JPH - Year 7, Volume 6, Number 3, 2009

ITALIAN JOURNAL OF PUBLIC HEALTH

Body Mass Index, family lifestyle, physical activity and eating behavior
on a sample of primary school students in a small town of Western Sicily

Enza Sidoti, Patrizia Mangiaracina, Gabriele Paolini, Giuseppe Tringali

University of Palermo, Department of Sciences for Health Promotion G. DAlessandro, Palermo, Italy.
Correspondence to: Prof. Enza Sidoti, Researcher, University of Palermo, Faculty of Sciences of Education, Department of Sciences for
Health Promotion G.DAlessandro, Polyclinic, Via del Vespro 133, Palermo 90127, Italy. E-mail: esidoti@unipa.it

Abstract
Background: Obesity is actually a discernible issue in prosperous western society and is dramatically
increasing in children and adolescents. Many studies indicate that obesity in childhood may become chronic
disease in adulthood and, particularly, those who are severely overweight have an increased risk of death by
cardiovascular disease. Understanding the determinants of life style and behavior in a persons youth and
making attempts to change childrens habits is considered a key strategy in the primary prevention of obesity.
This study aims to find a correlation between Body Mass Index, (BMI), physical activity and eating behavior
and to identify, eventually, risks, protective factors and possible directions for interventions on incorrect
nutritional/physical activity and intra-familiar life styles in a sample of young adolescents in a small town of
Western Sicily.
Methods: The research surveyed the entire population of the last three curricular years of two Primary
Schools in a town of western Sicily, (n=294). The instrument used for the survey was a questionnaire
containing 20 different items with multiple choices answers. Personal information, physical activity and
eating behaviors were collected both for parents and students to cross students and parents characteristics.
Data were codified and statistical analysis was computed through Statistica and Openstat software.
Results: Data obtained demonstrated a relevant percentage (18%) of obese children. Prevalence of
overweight was high as well, (23%), and many in this area (12%) were at risk since they were on the limits of
the lower class. A significant association was found between the percentage of students classified as having
an elevated BMI and a sedentary habit and/or an incorrect eating behavior. Among the overweight and obese
children a direct statistical association was also shown between the weight of their parents and some daily
life styles. An inverse association, on the contrary, was observed between those variables and the cultural
level of the family. Cultural level, in fact, was significantly associated with having breakfast, fruit and
vegetable consumption and practice of physical exercise. Multi linear regression analysis showed the weight
of some independent variables which were more strictly correlated with childrens BMI.
Conclusions: Increasing the proportion of adolescents meeting recommended dietary and physical activity
guidelines has been identified as an important strategy to contrast the epidemic increase in obesity,
especially in western countries. This study stressed the need to increase the knowledge and monitoring of the
consequent behaviors of adolescents with regards to dietary habits and the practice of physical activity.
School, communities and families are considered the best pathways to disseminate correct information and
knowledge and the more suitable channels to raise the awareness of the importance of correct dieting and
regular physical activity School and community-based intervention programs are, then, strongly requested to
activate preventive actions early in life and mainly in the development age. The importance of the family and
of the social context factors in health behavior was also emphasized. A familiar eco-systemic model that takes
into account the whole bio-social-psychological aspects was also sustained for a global therapeutic approach
to the obese child.

Key words: BMI, Physical Activity, Eating Behavior, Obesity

Introduction industrialized prosperous Western Countries fight

In recent years obesity has reached pandemic against the consequences of overfeeding. 20-30%
proportions. In the world, half of the whole of the adult population is affected by obesity and
population lack food, the other half in the obesity conditions [1, 2]. The World Health

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Organization Regional Office for Europe recently
stated that 300 million people in the world are
obese. The prevalence of obesity has increased by
25,0% in the last 20 years. In Europe 14 million
people are overweight, 6 million obese: 27,0% of
men, 38,0% of women. In many European
countries 15,0-20,0% of adults are overweight or
obese [3]. Obesity has a positive trend in the
Italian population: the Italian National Institute of
Statistics, (ISTAT) reported that in the preceding
five years (2000-05), obesity has increased at a rate
of 9,0%, with about 4.700.000 affected people.
Statistics show 30% of the population are
overweight, 10,0% are obese, with only about half
the population being of a normal weight. Health
costs linked to obesity equate to 7,0% in the
European Union, and up to 10,0% in Italy; with the
inclusion of cardiovascular conditions the
proportion raises to 30,0-35,0% [4-6].
A similar figure was also reported for children.
In recent years childhood obesity has become a
serious health problem in the world, an exacting
challenge for public health authorities, raising
great concern in families and communities.
Investigations reported that 1 out of 3 children are
overweight, 4,0 /6,0 % are obese [7-9].
Over the past 3 decades prevalence of obesity
has more than tripled for youth aged 6-11 and
more than doubled for youth aged 12-19. 18,8% of
children 6-11 years old and 17,4% of adolescents
12-19 years old were reported being over the 95th
percentile for age and gender, 37,0% and 34,0%,
respectively, over the 85th percentile, being at risk
of obesity [10,11]. The International Obesity Task
Force (IOTF), in Europe, reported in the northern
European regions from 10,0% to 20,0%
prevalence of obesity, compared with higher rates
(20,0-30,0%) in the southern regions [12].Surveys
conducted in Italy by the Italian National Institute
for Research on Nutrition (INRAN) assessed that
obesity, concerning children, had higher rates in 6
to 13 years old, males were fatter than females and
reported percentages of overweight between
12,0% and 34,0%, and of obesity from 4,7% to
22,3%. A series of surveys conducted in different
Italian regions reported about 20,0% of children 6-
11 being overweight and 4,0% obese [13,14]. A
survey on a sample of primary school children in
Pavia, northern Italy, reported that 31,3% of the
pupils did not practice any organized physical
activity. Prevalence of obesity in this group was
nearly double [15].
Obesity is considered a risk factor for many
chronic diseases as hypertension, carbohydrate
metabolism or type 2 diabete, hyperlipaemia,
atherosclerosis, [16]. Obesity was also linked to
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increased children morbidity and adult mortality
rates. Many studies indicate, in fact, that children
who are severely overweight have an increased
risk of death from cardiovascular disease in
adulthood, [17, 18]. Since overweight in childhood
persists into adulthood and an obese child will
have high probability of becoming an obese adult
[19], increased prevalence of overweight and
obesity in children will certainly led to an
exacerbation of obesity related chronic diseases
among adults [20,21]. This is considered a public
health threat as, in fact, obesity is associated in
adults with the development of many
pathological conditions as coronary heart disease,
ictus, sleep apnea, osteoporosis and premature
mortality [22, 23].
Causes of obesity are associated with certain life
style factors such as sedentary habits and
decreased physical activity. Important life style
modifications in young people, particularly, have
seen a decrease of time dedicated to organized
physical exercise and an increase in hours spent
watching TV, playing video games or using PCs
[24,25]. Sedentary habits and decrease physical
activity, in turn, have been reported to be
associated with unhealthy food consumption. The
influence of childhood diet may influence the
persistence of obesity and the development of
diseases later in life [26,27]. Reports indicate that
only 20,0% of children and adolescents eat five or
more servings of fruit and vegetables per day [28].
In the States, American children do not consume
the recommended servings and about 50,0% boys
and girls 12-19 consume less than one serving of
fruit and vegetables per day [29, 30]. Most
students (11,0% to 28,0%) skip breakfast, with
86,0% having hyper caloric snacks [31].
Students in middle and high school have access
to snack bars and school food stores selling foods
high in fat and calories. In addition, low milk
consumption and increasing soft drink
consumption is of increasing concern, beside
obesity, in respect to the risk of osteoporosis [32-
34]. It is necessary to prevent or treat obesity in
childhood since behaviors that lead to obesity are
established in this period of life: this should be
done in order to reduce the risk of adult obesity.
Increasing the proportion of children meeting
alimentary and physical guidelines with education
interventions from childhood, in fact, reinforces
prevention of obesity in adulthood, [35]. Results
reported by different authors indicate that
individual behaviors in nutrition and sedentary or
active physical engagement are largely influenced
by different variables such as age, gender, social,
economical, cultural factors and different settings

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[36, 37].
Understanding the determinants of life style and
behaviors in youth and attempting to change
childrens habits with the long term goal of
establishing healthy life style patterns to prevent
chronic diseases in adulthood is considered a key
strategy in the primary prevention of obesity.
Objectives and methods
The research aims to
to obtain data on the prevalence of overweight
and obese children
to gain knowledge and perceptions about
dieting behaviors and physical activity habits
and intra-familiar life style
to identify, eventually, risks and protective
factors in nutritional/physical activity habits and
intra-familiar life style among school youth in a
sample of school pupils attending the last three
years of primary school in a town of western
Sicily.
to emphasize the importance of the family and
of the social context, taking into account the
whole bio-social-psychological aspects to
support a global therapeutic approach to the
obese child.
The research was undertaken during the winter
of 2008.
The sample
The population of students in the last three
years of the two primary schools of the town
provided a total of 294 individuals. The schools
were contacted in advance and informed about
the objectives of the survey. The individuals were
drawn from the registers of the two surveyed
schools. Only those children who were regularly
attending school were considered for the study.
The adopted criteria was a percentage of absence
from school of at least 33,0% from the very
beginning of the scholastic year. Over a
population of 316 individuals, 297 were
interviewed. Children had an age range 8-11.
Anthropometric measures, (weight and height),
were collected using portable scales with
statimeter. Body Mass Index (BMI) [38, 39] was
calculated as weight in Kg divided by height in
square meters, from the measured eights and
weights and children were classified by means of
BMI for age, according to Coles tables, following
(<19,84); Overweight (19,84 24,05); Obese
their BMI based on adult cut-off as: Normal weight,
(>24,05), Children reported age but not birth date
on the questionnaire. Because exact age and
gender are used to classify children with the CDC
grow charts, child age was assigned as the
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midpoint for the reported age [40, 41].
The questionnaire
Nutritional and physical information as well as
data regarding personal life style and behaviors of
students and their families were obtained
administering a questionnaire in a face to face
interview, applying a time-use approach, [42]. The
questionnaire consisted of 20 simple questions,
since it had to be administered to children. It was
settled drawing from the already existing
literature [43-45], and was pre-tested and validated
in different contexts and small samples [46, 47],
with the results of a good level of understanding,
acceptability and reliability. Moreover, the
presence of many items which were simply
technical, (i.e., height and weight), reduced the
risk of having biased information, or misleading
cooperation. The reconstruction of dietary
behaviors was obtained recording answers to
questions as During the past seven days how
many times did you have high fat foods or
During the past seven days how many times
did you eat fruit? or During the past seven days
how many times did you have sugared drink?.
The same was done as regard to physical activity,
recording exercises in the past seven days that, for
at least 30 minutes, make or not make individuals
sweat and breathe hard. Personal information
related to intra-familiar lifestyle was obtained
within the questionnaire. Cultural level of the
families was considered according to the
upgrading of the Italian curricular school-leaving
certificates: elementary, middle, diploma,
university degree. Cultural level was referred to
the highest ranking certificate in the family and, in
case of one, any in the family. Profession of the
father was asked to students. The presence of
some control items, apart from those constituting
the questionnaire, was provided to check the
reliability of collected data, and the attention
individuals had in answering the questions. Those
questionnaires which did not passed the check
items were considered as erratic.
The interviewers were all well trained, with ad
hoc course, in order not to interfere with the
given answers and doing their best to let all
children fully understanding the items. The
interviewers, in fact, received special training on
how to conduct interviews to ensure uniformity
of behavior and answers. They were provided
with information regarding the way they should
collect data, to minimize the negative effects that
can cause a potential distortion in the collected
data, without interfering with the individuals but
being sure about their right understanding of the
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questions. The absolute respect of privacy was
assured to the interviewed. The concept of
respect for privacy has been widely repeated in
the practical administration of the survey. The
data, in fact, were proposed in an aggregate form
without having the possibility to trace the owners
of information. All subjects were told that the
participation in the investigation was voluntary
and that the data collected would have been used
only for this study. Participants were assured of
the confidentiality of their response and the
students' parents provided informed consent.
Ethical permission for the study was obtained
before collecting the data and after perusal of the
results by the University Ethic Committee and by
the School Authority.
Statistical analysis
The answers to questionnaires were
numerically codified and data were analyzed using
Statistica and OpenStat software in the whole
population and subgroups. Standard descriptive
statistics (percentages, means, standard
deviations) were computed to describe the
sample. Chi square tests were performed to
confirm statistical association among observed
variables. Test for the difference of two
proportions were performed to check a
significant difference in the observed percentages
in the population and its subgroups. Lilliefors tests
were performed to check the evidence against
normality in the distribution. The law of large
numbers assured a Gaussian distribution. A
multivariate linear regression analysis was
performed in order to explain the most significant
independent variables which influenced the
dependent variable BMI of children. This
technique has been implemented through a
stepwise selection which leaded to consider only
the most significant independent variables worthy
to be used in the analysis.The relative consistency
of the sample, made possible the estimation of
95% confidence intervals, considering the
observed data as normal distribution to zero mean
and unitary variance. A p-value <0,05 was
considered significant.
Results
The criteria of excluding those students who
gathered who had been absent more than 33,0%
from standing school, led to 19 individuals whose
exclusion from the study was mainly due to the
fact they were emigrating for a better life (6,0%).
Moreover, the presence of some control items led
to the rejection of 3 questionnaires in which the
attention of individuals was not considered
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significant, (1, 0%). Those questionnaires which
did not passed the check items were considered
as erratic. The low percentage of abnormal
questionnaires led to these being classified as
outliers and not representative.
Table 1 illustrated the distribution of units
according to age and gender.The rationale for this
choice was to check if the sample was biased
from this view bias under this point. The tests for
the difference of two proportions gave no
significant difference within the variable age,
(p>0, 05). Moreover, Lilliefors tests performed
over the distribution of females, males and total,
gave no evidence against normality, (p>0,05).
Table 2 crossed gender and weight through the
measure of BMI. The percentages of obese
children were slightly different for males and
females, (11,6% vs 8,5%). Tests of two proportions
were performed between the percentages of
females and males within the three BMI categories
and gave a significant result only in this case,
(p<0,05). The evidence was that in the other two
cases those observed differences could not be
considered significant, (p>0,05). A chi square test
was performed to check BMI versus total category,
but evidence obtained was not significant,
(p>0,05).
The two variables height and weight were
grouped with a step 5 class interval in order to
represent the collected data related to those
variables. Intervals of confidence were computed
for the average of the two proposed variables.The
position indexes are shown in table 3.The relative
small variability of the observed data resulted in a
strict range for the computed intervals, (129,9-
132,5 and 29,7-32,2).
Table 4 crossed information on students weight
with that of their parents. The proportions were
computed with respect to the total within the
three subgroups, (normal, over, obese). A
performed chi square test provided evidence of a
significant association (p<0,01) between the two
depicted variables. The percentage of students
who had both overweight parents was high,
(30,6%), but it was also observed an high
percentage of students who had one parent
overweight, (28,6%).
In table 5 data obtained crossing the BMI of
children with cultural level of their families is
shown. The percentage of families who had at
least one university degree was 10,2%, and with a
diploma 25,5%. Those families who have a
middle education were 64,3%. A chi square test
was performed to check for an association
between the two crossed variables.The result was
statistically significant (p<0,01), confirming a

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strong influence that cultural level of families
plays in the education of their children.
Table 6 crosses physical activity (PA) of the
individuals with their BMI.The age of children was
considered to define strong or vigorous PA, as
frequenting a gymnasium or playing in a group for
Table 1. Age of students versus gender.
Table 2. Gender versus weight.
Table 3. Distribution of weight and height.
Table 4. BMI of children with respect to the BMI of their parents.
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soccer, basket or similar competition. Only a
53,1% declared that they were moderately
practicing PA. 39,8% of children did not have any
PA. 4,3% of over weight and a 3,8% of obese
children reported to be involved in vigorous PA.
The chi square test stressed a strong association
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(p<0,01).
Children were also asked whether one of their
parents was actually involved in some form of PA
and in this last case they were asked how much.
The answers given are represented in table 7,
which crossed this information with the level of
childrens PA, (Table 6). A chi square test was
performed and the result was significant (p<0,01).
The behavior of parents seemed to significantly
influence their children. A further consideration
was that in spite of the association, the percentage
of parents who practiced a moderate or vigorous
PA, was not as high as it should have been (107
and 21).
Information about some alimentary and familiar
related habits were also obtained. Behaviors of
children seemed to be in some way different
among males and females. The second ones, in
fact, demonstrated a tendency to a low calorie,
hypoglucidic and hypoproteic diet with respect
to males. Among those individuals who regularly
ate some meat (66,0%), males were 48,0%, while
females 42,0%. Only a 40,0% regularly ate some
fish, (26,0% females and 74,0% males). Pasta
consumption was very high, (86,0%), and it was
distributed among 64,0% of males and 36,0% of
females, (data not shown). The most common life
styles habits are shown in Table 8. Data were
reported on some of the factors considered to
represent the most healthy life styles, such as
those relating to breakfast, fruit and vegetable
consumption and PA or sedentary habits like
watching TV for many hours per day.Among those
who have breakfast, only 16,0% and 11,0% of
Table 5. Students BMI with respect to cultural level of their families.
Table 6. Students BMI with respect to their physical activity.
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overweight and obese children respectively ate it
regularly, against 72,0% of normal weighted
students. But 63,0% and 66,0% among those who
were overweight and obese, respectively, skipped
breakfast. It must be noted, however, that the
percentage in the total number of children who
do not have breakfast was dramatically high,
(46,0%). Moreover unhealthy habits were
observed as terms of the consumption of flavored
drinks, high fat food and fruit and vegetable intake.
Higher percentages of sugared drinks and fat food
consumption were associated with low fruit and
vegetable intake especially among those who
were overweight and obese. It must be noticed
that between 30,0% to 40,0% of students did not
follow the dietary guidelines suggested by experts
for the items surveyed. The same can be repeated,
practically, about the data obtained relating to
movement and sedentary habits. Chi-square tests
gave significant association among all the
categories which were observed, (p<0,001).
Therefore, healthy or unhealthy eating and PA or
sedentary habits were strongly correlated with
the BMI of children.Table 9 crossed the overuse of
watching television during the meals with the
need of a snacking while watching TV in different
hours. The rationale was to check whether it was
possible to observe the acquisition of a
conditioned reflex and define an association
between these two variables. The evidence of chi
square test gave a significant statistical association,
(p<0,001). A multi linear regression analysis
stressed out the weight of some independent
variables which were more strictly correlated
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with childrens BMI. The need of avoiding
covariance disturb, leaded to a stepwise selection
of the variables which were significantly
associated with childrens BMI. The rationale was
to select, step by step, the most correlated ones,
which had, on their turn, a smaller intra-
Table 7. Parents PA versus childrens PA.
Table 8. Life style habits versus classes of BMI.
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correlation with the other selected variables.Thus,
a correlation matrix was preventively constructed,
in order to reach this aim, (not reported).
The evidence gave five variables which showed
a strong correlation with BMI, in order of strength,
Family eating habits, Family culture, Family PA,
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Table 9. Eating, watching TV and snacking behavior.
Table 10. Multivariate analysis of different factors which influence BMI in children.
Children eating habits, and Children Tv/games
habits. The linear multivariate regression analysis
gave the following results, 22,0%, 21,0%, 16,0%,
13,0%, 8,0% respectively as the strength of those
variables to determine BMI values in children.
Discussion
In our sample of young adolescents, primary
school students, 23,0% were overweight and
18,0% obese. Data obtained paralleled results
reported by other authors: prevalence of
overweight in Texas school children in 2004 was
as 50,0% higher (24%) than the prevalence
reported in the year 2000, [48]; prevalence of
overweight was reported from 20,0% to 30,0% in
youth from southern European regions, 33,4% in
Tuscan schoolchildren, including obesity [3,49]; in
a survey on a sample of primary school children
from northern Italy, 12,6% were obese and 26,3%
overweight, [15]. The prevalence of overweight
and obesity in Sicilian schoolchildren was
reported as high as 40% at age 11 and 25% at age
15 [50].
The evidence did not show the variable of
gender to be significantly associated with BMI.
Large variability among weight and height
between the surveyed children was not observed.
Information on other variables that entail
obesity risks, moreover, evidenced some more
troublesome aspects significantly linked to life
stile habits.
It has to be noted that the percentages of being
obese or overweight, was much higher when the
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parents were either obese or overweight.
Percentages of students with a high BMI, in fact,
increased in a way directly correlated with the
overweight of one or both parents. It was
observed a strict and significant association
between parents and their childrens weight.
Thus, negative weight characteristics in parents
do not certainly help children having a correct
BMI. Family cultural level plays a very important
influence on the education of their children, and
this is an aspect which should be considered as
very important to act an effective promotion for
health life styles habits. A strong association with
childrens PA, seemed to be the attitude of parents
in being involved in PA. This aspect was strictly
associated with the attitude of children in
undertaking regular PA, which is to be considered
a good way of avoiding overweight.
Only a minority of the surveyed children were
found to meet the fruit and vegetable intake
recommendation and less than half were
consuming only less than one serving of fruit and
vegetables per day. Recommended goals in fruit
and vegetable consumption in our sample of
primary school students were far from meeting
the standards of the nutrition guidelines.
Moreover, if the outcome is applied to the
corresponding universe of adolescents it means
that overall only approximately 1/4th, meets the
expert recommendation of five or more daily
servings of fruit and vegetables. In the groups of
overweight and obese children, moreover, about
2/3rd reported that they did not have breakfast
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before going to school.
Analyzing the sugared drinks and high fat food
consumption, a strong statistical association was
demonstrated between belonging to the
overweight and obese groups and the alimentary
habit related to those items.
The question of practicing PA in children, (see
tables 6 and 7), could be considered in such a way
misleading, so, in table 8, the results of children
being asked if they frequently do some physical
movement, like long walking, playing with friends,
etc.With regards to this it was reported that about
one third of children were not engaged in any
movement and the proportion was doubled if
computed in the overweight and obese groups.
Sedentary habits were even worsened by the data
that showed the average time spent watching TV
and playing video games instead of practicing
active games in the free time after school. It may
be of interest to infer from the observed data that
a kind of conditioned reflex can be assumed was
acquired, as snacking when watching TV was
prevalently needed by those who regularly watch
TV while eating.
Results reported by different authors indicated
also that individual behaviors in nutrition and
sedentary or active physical engagement are
largely influenced by different variables as age,
gender, social, economical, cultural factors,
different setting, [36, 37].
Evidence concerning the role of local context
factors in determining health behaviors were
brought to attention also in different Italian local
settings. Socio-cultural factors were identified as
being responsible for the different prevalence of
obesity and overweight between northern and
southern Italian regions [51]. Traditions and
alimentary symbols in the south, keep the family
more tied to preparations and consumption of
food as expression of social connection and,
moreover, of a well-being social status. A lower
prevalence was reported in the north, especially
in girls, probably to be referred to a higher
cultural level of families and a more intense
perception of body care [52,53]. Data obtained in
a recent survey, from Emilia Romagna, a region of
Central-North Italy, seem to confirm the fact that
prevalence of overweight and obesity is
influenced by the geographical origin of the
parents. Obese children had higher percentage of
parents who came from Southern Italy and the
islands. Differences were referred to a lower
socio-economic status of those families [54].
Prevalence of overweight and obesity, about
16,0% and 8,0%, in 6 years old and 20,0% and 9,0%
in 9 years old children respectively, was among
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the highest reported in Italy. But comparable data
were reported, about in the same period, in
primary school children from Sardinia [55]. In the
two studies obesity and overweight were
reported as closely influenced by the education
level, occupation and nutritional status of the
parents.
This research demonstrated that cultural
differences influence children behaviors and life
styles. A culturally high familiar context was
shown, in fact, to have a relevant weight and
results were positively associated with higher
percentage of normal BMI. Families are assumed
to be a good reference point and increasing
information and awareness of the families can,
thus, help adolescents to improve the quality of
their life. Consequently children should have this
awareness as early in their education as possible.
On the contrary, a negative point to be stressed
out was the confirmed observation that
overweight of parents have a strong association
with overweight and obese children, [56].Another
negative point to be noticed was the low
attention given by the family to regular breakfast
consumption, reported in a study carried out in
western Sicily, in a similar local social contest of
this investigation. About half of the children and
adolescents did not have breakfast and the
proportion increases as children grow. This
behavior was associated, too, with cultural level of
the family and cultural variables influence
behaviors, [31]. A nutritional education
intervention based on active didactic
methodologies and conducted by teachers [57]
seemed to be efficient with regards to the
modification of some nutrition habits in the short
term, in particular to having breakfast in the
morning and in eating less snacks.
Socio-environmental factors, as well, were
reported to influence dietary habits and familiar
lifestyles [58]. Assuming about 1/5th of genetic
interference, [59], the remaining percentage of
pathology must be researched on the negative
behavioral factors acting in the inner space of
familiar and social relational ecosystem. Italian
population in the last half of XXth century,
markedly increased the caloric intake and,
unlikely, reduced as well the energetic
expenditure [60]. Socio-environmental factors, in
fact, have great influence on the caloric intake of
children. Modified working necessities and social
relationship produced a new, attractive
perception of fast food, and create a kind of status
symbol in consuming fast food during the
working hours. Industries, on turn, invest in this
lucrative trade, promoting and integrating this
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practice as an image of the modern life style,
making the healthy Mediterranean way of dieting
old-fashioned and poor. Marketing strategies reach
the children, advertising target, through video and
other media, inducing passive consumption, out
of any physiologic organic stimulus [61].
Moreover, socio-cultural factors related to the
symbolic value of food leave the individual alone
in respect with his relational needs. It becomes
possible to fill this lack of social links with the
food. This seems particularly true when familiar
attitude to communication is disturbed and
management of emotional relationship is
disengaged [62]. The multivariate regression
analysis, in fact, showed that five variables were
able to influence the childrens BMI, and the three
having an higher weight were all related to the
intra familiar relational ecosystem: Family eating
habits, Family culture and Family PA. Including the
other two selected variables, Children eating and
Children TV/games habits, the overall value
reached a weight of 0,80. That is, according to the
obtained evidence, these variables may assume
the value of risk or protective factors, depending
from the potential capacity of the intra familiar
environment to implement their positive or
negative values and correlated influence.
Therefore, the variable BMI seemed to be strongly
affected by families and the social relational
system. The remaining factors acting accounting
for 20,0% could be worthy of future research.
One of the most referred to, social factor, is the
increase availability of fast food which contains
little fruits or nutrient rich vegetables and the
increased consumption of sweetened fruit drink
or sodas that contribute to a replacement of fruit
and vegetables from adolescents diet [63]. The
sources of lunch meal, in fact, are responsible of
short term changes in dietary habits of school
children [64-67]. Other social factors, as
perception and beliefs, are associated with the
development of obesity. In a recent investigation
on the parental perception of childhood obesity,
in the same local social contest of this survey [68],
availability of fast food, sugared beverages and
other junk food was considered among the most
effective obesogenic factors. Physical exercise
was perceived as a smaller contributor to
childhood obesity. Although 83,3% of parents
were convinced that weight excess was a serious
health hazard, about 1/3rd interpreted the
overweight in childhood as an expression of
health, perpetuating the social belief that
considers overweight children as good eaters ,
causing their parents less concern. In the same
survey, the majority of mothers, moreover,
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OF PUBLIC HEALTH
escaping from responsibility on their role,
indicated as risk factors and cause of a sedentary
habit lack of PA in school curriculum, lack of
space for PA, TV and internet advertising and time
spent playing videogames. Another study carried
out in Pavia, Northern Italy [15], evidenced as a
risk factor living in a medium or small town
where the use of bicycles and public transport is
less common. Physical activity, in fact, should be
encouraged, travelling to and from school and
work by walking, cycling or in any other active
way [67].
Recently in fact there has been an increase in
the awareness of the influential role of a kind of
toxic environment [69,70] and accordingly, in a
recently conducted surveys in Italy, most of the
responders agreed about the need of reversing it
by political intervention and considered
responsible for intervention health care services,
food companies and government [71].
The increasing prevalence of childhood obesity
in fact, results from changes in society linked to
social and economic development and policies in
the areas of agriculture, transport, urban planning,
food processing, distribution and marketing, as
well as education. The problem is societal and
therefore it demands a population-based multi-
disciplinary, and culturally relevant approach as
well as a sustained political commitment and the
collaboration of many public and private
stakeholders in shaping healthy environments and
making healthier diet options for children.
Results reported seemed to indicate, from all
points of view, that the bases are settled for
epidemic of overweight and obesity continuing to
spread and, worse, for an alarmingly increasing
trend.
Implications and Conclusions
Increasing the proportion of adolescents
meeting recommended dietary and physical
activity guidelines has been identified as an
important strategy to contrast the epidemic
increase in obesity, especially in western
Countries. Interventions have been generally
addressed to schools, communities and families,
considered the best pathways to spread correct
information and knowledge and the more suitable
channels to increase the awareness on the
importance of correct dieting and regular physical
activity, [72].
School based interventions have been the
forefront of activities and school based programs
have been largely activated at all level. Programs
aimed to increase knowledge and modify
behaviors, however, have had modest results and

ITALIAN JOURNAL
were associated with improvements on behaviors
only in the short term. An increase on knowledge
was generally reported but values of BMI
remained unchanged, [73]. Schools need to have
evidence and reference data on methods and
strategies suitable in gaining attention and
enhancing retention of the acquired knowledge.
School-based intervention programs are,
nevertheless, strongly requested and considered
fundamental for developing a rooted culture of
alimentary education and offer occasions to avoid
sedentary habits, thus, activating preventive
actions early in life and mainly in the development
age. School lunches contribute significantly to
correct dietary practice and, then, adequate and
different school lunches programs should be
directed to favorably influence in short term
alimentary education and in long term promotion
of health benefits and quality of life. Soft drinks,
candy bars and potato chips should be banned,
replacing the prohibited products with "healthy
alternatives" such fruit, unsalted nuts,
unsweetened fruit juice, wholegrain snacks,
mineral water and milk [74]. With regards to
communities, policymakers need to be active, at
the same time, in promoting community based
programs directed to develop environmental
initiatives able to establish contexts which should
enable to have occasions and choices for healthy
lifestyles. Adequate information on nutrition is
necessary through better information and
available healthy options for consumers. This
should be provided, also, through increasing
attention to agricultural policies supporting more
affordable market, providing adequate initiatives
and structures for physical activities, adequate
funding of food services in schools, tax barriers to
the diffusion of school food stores and snack bars,
together with more traditional practices of health
and nutrition education in different setting of the
community and for targeted specific groups.
Families are the key junction between
generations and social systems and their symbolic
codes must be considered inside the family
relations. Little attention, after all, has been given,
in general, so far to prevention as related to
specific familiar targets. Obesity is a multifaceted
pathology. The genetic component is responsible
for about 20,0% over the total risk, [59], the
remaining 75,0%-80,0% is due to contextual
environmental, psychological components, with a
relationship in continuum with the social
ecosystems. Few evaluated programs can be found
in the literature [75,76] and almost all follow a
type of methodological intervention to the
alimentary problems traditionally linked to a
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JPH - Year 7, Volume 6, Number 3, 2009
OF PUBLIC HEALTH
linear behavioral approach focused mainly to the
knowledge on correct alimentary habits, to low
caloric intake, to increase the energetic losses, to
behavioral modifications. Results are generally
negative with several drop out or, often, a big
eating effect. It seems necessary a global
approach which should take into consideration
the relationship with the family, the peers and the
society in general. In fact an integrated view of the
problem to approach obesity with a systemic-
relational method is required [77]. The Family is
key in determining of weight pathology through
the transmission of beliefs and behaviors: low
communication levels, loss of traditions,
consolatory food consumption, emotional eating,
serious and chronic disorganization of the family
nucleus, incorrect utilization of food as answer to
the child needs and supportive gratification.
Parents who are overweight, moreover, seem
reluctant to have an active consent educating
their children with respect obesity [78]. Few
studies have attempted to identify influence of
familiar and psychological factors in children
obesity [79]. The eco-systemic familiar model
(FEM) seems a possible answer to the problem of
integrating the bio-psycho-social and the eco-
systemic theory [80,81]. To take in charge an
obese child should mean to take care of the whole
social, cultural, relational context. An obese child
must be seen as a problem of the whole family,
and, consequently the whole family must be the
cornerstone of the therapeutic education.
Attention should be moved from focusing on the
sting of hunger to producing a cultural change of
the family, [82]. Beside the active involvement of
the parents the educational integrated
intervention should be supported by the capacity
of the multidisciplinary staff to take into
consideration the intra-familiar cognitive,
emotional and relational factors, [83]. It seemed
evident, then, the need of education of the
caregivers and sanitary operators for the
successful accomplishment of the intervention.
Results presented in this work, have large
limitations and cannot be considered exhaustive:
dietary data may be subject to recording errors
and underreporting; other factors, not assessed,
may have influenced reported data; findings may
not be generalized to school and students of other
geographical area; investigation would need to be
repeated again, to monitor the attitude of young
people regarding knowledge and behavior
referred to fruit and vegetable consumption,
physical practice and other life style behaviors.
This study, however, may offer useful information
for planning educational strategies involving
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ITALIAN JOURNAL
youth, families and communities to promote
healthy lifestyles. Further research is required to
determine the most favorable factors and
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