Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 1 ORIGINAL RESEARCH Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem Maha Nubani-Husseini 1,2 , Elliot Berry 1 , Ziad Abdeen 3 , Milka Donchin 1 1 Braun School of Public Health, Hadassah & the Hebrew University-Hadassah Medical School, Jerusalem, Israel; 2 Faculty of Public Health, Al-Quds University, Palestine; 3 Nutrition and Health Research Institute, Faculty of Medicine, Al-Quds University, Jerusalem, Palestine. Corresponding author: Maha Nubani-Husseini Maha, Braun School of Public Health, Hebrew University-Hadassah Medical School; Address: P.O.Box 19746, East Jerusalem, Israel; Telephone: +972522520104; Email: maha.husseini@mail.huji.ac.il. Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 2 Abstract Aim: This study aims to assess the Palestinian girls’ dietary habits and physical activity patterns as a baseline for intervention. Methods: A cross-sectional study of grade 4 and 5 pupils (mean age: 11 years) in 14 all-girl schools in East Jerusalem, of four different types of school ownership (overall N=897), was conducted, using self-administered questionnaires and height and weight measurements. Logistic regressions were conducted to determine predictors of healthy behaviours. Results: Only 36.6% of the pupils reported eating breakfast daily, with UNRWA schools having the highest rate of daily breakfast consumption (42.6%). About 28% reported eating the recommended daily quantity of five portions of fruits and vegetables. Only 15% of the pupils reported being active at least five days a week and more than one third of the schoolchildren viewed TV for ≥4 hours a day. The prevalence of overweight and obesity was 22.2% and 7.6%, respectively, with private schools having the highest rates, 29.6% and 12.8% respectively (P=0.001). Additional predictors of overweight and obesity were: being the first child in the family, watching TV for more than four hours a day, always eating while watching TV and being physically active less than five days a week. Conclusions: Most Palestinian pupils miss breakfast, eat less fruits and vegetables than recommended and have sedentary behaviours. These findings raise serious concerns and point to the urgent need for tailored interventions. Keywords: dietary and physical activity behaviour, obesity, Palestinian female schoolchildren. Conflicts of interest: None. Source of funding: This study is a part of Ph.D. degree. Maha Nubani-Husseini received a scholarship from Joint Distribution Committee (JDC). She thanks Nutrition and Health Research Institute Al-Quds University for funding part of the research. The Linda Joy Pollin Cardiovascular Wellness Center for Women at the Division of Cardiology of Hadassah University Medical Center, directed by Dr. Donna Zfat funded the mothers’ activities and lectures towards the end of the intervention, as well as the implementation of the programme at the control schools one year after the study ended, as they were promised when they got selected. Acknowledgments: The authors thank the participating schools, the Palestinian Ministry of Education, the UNRWA Office of Education and Jerusalem Municipality for facilitating fieldwork. Their gratitude also goes to Mr. Radwan Qasrawi (Al-Quds University), Dr. Marrio Baras and Dr. Deena Jaffeh (Hebrew University) for statistical support, and to Mrs. Suzy Daher for editing. Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 3 Introduction Healthy nutrition and physical activity are the key factors in preventing and reducing obesity in children (1). Additionally, adapting such a healthy lifestyle throughout one’s life span is essential for optimal physical growth and intellectual development (1). Obesity is known to be a significant risk factor for chronic diseases including type II diabetes mellitus, cardiovascular disease and certain types of cancer (2,3), and imposes a substantial economic burden (4). The obesity trend is especially alarming considering the increasing prevalence in children and adolescents. The need for effective preventive measures to control obesity has therefore become a major public health issue. In Palestine, rapid urbanization, modernization and sedentary lifestyle have contributed to the increasing prevalence of overweight and obesity in all age groups (5). However, there are few local studies focusing on eating habits and physical activity patterns. One study was part of the Health Behaviour School Children survey (HBSC) conducted in 2004 in the West Bank and Gaza strip. This survey acknowledged problems such as skipping breakfast particularly among girls, low consumption of vegetables and fruits and low intake of milk (6). Such data is lacking for female schoolchildren from East Jerusalem. The current study is done to fill this gap and is part of a baseline study of a school-based intervention programme in East Jerusalem to promote healthy eating and physical activity among schoolchildren, their mothers and teachers. The purpose of this paper is to describe nutritional and physical activity habits and their socio-demographic determinants among Palestinian girls in East Jerusalem schools of different types of ownerships. Methods Study design and population A cross-sectional study was performed in April-June 2011 to provide the baseline data in a randomized controlled programme trial, before allocating schools into intervention and control groups. The primary target population was girls in grades 4 and 5, as those elementary schoolchildren are old enough to be able to answer the questions, however, they are not yet close to puberty when hormonal changes could have altered the results. All schoolgirls from the different types of ownership in East Jerusalem were eligible for the study. This included 31 Jerusalem Municipality (JM) schools with 2,759 students, 23 Palestinian Authority (PA) schools with 2167 students, 40 Private schools with 820 students and eight United Nation Relief and Works Agency (UNRWA) schools with 1218 students. Average number of students per class is 34, with different numbers according to school type of ownership. Sampling was done in two stages: i) stratified sampling of schools according to their ownership; ii) a random selection of classes (by lottery). All students in the selected classes were included. Sample size calculation was based on the estimated prevalence of healthy behaviours relating to physical activity (>5 days per week), which was estimated at 25% among girls in grade 6 in the HBSC study (6). Assuming that this behaviour will increase among the intervention schools to 40%, and will remain at 25% in the control group, with a significance level of 5%, a power of 90%, intra-class correlation of 0.001 and a cluster size of 34, a sample of 14 schools was needed in order to provide 13% of the eligible population (952/6962). A random sample of schools was drawn in each of the four strata. This corresponded to six schools from the Jerusalem Municipality, four PA, two Private and two UNRWA schools, with 28 classes Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 4 and 935 students. Data collection A structured self-administered anonymous questionnaire was given to the pupils based on the HBSC questionnaire (6),which in turn was based on the WHO format (7). It focused on dietary assessment (eating breakfast, drinking before leaving for school, consumption of fruit and vegetables, milk consumption), physical activity (mode of transport to and from school, days per week active in sport for at least one hour per day), physical inactivity (watching TV) and knowledge (recommended daily consumption of fruits and vegetables). The class teacher supervised filling the questionnaire by reading out aloud each question and then asking for an immediate response. The main researcher (MH) was present during administration of the questionnaires to clarify questions if required. Respondents were informed that answering was voluntary and that information would be treated confidentially. The height and weight of each student were measured after they completed the questionnaire, Students’ weights were measured in their lightweight clothes (schools’ uniform with no jackets) and without shoes before 10 o’clock break according to a standard protocol and instrument. Care was taken to ensure that the measurements were done sensitively and separately in a private room with the presence of the class teacher’s supervisor. Mothers’ level of education and occupation was based on the mothers’ self reported questionnaire and school files of the children for missing data. Measures Eating breakfast was assessed based on the question “Do you always eat breakfast before you leave for school?” with response options (1) yes, every day, (2) yes, sometimes, (3) never. Whereas drinking in the morning: (1) yes, always, (2) yes, sometimes, (3) never. Next, both questions were categorized into Yes (yes, every day) or No (sometimes or never). Daily consumption and quantity of fruits and vegetables were calculated and converted to two categories <5 serving per day ≥5 servings per day. Physical activity assessment was categorized into: (1) physical activity >5 days a week; (2) ≤5 days a week. BMI-for-age was computed for each child using the WHO software AnthroPlus 2007 program. This program deduced z-score and percentiles using the exact age in days (8). Overweight was determined if a child’s z-score fell between ≤ + 1SD and +2 SD (85 th percentile). Obesity was determined if the child’s z-score fell above and equal 2 SD (97 th percentile), while underweight was determined if z-score fell below minus 2 SD (3 rd percentile). Mothers’ education was divided into three categories; (1) less than secondary, (2) secondary, (3) diploma and higher. Employment was divided into two categories; (1) yes, (2) no. Crowding index (the ratio between number of residents at home and number of rooms) was used as a proxy for socio- economic status and divided into (1) less than one; (2) 1-2, (3) more than 2. Statistical analysis Data analysis was performed using SPSS version 20. Chi-square tests were used to calculate associations between categorical variables by school ownership, grade, socio- demographic/economic variables. A stepwise forward logistic regression model was built for identifying independent predictors of eating breakfast daily, eating the recommended quantity of fruits and vegetables, physical activity and overweight and obesity. The variables in the final model of the stepwise forward logistic regression were tested again by entering them into the logistic regression models. Ethical considerations Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 5 Approval from the Israeli Ministry of Education, Palestinian Ministry of Education, UNRWA Office of Education Department and private school principals was obtained. The research program was approved by the Hebrew University of Jerusalem/Authority for Research Students Committee. Results Sample characteristics All 14 selected schools agreed to participate in the study. Of the 935 eligible schoolchildren, 897 (95.9%) participated (49.9% children were from grade 4 and 50.1% were from grade 5). Non-response was due to absence from school on the day of data collection. Table 1 presents the socio-demographic characteristics of the study population by school ownership. Table 1. Socio-demographic characteristics of the study population by school ownership Variable School Type Municipality (n=400) PA (n=236) UNRWA (n=136) Private (n=125) Total (n=897) Grade (%): 4 th Grade 5 th Grade 49.8 50.3 50.0 50.0 49.3 50.7 51.2 48.8 49.9 50.1 Age: Mean SD 11.02 0.70 11.00 0.78 11.10 0.87 10.98 0.71 11.02 0.71 Order in the family (%): 1 2-3 4 ≥5 19.2 39.0 15.6 24.8 19.1 30.9 16.1 33.9 16.9 37.5 15.4 30.1 29.6 51.2 9.6 9.6 20.6 38.4 15.2 25.9 Sibling (%): 0-2 3-4 ≥5 14.5 44.8 40.8 6.8 42.4 50.4 5.9 38.2 55.9 43.2 46.4 10.4 15.2 43.4 41.4 Crowding index (%): <1 1-2 >2 9.0 54.5 36.5 6.4 66.1 27.1 8.1 51.5 40.4 17.6 62.4 20.0 9.4 58.3 32.3 Religion (%): Muslim Christian 100.0 0.0 100.0 0.0 100.0 0.0 59.2 40.8 94.3 5.7 Mother education (%): Less than secondary Secondary Diploma & higher 45.6 40.0 14.4 49.0 34.3 16.7 52.7 36.4 10.9 7.1 38.1 54.9 42.2 37.7 20.1 Mother employment (%): Yes No 16.6 83.4 15.9 84.1 14.5 85.0 33.9 66.1 18.5 81.5 The age of students ranged between 9-14 years (mean: 11.02, SD±0.71). About 94% were Muslims and 6% were Christians, all attending private schools. The mean family size was Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 6 7.1; Schoolchildren from Municipality, P.A and UNRWA had more siblings compared to those in Private schools. Schoolchildren from Municipality and UNRWA schools lived in higher crowding index (residents per room) compared to PA and Private Schools. About 81% of the mothers did not work and 20% had a diploma or higher education. Dietary habits The percent of schoolchildren who reported having breakfast was 36.6%. There was a significant difference between school ownership with UNRWA schools having the highest rate of daily breakfast consumption (42.6%), compared to Municipality, PA and Private (P=0.032) (Table 2). More Muslim schoolchildren (29.7%) consumed breakfast compared to Christian schoolchildren (25.5%) in Private schools. Table 2. Dietary pattern, physical activity, knowledge perception, overweight and obesity (%) by school type and crowding index BEHAVIOURAL CHARACTERISTICS School ownership Crowding index JM N=400 PA N=236 UNRWA N=136 Private N=125 <1 (n=84) 1-2 (n=522) >2 (n=290) Dietary pattern Always eating breakfast 38.3 34.7 42.6 28.0 * 56.0 33.3 33.6 † Always drinking in the morning 46.0 42.0 51.5 47.0 52.2 48.8 45.2 Always eating vegetable at 10 o’clock break 18.3 8.5 22.8 16.0 ‡ 23.8 15.7 14.5 Always eating fruits at 10 o’clock break 18.3 11.4 20.6 16.1 16.7 15.9 17.6 Eating ≥5 serving of vegetables and fruits/day 35.8 22.1 14.0 27.2 ‡ 29.8 27.2 27.2 Eating vegetables once or more per day 21.3 27.5 13.2 23.2 * 26.2 21.5 21.4 Eating fruits once or more per day 23.3 19.6 16.9 23.2 29.8 22.2 17.0 * When thirsty water is the most used drink 69.5 90.3 79.0 68.0 ‡ 78.6 74.7 78.3 Drinking milk every day 43.3 40.7 27.2 52.0 ‡ 59.5 41.8 35.5 ‡ Lunch is the main meal at home 74.2 77.5 61.0 77.6 * 76.2 73.9 72.3 * Eating with family or at least one parents 79.5 77.0 77.2 72.8 77.4 78.1 76.6 Eating while watching TV 27.0 21.7 20.6 32.0 ‡ 28.6 24.9 25.3 Eating while using computer 5.3 1.70 8.1 4.80 † 3.6 4.6 5.2 Eating when bored/angry/stressed/frustrated 6.5 4.2 4.4 1.6 † 4.8 5.2 4.5 Physical activity pattern Walking to school in the morning 65.3 71.6 93.4 39.2 ‡ 57.1 64.4 76.2 ‡ Walking back after school 73.3 76.3 97.1 40.0 ‡ 61.9 70.3 80.7 † Physically active ≥5 days a week 16.8 13.6 8.1 16.0 20.2 16.5 9.30 Sedentary behaviours Using computer >4 hours 20.0 14.0 7.4 17.6 † 22.6 14.9 16.2 TV viewing ≥4 33.0 36.0 38.2 38.0 ‡ 33.3 33.5 34.5 Knowledge Acknowledge importance of breakfast 91.7 94.5 94.0 94.4 94.0 93.7 92.0 Acknowledge importance of fruits & vegetables 97.7 97.0 95.6 100.0 96.4 98.1 96.9 Acknowledge importance of water 98.0 95.8 100.0 99.2 * 97.6 98.1 97.9 Know recommended serving vegetables/fruits 12.5 12.0 10.3 14.4 25.0 21.3 23.5 BMI Overweight 24.8 14.4 21.3 29.6 29.8 19.3 25.2 Obese 7.5 3.4 10.3 12.8‡ 7.1 8.4 6.2 * P<0.05; † P<0.01; ‡ P<0.001. Eating breakfast daily was associated with the socio-economic status of the family, measured by crowding index. Those living in a house with fewer than one person per room had a 2.4- Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 7 fold increase in the likelihood of eating breakfast (OR=2.38, 95%CI=1.36-4.18), controlling for school type (logistic regression, Table 3). UNRWA schoolchildren were more likely to eat breakfast (OR=1.75, 95%CI=1.07-2.88) compared to other school types of ownership. If mothers always prepared breakfast for their daughters, there was a 4-fold increase in the likelihood of the child eating breakfast (OR=3.83, 95%CI=0.82-17.96), although this finding was not statistically significant. These three determinants contributed independently to having breakfast daily (logistic regression, Table 3). The mother’s level of education and employment status, beliefs, and knowledge regarding the importance of breakfast meals and birth order were found to have no effect on eating daily breakfast. “Not feeling hungry” was the main reason for skipping breakfast (78.6%). Table 3. Determinants of eating breakfast – logistic regression models * Variable Number OR P-value 95%CI Crowding index: <1 1-2 >2 73 432 230 2.38 0.75 1.00 <0.001 (2) † 0.003 0.099 - 1.36-4.18 0.53-1.06 reference School ownership: JM PA UNRWA Private 341 193 86 115 1.00 0.91 1.75 0.55 0.004 (3) 0.640 0.030 0.018 - 0.62-1.34 1.07-2.88 0.34-0.90 reference Mother preparing breakfast to her daughter: Never Sometimes Always 13 235 487 1.00 1.41 3.83 <0.001 (2) - 0.67 0.089 reference 0.29-6.76 0.82-17.96 * The last variables left of the stepwise forward logistic regression were entered into the logistic regression model. † Overall p-value and degrees of freedom (in parentheses). The most commonly consumed food for breakfast was za’ater and oil with bread. This choice varied widely between school ownership type (P<0.001), where UNRWA schoolchildren consumed the most (61.6%). Other relevant variables were Muslim religion (P<0.001) and mothers who had not attained secondary education (P<0.001). The proportion of schoolchildren who reported drinking in the morning before leaving for school was 46.2%. This was not found to be associated with school ownership, grade, or with socio-economic variables. About 28% of the schoolchildren reported consuming the recommended number of daily servings of fruits and vegetables (five servings a day), with a significant difference between school types of ownership (P<0.001) and the mother’s level of education (P=0.01). Only 12.3% of schoolchildren reported the correct answer for the daily recommended consumption of fruits and vegetables. Children of mothers with a diploma or higher level of education had a higher proportion of consuming the recommended number of servings (47.9%). School type of ownership and the mother’s level of education remained statistically significant in the final multilevel logistic regression model. Being in a JM school increased the probability of consuming the recommended quantity of vegetables and fruit by 1.55 times (OR=1.53, 95%CI=0.76-1.96). Having a mother with a diploma or higher education increased it by 1.8 Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 8 times (OR=1.80, 95%CI=1.25-2.60). The mother’s employment status, religion, and crowding index were found to have no effect. School ownership had a significant effect (P<0.001) on daily milk consumption, with private schools having the highest consumption (52%). Another predictor was the crowding index, which was inversely associated (P<0.001). Most of the schoolchildren had lunch as the main meal which they ate with at least one parent. Physical activity The majority of schoolchildren reported walking to and from the school (67.6% and 72.9%, respectively). There was a significant difference between school ownership type (Table2), with UNRWA schools having the highest level (93.4% and 97.1%, respectively, P<0.001). The overall reported physical activity in schoolchildren showed that pupils were only slightly active in sport. About 14% of schoolchildren reported being active at least five days a week (Table 2). This proportion was significantly inversely associated with the crowding index (20.2%, 16.5%, and 16.5% for up to one, between 1-2, and more than two, respectively, P=0.006). A positive significant association was also found with mothers’ level of education (12.9%, 13.4% and 21.5% for less than secondary, secondary and diploma or higher education, respectively, P=0.027). No other tested variables were associated with physical activity. Sedentary behaviours One-third of the students (33.9%) viewed TV for ≥4 hours a day and this was significantly associated with the school ownership (P<0.001). The highest percentages reporting viewing television were found in UNRWA and Private Schools (38.2% and 38.0%, respectively). (Table 2). Sedentary behaviour was not associated with the crowding index, mothers’ education or employment. No correlation was found between television viewing and being physically active. Body weight The overall prevalence of overweight and obesity was 22.2% and 7.6%, respectively. The difference between school ownership types was statistically significant (P<0.001), where the highest proportion was among Private schoolchildren (42.4%). More Christian schoolchildren in the private schools (47.1%) were overweight and obese compared to Muslim schoolchildren (39.2%). About 1% of schoolchildren were underweight, with highest rates among PA schoolchildren (3%) (Table 2). A significant higher prevalence of overweight and obesity was noticed with the first child in the family. The other independent determinants of overweight and obesity (logistic regression) were: watching TV more than four hours a day (OR=4.13, 95%CI=2.93-5.82); being physically inactive (less than five days a week) (OR=1.95, 95%CI=1.17-3.24) and always eating while watching TV (OR=3.42, 95%CI=2.27-5.13) (Table 4). No association was found with crowding index, mothers’ level of education or employment. About 75% of overweight/obese children considered their weight as normal, whereas 66% of those who perceived themselves as “high weight for their age” were actually overweight/obese children (data not shown). Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 9 Table 4. Determinants of overweight and obesity – logistic regression models * Variable Number OR P-value 95%CI Family order: 1 2-3 4 ≥5 185 343 136 231 1.00 0.48 0.91 0.57 0.003 (3) † - 0.001 0.74 0.024 reference 0.31-0.74 0.54-1.56 0.35-0.93 School ownership: JM PA UNRWA Private 399 235 136 125 1.00 0.38 0.90 1.71 <0.001 (3) - <0.001 0.660 0.026 reference 0.24-0.59 0.56-1.45 1.07-2.75 Physical activity: <5 days/week ≥5 days/week 761 135 1.95 1.00 0.010 1.17-3.24 Reference TV viewing: ≤4 hours/day >4 hours/day 597 299 1.00 4.13 <0.001 2.93-5.82 Reference Eating while watching TV: Never Several times a week Every day 315 534 266 1.00 0.71 3.42 <0.001 (2) - 0.010 <0.001 reference 0.48-1.07 2.27-5.13 * Overweight and obesity were combined. The last variables left of the stepwise forward logistic regression were entered into the logistic regression model. † Overall p-value and degrees of freedom (in parentheses). Discussion The aim of this study was to provide baseline information of schoolchildren living in East Jerusalem as the first stage of a randomized controlled intervention programme. The results showed that most children fail to meet the international dietary and physical activity recommendations. There was a significant independent difference between school ownership and socio-economic groups, measured by the crowding index, but no significant difference was observed between grades for all the studied variables. Approximately one third (36.6%) of female schoolchildren ate breakfast before school. This finding is consistent with the finding of dietary habits among Palestinian adolescents where 34.7% ate breakfast (9). Most of the schoolchildren reported “not feeling hungry” as the main reason for skipping breakfast, which is a growing concern worldwide, especially among females (10). In private schools, although the pupils come from higher social classes and are assumed to be in a better position to provide good food for their children, the level of skipping breakfast was the highest. Za’ater and olive oil with bread is the most commonly consumed breakfast meal. This could be because of its prominent role in cultural heritage, due to the widely held belief that za’ater helps to keep mind alert especially prior to exams or school. Olive oil is known to be a main component of the Mediterranean diet, a rich source of monounsaturated fatty acids and an antioxidant agent, which has several beneficial biological functions for health (11). Studies also have proved that olive oil intake is associated with the reduced risk of cardiovascular disease and mortality in individuals at high risk (12). Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 10 Drinking milk was reported only by 40% of schoolchildren. Adequate calcium intake for children is essential for the development of bone mass and mineral density (13) and in the maintenance of health and prevention of chronic diseases (14). Strategies to encourage milk consumption by schoolchildren need special attention. The reported fruit and vegetable intake was lower in our study than that found in the 2004 Palestinian HBSC survey (6). This could be due to rapid and progressive shifting among Palestinian adults to Western-style food patterns (9). Less than one third of schoolchildren reached the recommended daily dietary intake of five servings of fruits and vegetables (1). This means that these children may fail to obtain appropriate nutritional intakes of vitamins, mineral and fiber to protect them from diet-related chronic diseases (15), including overweight and obesity (16,17), despite the fact that Palestinian markets have a wide variety of vegetables and fruits at low prices. Therefore, the need to promote the consumption of more vegetables and fruits is viable and a public health priority. Regular physical activity plays an important role in improving the quality of life. Although more than two thirds of schoolchildren reported walking in the morning to and from school, respondents did not engage in regular sport and physical activity in leisure time. Therefore, they do not achieve the recommended level of being one hour or more physically active per day (18). In Arab countries, including Palestine, women are prohibited by the socio-cultural norms from participation in outdoor sports activities. Therefore, there is a need to develop good physical education practices (e.g. skipping, which can be performed at home) to increase physical activities among girls. In parallel, there is an increase in sedentary behaviours among schoolchildren, which is due mainly to time spent watching television, as in many other countries (15). This is because television is so accessible and available. Current recommendations are that children should spend no more than two hours watching television a day (19). The problem of obesity The prevalence of overweight and obesity is high among Palestinian schoolchildren, associated with lack of physical activity and increased sedentary behaviours. Childhood obesity is an increasingly worldwide problem. This study found that the prevalence of overweight is 22.2% and obesity is 7.6% which is higher than adolescents in the Gaza strip (17.0% and 5.45%, respectively) (20), Ramallah (18.9% and 3.3%, respectively), Hebron (14.9% and 2.0%, respectively) (9), but slightly lower than a previous study conducted in East Jerusalem in 2002 (24.3% and 9.9%, respectively) (21). The overweight/obese schoolchildren were found more likely to watch television for more than four hours. This is in accordance with several cross-sectional and longitudinal studies showing very strong associations between television viewing and childhood obesity (22,23). Significant positive associations were found between eating while watching television and the risk of becoming overweight/obese. Watching television for many hours may lead to a snacking while watching (24), which is independently associated with overweight/obesity among children (25). Schoolchildren in private schools have higher standards of living. Several studies have demonstrated that socioeconomic status is directly related to childhood obesity in developing countries (26), which is higher in urban areas (27,28). The discussed culture restrictions placed on girls which results in their staying at home with easy access to food, contribute to their increased risk of overweight and obesity. Evidence suggests that measures should be introduced as early as possible, so that healthy lifestyle habits are learnt from childhood (29). Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 11 Study limitations The study involved a cross-sectional design, and therefore cannot address causality. Another limitation is using a self-reported questionnaire from schoolchildren in grades 4 and 5 which could have influenced its validity and reliability. However, studies show that results from self-administered questionnaires tend to minimize social desirability bias compared to interviewer-administered questionnaires (30). Conclusion This study shows that Palestinian girls miss breakfast, eat less fruits and vegetables than the recommended requirements, and have sedentary behaviours, which is associated with high prevalence of overweight and obesity. There is a need for developing effective intervention programmes to promote healthy eating and physical activity among Palestinian schoolchildren. References 1. World Health Organization. Diet, Nutrition and the Prevention of Chronic Disease. Geneva: World Health Organization, 2003. Available at: http://www.who.int/dietphysicalactivity/publications/trs916/en/ (accessed: January 16, 2016). 2. Wyatt SB, Winters KP, Dubbert PM. Overweight and obesity: prevalence, consequences, and causes of a growing public health problem. Am J Med Sci 2006;331:166-74. 3. Lobstein T, Baur L, Uauy R, Obesity I. Obesity in children and young people : a crisis in public health. Obes Rev 2004;5:4-85. 4. World Health Organization. The challenge of obesity in the WHO European Region and the strategies for response. Geneva: World Health Organization Regional Office for Europe, 2007. 5. Badran M, Lather I. Obesity in Arabic-Speaking Countries. Journal of Obesity 2011;2011:1-9. 6. Al Sabbah H, Vereecken C, Kolsteren P, Abdeen Z, Maes L. Food habits and physical activity patterns among Palestinian adolescents: findings from the national study of Palestinian schoolchildren (HBSC-WBG2004). Public Health Nutr 2007;10:739-46. 7. Currie C, Hurrelmann K, Settertobulte W, Smith R TJ (editors). Health Behaviour in School-aged Children: a WHO Cross- National Study ( HBSC) International Report. Copenhagen: World Health Organization Regional Office for Europe; 2000. 8. World Health Organization. WHO AnthroPlus for Personal Computers Manual. Geneva: World Health Organization, 2007. 9. Mikki N, Abdul-Rahim HF, Shi Z, Holmboe-Ottesen G. Dietary habits of Palestinian adolescents and associated sociodemographic characteristics in Ramallah, Nablus and Hebron governorates. Public Health Nutr 2010;13:1419-29. 10. Savige G, Macfarlane A, Ball K, Worsley A, Crawford D. Snacking behaviours of adolescents and their association with skipping meals. Int J Behav Nutr Phys Act 2007;4:1-9. 11. Lastra CA De, Barranco, Motilva V, Herrerías JM. Mediterranean Diet and Health: Biological Importance of Olive Oil. Curr Pharm Des 2001;7:933-50. Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 12 12. Guasch-Ferré M, Hu FB, Martínez-González M a, Fitó M, Bulló M, Estruch R, et al. Olive oil intake and risk of cardiovascular disease and mortality in the PREDIMED Study. BMC Med 2014;12:78. 13. Larson NI, Neumark-Sztainer D, Harnack L, Wall M, Story M, Eisenberg ME. Calcium and Dairy Intake : Longitudinal Trends during the Transition to Young Adulthood and Correlates of Calcium Intake. J Nutr Educ Behav 2009;41:254-60. 14. Dietary Guidelines for American 2005. U.S Department of Health and Human Services. Department of Agriculture. Available at: http://health.gov/dietaryguidelines/dga2005/document/pdf/dga2005.pdf (accessed: January 16, 2016). 15. World Health Organization. Young People’s Health in Context. Health Behaviour in School-aged Children (HBSC) Study: International Report from the 2001/2002 Survey. World Health Organization/ Europe. Available at: http://www.euro.who.int/en/publications/abstracts/young-peoples-health-in-context.- health-behaviour-in-school-aged-children-hbsc-study-international-report-from-the- 20012002-survey (accessed: January 18, 2016). 16. Rolls BJ, Ello-Martin JA TB. What can intervention studies tell us about the relationship between fruit and vegetable consumption and weight management. Nutr Rev 2004;62:1-17. 17. I.TETENS and S. ALINIA. The role of fruit consumption in the prevention of obesity. J Hortic Sci Biotechnol 2009;84:47-51. 18. World Health Organization. Global Recommendations on Physical Activity for Health.Geneva : World Health Organization. Geneva, 2010. Available from: http://www.who.int/dietphysicalactivity/factsheet_recommendations/en/(accessed: February 11, 2016). 19. American Academy of Pediatrices. Children, Adolescents, and Television. Pediatrics 2001;107:423-6. 20. Kanao BJ, Abu-Nada OS, Zabut BM. Nutritional status correlated with sociodemographic and economic factors among preparatory school-aged children in the Gaza Strip. J Public Health 2008;17:113-9. 21. Jildeh C, Papandreou C, Abu Mourad T, Hatzis C, Kafatos A, Qasrawi R, et al. Assessing the nutritional status of Palestinian adolescents from East Jerusalem: a school-based study 2002-03. J Trop Pediatr 2011;57:51-8. 22. Temple JL, Giacomelli AM, Kent KM, Roemmich JN, Epstein LH. Television watching increases motivated responding for food and energy intake in children. Am J Clin Nutr 2007;85:355-61. 23. Veldhuis L, Vogel I, Renders CM, van Rossem L, Oenema A, HiraSing R a, et al. Behavioral risk factors for overweight in early childhood; the “Be active, eat right” study. Int J Behav Nutr Phys Act 2012;9:74. 24. Ouwens M a, Cebolla A, van Strien T. Eating style, television viewing and snacking in pre-adolescent children. Nutr Hosp 2012;27:1072-8. 25. Pate RR, Mitchell JA, Byun W, Dowda M. Sedentary behaviour in youth. Br J Sport Med 2011;45:906-13. 26. Mcdonald CM, Baylin A, Arsenault JE, Mora-plazas M, Villamor E. Overweight Is More Prevalent Than Stunting and Is Associated with Socioeconomic Status, Maternal Obesity , and a Snacking Dietary Pattern in School Children from Bogota. J Nutr 2009;139:370-6. Nubani-Husseini M, Berry E, Abdeen Z, Donchin M. Dietary patterns and physical activity among Palestinian female schoolchildren in East Jerusalem (Original research). SEEJPH 2016, posted:15 February 2016. DOI 10.4119/UNIBI/SEEJPH-2016-92 13 27. Mirmiran P, Azizi F. Childhood obesity in the Middle East : a review. East Mediterr Heal J 2010;16:1009-17. 28. Neuman M, Kawachi I, Gortmaker S, Subramanian S V. Urban-rural differences in BMI in low- and middle-income countries : the role of socioeconomic status. Am J Clin Nutr 2013;97:428-36. 29. Doak CM, Visscher TLS, Renders CM, Seidell JC. The prevention of overweight and obesity in children and adolescents : a review of interventions and programmes. Obes Rev 2006;7:111-36. 30. Hebert JR, Clemow L, Pbert L, Ockene IS, Ockene JK. Social desirability bias in dietary self-report may compromise the validity of dietary intake measures. Int J Epidemiol 1995;24:389-98. ___________________________________________________________ © 2016 Nubani-Husseini et al; This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.