CHILDHOOD OBESITY AND FAMILY INFLUENCE ON CHILDREN’S NUTRITION INTAKE, PHYSICAL ACTIVITY PATTERNS, AND BMI Z-SCORES IN OMAN Basma Al Yazeedi A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of Nursing. Chapel Hill 2018 Approved by: Diane Berry Jennifer Leeman Jamie Crandell Jada Brooks Amanda Thompson ©2018 Basma Al Yazeedi ALL RIGHTS RESERVED ii ABSTRACT Basma Al Yazeedi: Childhood Obesity and Family Influence on Children’s Nutrition Intake, Physical Activity Patterns, and BMI z-scores in Oman (Under the direction of Diane C. Berry) Childhood Obesity is a public health problem. It poses a significant health risk, which has been demonstrated to track into adulthood and decreases children’s physical and psychosocial well-being. The purpose of this study was to examine the relationship between weight status, nutrition intake, and physical activity patterns of Omani middle age children and explore the familial factors that influence them. The sample of the study consisted of 204 Omani mother-child dyads. The mean age of children was 7.74 years (SD ± 1.16). Among examined children, 17.4% were either overweight or obese, and more than 72% of mothers were found to be overweight or obese. Weak associations between children’s nutrition and physical activity pattern and obesity were found. Main familial factors that showed influence on children’s nutrition intake were parental education level, family income, and family nutrition and physical activity patterns. Children’s physical activity patterns as reflected by moderate to vigorous physical activity (MVPA), screen time, and sleep time were found to be influenced by maternal BMI, parental education level, and working status, as well as family nutrition and physical activity patterns. Interestingly, the results of the study indicated that child’s BMI z-score were strongly associated with maternal BMI and parental education level, particularly the mothers’. iii This dissertation work is dedicated to my parents, Mohammed and Laila, whose prayers for my success never stopped. They are my source of power for my achievements. This work is also dedicated to my beloved husband, Yahya, who has been a continued source of support. I am thankful for having him in my life. This work is also dedicated to my children, Elias and Azzam, who are a great blessing and source of joy in my life. iv ACKNOWLEDGEMENTS I am so grateful to Dr. Diane Berry, my advisor and dissertation committee chairperson, for efficiently supporting me through my academic and research journey in the PhD program. This work could not be completed without her continued guidance, support, and feedback. I am also grateful to Dr. Jamie Crandell for supporting me through the analysis of the study results in such a short period of time. I highly appreciated her statistical feedback and guidance. I am also thankful for having Dr. Jennifer Leeman, Amanda Thompson, and Jada Brooks as members of my dissertation committee. Their research expertise had added a lot to my dissertation work. I would also like to acknowledge my sponsor, Sultan Qaboos University, for offering me a full scholarship to pursue my PhD degree. I am ready to go back to Oman and serve as a faculty member with all intentions to give back as much as possible. v TABLE OF CONTENTS LIST OF TABLES ..................................................................................................................... xi LIST OF FIGURES ................................................................................................................. xvi LIST OF ABBREVIATIONS ................................................................................................. xvii CHAPTER 1: INTRODUCTION ................................................................................................ 1 Statement of the Problem ................................................................................................ 1 Definition of Childhood Overweight and Obesity ............................................................ 2 Prevalence of Childhood Obesity..................................................................................... 3 Targeting Middle Childhood for Obesity-Related Research ............................................. 3 Etiology of Childhood Obesity ........................................................................................ 4 Genetic Factors......................................................................................................... 4 Perinatal and Postnatal Factors ................................................................................. 5 Environmental Factors .............................................................................................. 6 Nutrition Intake and Physical Activity Pattern in Children in Oman ................................ 8 Home ..................................................................................................................... 10 Community ............................................................................................................ 11 Purpose of the Study...................................................................................................... 16 Research Questions ................................................................................................ 16 Conceptual Framework ................................................................................................. 17 Parenting Styles and Family Characteristics ........................................................... 19 Significance of the Study ............................................................................................... 19 Chapter Summary .......................................................................................................... 20 vi CHAPTER 2: LITERATURE REVIEW ................................................................................... 21 Introduction ................................................................................................................... 21 Results .......................................................................................................................... 32 Childhood Obesity Prevalence ................................................................................ 32 Children Risk Factors for Obesity ........................................................................... 33 Discussion ..................................................................................................................... 39 Childhood Obesity Prevalence ................................................................................ 39 Childhood Obesity Risk Factors ............................................................................. 39 Summary ....................................................................................................................... 51 CHAPTER 3: METHODS ........................................................................................................ 52 Introduction ................................................................................................................... 52 Aims ............................................................................................................................. 56 Philosophical Assumptions ............................................................................................ 56 Parenting Styles and Family Characteristics That Influence Children’s Nutrition Intake ...................................................................................................... 57 Parenting Styles and Family Characteristics That Influence Children’s Physical Activity .................................................................................................... 57 Design ........................................................................................................................... 57 Institutional Review Board ............................................................................................ 58 Settings ......................................................................................................................... 58 Sample .......................................................................................................................... 59 Sample Size and Power .......................................................................................... 60 Variables and Their Measurement ................................................................................. 61 Anthropometric Measurements ............................................................................... 62 Socio-Demographic Data Survey ............................................................................ 63 Health Behavior Instruments .................................................................................. 63 vii Procedures ..................................................................................................................... 66 School Sites Recruitment ........................................................................................ 66 Participant Recruitment .......................................................................................... 67 Obtaining Mothers Consent and Children Assent .................................................... 68 Data Collection......................................................................................................