IJE Advance Access originally published online on January 19, 2008
International Journal of Epidemiology 2008 37(1):162-172; doi:10.1093/ije/dym252
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Ethnic differences in overweight and obesity in early adolescence in the MRC DASH study: the role of adolescent and parental lifestyle
1Medical Research Council, Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow, Scotland G12 8RZ, UK.
2Division of Cardiovascular and Endocrine Sciences, University of Manchester, Core Technology Facility, Manchester M13 9NT, UK.
* Corresponding author. Medical Research Council, Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow, Scotland G12 8RZ, UK. E-mail: seeromanie{at}sphsu.mrc.ac.uk
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Abstract |
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Background: Ethnicity is a consistent correlate of excess weight in youth. We examine the influence of lifestyles on ethnic differences in excess weight in early adolescence in the UK.
Method: Data were collected from 6599 pupils, aged 11–13 years in 51 schools, on dietary practices and physical activity, parental smoking and overweight, and on overweight and obesity (using International Obesity Task Force criteria).
Results: Skipping breakfast [girls odds ratio (OR) 1.74, 95% confidence interval (CI) 1.30–2.34; boys OR 2.06; CI 1.57–2.70], maternal smoking (girls OR 2.04, CI 1.49–2.79; boys OR 1.63, CI 1.21–2.21) and maternal overweight (girls OR 2.01, CI 1.29–3.13; boys OR 2.47, CI 1.63–3.73) were associated with obesity. Skipping breakfast, more common among girls, was associated with other poor dietary practices. Compared with White UK peers, Black Caribbeans (girls OR 1.62, CI 1.24–2.12; boys OR 1.49, CI 1.15–1.95) and Black Africans (girls OR 1.96, CI 1.52–2.53; boys OR 2.50, CI 1.92–3.27) were more likely to skip breakfast and engage in other poor dietary practices, and Indians were least likely. White Other boys reported more maternal smoking (OR 1.37, CI 1.03–1.82). All these reports were more common among those born in the UK than those born elsewhere. Black Caribbean girls were more likely to be overweight (OR 1.38, CI 1.02–1.87) and obese (OR 1.65, CI 1.05–2.58), Black African girls to be overweight (OR 1.35, CI 1.02–1.79) and White Other boys to be overweight (OR 1.37, CI 1.00–1.88) and obese (OR 1.86, CI 1.15–3.00). Adverse dietary habits and being born in the UK contributed to these patterns.
Conclusion: These findings signal a potential exacerbating effect on ethnic differences in obesity if adverse dietary habits persist. Combined adolescent and parent-focused interventions should be considered.
Accepted 28 November 2007
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Introduction |
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Childhood obesity is a major public health concern with serious implications for the sustainability of healthcare systems. Its prevalence has doubled over the last two decades in the United Kingdom (UK) and is predicted to continue to rise, increasing the likelihood that Type 2 diabetes, heart disease and a range of other co-morbidities will occur before or during early adulthood. Studies in the United States of America (US)1 and UK2–4 have shown that ethnicity is a consistent correlate of childhood obesity, with Black African origin girls in particular being more vulnerable to overweight and obesity than their White peers. South Asians generally have a higher level of fat per unit of body mass index (BMI) compared with Whites5, even at birth, and the relationship between a given degree of adiposity, particularly central adiposity and cardiovascular risk may be stronger.6–8 Furthermore, Type 2 diabetes and cardiovascular disease are more common among adult Black African and South Asian origin populations9 and a potential worsening of obesity-related risk in their children carries implications for persisting disparities in these diseases across generations.
Childhood and adolescence are critical periods for the development of obesity, associated with the imbalance between energy consumed and expended through physical activity. Response to environmental ‘triggers’ of obesity may vary among individuals but the rise in obesity in both developed and developing countries, and the lower levels of obesity and related chronic diseases among African populations in West Africa than in the Caribbean and the US, suggest that environmental rather than genetic factors are the major drivers for ethnic differences in obesity.10 In the UK, increasing cardiovascular risk with length of residence among South Asian migrants11 and higher intake of fat among UK-born compared with migrant Caribbeans12 suggest a shift away from traditional diets with high fruit and vegetable content. Children of ethnic minorities may be more susceptible than migrant parents to the obesogenic environment (obesity promoting13) as they may engage in local culture more than their parents. No known studies in the UK have examined ethnic patterns in childhood or adolescent obesity in relation to the health-related behaviours of both parents and of children.
This article uses data from the Medical Research Council Determinants of Adolescent Social well being and Health study (DASH) to test the hypotheses that parental and adolescent obesity-related behaviours will differ by ethnicity and that this will contribute to ethnic differences in overweight in early adolescence.
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Methods |
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The sample was recruited from 51 schools in 11 London boroughs, chosen because of high proportions of the main ethnic minority groups. Pupils aged 11–13 years (in first and second years of secondary school) in randomly selected mixed ability classes were invited to take part. The response rate was 81%. Fieldworkers were trained for 5 days prior to data collection and recertified at regular intervals. Fieldwork took place between September 2002 and July 2003. Further details of the study can be found elsewhere.14
Risk factors, confounders and outcomes
Height was measured using portable stadiometers, and weight using Salter electronic scales. Body Mass Index (BMI) was derived as weight (kg)/height (m2). Protocols for measurements were taken from the World Health Organisation manual.15 Waist circumference (cm) was measured midway between the 10th rib and the top of the iliac crest, and 0.5 cm subtracted to correct for measurement over T-shirt or vest. The mean of two duplicate measures was derived. The measures were converted to Z-scores, expressed as standard deviation scores (SDS), based on the 1990 British growth reference curves,16 and pupils were classified as not overweight, overweight or obese using the International Obesity Task Force (IOTF) age-specific thresholds.17 Pubertal status was assessed using the self-complete Tanner questionnaire,18 supervised by a nurse. Pupils were classified as pre-pubertal (Tanner stage 1 for breasts or genitalia and pubic hair), early puberty (Tanner stages 2 and 3 for breasts and genitalia), or late puberty (Tanner stages 4 and 5).
Ethnicity of White UK, Black Caribbean, Black African, Indian, Pakistani and Bangladeshi origin was determined by consistent background of parents and grandparents; self-reported ethnicity of the pupil was used in conjunction with at least one parent with the same ethnicity and at least three grandparents born in home countries. We focus here mainly on Black African, Black Caribbean and South Asian origin groups. The Bangladeshi group (n = 219) was too small to examine separately and was combined with Pakistanis. The sample sizes of other ethnicities were small and were aggregated to ‘Mixed’ ethnicities (mainly of White and Black Caribbean ethnicity) or ‘White Other’ (mainly Eastern Europeans and Irish). Pupils were classified as first generation if they were born abroad and resident in the UK for <10 years, otherwise classified as second generation.
Parental and adolescent behavioural influences were reported by the pupil. Details of the questions can be found at http://www.sphsu.mrc.ac.uk/studies/dash/. Parental smoking and overweight refer to current status and responses were classified as ‘yes’ or ‘no’. Physical activity, based on 37 vigorous sporting activities (e.g. running, cycling, football, kick-boxing), was classified in quartiles depending on the number of activities and the frequency of taking part (every day, most days, weekly and less than weekly). Access to 17 standard of living items (in quartiles) and household type (classified as two-parent, lone parent, other) were used as proxy measures of socio-economic circumstances (SES).
Statistical analysis
Multivariate multinomial logistic regression models were used to examine the inter-relationships between ethnicity, parental and adolescent health related influences, overweight and obesity. Overweight and obese categories were combined in some of the minority groups (due to small number of those obese) and multivariate logistic regression models were used when this was done. There were significant interactions between gender, overweight and pubertal status. All multivariate analyses examining ethnic differences in overweight or obesity were gender specific, with adjustment for age (6 monthly), height (SDS) and pubertal status. Adolescent behaviours were added separately from that of parental factors to the baseline model due to the correlation between these variables. Height and/or weight measures were missing for 182 pupils and age, gender and ethnic specific means were imputed to replace the missing values. Missing data for all other variables were coded as ‘unknown’ to prevent bias that may have resulted from excluding the records. From a total sample of 6644, 45 (4.3%) pupils were excluded because of extreme anthropometric measurements (27) or missing information on sex (10) or age (8). Non-response to specific items or exclusions of records did not vary by ethnicity.
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Findings |
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Table 1 shows the baseline characteristics by ethnicity for girls and boys. The proportions born abroad were highest in the Black African and White Other group. Generally Black Caribbean and Black Africans were taller and heavier while South Asians were shorter and lighter. More of the Black Caribbean girls were overweight or obese, and more of the Black African girls were overweight than White UK girls. In every ethnic group, more girls than boys reported skipping breakfast and less vigorous physical activity.
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Maternal smoking and skipping breakfast were independent correlates of overweight and obesity (Table 2). Maternal overweight was related to overweight and obesity among girls but only to obesity among boys. The effect of paternal influences varied by gender; paternal overweight associated with obesity among girls, and paternal smoking with overweight among boys. Although fruit and vegetable and fizzy drink consumption and physical activity were not related to overweight or obesity, we observed a clustering of behaviours independent of SES. Table 3 shows that those skipping breakfast were more likely to report that they consumed less than five portions of fruit and vegetables daily and that they were also more likely to consume fizzy drinks daily, compared with those who have breakfast most days. Similarly, the likelihood of being in the least physically active fourth quartile was greater among those who did not have the recommended intake of fruits and vegetables than those who did (girls OR 3.66, CI 2.86–4.67; boys OR 3.33, CI 2.62–4.23).
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Table 4 shows the odds of having each of the risk factors, adjusted for ethnicity (White UK = 1.00), generation status, family type and SES using multinomial models. With few exceptions, the odds of adverse parental influences among ethnic minorities was generally either lower or not different from those for White UK boys and girls. White Other boys reported more maternal and paternal smoking, White other girls more paternal smoking and Pakistani boys more maternal overweight. In contrast, poor dietary habits tended to be more common among ethnic minorities than their White UK peers. Black Caribbean and African boys and girls and Mixed ethnicity girls were more likely to skip breakfast, Black Caribbean girls and Black African and Pakistani/Bangladeshi boys to consume fizzy drinks everyday, and Black African boys and girls and Pakistani/Bangladeshi boys to have less than one portion of fruits and vegetables. Data for physical activity (not included in Table 4), however, showed that Black Caribbean [odds ratio (OR) 0.47, 95% confidence interval (CI) 0.32–0.69], Black African (OR 0.33, CI 0.22–0.48), and Pakistani/Bangladeshi (OR 0.54, CI 0.37–0.79) boys and Black Caribbean (OR 0.59, CI 0.40–0.88) and Black African (OR 0.66, CI 0.45–0.97) girls were less likely than their White peers to be in the least active fourth quartile.
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First generations were less likely to report maternal smoking, skipping breakfast or not having the recommended daily intake of fruits and vegetables. Living in a lone-parent household and material disadvantage also had an independent effect on some of these behaviours. The ORs in Table 4 are adjusted for SES, which removed some of the ethnic difference in dietary practices, notably for Pakistani/Bangladeshi and Black African girls (unadjusted ORs in footnote of Table 4).
Figure 1a (girls) and 1b (boys) show the separate effects of adjusting for adolescent and for parental factors on ethnic differences in overweight and obesity. In a model with age, height (SDS) and pubertal status, Black Caribbean girls were more likely to be overweight and to be obese, Black African girls to be more overweight, White Other boys to be more overweight and to be more obese, and Black Caribbean boys to be less overweight than their White UK peers. With additional adjustment for SES, generational status, and all adolescent behaviours, Black caribbean and Black African girls were no longer more likely to be overweight. However, Pakistani/Bangladeshi boys were now more likely to be obese. In contrast, adding parental behaviours, SES, generational status to the model with height, weight and pubertal status, did not change the patterns for Black Caribbean girls, Black African girls or White Other boys. As with adjustment for adolescent behaviours, adjustment for parental behaviours augmented the relationship with obesity for Pakistani/Bangladeshi boys. There were no significant interactions observed between ethnicity and adolescent or parental behaviours in these models.
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indicates adjusted for and age, height, pubertal status (baseline model). 
indicates adjusted for baseline plus adolescent behaviours, generation status, family type, socio-economic circumstances (SES) and 
indicates adjusted for baseline plus parental influences, generation status, family type, SESApart from the correlates shown in Table 2, generation status was an independent correlate of obesity in these models, with first generations being far less likely to be obese than second generations (adjusted for anthropometry, SES and adolescent behaviours: girls OR 0.62, 95% CI 0.42–0.91; boys OR 0.56, CI 0.40–0.80). In models adjusted for adolescent behaviours and extended to examine the effect of generational differences within minority groups, Black Caribbean girls born in the UK were more likely to be overweight (OR 1.57, CI 1.12–2.19, cases = 99) and obese (OR 1.89, CI 1.17–3.06, cases = 48) compared with White UK girls, but those born in the Caribbean were not. Similarly among White Other boys, only those born in the UK were more likely to be overweight (OR 1.49, CI 1.02–2.18, cases = 53) and obese (OR 2.80, CI 1.66–4.72, cases = 31) than White UK boys. This effect of higher risk among those born in the UK was not observed for Black African girls.
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Discussion |
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This is the first UK-based study to examine ethnic differences in parental and adolescent lifestyles and its relation to ethnic differences in overweight and obesity in early adolescence. Apart from Indians, ethnic minorities were generally more likely to engage in poor dietary behaviours, those born in the UK and girls being more susceptible. Parental behaviours were generally more adverse in White UK and White Other groups than other ethnic groups. Black Caribbean girls and White Other boys were more likely to be overweight and obese, and Black African girls to be overweight than their White UK peers. Differences in adolescent or parental behaviours did not account for these ethnic differences in obesity. Excess overweight among Black Caribbean and Black African girls was associated with adverse adolescent behaviours. There is correspondence between our findings and those reported for ethnic minorities in US-based studies.19
Adolescent behaviours
Children who skip breakfast could be at increased risk of weight gain and other health compromising behaviours,19 the argument being that skipping breakfast may be associated with snacking later in the day or indicative of unhealthy family behaviours. Girls were more likely to miss breakfast than boys, with just under half of all girls skipping breakfast regularly compared with a third of boys. These proportions are roughly similar to those published recently which showed that children in the UK were much more likely to skip breakfast than children in many other European countries.20 Girls may skip breakfast to lose weight. Ethnic differences in the propensity to skip breakfast were evident from the findings of our study. Indians were least likely to skip breakfast, suggesting a link with a family environment that protects against adverse dietary practices. This may also be linked to Indians being far less likely than any other group to be in a lone parent household. Disadvantage was also less common in this group. Similar to US-based studies,21 obesity promoting dietary behaviours were less common in first generation children.
The association between physical activity and obesity is inconsistent. In our study the groups that were more susceptible to obesity were more physically active. Our measure of physical activity captured vigorous activity (outside of school hours) and did not take into account time spent in sedentary behaviour. It did not capture the pattern or intensity of physical activity, issues that are increasingly being shown to be important. Furthermore, differences in physical activity may not correspond with differences in energy expenditure among obese and non-obese individuals.22 Sedentary behaviour, such as television viewing,19 can influence energy balance not only through reducing energy expended on activity, but also through snacking on energy dense foods or high sugar drinks.23
Parental influences
Parental overweight is a predictor of childhood obesity,24 possibly due to genetic factors but also shared lifestyles. Parental overweight was reported by the pupil and we cannot rule out inaccuracies in the reporting. In the Health Survey for England,25 Black African women aged 16–34 years and Black Caribbean, Black African, Indian and Pakistani women aged 35–54 years were more likely to be overweight and Black Caribbean and Black African men of the same ages were less likely to be overweight than the national average. Reported ethnic differences in overweight in DASH correspond for fathers but not for mothers. The difficulty with using these data as a comparison is that it refers to a national sample and not to London, where the overall prevalence of overweight for the adult population tends to be lower than average.26 Reporting bias, on the other hand, for current parental smoking is less likely and the pattern of lowest prevalence among South Asian and Black African women corresponds closely with published data. We found maternal smoking to be a consistent correlate of overweight and obesity for the whole sample with no significant interactions with ethnicity for minority groups with a large number of mothers who were smokers (such as White Other or Black Caribbeans). Maternal smoking in pregnancy is thought to be related to subsequent adiposity in children19 possibly via poorer intrauterine growth followed by accelerated postnatal growth. Few studies have examined the effect of smoking after pregnancy. It is likely that both material disadvantage and family lifestyle factors are implicated as adolescents who reported skipping breakfast were also more likely to report maternal smoking than those who had breakfast everyday.
Apart from those mentioned above, there are other limitations in this study. Notably, BMI may underestimate fat mass in South Asians27 and overestimate fat mass in African origin populations.28 Corresponding analyses were undertaken using waist circumference to define overweight (SD score 1.33) and obesity (SD score 2).29 Briefly, in contrast to using BMI, there were no ethnic differences in overweight or obesity for girls. The results for boys corresponded with results based on BMI. Overweight in Black Caribbean and Black African girls is possibly better captured by BMI than waist. Lower mean BMIs for 11–12 year olds in Jamaica30 than same-aged Black Caribbeans in the DASH study indicate bigger body sizes for those in the UK. The follow-up of the DASH cohort, recently completed, will allow these issues to be explored more fully as data on impedance and percentage body fat were collected. The Mixed ethnicity group and White Other groups are clearly of significance given the growing diversity of Britain but we could not explore variations within this group due to small numbers in the sub-groups. The African group is heterogeneous, with a mixture of Nigerians, Ghanaians, Somalis, Ethiopians, Eritreans, etc. The latter three groups are likely to be children of refugees who arrived in the 1980s and whether the differences in the nature of migration contribute to differences in susceptibility requires focused research. In addition, comprehensive measures of habitual diets and energy intake are desirable to understand energy balance rather than the frequency of self-assessed servings.
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Conclusion |
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Apart from Indians, ethnic minorities were generally more likely to engage in poor dietary behaviours than their White UK peers, those born in the UK being more susceptible. These findings suggest a potential exacerbating effect on ethnic differences in obesity if adverse dietary habits persist. Strategies to promote behaviour change among ethnic minority children are under-researched in the UK. Our findings suggest that obesogenic family clusters may differ across minority groups but that a combination of child- and parent- focused interventions should be considered regardless of ethnicity.
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Acknowledgement |
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We are grateful to Professor Macintyre and the anonymous referees for their comments on the manuscript. S.H. is the Principal Investigator of DASH, produced the first draft of the manuscript and is the guarantor of the article, A.T. and S.H. conducted the analyses, A.T., M.M. and K.C. contributed to the writing of the manuscript, and all authors were involved in the formulation of the research question. The study was funded by the Medical Research Council WBS code U.1300.00.003.00001.01.
Conflict of interest: None declared.
KEY MESSAGES
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