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