Rathnayake et al.

BMC Public Health 2014, 14:1291

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RESEARCH ARTICLE

Open Access

Nutritional and behavioral determinants of

adolescent obesity: a casecontrol study in
Sri Lanka
Kumari M Rathnayake1*, Tharrmini Roopasingam1 and VP Wickramasighe2

Abstract
Background: Global prevalence of adolescent obesity is rising at an alarming rate leading to increase risk of adult
obesity. Obesity in adolescence is postulated to have a significant impact on both physical and psychological
health of an individual. The study aim was to identify nutritional and behavioral risk factors associated with obesity
among adolescent Sri Lankan school girls.
Methods: In this casecontrol study, age and ethnicity matched 100 cases (BMI-for-age above +2SD) and 100
controls (BMI-for-age between -2SD to +1 SD) adolescent girls between 14 to 18 years of age were recruited.
Predicted risk factors of obesity were assessed through an interviewer administrated questionnaire. A three day diet
diary and long version of international physical activity questionnaire were used to assess daily energy intake and
energy expenditure from physical activity, respectively. The significant differences in mean values were evaluated
using paired t-test. Multivariable logistic regression analysis was performed to assess the risk factors associated
with obesity.
Results: Obese girls had significantly higher BMI (31.3, 20.2 kgm2 p < 0.0001), waist circumference (90.8, 68.2 cm
p < 0.0001), energy intake (2235.4, 1921.7 kcal p < 0.0001) and lower energy expenditure from physical activity
(894.6, 1844.3 MET (metabolic equivalent)-min/week p < 0.0001). High family income (Odds ratio [OR], 2.99, 95%
confidence interval [CI] 1.13-7.88), first born in family (2.73, 1.25-5.97), skipping breakfast (3.99, 1.81-8.80),
consumption of fruits < 4 days per week (2.18, 1.02-4.67), screen viewing > 2 hours/ day (2.96, 1.33-6.61), energy intake
(3.97, 3.19-16.36), significantly increased the risk of obesity, whereas increased physical activity (4.34, 1.33-14.14)
decreased the risk. Irregular menstruation (4.34, 1.33-14.14) was noted among the obese.
Conclusion: Socioeconomic and behavior factors are major determinants of adolescent obesity in Sri Lanka. There is an
urgent need to implement awareness as well as behavior modification programmes targeting adolescents, parents and
schools to control childhood and adolescent obesity.
Keywords: Determinants of obesity, Adolescent obesity, Sri Lankan adolescents

Background
Obesity in adolescence is postulated to have a significant
impact on both physical and psychological health of an
individual. It is an antecedent of adult obesity. The
higher prevalence of childhood obesity were usually observed in developed countries. However, in recent years
its prevalence has increased in developing countries such
as Sri Lanka due to the socio-economic transition [1-3].
* Correspondence: rldk_rathnayake@yahoo.com
1
Department of Applied Nutrition, Faculty of Livestock, Fisheries & Nutrition,
Wayamba University of Sri Lanka, Makandura 60170, Sri Lanka
Full list of author information is available at the end of the article

Increase in obesity over recent years is mainly due to

environment and lifestyle influences rather than genetic
determinants [2]. Childhood and adolescence are pivotal
periods of life, where major physiological and psychological changes take place, which would transform into
adult behaviour and health status. Obesity is associated
with metabolic risk including high blood pressure, hypercholesterolemia, hypertriglycerinemia and insulin resistance in both old and young [4].
Adolescence is identified as a critical period for the development of obesity related metabolic derangements [5].

2014 Rathnayake et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.

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Majority of the studies have reported females to be at a

higher risk of developing obesity and its consequences. Fat
deposition begins to occur early in females with the onset
of puberty and continues unless consciously controlled
[6]. Thus steps should be taken to prevent obesity as early
as possible in adolescence. Hence, the environmental and
behaviour determinants of obesity need to be identified to
design effective interventions to control this condition effectively. Recent data have shown that obesity related
metabolic abnormalities are seen among Sri Lankan children of 510 years of age [7].
Although studies have identified adverse consequences
of obesity [7], research done to identify specific risk factors associated with obesity is limited in adolescent age
group. Therefore, the aim of our present study was to
determine the nutritional and behavioural risk factors
associated with obesity in Sri Lankan adolescent girls.
This casecontrol study would be useful in designing effective interventions to combat adolescent obesity.

Methods
Study design and participants

This was a case control study of 100 subjects in each

arm among pubertal adolescent school girls aged between 14 and 18 years, to examine a broad range of possible determinants of adolescent obesity. The cases (here
after referred obese) and controls (here after referred
non-obese) were recruited from five different schools and
segregated according to BMI. BMIforage above +2SD
and between -2SD and +1SD, of WHO 2007 growth standards, were considered as cases and controls, respectively
[8]. Those who had a BMI between +1SD and +2SD were
excluded. Age and ethnicity matched cases and controls
were recruited on a 1:1 ratio individually from the same
school and class. Ethical aspects of the study was evaluated and the Department of Applied Nutrition, Wayamba
University of Sri Lanka approved the study protocol. Informed consent was obtained from the parents and assent
from children before the data was collected.
Data collection

An interviewer administered questionnaire was used to

collect the information from the subjects. The questionnaire was designed to capture the dietary, behavioural and
socioeconomic factors associated with obesity, from the
individuals. Pubertal characteristics such as age of menarche and menstrual pattern (either regular/irregular) were
obtained from the subjects during the interview.

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pattern and the nutrient intake. Subjects were asked to

record all the food and drinks consumed during the day.
Information on their dietary intake was taken in household measurements and was converted to grams by using
standard reference tables. Mean total energy intake was
calculated using FoodBase 2000 version 2, computerized
food composition tables comprising nutrient compositions
of Sri Lankan foods.
In addition, frequency of eating out of home, screen
viewing time per day and fast food consumption patterns
were obtained to assess the behaviour of the subjects. A
semi quantitative food frequency questionnaire, which included common fast foods eaten by the children, was used
to assess the frequency of fast food intake.
Physical activity pattern

Total physical activity pattern for a typical week was

assessed using the long version of the international
physical activity questionnaire (IPAQ) [9]. It includes
three types of activities; vigorous, moderate and time
spent for walking. The total amount of energy spent for
physical activity was calculated by multiplying the total
time spent in each type of activity by the respective MET
(metabolic equivalent) values and then adding up these
values. Subjects were categorized into three groups; physically less active (<1500 MET-min/week), moderately active (15003000 MET-min/week) and highly active (3000
MET-min/week) based on the IPAQ cut- off values.
Anthropometry

Body weight, height and waist circumference were measured within the school premises, in an isolated area
which did not affected the routing daily activity of the
school and secured the privacy of the participants, by a
trained female investigators using standard equipment
and guidelines [10]. Subjects were asked to remove
shoes and empty their pockets, before body weight was
measured using calibrated electronic scale placed on an
even concrete floor (Seca 813, Hamburg, Germany) accurate to the nearest 0.1 kg. Height was measured to the
nearest 0.1 cm with an upright plastic portable stadiometer (Invicta Plastics-Model IP0955, Leicester, UK).
Waist circumference was measured midway between the
highest point of iliac crest and the lower point of costal
margin in the mid axillary line, at the end of normal expiration, using a plastic flexible tape to the nearest
0.1 cm with the subject having minimum clothing at the
waist area. BMI was calculated as weight in kilograms
divided by height squared in meters (kg/m2).

Dietary assessment

Information on meal frequency, patterns of meal skipping,

frequency of consumption of fruit and vegetables were
gathered. A 3-day diet diary, which included two weekdays
and one weekend day, was used to determine the meal

Data analysis

The statistical analysis was carried out by using the SPSS

16.0 software. Single and multiple logistic regression analysis were performed to analyse the association between

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potential categorical factors. Paired t-test was performed

for the continuous data to find out any significant difference between the mean values of matched cases and controls. The Odds ratio (OR) and its 95% confidence interval
(CI) were also estimated and computed for each significant categorical factor using binary logistic regression. A
factor with an OR significantly (p < 0.05) higher than 1.00
was taken as a risk factor of obesity, while OR significantly
(p < 0.05) less than 1.00 was regarded as a protective factor. In the paired t-test analysis a factor with a p value <
0.05 was considered as significant and > 0.05 was considered as insignificant. The goodness of fit of the final
logistic regression model was analysed using the
Hosmer-Lemeshow technique, in which a p value >0.05
indicates a good model.

Results
The study population consisted of 100 adolescent girls,
aged between 1418 years, in each group (obese and
non-obese). Table 1 shows the general characteristics of
the study sample. There were no significant differences
in age, birth weight and age of menarche.
Obese children had significantly higher BMI and waist
circumference. The total energy expenditure from physical
activity was significantly higher among the non-obese. As
described in the literature, variables such as family income,
mothers educational level, fathers educational level, first
born status, skipping breakfast, frequency of fruit, vegetable and fast food consumption, screen viewing time, energy intake, energy expenditure from physical activity and
menstruation pattern were considered as variables for logistic regression analysis. Factors which indicated significant relationship with obesity were carried forwarded for
the multiple regression (Table 2).
Income of the family, being the first-born child in the
family, skipping breakfast, frequency of fruits consumption,
Table 1 General characteristic of obese and non-obese
adolescent girls
Characteristic

Obese

Non-obese

p-value

Mean

SD

Mean

SD

Age (years)

15.34

1.29

15.33

1.29

0.957

Weight (kg)

77.5

8.5

49.18

3.5

<0.0001

Height (cm)

157.3

6.1

156. 2

4.3

0.143

BMI (kgm2)

31.3

2.7

20.2

0.9

<0.0001

Waist circumference (cm)

90.8

5.3

68.2

3.7

<0.0001

Birth weight (kg)

2.81

0.57

2.92

0.45

0.129

Age at menarche (years)

11.9

1.4

12.2

1.2

0.073

Energy intake (kcal)

2235.4

252.6

1921.7

223.7

<0.0001

Total energy expenditure

(MET-min/week) from
physical activity

894.6

730.6

1844.3

996.3

<0.0001

P value < 0.05 was considered as significant.

frequency of fast food consumption, screen viewing time,

irregular menstruation, high energy intake from food and
low energy expenditure from physical activity were associated with obesity in this group of adolescent school girls.
According to multiple logistic regression analysis, the adolescent child has higher chances of being obese, when she
was from a high income family and being the first child in
the family. A number of behavioural risk factors have been
postulated, with increasing likelihood of being obese including eating patterns, diets with a high energy density,
high level of sedentary behaviour and low level of physical
activity. Irregular menstruation, which is a complication of
obesity, was higher among obese adolescent girls (Table 2).

Discussion
Recent research has given much attention in identifying
risk factors for obesity. Despite the existence of undernutrition and micronutrient deficiencies, recent socioeconomic transition and changes in the physical activity
pattern, have led to the emergence of obesity related
metabolic problems among Sri Lankan children. A recent study reported that prevalence of overweight, obesity and central obesity among Sri Lankan adults to be
25.2%, 9.2% and 26.2%, respectively with a clear upward
trend [11]. Age-adjusted prevalence of Metabolic Syndrome among Sri Lankan adults was 24.3% (95% CI:
23.025.6) [12]. Risk factors associated with obesity in
specific groups need to be identified to combat the increasing prevalence of childhood obesity. An early adiposity rebound is associated with an increased risk of
adult obesity independent of parent obesity [13]. Foetal
life, the period at which adiposity rebound occurs (age
47 y) and adolescence have been identified as pivotal
periods in the development of obesity [5]. Moreover,
Katulanda et al. have reported that female gender, urban
living, higher level of education, higher income and middle age are risk factors for obesity among Sri Lankan
adults [14].
Therefore, this study was carried out to identify the
nutrition and behavioural risk factors associated with
obesity among adolescent school girls in Sri Lanka.
About, one-fifth of the total Sri Lankan population (20.4
million) consists of adolescents between the ages of 10
to 19 years [15]. Traditionally, pre and primary school
children were identified as nutritionally vulnerable populations in Sri Lanka. However, at present it is quite evident that adolescent age group need more attention if
we are serious about controlling non-communicable diseases among Sri Lankan adults. Most of the modifiable
risk factors in obese individuals are in an adverse state.
Therefore, it shows that it is important to take steps to
prevent them occurring in children. This study showed
that the obese individuals had a lower mean birth weight
compared to the lean individuals although it was not

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Table 2 Potential risk factors associated with adolescent obesity

Factor
Monthly income

Univariable analysis

Multivariable analysis

OR

P value

OR

P value

95% Confidence intervala

3.42

0.001

2.99

0.027

1.13-7.88

Firstborn status

3.17

0.0001

2.73

0.012

1.25-5.97

Skipping breakfast

3.19

0.0001

3.99

0.001

1.81-8.80

Fruit consumption frequency (<4 days/week)

2.93

0.0002

2.18

0.045

1.02-4.67

Fast food consumption frequency (4 days/week)

1.88

0.038

0.88

0.756

0.39-2.00

Screen viewing hours/day (>2 hours/day)

3.34

0.0002

2.96

0.008

1.33-6.61

Energy intake

6.73

0.0001

7.23

0.0001

3.19-16.36

Energy expenditure from physical activity

2.87

0.018

3.94

0.012

1.34-11.56

Irregular menstruation

4.47

0.001

4.34

0.015

1.33-14.14

OR, Odds ratio.

a
The confidence intervals, p values and OR were obtained from corresponding multivariable binary logistic regression analysis.
Significant p values in multivariable binary logistic regression analysis (<0.05) are given in bold type.

statistically significant. Moreover, prevalence of low birth

weight was higher among obese girls. This is keeping
with the misconceive notion of that low birth weight babies need catch up growth, which quite eloquently shows
in this study that is should not be the case. Barkers described that low birth weight was associated with noncommunicable disease later in life. These relationships
were independent of the Childs gestational age at birth
and current social class [16]. Although not significant,
obese girls attained menarche at a younger age than
their lean counterparts. This is keeping in with the normal phenomena of obesity leading to early maturation
[17]. Obese girls had significantly higher intake of energy, carbohydrate and fat compared to non-obese girls
(data not shown).
A nationally representative cross-sectional study identified that skipping breakfast, inadequate consumption
of green leafy vegetables and fruits, physical inactivity
and increasing television viewing as potential challenges
faced by Sri Lankan adolescents [18]. This study has
shown the implications of those ill adoptive behaviours.
Our data showed that adolescent girls of high income
families were at a higher risk of being obese than those
from low income families. This is the normal trend seen
in economies in transition as people of affluent strata have
more purchasing power to buy refined, calorie dense food
in contrast to developed nations where fruits and vegetables are more expensive and high sugar and fat containing
foods are available at a lower price. [19]. Keeping with the
results of the present study, high prevalence of overweight
was seen among adolescent girls of higher socio-economic
group in urban India [20].
Our findings show an influence of birth order on obesity. It is interesting to note that the first-born status of
the subject was both individually and collectively associated with higher risk of obesity at adolescent age. Previous findings suggest that although first-born offspring

are lighter at birth, has increased fat mass as adolescence [21]. The mechanisms that operate are not
known, but research postulates that resetting of the leptin and glucocorticoid axis within the adipocyte, contributing to increased adipo-genesis during late gestation and
continuing after birth could be the mechanism [22]. It is
highlighted that this may contribute to the obesity epidemic in communities where there are restrictions in family size and a generation with greater proportion of firstborn children [23].
This study emphasizes the importance of targeting the
family environment for the promotion of healthy eating
behaviours among adolescents. Therefore, future studies
should aim at identifying factors that influence feeding
behaviour and the critical window at which these
changes begin to occur. Even though, intake of fast food
was not significantly associated with obesity in multivariable analysis, bakery items (wheat flour based food), soft
drinks and candies were the most frequent fast foods consumed as snacks on a daily basis and obese adolescents
consumed more fast foods than their lean counterparts. A
recent study in Sri Lanka reported that unhealthy food
habits are rising among adolescents, which is a crucial
period in establishing dietary habits that are likely to persist into adulthood [24]. As this study shows that high energy intake and low energy expenditure (low physical
activity) is associated with obesity. Therefore it is important to encourage consumption of low energy containing
foods and have an active lifestyle to balance the energy.
Framingham Childrens longitudinal study showed that
children who watched more television during childhood
had the greatest increase in body fat over time [25]. A
study conducted among adolescent school children in
India revealed that the risk of overweight was seven times
higher among those who had screen time 4 hours/day
[26]. Our study, showed that >2 hours of screen time per
day had three times higher risk of becoming obese.

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Furthermore, those with low physical activity had four

times higher risk of being obese. Participation in physical
activity programmes or sports activities during school time
were less among both obese and non-obese groups. Studies have shown that adolescent participation in school
physical education programs is considerably low and decreased with age. However those who engage in daily
physical activity either at school or community recreation
centre were associated with an increased likelihood of engaging in moderate to high physical activity during normal
life [27]. High prevalence of irregular menstruation among
obese girls in this study group shows that the endocrine
effects of obesity begins at an early stage of life.
Some limitations of the study must be noted in the interpretation of the findings. The sample size could have
been expanded more, so that stronger association of risk
factors could have been demonstrated. Sine this is a
casecontrol study, certain risk factors would have been
reversed during the time of data collection as the condition is known. Therefore, the true relationship of certain
current factors could have been affected.

Conclusion
The current case control study indicates socio-economic
status, firstborn status, skipping breakfast, low fruits and
vegetable consumption, high screen viewing, high energy
intake and physical inactivity are contributory factors for
adolescent obesity. Combined adolescent and parentfocused public health interventions should be considered
in addition to school programmes in order to reduce the
future burden of obesity associated chronic diseases.
Schools would be the best place to have prevention programmes for adolescents. However, more robust studies
need to be designed to identify factors associated with
adolescent obesity, in order to design better control programmes in a Sri Lankan context.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
KMR participated in the design of the study, data interpretation and drafted
the manuscript. TR contributed to the data collection, data analysis and
coordination of the study. VPW assisted in critically revision of the
manuscript. All authors read and approved the final manuscript.
Acknowledgements
This research received no specific grant from any funding agency in the
public, commercial and not-for-profit sectors. We express appreciation to the
participants for their enthusiastic cooperation with this study and also the
Nutrition Research Team of the Department of Applied Nutrition, Wayamba
University of Sri Lanka, for their valuable support.
Author details
1
Department of Applied Nutrition, Faculty of Livestock, Fisheries & Nutrition,
Wayamba University of Sri Lanka, Makandura 60170, Sri Lanka. 2Department
of Paediatrics, University of Colombo, Colombo, Sri Lanka.
Received: 26 May 2014 Accepted: 8 December 2014
Published: 17 December 2014

Page 5 of 6

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doi:10.1186/1471-2458-14-1291
Cite this article as: Rathnayake et al.: Nutritional and behavioral
determinants of adolescent obesity: a casecontrol study in Sri Lanka.
BMC Public Health 2014 14:1291.

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