**Dietary, Lifestyle and Socio-Economic Correlates of Overweight, Obesity and Central Adiposity in Lebanese Children and Adolescents**

**Lara Nasreddine 1,†,‡, Farah Naja 1,†,‡, Christelle Akl l , Marie Claire Chamieh 1 , Sabine Karam <sup>1</sup> , Abla-Mehio Sibai 2,‡,\* and Nahla Hwalla 1,‡,\*** 


*Received: 24 December 2013; in revised form: 11 February 2014 / Accepted: 17 February 2014 / Published: 10 March 2014* 

**Abstract:** The Eastern Mediterranean region is characterized by one of the highest burdens of paediatric obesity worldwide. This study aims at examining dietary, lifestyle, and socio-economic correlates of overweight, obesity, and abdominal adiposity amongst children and adolescents in Lebanon, a country of the Eastern Mediterranean basin. A nationally representative cross-sectional survey was conducted on 6–19-year-old subjects (*n* = 868). Socio-demographic, lifestyle, dietary, and anthropometric data (weight, height, waist circumference) were collected. Overweight and obesity were defined based on BMI *z*-scores. Elevated waist circumference (WC) and elevated waist to height ratio (WHtR) were used as indices of abdominal obesity. Of the study sample, 34.8% were overweight, 13.2% were obese, 14.0% had elevated WC, and 21.3% had elevated WHtR. Multivariate logistic regression analyses showed that male gender, maternal employment, residence in the capital Beirut, sedentarity, and higher consumption of fast food and sugar sweetened beverages were associated with increased risk of obesity, overweight, and abdominal adiposity, while regular breakfast consumption, higher intakes of milk/dairies and added fats/oils were amongst the factors associated with decreased risk. The study's findings call for culture-specific intervention strategies for the promotion of physical activity, healthy lifestyle, and dietary practices amongst Lebanese children and adolescents.

**Keywords:** paediatric; obesity; abdominal adiposity; prevalence; correlates; diet; Lebanon; Eastern Mediterranean region

#### **1. Introduction**

The Eastern Mediterranean region is characterized by one of the highest burdens of overweight and obesity worldwide [1]. Of more concern is the high level of childhood obesity in countries of the region, with approximately 10% of school-aged children being obese, an estimate that is projected to follow an escalating secular trend [2]. Paediatric obesity is associated with both immediate and longer-term risks to health [3]. Among the immediate risks are metabolic abnormalities including increased blood cholesterol, triglycerides and glucose levels, insulin resistance, metabolic syndrome, and hypertension [3–5]. Childhood obesity is also a strong risk factor for adult obesity and its consequences including type 2 diabetes, cardiovascular diseases (CVDs), and certain types of cancer, in addition to psychological disturbances, such as low self-esteem and depression [6,7].

Obesity-related comorbidities were found to be more closely associated with abdominal adiposity and visceral fat depots than with the amount of total body fat [8]. Consequently, the use of body fat distribution indices has been increasingly recommended, and particularly the use of waist circumference (WC) and waist to height ratio (WHtR). These simple and non-invasive indices were shown to correlate with visceral fat in children and to predict risk for obesity-related comorbidities beyond that predicted by Body Mass Index (BMI) alone [8–14]. Being a relatively age-independent measure, the use of WHtR for assessing central fatness in children has been recommended in paediatric primary care practice, as well as epidemiological studies [14–16]. In a cohort of almost 1500 Caucasian children aged 5 to 15 years, both WC and WtHR were able to identify children with the highest metabolic and cardiovascular risks among those who were overweight [13]. An extensive review by Huxley *et al.* (2010) concluded that measures of abdominal obesity including WC and WHtR, may be better than BMI in predicting CVD risk, although combining BMI with these measures may improve their discriminatory capability [17].

The high disease burden of childhood obesity highlights the need for rigorous investigations of its determinants, context-specific patterns and associated factors. Most of the studies investigating obesity correlates in youth have been conducted in high-income countries and, as such, findings may not be applicable to low and middle-income countries. Among the latter, the Middle-East has been largely under-represented, although the region has one of the highest rates of childhood obesity [2]. The present study aims at examining the prevalence and correlates of overweight, obesity and abdominal adiposity in a nationally representative sample of children and adolescents, aged six years and above, in Lebanon. Gaining greater insight into factors that are associated with paediatric obesity could catalyze the development of effective interventions and policies aiming at curbing the obesity epidemic in Lebanon, orient further studies, and assist policy makers in implementing successful, culture specific childhood obesity prevention strategies in the region.

#### **2. Materials and Methods**

#### *2.1. Study Design and Subjects*

Data for the present study is drawn from a national cross-sectional survey that was conducted in 2009, in Lebanon, on subjects aged six years and above. The study sample was based on the sampling frame provided by the National Survey of Household Living Conditions, which was conducted by the Ministry of Social Affairs/Central Administration of Statistics in collaboration with United Nations Development Programme (UNDP) and which covered primary residences across the Lebanese territory [18]. Sample size calculation for the study was performed based on previously estimated prevalence rates for the main outcome of interest [19]. As such, a minimum of 751 participants were needed to estimate a prevalence of obesity of 4.8% in children and adolescents [19], allowing a power of 80% and a margin of error of 1.5% at 95% confidence interval (CI). Recruitment efforts targeted a sample with an age, sex and district distribution proportionate to that of the Lebanese population [18].

Lebanon is divided into six administrative regions referred to as "governorates", which cover the totality of the country. Except for the governorate of Beirut, which is considered purely urban, the other governorates are essentially composed of rural regions inter-mixed with urban cities. In this study, the sample was drawn from randomly selected households, based on stratified cluster sampling: the strata were the Lebanese governorates, the clusters were selected further at the level of districts, urban and rural areas, and the housing units constituted the primary sampling units in the different districts of Lebanon. One adult from each household and one child/adolescent from every other household were selected from the household roster. Field-work was carried out between May 2008 and August 2009. The final sample consisted of 3636 subjects, including 939 children and adolescents aged 6 years and above [20]. Refusal rate at the household level was estimated at 10.7%, with the main reasons for refusal to participate in the survey being lack of time or disinterest in the study. The design and conduct of the survey was approved by the Institutional Review Board of the American University of Beirut, and informed consent from adults/parents and informed assent from children and adolescents were obtained prior to enrolment in the studies.

Socio-demographic and lifestyle data were collected from study participants using a multi-component questionnaire that was developed for the purpose of this study. Data collection was performed by trained nutritionists in the household setting through face to face interviews which lasted for approximately one hour. Quality control measures including training, pre-testing of the study instruments, equipment, and data collection procedure and field monitoring of data collection, were applied. Household and parental data were collected from the adult participant (mother or father) using a multicomponent questionnaire covering information on demographic, socioeconomic and lifestyle characteristics, in addition to medical history and health seeking behavior. Data pertinent to the child/adolescent were collected using a child-specific questionnaire which enquired about sex, age, medical history, meal pattern, eating habits, dietary intake, physical activity, and sedentary time. For children aged less than 11 years old, data was obtained by proxy (typically the mother), while the interview was conducted directly with subjects aged 11 years and above.

#### *2.2. Anthropometric Measurements*

Anthropometric measurements were taken using standardized protocols [21] and calibrated equipment. Height and body weight were measured according to standard procedures, using a portable stadiometer (Holtain, Crymych, UK) and a Secacalibrated electronic weighing scale (Hamburg, Germany), respectively. Subjects were weighed to the nearest 0.1 kg in light indoor clothing and with bare feet or stockings. Height was measured without shoes and recorded to the nearest 0.5 cm. A calibrated plastic measuring tape was used to measure waist circumference at the level of the umbilicus to the nearest 0.1 cm, with the subject standing and after normal expiration. Anthropometric measurements were taken and recorded by trained nutritionists who were working in teams of two, the examiner and the recorder. All measurements were taken twice and the average of the 2 values was adopted.
