Sultan Qaboos Univ Med J. 2013 Nov; 13(4): 510–519.

Published online 2013 Nov 8. PMCID: PMC3836639 PMID: 24273660

Lifestyle Habits
Diet, physical activity and sleep duration among Omani adolescents
Hashem Kilani,1,* Hazzaa Al-Hazzaa,2 Mostafa I. Waly,3 and Abdulrahman Musaiger4
Advances in Knowledge

 - The results of this research supply comprehensive and recent data on physical activity
(PA)/inactivity patterns, eating habits and sleep duration in Omani adolescents, and their
relationships to risk factors measures.
 - These data represent baseline lifestyle characteristics to be used for potential
intervention programmes in Oman.
 - Information on the lack of PA, low amounts of sleep, the consumption of high calorie
foods and a normal body mass index could be used for further research, including on the
heritability of the Omani phenotype.

Application to Patient Care

 - The information in this study will stimulate society and healthcare providers to
encourage increased PA, reduced electronic screen exposure, healthy dietary choices and
sufficient amounts of sleep.
 - Awareness of sleep deprivation may reduce automobile accidents, a significant
percentage of which occur due to lack of sleep.
 - This study provides information on characteristic lifestyle patterns for the consideration
of Oman’s Ministry of Education, physical education curriculum supervisors, public
health authorities, policy makers and healthcare providers.

WORLDWIDE , A LIFESTYLE THAT  incorporates a healthy diet and physical activity (PA) is well-
documented as being preventative of non-communicable diseases (NCDs) including type 2
diabetes (T2DM) and heart diseases. Lifestyle and well-being patterns are rooted in the habits of
late adolescence and early adulthood and affect health in the long term. In 2005, the World
Health Organization (WHO) estimated that 61% of deaths (35 million) and 49% of the global
burden of diseases were attributable to NCDs, with 80% of such deaths occurring in low- and
middle-income developing countries where health resources are limited.1
Oman, located in the southeastern corner of the Arabian Peninsula, is one of the developing
countries in the Arabian Gulf. Oman’s population numbers 3,090,150 of which 51% are under 24
years old.2 In terms of its health profile, Oman has moved in less than half a century from a
country dominated by infectious diseases to a country burdened by NCDs, including
cardiovascular diseases, T2DM, obesity, hyperlipidaemia, and metabolic syndrome
disorders.3 Overweight and obesity are linked to the aetiology of NCDs, including T2DM, and
are two conditions for which Omanis are considered a high-risk group.3,4 The westernisation of
lifestyle is associated with a high incidence of obesity and NCDs in the Gulf countries, including
Oman.5
The risk of NCDs among the Arab population is reported to start at adolescence and is indicated
by a high body mass index (BMI).6,7 Physical inactivity and lack of knowledge about healthy
and energy-dense foods might be considered risk factors for overweight and obesity among
Omani adolescents, yet there are little data on the lifestyle habits of Omani adolescents.8,9 It is
important to monitor the lifestyle habits of young adolescents, as recent research has indicated an
association between young people’s lack of exercise, unhealthy dietary behaviour, self-imposed
sleep reduction and an increased risk of developing NCDs.1,10
In addition, recent research on adolescents in Saudi Arabia has observed a high prevalence of
sleep deprivation which was significantly associated with an increased risk of overweight and
obesity.11,12Epidemiological studies suggest that self-reported sleep complaints are associated
with an increased relative risk of cardiovascular morbidity and mortality.13
According to the National Commission on Sleep Disorders Research and reports from the
National Highway Safety Administration, high-profile accidents can partly be attributed to
people suffering from a severe lack of sleep.14 This is a matter of alarm as those subjecting
themselves to self-imposed sleep curtailment are at an increased risk for such accidents as well
as likely to develop a sedentary lifestyle and obesity.
It is helpful to understand the Omani risk factors and relate those to our results. Indeed, Omani
lifestyle changes during the last 5 decades have influenced the culture, and it has become
apparent that certain phenotypical factors seem to have influenced the Omani population’s
anthropometry. Few studies have tackled the problem of sedentary behaviours, limited PA, sleep
duration (SD) or the eating habits (EH) of Arab adolescents. Therefore, the aim of this study was
to investigate the lifestyle habits, including PA, EH and SD of Omani adolescents, and to
examine the gender differences in such variables. We also sought to address the following
specific questions: (1) What are the current lifestyle habits related to diet, PA/inactivity, and
sleep deprivation among Omani adolescents? (2) Are there associations between lifestyle habits
and BMI or overweight? (3) Are there differences between male and female lifestyles?
Methods
The participants were drawn from students attending secondary schools in the city of Muscat, the
capital of Oman. The data were collected during October and November 2010. Two
questionnaires were simultaneously used for the study’s cohort: the Arab Teens Lifestyle Study
(ATLS) for the assessment of PA, anthropometrics and sleeping hours, and a semi-quantitative
food frequency questionnaire (FFQ) for dietary intake assessment.6 Anthropometric
measurements (body weight, height and waist circumference [WC]) were also taken.
This research is part of the ATLS, an epidemiological, cross-sectional and multicentre project
designed to study the lifestyle of adolescents living in major Arab cities.6 The minimum sample
size needed (± 0.05 of the population proportion with a 95% confidence level) was calculated as
770 adolescents, assuming the population proportion to be 0.50. The sample size was estimated
using Epi Info 2008 (Centers for Disease Control and Prevention, Atlanta, Georgia, USA) and
was based on a population of 40,000 students.
A multistage stratified-cluster random sampling technique was used to select the required
sample. At the first stage, stratification was determined based on gender and geographical
locations. Therefore, 6 schools were randomly selected from the three major geographical areas
in Muscat, the northern, central and southern areas. To select the schools, a systematic random
sampling procedure was used. Later on, classes were selected at each grade (level) using a
simple random sampling design. Thus, we selected 18 classes (9 classes each at boys’ and girls’
schools).
The study subjects were recruited on a voluntary basis. The inclusion criteria required
participants to be healthy, and free of endocrine disorders and chronic diseases. This inclusion
criterion was important since we wanted to examine the lifestyle habits of healthy people. The
exclusion criteria included physical deformities and chronic diseases. This information was
obtained from the school students’ medical records. The total sample size consisted of 802
adolescents (males = 360; females = 442).
The study protocol and procedures were approved by the Office of the Advisor for Academic
Affairs at Sultan Qaboos University (SQU) as well as by the Ministry of Education’s Directorate
General of School Education in the Muscat Governorate. We also obtained school and parent
consent for conducting the survey as well as the agreement of students to participate.
Anthropometric variables included body weight, height and WC. Measurements were taken in
the morning by trained researchers using standardised procedures. All research assistants were
volunteers from the Physical Education Department at the College of Education at SQU. Body
weight was measured to the nearest 100 g with minimal clothing and without shoes, using a
calibrated portable scale. Height was measured to the nearest cm with the subject in the full
standing position without shoes and using a calibrated portable measuring rod. BMI is defined as
the individual's body mass divided by the square of their height (Kg/m 2). The International
Obesity Task Force’s (IOTF) age- and sex-specific BMI reference values were used to define
overweight and obesity in adolescents aged 14–17 years. For adolescents 18 years and older, we
used the cut-off points for adults (normal, overweight and obese, based on 18–24.9, 25–29.9, and
≥30 Kg/m2, respectively). WC was measured horizontally at navel level and at the end of gentle
expiration to the nearest 0.1 cm using a non-stretchable measuring tape.6
The ATLS research instrument was used to record lifestyle information.3,7 The questionnaires
included items for the assessment of PA, sedentary behaviours, EHs and SD. To ensure accurate
and consistent measurements throughout this study, the research assistants were trained and
provided with a standardised written protocol.
Different PAs were assigned metabolic-equivalent (MET) values based on a compendium of PAs
and the compendium of PAs for youth.6 Moderate-intensity PAs include normal paced walking,
brisk walking, recreational swimming, household activities, and recreational sports such as
volleyball, badminton and table tennis. Moderate-intensity recreational sports were assigned an
average MET value equivalent to 4 METs. Household activities were given an average MET
value of 3. Slow walking, normal paced walking and brisk walking were assigned values of 2.8,
3.5 and 4.5 METs respectively, based on the modified MET values in the compendium of PA for
youth.15 Vigorous-intensity PAs and sports include stair climbing, jogging, running, cycling,
self-defense, weight training, soccer, basketball, handball, and singles tennis. Vigorous-intensity
sports were assigned an average MET value of 8. To measure the participants’ levels of PA, the
total METs-mins per week and the METs-mins per week spent in each of the moderate- and
vigorous-intensity PAs were used. For PA cut-off values, three categories (low, medium and
high activity) based on tertiles of total METs-mins per week, METs-mins per week from
vigorous-intensity PA, and METs-mins per week from moderate-intensity PA were used.
Inactivity was defined as 1,680 METS (60 mins per day × 7 days per week × 4 METs).
The ATLS instrument also included questions on sedentary behaviours, assessing the typical
amount of time spent per day on screen-related activities, including television viewing, electronic
games, and computer and Internet use. Participants were asked to state their typical time (hrs) per
week spent on these activities without differentiating between weekdays and the weekend. For
total screen-viewing time cut-off values, we used the American Academy of Paediatrics (AAP)
guidelines of a maximum of 2 hours per day.6,7
The retrospective dietary intake of the study participants was estimated using a semi-quantitative
FFQ where all subjects were asked to report the frequency and portion size for each food item
consumed over the past 6 months.16 This period was chosen to take into account the seasonal
variation in food consumption. Also, all study subjects were asked if they had changed their diets
from their usual routines in the last 12 months. The FFQ was adapted according to portion sizes
based on commonly used household serving units/utensils in Oman, and was tested for its
validity, reliability and reproducibility before conducting the study.17
The different food groups included in the questionnaire were as follows: breads/cereals,
vegetables, fruits, meat/meat substitutes, milk/dairy products, desserts, beverages, sandwiches,
and traditional Omani dishes. The collected dietary data were categorised into two groups: (1)
Food group analysis, or the number of daily servings of food groups based on the frequency of
consumption. All participants were subsequently grouped according to the Food Guide Pyramid
from USA Departments of Agriculture and Health and Human Services.18 (2) Nutrient density,
or the percentage of energy contribution from the daily macronutrients intake to the total energy
intake. The Food Processor software, Version 10.2 (ESHA Research, Salem, Oregon, USA) was
used to calculate the means of daily nutrient intake of macronutrients and total energy intake as
estimated from the portion sizes and nutrient content for all foods reported by each participant.
All participants were asked about the number of typical sleeping hours per day (night and day)
using a self-reported questionnaire included in the ATLS. No differentiaton between weekdays
and weekends in sleeping hours was ascertained. In this study, insufficient sleep was defined as
sleeping less than 7 hours per night according to the definition of the National Sleep Foundation
for the adolescent population.14
Data were presented as means ± standard deviation (SD). Statistical analysis was conducted
using the Statistical Package for Social Sciences (SPSS), Version 19 (IBM, Corp., Chicago, IL,
USA). The Chi-square test was used to analyse categorical variables. The one-way analysis of
variance (ANOVA) followed by Freeman-Tukey’s test or the unpaired Student’s t-test were used
for analysing continuous variables. Multinomial logistic regression analysis was used where the
dependent variable was BMI. A P value of <0.05 was considered statistically significant.

Results
The descriptive characteristics of the participants are shown in Table 1. All the Omani
adolescents who participated in this study were similar in age (17.1 ± 1.2 years for males and
16.7 ± 1.3 years for females). The percentage of females in the sample slightly exceeded that of
males (55.1% versus 44.9%). Although males and females had similar values for BMI and WC,
the prevalence of overweight or obesity was higher in females than males, but only by a very
small proportion. However, the total screen time was also higher in females than males
(3.7 versus 2.8 hours/day, respectively).

Published online 2018 Feb 9. doi:  10.3389/fnut.2018.00010

PMCID: PMC5811476 PMID: 29479531

Association of Anthropometric and Lifestyle Parameters with Fitness Levels in Greek

Schoolchildren: Results from the EYZHN Program
Giannis Arnaoutis,1,* Michael Georgoulis,1 Glykeria Psarra,1 Anna Milkonidou,1 Demosthenes B.
Panagiotakos,1Dafni Kyriakou,1 Elena Bellou,1 Konstantinos D. Tambalis,1 and Labros S.
Sidossis1,2

Introduction
Physical fitness (PF) is defined as “the ability to carry out daily tasks with vigor and alertness,
without undue fatigue and with ample energy to enjoy leisure-time pursuits and to meet
unforeseen emergencies” (1). PF is a complex term involving cardiorespiratory endurance,
muscle endurance, and muscle strength, as well as flexibility, balance, agility, and coordination.
Although PF is the outcome of a multifactorial behavior, recent data explain differences between
subjects, in part, by genetic variation. More precisely, specific genetic loci have been found to
relate performance and health-related fitness phenotypes. Polymorphisms in several genes have
been found to be associated with cardiorespiratory fitness, including β2-adrenergic receptor
(ADRB1) and β2-adrenergic receptor (ADRB2), and baseline muscle strength, including vitamin
D receptor (VDR) (2–4). Therefore, PF actually represents a set of attributes or abilities that an
individual has or achieves in order to perform physical activity efficiently. A high PF level in
childhood is considered essential for the maintenance of good health and general wellness.
According to accumulating epidemiologic evidence, high PF level is related to a favorable body
composition, improved skeletal health, protection against cardiometabolic risk factors (e.g.,
hypertension and dyslipidemia), as well as improved mood, psychological health, academic
performance, and quality of life (5). In addition, longitudinal studies reveal a significant graded
association between low PF levels in adolescence and an increase in the risk of cardiovascular
disease and early death in adulthood (6, 7). However, worldwide data indicate significantly low
percentages of children who are classified as physically fit. A recent systematic review which
included data from 50 countries indicated extremely low levels of fitness for children and youth
aged 9–17 years, especially in the South America and South European countries (8). In Greece,
Tambalis and his colleagues (9) have also demonstrated a significant increase in the percentage
of children classified in the lowest quartile of aerobic performance from 21 to 48.2% in girls and
from 25.7 to 38.7% in boys, during an 11-year period (1997–2007). Thus, promoting PF in
childhood, through identifying and intervening on its modifiable determinants, is crucial for
public health strategies aiming at promoting the health of the pediatric population.
Several factors associated with physique and lifestyle can potentially have an impact on the PF
levels in childhood; however, their correlation has not been systematically investigated in a large
number of large-scale studies so far. Regarding anthropometric parameters, longitudinal inverse
trends in obesity and PF levels have been reported in schoolchildren (9), a fact that raises
concerns given the global obesity epidemic. Indeed, childhood obesity and abdominal adiposity
are considered as escalating health problems globally (10–13), and policy interventions for their
management are urgently needed. Moreover, since they persist through adulthood (14) and pose
a great threat for children’s health being associated with increased cardiovascular disease risk, as
well as endocrine, gastrointestinal, respiratory, musculoskeletal, and psychological disorders
(15–17). However, reductions in children’s PF levels have been reported to be independent of the
increasing trends in obesity (9), suggesting that other factors, probably related to lifestyle, are
also significant determinants of PF levels in the youth. The increase in the prevalence of
pediatric obesity and associated comorbidities has been mostly attributed to environmental
factors and specifically poor lifestyle habits, as documented in several studies both in developed
and developing countries (18). For instance, the “nutrition transition phenomenon” has gradually
led to the westernization of children’s diet and a gradual shift from traditional prudent dietary
patterns, including the Mediterranean diet (MD), to patterns characterized by increased
consumption of fast food, sweets, soda, and meat products (19–21). Moreover, physical
inactivity is nowadays estimated to be common among the youth, as indicated by
epidemiological data which show that only a small proportion of children and adolescents
achieve the recommended levels of physical activity for health promotion [~25% of children (6–
15 years old) are classified as at least moderately active for 60 min per day on at least 5 days per
week] (22–24).
Considering the importance of a high PF level in childhood, as well as the lack of studies
assessing its correlation with lifestyle in youth, the purpose of the present study was to determine
PF levels, to explore the association between the performance in various PF tests and
anthropometric and lifestyle parameters, as well as to identify the most significant modifiable
predictors of total poor PF level in a nationally representative sample of Greek schoolchildren.

Materials and Methods

Participants
Population-based data were derived from a nationwide school-based survey, i.e., the EYZHN
(National Action for Children’s Health) program, performed under the auspices of Harokopio
University of Athens and the Greek Ministry of Education, Research and Religious Affairs and
aiming to record health- and lifestyle-related parameters of the total student population of
Greece. In the context of the EYZHN program, all Primary and Secondary schools of Greece
(both public and private and from all geographical districts of the country) were invited to
participate, following a formal letter sent from the Greek Ministry of Education, Research and
Religious Affairs to all Primary and Secondary Education Boards of the country. For the current
work, anthropometric, dietary, physical activity, and PF data, along with information on age and
sex, from a total sample of 335,810, 6–18 year old students, who participated in the EYZHN
program during the school year 2014–2015, were analyzed. Data were collected from March
2015 to May 2015, and participation rate was 40% of the total Greek student population. All
students had Greek nationality, were informed about the study experimental procedures, and a
verbal assent was obtained from each participating child, along with a written informed consent
provided by their parents. The study was conducted according to the guidelines laid down in the
Declaration of Helsinki, and all procedures involving human subjects/patients were approved by
the Review Board of the Ministry of Education and the Ethical Committee of Harokopio
University of Athens.
Anthropometric Measurements
All anthropometric measurements were performed by trained physical education professionals at
schools, and a standardized procedure was implemented, along with a systematic calibration of
the devices (e.g., weight scales), in order to ensure maximum validity and accuracy. Students’
body mass and stature were measured in the morning, without shoes using a standardized
protocol (25). Body mass was measured in the standing upright position with electronic scales
with a precision of 100 g. Stature was measured to the nearest 0.1 cm with the children’s weight
equally distributed on their feet and their head, back, and buttocks on the vertical line of the
height gage. Children body mass index (BMI) was calculated, as the ratio of the body weight to
the square of body height (kg/m2) based on the aforementioned measurements. BMI values were
transformed into BMI z scores using WHO reference values for pediatric BMI (26). The
presence of overweight and obesity was defined according to the international age- and gender-
specific criteria proposed by Cole et al. (27). For the purpose of the present analysis,
underweight children were incorporated with their normal weight counterparts. Waist
circumference (WC) was measured to the nearest 0.1 cm midway between the lowest rib and the
superior border of the iliac crest at the end of normal expiration with the use of a non-elastic
measuring tape positioned at a level parallel to the floor and with the subject in a standing
position. The evaluation of abdominal adiposity was based on waist to height ratio (WHtR),
calculated as the ratio of WC (cm) to height (cm). Central obesity presence was defined as
WHtR ≥ 0.5, given that this specific cutoff point has been found suitable for the estimation of
abdominal adiposity in children and for the prediction of cardiometabolic abnormalities (28, 29).

Assessment of PF Levels
The Eurofit PF test battery was used to evaluate children PF levels (30), initially proposed by the
Council of Europe and used systematically from many European countries during the last few
decades. The battery consists of five tests, i.e., (a) a multistage 20 m shuttle run test (20 m SRT),
to estimate cardiorespiratory endurance; (b) a maximum 10 × 5 m shuttle run test (10 × 5 m SRT)
from a standing start to evaluate speed and agility; (c) a sit-ups (SUs) test in 30 s, in which the
student lies on the mat with the knees bent at right angles, with the feet flat on the floor and held
down by a partner, to measure the muscular endurance of the abdominals and hip flexors; (d) a
standing long jump (SLJ), where the children are asked to bend their knees with their arms in
front of them, parallel to the ground, then swing both arms, push off vigorously and jump as far
as possible, trying to land with their feet together and stay upright, to evaluate lower body
muscular strength; and (e) a sit and reach (SR) test that involves sitting on the floor with legs
stretched out straight ahead without shoes to measure flexibility. In detail, the 20 m SRT test
consists of measuring the number of laps completed by participants running up and down
between two lines in groups, set 20 m apart, at an initial speed of 8.5 km/h which increases by
0.5 km/h every minute, using a pre-recorded audio tape (31, 32). The test is terminated when
participants stop due to fatigue or when they fail to reach the end line concurrent with the signals
on two consecutive occasions, and the last completed stage or half-stage is recorded. For the SR
test, the soles of the feet are placed flat against a box. With the palms facing downwards, and the
hands on top of each other or side by side, the participant reaches forward along the measuring
line as far as possible. The score is recorded to the nearest centimeter as the steady distance
reached by the hand for at least 2 s, using 15 cm at the level of the feet. Two trials were allowed
for the SLJ, SR, SUs, and 10 × 5 m SRT, with the best performance of each recorded. All five
fitness tests were administered during the physical education class by physical education
professionals, who were instructed through a detailed manual of operations and followed a
standardized procedure of measurements in order to minimize the inter-rate variability among
schools.
Student performance in PF tests was evaluated based on the recently published PF normative
age- and sex-specific values for 6- to 18-year-old Greek boys and girls (33). Specifically, for
each of the five PF tests applied, a performance ≤25th percentile was considered as low, between
the 25th and 75th as average, and ≥75th as high. Based on this categorical classification, a binary
outcome (0 versus 1) of low PF was utilized for each PF test applied. For example, low PF in the
20 m SRT was defined as a performance ≤25th percentile of normative age- and sex-specific
values of the 20 m SRT. Using the abovementioned binary classification for each PF test, a
combined variable representing total poor PF (0 versus 1) was constructed. This variable was
defined as the combined low performance (≤25th percentile) in all five PF tests applied.
Therefore, student total PF was characterized as poor if performance was ≤25th percentile of
normative age- and sex-specific values in all five PF tests applied.

Lifestyle Assessment
Participating children’s lifestyle (dietary and physical activity habits) habits were
recorded via the use of an electronic questionnaire that was completed at school with the
presence and assistance of their teachers and/or Information Technology professors, all
previously provided with specific written guidelines for its proper completion, in order to
provide an accurate reflection of their habits and for a standardized evaluation protocol to be
implemented among all participating schools. Regarding students’ dietary habits, these were
assessed through the KIDMED (Mediterranean Diet Quality Index for children and adolescents),
developed by Serra-Majem et al. (34). The KIDMED index was developed in an attempt to
combine the MD guidelines for adults with the general dietary guidelines for children in a single
index. The index comprises 16 yes or no questions, including dietary habits that are in
accordance with the principles of the Mediterranean dietary pattern and the general dietary
guidelines for youth (e.g., consumption of at least one fruit at a daily basis, consumption of 2–3
fish per week, use of olive oil as the main culinary fat in salad and cooking, etc.), and other
habits that undermine them (e.g., breakfast skipping, daily consumption of sweets, frequent
consumption of fast food, etc.). Questions denoting a negative connotation with respect to a
high-quality diet are assigned a value of −1, while those with a positive aspect are assigned a
value of +1. Thus, the total KIDMED score ranges from −4 to 12 and is classified into three
levels: ≥8, suggesting an optimal adherence to the MD; 4–7, suggesting an average adherence to
the MD and an improvement needed to adjust dietary intake to guidelines; and ≤3, suggesting a
low adherence to the MD and generally a low diet quality. With regard to physical activity
habits, the questionnaire applied has been previously used in children in other large-scale
epidemiological studies (13) and included simple closed-type questions regarding children’s
frequency and time of participation in sports activities, active play, and sedentary activities. For
the current analysis, student’s weekly frequency of participation in organized sports activities
(range 0–7, i.e., from rare to daily participation) as well as weekly frequency (range 0–7, i.e.,
from rare to daily participation) and average duration (in hours) per bout of engaging in
sedentary activities (such as television, computer and video games) were used. Daily time (in
hours) spent in sedentary activities was also calculated for each student (via multiplying the
weekly frequency of participation with the duration per bout of participation in sedentary
activities and then dividing by 7). Using the threshold of 2 h/day proposed by current scientific
evidence and guidelines (35–38), the students were classified as sedentary or not, i.e., exceeding
(>2 h per day) or not (≤2 h per day) the recommended daily time spent in sedentary activities. All
questionnaires were answered in Greek.

Statistical Analysis
Data are presented as mean ± SD for continuous variables and as frequencies for categorical
ones. Continuous variables were compared between groups using the Student’s t-test, and
correlations between them were tested using the Pearson correlation coefficient (r), while the
chi-square test was used to test differences between categorical variables. Multiple logistic
regression analysis was used to explore the relationship between anthropometric or lifestyle
parameters and the likelihood of total poor PF, with results presented as odds ratios (OR) with
their corresponding 95% confidence intervals (95% CI) for each independent variable. The
Hosmer–Lemeshow statistic was used to test models’ goodness-of-fit, and the Wald test was
used to determine the hierarchy of independent variables regarding their contribution to the
prediction of PF. All statistical analyses were performed using SPSS version 21.0 (SPSS Inc.,
IBM Hellas, USA). The significance level was set up at 0.05.

Discussion
In the present study, we evaluated PF levels in relationship with anthropometric characteristics
and lifestyle habits and assessed the most significant determinants of low PF levels in a
nationally representative sample of Greek students. The major findings from our data are that the
presence of obesity and central obesity are both negatively associated with all the components of
PF that we examined and are the most aggravating factors responsible for total low PF,
accompanied by lack of engagement in physical activity, poor dietary habits, and sedentariness.
Overweight and obesity have been repeatedly identified as the cornerstone for numerous health
pathologies during childhood (15–17). In our study, excess body weight was associated with
poor PF, a fact that is in accordance with other studies supporting that overweight or obese
children are not sufficiently active and consequently appear to be less physically fit. The most
eminent explanation is that weight-bearing exercises, i.e., exercises that require “carrying”
someone’s body mass, are disadvantageous for children with excess body weight (39, 40).
Noteworthy, according to our results, the presence of central obesity was an even stronger
predictor of poor PF in childhood than general adiposity. Although the association between
abdominal obesity and PF has not been thoroughly examined in the literature, it is well-
documented that the prevalence of central obesity is nowadays particularly high among children,
and despite the attention given to the epidemic of childhood obesity, WC has increased at a
higher rate than total body weight over the past 10–30 years in the youth (13). In addition, the
presence of central obesity in children has been proposed to have a higher predictive value with
regard to metabolic disorders and chronic diseases, compared to whole-body fat mass, a fact that
suggests a parallel increase in the cardiometabolic risk of children and adolescents worldwide
(29, 41). Besides its well-established metabolic and inflammatory complications (42), this
negative impact of central obesity on cardiometabolic indices could also be partially explained
by its negative association with PF levels observed in the present study, a fact that needs further
investigation. Based on the aforementioned, the use of WHtR or other indices to assess
abdominal adiposity in the routine pediatric practice should be encouraged, and children
presenting with central obesity should undergo a further assessment in terms of lifestyle, PF, and
cardiometabolic risk.
Besides adiposity, the second most important predictor of PF concluded by the results in our
study was the frequency of engagement in physical activity, a reasonable observation given that
the relationship between increased physical activity and ameliorated PF is well documented
(7, 43, 44). However, children nowadays are more sedentary than ever. Reasons for that are
multiple and include the widespread use of computer and video games along with increased time
of television viewing, inactive role models (e.g., parents), limited free time, unsafe environment,
lack of sport facilities or insufficient funds to participate in certain recreation programs, and
insufficient access to quality daily physical education (22–24). In contrast, regular physical
activity (regardless of its type; strength or aerobic exercise) is essential for weight regulation
and/or reduction, increases in bone health and muscle strength, and improvements in
cardiovascular function (45). At the same time, it is beneficial psychologically, since it is
associated with an increase in self-esteem and self-concept and a concomitant decrease in
anxiety and depression (45). Given the aforementioned, along with the finding that the higher the
participation in organized sports the lower the presence of children with low PF, it can be
reasonably suggested that the lesson of physical education in schools can serve as an important
tool for promoting student engagement in athletic activities and reducing sedentariness, and
presumably, in the long term, as a way of improving their PF level.
An interesting finding of our study is that the level of adherence to the MD was also a significant
predictor of PF level, following adiposity and engagement in physical activity. According to
accumulated epidemiological and interventional studies, the adoption of a healthy dietary pattern
such as the MD has been proven to be efficient not only in protecting against the development of
but also in the management of several chronic diseases, including cardiovascular diseases,
diabetes mellitus, neurodegenerative diseases, and obesity (46). Regarding its association with
PF, direct data are scarce; however, it is well established that nutrition is an important part of
athletic performance especially during childhood and adolescence, in addition to allowing for
optimal growth and development (47). Furthermore, published data show a positive relationship
between the degree of adherence to the MD and physical activity (43, 48, 49), as well as a
negative relationship with indices of abdominal adiposity (50) in children. Thus, it can be
proposed that such a model of a well-balanced diet, providing adequate energy sources
throughout the day, rich in all essential nutrients and natural antioxidants, poor in saturated fat,
and based on an abundant consumption of fruits, vegetables, legumes, fish, nuts, and olive oil,
can also improve PF during childhood, especially when combined with increased physical
activity and given that it is associated with a more favorable body composition. Therefore,
besides the promotion of a physically active lifestyle, strategies aiming at improving
schoolchildren’s dietary habits toward a prudent dietary pattern, such as the MD, are also crucial,
as a mean to improve their PF and safeguard their health in general.
A limitation of our study derives from its design. Cross-sectional studies are generally limited in
providing causal relationships and can only generate hypotheses about the possible links between
parameters, in this case between anthropometric and lifestyle characteristics and poor PF during
childhood and adolescence. Although our data provide evidence that anthropometric and lifestyle
habits are closely associated with PF in childhood, it should be noted that several other
parameters could also have an impact on PF, indirectly through an effect on lifestyle habits.
Nevertheless, factors such as family socioeconomic status, parental educational level, and
residential environment characteristics (e.g., access to green spaces or athletic facilities) were not
assessed in the present study, mainly due to practicality reasons. Moreover, although a clear
methodology was implemented in order to ensure accuracy in student anthropometric and
lifestyle assessment, under- or overestimations cannot be excluded. This limitation is more
evident with regard to the lifestyle questionnaire used, which may have been difficult for
younger students to answer. However, we tried to overcome this restriction through
implementing a standardized protocol, according to which students provided their answers with
the assistance of their previously well-trained teachers. Last but not least, it should be mentioned
that several additional measurements, which were not economically feasible due to the large
sample size, could add to the accuracy and strength of our results, including a more
comprehensive assessment of PF using all nine Eurofit tests, as well as the assessment of body
composition for a more accurate estimation of adiposity.
In conclusion, anthropometric characteristics such as excess body weight and increased
abdominal fat accumulation, as well as lifestyle parameters including the lack of physical activity
and the adoption of poor dietary habits, are strongly and positively associated with poor PF in
childhood and adolescence. It is urgent that large-scale interventions and relevant public health
policies are designed and implemented toward the promotion of PF level of the pediatric
population and ultimately their health status. In the context of such interventions and health
policies, cardiorespiratory fitness should be the primary target, given that it is the most well-
studied component of PF, with the majority of studies emphasizing on its significant preventative
and health-promoting role both in children and adults (6, 7, 44). Our results suggest that
emphasis should be placed primarily toward preventing childhood obesity and abdominal
adiposity and secondarily toward providing schoolchildren with the adequate stimuli for
engaging in physical activity and following a prudent dietary pattern, with a view to accomplish
beneficial changes in their PF and health in general.
Iran J Public Health. 2015 Apr; 44(4): 486–494.
Published online 2015 Apr. PMCID: PMC4441961 PMID: 26056667
Comparative Study of Lifestyle: Eating Habits, Sedentary Lifestyle and Anthropometric
Development in Spanish 5- To 15-yr-Olds
María MORALES-SUÁREZ-VARELA,1,3,* Candelaria RUSO JULVE,1 and Agustín LLOPIS
GONZÁLEZ1,3

Introduction
Lifestyles are considered to interact between life conditions and individual patterns of conduct, which are
determined by socio-cultural factors and individuals’ personal characteristics, according to WHO (1).
These factors include conducts and preferences related with food types, physical activity, recreational
activities and consumption patterns (2). Living an inadequate lifestyle in infancy can favour increased
body weight, which, in recent years, has been related with a higher over-weight and obesity prevalence
(3). The enKid study (1998–2000) respectively reported a prevalence of 13.9% and 12.4% for obesity and
being overweight in Spanish children, with obesity being higher in males (15.6%) than in females (12%),
and if this trend continues, an overall level of 9.1% will be reached by 2020 ( 4). A balanced diet in
childhood and adolescence is crucial for well-being and growth, but also for establishing dietary habits
that will persist later in life (5). The nutrition transition, associated with rapid demographic and socio-
economic change, has increased the risk of obesity in childhood, as excessive intake of refined foods with
high concentrations of sugars, fats and energy, and low intake of fibre, pulses, fruit and vegetables (6).
This change inevitably affect choice of processed foods, mainly of animal origin, which means loss of
traditional eating patterns, and increased use of technology, which encourages sedentary activity ( 7, 8). In
Spain, the Mediterranean diet is characterised for a wide variety of foods and nutrients that reduce
morbidity and mortality (9), and for lowering the prevalence of processes related to cardiovascular
diseases (CVD) and metabolic syndrome, among other (10–12). Breakfast is considered one of the most
important meals of the day as it has an impact on general health and academic performance ( 13). In
Spain, 10–15% of children do not eat breakfast before school, or 20–30% does not eat full breakfast (14).
The term sedentary lifestyle is used to characterise reduced energy expenditure through lack of or reduced
physical activity, and is associated with substantial health consequences (15). It is also linked with
modern society lifestyles, which have drifted towards sedentary habits that are more harmful for health
(16). New media technologies, such as television (TV), computers and games consoles, have provided
new opportunities for sedentary activity (17). The American Academy of Paediatrics recommends
removing TV sets from children’s bedrooms and not spending more than 2 hours/day on sedentary
activities (18).
This study aimed to evaluate the factors that influence lifestyle by centring on diet quality and sedentary
activities by assessing the causes and effects they have on Spanish 5- to 15-year olds’ anthropometry for
the two periods corresponding to the last two Spanish National Health Surveys (ENSE; 2006 and 2013).

Discussion
We found in our results that eating habits improved when we compared the alimentation in
Spanish 5- to 15-year-olds in 2006 with 2013, but BMI did not change significantly, it could be
for tendency of reduce physical exercise or increase of sedentary style life of this culture.
In the last decade, society has faced a series of modifications that have acted on its lifestyles, and
an impact on health has been seen (23). Globalisation has had a direct influence on changes in
diet patterns, with a shift from a diet rich in carbohydrates and fibre to one rich in fats and
sugars. Consequently, the nature of the diseases that the population suffers has shifted to
malnutrition due to excess and higher cardiovascular risk (23).
This modification in food intake has implied abandoning basic, traditional foods to select more
meat products, dairy products, vegetable oils (coconut and palm), salt and sugar. All of this has
disparate effects on different population groups (23).
The ENSE study has allowed us to evaluate a representative sample of Spanish 5- to 15-year-
olds during two periods with a homogeneous criterion, which is maintained systematically over
time. One of the effects generated in this young population is increased body weight. In
developing countries, as in Europe, Spain is at the top of child obesity data, exceeded only by
Malta, Greece and Italy (24). The obesity prevalence in Spain is 12.6%, with a 26.0% rate of
being overweight, according to the WHO (4), which correlate with their parents’ socio-economic
level and level of education (25). The assessment made of our data led us to note a slight
improvement in BMI, which has led to an increased prevalence of normo-weight individuals.
However, the overall percentage of being overweight was still 24.3%.
Another of the effects produced was a change in the food intake trend. In the last few years, less
bread, pulses, potatoes, pasta and rice are eaten; that is, diets rich in complex carbohydrates, the
basis of Spanish diet, are not on the increase (26). Our data confirm this trend as the intake of
such foods has lowered. More meat (pork and chicken), fish, milk and cheese are being eaten,
which spells a diet rich in proteins and, consequently, one rich in saturated fats (26). In the ENSE
evaluation, the daily intake of such foods has significantly lowered in recent years. Although
eating vegetables on a daily basis increased by 7.9%, it is still insufficient. A drop of 6.7% in
drinking soft drinks was also found. This result is favourable as there is evidence that relates
frequent soft drink consumption with increased indicators of adiposity and, therefore, with a
higher prevalence of obesity (27). Likewise, one of the factors that have changed the most is
breakfast. In the ENSE evaluation, we can see better quality when selecting food items for
breakfast, which is composed mainly of liquid (milk, juice) and solid (cereals, bread, biscuits)
food. Breakfast is the first meal of the day and is directly related with intellectual performance. A
bad quality breakfast will make cognitive performance and learning difficult (28), and will not
contribute to fulfilling daily dietary recommendations of calories and nutrients, especially
micronutrients (29).
Finally, the most outstanding result obtained from the present study is that the Spanish infant-
juvenile study population has increasingly acquired lifestyles that are more sedentary. The cause
of this increase might be progressive urbanisation, new technologies and passive entertainment,
among others (30). In the last 40 years, many epidemiological studies have demonstrated that
physical inactivity has negative effects for health (30). The ENSE evaluation shows us a
significant increase in the time spent by the Spanish infant-juvenile study population using
communication technologies on weekdays and at weekends. The time spent watching TV not
only means less time for physical activity, but also favours greater calorie intake of foods rich in
fats and sugars (31). In Italy, 29.0% watch TV between 2–2.5 hours/day, 25.0% do so for 3–3.5
hour/day and 23.0% spend 4 hours/day (32). In Spain, the time our study population spends
watching TV every day is 2–3 hours/day on average, especially in families with a low level of
education (33).
In short, today’s lifestyle is followed by the Spanish infant-juvenile population. This implies a
social pattern that continues to undergo constant change. In the subjects’ diet, animal-based
proteins rich in saturated fats predominate, while the choice of fish as the main protein intake
remains low. Eating foods of plant origin, such as pulses, vegetables or fruit, has increased
slightly, but remains insufficient. Notwithstanding, drinking soft drinks have significantly
lowered in recent years, while intake of sweetmeats remains constantly high. The time spent on
physical activities is being gradually substituted for sedentary activities owing to an increasing
use of the technology that the study population is surrounded by. Such changes affect
anthropometry while these individuals grow and develop. Thus, we observe that prevalence of
being overweight is high and must be taken into account for their future health status.

Conclusion
The results obtained herein when comparing both periods reveal that lifestyle, eating habits and
physical activity are strongly associated with the infant-juvenile 5- to 15-year-old study
population’s anthropometry, which acts on the prevalence of them being overweight and obese.
Nowadays, this age group is abandoning traditional Spanish eating patterns, such as the typical
eating habits in the Mediterranean region, and substituting them for more animal-based, highly
processed and industrialised foods. They also use more communication technologies at home,
which encourage a sedentary lifestyle and can have a negative effect on their future quality of
life.
An Assessment Of Maturity From Anthropometric Measurements

ROBERT L. MIRWALD, ADAM D. G. BAXTER-JONES, DONALD A. BAILEY, and GASTON P. BEUNEN College
of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, CANADA; Department of Human
Movement Studies, University of Queensland, Brisbane, AUSTRALIA; and Department of Sport and
Movement Sciences, Faculty of Physical Education and Physiotherapy, Katholieke Universiteit Leuven,
Leuven, BELGIUM

ABSTRACT

MIRWALD, R. L., A. D. G. BAXTER-JONES, D. A. BAILEY, and G. P. BEUNEN.

An assessment of maturity from anthropometric measurements. Med. Sci. Sports Exerc., Vol. 34, No. 4,
pp. 689–694, 2002. Purpose: The range of variability between individuals of the same chronological age
(CA) in somatic and biological maturity is large and especially accentuated around the adolescent growth
spurt. Maturity assessment is an important consideration when dealing with adolescents, from both a
research perspective and youth sports stratification. A noninvasive, practical method predicting years
from peak height velocity (a maturity offset value) by using anthropometric variables is developed in one
sample and cross-validated in two different samples. Methods: Gender specific multiple regression
equations were calculated on a sample of 152 Canadian children aged 8–16 yr (79 boys; 73 girls) who
were followed through adolescence from 1991 to 1997. The equations included three somatic
dimensions (height, sitting height, and leg length), CA, and their interactions. The equations were cross-
validated on a combined sample of Canadian (71 boys, 40 girls measured from 1964 through 1973) and
Flemish children (50 boys, 48 girls measured from 1985 through 1999). Results: The coefficient of
determination (R2 ) for the boys’ model was 0.92 and for the girls’ model 0.91; the SEEs were 0.49 and
0.50, respectively. Mean difference between actual and predicted maturity offset for the verification
samples was 0.24 (SD 0.65) yr in boys and 0.001 (SD 0.68) yr in girls. Conclusion: Although the cross-
validation meets statistical standards for acceptance, caution is warranted with regard to
implementation. It is recommended that maturity offset be considered as a categorical rather than a
continuous assessment. Nevertheless, the equations presented are a reliable, noninvasive and a
practical solution for the measure of biological maturity for matching adolescent athletes Key Words:
CHILDREN, ADOLESCENCE, GROWTH SPURT, PUBERTY, MATURITY, LONGITUDINAL STUDY

It is essential that all prospective studies in
children, both in context of youth sport
classification and research investigations,
attempt to control for maturity. Matching
children to equalize competition, enhance
chance for success, and reduce injury is an
objective that many coaches and health
professionals have emphasized (3,15). Maturity
assessment has specific application in the
classification of children for sport during the
adolescent period. The range of variability
between individuals of the same chronological
age in somatic and biological growth is large
and especially accentuated around the
adolescent growth spurt (13,17,18,26). The
formal methodologies to assess maturation are
beyond the resources of sport-governing bodies
or youth sport organizations and, therefore, the
need to revert to chronological age as the
classification criteria. Despite the major
maturity-related differences in height, weight,
strength, speed, and endurance of children at
identical chronological age classifications
(16,19), chronological age remains the only
accepted classification criterion. To date,
maturity status has rarely been a factor used in
participant classification into youth sports.
Chronological age is of limited utility in the
assessment of growth and maturation (14). The
need to assess maturation, the tempo and
timing of the progress toward the mature state,
is imperative in the study of child growth.
Although existing methodology provides the
required mechanism to assess maturation,
there are limitations to the available
methodologies (4). Skeletal age assessment, the
single best maturational index, is costly,
requires specialized equipment and
interpretation and incurs radiation safety
issues. Although the methodology covers the
entire period of growth from birth to maturity,
it does not lend itself to fieldwork. Dental age
and morphological age are broader
measurement techniques with limited
applicability. The assessment of secondary sex
characteristics is limited to the adolescent
period and in a nonclinical situation is
considered to be personally intrusive by
adolescent children and their parents. In
addition to a limited application period,
secondary sex characteristics do not reflect the
timing of growth. Somatic methods like age of
peak height velocity (PHV) or the differential
growth associated with regional growth require
serial measurements for a number of years
surrounding the ccurrence of peak velocity and
thus are unusable in a one-off measurement in
time. Age of PHV is the most commonly used
indicator of maturity in longitudinal studies of
adolescence (16). It provides an accurate
benchmark of the maximum growth during
adolescence and provides a common landmark
to reflect the occurrence of other body
dimension velocities within and between
individuals. Using the known differential timings
of growth of height, sitting height and leg length
(Fig. 1) we hypothesized that the changing
relationship between leg length and sitting
height with growth may provide an indication of
maturational status. The purpose of the present
study was to develop a simple, nonintrusive
method to assess maturity status in children,
years from peak height velocity, using
anthropometric variables. The availability of
data from three longitudinal studies provided a
unique opportunity to develop predictive
equations and verification samples to apply and
test the equations.
DISCUSSION During adolescence, it is essential
that the effects of maturation be controlled for
both in context of youth sport classification and
research investigations. All prospective studies
that evaluate the physiological process in
children must attempt to control for maturity.
Equitable classification of participants in youth
sport remains an important but unresolved
issue. The purpose of this investigation was to
establish a noninvasive and practical method to
assess maturity status during adolescence. We
have shown that age from peak height velocity,
a maturational benchmark, can be predicted
with a reasonable degree of accuracy by
measuring height, sitting height, body mass, and
chronological age. Although the Bland-Altman
procedure (8) provides the appropriate
methodology to assess the prediction
equations, the acceptance of the prediction
equations requires the researcher to establish
reasonable and practical limits for the
prediction. For the purposes of the present
investigation, the authors suggest acceptable
limits to approximate the mean plus or minus 1
yr (assuming a mean of zero and an SD of 0.5
yr). Within the limitations stated above, the
cross-validation of the prediction equations
meets statistical standards for acceptance.
Ideally, further verification on different samples
would provide additional support. The cross-
validation allows the prediction equations to be
tested for generalizability. When population
specific equations are applied to other samples,
there may be a loss in the accuracy of the
prediction or shrinkage reflected in the
reduction of the R2 value (27). The R2 values for
the boys and girls in the BMAS were 0.92 and
0.91. When the prediction equations were
applied to the verification samples, the R2
values were 0.89 and 0.88 for male and female
subjects, respectively. This difference would
indicate a small amount of shrinkage from the
development sample to the prediction sample.
However, the increase in the standard deviation
of the difference between predicted and actual
maturity offset values 0.49 in boys and 0.50 in
girls from the development sample (BMAS) to
0.65 in boys and 0.68 in girls in the verification
samples (SGDS and LLTS) is a more critical
evaluation of the prediction equations. When
the three studies are combined, the predictive
Equations 3 and 4 provided a more complete
and balanced sample. Note that measurements
were taken once a year in SGDS and twice a
year in the BMAS and LLTS. It is recommended
that the three study prediction equations be
used to predict maturity offset. With more
extensive observations on either side of PHV
and the increase in observations, these latter
prediction equations are more robust and
possibly afford greater generalizability given the
combination of three different samples. Both
the age range and variability of the predicted
value should be considered in the application of
the predictive equations. Although it is possible
to predict a continuous maturity measure, years
from PHV, an alternative may be the application
of categorical maturity offset values (6). For
example, any negative maturity offset
prediction should classify the individual as pre-
PHV and any positive prediction as post-PHV.
Used in this manner, a common benchmark
maturity classification can be constructed for
both boys and girls. This would be similar to a
pre- and postmenarcheal categorization, which
is only available in girls. To assure the best
estimate of maturity from these prediction
equations, care and attention must be paid to
standardized measurement procedures,
especially in the measurement of sitting height.
The magnification of measurement error by
prediction equations is a major limitation to any
method but especially where one
measurement, sitting height, has a direct
relationship with a number of independent
variables. The quest to develop a noninvasive
measurement of maturity is not a new issue
(7,24). For nearly 100 years, there have been
advocates for various classification indexes to
account for size and maturity in elementary,
junior, and senior high school and college men
and women (9–12,19,22,25,28). The purpose of
these classifications was to improve instruction
and to place students into equitable groups
according to “their capacities and their
achievements on which they are likely to
succeed” (19). The earlier approaches predict
adult stature and calculate maturity as a
percentage of adult stature. The current
investigation attempts to assess maturation by
predicting the tempo of growth or where the
individual is in relation to a maturational
benchmark, PHV. The test of any approach is
the generalizability to other populations and
other maturity assessment methods. Skeletal
age is another common and important method
of assessing maturity. Is there a relationship
between skeletal age assessment and maturity
offset? The male subjects in the SGDS had
skeletal hand-wrist x-rays assessed at age 11 yr.
The correlation coefficient between skeletal age
offset from chronological age and PHV maturity
offset from chronological age was 0.83.
Although the methods are different, the
direction and strength of the relationship
indicate a maturational commonality between
the two methodologies. Although it is feasible
and possible to seek a biologically based
classification system, the practical application of
this outcome rests with the acceptance by
sport-governing body authorities and youth
sport organizers. An application of these
predictive equations is illustrated in the
following example: two male individuals, A and
B, were first tested at chronological ages 11.4
and 11.3. The difference in their height and
weight was 4.7 cm and 6.2 kg. The application
of the maturity offset prediction equation
categorized each individual as pre-peak height
velocity. When both individuals were 14 yr of
age, the difference in their height was 25.8 cm
and in their weight was 13.7 kg. The maturity
offset prediction categorized the taller and
heavier individual as post-peak height velocity
and the other individual as prepeak height
velocity. At 17 yr of age, there was less than a 1-
cm difference in height and a 2-kg difference in
weight, and both individuals were predicted as
post-peak height velocity. The age of PHV for
the two individuals was 13.09 and 15.09 yr. This
example illustrates the effect of tempo of
growth in two individuals of the same
chronological age who were relatively the same
size before and after adolescence. However, the
path to maturity is variable and an individual
one. All studies of adolescent children need to
control for the confounding effects of
maturation. Current assessment methodologies
are invasive, intrusive, and/or gender specific.
Gender-specific equations are presented that
predict age from peak height velocity (a
measure of maturity offset) by using four
anthropometric variables (chronological age,
stature, sitting height, and body mass). The use
of stature and sitting height in the prediction
takes into consideration the differential timing
of the adolescent spurt in body dimensions and
also their interactions with chronological age.
The present results indicate that maturity offset
can be estimated within an error of 1 yr 95% of
the time. We believe this level of accuracy is
sufficient for adolescence to be assigned a
maturational classification. A classification that
can be applied to various research designs. In a
sporting context, matching adolescence sports
groups biologically rather than chronologically
may equalize competition, enhance chances for
success, and possibly reduce incidence of injury.