhenaei H, Al-Saqabi S, Mustafa AR and Ben-Nakhi A. (2007) Cultural factors and patients' adherence to lifestyle measures. British J of General Practice, 57(537):291-5. [9] Kandela P. (1999) The Kuwaiti passion for food cannot be shaken. The Lancet, 353:1249. [10] Hamid AW. (1993) Islam the Natural Way. Maraisburg: Asmara Distributors. [11] Dattilo AM, Birch L, Krebs NF, Lake A, Taveras EM, Saavedra J. (2012) Need for early interventions in the prevention of pediatric overweight: Review and upcoming directions. Journal of Obesity. [12] Hobin EP, Leatherdale ST, Manske S, Dubin JA, Elliott S, Veugelers P. (2012) A multilevel examination of gender differences in the association between features of the school environment and physical activity among a sample of grades 9 to 12 students in Ontario, Canada. BMC Public Health, 12(1):74. [13] van Hook J, Altman CE. (2012) Competitive Food Sales in Schools and Childhood Obesity: A Longitudinal Study. Sociology of Education, 85(1):23-39. [14] Von Hippel PT, Powell B, Downey DB, Rowland NJ. (2007) The Effect of School on Overweight in Childhood: Gain in Body Mass Index during the School Year and during Summer Vacation. American Journal of Public Health, 97:696-702. [15] Price RA, Stunkard AJ, Ness R et al. Childhood onset (age less than 10) obesity has high familial risk. Int. J. Obes. 1990;14:185-95. [16] American Academy of Pediatrics. (2003) Prevention of Pediatric Overweight and Obesity Pediatrics, 112(2):424-30. [17] Alkharfy KM. (2011) Food advertisements: to ban or not to ban? Ann. Saudi Med., 31(6):567-8. [18] Robinson T. Reducing children’s television viewing to prevent obesity: a randomized controlled trial. JAMA, 1999;282:1561–1567. [19] Ramadan J, Vuori I, Lankenau B, Schmid T, and Pratt M. (2010) Developing a national physical activity plan: the Kuwait example. Global Health Promotion, 17:52. [20] Serour M, Alqhenaei H, Al-Saqabi S, Mustafa AR and Ben-Nakhi A. (2007) Cultural factors and patients' adherence to lifestyle measures. British J. of General Practice, 57(537):291-5. [21] Naser Al-Isa A, Campbell J, Desapriya E. (2011) Factors Associated With Overweight and Obesity Among Kuwaiti Men. Asia Pac. J. Public Health, Jun 28, 2011. [Epub ahead of print].



Index # age, vii, viii, x, 1, 2, 3, 4, 7, 8, 9, 13, 14, 15, 20, 21, 22, 23, 24, 30, 39, 45, 46, 47, 49, 50, 51, 52, 53, 21st century, 34 54, 55, 56, 64, 67, 69, 75, 77, 91, 92, 93, 96, 100, 103, 110, 111, 112, 113, 114, 119, 121, 122, 123, A 124, 132, 133, 135 academic performance, ix, 89, 91, 103, 104 agencies, 69 acceptable daily intake (ADI), ix, 68, 73, 74, 84 aggressive therapy, 21 access, 3, 65, 122 aging process, 57 achondroplasia, 14 agriculture, 70 acid, viii, 59, 67, 73, 76, 79, 80, 83, 86, 111 airways, 115 acidic, 17, 31 albumin, 9, 10, 12, 16, 28, 38 acromion, 8 alcohol consumption, 102 activity level, 6, 13 allergens, x, 12, 107, 108, 115, 116 acute leukemia, 2, 42 allergic reaction, 75 acute lymphoblastic leukemia, 6, 34, 37, 38 allergic rhinitis, 112 acute myelogenous leukemia, 6 allergy, vii, x, 42, 107, 108, 111, 112, 113, 114, 115, AD, 113, 114 ADA, 35 116, 117, 119 additives, 69, 72, 74, 75, 76, 77, 81, 83, 84, 86 altered taste, vii, 1, 15 adipose, 16 alternative medicine, 63 adipose tissue, 16 alters, 118 adiposity, 102, 123 amenorrhea, 24 adjustment, 18 American Heart Association, 103 adolescents, vii, viii, 1, 2, 4, 7, 8, 9, 16, 20, 30, 31, amino, 18, 25 amino acid(s), 18, 25 33, 34, 35, 36, 37, 45, 46, 50, 59, 60, 61, 63, 65, ammonia, 22 91, 99, 101, 102, 103, 104, 105, 116 anemia, 11, 38 ADP, 6, 9 angioedema, 119 adulthood, x, 91, 103, 112, 116, 121 anorexia, 25, 26 adults, vii, ix, 1, 4, 7, 24, 35, 38, 45, 47, 49, 52, 58, antibiotic, 18 68, 103, 104, 107, 108, 112, 113, 118, 119 anti-cancer, 12, 17, 26 adverse effects, viii, 2, 28, 31, 46, 47, 57, 58, 69, 72 antiemetics, 33 advertisements, 97, 135 antigen, 12, 109, 110, 114 affluence, 132 anxiety, 24 Africa, 2, 3 apoptosis, 113, 118 African-American, 101, 104 appetite, vii, ix, 1, 4, 23, 25, 28, 31, 33, 89, 95, 96 arthralgia, 24 arthritis, 116 ascites, 6, 17

138 Index Asia, v, vii, viii, 43, 44, 45, 51, 56, 60, 62, 65, 104, body density, 9 135 body fat, 8, 36, 57, 58, 64 body mass index (BMI), x, 6, 7, 36, 39, 64, 91, 92, Asian Americans, 51 Asian countries, viii, 44 101, 102, 104, 121, 122 assessment, vii, 1, 4, 5, 6, 8, 11, 12, 13, 30, 35, 36, body size, 5, 45, 64 body weight, 4, 8, 9, 20, 21, 36, 47, 50, 57, 58, 68, 37, 39, 68, 71, 72, 73, 76, 83, 84, 87 asthma, x, 85, 107, 108, 110, 111, 112, 115, 116, 72, 75, 76, 77, 79, 83, 104 bone, viii, 9, 11, 23, 38, 40, 41, 43, 44, 45, 46, 49, 117, 118, 119 asthmatic children, 87, 112, 114 50, 55, 56, 57, 59, 60, 61, 62, 63, 64, 65, 108, 115 ataxia, 24 bone marrow, 11, 38, 40, 41 atopic dermatitis, 113, 117, 119 bone marrow transplant, 38, 40, 41 atopic eczema, 111, 114 bone mass, 45, 56, 57, 59, 60, 61, 64, 65 atopy, 112, 118, 119 bone mineral content, 9, 62 attitudes, ix, 63, 89, 132 bone resorption, 56 authority, 70 boosters, 31 autologous bone marrow transplant, 38 bowel, 23, 24, 32 avoidance, 59, 122 brain, 2, 6 awareness, 68, 132, 134 brain tumor, 2, 6 breakdown, 12, 20 B breastfeeding, 30, 52, 53, 63 bronchial epithelial cells, 112 bacteremia, 41 bronchoscopy, 113 bacteria, 17, 18, 27, 28, 31, 32, 70, 74 brothers, 122, 124, 125, 127, 128, 129, 131 bad habits, 99 ban, 84, 135 C Bangladesh, 56, 63 barriers, ix, 60, 89, 92, 132 cabbage, 32, 59 base, 58, 74, 114 cachexia, vii, 2, 4, 6, 15, 16 beef, 29, 102 caffeine, 32 beer, 26 calcium, vii, viii, 23, 28, 43, 44, 45, 46, 47, 48, 49, behaviors, 101, 102, 103, 104, 133 Beijing, 45, 52, 61 50, 51, 52, 53, 55, 56, 57, 58, 59, 60, 61, 62, 63, beneficial effect, 56 64, 65, 91, 101, 108, 110, 116, 118 benefits, viii, ix, 43, 45, 60, 70, 107, 113, 115 calcium carbonate, 53, 55, 56, 59, 65 beverages, 33, 51, 64, 68, 76, 79, 104, 132, 133 calcium gluconate, viii, 44, 55 BIA, 8 calcium supplements, viii, 43, 44, 45, 52, 53, 55, 56, bias, 9 57, 58, 59, 63, 65 bile, 5, 13 caloric intake, 132 bile duct, 5 calorie, 13, 19, 39 bilirubin, 16, 28 calorimetry, 19, 20, 40 bioavailability, 47, 56, 59, 60, 63, 65 cancer, vii, viii, 1, 2, 3, 4, 6, 9, 10, 11, 12, 15, 16, 18, birth weight, 42 20, 23, 25, 28, 29, 30, 32, 34, 35, 36, 38, 39, 41, Blacks, 2 42, 122 bleeding, 24 cancer cachexia, vii, 2, 15, 16 blood, 9, 10, 11, 16, 17, 21, 23, 25, 28, 40, 101, 110, cancer therapy, vii, 1 capillary, 22 111, 112, 115, 118, 122 carbon, 19 blood cultures, 25 carbon dioxide, 19 blood urea nitrogen, 16, 21 caregivers, 5, 13, 122 blood vessels, 17 catabolism, 11, 16 bloodstream, 17 category a, 78 BMI, x, 6, 7, 8, 13, 14, 15, 35, 91, 98, 102, 103, 121, category b, 26 Caucasian population, 46 122, 123, 124, 125, 127, 128, 129, 131, 133 causal relationship, 114 body composition, 5, 6, 7, 8, 9, 16, 36, 57, 64