Breakfast Eating Habits and Lifestyle Behaviors among Saudi Primary School Children Attending Public Versus Private Schools

Abstract

We investigated breakfast eating habits and lifestyle behaviors among Saudi school children attending public versus private schools. A random sample of 1149 children (girls: 54.4%) from public and private schools was selected from elementary schools using the multistage stratified cluster method. Measurements included body weight, height, body mass index (BMI), and self-reported questionnaires filled by the child’s parents. There was no significant (p = 0.44) difference in the prevalence of breakfast intake between children attending public (20.6%) versus private (19.4%) schools. However, there was a gender by school type interactions in breakfast intake frequency, as boys in private but not in public schools had significantly (p = 0.006) higher (26.3%) daily breakfast intake than girls (13.3%). Over 56% of the children ate and drank from the school canteen, and impacting factors on children’s choices were children’s desire, food taste, and parental influence. More parents of children in private (12.1%) than in public (6.9%) schools were satisfied with the food in the school canteen. Younger age (aOR = 0.889, 95% CI = 0.815–0.970, p = 0.008), higher father education (aOR = 1.380, 95% CI = 1.130–1.686, p = 0.002), family income (aOR = 1.227, 95% CI = 1.005–1.498, p = 0.044), and insufficient sleep duration (aOR = 0.740, 95% CI = 0.553–0.990, p = 0.042) were significantly associated with being in a private school. Furthermore, no significant differences, when adjusted for socio-demographic factors, appeared in breakfast intake or overweight/obesity relative to school type. Interventions to improve daily breakfast consumption and lifestyle behaviors of Saudi children are warranted.

Full text

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Children2021,8,134.https://doi.org/10.3390/children8020134www.mdpi.com/journal/children
Article
BreakfastEatingHabitsandLifestyleBehaviorsamong
SaudiPrimarySchoolChildrenAttendingPublicVersus
PrivateSchools
LauraJabri
1
,AmaniA.Al‐Rasheedi
2
,RayanA.Alsulaimani
3
andHazzaaM.Al‐Hazzaa
4,
*
1
AmericanInternationalSchoolofJeddah,Jeddah21352,SaudiArabia;laurajabri@gmail.com
2
FoodandNutritionDepartment,FacultyofHumanSciencesandDesign,KingAbdulAzizUniversity,
Jeddah42751,SaudiArabia;aalrasheedi@kau.edu.sa
3
DepartmentofPharmacology,FacultyofMedicine,KingAbdulAzizUniversity,
Jeddah42751,SaudiArabia;raalsulaimani@kau.edu.sa
4
LifestyleandHealthResearchCenter,HealthSciencesResearchCenter,PrincessNourahbintAbdulrahman
University,Riyadh11671,SaudiArabia
*Correspondence:halhazzaa@hotmail.com
Abstract:WeinvestigatedbreakfasteatinghabitsandlifestylebehaviorsamongSaudischool
childrenattendingpublicversusprivateschools.Arandomsampleof1149children(girls:54.4%)
frompublicandprivateschoolswasselectedfromelementaryschoolsusingthemultistage
stratifiedclustermethod.Measurementsincludedbodyweight,height,bodymassindex(BMI),and
self‐reportedquestionnairesfilledbythechild’sparents.Therewasnosignificant(p=0.44)
differenceintheprevalenceofbreakfastintakebetweenchildrenattendingpublic(20.6%)versus
private(19.4%)schools.However,therewasagenderbyschooltypeinteractionsinbreakfastintake
frequency,asboysinprivatebutnotinpublicschoolshadsignificantly(p=0.006)higher(26.3%)
dailybreakfastintakethangirls(13.3%).Over56%ofthechildrenateanddrankfromtheschool
canteen,andimpactingfactorsonchildren’schoiceswerechildren’sdesire,foodtaste,andparental
influence.Moreparentsofchildreninprivate(12.1%)thaninpublic(6.9%)schoolsweresatisfied
withthefoodintheschoolcanteen.Youngerage(aOR=0.889,95%CI=0.815–0.970,p=0.008),
higherfathereducation(aOR=1.380,95%CI=1.130–1.686,p=0.002),familyincome(aOR=1.227,
95%CI=1.005–1.498,p=0.044),andinsufficientsleepduration(aOR=0.740,95%CI=0.553–0.990,
p=0.042)weresignificantlyassociatedwithbeinginaprivateschool.Furthermore,nosignificant
differences,whenadjustedforsocio‐demographicfactors,appearedinbreakfastintakeor
overweight/obesityrelativetoschooltype.Interventionstoimprovedailybreakfastconsumption
andlifestylebehaviorsofSaudichildrenarewarranted.
Keywords:breakfastintake;children;lifestylebehaviors;BMI;socio‐demographicfactors;private
schools
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1.Introduction
Habitualbreakfastconsumptioncontributessubstantiallytoachild’sphysicalhealth
andwellbeingbyimprovingnutrientintakeandoveralldietaryquality[1–4].Amore
balancedmacronutrientdistributionincludinghigherfiberandlowersaturatedfatintake
wasfoundamongCanadianchildrenandadolescentswhowerebreakfastconsumers[5].
HigherlevelsofessentialmicronutrientsincludingvitaminD,vitaminC,andfolatehave
alsobeenobservedinEuropeanadolescentswhoconsumedbreakfastcomparedtothose
whoskippedthebreakfastmeal[6].Conversely,breakfastskippingisassociatedwith
severalnegativehealtheffectsandworseanthropometricsincludinghigherbodymass
index(BMI)z‐scores,waistcircumferences,andoverweight/obesityprevalenceamong
Citation:Jabri,L.;Al‐Rasheedi,A.A.;
Alsulaimani,R.A.;Al‐Hazzaa,H.M.

BreakfastEatingHabitsandLifestyle
BehaviorsamongSaudiPrimary
SchoolChildrenAttendingPublic
VersusPrivateSchools.Children
2021,8,134.https://doi.org/10.3390/
children8020134
Received:31December2020
Accepted:8February2021
Published:11February2021
Publisher’sNote:MDPIstays
neutralwithregardtojurisdictional
claimsinpublishedmapsand
institutionalaffiliations.

Copyright:©2021bytheauthors.
LicenseeMDPI,Basel,Switzerland.
Thisarticleisanopenaccessarticle
distributedunderthetermsand
conditionsoftheCreativeCommons
Attribution(CCBY)license
(http://creativecommons.org/licenses
/by/4.0/).

Children2021,8,1342of16
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childrenandadolescents[2,7,8].Asystematicreviewofstudiesfrom33countriesfound
thatskippingbreakfastalsonegativelyalteredbloodlipidprofilesandmaybeassociated
withanincreasedriskfordevelopingthemetabolicsyndrome,afindingpossibly
explainedbyhigherpostprandialglycemicresponseinbreakfastskippers[9].Breakfast
skippingwasalsoshowntobeassociatedwithvarioussuboptimallifestylebehaviors
suchasengaginginlessphysicalactivityandmorescreentime,havinglessnocturnal
sleeptimeandpoorerdietaryhabitsoverall[7,10–13].
Breakfastconsumptionamongchildrenandadolescentsisinfluencedbyseveral
socio‐demographicfactorsincludingageandsex[3,4,14,15].Othersocio‐demographic
factorsassociatedwithhigherbreakfastskippingamongchildrenaresingle‐parenthomes
andlowersocioeconomicstatus,whichisreflectedthrougheitherfamilyincome,parental
education,oroccupation[1,3,14,16].However,whilealargecross‐sectionalstudy
reportedaninverseassociationbetweenbreakfastconsumptionandsocioeconomicstatus
inmostEuropeanandNorthAmericanregions,suchanassociationwithbreakfastintake
mayreflectsocio‐culturalperceptionsratherthansocioeconomicstatusitself[14].Infact,
astudyonschoolchildreninPakistanreportedcontrastingfindings,showingthat
childrenfromuppersocioeconomicbackgroundsandhigherparentaleducationreported
anincreasedprevalenceofbreakfastskipping[17].
EducationplaysavitalroleinachievingSaudiArabia’sVision2030targets[18].
Currently,publicschoolsinSaudiArabiadominateK–12education,accountingfor87%
ofstudentenrollment[19].However,privateschoolsinthecountryhaveincreasedinthe
lastfiveyearsby13%[19].Futureprivateschoolenrollmentisexpectedtoincreasemuch
further,astheSaudigovernmentistargetinganincreaseof25%inprivateschool
enrollmentbytheyear2025[18].Thegrowthintheprivateschoolmarketisbeingdriven
byanincreaseinpopulation,thegovernment’sVision2030educationinitiatives,and
increasedemphasisonparentalattitudesandthinkingtowardtheimportanceoftheir
children’seducation[19].Aninterestingfindingfromalongitudinalstudyconductedin
Britainshowedthatprivateschoolchildrenreportedfewerbehavioralproblemsovertime
thanpublicschoolers[20].However,aftercontrollingforschoolselectioncriteria,the
privately‐educatedchildrenappearedtobelessriskaverseanddrinkatyoungerages
thantheirpublicschoolcounterparts,andthestudyconcludedthatprivateeducation
addedlittlepositivevaluetothechildren’ssocial‐emotionaldevelopment[20].
Nevertheless,therearesomeconcernsabouthowmuchprivateschoolscanofferforthe
overalldevelopmentofchildincludingeatinghabitsandlifestylebehaviors[20].
Globally,itappearsthattherearemarkedsocioeconomicdisparitiesamongstudents
frompublicandprivateschools[21],whicharereflectedintheassociationbetween
socioeconomicandhealth‐relatedfactors[21–25]orintheconsumptionofminimally
processedandultra‐processedfoods[26].Inaddition,thereisascarcityofinformationon
thedifferencesinbreakfasteatinghabitsandlifestylebehaviorsbetweenchildrenin
publicandprivateschools,despitethedifferencesinthesocioeconomicstatusoffamilies
ofchildrenattendingprivateschoolscomparedtothoseattendingpublicschools[21].
Additionally,publishedstudiesinSaudiArabiahavebeenfocusingontheprevalenceof
breakfastskippingingeneralanditsassociationswithlifestylebehaviorswithoutpaying
attentiontothedisparitiesinbreakfasteatingandlifestylehabitsbetweenpublicand
privateschools[27–31].Generallyspeaking,researchevaluatingthedifferencesineating
habitsandlifestylebehaviorsrelativetoschooltypeislimited.Therefore,thepresent
studyaimedtoassessthebreakfasteatinghabitsandlifestylebehaviorsamongprimary
schoolchildrenattendingpublicversusprivateschoolsinJeddah,SaudiArabia,while
adjustingforsocio‐demographicconfounders.


Children2021,8,1343of16
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2.MaterialsandMethods
2.1.Participants
Thesamplewasdrawnfromstudentsinpublicandprivateelementaryschoolsinthe
cityofJeddah,westernSaudiArabia.Amultistagestratifiedclusterrandomsampling
techniquewasutilizedtoselectthestudents.Thetotalsamplesizewasestimatedtobe
960boysandgirls,basedonaproportionof0.50witha95%confidencelevelandanerror
of4%.Thisfigureincludedanadditional20%tothesamplesizetoaccountfornon‐
respondersandmissingdata.Thestratificationschemeincludedgender(boysandgirls
schools),geographicallocationsoftheschools(east,west,north,andsouth),andtypeof
school(publicversusprivate).Twoprivateandfourpublicschoolswererandomly
selectedfromeacharea.Withineachschool,oneclasssectionwasrandomlychosenfrom
eachofthesixgradelevelsintheelementaryschool.Allstudentsintheselectedclasses
weretheninvitedtoparticipateinthisstudy.Thefinalsamplesizewas1149children(523
boys,626girls).Thisrepresents869and280studentsfrompublicandprivateschools,
respectively.Amoredetaileddescriptionofthestudydesign,sampling,andprocedure
hasbeenpreviouslypublished[27,28].
EthicalapprovalforthestudywassecuredfromtheInstitutionalReviewBoard(IRB)
atPrincessNourahbintAbdulrahmanUniversity,Riyadh(IRBLogNumber:19‐0014).
Writtenconsentwasobtainedfromtheparentsofallparticipatingchildren.Inaddition,
approvalforconductingthisresearchinschoolswasobtainedfromtheJeddahDirectorate
ofSchools,MinistryofEducation,andfromtheprincipalsofallselectedschools.
2.2.MeasurementsandProcedures
Bodyweight(tothenearest100g)andheight(tothenearest0.1cm)weremeasured
usingcalibratedportablemedicalscales(Seca869,Birmingham,UK)withminimal
clothingandwithoutshoes.Bodymassindex(BMI)wascalculatedastheratioofweight
inkilogramsdividedbythesquaredheightinmeters.TheextendedInternationalObesity
TaskForce(IOTF)age‐ andsex‐specificBMIcutoffreferencestandardswereusedto
classifyunderweight,normalweight,andoverweightorobesityrelativetothechild’sage
[32].Inaddition,socio‐demographicmeasurementsincludedage,sex,maternaland
paternalage,educationlevel,andfamilyincome.
Thebreakfastintakefrequencyaswellasfoodchoicesandpreferenceswereassessed
usingaspecificallydesignedself‐reportedquestionnaire[27,28].Commonbreakfast
choicesthatwerelistedinthequestionnaireincluded:egg,cheese,peanutbutter,or
hummussandwiches;pizza;ready‐to‐eatcereals;potato;sausage;cookiesormuffinsas
wellaslocalfoodchoices.Informationabouttheschoolcanteenandparentsatisfaction
withthefoodprovidedintheschool’scanteenwereincluded.Thequestionnairealso
containeditemsrelatedtothemostinfluencingfactorsonbreakfastchoicesbySaudi
children.Theinstrumentwaspreviouslydevelopedandcontentvalidated[27].Questions
relatingtosocio‐demographicfactorsandselectedlifestylebehaviorswerealsoincluded
inthequestionnaire.Thequestionnairesweretobefilledbythechildren’sparentsoradult
guardians.
Assessmentofscreenviewingtimeincludedquestionsonthetypicaldailytimethat
thechildspentonscreentimeincludingtimespentviewingTV,playingvideogames,and
oncomputerandInternetrecreationaluse.Thisincludedhoursspentonscreentime
duringweekdaysandweekends.Sedentarybehaviorswerethencategorizedintoacutoff
basedonaboveorbelowtwohoursperday[33].
Physicalactivitywasevaluatedusingthetotaldailytimespentbythechildonall
typesofphysicalactivityincludingsportsduringwhichthechild’sbreathingwas
increasedconsiderably.Thesufficientphysicalactivitylevelwasbasedon60minormore
ofdailyphysicalactivity[33].Physicalactivitywascategorizedasloworhighactivity
basedonaminimalrecommendedcut‐offvalueof420totalminutesperweek[33].

Children2021,8,1344of16
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Inaddition,weassessednocturnalsleepdurationonweekdays(schooldays)and
weekends.Parentswereaskedtoprovidehowmanyhourstheirchildrenusuallysleptat
nightonweekdaysandweekends.Insufficientsleep(shortsleepers)wasdefinedas
sleepinglessthan9hpernight,accordingtotheNationalSleepFoundationforschool‐
agechildren6–13years[34].
2.3.StatisticalAnalysis
DatawereenteredintoaSPSSdatafile,checked,cleaned,andanalyzedusingIBM‐
SPSSprogram,version22(Chicago,IL,USA).Descriptivestatisticswereobtainedforall
variablesandreportedasmeansandstandarddeviationsorpercentages.Differencesin
descriptivecharacteristicsoftheparticipantsweretestedusingtwo‐wayanalysisof
variance(schooltypebygender).TheproportionsandChi‐squaretestswereusedtotest
thedifferencesinsocio‐demographicandlifestyleparametersoftheparticipantsrelative
toschooltype.Multivariableanalysisusingtwo(publicversusprivateschools)bytwo
(boysversusgirls)multivariateanalysisofvariancewereusedtotestthedifferencesin
selectedbreakfast,BMI,andlifestylevariableswhilecontrollingforageandsocio‐
demographicfactors.Wilks’Lambdap‐valueswerereported.Moreover,logistic
regressionanalysiswhileadjustingforage,gender,andsocio‐demographicfactorswas
usedtotestthedifferencesbetweenchildrenattendingpublicversusprivateschoolsin
breakfastintake,overweightorobesity,andselectedlifestylebehaviors.Adjustedodds
ratios(aOR)andconfidenceintervals(95%CI)werereported.Alphalevelat0.05orless
wassetassignificant.
3.Results
Table1presentsthecharacteristicsoftheparticipantsrelativetogenderandtypeof
school.Themeanage(SD)ofthesamplewas9.2(1.7)years,rangingfrom5.8to13years.
Two‐wayanalysisofcovariancetests(genderbyschooltype),whilecontrollingforage,
revealednosignificantdifferencesinbodyweight,height,BMI,oroverweightorobesity
status.However,therewasasignificant(p=0.029)genderbyschoolinteractioneffecton
breakfastintake(days/week).Inaddition,therewerenodifferencesintheproportionsof
dailybreakfastintakebetweenchildreninpublic(20.6%)andprivate(19.6%)schools.
Additionally,therewasnosignificantdifferenceintheproportionofchildrenhaving
breakfastfiveormoredaysperweekbetweenpublic(39.8%)andprivate(42.1%)schools.
Althoughtherewasnooveralldifferenceintheprevalenceofdailybreakfastintake
relativetogenderinpublicschools,boys(26.3%)inprivateschoolsshowedhigher(p=
0.006)dailybreakfastintakethangirls(13.3%).
Thesocio‐demographiccharacteristicsandlifestylebehaviorsofSaudichildren
relativetoschooltypearedisplayedinTable2.Higherfathereducationlevel(p<0.001)
andgreaterfamilyincome(p=0.002)weresignificantlyassociatedwithprivateschool
enrollment.Moreover,twolifestylebehaviorsweresignificantlyandpositivelyassociated
withprivateschoolenrollmentincludingsleepdurationatoraboveninehourspernight
(p=0.003)andhighweeklyphysicalactivity(p=0.042).Comparedtochildreninpublic
schools,childreninprivateschoolsspentahigheramountoftimebeingactiveatorabove
420minperweek(p=0.018).Table3showstheresultsoftwo‐wayMANCOVAfor
selectedbreakfast,BMI,andlifestylevariableswhilecontrollingforageandsocio‐
demographicfactorsstratifiedbygenderandschooltype(publicversusprivate).There
werenosignificantdifferencesrelativetogender,schooltype,orgenderbyschooltype
interactionsinbreakfastintake,BMI,orsleepduration.However,thereweresignificant
(p<0.001)genderdifferencesinscreentimeandphysicalactivity.


Children2021,8,1346of16
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Table1.Characteristicsoftheparticipantsrelativetogenderandtypeofschool.
VariableSchoolTypeAll
N=1149
Boys
N=523
Girls
N=626p‐Value1
Age(years)
(mean±SD)
Public9.4±1.69.3±1.69.5±1.6Gender:0.785
Schooltype:0.198
Genderbyschoolinteractions:0.310
Private9.1±1.79.1±1.79.0±1.7
Bodyweight(kg)
(mean±SD)
Public33.0±11.532.4±11.233.5±11.6Gender:0.745
Schooltype:0.672
Genderbyschoolinteractions:0.289
Private32.5±10.832.7±10.532.2±11.2
Bodyheight(cm)
(mean±SD)
Public133.4±11.9133.3±10.8133.5±12.0Gender:0.567
Schooltype:0.573
Genderbyschoolinteractions:0.156
Private132.5±11.0133.5±9.6131.5±12.2
Bodymassindex(kg/m2)
(mean±SD)
Public18.1±3.917.8±4.018.3±3.8Gender:0.196
Schooltype:0.933
Genderbyschoolinteractions:0.633
Private18.0±4.017.9±4.118.2±4.0
Breakfastintake(days/week)
(mean±SD)
Public3.76±2.33.65±2.33.84±2.3Gender:0.730
Schooltype:0.951
Genderbyschoolinteractions:0.029
Private3.77±2.34.02±2.43.52±2.1
Dailybreakfastintake(%)Public20.619.421.50.446
Private19.626.313.30.006
Breakfastintake(%)
>5days/week
Public39.838.341.00.444
Private42.146.737.80.147
Overweightorobesity
byschooltype(%)
Public27.825.030.10.097
Private31.534.328.90.329
1Two‐wayANOVA‐testsorChi‐squaretestsfortheproportion.Dataaredisplayedasmeans±standarddeviationsorpercentages.

Children2021,8,1347of16
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Table2.Socio‐demographiccharacteristicsandlifestylebehaviorsoftheparticipantsrelativetoschooltype.
VariableAllPublicSchoolsPrivateSchoolsp‐Value1
Gender(%)0.188
Boys45.544.448.9
Girls54.555.651.1
Parentansweringthequestionnaire(%)0.096
Father36.538.131.4
Mother60.558.866.1
Someoneelse3.03.12.5
Numberofchildreninthefamily(%)0.109
1–215.815.516.8
3–451.249.855.3
≥533.034.627.9
Numberoffamilymembersinthehouse(%)  0.189
1–35.75.46.4 
4–541.840.545.7
≥652.554.147.9
Father’sage(%)0.206
<30years0.60.80.0
30–39years30.529.433.7
40–49years49.150.544.9
50–59years16.816.218.8
≥60years3.03.12.5
Mother’sage(%)0.669
<30years8.58.29.6
30–39years62.062.958.9
40–49years26.225.727.9
50–59years3.33.23.6
≥60years0.000.000.00
Father’seducation(%)<0.001
Intermediateorless12.813.89.6
Highschool28.730.622.5
Universitydegree49.448.253.2
Postgraduatedegree9.17.414.6
Mother’seducation(%)0.357
Intermediateorless11.112.0 8.6
Highschool29.429.728.6
Universitydegree55.254.357.8
Postgraduatedegree4.34.05.0
Familyincome(%)20.002
≤10,000SR44.546.6 37.9
10,001–20,000SR39.238.940.0
20,001–30,000SR12.110.118.2
≥30,001SR4.24.43.9
Breakfastintake(dailyversusnon‐daily)0.730
Non‐daily79.679.480.4
Daily20.420.619.6
Breakfastintake(5+versus<5days/week)0.490
>5days/week59.660.257.9
<5days/week44.439.842.1
Screentime0.965
≤2h/day30.530.530.4
>2h/day69.569.569.6
Sleepduration0.003
<9h/night65.868.158.6
≥9h/night34.231.941.4

Children2021,8,1348of16
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Physicalactivity(%)0.042
Nophysicalactivity52.253.348.9
<30min/day21.021.320.0
30min/dayto<60min/day11.611.611.4
60min/day9.27.913.3
>60min/day6.05.96.4
Physicalactivity/inactivity(%)0.018
Lowactive(<420min/week)84.886.280.4
Highactive(≥420min/week)15.213.819.6
Meansoftravellingtoschool(%)0.147
Walking4.34.34.3
Familyorprivatecar88.089.085.4
Schoolbus7.76.810.4
BMIcategory(%)30.233
<25kg/m271.372.268.5
≥25kg/m228.727.831.5
1Chi‐squaretestsforthedifferencesintheproportionsbetweenpublicandprivateschools.2SR=SaudiRiyal=3.75USD.
3BasedonInternationalObesityTaskForce(IOTF)age‐andsex‐specificBMIcutoffreferencestandardstoclassifynormal
weightandoverweightorobesity[32].
Table3.Multivariableanalysisforselectedbreakfast,bodymassindex(BMI),andlifestylevariableswhilecontrollingfor
ageandsocio‐demographicfactorsstratifiedbygenderandschooltype(publicversusprivate).
VariableGenderSchoolTypep‐Value1
PublicPrivate
BreakfastIntakes
(day/week)
Boys3.65±2.34.02±2.4Schooltype:0.994
Gender:0.624
Schooltypebygenderinteractions:0.166
Girls3.83±2.33.54±2.1
All3.75±2.33.77±2.3
BMI
(kg/m2)
Boys17.8±4.018.0±3.9Schooltype:0.207
Gender:0.187
Schooltypebygenderinteractions:0.759
Girls18.3±3.818.2±4.0
All18.1±3.918.1±4.0
Screentime
(hours/night)
Boys3.38±1.73.22±1.6Schooltype:0.339
Gender:<0.001
Schooltypebygenderinteractions:0.894
Girls2.83±1.62.68±1.6
All3.08±1.72.95±1.6
Sleepduration(hours/night)
Boys8.20±1.28.64±0.98Schooltype:0.076
Gender:0.238
Schooltypebygenderinteractions:0.133
Girls8.43±1.28.44±1.2
All8.33±1.28.54±1.1
Physicalactivity
(minutes/week)
Boys199.1±229.3214.1±231.2Schooltype:0.442
Gender:<0.001
Schooltypebygenderinteractions:0.543
Girls90.5±159.2106.0±154.1
All139.2±201.1159.1±202.8
Dataaremeansandstandarddeviations.1Wilks’Lambdap‐values:age<0.001;fatherage=0.036;motherage=0.085;
father’seducation=0.014;mother’seducation=0.022;familyincome=0.377;schooltype=0.286;gender<0.001;andschool
typebygenderinteraction=0.509.
Table4showstheparentresponsestoquestionsontheschoolcanteenstratifiedby
schooltype.Morethan56%ofallchildrenateanddrankfromtheschoolcanteen,with
significantdifferences(p<0.001)betweenschooltypes.Itappearsthatmoreparentsof
childreninprivate(12.1%)thaninpublic(6.9%)schoolsweresatisfied(p=0.003)withthe
foodofferedtotheirchildrenbytheschoolcanteen.Overall,morethanone‐thirdof
parentswereeithersatisfiedorsomewhatsatisfiedwiththedrinkchoicesofferedbythe
schoolswithoutanysignificantdifferencesbetweenpublicandprivateschools.


Children2021,8,1349of16


Table4.Parentresponsesrelatedtoschoolcanteenbyschooltype.
Variable
SchoolType
p‐Value1
All
N=1149
Public
N=869
Private
N=280
Doesyourchildeatordrinkfromtheschool’scanteen?<0.001
Eats&drinksfromtheschoolcanteen56.359.446.8
Eatsonlyfromtheschoolcanteen21.722.020.7
Doesnoteatordrinkfromtheschoolcanteen15.612.824.3
Drinksonlyfromtheschoolcanteen6.45.98.2
Areparentssatisfiedwiththefoodsprovidedintheschool’scanteen?   0.003
Yes,satisfied8.26.912.1
Somewhatsatisfied32.633.632.6
Notsatisfied31.933.526.8
Doesnotknowaboutthefoodsintheschoolcanteen27.426.031.8
Areparentssatisfiedwiththedrinksprovidedintheschool’scanteen?0.090
Yes,satisfied14.813.817.9
Somewhatsatisfied31.933.427.5
Notsatisfied25.826.423.9
Doesnotknowaboutthedrinksintheschoolcanteen27.526.530.7
1Chi‐squaretestsforsignificantdifferencesintheproportionsbetweenpublicandprivateschools.
ThemostinfluencingfactorsonbreakfastchoicesbySaudichildrenrelativetoschool
typearepresentedinTable5.Children’sdesire,foodtaste,andparentalinfluencewere
chosenasthetopfactorsthatimpactedonchildren’sbreakfastchoices.Surprisingly,only
16%ofchildrenwereinfluencedbyTVadvertisementsontheirpreferenceofbreakfast
choice.Table6showstheparents’perceptionsregardingthehealthqualityofchildren’s
commonbreakfastchoicesrelativetoschooltype.Eggsandwich,thymesandwich,
breakfastcerealsfromwholewheatoroats,yogurt,tunasandwich,favabeans(Foul),and
chickpeas(hummus)scoredabove70%ashealthybreakfastchoicesbytheparents.The
followingbreakfastchoicesexhibitedsignificant(<0.050)differencesinparents’responses
relativetoschooltype:breakfastcereals,favabeans,Oreobiscuits,Nutellahazelnut
spreadsandwich,andhamburgers.
Table5.FactorsinfluencingbreakfastchoicesbySaudichildrenrelativetoschooltype(morethan
onechoicewaspossible).
VariableSchoolTypep‐Value1
AllPublicPrivate
Child’swishordesire55.455.953.90.559
Foodstaste39.941.235.70.103
Parentalinfluence33.933.834.30.889
Brothersorsisters17.917.519.30.496
Child’sfriends17.415.722.90.006
TVpromotions(TVads)16.116.913.60.185
Otherfactors1.11.30.40.193
1Chi‐squaretestsforsignificantdifferencesintheproportionsbetweenpublicandprivateschools.
Table6.Chi‐squaretestsforsignificantdifferencesintheproportionsbetweenpublicandprivateschools.
VariableSchoolTypeHealthySomewhatHealthyNotHealthyp‐Value1
Eggsandwich Public91.47.41.30.742
Private92.17.10.7
ThymesandwichPublic82.715.81.50.334
Private81.415.72.9

Children2021,8,13410of16


BreakfastcerealsfromwholewheatoroatsPublic81.517.31.20.047
Private81.815.03.2
YogurtwithfruitsPublic79.117.43.60.802
Private77.518.24.3
TunasandwichPublic75.022.42.50.185
Private80.417.91.8
Favabeans(Foul)Public67.328.44.30.050
Private75.022.12.9
Chickpeas(Hummus)Public69.326.74.00.152
Private73.921.15.0
PeanutbuttersandwichPublic44.545.310.10.083
Private51.437.910.7
SolidcheesesandwichPublic30.553.615.90.694
Private33.251.415.4
PancakePublic19.855.125.10.495
Private21.851.127.1
CroissantPublic15.154.330.60.683
Private13.256.830.0
SpreadcheesesandwichPublic11.136.052.90.896
Private11.137.551.4
PizzaPublic9.749.141.20.906
Private8.950.440.7
Mortadellasandwich(curedmeat)Public6.034.259.80.101
Private7.527.565.0
OreobiscuitPublic5.937.356.80.024
Private10.432.557.1
DonutsPublic4.932.962.10.170
Private7.128.264.6
Nutellasandwich
(hazelnutchocolatespread)
Public4.332.862.90.050
Private7.929.662.5
FrenchfriesPublic2.925.072.10.317
Private4.327.568.2
HamburgerPublic2.326.271.50.002
Private6.427.965.7
HotdogPublic2.922.474.70.676
Private3.220.076.8
1Chi‐squaretestsforsignificantdifferencesintheproportionsbetweenpublicandprivateschools.
Finally,theresultsofthelogisticregressionanalysisofselectedlifestylebehaviors,
adjustedforage,gender,andsocio‐demographicfactors,relativetoschooltypeare
presentedinTable7.Amongallvariablesintheregressionmodel,onlyolderage(aOR=
0.889,95%CI=0.815–0.970,p=0.008),higherfathereducation(aOR=1.380,95%CI=
1.130–1.686,p=0.002),higherfamilyincome(aOR=1.227,95%CI=1.005–1.498,p=0.044),
andinsufficientsleepduration(aOR=0.740,95%CI=0.553–0.990,p=0.042)appeared
significantlyassociatedwithchildenrollmentinaprivateschool.
Table7.Resultsoflogisticregressionanalysisofselectedlifestylebehaviors,adjustedforgender,
andsocio‐demographicfactors,relativetoschooltypeamongSaudichildren.
VariablePublicversusPrivateSchool1
aOR(95%CI)SEEp‐Value
Age(youngerage=ref)1.00 
Olderage0.8890.815–0.9700.0440.008
Gender(girls=ref)1.00
Boys0.8680.649–1.1610.1480.341

Children2021,8,13411of16


Fatherage(olderage=ref)1.00 
Youngerage1.1290.911–1.3980.1090.268
Motherage(olderage=ref)1.00 
youngerage1.0710.825–1.3910.1330.606
Fathereducation(low=ref)1.00 
Higheducation1.3801.130–1.6860.1020.002
Mothereducation(low=ref)1.00 
Higheducation0.9580.773–1.1860.1090.693
Familyincome(low=ref)1.00 
Highincome1.2271.005–1.4980.1020.044
Screentime(high=ref)1.00 
Lowscreentime1.3360.995–1.7940.1580.868
Sleepduration(sufficient=ref)1.00 
Insufficientsleep0.7400.553–0.9900.1490.042
Physicalactivity(highactive=ref)1.00 
Lowactive 0.7560.518–1.1020.1930.146
Breakfastintakefrequency(non‐daily=ref)1.00 
Daily 1.1310.795–1.6080.1800.495
Overweightorobesity(overweight/obesity=ref)1.00 
Non‐overweight/non‐obesity0.8160.603–1.1060.1550.190
1Publicschoolwasusedasareferencecategory.aOR=adjustedoddsratio;CI=confidence
interval;ref=referencecategory;SEE=standarderror.
4.Discussion
Thecurrentresearchinvestigatedthebreakfasteatinghabitsandlifestylebehaviors
amongSaudiprimaryschoolchildrenattendingpublicversusprivateschools.Themajor
findingsindicatedthattherewaslowprevalenceofbreakfastintakeamongbothchildren
inthepublicandprivateschools.Additionally,agenderbyschooltypeinteractioneffect
inbreakfastintakewasfound,asboysinprivatebutnotinpublicschoolsshowed
significantlyhigherdailybreakfastintakethangirls.Moreparentsofchildreninprivate
thaninpublicschoolsweresatisfiedwiththefoodsprovidedintheschoolcanteenand
thatchildren’sdesire,foodtaste,andparentalinfluencewerethetopfactorsimpacting
children’sbreakfastchoicesinbothtypesofschools.Inaddition,youngerage,higher
fathereducation,familyincome,andsufficientsleepdurationweresignificantly
associatedwithbeinginaprivateschool.Nosignificantdifferences,whenadjustedfor
socio‐demographicfactors,appearedinbreakfastintakeoroverweight/obesityrelativeto
schooltype.
Fromthefindingsofthepresentstudy,whichshowedalmost20%dailybreakfast
intake,andcomparingthisfiguretotheresultsfromanothercrosssectionalstudy
conductedtwodecadesagothatreportedthat85%ofschool‐agechildrenandadolescents
consumedbreakfastonadailybasis[30],itappearsthatthetrendofdailybreakfast
consumptioninJeddahhasdeclinedsignificantly.InRiyadh,anotherlargecityinSaudi
Arabia,theproportionofprimaryschoolstudentswhoconsumedbreakfastdailyhadalso
declinedfromabout80%in1999tonearly21%in2017[27,35].Althoughthisisinline
withthedecliningglobaltrendofdailybreakfastconsumptioninmostcountriesaround
theworld,SaudiArabianowranksamongthosewiththelowestfiguresofbreakfast
consumption:alargestudyusingdataobtainedfrom31countriesbyaWorldHealth
Organizationcollaborativestudyonhealthbehaviorsofschool‐agedchildrenfoundthat
theproportionofadolescentswhoconsumedbreakfastdailyrangedbetween37.8%in
Sloveniato72.6%intheNetherlands[36].Thelargegapbetweenbreakfastintake
prevalenceinoursampleandthatreportedforchildreninEuropeanandNorthAmerican
countries[36]pointstoaneedtoconsiderothercountries’policiesandprograms
regardingbreakfastintakeinordertoimplementsimilarstrategiesinSaudiArabiainan
efforttoincreasedailybreakfastconsumptionamongschool‐agedchildren.

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Previousresearchhasshownthatgirlstendtoskipbreakfastmorefrequentlythan
boys[1],afindingthatwassignificantonlyamongprivateschoolstudentsinoursample.
Oneexplanationinpreviouslyexistingliteratureisthegirls’concernforweightorbody
image[16,37].Privateschoolstudentstypicallycomefromfamiliesofhigher
socioeconomicstatus(thecurrentfindingsshowedthatchildreninprivateschoolscame
fromparentswithsignificantlyhigherincomeandpaternaleducationcomparedwith
childreninpublicschools),however,therewerenosignificantdifferencesbetweenthe
childrenskippingbreakfastathomerelativetohighincomestatus(thepercentagesof
childrenwithnon‐dailybreakfastintakeinprivateandpublicschoolsearningmorethan
20,000SaudiRiyalswere12.6%and13.0%,respectively).Nonetheless,wedidnotassess
(andaccountfor)thenumberofchildreninthefamily,afactorthatmayinfluence
enrollingchildreninprivateschools.Itisalsomorelikelythatchildrenwithhigherfamily
incomeandeducationtoownmorepersonalelectronicdevicesandhavemore
accessibilitytosocialmediaplatforms,whichpropagatebodyimageissuesand
insecurities,andthusmaybeskippingbreakfasttocounteractsuchinsecurities[38].
FurtherinvestigationintothismatterisneededtoexploreSaudigirls’reasonsforskipping
breakfastandtheassociationswithbodyimageperceptionsandBMIstatus.
Inthepresentstudy,multivariableanalysisdidnotshowanysignificantgender
differencesinbreakfastintakefrequency.However,theboysspentsignificantlymoretime
onscreenviewingandengaginginphysicalactivitythanthegirls.Thesefindingswerein
linewithearlierresearchshowingthatadolescentfemalesinthreemajorSaudicitieswere
significantlymoresedentaryandlessphysicallyactivethantheirmalecounterparts[31].
Relianceonautomotivetransportation,limitedphysicaleducationinschools[31],cultural
acceptanceoffemalesplayingsportsaswellashigheraccessibilityofmalestosportsclubs
thanfemaleswereallfactorsthatcontributedtotheabove‐mentionedgenderdifferences
inphysicalactivity.However,therehasbeenagrowingshiftinrecentyearsincultural
perceptionsaswellasinincreasedopportunitiesforyoungSaudigirlstoactively
participateinphysicalactivityandorganizedsports.
Aftercontrollingforconfounders(age,gender,andsocioeconomicfactors),children
inourstudywhoattendprivateschoolswerefoundtohavelessinsufficientsleep(longer
sleepduration)thantheirpublicschoolcounterparts.Whilepreviousresearchhasshown
thatlongernocturnalsleepispositivelyassociatedwithbreakfastconsumption[10,13],
wefoundnosignificantdifferencesindailybreakfastconsumptionbetweenprivateand
publicschoolstudentsafteradjustingforpossibleconfounders.However,thereissome
evidenceintheliteratureindicatingthatbreakfastconsumptionishigheramongpublic
comparedwithprivateIndianschoolstudents[39].Furthermore,thepresentstudy
showedthathigherfamilyincomecorrelatedpositivelywithchildren’senrollmentin
privateschools.Additionally,higherpaternalbutnotmaternaleducationlevelswere
positivelyassociatedwithenrollmentinprivateschools.Thisfindingmayneedfuture
investigationinlightofthefactthatmoreSaudifemalesthanSaudimalesholdcollege
degrees.Nevertheless,researchshowedthatdifferencesexistinthesocioeconomicstatus
offamiliesofchildrenattendingprivateschoolscomparedtothoseinpublicschools[15].
Thecurrentstudyshowedthatthefrequencyofbreakfastconsumptionwasnot
associatedwithBMI.Suchfindingsappearedsimilartothosereportedrecentlyfor
primaryschoolchildrenfromRiyadh[27].Thelinkbetweenhigherfrequencyofbreakfast
consumptionandhealthierBMIscoreshasbeenestablishedintheliterature[2,7,8,16,40].
OurpresentfindingsdidnotobserveanyassociationbetweenthetypeofschoolandBMI
status(e.g.,overweightorobesitylevels).Anearlierstudyconductedonchildrenfrom
Riyadh,usingsimilarmethodologydidfindasignificantinteractioneffectinBMIbetween
typeofschoolandgender[26].Elsewhere,theprevalenceofover‐nutritionwas
significantlyhigheramongEthiopianprimaryschoolchildrenattendingprivateschools
comparedtothoseinpublicschools[41].Additionally,acrosssectionalinvestigation
involvingchildrenfromGhanashowedthatamongstfactorsrelatedtooverweightor
obesitywashigherenrollmentinprivateschools[22].Incontrast,alongitudinalanalysis

Children2021,8,13413of16
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
from2005to2016ofoverweightandobesityamongArgentinianchildrenfound
significantchangesinadiposityinboysandgirlsattendingpublicschoolsbutnotin
childrenattendingprivateschools[42].
Ourresultsshowedthatparentsofchildrenenrolledinprivateschoolsweremore
satisfiedwiththefoodchoicesofferedbytheschoolcanteenthanparentsofchildrenin
publicschools.Thiscouldbeduetobetterqualityfoodanddrinkoptionssoldatprivate
schoolcanteensandmoreorganizedfoodset‐up.However,arecentstudyconductedon
SaudipublichighschoolsinRiyadhfoundthattheactualimplementationofand
compliancewiththeguidelinesonschoolcanteenfoodanddrinkregulationspublished
bytheMinistryofEducationincoordinationwiththeMinistryofHealthislimited[43].
Noneoftheschoolsfromtheaforementionedstudysoldanyfruitsorvegetables,and
insteadcommonlysoldcroissants,potatochips,friedfoods,andconfectionery,allof
whichareenergy‐densenutrient‐poorfoods.AccordingtothefindingsofanAustralian
study,mostchildrenperceivedcanteenfoodanddrinktobe‘atreat’andthuspurposely
purchasedunhealthyitems[44].Moreimportantly,wefoundthatmorethanaquarterof
theparentsinourstudywereunawareofthefoodanddrinkchoicessoldinthecanteen.
Thisisalarmingbecauseasmajorstakeholders,parentscanhaveastrongsayin
promotinghealthyfoodchoicesintheirchildren’sschoolcanteen.
Breakfastchoicesamongchildreninourstudyweremostlydeterminedbythechild’s
desire,foodtaste,andparentalinfluence,withoutsignificantdifferencesinthe
proportionsofthesefactorsbetweenpublicandprivateschools.Thesefindingshighly
correspondwithresultsfromalargecross‐sectionalstudyonEuropeanadolescentsin
whichthetopfactorswerechildhungerlevels,foodtaste,andparentalinfluence,in
additiontoconcernforhealth,whichwasnotlistedasanindependentchoiceinour
survey[45].Givenourfindingthatthechild’sdesirewasthemostinfluencingfactor,we
canassumethatSaudichildrenenjoyatleastsomelevelofautonomyinchoosingtheir
ownfoods,althoughtheextentofsuchautonomyofchildrenchoosingtheirown
breakfastitemsathomeisyetunclear.Theanalysisofthedietaryhabitsofnormal‐weight
andobesechildreninSaudiArabiaalsofoundthatchildrenwhoatebreakfastathome
hadhigheroddsofobesity,indicatingthatthebreakfastqualityofobesechildrenis
possiblysuboptimal[46].Thisleavesroomforfutureinterventionstoincludechildrenin
additiontoparentsinordertoeducateallfamilymembersabouthealthybreakfast
options.However,friendsasaninfluencingfactorwasfoundtobesignificantlydifferent
betweenpublicandprivateschoolattendees.Sincealowerproportionofprivateschool
studentsboughtfoodanddrinkfromthecanteen,thisimpliestheyarebringingmore
foodfromhome,whichpotentiallycomprisesavarietyofuniquefoodanddrinksnot
otherwisefoundinthecanteen.Assuch,studentsinprivateschoolsmaybemore
influencedbytheirpeers’foodanddrinkchoicescomparedtostudentsinpublicschools,
wheretheygenerallyeatamoreuniformarrayoffoodallfromtheschoolcanteen.
Furthermore,whileonlyasmallproportionofparentsansweredthatTV
advertisementsinfluencedtheirchild’sbreakfastchoices,researchhasshownthat
televisionfoodmarketingispotentiallyaspowerfulonchildrenasparentalinfluence[47].
Whiletelevisionastheprimaryplatformforadvertisingtochildrenhasdeclinedinrecent
years,othermediasuchasInternetwebsitesarelargelybeingusednowadaystomarket
variousfoodsandbeveragestochildren[47,48].Itisworthnotingthatfoodmarketingto
childreninSaudiArabiaismostlyunregulated,especiallyononlineplatforms.Therefore,
educatingparentsaboutthemagnitudeofonlinemarketingchildreninSaudiArabiais
needed.
Finally,whilewefoundthatmostparentsaregenerallyknowledgeableaboutthe
healthqualityofcommonbreakfastchoices,therearestillseveralmisconceptions
regardingunhealthyfoodchoices,namelyOreobiscuits,hazelnutchocolatespread
sandwiches,hotdogs,Frenchfries,anddonuts,whichwereratedas‘somewhathealthy’
byalargeproportionofparents.Parentalknowledge,attitudes,andbehaviorsregarding
healthyfoodandproperchildnutritiondirectlyandstronglyinfluencetheirchildren’s

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dietaryqualityandeatinghabits[48].Higherparentalknowledgeofhealthyeatingand
activeimplementationofsuchknowledgeinthehomewasassociatedwithdecreased
childobesityriskinRiyadh[46].Thisarearequiresin‐depthexplorationofSaudi
parentingstylesandotherculturalfactorsinvolvedinordertodesigntailored
interventionstoimproveparentalknowledgeaboutdietquality,correctmisperceptions
regardingfood,andeducatethemaboutappropriatechild‐feedingpractices[48].
4.1.StrengthsandLimitations
Thisstudyaddstothelimitedliteratureregardingbreakfasteatinghabitsand
lifestylebehaviorsofprimaryschoolchildrenrelativetopublicorprivateschool
attendance.WeincludedalargeandrepresentativesampleofSaudichildrenfromboth
publicandprivateschools.However,therearesomenoteworthylimitationsofthisstudy.
Wedidnotspecificallymeasurethecompositionorqualityofbreakfastitemsconsumed
bychildreninthisstudy.Amajorlimitationinourstudyistheadministrationofsurveys
bytheparentsorguardiansofchildren,asthisleavesroomforself‐reportingandsocial‐
desirabilitybiases,bothofwhichcanprovideinaccuraciesinresults.Inaddition,the
varyingdefinitionsof‘breakfastconsumption’and‘breakfastskipping’intheliterature
leavesroomforspeculationwhethereatingbreakfastat9a.m.duringschoolrecesshas
similarbeneficialeffectsonprimaryschoolchildrenaseatingbreakfastearlyinthe
morningbeforegoingtoschool.Finally,duetothelargesamplesize,weusedasubjective
measureofphysicalactivityratherthanamoreobjectiveassessmentsuchasmotion
sensors.Thismayhaveimpactedontheaccuracyofthephysicalactivityassessment.
4.2.FutureImplications
Fromthefindingsofthepresentstudy,itwasclearthatfuturestudyneedsto
thoroughlyconsiderinvestigatingthereasonsthatgirlsinprivatestudyconsumed
breakfastathomelessfrequentlythangirlsinpublicschoolsorevenlowerthanboysin
privateschools.Thisisoccurringdespitethefactthatchildreninprivateschoolswere
generallyeatingfoodfromtheschoolcanteenlessfrequentlythanthoseinpublicschools.
Futureinterventionsshouldaimtoeducateparentsaboutfosteringandpromotingseveral
healthylifestylebehaviorsfortheirchildrenincludingsufficientnocturnalsleep,daily
breakfastconsumption,andregularphysicalactivity,astheyareallstronglypartofthe
healthierlifestylebehaviorsinchildren.Furthermore,culturally‐appropriateeducation
forparentsabouthealthynutritionandappropriatechilddietarypracticesiswarranted.
Educationalcampaignsandinterventionsonhealthybreakfastfoodchoicesshouldaim
toincludebothparentsandchildren.Furtherresearchintoseveralkeyareasisalsoneeded
includingbutnotlimitedtochildren’sperceptionsofweight,bodyimage,andmeal
skipping,especiallyforgirlsaswellasfortheanalysisofthedietaryqualityofspecific
foodanddrinkssoldinschoolcanteens.
5.Conclusions
Themajorityofchildrenattendingpublicandprivateschoolsdonotconsume
breakfastdaily,andgirlsinprivateschoolsskipbreakfastsignificantlymorethanboys.
Mostchildreneatordrinkfromtheschoolcanteen,whilemostparents(moresoinprivate
schools)weresomewhatsatisfiedwiththefoodsprovidedintheschool’scanteen.
Children’sdesire,foodtaste,andparentalinfluencewerethetopfactorsinfluencing
children’sbreakfastchoicesinbothtypesofschools.Inaddition,youngerage,higher
fathereducation,familyincome,andsufficientsleepdurationweresignificantly
associatedwithbeinginaprivateschool.Nosignificantdifferences,whenadjustedfor
socio‐demographicfactors,appearedinbreakfastintakeoroverweightorobesitystatus
relativetoschooltype.
AuthorContributions:Conceptualization,H.M.A.‐H.,A.A.A.‐R.,L.J.,andR.A.A.;Datacollection
supervision,L.J.,A.A.A.‐R.,andR.A.A.;Statisticalanalyses,H.M.A.‐H.;Interpretationofthe

Children2021,8,13415of16


findings,H.M.A.‐H.,L.J.,A.A.A.‐R.,andR.A.A.;Draftingthemanuscript:L.J.andH.M.A.‐H.All
authorscriticallyread,revised,approved,andagreedtothepublishedversionofthemanuscript.
Funding:ProfessorHazzaaAl‐HazzaawasfundedbytheDeanshipofScientificResearchat
PrincessNourahbintAbdulrahmanUniversitythroughtheFast‐trackResearchFundingProgram.
InstitutionalReviewBoardStatement:Thestudywasconductedaccordingtotheguidelinesofthe
DeclarationofHelsinki,andapprovedbytheInstitutionalReviewBoard(IRB)atPrincessNourah
bintAbdulrahmanUniversity,Riyadh(IRBLogNumber:19‐0014).
InformedConsentStatement:Writteninformedconsentwasobtainedfromtheparentsofall
participatingchildren.
DataAvailabilityStatement:Alldatageneratedoranalyzedduringthisstudyareincludedinthis
publishedarticle.Anyadditionaldataareavailablefromthecorrespondingauthoronreasonable
request.
Acknowledgments:Wewouldliketothankalltheparticipantsfortakingpartinthisstudy.
ConflictsofInterest:Theauthorsdeclarenoconflictsofinterest.
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