Volume 20 / No. 7 July/Juillet

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Health Journal

La Revue de Santé de la Méditerranée orientale

Volume 20 / No. 7 July/Juillet

ÂØ{LëíP_UÐ{dCÐ

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2014

The prevalence of risk factors for noncommunicable diseases (NCDs), including unhealthy diets and physical inactivity, is high in most countries of the Region. Escalating levels of overweight and obesity among children and adolescents is of particular concern. Healthy behaviours from the early stages of life can help avoid the development of NCDs.

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EASTERN MEDITERRANEAN HEALTH JOURNAL

IS the official health journal published by the Eastern Mediterranean Regional Office of the World Health Organization. It is a forum for the presentation and promotion of new policies and initiatives in health services; and for the exchange of ideas, concepts, epidemiological data, research findings and other information, with special reference to the Eastern Mediterranean Region.

It addresses all members of the health profession, medical and other health educational institutes, interested NGOs, WHO Col- laborating Centres and individuals within and outside the Region.

LA REVUE DE SANTÉ DE LA MÉDITERRANÉE ORIENTALE

EST une revue de santé officielle publiée par le Bureau régional de l’Organisation mondiale de la Santé pour la Méditerranée orientale. Elle offre une tribune pour la présentation et la promotion de nouvelles politiques et initiatives dans le domaine des ser-vices de santé ainsi qu’à l’échange d’idées, de concepts, de données épidémiologiques, de résultats de recherches et d’autres informations, se rapportant plus particulièrement à la Région de la Méditerranée orientale. Elle s’adresse à tous les professionnels de la santé, aux membres des instituts médicaux et autres instituts de formation médico-sanitaire, aux ONG, Centres collabora- teurs de l’OMS et personnes concernés au sein et hors de la Région.

EMHJ is a trilingual, peer reviewed, open access journal and the full contents are freely available at its website:

http://www/emro.who.int/emhj.htm EMHJ information for authors is available at its website:

http://www.emro.who.int/emh-journal/authors/

EMHJ is abstracted/indexed in the Index Medicus and MEDLINE (Medical Literature Analysis and Retrieval Systems on Line), ISI Web of knowledge, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), CAB International, Lexis Nexis, Scopus and the Index Medicus for the WHO Eastern Mediterranean Region (IMEMR).

Disclaimer

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication.

ISSN 1020-3397

Cover designed by Diana Tawadros

Internal layout designed by Emad Marji and Diana Tawadros Printed by WHO Regional Office for the Eastern Mediterranean

Cover photograph: WHO/J. Nicholson

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Prevention of cardiovascular diseases: a spearhead for control of noncommunicable diseases

Pekka Puska¹

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1Former Director General, National Institute for Health and Welfare, Finland; President, International Association of National Public Health Institutes.

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References

1. Relationship of blood pressure, serum cholesterol, smoking habit, relative weight and ECG abnormalities to incidence of major coronary events: ﬁnal report of the pooling project.

The pooling project research group. J Chronic Dis. 1978 Apr;31(4):201–306. PMID:681498

2. Puska P, Vartiainen E. Community-based intervention studies in high-income countries. In: Detels R, Beaglehole R, Lansang MA, Gulliford M, editors. Oxford textbook of public health.

Oxford: Oxford University Press; 2009:557–66.

3. Puska P, Vartiainen E, Laatikainen T, Jousilahti P, Paavola M, editors. The North Karelia Project: from North Karelia to National Action. Helsinki: Helsinki University Printing House; 2009.

4. Sarrafzadegan N, Kelishadi R, Sadri G, Malekafzali H, Pour- moghaddas M, Heidari K, et al. Outcomes of a comprehensive healthy lifestyle program on cardiometabolic risk factors in a developing country: the Isfahan Healthy Heart Program. Arch Iran Med. 2013 Jan;16(1):4–11. PMID:23273227

5. Protocol and Guidelines: Countrywide Integrated Noncom- municable Diseases Intervention (CINDI) Programme. Co- penhagen: WHO Regional Ofﬁce for Europe; 1996 (EUR/

ICP/CIND 94 02/PB04 (http://whqlibdoc.who.int/hq/1994/

EUR_ICP_CIND_94.02_PB04.pdf, accessed 26 June 2014).

6. WHO. Global Action Plan for the Prevention and Control of Noncommunicable diseases 2013-2020. Geneva: World Health Organization; 2013.

7. Global strategy for the prevention and control of noncommunicable diseases. Report by the Director-General (http://

apps.who.int/gb/archive/pdf_ﬁles/WHA53/ea14.pdf?ua=10, accessed 26 June 2014)

8. Tunstall-Pedoe H. Cardiovascular Risk and Risk Scores: AS- SIGN, Framingham, QRISK and others: how to choose. Heart.

2011 Mar;97(6):442–4. PMID:21339319

9. Kottke TE, Puska P, Salonen JT, Tuomilehto J, Nissinen A. Pro- jected effects of high-risk versus population-based prevention strategies in coronary heart disease. Am J Epidemiol. 1985 May;121(5):697–704. PMID:4014161

10. Political Declaration of the High-level Meeting of the Gen- eral Assembly on the Prevention and Control of Non-communicable Diseases 2011 (http://www.who.int/nmh/events/

un_ncd_summit2011/political_declaration_en.pdf, accessed 26 June 2014)

11. Moran A, Tsong K, Forouzanfar M, Roth G, Mensah G, Ezzati M, et al. Variations in Ischaemic Heart Disease Burden and Risk Factors 2010 Study. Global Heart. 2014;9:91–9 (http://down- load.journals.elsevierhealth.com/pdfs/journals/2211-8160/

PIIS221181601300210X.pdf, accessed 26 June 2014).

12. Laatikainen T, Critchley J, Vartiainen E, Salomaa V, Ketonen M, Capewell S. Explaining the decline in coronary heart disease mortality in Finland between 1982 and 1997. Am J Epidemiol.

2005 Oct 15;162(8):764–73. PMID:16150890

13. Kontis V, Mathers CD, Rehm J, Stevens GA, Shield KD, Bonita R, et al. Contribution of six risk factors to achieving the 25×25 noncommunicable disease mortality reduction target: a modelling study. Lancet. 2014 May 2; 10.1016/s0140-6736(14)60616-4 [Epub ahead of print]. PMID:24797573

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Breastfeeding practice in Kuwait: determinants of success and reasons for failure

M.F. Nassar,¹ A.M. Abdel-Kader,² F.A. Al-Refaee,³ Y.A. Mohammad,³ S. Al Dhaﬁri,⁴ S. Gabr ⁴ and S. Al-Qattan ⁴

ABSTRACT To explore the possible determinants of duration of breastfeeding in Kuwait, 234 mothers completed a questionnaire concerning the feeding of their youngest infant. The questionnaire addressed the factors that contributed to their willingness to continue breastfeeding and enquired about the factors leading to their decision to end it. Only 26.5% of the mothers had continued breastfeeding for 6 months or more. Separate family housing, higher maternal age, late initiation of breastfeeding, being employed without the feasibility to breastfeed at work, breastfeeding information given after rather than before birth, and maternal and infant sickness were all significant contributors influencing early cessation. Father’s support was a significant factor that encouraged the practice. In conclusion, preventive strategies are recommended for boosting breastfeeding, with special emphasis on the factors linked to early cessation, aiming at full implementation of the WHO global public health recommendations for successful breastfeeding in Kuwait.

1Department of Paediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt (Correspondence to M.F. Nassar: [email protected]).

2Department of Paediatrics, Faculty of Medicine, University of Mansoura, Dakahlia, Egypt. ³Gastroenterology, Hepatology and Nutrition Unit, Department of Paediatrics; ⁴Department of Food and Nutrition, Al Adan Hospital, Ministry of Health, Kuwait.

Received: 06/11/13; accepted: 23/02/14

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Pratique de l'allaitement maternel au Koweït : déterminants de réussite et motifs d'échec

RÉSUMÉ Afin d'étudier les déterminants possibles de la durée de l'allaitement maternel au Koweït, 234 mères ont rempli un questionnaire sur l'alimentation de leur plus jeune enfant. Le questionnaire portait sur les facteurs contribuant à leur volonté de poursuivre l'allaitement et sur les facteurs qui les ont conduit à leur décision d'y mettre fin. Seules 26,5 % des mères ont allaité au sein pendant au moins 6 mois. Les facteurs contribuant significativement à un arrêt précoce de l'allaitement au sein étaient les suivants : une résidence familiale séparée, un âge maternel élevé, une initiative tardive de l'allaitement, un emploi sans possibilité d'allaiter sur le lieu de travail, une communication sur l'allaitement faite après la naissance plutôt qu'avant, et une affection chez la mère et/ou chez l'enfant. Le soutien du père était un facteur important qui favorisait la pratique de l'allaitement.

En conclusion, des stratégies préventives sont recommandées aﬁn de promouvoir l'allaitement au sein tout en prenant particulièrement en compte les facteurs liés à un arrêt précoce de l'allaitement, et de viser une mise en oeuvre intégrale des recommandations mondiales de l'OMS en santé publique pour la réussite de l'allaitement maternel au Koweït.

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Introduction

Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants.

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Methods

Study design and sample ĉJT FYQMPSBUPSZ TUVEZ JODMVEFE women of childbearing age living in Ku wait. The study was conducted between

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"INBEJSFHJPOMPDBUFETPVUIPG,VXBJU 5XPQBFEJBUSJDDMJOJDTBĨFOEFEXFFLMZ CZUIFQSJODJQBMSFTFBSDIFSXFSFVTFE GPSSFDSVJUJOH"SBCNPUIFSTUPUIFTUVEZ

Data collection

"RVFTUJPOOBJSFCBTFEPOUIBUPGUIF Infant Feeding Practices Study II by UIF$FOUFSTGPS%JTFBTF$POUSPMBOE Prevention (7)XBTUSBOTMBUFEUP"SB CJDBOECBDLUSBOTMBUFEUP&OHMJTIGPS verification by independent person OFM'JOBMMZUIF"SBCJDGPSNXBTQJMPU tested on 20 randomly chosen mothers.

The questionnaire was modified for better comprehension as perceived CZUIFNPUIFST"ěFSPCUBJOJOHUIFJS JOGPSNFEWFSCBMDPOTFOUFBDIFMJHJCMF mother completed the questionnaire concerning the feeding history of their mZFBSPMEDIJMEĉFRVFTUJPOOBJSF was administered by the researchers via BGBDFUPGBDFJOUFSWJFXXIJDIIBEUIF advantage of ensuring that it was under TUPPEBOEGVMMZDPNQMFUFE0OMZ"SBC mothers were targeted to ensure proper

understanding of the questionnaire and to nullify the effect of culture and ethnic differences on breastfeeding. Mothers who refused to participate and those giving birth to premature babies with congenital malformations or needing OFPOBUBMJOUFOTJWFDBSF /*$6BENJT TJPOXFSFFYDMVEFEGSPNUIFTUVEZ

ĉFRVFTUJPOOBJSFJODMVEFETFD UJPOTĉFėSTUFYQMPSFEUIFTPDJPEFNP graphic data of the mother and details BCPVUIFSJOGBOUTEJFUIJTUPSZĉFTFD ond addressed the factors that might have contributed to her willingness to DPOUJOVFCSFBTUGFFEJOHBOEUIFMBTUTFD tion enquired about the factors leading to her decision to end breastfeeding.

The weight of each factor was requested BTBQPJOU-JLFSUTDBMF OPUJNQPSUBOU TPNFXIBUJNQPSUBOUJNQPSUBOUWFSZ important).

Data analysis

SPSSTUBUJTUJDBMQBDLBHFWFSTJPOXBT used for data analysis. Descriptive sta tistics were generated for demographic GBDUPSTUIFDIJTRVBSFEUFTUXBTVTFE to compare categorical data and the tUFTUXBTVTFEUPDPNQBSFDPOUJOVPVT data. For assessment of factors associ BUFEXJUICSFBTUGFFEJOHDFTTBUJPOBU NPOUITPGBHFXFVTFENVMUJWBSJBUF$PY SFHSFTTJPOBOBMZTFT"UPUBMPGWBSJ ables were included in the final model that was constructed using factors that had an association with breastfeeding duration based on the univariate asso ciation (the level of significance was set at PBTXFMMBTGBDUPSTSFQPSUFE to influence breastfeeding initiation and duration from previous studies (5,6,8–10) and that were considered to potentially affect breastfeeding practice in our local region.

The variables included in the mul UJWBSJBUF$PYSFHSFTTJPONPEFMTXFSF NPUIFSTBHF ZFBSTOBUJPOBMJUZ ,V XBJUJ OPO,VXBJUJ FEVDBUJPO QSJ NBSZTFDPOEBSZVOJWFSTJUZSFTJEFODF MJWJOH XJUIJO GBNJMZ IPNF TFQBSBUF IPVTJOH XIFUIFS UIF NPUIFS IBE CSFBTUGFECFGPSF ZFTPSOPXIFOUIF

(9)

NPOUIT PS NPSF DPNQBSFE XJUI PG"SBCNPUIFSTJO2BUBSXIP DPOUJOVFECSFBTUGFFEJOHBUZFBS(12).

4IBXLZ BOE "CBMLIBJM SFQPSUFE UIBU PG UIFJS TFSJFT PG NPUIFST XIP MJWFE JO +FEEBI 4BVEJ "SBCJB XFSF CSFBTUGFFEJOH BU ZFBS(9). Reports of breastfeeding practices vary greatly BSPVOEUIFXPSME"$BOBEJBOTUVEZ SFQPSUFEOFBSMZBJOJUJBUJPOSBUF BOECSFBTUGFFEJOHSBUFBUNPOUIT (13)XIJMFBOPUIFSTUVEZGSPN)POH ,POHSFDPSEFEBOJOJUJBUJPOSBUFPGPOMZ BOECZUIFUIXFFLPOMZPG mothers were still breastfeeding (14).

*OXFTUFSO'SBODFBOBSFBPGMPXJOJUJB UJPOPGNPUIFSTXFSFSFQPSUFEUP CSFBTUGFFEVOUJMNPOUIT(15).

The data of this study highlights that MJWJOHTFQBSBUFMZGSPNUIFSFTUPGGBNJMZ IJHIFSNBUFSOBMBHFMBUFSJOJUJBUJPOPG CSFBTUGFFEJOHOPQPTTJCJMJUZPGCSFBTU GFFEJOHBUXPSLCSFBTUGFFEJOHJOGPSNB UJPOHJWFOBěFSSBUIFSUIBOCFGPSFCJSUI NBUFSOBMBOEJOGBOUTJDLOFTTBTXFMMBT BCTFODFPGGBUIFSTFODPVSBHFNFOUXFSF all significant factors influencing early DFTTBUJPOPGCSFBTUGFFEJOHBTSFQPSUFE by mothers.

ĉFQBSUOFSTTVQQPSUJOHJOĚVFODF BOE FYUFSOBM FODPVSBHFNFOU GPS UIF lactating mother were highlighted in previous studies (14,16,17)"EEJUJPO BMMZNBUFSOBMJMMOFTTXBTQFSDFJWFECZ the studied mothers as an important DBVTFPGGBJMVSFUPCSFBTUGFFE8PSUI mentioning here is that misconcep tions regarding breastfeeding are not VODPNNPO*O,VXBJU*CSBIJNFUBMSF QPSUFEUIBUBOEPGGFNBMF university students thought mothers should temporarily stop breastfeeding if UIFZIBEBGFWFSTLJOSBTIPSTPSFUISPBU respectively (18).

The current study reported that ad WBODFENBUFSOBMBHFXBTBSJTLGBDUPSGPS early cessation of breastfeeding. This is DPOUSBSZUP"M#VTUBOBOE,IPMJXIP demonstrated a positive association between the duration of breastfeeding among Kuwaiti mothers and mater OBMBHFBTXFMMBTQBSJUZBOEBOFHBUJWF NPUIFSTUBSUFEUPCSFBTUGFFE IPVST

UJNF PG XFBOJOH NPOUIT NPUIFST BCJMJUZUPCSFBTUGFFEBUXPSL OPUFN QMPZFEFNQMPZFEBOEDBOPSDBOOPU CSFBTUGFFEBUXPSLUJNFUIFNPUIFS received information regarding breast GFFEJOH EVSJOHQSFHOBODZBěFSCJSUI source of breastfeeding information EPDUPSOVSTFSFMBUJWFTBOEGSJFOETUIF NFEJBBEFRVBDZPGNJMLQSPEVDUJPO EVSJOHUIFėSTUXFFLPGCSFBTUGFFEJOHBT QFSDFJWFECZUIFNPUIFS BEFRVBUFJO BEFRVBUFDIJMETCJSUIPSEFS TUOE SEUIUIĉFGPMMPXJOHWBSJBCMFT XFSFBMTPJODMVEFEJOUIFJOJUJBMNPEFM FBDIBTTFTTFEPOBQPJOU-JLFSUTDBMF OPUJNQPSUBOUTPNFXIBUJNQPSUBOU JNQPSUBOUWFSZJNQPSUBOUNPUIFST perception of the effect of encourage ment to continue breastfeeding from fa UIFSHSBOENPUIFSEPDUPSBOEUSFBUJOH UFBNNPUIFSTQFSDFQUJPOPGUIFFĎFDU of her own illnesses or her baby's illness (if any) on continuation of breastfeed JOHNPUIFSTQFSDFQUJPOPGUIFGFBSUIBU the baby was not growing well and its effect on continuation of breastfeeding;

BOENPUIFSTQFSDFQUJPOPGUIFSPMFPG LOPXJOHCSFBTUGFFEJOHCFOFėUTIBWJOH TVDDFTTGVMFYQFSJFODFTXJUICSFBTUGFFE ing and the effect of domestic responsi bilities on the duration of breastfeeding.

Results

The results of the current study revealed UIBUPVUPGTDSFFOFENPUIFST were eligible (i.e. their youngest child XBT m ZFBST PME 0VU PG UIF NPUIFSTXFSFFYDMVEFE SFGVTFE BOEIBEIBEUIFJSCBCJFTBENJĨFEUP UIF/*$6GPSQSFNBUVSJUZPSDPOHFOJUBM NBMGPSNBUJPOTBOE IBEOPU initiated breastfeeding for their infants.

0GUIFFOSPMMFEXPNFO IBECSFBTUGFEGPSɓNPOUIT

The demographic and social char acteristics of the study sample are TIPXOJO5BCMFXIJDIBMTPQSPWJEFTB comparison between mothers who had CSFBTUGFEGPSNPOUITBOEUIPTFXIP

IBECSFBTUGFEGPSɓNPOUIT*UTIPXT UIBU NPUIFST XIP IBE DPNQMFUFE months of breastfeeding initiated their breastfeeding earlier and their infants were weaned at a later age than the NPUIFSTXIPCSFBTUGFEGPSNPOUIT and this was a statistically significant dif ference (P0UIFSGBDUPSTUIBU showed statistical significance were:

OBUJPOBMJUZMFWFMPGFEVDBUJPOGFBTJCJMJUZ PGCSFBTUGFFEJOHBUXPSLUJNJOHPGSF DFJWJOHCSFBTUGFFEJOHJOGPSNBUJPOBOE TFMGQFSDFJWFEBEFRVBDZPGCSFBTUNJML

5BCMF EFNPOTUSBUFT GBDUPST JO fluencing breastfeeding duration as QFSDFJWFE CZ UIF NPUIFST "NPOH UIFDBVTFTPGTVDDFTTPOMZUIFGBUIFST encouragement reached statistical sig nificance (P3FHBSEJOHUIF SFBTPOT GPS GBJMVSF POMZ UIF NPUIFST TJDLOFTTSFBDIFETUBUJTUJDBMTJHOJėDBODF (P

Factors associated with termination PGCSFBTUGFFEJOHCFGPSFNPOUITJOUIF SFHSFTTJPOBOBMZTJTBSFTVNNBSJ[FEJO5B CMFĉFEBUBTIPXUIBUTFQBSBUFIPVT JOHIJHIFSNBUFSOBMBHFMBUFJOJUJBUJPO PG CSFBTUGFFEJOH XPSLJOH XJUIPVU UIF feasibility of breastfeeding the infant at XPSLCSFBTUGFFEJOHJOGPSNBUJPOHJWFOBG UFSSBUIFSUIBOCFGPSFCJSUIBOENBUFSOBM BOEJOGBOUTJDLOFTTXFSFBMMTJHOJėDBOUGBD tors influencing early cessation of breast GFFEJOHBTSFQPSUFECZNPUIFST0OUIF PUIFSIBOEGBUIFSTFODPVSBHFNFOUBOE support to continue breastfeeding was a significant factor that protected against early breastfeeding cessation.

Discussion

The initiation rate for breastfeeding in UIFDVSSFOUTUVEZXBTXIJDIJT close to that reported by Dashti et al. in Kuwait (5)BOE9VFUBMJO$IJOB(8).

)JHIFSJOJUJBUJPOSBUFTPG BOEXFSFSFQPSUFEBNPOH4BVEJ

"SBCJBO(9)5VOJTJBO(11) and Emirati mothers (10) respectively.

0OMZPGUIFFOSPMMFEXPNFO in the current study had breastfed for

(10)

BTTPDJBUJPO XJUI NPUIFST MFWFM PG education (6). This contradiction might CFBĨSJCVUFEUPUIFJODMVTJPOPG"SBC OPO,VXBJUJ NPUIFST JO UIF QSFTFOU study which was not the case in the

MBĨFSPOFBėOEJOHXIJDIOFFETGVSUIFS consideration.

Similar to the results of the current TUVEZ8BOHFUBMGPVOEUIBUUIFFBSMJFS UIFJOJUJBUJPOPGCSFBTUGFFEJOHUIFMPOHFS

the duration of breastfeeding (14). In BEEJUJPOUIFQSFTFOUXPSLsuggested that breastfeeding information given be fore birth can boost rates of breastfeed JOHBOEUIJTBHSFFTXJUI#PVBOFOFFU

Table 1 Demographic data of mothers who breastfed their infant for less than 6 months or 6 months or more

Variable Total Duration of breastfeeding

< 6 months ≥ 6 months P-value

Maternal age (years) [mean (SD)] – 32.7 (9.2) 31.5 (5.4) 0.323

Time of starting breastfeeding (hours) [mean (SD)] – 36.1 (26.5) 21.7 (18.9) < 0.001

Weaning age (months) [mean (SD)] – 4.53 (1.36) 5.16 (1.15) 0.001

Nationality (no., %) – – –

Kuwaiti 169 72.2 131 76.2 38 61.3

0.038

Non-Kuwaiti 65 27.8 41 23.8 24 38.7

Education

Primary 76 32.5 63 36.6 13 21.0

0.004

Secondary 67 28.6 53 30.8 14 22.6

University 91 38.9 56 32.6 35 56.5

Residence (no., %)

With family 177 75.6 134 77.9 43 69.4

0.241

Separate housing 57 24.4 38 22.1 19 30.6

Breastfed before (no., %)

Yes 170 72.6 120 69.8 50 80.6

0.139

No 64 27.4 52 30.2 12 19.4

Breastfeeding in the workplace (no., %)

Not employed 52 22.2 33 19.2 19 30.6

0.013

Can breastfeed at work 121 51.7 86 50.0 35 56.5

Cannot breastfeed at work 61 26.1 53 30.8 8 12.9

Timeliness of receiving breastfeeding information (no., %)

During pregnancy 90 38.5 58 33.7 32 51.6

0.020

After birth 144 61.5 114 66.3 30 48.4

Adequacy of milk production as perceived by mother (no., %)

Adequate 89 38.0 57 33.1 32 51.6

0.016

Inadequate 145 62.0 115 66.9 30 48.4

Birth order of child (no., %)

1st 40 17.1 27 15.7 13 21.0

0.260

2nd 62 26.5 47 27.3 15 24.2

3rd 47 20.1 32 18.6 15 24.2

4th 34 14.5 23 13.4 11 17.7

> 4th 51 21.8 43 25.0 8 12.9

Source of breastfeeding information (no., %)

Doctor 107 45.7 73 42.4 34 54.8 0.346

Nurse 65 27.8 49 28.5 16 25.8

Relatives and friends 48 20.5 39 22.7 9 14.5

News and media 14 6 11 6.4 3 4.8

Breastfed refers to any breastfeeding (exclusive and non-exclusive).

SD = standard deviation.

(11)

Table 2 Factors inﬂuencing duration of breastfeeding as perceived by mothers

Variable Total Duration of breastfeeding P-value

< 6 months ≥ 6 months

No. % No. % No. %

Previous experience

Not important 52 22.2 40 23.3 12 19.4 0.931

Somewhat important 26 11.1 19 11.0 7 11.3

Important 49 20.9 35 20.3 14 22.6

Very important 107 45.7 78 45.3 29 46.8

Doctor’s & team’s encouragement

Not important 42 17.9 34 19.8 8 12.9

Somewhat important 33 14.1 20 11.6 13 21.0 0.068

Important 61 26.1 50 29.1 11 17.7

Very important 98 41.9 68 39.5 30 48.4

Father’s encouragement

Not important 47 20.1 43 25.0 4 6.5 0.019

Important 45 19.2 32 18.6 13 21.0

Very important 92 39.3 63 36.6 29 46.8

Grandmother’s encouragement

Not important 26 11.1 21 12.2 5 8.1

Important 38 16.2 25 14.5 13 21.0

Very important 141 60.3 105 61.0 36 58.1

Knowledge of beneﬁts

Not important 3 1.3 3 1.7 0 0.0 0.248

Important 28 12.0 24 14.0 4 6.5

Very important 197 84.2 140 81.4 57 91.9

Mother’s sickness

Not important 117 50.0 79 45.9 38 61.3 0.046

Important 39 16.7 29 16.9 10 16.1

Very important 51 21.8 45 26.2 6 9.7

Baby’s sickness

Not important 100 42.7 68 39.5 32 51.6 0.142

Important 36 15.4 28 16.3 8 12.9

Very important 56 23.9 47 27.3 9 14.5

Baby not growing well

Not important 113 48.3 81 47.1 32 51.6

Important 26 11.1 19 11.0 7 11.3

Very important 70 29.9 58 33.7 12 19.4

Effect of domestic responsibilities on mother’s ability to breastfeed

Not important 141 60.3 109 63.4 32 51.6

Important 55 23.5 39 22.7 16 25.8

Very important 17 7.3 13 7.6 4 6.5

(12)

Table 3 Factors associated with termination of breastfeeding before 6 months

Variable Hazard ratio 95% CI

Residence

With family 1.00^a –

Separate housing 1.77 1.20–2.59

Age (years 0.98 0.96–1.00

Time of starting breastfeeding (hours 1.01 1.00–1.01 Breastfeeding in the workplace

Not employed 1.00^a –

Can breastfeed at work 1.17 0.75–1.83

Cannot breastfeed at work 1.71 1.07–2.74

Timeliness of receiving breastfeeding information

After birth 1.00^a –

During pregnancy 0.60 0.43–0.84

Mother’s sickness

Not important 1.00^a –

Somewhat important 1.03 0.60–1.76

Important 1.07 0.67–1.70

Very important 2.61 1.74–3.91

Baby’s sickness

Important 1.47 0.89–2.43

Father’s encouragement

Important 0.30 0.18–0.50

aReference group; CI = conﬁdence interval.

BMXIPFNQIBTJ[FEUIFJNQPSUBODFPG giving breastfeeding information before SBUIFSUIBOBěFSCJSUI(11)BOE8BOHFU BMXIPIJHIMJHIUFEUIFJNQPSUBODFPG NPUIFSTJOUFOUJPOUPCSFBTUGFFEJOUIF success of the practice (14).

Being employed without having UIFGFBTJCJMJUZUPCSFBTUGFFEBUXPSLXBT reported by our sample of mothers as an important determinant for cessation of breastfeeding. Bonet et al. reported that the sooner the mothers returned to

XPSLUIFMFTTMJLFMZUIFZXFSFCSFBTUGFE UIFJSCBCJFTBUNPOUITPGJOGBOUTBHF JOEFQFOEFOUMZPGGVMMUJNFPSQBSUUJNF employment (19). The authors further added that in a society where breast GFFEJOHJTOPUUIFOPSNXPNFONBZ IBWFEJđDVMUJFTDPNCJOJOHXPSLBOE CSFBTUGFFEJOHBTJUVBUJPOXIJDITIPVME OPUQPTFBQSPCMFNJOUIF"SBCXPSME where breastfeeding is the norm.

-FHJTMBUJPOJONPTU"SBCDPVOUSJFT is derived from Islamic sharia law based

on the Holy Quran and the Hadiths.

The Quran says that the mothers shall HJWFTVDLUPUIFJSPĎTQSJOHGPSDPN plete years (20)XIJDINJHIUHJWF"SBC mothers an advantage over mothers in PUIFSDVMUVSFT/FWFSUIFMFTTUIFSBUFPG NPUIFSTCSFBTUGFFEJOHGPSɓNPOUIT recorded in the current study are still far CFMPX8)0SFDPNNFOEBUJPOT

ĉFDVSSFOUXPSLIBEJUTPXOMJNJUB tions. The mothers were enrolled from POFIPTQJUBMBOEPOMZUIFDMJOJDTBĨFOE ed by the principle researcher were uti MJ[FEGPSTBNQMFDPMMFDUJPOXIJDIDPVME have contributed to the small sample TJ[FBMUIPVHIUIJTXBTEPOFUPNJOJNJ[F interviewer bias. Possible recall bias by UIFNPUIFSTXBTBOPUIFSMJNJUBUJPO"O important limitation was that our defini tion of breastfeeding covered any type breastfeeding; future research enrolling BMBSHFOVNCFSPGFYDMVTJWFMZCSFBTUGFE infants might show significant associa tions specific to this category. Nonethe MFTT UIF DVSSFOU XPSL BEESFTTFE UIF low rate of breastfeeding in this part of the world and highlighted important factors that can be specifically modified to enhance the practice.

*ODPODMVTJPOCSFBTUGFFEJOHQSBD tice in Kuwait showed a good rate of initiation yet a poor rate of continua tion. The common causes for failure to proceed in breastfeeding were separate GBNJMZ IPVTJOH IJHIFS NBUFSOBM BHF MBUFJOJUJBUJPOPGCSFBTUGFFEJOHCFJOH employed without having the feasibility UPCSFBTUGFFEBUXPSLCSFBTUGFFEJOHJO GPSNBUJPOHJWFOBěFSSBUIFSUIBOCFGPSF CJSUIBOENBUFSOBMBOEJOGBOUTJDLOFTT Preventive strategies are needed for boosting breastfeeding in Kuwait with special emphasis on these points with the aim of full implementation of the 8)0HMPCBMQVCMJDIFBMUISFDPNNFO EBUJPOTGPSFYDMVTJWFCSFBTUGFFEJOH

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Dietary habits and physical activity levels in Jordanian adolescents attending private versus public schools

R.F. Tayyem,¹ H.M. Al-Hazzaa,² S.S. Abu-Mweis,¹ H.A. Bawadi,³ S.S. Hammad ¹ and A.O. Musaiger ⁴

ABSTRACT The present study examined differences in dietary habits and physical activity levels between students attending private and public high schools in Jordan. A total of 386 secondary-school males and 349 females aged 14–18 years were randomly recruited using a multistage, stratified, cluster sampling technique. Dietary habits and physical activity level were self-reported in a validated questionnaire. The prevalence of obesity was significantly higher among adolescents in private (26.0%) than in public schools (16.7%). The frequency of breakfast intake was significantly higher among adolescents in private schools, whereas French fries and sweets intake was significantly higher in public schools. Television viewing showed a significant interaction with school type by sex. A higher rate of inactivity was found among students attending private schools. Despite a slightly better overall dietary profile for students in private schools, they had a higher rate of overweight and obesity compared with those in public schools.

1Department of Clinical Nutrition and Dietetics, The Hashemite University, Zarqa, Jordan (Correspondence to R.F. Tayyem: [email protected]).

2Pediatric Exercise Physiology Research Laboratory, College of Education, King Saud University, Riyadh, Saudi Arabia. ³Department of Nutrition and Food Technology, Jordan University of Science and Technology, Irbid, Jordan. ⁴Arab Center for Nutrition, Manama, Bahrain, and Nutrition and Health Studies Unit, Deanship of Scientiﬁc Research, University of Bahrain, Sakheer, Bahrain.

Received: 11/07/13; accepted: 04/02/14

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}bh[CÐ1}UÐ{LºØn1î|IºïØÐ=pwºxY=ÌØngHºâÐ ~4ÐâÐ ~wº¬hó>5xÚ pååÉn#ÐÜÚÐ{ååCÐ:pååxinUÐpåådA}CÐ:|ååhYĆUÐNåå=©{ååUÐànååZfUÐîååYípååhýÐ|`UÐÓÐØnåå_UÐ:çÚÐååaUÐpååHÐÚ{UÐì|ååwéínååf>oååÉ°#Ð

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Habitudes alimentaires et niveau d'activité physique chez les adolescents jordaniens fréquentant une école privée par rapport à ceux fréquentant une école publique

RÉSUMÉ La présente étude a examiné les différences dans les habitudes alimentaires et les niveaux d'activité physique entre les élèves des écoles publiques et ceux des écoles privées en Jordanie. Au total, 386 garçons et 349 ﬁlles fréquentant des établissements d'enseignement secondaires âgés de 14 à 18 ans ont été recrutés aléatoirement au moyen d'une technique d'échantillonnage en grappes, stratiﬁé à plusieurs degrés. Les habitudes alimentaires et le niveau d'activité physique ont été autodéclarés à l'aide d'un questionnaire validé.

La prévalence de l'obésité était signiﬁcativement plus élevée chez les adolescents des écoles privées (26,0 %) que chez ceux des écoles publiques (16,7 %). La prise d'un petit-déjeuner était nettement plus fréquente chez les adolescents des écoles privées, tandis que la consommation de frites et de sucreries était beaucoup plus importante chez les élèves des écoles publiques. Le nombre d'heures passées à regarder la télévision était très différent entre les élèves des écoles privées et ceux des écoles publiques en fonction du sexe. Un taux d'inactivité plus élevé a été observé chez les élèves des écoles privées. En dépit du proﬁl diététique légèrement meilleur des élèves des écoles privées, leurs taux de surpoids et d'obésité étaient supérieurs à ceux des écoles publiques.

(15)

Introduction

4UVEJFTJO"SBCDPVOUSJFTIBWFTIPXO a high prevalence of overweight and PCFTJUZBNPOHBEPMFTDFOUTXJUISBUFT SBOHJOHGSPNUP(1). The prev alence of overweight among Jordanian male and female adolescents was found UPCFBOESFTQFDUJWFMZ(2).

Poor eating habits and physical inactiv JUZBSFUIFNPTUJNQPSUBOUSJTLGBDUPST for obesity and other chronic diseases (3). Dietary and lifestyle behaviours of adolescents in the Middle Eastern countries have changed dramatically during the past 2 decades (1). Studies JOTFWFSBM"SBCDPVOUSJFTIBWFTIPXO that the food habits of adolescents are DIBSBDUFSJ[FECZIJHIJOUBLFTPGGPPE SJDIJOGBUBOEDBMPSJFTBTXFMMBTJOTBMU BOETVHBS*O4BVEJ"SBCJBGPSFYBNQMF

"M)B[[BBFUBMGPVOEUIBUBCPVUUXP thirds of Saudi adolescents consumed TVHBSTXFFUFOFE ESJOLT NPSF UIBO UJNFTBXFFLBOEBCPVUBUIJSEPGUIFN DPOTVNFEGBTUGPPENPSFUIBOUJNFT BXFFL(4)*O#BISBJOIBMGPGUIFBEP MFTDFOUTEPOPUFBUCSFBLGBTUEBJMZBOE about third of them rarely ate fruits and/

or vegetables (5)'VSUIFSNPSFJOBDUJW ity and a sedentary lifestyle have be come widespread among adolescents in UIJTSFHJPO'PSFYBNQMFBCPVUUIJSEPG Bahraini adolescents watched television GPSNPSFUIBOIPVSTBEBZBOEBCPVU PGNBMFTQSBDUJTFETQPSUTFWFSZEBZ DPNQBSFEXJUIPGGFNBMFT(5).

'FXTUVEJFTIBWFDPSSFMBUFEPCFTJUZ dietary habits and lifestyles of children and adolescents with socioeconomic status (SES) in developing countries (6m8) "MUIPVHI OPU UIF NPTU DPN NPOMZVTFEJOEJDBUPSTDIPPMUZQF QSJ WBUFWFSTVTQVCMJDDBOCFBQSPYZGPS SES because the majority of students enrolled in private schools come from NPEFSBUF UP IJHIJODPNF GBNJMJFT (67). The prevalence of unhealthy XFJHIU VOEFTJSBCMF EJFUBSZ QBĨFSOT sedentary behaviours and physical in BDUJWJUZIBTCFFOGPVOEUPCFNBSLFEMZ higher in private than public schools in

NBOZDPVOUSJFT"TUVEZCZ$IBLBSBOE Salameh showed that the prevalence of PCFTJUZBOEPWFSXFJHIUXBTBOE SFTQFDUJWFMZ BNPOH -FCBOFTF adolescent attending private schools (6). They attributed this to the higher 4&4PGQVQJMTBUQSJWBUFTDIPPMTXIJDI could allow a greater adoption of un IFBMUIZ OVUSJUJPOBM IBCJUT GBTU GPPE FOFSHZEFOTFTOBDLTTXFFUTFUD(6).

*O4BOBBDJUZ:FNFOPWFSXFJHIUBOE obesity had a significantly higher preva lence among children attending private schools (7)"OPUIFSTUVEZJO1BLJTUBO found that the prevalence of overweight (including obesity) was significantly higher among private schoolboys (9).

)PXFWFS"M/VBJNFUBMSFQPSUFEUIBU Saudi female adolescents who attended public schools were more active than those who attended private schools (10).

The aim of this study was to investi gate the differences in anthropometric NFBTVSFNFOUTEJFUBSZIBCJUTBOEMJGF style factors between students attending QSJWBUFBOEQVCMJDTDIPPMTJO+PSEBO5P UIFSFTFBSDIFSTLOPXMFEHFUIJTJTUIF ėSTUTUVEZPGJUTLJOEJO+PSEBO

Methods

Sample

ĉFQSFTFOUTUVEZJTQBSUPGUIF"SBC 5FFOT-JGFTUZMF4UVEZ "5-4XIJDI JT B QBO"SBC TDIPPMCBTFE NVMUJ centre collaborative project conducted CFUXFFO 0DUPCFS BOE %FDFNCFS PG (11). The study protocol and procedures were approved by the ethics committee of the Jordanian Ministry of Education.

The participants were adolescent males and females selected from grades BOEPGTFDPOEBSZTDIPPMT JOUIFDBQJUBMPG+PSEBO"NNBOĉF NJOJNVNTBNQMFTJ[FXBTEFUFSNJOFE so that the sample proportion would be XJUIJOPGUIFQPQVMBUJPOQSPQPS UJPOXJUIBDPOėEFODFMFWFMĉF population proportion was assumed to

CFBTUIJTNBHOJUVEFZJFMEUIFNBY JNVNQPTTJCMFTBNQMFTJ[FSFRVJSFE

5P HBUIFS UIF SFRVJSFE TBNQMF B NVMUJTUBHF TUSBUJėFE DMVTUFS SBOEPN sampling technique was used. In the ėSTUTUBHFBTZTUFNBUJDSBOEPNTBN pling procedure was used to select the schools. The schools were stratified JOUPCPZTBOEHJSMTTFDPOEBSZTDIPPMT with further stratification into public and private schools. Four large public TDIPPMTBTXFMMBTQSJWBUFTDIPPMTXFSF selected. Girls and boys were selected from 2 private and 2 public schools. The selection of private and public schools XBT QSPQPSUJPOBM UP QPQVMBUJPO TJ[F

"MMTUVEFOUTJOUIFTFMFDUFEDMBTTFTXIP were free from any physical deformity were invited to participate in the study.

" GPSNBM MFĨFS GSPN UIF .JOJTUSZ PG Education was directed to the schools to facilitate completing the validated RVFTUJPOOBJSF"MMUIFTDIPPMTBOETUV dents were formally consented to be involved in the survey. The final sample TJ[FDPOTJTUFEPGBEPMFTDFOUT NBMFTBOEGFNBMFTTUVEFOUT GSPNQVCMJDTDIPPMTGSPNQSJWBUF schools).

Data collection

Anthropometric measurements Body weight was measured with stu dents wearing minimal clothing and XJUIPVUTIPFTBOEUPUIFOFBSFTUH using a calibrated portable scale. Height was measured in the full standing posi tion without shoes and to the nearest DN VTJOH B DBMJCSBUFE QPSUBCMF NFBTVSJOHSPE#PEZNBTTJOEFY #.*

was calculated as the ratio of weight LHUPUIFTRVBSFPGIFJHIU NĉF

*OUFSOBUJPOBM0CFTJUZ5BTL'PSDFBHF BOETFYTQFDJėD#.*SFGFSFODFWBMVFT were used to define overweight and PCFTJUZJOBEPMFTDFOUTBHFEmZFBST (12) 'PS QBSUJDJQBOUT BHFE ZFBST XF VTFE UIF DVUPĎ QPJOUT GPS BEVMUT PWFSXFJHIUmLHN²; obesity ≥ LHN²8BJTUDJSDVNGFSFODF 8$

XBTNFBTVSFEIPSJ[POUBMMZUPUIFOFBS FTUDFOUJNFUSFVTJOHBOPOTUSFUDIBCMF

Volume 20 / No. 7 July/Juillet

Health Journal

La Revue de Santé de la Méditerranée orientale