Sedentary behavior during leisure time, physical activity and dietary habits as risk factors of overweight among school children aged 14–15 years: case control study
Godakanda et al. BMC Res Notes
Sedentary behavior during leisure time, physical activity and dietary habits as risk factors of overweight among school children aged 14-15 years: case control study
Indrani Godakanda 2
Chrishantha Abeysena chrishantha‑ 0
Ayesha Lokubalasooriya 1
0 Department of Public Health, Faculty of Medicine, University of Kelaniya , Kelaniya , Sri Lanka
1 Adolescents Health Unit, Family Health Bureau , Colombo , Sri Lanka
2 Ministry of Health , Colombo , Sri Lanka
Objective: To determine the risk of sedentary behavior during leisure time, physical activity and dietary habits on overweight among school children aged 14-15 years in Kalutara District, Sri Lanka. Results: School based case-control study was conducted during September to November 2013 including 176 overweight children as cases and 704 children with normal weight as controls. Cases were defined as body mass index for age and sex of ≥ +1SD and controls as those in the range of −2SD to +1SD. Validated instruments were used for data collection. Multiple logistic regression was applied and results were expressed with adjusted odds ratios (OR) and 95% confidence intervals (CI). Risk factors for overweight were insufficient physical activity (OR 1.6, 95% CI 1.1-2.4), watching video/DVD ≥ 2 h (OR 3.1, 95% CI 1.8-5.3), watching television ≥ 2 h (OR 2.6, 95% CI 1.7-3.8) and doing homework ≥ 2 h, (OR 1.8, 95% CI 1.2-2.7). Consuming meat (OR 1.9, 95% CI 1.2-3.1), fish or other sea foods (OR 1.6, 95% CI 1.1-2.8), fast food/fried rice/oily foods (OR 1.9, 95% CI 1.2-2.9), carbonated drinks or sugary drinks (OR 1.9, 95% CI 1.2-2.8), sweets, cookies or ice cream (OR 1.8, 95% CI 1.2-2.9) were dietary risk factors for overweight. Consuming legumes and seeds (OR 0.50, 95% CI 0.3-0.7), vegetables and fruits (OR 0.6, 95% CI 0.4-0.9) were protective factors for overweight.
Diet; Leisure time; Overweight; Physical activity; Sedentary
A few years back overweight and obesity were considered
as a problem found mainly in high income countries.
However, it is now dramatically on the rise in low- and
middle-income countries as well [
]. The nutrition
transition in developing countries shifted people from their
traditional diet based on cereals, legumes, vegetable and
fruits to an energy dense diet, rich in saturated fatty acids,
salt and sugar. In addition to changing, the dietary
behaviours declining physical activities with increased time
spent in sedentary activities are major factors underlying
childhood obesity [
]. A review [
] reported that the risk
of overweight/obese youth becoming overweight/obese
adults is increased by 75%.
Sedentary behaviour is not simply a lack of physical
activity, instead of individual behaviours where sitting or
lying is the dominant mode of posture and where energy
expenditure is very low [
]. Assessment of sedentary
behavior includes the time spent in a comprehensive
range of sedentary activities [
]. The literature
emphasized the distinction between sedentary behaviour and
the absence of moderate and vigorous physical activities
]. A systematic review revealed that
sedentary behaviors, as measured by total screen-viewing time,
lower fruit and vegetable intake and higher consumption
of energy-dense snacks, and fast foods were associated
with overweight . One study revealed that sedentary
behavior was inversely associated with risk of
]. However, another study found that
total sedentary time spent was not associated with
overweight/obese independent of MVPA [
]. Further, case
control or a cohort studies are more suitable for
assessment of risk factors of a disease rather than descriptive
Adolescence, considered as a decisive period in life is
the period of transition from childhood to adulthood. It
is defined as the age group from 10 to 19 years [
Adolescent population consists of 18.8% of the total
population in Sri Lanka [
]. At present Sri Lankan adolescents
too are being influenced by a range of individual and
environmental transitions. In relation to the Sri Lankan
context extremely limited number of studies published in
related to sedentary activities. The purpose of this study
was to determine the risk of sedentary behavior during
leisure time, physical activity and dietary habits on
overweight among school children aged 14–15 years in
Kalutara District, Sri Lanka.
A case control study was carried out in Grade 9 and 10
in the schools of Kalutara District in Sri Lanka during
September to November 2013. A case was defined as a
child who had a body mass index (BMI) for age and sex
of ≥ +1SD (overweight) according to the growth chart of
World Health Organisation [
]. A control was defined
as a child who had a BMI for age and sex in the range
of −2SD to < +1SD (normal weight) [
]. Children who
had past history of overweight management such as diet
control, or any other treatment or any health education
related to overweight were excluded.
Multi-stage cluster sampling method with
probability proportionate to the size was applied considering the
large geographical area and variability of schools by
sector and functional type. A class was considered as a
cluster. For the sample size calculation the proportion
of sedentary behavior among controls was considered
as 16% [
], with a design effect of 1.3, odds ratio of 2,
power of 80% and Z−1α/ 2 of 0.05. Case to control ratio
was taken as 1:4. Therefore, the required sample size was
169 cases. Assuming non responses rate of 5%, the final
sample size required for recruitment was 176 for the
cases and 704 for the controls.
Selection of cases and controls were carried out
independent of knowledge on their exposure status. The
anthropometric measurements were made using
standardized equipment and standard procedures. The same
instruments were used throughout the study and all
equipment were calibrated prior to the
commencement of taking measurements at each session. The
circumstances under which data were collected from
cases and controls were comparable.
Validated Adolescents Sedentary Activity
] and Physical Activity
] were used for assessing sedentary and
physical activities respectively. Validated 3-day dietary
] was used to assess dietary constituents on
each day. Parental questionnaire was used to collect data
of the parents. All participants were asked to recall their
daily activities (before and after school) and the time
spent on each of the different activities during the 7 days.
Data collection was done during term time in a week
devoid of any extracurricular activities or examinations
to ensure minimum information bias.
Pattern of sedentary activities was assessed in minutes
spent on each activity on each day of the week.
Sedentary behaviour was assessed by summing up the total
sedentary hours spent per day and which was
] as ‘more sedentary’ and ‘less sedentary’ (total
sedentary activities ≥ 4 and < 4 h per day respectively).
In addition, each sedentary activity was categorized into
two ≥ 2 and < 2 h. A participant in MVPA for at least
60 min per day for ≥ 5 day per week were categorized as
‘sufficiently active’ and otherwise as ‘insufficiently active’
]. Each food item was categorized under one of the
25 food domains and a raw score was assigned. Each raw
score was grouped under 11 major food groups based on
Food and Agriculture Organization (FAO) guidelines [
and these include as legumes and seeds; vegetables; dark
green leaves; fruits; meat; fish or other sea foods; eggs;
milk; fast foods, fried rice, oily foods; carbonated drinks,
sugary drinks, ice packets; sweets, biscuits or ice cream.
Consumption of each food group was categorized as
‘taken’ or ‘not taken’.
Bivariate analysis was carried out to assess the
association of each probable risk factor and being overweight.
Variables that showed a probability value of < 0.20 in the
bivariate analysis were considered as eligible variables
for the regression model. Multiple logistic regression was
performed to identify the independent risk of each
variable with overweight. Purposeful selection method was
performed. Results were expressed as odds ratios (OR)
and the respective 95% confidence intervals (CI).
Majority (67.7%, n = 596) of the participants were
14 years old. Among the cases 52.8% (n = 93) were males
and among the controls the figure was 54% (n = 380).
Majority of participants (63%. 110 cases versus 70.6%,
497 controls) were from rural schools. Being unemployed
(p = 0.01) and higher educational level of the mother
(p = 0.02) and higher family income (p = 0.02) were
associated with increased risk of overweight.
Sedentary activities were associated with higher risk
of overweight except participating ≥ 2 tuition/extra
classes per day, performing music for ≥ 2 h per day and
not playing for sports clubs during the last 12 months
Of the 176 cases, 151 responded satisfactorily to
the 3 day dietary record. Out of the 704 controls 617
responded the 3-day dietary record. Of them 604 controls
were randomly selected to keep the case–control ratio of
1:4. Consumption of all food items except consumption
of dark green vegetables, eggs and milk, were associated
with a higher risk of being overweight (Table 2).
Results of multiple logistic regression analysis is shown
in Table 3. Risk factors for overweight were watching
video/DVD for ≥ 2 h (OR 3.1, 95% CI 1.8–5.3),
watching television for ≥ 2 h (OR 2.6, 95% CI 1.7–3.8), doing
homework for ≥ 2 h (OR 1.8, 95% CI 1.2–2.7) and
insufficient physical activity (OR 1.6, 95% CI 1.1–2.4).
Consumption of meat (OR 1.9, 95% CI 1.2–3.1), fish or other
sea food (OR 1.6, 95% CI 1.1–2.8), fast food, fried rice and
OR, odds ratio; CI, confidence interval
Television watching time ≥ 2 h/day
Video/DVD watching ≥ 2 h/day
Homework ≥ 2 h/day
In sufficiently physical activity
Legumes and seeds consume
Fish, other sea foods consume
Fast food, fried rice, oily foods consume
Carbonated drinks, sugary drinks, ice packets
Sweets, cookies, ice cream consume
Mothers education O/L and above
oily foods (OR 1.9, 95% CI 1.2–2.9), carbonated drinks,
sugary drinks and ice packets (OR 1.9, 95% CI 1.2–2.8)
demonstrated higher risk for overweight in comparison
to controls. Consumption of legumes and seeds (OR 0.50,
95% CI 0.3–0.7), vegetables and fruits (OR 0.60, 95% CI
0.4–0.9) demonstrated a protective effect for overweight.
We found that watching television for ≥ 2 h per day and
video/DVD for ≥ 2 h per day were risk factors for
overweight. Several studies have revealed similar findings
despite using different study designs, settings and cutoff
values of exposure status [
]. Those who spent≥ 2 h
of homework demonstrated 1.8 times risk for overweight
in our study. Though evidence related to risk of
homework time for overweight is unavailable, students are also
expected to engage in sedentary behaviour in the form of
However, we could not find an association between
spending ≥ 4 h of total sedentary time (more sedentary)
and overweight. We found that unadjusted odds ratio was
statistically significant. Our findings are consistent with
two other studies [
], revealed that sedentary
behavior was not a risk factor for overweight/obesity,
independent of the VMPA. In contrast, a case control study
revealed that ≥ 4 h of total sedentary time was a risk
factor for overweight/obesity . Those who were physically
inactive were 1.6 time at a higher risk of overweight than
those who were sufficiently active. The findings are
comparable to the results of number of studies [
9, 10, 21, 22
Present study too revealed that consuming pulses and
seeds provides a protective effect against overweight. It
was same for consuming fruits and vegetables. Our
findings are consistent with several other studies conducted
among adolescents as well as among adults in different
geographical areas [
20, 23, 24
]. Fruits and vegetables
are of low energy density and therefore a larger volume
of food has to be consumed to obtain a certain level of
In the present study meat consumption showed a
positive association with overweight with an odds ratio of 1.9.
This finding has been confirmed by another study [
Consumption of fish or other sea food varieties
demonstrated a positive association with overweight in the
present study. Suematsu et al. [
] showed that the incidence
of out-of-hospital cardiac arrests was positively
associated with the consumption of tuna, salmon, saury, and
cuttlefish. Though fish intake is recommended as a good
dietary behavior, consumption of fried fish, pawns, crabs
and cuttlefish can be associated with overweight.
We found that those who consume fast food, fried rice
and oily foods were 1.9 times of a higher risk of becoming
overweight. Several studies from different geographical
locations reported that consumption of fast foods have a
higher risk of weight gain, overweight or obesity [
]. These foods typically contain potentially adverse
dietary factors including saturated and trans-fat, high
glycemic index, high energy density, and, increasingly large
portion size. Additionally, these foods tend to be low in
fiber, micronutrients, and antioxidants [
We found that those who consume carbonated drinks
sugary drinks and ice packets were also at higher risk of
overweight. Two other studies also reported that
sugarsweetened beverage were associated with a higher risk
of overweight or obesity [
]. In addition, those
who consume of sweets, biscuits and ice cream
demonstrated too are a higher risk of (1.8 times) overweight.
However, contradictory to our findings, two studies
reported that higher sweet intake was negatively
associated with overweight/obesity [
]. This may be
due to the fact that overweight adolescents are more
likely to under-report unhealthy food intake or they
have changed their behavior and consume less sweets
because of their concern of being overweight [
The study was carried out in all three educational
zones in the District of Kalutara enabling the
generalization of the study findings to all the schools in the
One of the limitations was difficulty in establishing
temporal relationship between the exposures and overweight
because of the cross-sectional nature of a case control
study. Even though we used validated and reliable
selfadministrated questionnaires, there would be the
tendency to under or over report exposures. In addition, the
possibility of recall bias could not be totally excluded.
However, objective measures were not feasible for
assessing exposures on behaviours. A school based high quality
interventional study which assess effectiveness of
educational package would be recommended.
BMI: body mass index; CI: confidence interval; FAO: Food and Agriculture
Organization of the United Nation; MVPA: moderate to vigorous intensity
physical activity; OR: odds ratio; SD: standard deviation; WHO: World Health
IG participated in the design of the study, coordinated data collection, per‑
formed the statistical analysis and drafted the first version of the manuscript.
CA participated in the design of the study, performed the statistical analysis,
interpreted the data and helped to draft the manuscript. AL participated in
the design of the study. All authors read and approved the final manuscript.
We are grateful to the Postgraduate Institute of Medicine, University of
Colombo and the data collectors for the study.
The authors declare that they have no competing interests.
Availability of data and materials
The datasets used and/or analysed during the current study are available from
the corresponding author on reasonable request.
Consent for publication
Ethics approval and consent to participate
The Ethics Review Committee of the Sri Lanka Medical Association granted
ethical clearance. Informed written consent was obtained from parents
and the school children prior to data collection. Permissions were obtained
from the Provincial Director of the Western Province, the District and Zonal
Directors of Education, School Principals of the District and Deputy Provincial
Director of Health Services, Kalutara District.
Springer Nature remains neutral with regard to jurisdictional claims in pub‑
lished maps and institutional affiliations.
1. WHO. Health and development challenges of non communicable diseases in the South‑East Asia region WHO report . 2011 .
2. World Health Organization Global Report. Preventing chronic diseases: a vital investment . 2005 . http://www.who.int/nmh/en. Accessed 16 May 2012 .
3. Anderssen SA , Engeland A , Sogaard AJ . Changes in physical activity behavior and the development of body mass index during the last 30 years in Norway . Scand J Med Sci Sports . 2008 ; 18 : 309 - 17 .
4. Biddle SJ , Pearson N , Ross GM , Braithwaite R . Tracking of sedentary behaviours of young people: a systematic review . Prev Med . 2010 ; 51 ( 5 ): 345 - 51 .
5. Hardy LL , Bass SL , Booth ML . Changes in sedentary behavior among adolescent girls: a 2.5‑ year prospective cohort study . J Adolesc Health . 2007 ; 40 ( 2 ): 158 - 65 .
6. Owen N , Healy GN , Matthews CE , Dunstan DW . Too much sitting: the population health science of sedentary behavior . Exerc Sport Sci Rev . 2010 ; 38 ( 3 ): 105 - 13 . https://doi.org/10.1097/jes.0b013e3181e373a2.
7. Pate RR , O'Neill JR , Lobelo F. The evolving definition of “sedentary” . Exerc Sport Sci Rev . 2008 ; 36 : 173 - 8 .
8. Singh AS , Mulder C , Twisk JW . Tracking of childhood overweight into adulthood: a systematic review of the literature . Obes Rev . 2008 ; 9 : 474 - 88 .
9. Bhuiyan MU , Zaman S , Ahmed T . Risk factors associated with overweight and obesity among urban school children and adolescents in Bangladesh: a case-control study . BMC Pediatr . 2013 ; 13 : 72 . https://doi. org/10.1186/ 1471 ‑2431‑13‑72.
10. Keane E , Li X , Harrington JM , Fitzgerald AP , Perry IJ , Kearney PM . Physical activity, sedentary behavior and the risk of overweight and obesity in school‑aged children . Pediatr Exerc Sci . 2017 ; 29 ( 3 ): 408 - 18 . https://doi. org/10.1123/pes.2016‑ 0234 .
11. WHO technical report series. 'Pregnancy and abortion in adolescents', report of WHO meeting, no. 583 . 1975 .
12. Annual Health Statistics, Sri Lanka. Ministry of Health 2006 .
13. World Health Organization. Growth reference data for 5-19 years . Geneva: WHO; 2007 . http://www.who.int/growthref/en/.
14. Ranasingha RDS . Physical activity and selected correlates among adolescent school children aged 13 to 14 years in the Rathnapura district . Thesis (MD Community Medicine): Postgraduate Institution of Medicine, Colombo . 2009 .
15. Godakanda IP , Abeysena C , Lokubalasooriya A. The pattern of sedentary behaviour during leisure time and physical activity, and its risk for overweight among school children aged 14-15 years in the Kalutara District . Thesis (MD Community Medicine): Postgraduate Institution of Medicine, Colombo . 2014 .
16. Karunapema RPR . Evaluation of the effectiveness of a life style intervention in primary prevention of Diabetes among adult with impaired fasting glucose from a rural area of Gampaha District. Dissertation, MD Community Medicine , Postgraduate Institute of Colombo, Sri Lanka. 2006 .
17. FAO Guidelines . Preparation and use of food‑based dietary guidelines . 2011 .
18. Gubbels JS , Patricia VA , Stef PJK . Physical activity, sedentary behavior, and dietary patterns among children . Curr Nutr Rep . 2013 ; 2 : 105 - 12 .
19. Li MJ , Dibley D , Sibbritt D , Yan H . Factors associated with adolescents' overweight and obesity at community, school and household levels in Xi'an City, China: results of hierarchical analysis . Eur J Clin Nutr . 2008 ; 62 : 635 - 43 .
20. Piryani S , Baral KP , Pradhan B , et al. Overweight and its associated risk factors among urban school adolescents in Nepal: a cross‑sectional study . BMJ Open . 2016 ; 6:e010335 . https://doi.org/10.1136/bmjopen‑2015‑ 010335.
21. Mitchell JA , Mattocks C , Ness AR , Leary S , Pate RRM , Dowda SNB , Riddoch C . Sedentary behaviour and obesity in a large cohort of children . Obesity . 2009 ; 17 ( 8 ): 1596 - 602 . https://doi.org/10.1038/oby. 2009 . 42 .
22. Anteneh ZA , Gedefaw M , Tekletsadek KN , Tsegaye M , Alemu D . Risk factors of overweight and obesity among high school students in Bahir Dar City, North West Ethiopia: school based cross‑sectional study . Adv Prev Med . 2015 . https://doi.org/10.1155/ 2015 /294902.
23. Lin BH , Morrison RM . Higher fruit consumption linked with lower body mass index . Food Rev . 2002 ; 25 : 28 - 32 . 56( 11 ): 2655 - 2667 . (6): 1764 - 78 .
24. American Dietetic Association. Individual, family, school and community‑based interventions for pediatric overweight . J Am Diet Assoc . 2006 ; 106 : 925 - 45 .
25. Suematsu Y , Miura S , Zhang B , Uehara Y , Tokunaga M , Yonemoto N , et al. Associations between the consumption of different kinds of seafood and out‑ of‑hospital cardiac arrests of cardiac origin in Japan . IJC Heart Vessels . 2014 ; 2 : 8 - 14 .
26. Hu FB , Vandam RM , Liu S. Diet and risk of type II diabetes: the role of types of fat and carbohydrate . Diabetologia . 2001 ; 44 : 805 - 17 .
27. Janssen I , Katzmarzyk PT , Boyce WF , Vereecken C , Mulvihill C , Roberts C , et al. Health behaviour in school‑aged children obesity working group: comparison of overweight and obesity prevalence in school‑aged youth from 34 countries and their relationships with physical activity and dietary patterns . Obes Rev . 2005 ; 6 : 123 - 32 .
28. Garaulet M , Martínez A , Victoria F , Pérez‑Llamas F , Ortega RM , Zamora S. Difference in dietary intake and activity level between normal‑ weight and overweight or obese adolescents . J Pediatr Gastroenterol Nutr . 2000 ; 30 ( 3 ): 253 - 8 .