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Community and International Nutrition

Dietary Factors Are Not Associated with High Levels of Obesity in New Zealand Pacific Preschool Children¹

Department of Human Nutrition, University of Otago, Dunedin, NZ and ^* Pacific Island Advisory Council, Dunedin, NZ

²To whom correspondence should be addressed. E-mail: elaine.ferguson{at}stonebow.otago.ac.nz.

	ABSTRACT

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
Pacific children living in New Zealand (NZ) are prone to excessive weight gain. In this study, we assessed the anthropometric status of 2- to 5-y-old Pacific children (n = 60) in relation to their macronutrient intakes. Measurements of height (n = 56), weight (n = 60), midarm circumference, and triceps skinfold thickness (n = 58), and 2-d weighed food records (n = 60) and demographic data were collected. Z-score results (mean ± SD) showed that these children were tall (0.61 ± 1.1) and heavy (1.67 ± 1.1) for their age, and had high arm-muscle-area-for-height (geometric mean, 2.05). Over 64 and 45% of children were classified as overweight (including obesity) and obese, respectively. The percentage of energy contributed by fat in their diets met recommendations. In contrast, the percentage of energy contributed by sugar was high. The macronutrient intakes of children classified as obese (n = 32) compared with non-obese (n = 24) did not differ; however, their adjusted energy intakes were higher [5.79 (1.4) vs. 4.97 (1.4) MJ/d; P = 0.01]. Overweight and obesity were very common among very young NZ Pacific children, although the dietary etiology was not elucidated. These results emphasize the urgent need for obesity prevention for NZ Pacific children that begins early in life to avoid a future public health crisis.

KEY WORDS: • Pacific children • anthropometric status • obesity • diet • New Zealand

Childhood obesity is rapidly emerging as a public health issue in many countries. In New Zealand (NZ),³ individuals of Pacific ethnicity are particularly prone to excessive weight gain. The 2002 NZ Children’s Nutrition Survey (CNS) of 5- to 14-y-old children showed that 29% of Pacific children compared with under 17% of NZ Maori and 7% of European–others were classified as obese (1). Smaller, localized studies of Pacific children also reported high levels of obesity and a central pattern of fat distribution (2–6).

At an individual level, obesity is caused by an imbalance between energy intake and energy expenditure (7). Nevertheless, the dramatic rise in body weight of Pacific adults and children after migration, its marked increase in the last decade compared with other ethnic groups in NZ (2), and the differences in body weight between rural and urban populations in the Pacific Islands (8,9) indicate a susceptibility to excessive weight gain with the western diet and/or lifestyle.

These high levels of obesity in NZ Pacific children are cause for concern. Even in childhood, excess adiposity is associated with poor lipid profiles, elevated insulin levels, and hypertension (10). Nevertheless, the limited success of obesity intervention programs is well known (11). This emphasizes the need for obesity prevention in NZ Pacific communities given the high prevalence of obesity reported across diverse age groups (1–5,12–14). Such programs require information on the age at which obesity becomes prevalent in NZ Pacific populations, as well as potential environmental factors contributing to it. In particular, information on the dietary practices of very young NZ Pacific children in relation to their anthropometric status is needed, because close to 1 in 3 NZ Pacific children is overweight by 5–6 y of age (1).

Therefore, this study aimed to assess the anthropometric status of 2- to 5-y-old NZ Pacific children in relation to their dietary macronutrient intakes. Such information will elucidate the age at which obesity prevention measures are needed for NZ Pacific children, as well as potential associated dietary factors.

	SUBJECTS AND METHODS

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
A cross-sectional survey was conducted in collaboration with the Pacific Island Advisory Council between December 1998 and August 1999 in Dunedin, NZ. Sixty children were recruited by Pacific community workers (n = 8) through personal networks and local churches. Children aged 2–5 y were included if they had at least 1 biological parent of Pacific Island ethnicity and the child had no reported chronic disease. In households with more than 1 eligible child, 1 child was randomly selected. Dietary, anthropometric, and demographic data (an interviewer administered questionnaire) were collected during 2 home visits. Ethical approval was granted by the University of Otago Ethics Committee.

Two measurements of height, weight, mid-upper-arm circumference (MUAC) and triceps skinfold (TSK) were made by 2 anthropometrists (A.M.G. and E.L.F.) by using standardized procedures (15). Where measurements did not agree to 0.5 cm for height, 0.5 kg for weight, 0.5 cm for MUAC, and 1.0 mm for the TSK, a third measurement was taken. Standing height was measured by using a stadiometer accurate to ±0.1 cm or a microtoise calibrated to the stadiometer and accurate to ±0.1 cm, if the child’s height was <95 cm. Weight was measured by using a Seca 770 Alpha Scale (Seca) accurate to ±0.1 kg, calibrated with a 5.3 kg weight. MUAC and TSK measurements were taken on the right side of the body, by using a fiberglass insertion tape accurate to ±0.1 cm and a Lange caliper (Lange, Cambridge Scientific Industries) accurate to ±1.0 mm. Three children were excluded from the analyses due to height errors, and two refused to have arm measurements taken, one of which also refused height. Therefore, the numbers of children, for height- or arm-related measures, do not total 60 children. Arm-fat area and arm-muscle area were calculated by using standard equations (16). The percentage technical error of measurement calculated for height (0.2%), weight (0.3%), TSK (2.4%), and MUAC measurements (0.7%) were within the recommended error limits of 5% for skinfolds, 1–3% for circumferences, and 0.5% for height and weight measurements for both anthropometrists (17).

Z-scores for height-for-age, BMI-for-age, and weight-for-height (WH) were calculated by using the least mean square (LMS) method with the CDC reference data in an epidemiology information program (EPINFO, version 6, USD). Z-scores for TSK-for-age, arm-fat-area-for-age and arm-muscle-area-for-height were calculated by the LMS method of Cole (18), by using the combined ethnicity National Center for Health Statistics (NHANES survey I and II) reference data (16). Z-scores are reported rather than percentiles because the measurement distributions were shifted far to the right compared with the reference data. Children were classified as obese or overweight (including obese) by using each of three different classification systems, to enable comparisons with previous or future studies. These were as follows: 1) a BMI-for-age above the 95th or 85th percentile of the CDC reference data (19); 2) a BMI above the age- and gender-specific cutoff BMI values of 30 or 25, as defined by the International Obesity Taskforce (IOTF) (20); and 3) a BMI-for-age or a WH Z-score 1.65 SD (obese only), by using the Frisancho classification criteria (16). Similarly, height-for-age, TSK-for-age, arm-fat-area-for-age, and arm-muscle-area-for-height Z-scores 1.65 SD were classified as very high (16).

Children’s daily food intake was estimated by using a 2-d weighed dietary record. Dietary intakes were recorded on randomly selected nonconsecutive days, including one weekday and one weekend day over a 1–2 wk period by using an electronic scale accurate to ±1 g. An attempt was made to equally represent each day of the week across the population to minimize the day-of-the-week effect on intake estimates. Only 2 d of intake were recorded to reduce respondent burden, which was a major barrier to survey participation. The disproportionately higher number of weekend days to weekdays was adjusted by weighting the weekday energy and nutrient intakes (multiplied by 2.5). The food intake data were converted into energy and nutrient intakes by using Diet Cruncher software (Way Down South Software) and Version 9 of Foodfiles for the NZ food composition database. One person entered all the diet records (A.M.G.) to ensure consistency in the diet entry decisions.

All statistical analyses were performed by using SPSS version 10 for Macintosh. All variable distributions were examined and log-transformed where appropriate. Means and SD were calculated and, where distributions were log-transformed, the geometric mean and SD were calculated. The one-sample t test was used to assess whether the mean Z-score for each anthropometric index was different from the reference population. Sociodemographic and dietary intake differences by age group and in those classified above and below the 95th percentile for BMI-for-age were compared by using an ANOVA or analysis of covariance to adjust for age and/or gender, where appropriate, and the Pearson’s ² test to assess differences in categorical variables. When the former analysis was repeated comparing children with a BMI-for-age above or below the 85th instead of the 95th percentile, similar results were found. Therefore, only the latter results are presented. All statistical analyses were considered significant when P < 0.05.

	RESULTS

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
The mean age of all children was 3.8 ± 1.1 y (range 2–5.8 y). A slightly higher percentage of the children were male (57%), and most children had two Pacific parents (72%). Among the different Pacific groups, most children had at least one parent who was Samoan (63%), followed by Tongan (18%), Cook Islands Maori (17%), and Tokelauan (7%). Of the households that reported income (n = 26; 43%), 46% had a combined annual income less than NZ$30,000. Among the parents who reported education levels, 25% of the children’s mothers (14 of 57 mothers) and 31% of fathers (14 of 45 fathers) had a tertiary education.

The BMI [geometric mean (SD)] for these NZ Pacific children was 19.3 (1.2) kg/m². Their Z-score values for all anthropometric indices, except the TSK, were significantly higher than the American reference population (P < 0.001) (Table 1), indicating that this group was large in comparison to this reference population. Z-scores of WH, BMI, and arm-muscle-area-for-height were notably high (Table 1), with over 55% of children having Z-scores 1.65 SD. Older children (4–5 y) had higher Z-score values for indices of fatness (i.e., BMI, TSK, and arm-fat area) when compared with younger children.

The dietary results (Table 2) show that the percentage of energy contributed by fat and carbohydrate in both age groups met current recommendations (21). However, sugars did not meet current recommendations. They contributed approximately half of the energy from carbohydrates, and sucrose contributed just under half of the percentage energy from sugars (Table 2).

	DISCUSSION

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
This study provides unique data on the body size of preschool NZ Pacific children in relation to diet. It shows that the onset of obesity begins very early in life for NZ Pacific children, and, except for energy intakes, there were no differences in macronutrient intakes between obese and non-obese children. The relation between dietary energy intakes and body size was not surprising. Heavier persons generally have higher metabolic rates and therefore higher energy needs than lighter persons (22). Indeed, when energy intakes were expressed as a percentage of each child’s estimated energy requirements (22), children with a BMI 95th percentile did not differ from those with a BMI < 95th percentile (P = 0.74).

The high prevalence of obesity in these young NZ Pacific children is of concern. It is well above levels reported for Pima Indian preschool children (57 vs. 27–30%), who have the highest reported rates of childhood obesity among the major ethnic groups in the United States (23). It is also above levels reported for older Pacific children living in other regions of NZ (57 vs. 15–27%) (1,2,4). This was unexpected, because the prevalence of obesity usually increases with age (7) and did so in our study (Table 1). Therefore, these interstudy differences suggest an over-estimation of the true prevalence of obesity in our study, via a selection bias and/or marked regional differences in its prevalence in New Zealand.

Irrespective of interstudy differences, all studies (2–4) show a high level of obesity in NZ Pacific children, which, based on our results, begins very early in life. This is of concern because excessive body fat, even from early childhood, tracks into adulthood (7) and is associated with poor lipid profiles, elevated insulin levels, and hypertension in childhood (10). Clearly, obesity prevention measures need to begin very early in life for NZ Pacific children to avoid these related health problems, especially given the recent 6-fold increase in the proportion of NZ adolescents with type 2 diabetes, attributable to both high body weight and a family history of diabetes (24).

The dietary factors contributing to the high levels of adiposity in these NZ Pacific children were not elucidated by our study. Their reported energy intakes and the percentage of energy contributed by macronutrients were comparable with those of other predominantly Caucasian NZ preschoolers (25–27), despite marked differences in rates of obesity. Dietary assessment is notoriously prone to reporting errors, which may be more pronounced in non-Caucasian immigrant ethnic groups and overweight children (28). However, similar results were observed in the recent NZ national nutrition survey for older Pacific children compared with non-Pacific children (1) when using a different dietary assessment technique. Such findings suggest a strong predisposition for excessive weight gain for NZ Pacific children.

Except for simple sugar intakes, the dietary intakes of the children in our study met current recommendations (29). Simple sugars provided 30.3 and 25.9% of total energy in children 2–3 y old and 4–5 y old, respectively, instead of the current recommended levels of 10% (29). Sugar intakes were also above those reported for preschool children in other countries (30,31) but were similar to those of 5- to 6-y-old NZ children (1) and 4- to 7-y-old Australian children (32). The main food source of sucrose for these NZ Pacific children was sweetened beverages (34.5% of the energy contributed from sucrose). Recent studies indicate that sweetened beverage consumption contributes to excessive weight gain in childhood (33–35). Clearly, their consumption should be discouraged among NZ Pacific children.

Several internationally recognized classifications for overweight and obesity were used in this study (16,19,20). The IOTF cutoffs correspond approximately to the 90th and the 97th percentiles in the CDC reference distribution (20); hence, the interindex differences were expected. Of greater interest was their impact on prevalence estimates for NZ Pacific children, which is more pronounced than for non-Pacific children, because their BMI distribution is shifted far to the right of the reference population. Indeed, compared with French and Singaporean Chinese children (36,37), a 12% interclassification difference was found in our study vs. 9.5 and 3.6% for the French and Chinese children, respectively. These comparisons, as noted elsewhere (36,37), emphasize the importance of using identical criteria when making interstudy comparisons of obesity prevalence among NZ children of different ethnic backgrounds.

The very high arm-muscle-area-for-height Z-scores suggest that, like Pacific adults (14), ethnic-specific BMI cutoff points are necessary for Pacific children. However, as reported previously (3), high arm-muscle-area Z-scores partially reflect the higher proportion of fat that is deposited on the trunk than on the arm among Pacific children, compared with the predominantly Caucasian American reference population. Notwithstanding, obesity indices based on weight alone or on weight in relation to height need cautious interpretation, until Pacific-specific reference norms are created.

Another noteworthy observation in our study was the higher BMI Z-scores and levels of obesity among older (4–5 y) compared with younger (2–3 y) children (Table 1). Such marked interage group differences perhaps partially reflect a statistical artifact related to the mean age of adiposity rebound. Both an early age of maturation and high height-for-age Z-scores, which are associated with an early adiposity rebound in childhood (38), are common among NZ Pacific children (1), and the children in our study were tall for their age (Table 1). In early adiposity rebound, the BMI values diverge from the reference population when the rebound occurs (36), making their BMI values high relative to the reference population despite more similar BMI before the rebound occurred. Indeed, BMI, as an index of adiposity, is particularly prone to error during the late preschool years, due to these individual or ethnic-specific differences in the rate of height relative to weight gain (39).

One of the main limitations of our study was the nonrandom sampling procedure. Nevertheless, the household size, income level, and ethnic makeup of our sample were similar to those of the Pacific population in Dunedin (40). In contrast, maternal education levels were higher than the national average for Pacific women which, if anything, suggests an underestimation rather than an overestimation of obesity levels, based on studies in non-Pacific populations (41).

In conclusion, this study shows extremely high rates of overweight and obesity in very young NZ Pacific children. Their reported energy intakes suggest a strong predisposition to excessive weight gain, which is manifest from a very early age. Further research is required to determine the modifiable dietary and/or behavioral factors that contribute to this excessive weight gain. This is urgently needed to develop effective lifelong obesity prevention measures that will help avoid a public health crisis in NZ Pacific communities.

	ACKNOWLEDGMENTS

 
We thank the Dunedin children and families for taking part in this research. The partnership of the Pacific Island Advisory Council and the community workers made this possible. In particular, we would like to thank Mr. F. Muliau, Mrs. S. Muliau, Mrs. P. Leota-Sei’uli Seufatu, Mrs. F. Taungapeau, Mrs. N. Pavihi, Mrs. M. Rouvi, Mr. Te Ariki Nooroa, and Mrs. K. Ikahihifo for their hard work.

We dedicate this research to Mr. Te Ariki Nooroa, who worked on the project. He passed away shortly after its completion, while developing intervention programs for Pacific children. Te Ariki was an exceptional person, committed to improving the health of NZ Pacific children.

	FOOTNOTES

 
¹ This study was supported by an Otago Research Grant.

³ Abbreviations used: CNS, Children’s Nutrition Survey; IOTF, International Obesity Taskforce; LMS, least mean square; MUAC, mid-upper-arm circumference; NZ, New Zealand; TSK, triceps skinfold; WH, weight-for-height.

Manuscript received 17 May 2004. Initial review completed 12 June 2004. Revision accepted 11 July 2004.

	LITERATURE CITED

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 

1. Ministry of Health (2003) NZ Food NZ Children: Key Results of the 2002 National Children’s Nutrition Survey 2003 Ministry of Health Wellington, New Zealand .

2. Turnbull, A., Barry, D., Wickens, K. & Crane, J. (2004) Changes in body mass index in 11–12-year-old children in Hawkes Bay, New Zealand (1989–2000). J. Paediatr. Child Health 40:33-37.[Medline]

3. Gordon, F., Ferguson, E., Toafa, V., Henry, T., Goulding, A., Grant, A. & Guthrie, B. (2003) Childhood obesity among 3–7 year old Pacific children living in New Zealand is a public health concern. J. Nutr. 133:3456-3460.[Abstract/Free Full Text]

4. Tyrrell, V., Richards, G., Hofman, P., Gillies, G., Robinson, E. & Cutfield, W. (2001) Obesity in Auckland school children: a comparison of the body mass index and percentage body fat as the diagnostic criterion. Int. J. Obes. 25:164-169.

5. Salesa, J., Bell, A. & Swinburn, B. (1997) Body size of New Zealand Pacific Islands children and teenagers. N. Z. Med. J. 110:227-229.[Medline]

6. Ramirez, M. & Mueller, W. (1980) The development of obesity and fat patterning in Tokelau children. Hum. Biol. 52:675-687.[Medline]

7. Livingstone, B. (2000) Epidemiology of childhood obesity in Europe. Eur. J. Pediatr. 159(suppl.):S14-S34.

8. Tonkin, S., Eyles, E., Salmond, C. & Rees, R. (1979) The Tokelau Island Children’s study: atoll and New Zealand comparisons: physical growth. N. Z. Med. J. 89:429-432.[Medline]

9. Bindon, J. R. & Zansky, S. M. (1986) Growth patterns of height and weight among three groups of Samoan preadolescents. Ann. Hum. Biol. 13:171-178.[Medline]

10. Must, A. & Strauss, R. (1999) Risks and consequences of childhood and adolescent obesity. Int. J. Obes. 23(suppl. 2):S2-S11.

11. Schonfeld-Warden, N. & Warden, C. (1997) Pediatric obesity. An overview of etiology and treatment. Pediatr. Clin. North Am. 44:339-361.[Medline]

12. Russell, D., Parnell, W., Wilson, N., Faed, J., Ferguson, E., Herbison, P., Horwath, C., Nye, T. & Reid, P., et al (1999) NZ Food: NZ People. Key Results of the 1997 National Nutrition Survey 1999 Ministry of Health Wellington, New Zealand.

13. Brewis, A., McGarvey, S., Jones, J. & Swinburn, B. (1998) Perceptions of body size in Pacific Islanders. Int. J. Obes. 22:185-189.

14. Swinburn, B., Ley, S., Carmichael, H. & Plank, L. (1999) Body size and composition in Polynesians. Int. J. Obes. 23:1178-1183.

15. Lohman, T., Roche, A. & Martorell, R. (1988) Anthropometric Standardization Reference Manual 1988 Human Kinetics Publishers Champaign, IL.

16. Frisancho, A. (1990) Anthropometric Standards for the Assessment of Growth and Nutritional Status 1990 The University of Michigan Press Ann Arbor, MI.

17. Pederson, D. & Gore, C. (1996) Anthropometry measurement error. Norton, K. Olds, T. eds. Anthropometrica: A Textbook of Body Measurements for Sports and Health Courses 1996:77-96 University of New South Wales Press Sydney, Australia. .

18. Cole, T. (1990) The LMS method for constructing normalized growth standards. Eur. J. Clin. Nutr. 44:45-60.[Medline]

19. Kuczmarski, R., Ogden, C., Guo, S., Grummer-Strawn, L., Flegal, K., Mei, Z., Wei, R., Curtin, L., Roche, A. & Johnson, C. (2002) 2000 CDC Growth Charts for the United States: Methods and Development. National Center for Health Statistics. Vital Health Stat. 11:246.

20. Cole, T., Bellizzi, M., Flegal, K. & Dietz, W. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320:1-6.[Abstract/Free Full Text]

21. Ministry of Health (1997) Guidelines for Healthy Children (aged 2–12 years): A Background Paper 1997 Ministry of Health Wellington, New Zealand.

22. FAO/WHO (1985) Energy and protein requirements: report of a Joint FAO/WHO/UNU Expert Consultation 1985 World Health Organization Geneva, Switzerland.

23. Caballero, B., Himes, J., Lohman, T., Davis, S., Stevens, J., Evans, M., Going, S. & Pablo, J., for the Pathways Study Research Group (2003) Body composition and overweight prevalence in 1704 schoolchildren from 7 American Indian communities. Am. J. Clin. Nutr. 78:308-312.[Abstract/Free Full Text]

24. Hotu, S., Carter, B., Watson, P., Cutfield, W. & Cundy, T. (2004) Increasing prevalence of type 2 diabetes in adolescents. J. Paediatr. Child Health 40:201-204.[Medline]

25. Ferguson, E. & Scanlon, W. (2000) Dietary assessment techniques for preschool children. Proceedings of the Conference of New Zealand Diabetic Association. 5:80-83.

26. Guha-Chowdhury, N. (1996) Diet of 3 and 4 year olds in Dunedin: relevance to dental caries. Pac. Health Dialog 3:15-19.

27. McMahon, J., Parnell, W. R. & Spears, G. (1993) Diet and dental caries in preschool children. Eur. J. Clin. Nutr. 47:794-802.[Medline]

28. Livingstone, M. & Robson, P. (2000) Measurement of dietary intake in children. Proc. Nutr. Soc. 59:279-293.[Medline]

29. Ruxton, C.H.S., Garceau, F.J.S. & Cottrell, R. C. (1999) Guidelines for sugar consumption in Europe: is a quantitative approach justified?. Eur. J. Clin. Nutr. 53:503-513.[Medline]

30. Somerset, S. (2003) Refined sugar intake in Australian children. Public Health Nutr. 6:809-813.[Medline]

31. Kersting, M., Sichert-Hellert, W., Alexy, U., Manz, F. & Schoch, G. (1998) Macronutrient intake of 1 to 18 year old German children and adolescents. Z. Ernahrungswiss 37:252-259.[Medline]

32. McLennan, W. & Podger, A. (1995) National Nutrition Survey: Selected Highlights 1995 Australian Bureau of Statistics 1997 Canberra, Australia.

33. Mrdjenovic, G. & Levitsky, D. (2003) Nutritional and energetic consequences of sweetened drink consumption in 6- to 13-year-old children. J. Pediatr. 142:604-610.[Medline]

34. Ludwig, D., Peterson, K. & Gortmaker, S. (2001) Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet 357:505-508.[Medline]

35. Giammattei, J., Blix, G., Marshak, H., Wollitzer, A. & Pettitt, D. (2003) Television watching and soft drink consumption—associations with obesity in 11-to 13-year-old schoolchildren. Arch. Pediatr. Adolesc. Med. 157:882-886.[Abstract/Free Full Text]

36. Rolland-Cachera, M.-F., Castetbon, K., Arnault, N., Bellisle, F., Romano, M.-C., Lehingue, Y., Frelut, M.-L. & Hercberg, S. (2002) Body mass index in 7–9-y-old French children: frequency of obesity, overweight and thinness. Int. J. Obes. 26:1610-1616.

37. Fu, W., Lee, H., Ng, C., Tay, Y.-K., Kau, C., Seow, C., Siak, J. & Hong, C. (2003) Screening for childhood obesity: international vs. population-specific definitions. Which is more appropriate?. Int. J. Obes. 27:1121-1126.

38. Williams, S. & Dickson, N. (2002) Early growth, menarche, and adiposity rebound. Lancet 359:580-581.[Medline]

39. Rolland-Cachera, M.-F., Deheeger, M., Bellisle, F., Sempe, M., Guilloud-Bataille, M. & Patois, E. (1984) Adiposity rebound in children: a simple indicator for predicting obesity. Am. J. Clin. Nutr. 39:129-135.[Abstract/Free Full Text]

40. Statistics New Zealand (1998) Pacific Islands People. 1996 New Zealand Census of Population and Dwellings 1998 Statistics New Zealand Wellington, New Zealand.

41. Wang, Y. (2001) Cross-national comparison of childhood obesity: the epidemic and the relationship between obesity and socioeconomic status. Int. J. Epidemiol. 30:1129-1136.[Abstract/Free Full Text]

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