Original Research Communications
Asthma, obesity, and eating behaviors according to the Diagnostic and
Statistical Manual of Mental Disorders IV in a large population-based
sample of adolescents1–3
David Moreau, Sofia Kalaboka, Marie Choquet, and Isabella Annesi-Maesano
Background: Obesity is related to asthma, but factors influencing
this relation have not been clearly defined.
Objective: This study was designed to assess the role of eating
behaviors and weight concerns in the association between obesity
Design: A population-based sample of 11,710 adolescents, re-
cruited from 186 secondary schools of 8 educational districts in
France, completed a self-administered standardized questionnaire
including DSM IV (Diagnostic and Statistical Manual of Mental
Disorders) questions on eating disorders.
Results: Obesity (body mass index ?95th percentile according to
age and sex) was associated with asthma in girls (odds ratio: 1.48;
95% CI: 1.05, 2.08) but not in boys (odds ratio: 1.07; 95% CI: 0.75,
1.54). Both obese and asthmatic adolescents were more likely to
have abnormal eating behaviors and weight concerns (P , 0.05). In
an adjusted polytomous logistic model with 4 categories based on
the presence and/or the absence of asthma and obesity as the de-
pendent variable, the odds ratio for weight concerns increased from
a minimum value for asthmatic nonobese adolescents (odds ratio: ,1.5;
P , 0.03) to a maximum value for asthmatic obese adolescents
(odds ratio: .6.3; P , 0.001) with nonasthmatic, nonobese adoles-
cents as the reference group. Similar patterns were observed for
Conclusions: Our data suggest that, besides well-known factors
such as genetic background, direct mechanical effects, and reduced
physical activity, abnormal eating behaviors and weight concerns
might intervene in the relation between obesity and asthma. Psy-
chosocial dimension has to be considered to disentangle the com-
plex relation between obesity and asthma in adolescence in view of
prevention.Am J Clin Nutr 2009;89:1292–8.
Various epidemiologic studies have shown that both asthma
and obesity have increased in prevalence in industrialized
to be positively related to asthma (1, 2), although the nature of
this link has not been clarified (3, 4). In particular, the factors
influencing this relation have not been clearly identified.
Eating behaviors and weight concerns affect obesity, and it
cannot be excluded that they might intervene in the association
between obesity and asthma. Indeed, eating behaviors and weight
concerns are influenced by hormonal (5) and psychosocial (6)
factors, which have also been implicated in the etiology and the
progression of asthma. Understanding this interrelation may
contribute to the development of effective prevention strategies.
The aim of this study was to explore the interrelations between
eating behaviors, weight concerns, asthma, and obesity in a large
population-based sample of adolescents recruited in the frame of
conducted in France to investigate somatic as well as psycho-
logical health and associated risk factors in adolescence (7, 8),
among which eating behaviors and weight concerns according to
the Diagnostic and Statistical Manual of Mental Disorders
SUBJECTS AND METHODS
A 3-stage selection procedure was used to obtain a represen-
tative sample of students in French secondary public school. As
schools of 8 metropolitan educational districts (‘‘Acade ´mies’’ in
French), namely those of Strasbourg, Clermont-Ferrand, Nice,
Amiens, Cre ´teil, Aix-Marseille, Rennes, and Bordeaux. Students
were requested to complete a self-administered standardized
questionnaire in the classroom during school time. The protocol
was submitted to and approved by the Ethical Committee
(Comite ´ National Consultatif d’Ethique) and the Commission
Nationale de l’Informatique et des Liberte ´s, the latter to protect
the anonymity of the subjects.
1From INSERM, Epidemiology of Allergic and Respiratory Diseases,
Paris, France (DM, SK, and IA-M); Pierre et Marie Curie University, Epide-
miology of Allergic and Respiratory Diseases, Paris, France (DM, SK, and IA-
M); and INSERM U669, Maison des Adolescents, Ho ˆpital Cochin, Paris,
2Supported by the French Ministry of Education, Direction Ge ´ne ´rale de la
Sante ´, Fond National de Sante ´ Publique, Mutuelle Ge ´ne ´rale de l’Education
Nationale, and Comite ´ Franc xais d’Education pour la Sante ´.
3Reprints not available. Address correspondence to I Annesi-Maesano,
Epidemiology of Allergic and Respiratory Diseases, UMR-S 707, INSERM
and UPMC-Paris 6, Medical School, Saint Antoine 27 rue Chaligny 75571,
Paris CEDEX 12, France. E-mail: firstname.lastname@example.org.
Received September 10, 2008. Accepted for publication February 20, 2009.
First published online March 25, 2009; doi: 10.3945/ajcn.2008.26954.
Am J Clin Nutr 2009;89:1292–8. Printed in USA. ? 2009 American Society for Nutrition
by guest on October 21, 2015
terms of antioxidants and rich in total fat—that, in turn, may
pave the way not only for overweight and obesity but also for
asthma (30, 31). In this context, weight concerns seem to be
a simple consequence of eating disorders. The effect of eating
behaviors and weight concerns did not differ among ethnicities,
which suggests that our results obtained in France remain con-
stant across cultures.
that, in addition to direct mechanisms, such as a shared genetic
background, hormonal factors, and diminished physical activity,
and underlying factors may modulate the obesity-asthma associa-
tion. The findings further support the hypothesis that the psycho-
social dimension may be important to disentangling the complex
relation between obesity and asthma during adolescence and
strengthen the need to use this dimension in prevention strategies.
We are indebted to the school authorities, the parents, and the adolescents
who participated in the survey.
The authors’responsibilities were as follows—DM: participated in the sta-
tistical analyses, the data interpretation, and the final writing of the manu-
script; SK: participated in the data interpretation and the final writing of
the manuscript; MC: designed the survey on the health of the adolescents
and collected the data; and IA-M: participated in the design of the study,
the collection of the data concerning asthma, the statistical analysis, the in-
terpretation of the data, and the final writing of the manuscript. None of the
authors had a financial or personal relationship with an organization that has
an interest in the subject of this manuscript, and all authors had access to all
the data in the study and approved the final version of the manuscript to be
submitted for publication.
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