Indian J Pediatr DOI 10.1007/s12098-014-1472-x
ORIGINAL ARTICLE
Physical Activity Patterns Among School Children in India Achal Gulati & Alexander Hochdorn & Haralappa Paramesh & Elizabeth Cherian Paramesh & Daniele Chiffi & Malathi Kumar & Dario Gregori & Ileana Baldi
Received: 27 March 2014 / Accepted: 23 April 2014 # Dr. K C Chaudhuri Foundation 2014
Abstract Objective To assess the prevalence of physical activity and its relation with socio-demographic variables and eating habits among school-aged children in India. Methods The study incorporated secondary analysis of anthropometric measurements and questionnaires on lifestyle and dietary habits of 1,680 school children aged between 3 and 11 y, obtained while carrying out the OBEY-AD project. The inventory contained questions about several variables concerning to physical activity, educational background, lifestyles and eating habits for both children and parents. Questions were organized along specific contents, which could be informative topics, picture choices and multiple answers choices. Results Prevalence of inactivity was 21 % and exhibited significant variations between cities. Physical activity was significantly associated to socio-economic status and consumption of fruits and vegetables. No association could be revealed with children’s BMI. Conclusions Health-promotion interventions aimed at improving healthy lifestyles in Indian children should focus on population strata with low socio-economic status.
A. Gulati (*) Department of Otorhinolaryngology (ENT), Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi 110002, India e-mail: [email protected] A. Hochdorn : D. Chiffi : D. Gregori : I. Baldi Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua, Italy H. Paramesh : E. C. Paramesh College of Nursing, Lakeside Institute of Child Health, Lakeside Hospital, Bangalore, India M. Kumar Internal Research Unit, Kare Centre, Chennai, India
Keywords Physical activity . Eating habits . Context . Obesity . Children
Introduction Dietary and lifestyle factors play an important role in the development of non-communicable diseases (NCDs), like diabetes [1], cardiovascular diseases [2] and obesity [3]. Consumption of high-energy, high fat diets and deterioration in dietary quality coupled with sedentary behavior often causes accumulation of adipose tissue and consequently, a progressive rise of overweight. Amount of energy intake and weight are strictly related to insulin resistance, low-grade inflammation and increased risk of cardio-metabolic abnormalities [4]. Ethnical specific peculiarities in physiology and anatomy of overweight bodies make this phenomenon quite unique in Asian contexts. Contrary to westernized societies, in India and more generally in South-Asian countries, overweight and fat deposals are mostly visible through abdominal adiposity. A high rate of overweight and a general trend of obesity on an abdominal level are quite frequent also in early age, as shown by surveys on children and adolescents [3]. A reduction in outdoor activities and a preference for indoor activities such as TV viewing could partially explain the rise in childhood obesity rates [5]. The World Health Organization (WHO) defines physical activity as a bodily movement produced by skeletal muscles that substantially elevates energy expenditure [6]. It may promote weight loss, reduction of visceral fat, lower blood pressure [7] and even prevent of the onset of type 2 diabetes [8]. Furthermore as evidenced by Willet et al., regular (>3 times per wk) physical activity, exercised with moderate intensity, reduces the rise of risk factors related to NCDs [9]. A recent meta-analysis on the relation between physical activity
Indian J Pediatr
and health status of children in Hong Kong, highlighted the beneficial effects of regular motor activity [10]. Co-causing risk factors promoting obesity and overweight in children, such as TV exposure, advertising and brand awareness have been investigated by several studies on different age-groups worldwide: 5–7 y [11] and 9–11-y-old school kids in the UK [12]; 4–12-y-old children in the Netherlands [13]; 3–10-y-old in Latin-American countries [14] and 5–11-y-old in the USA [15]. Furthermore these variables have been individuated as facilitating factors for inactivity, promoting rise of weight status, as shown by findings of a survey on 6–16-y-old children and adolescents in southern India [16]. A few studies [5, 17, 18], conducted up to day in India about the association between metabolic and contextual causes of obesity in children, found some relevant links among weight increase and a general reduction of physical activities, enhanced by sedentary lifestyles. As highlighted by small scale studies, realized in the 1990s and based on urban samples, the proportion of the overweight population in Indian towns and cities is large and increasing, ranging from 33 % to 51 % [19]. A progressive transition of Asian population from rural to metropolitan areas may explain the rapidly escalating epidemics of NCDs in large urban contexts [20]. Furthermore, as pointed out by Ramachandran et al. [5], lifestyle changes resulting in decreased levels of physical activity and increased intake of energy dense diet could be related to three main reasons: 1) a nutrition transition, with a rising prevalence of obesity and overweight in the general population in developing countries, especially in South-Asia [21, 22]; 2) introduction of fast food consumption products (snacks and soft drinks) [23] and finally 3) migration processes from rural to urban areas [20]. Central to the challenge of obesity prevention and management is the understanding of its multiple, and often, interacting determinants. For this reason obesity research should adopt a multi-faceted approach embracing cultural-specific, behavioral as well as socio-demographic characteristics. The aim of the present paper, therefore, consisted in comprehending, if frequency and intensity of physical activity are associated to pondered, high qualitative eating habits, better education as well as adequate socio-economic status.
Material and Methods The study incorporated secondary analysis of anthropometric measurements and questionnaires on lifestyle and dietary habits of 1,680 school children aged between 3 and 11 y obtained while carrying out the OBEY-AD project. Details of the study protocol are given elsewhere [24]. Research’s population was recruited in school contexts across seven major cities of India: Bengaluru, Chennai, Hyderabad, Kolkata, Mumbai, New Delhi and Surat. The sample
is composed of 1,680 children balanced by gender and age (3– 6 and 7–11 y). Children presenting psychiatric diagnosis as well disorders on a physiological level (allergies, metabolic diseases) were excluded. Informed consent was obtained and research goals were communicated to all the parents, gathered for this research. Scientific treatment of the collected data was in full respect with the guidelines and ethical parameters established by the American Psychological Association [25]. Appropriate permission was obtained by the Institutional Review Boards. Children were weighed and measured in light clothing and without shoes on a balance scale and with a body meter measuring tape with wall stop. Weights and heights were utilized to calculate body mass index (BMI) and each BMI value was standardized (z-BMI) in clusters categorized by age and gender, using World Health Organization (WHO) 2007 growth charts for children aged 5–19 [26] and WHO Multicentre Growth Reference Study (MGRS) for those aged 0–5 [27], in order to propose target appropriate standards (kids from 3 to 11 y). The adoption of these references are in line with the indications released by the Indian Academy of Pediatrics (IAP) [28]. Until nowadays IAP recommends the use of BMI criteria promoted by WHO, developed by an international scientific board including also contributors from India. The definition of infant growth charts, specifically adjusted for Indians, already in progress, is monitored by The National Meeting of the Growth Monitoring Committee of IAP. Children’s z-BMI were categorized according to these criteria: a) underweight: z-BMI 7) performed by children. The second section of the instrument, instead, investigates specifically on children’s eating habits. Combination of these different sections, constituting the inventory, makes emerge the complexity between behavioral patterns, cultural coordinates and alimentary habits of children and their parents, and offers a pluralistic view of potential risk factors for obesity.
Indian J Pediatr
Basic exploratory data analysis was performed on the sample and reported using median (I–III quartile) for continuous variables and percentages (absolute numbers) for categorical variables, whenever appropriate. Descriptive analysis of frequencies, duration and intensity of the different factors was performed. Chi-square and Anova were used to test variations across physical activity levels for categorical and continuous variables, respectively.
Results Participants, recruited for this study, constituted a sample of 1,680 children (Table 1), balanced by gender and age (3–6 and 7–11 y), with a median age of 6.50 y [Interquartile range (IQR): 5.00–8.00]. Research’s population was distributed along seven Indian major cities, namely 240 subjects for each town. According to BMI standards defined by WHO, normal weight infants count about 985 (59 %), underweight 307 (18 %), overweight 198 (12 %) and obese 185 (11 %). Anthropometric data revealed that children aged 3–7 y had a median waist circumference of 54 cm (IQR: 50–60), a median hip circumference of 61 cm (IQR: 56–67) and a median height of 120 cm (IQR: 112–128). Figures for children aged 8–11 y were 60 cm (IQR: 54–68), 69 cm (IQR: 62–76) and 137.5 cm (IQR: 128–146), respectively. Information on family background was collected through a validated questionnaire to parents. As shown in Table 1, mothers had a median BMI value of 23.73 (IQR: 21.63–26.04), while fathers’ had median BMI of 24.69 (IQR: 22.59–26.83). With regard to employment, 1,410 fathers (84 %) declared to have a working activity, while only 489 mothers (29 %) were engaged in a job outside the household. As to educational attainment, mothers and fathers exhibited almost the same distribution: the majority holded an academic degree and less than 10 % had a low education. This study being focused on physical activity associated to sedentary lifestyle, structural components of the household where a child lived, have also been taken into consideration. Households disposed of a median of two rooms (IQR: 2.00– 3.00) with a median of one television (IQR: 1.00–2.00) per house. Households providing television in children’s rooms represented 12 % (n=207) of the whole sample. Time spent by children in watching TV amounts to a median of 10 h (IQR: 7.00–16.00) per wk and 29 % (n=89) of children declared to spend between a half and one hour weekly in playing video games. Children, who did not play video-games constituted 48 % (n=808) of the sample. Overall, among the 1,680 children of the sample 350 (21 %) were inactive, 303 (18 %) exercised at least 1 time per wk and 349 (21 %) between 2 and 3 times weekly.
Significant differences by town were seen, with highest percentages in Chennai (29 %) and lowest in Hyderabad (4 %). Descriptive analysis (Table 1) made emerge that for 59 % of children who practiced physical activity on regular basis (more than 3 times per wk), the intensity of exercise varied from half an hour to an hour. Infants declaring to practice more than seven hours weekly represented a minority in the whole sample (n=88). Girls were more inactive than boys. According to WHO recommendations, affirming that children/adolescents aged 5–17 y should practice at least 60 min of physical activity per day [29], only 17 % (250) of children’s aged 5–17 y in the study sample were in line with this value. Figure 1 shows the distribution of children meeting this recommendation by city and gender. Results on physical activity of parents must be interpreted with caution since the percentage of non-respondents was high, nearly 50 %. Generally, children who practiced physical activities consumed more fruits (p value
ORIGINAL ARTICLE
Physical Activity Patterns Among School Children in India Achal Gulati & Alexander Hochdorn & Haralappa Paramesh & Elizabeth Cherian Paramesh & Daniele Chiffi & Malathi Kumar & Dario Gregori & Ileana Baldi
Received: 27 March 2014 / Accepted: 23 April 2014 # Dr. K C Chaudhuri Foundation 2014
Abstract Objective To assess the prevalence of physical activity and its relation with socio-demographic variables and eating habits among school-aged children in India. Methods The study incorporated secondary analysis of anthropometric measurements and questionnaires on lifestyle and dietary habits of 1,680 school children aged between 3 and 11 y, obtained while carrying out the OBEY-AD project. The inventory contained questions about several variables concerning to physical activity, educational background, lifestyles and eating habits for both children and parents. Questions were organized along specific contents, which could be informative topics, picture choices and multiple answers choices. Results Prevalence of inactivity was 21 % and exhibited significant variations between cities. Physical activity was significantly associated to socio-economic status and consumption of fruits and vegetables. No association could be revealed with children’s BMI. Conclusions Health-promotion interventions aimed at improving healthy lifestyles in Indian children should focus on population strata with low socio-economic status.
A. Gulati (*) Department of Otorhinolaryngology (ENT), Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi 110002, India e-mail: [email protected] A. Hochdorn : D. Chiffi : D. Gregori : I. Baldi Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padua, Italy H. Paramesh : E. C. Paramesh College of Nursing, Lakeside Institute of Child Health, Lakeside Hospital, Bangalore, India M. Kumar Internal Research Unit, Kare Centre, Chennai, India
Keywords Physical activity . Eating habits . Context . Obesity . Children
Introduction Dietary and lifestyle factors play an important role in the development of non-communicable diseases (NCDs), like diabetes [1], cardiovascular diseases [2] and obesity [3]. Consumption of high-energy, high fat diets and deterioration in dietary quality coupled with sedentary behavior often causes accumulation of adipose tissue and consequently, a progressive rise of overweight. Amount of energy intake and weight are strictly related to insulin resistance, low-grade inflammation and increased risk of cardio-metabolic abnormalities [4]. Ethnical specific peculiarities in physiology and anatomy of overweight bodies make this phenomenon quite unique in Asian contexts. Contrary to westernized societies, in India and more generally in South-Asian countries, overweight and fat deposals are mostly visible through abdominal adiposity. A high rate of overweight and a general trend of obesity on an abdominal level are quite frequent also in early age, as shown by surveys on children and adolescents [3]. A reduction in outdoor activities and a preference for indoor activities such as TV viewing could partially explain the rise in childhood obesity rates [5]. The World Health Organization (WHO) defines physical activity as a bodily movement produced by skeletal muscles that substantially elevates energy expenditure [6]. It may promote weight loss, reduction of visceral fat, lower blood pressure [7] and even prevent of the onset of type 2 diabetes [8]. Furthermore as evidenced by Willet et al., regular (>3 times per wk) physical activity, exercised with moderate intensity, reduces the rise of risk factors related to NCDs [9]. A recent meta-analysis on the relation between physical activity
Indian J Pediatr
and health status of children in Hong Kong, highlighted the beneficial effects of regular motor activity [10]. Co-causing risk factors promoting obesity and overweight in children, such as TV exposure, advertising and brand awareness have been investigated by several studies on different age-groups worldwide: 5–7 y [11] and 9–11-y-old school kids in the UK [12]; 4–12-y-old children in the Netherlands [13]; 3–10-y-old in Latin-American countries [14] and 5–11-y-old in the USA [15]. Furthermore these variables have been individuated as facilitating factors for inactivity, promoting rise of weight status, as shown by findings of a survey on 6–16-y-old children and adolescents in southern India [16]. A few studies [5, 17, 18], conducted up to day in India about the association between metabolic and contextual causes of obesity in children, found some relevant links among weight increase and a general reduction of physical activities, enhanced by sedentary lifestyles. As highlighted by small scale studies, realized in the 1990s and based on urban samples, the proportion of the overweight population in Indian towns and cities is large and increasing, ranging from 33 % to 51 % [19]. A progressive transition of Asian population from rural to metropolitan areas may explain the rapidly escalating epidemics of NCDs in large urban contexts [20]. Furthermore, as pointed out by Ramachandran et al. [5], lifestyle changes resulting in decreased levels of physical activity and increased intake of energy dense diet could be related to three main reasons: 1) a nutrition transition, with a rising prevalence of obesity and overweight in the general population in developing countries, especially in South-Asia [21, 22]; 2) introduction of fast food consumption products (snacks and soft drinks) [23] and finally 3) migration processes from rural to urban areas [20]. Central to the challenge of obesity prevention and management is the understanding of its multiple, and often, interacting determinants. For this reason obesity research should adopt a multi-faceted approach embracing cultural-specific, behavioral as well as socio-demographic characteristics. The aim of the present paper, therefore, consisted in comprehending, if frequency and intensity of physical activity are associated to pondered, high qualitative eating habits, better education as well as adequate socio-economic status.
Material and Methods The study incorporated secondary analysis of anthropometric measurements and questionnaires on lifestyle and dietary habits of 1,680 school children aged between 3 and 11 y obtained while carrying out the OBEY-AD project. Details of the study protocol are given elsewhere [24]. Research’s population was recruited in school contexts across seven major cities of India: Bengaluru, Chennai, Hyderabad, Kolkata, Mumbai, New Delhi and Surat. The sample
is composed of 1,680 children balanced by gender and age (3– 6 and 7–11 y). Children presenting psychiatric diagnosis as well disorders on a physiological level (allergies, metabolic diseases) were excluded. Informed consent was obtained and research goals were communicated to all the parents, gathered for this research. Scientific treatment of the collected data was in full respect with the guidelines and ethical parameters established by the American Psychological Association [25]. Appropriate permission was obtained by the Institutional Review Boards. Children were weighed and measured in light clothing and without shoes on a balance scale and with a body meter measuring tape with wall stop. Weights and heights were utilized to calculate body mass index (BMI) and each BMI value was standardized (z-BMI) in clusters categorized by age and gender, using World Health Organization (WHO) 2007 growth charts for children aged 5–19 [26] and WHO Multicentre Growth Reference Study (MGRS) for those aged 0–5 [27], in order to propose target appropriate standards (kids from 3 to 11 y). The adoption of these references are in line with the indications released by the Indian Academy of Pediatrics (IAP) [28]. Until nowadays IAP recommends the use of BMI criteria promoted by WHO, developed by an international scientific board including also contributors from India. The definition of infant growth charts, specifically adjusted for Indians, already in progress, is monitored by The National Meeting of the Growth Monitoring Committee of IAP. Children’s z-BMI were categorized according to these criteria: a) underweight: z-BMI 7) performed by children. The second section of the instrument, instead, investigates specifically on children’s eating habits. Combination of these different sections, constituting the inventory, makes emerge the complexity between behavioral patterns, cultural coordinates and alimentary habits of children and their parents, and offers a pluralistic view of potential risk factors for obesity.
Indian J Pediatr
Basic exploratory data analysis was performed on the sample and reported using median (I–III quartile) for continuous variables and percentages (absolute numbers) for categorical variables, whenever appropriate. Descriptive analysis of frequencies, duration and intensity of the different factors was performed. Chi-square and Anova were used to test variations across physical activity levels for categorical and continuous variables, respectively.
Results Participants, recruited for this study, constituted a sample of 1,680 children (Table 1), balanced by gender and age (3–6 and 7–11 y), with a median age of 6.50 y [Interquartile range (IQR): 5.00–8.00]. Research’s population was distributed along seven Indian major cities, namely 240 subjects for each town. According to BMI standards defined by WHO, normal weight infants count about 985 (59 %), underweight 307 (18 %), overweight 198 (12 %) and obese 185 (11 %). Anthropometric data revealed that children aged 3–7 y had a median waist circumference of 54 cm (IQR: 50–60), a median hip circumference of 61 cm (IQR: 56–67) and a median height of 120 cm (IQR: 112–128). Figures for children aged 8–11 y were 60 cm (IQR: 54–68), 69 cm (IQR: 62–76) and 137.5 cm (IQR: 128–146), respectively. Information on family background was collected through a validated questionnaire to parents. As shown in Table 1, mothers had a median BMI value of 23.73 (IQR: 21.63–26.04), while fathers’ had median BMI of 24.69 (IQR: 22.59–26.83). With regard to employment, 1,410 fathers (84 %) declared to have a working activity, while only 489 mothers (29 %) were engaged in a job outside the household. As to educational attainment, mothers and fathers exhibited almost the same distribution: the majority holded an academic degree and less than 10 % had a low education. This study being focused on physical activity associated to sedentary lifestyle, structural components of the household where a child lived, have also been taken into consideration. Households disposed of a median of two rooms (IQR: 2.00– 3.00) with a median of one television (IQR: 1.00–2.00) per house. Households providing television in children’s rooms represented 12 % (n=207) of the whole sample. Time spent by children in watching TV amounts to a median of 10 h (IQR: 7.00–16.00) per wk and 29 % (n=89) of children declared to spend between a half and one hour weekly in playing video games. Children, who did not play video-games constituted 48 % (n=808) of the sample. Overall, among the 1,680 children of the sample 350 (21 %) were inactive, 303 (18 %) exercised at least 1 time per wk and 349 (21 %) between 2 and 3 times weekly.
Significant differences by town were seen, with highest percentages in Chennai (29 %) and lowest in Hyderabad (4 %). Descriptive analysis (Table 1) made emerge that for 59 % of children who practiced physical activity on regular basis (more than 3 times per wk), the intensity of exercise varied from half an hour to an hour. Infants declaring to practice more than seven hours weekly represented a minority in the whole sample (n=88). Girls were more inactive than boys. According to WHO recommendations, affirming that children/adolescents aged 5–17 y should practice at least 60 min of physical activity per day [29], only 17 % (250) of children’s aged 5–17 y in the study sample were in line with this value. Figure 1 shows the distribution of children meeting this recommendation by city and gender. Results on physical activity of parents must be interpreted with caution since the percentage of non-respondents was high, nearly 50 %. Generally, children who practiced physical activities consumed more fruits (p value
