1189

Physical activity, energy intake, and obesity

prevalence among urban and rural schoolchildren
aged 1112 years in Japan
Aya Itoi, Yosuke Yamada, Yoshiyuki Watanabe, and Misaka Kimura

Abstract: The prevalence of childhood overweight and obesity has been shown to differ among regions, including rural
urban regional differences within nations. This study obtained simultaneous accelerometry-derived physical activity, 24 h
activity, and food records to clarify the potential contributing factors to ruralurban differences in childhood overweight
and obesity in Japan. Sixth-grade children (n = 227, 1112 years old) from two urban elementary schools in Kyoto
and four rural elementary schools in Tohoku participated in the study. The children were instructed to wear a pedometer that included a uniaxial accelerometer and, assisted by their parents, keep minute-by-minute 24 h activity and food
records. For 12 children, the total energy expenditure was measured by the doubly labeled water method that was used
to correct the Lifecorder-predicted activity energy expenditure and physical activity level. The overweight and obesity
prevalence was significantly higher in rural than in urban children. The number of steps per day, activity energy expenditure, physical activity level, and duration of walking to school were significantly lower in rural than in urban children. In contrast, the reported energy intake did not differ significantly between the regions. The physical activity and
duration of the walk to school were significantly correlated with body mass index. Rural children had a higher prevalence of overweight and obesity, and this may be at least partly caused by lower physical activity, especially less time
spent walking to school, than urban children.
Key words: walking to school, active commuting, physical activity level, dietary intake, obesity, urban and rural regions,
schoolchildren.
Rsum : Daprs des tudes, la prvalence de surpoids et de lobsit diffre dune rgion lautre et on note des diffrences ruraleurbaine dans une mme nation. Cette tude prsente des observations en matire dactivit physique issues du
port dun acclromtre et des carnets dactivit physique et dalimentation sur une priode de 24 h, et ce, pour clarifier
limportance des facteurs contributifs dans les diffrences ruraleurbaine chez des enfants prsentant un surpoids et de lobsit au Japon. Des enfants de 6e anne (n = 227, 1112 ans) provenant de deux coles lmentaires en milieu urbain
(Kyoto) et de quatre coles lmentaires en milieu rural (Tohoku) participent cette tude. On demande aux enfants de porter un podomtre comprenant un acclromtre uniaxial et, avec laide des parents, dinscrire toutes les minutes les activits
effectues et lapport alimentaire sur une priode de 24 h. Chez 12 enfants, on value la dpense totale dnergie par la mthode de leau deux isotopes et on se sert des rsultats pour estimer avec plus de prcision la dpense dnergie pour lactivit physique et le niveau dactivit physique . La prvalence de surpoids/obsit est significativement plus grande chez les
enfants en milieu rural quen milieu urbain. Le nombre de pas effectus dans une journe, lnergie pour lactivit physique,
le niveau dactivit physique et la dure de la marche vers lcole sont significativement plus faibles chez les enfants en milieu rural quen milieu urbain. Par contre, on nobserve pas de diffrences significatives dapport alimentaire consign dun
milieu lautre. Lactivit physique et la dure de la marche vers lcole sont significativement corrles avec lIMC. La
prvalence de surpoids et de lobsit des enfants en milieu rural est plus grande quen milieu urbain et cest probablement
cause dun niveau plus faible dactivit physique et notamment de la plus faible dure de marche vers lcole.
Motscls : marche vers lcole, dplacements actifs, niveau dactivit physique, apport alimentaire, obsit, rgions urbaines
et rurales, coliers.
[Traduit par la Rdaction]

Received 9 February 2012. Accepted 1 June 2012. Published at www.nrcresearchpress.com/apnm on 31 October 2012.
A. Itoi. Department of Health, Sports and Nutrition, Faculty of Health and Welfare, Kobe Womens University, 4-7-2
Minatojimanakamachi, Chuo-ku, Kobe, Japan; Department of Epidemiology for Community Health and Medicine, Graduate School of
Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan.
Y. Yamada. Laboratory of Applied Health Science, Graduate School of Nursing for Health Care Science, Kyoto Prefectural University of
Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan; Research Fellow, Japan Society for the Promotion of Science, Tokyo,
Japan.
Y. Watanabe. Department of Epidemiology for Community Health and Medicine, Graduate School of Medical Science, Kyoto Prefectural
University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan.
M. Kimura. Laboratory of Applied Health Science, Graduate School of Nursing for Health Care Science, Kyoto Prefectural University of
Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan.
Corresponding author: Yosuke Yamada (e-mail: yyamada831@gmail.com).
Appl. Physiol. Nutr. Metab. 37: 11891199 (2012)

doi:10.1139/H2012-100

Published by NRC Research Press

1190

Introduction
The prevalence of childhood obesity and its related chronic
diseases has increased in the last few decades (van Cleave et
al. 2010), and it has become a major public health problem
in both developed and developing countries (Benson et al.
2009; Esquivel and Gonzalez 2010). Childhood obesity often
continues into adolescence and adulthood (Guo and Chumlea
1999; Wang et al. 2000) and is related to adult all-cause and
cardiovascular mortality (Gunnell et al. 1998). The Endocrine
Society's Clinical Practice Guidelines recommend controlling
caloric intake and engaging in 60 min of daily moderate to
vigorous physical activity (PA) for the treatment of pediatric
obesity (August et al. 2008). The prevalence of obese children in Japan is approximately 10% compared with 6% three
decades ago (Ministry of Education Culture Sports Science
and Technology Japan 2010).
The prevalence of childhood obesity differs among regions, and previous studies have indicated that there are ruralurban differences in the prevalence of overweight and
obese children even within a nation (Bertoncello et al. 2008;
Lewis et al. 2006; McMurray et al. 1999; Plotnikoff et al.
2004; Tognarelli et al. 2004). McMurray et al. (1999) indicated that living in a rural area was an independent risk factor for obesity in third- to fourth-grade children in North
Carolina, USA. Joens-Matre et al. (2008) examined body
mass index (BMI) and questionnaire-derived PA of fourth- to
sixth-grade children in Iowa, USA. The prevalence of being
overweight was higher and PA was lower, particularly around
lunchtime, among rural children compared with urban children. In contrast, Bathrellou et al. (2007) reported that the
prevalence of being overweight or obese and questionnairederived vigorous or moderate to vigorous physical activities
did not differ between urban and rural areas in Cyprus. Bassett et al. (2007) found that Old Order Amish youth had high
daily physical activity levels, as measured by a step counter
and that obesity prevalence was rare.
These previous studies suggest that there is variation in
ruralurban differences in the prevalence of childhood obesity that might be explained by PA differences. However,
despite the role of low PA levels and (or) excess energy intake (EI) in the etiology of obesity (de Gouw et al. 2010;
van der Sluis et al. 2010), no previous studies have examined the ruralurban differences in PA energy expenditure
(EE) and EI simultaneously. In Japan, Tohoku is a region
with many rural and agricultural areas, and it has a high prevalence of childhood overweight and obesity (Ministry of Education Culture Sports Science and Technology Japan 2010).
The reasons for the difference in overweight and obesity between rural and urban regions, specifically the contributions
of PA and dietary intake, remain unknown. The low birthrate in Japan has played a role in the decrease in population
in rural areas. In addition, the amalgamation of elementary
schools in rural areas has increased the size of each school
zone. The result is that many children cannot walk to
school or to a friends house after school in these areas
and are forced to use a car or bus to commute to school.
In contrast, children in urban areas are able to walk to
school or to a friends house because walkways to school
are generally well maintained and neighborhood adults volunteer to assist with road crossing.

Appl. Physiol. Nutr. Metab. Vol. 37, 2012

The 24 h daily physical activity energy expenditure (PAEE)

can be calculated most accurately using a combination of total energy expenditure (TEE), measured by the doubly labeled
water (DLW) method, and resting metabolic rate (Schoeller et
al. 1986; Westerterp et al. 1986). However, access to the
DLW method is limited because of the costs of the isotopes
and the methodological effort involved. Accelerometers have
been used to monitor PA in a range of populations from children to the elderly. Accelerometers were initially developed in
laboratory settings and validated using indirect calorimetry.
They were also validated under free-living conditions using
the DLW method (Chen and Sun 1997; Kumahara et al.
2004; Plasqui and Westerterp 2007; Tanaka et al. 2007;
Westerterp 1999; Yamada et al. 2009b). The Kenz Lifecorder is a uniaxial accelerometer that can accurately assess
step counts and various intensities of activity. The PAEE
estimated by the Lifecorder is highly correlated with the
PAEE measured by the DLW method in children and adults
(Adachi et al. 2007; Rafamantanantsoa et al. 2002). However, it significantly underestimates PAEE compared with
the DLW method (Rafamantanantsoa et al. 2002; Yamada
et al. 2009b). A previous study found that the Lifecorder
could not accurately measure EE during sedentary activities,
light intensity activities, or several vigorous intensity activities
(running, cycling, swimming, and hill climbing) (Yamada et
al. 2009b). However, if the output is corrected, the daily
PAEE can be estimated reasonably accurately in children.
A systematic review concluded that active commuting (i.e.,
walking or cycling to school) is associated with daily PA
(Davison et al. 2008; Mendoza et al. 2011b). However, the
relationship between active commuting and weight status is
inconsistent among studies, with some reporting a positive association (Heelan et al. 2005), no association (Ford et al.
2007; Metcalf et al. 2004), or an inverse association (GordonLarsen et al. 2005; Rosenberg et al. 2006). Mendoza et al.
(2011b) suggested that these inconsistent findings, which
may confound the relationship with energy balance, may be
related to subjective measurements of PA, sampling from local or regional populations, or not controlling for dietary EI.
The purpose of the present study was to examine the daily
PA levels and EI of Japanese rural and urban children. We
hypothesized that (i) rural children would have a higher prevalence of overweight and obesity, a lower daily PA because
of lower active commuting, and a higher EI compared with
urban children; and (ii) the lower daily PA and lower active
commuting would be associated with weight status.

Materials and methods

Participants
A total of 227 sixth-grade children (1112 years old) from
six elementary schools in Japan participated in this study.
The children comprised 77 boys and 79 girls from two elementary schools in an urban area of Kyoto, and 45 boys and
26 girls at four elementary schools in a rural area of Tohoku.
These schools were selected by convenience sampling. All
measurements were conducted in the fall (OctoberNovember)
of 2000. Informed consent was obtained from the children
and their parents and teachers according to the Declaration
of Helsinki, and the study was approved by the Kyoto Prefectural University of Medicine Ethics Committee.
Published by NRC Research Press

Itoi et al.

Anthropometric characteristics
Physical characteristics of the children were assessed in addition to age, grade, and sex. Body mass (kg) and height
(cm) were measured to the nearest 0.1 kg and 0.1 cm, respectively, in one layer of light clothing, without shoes, using a
professional physicians scale and stadiometer. We used a stadiometer that passed the Measurement Act established by the
Ministry of Economy, Trade and Industry, Japan. The scale
and stadiometer are calibrated every 2 years using standardized methods outlined in the Measurement Act. BMI
(kgm2) for each child was calculated using their body mass
(kg) divided by height squared (m2). Classifications of overweight and obesity were determined using the international
definitions for childhood obesity developed in a workshop organized by the International Obesity Task Force (IOTF)
(Cole et al. 2000). The IOTF used six nationally representative growth studies and constructed BMI growth curves such
that the curves at 18 years of age passed through the BMI
cutoff points of 25 and 30 for adults. The resulting curves
were then averaged to arrive at age- and sex-specific cutoff
points for overweight and obesity (Bassett et al. 2007). However, because a Japanese population was not included in the
survey, we conducted an additional group classification using
domestic definitions. Two different national definitions were
released by the Japanese government, one from the Ministry
of Education, Culture, Sports, Science and Technology
(MEXT) and the other from the Ministry of Health, Labour
and Welfare (MHLW) (2010). These equations and cutoffs
were also used to define overweight and obesity.
Accelerometer
A uniaxial accelerometer (Kenz Lifecorder/Calorie counter;
Suzuken Co. Ltd., Nagoya, Japan; 72.5 41.5 27.5 mm,
weighing 60 g including the battery) was continuously and
rigidly attached to the waistband of the children during all
waking hours for one week, excluding time spent bathing or
in water. The participants were requested to record the time
and date that they did not wear the Lifecorder. The records
and Lifecorder data were checked and the children were interviewed if a lack of compliance was suspected. The device
was previously validated against an indirect calorimeter, as
well as the DLW method in adults (Kumahara et al. 2004;
Rafamantanantsoa et al. 2002; Yamada et al. 2009b). The
technical and estimation equation details of the uniaxial accelerometer have been described elsewhere (Kumahara et al.
2004, 2010; Yamada et al. 2009b). Briefly, the device measures acceleration in the vertical direction ranging from 0.06
to 1.94 times the acceleration of gravity at a sampling frequency of 32 Hz. The accelerometer is designed to estimate
the daily EE in kilocalories from the subjects characteristics
and the accelerometry signals caused by body movements.
The number of steps taken per day was also determined
from the accelerometric signals. The reported margin of error
regarding the number of steps was less than 3%. In addition,
the accelerometer has a superior step counting accuracy
under controlled and free-living conditions in comparison
with other instruments.
Previous studies indicated that the TEE and AEE estimated
by the uniaxial accelerometer were highly correlated with the
TEE and AEE measured by the DLW method. However, the
accelerometer significantly underestimated the TEE and AEE

1191

in young, middle-aged, and aged adults (Kumahara et al.

2004, 2010; Yamada et al. 2009b). Kumahara et al. (2004b,
2010) reported that the Lifecorder underestimated EE by
8%9% for adults. Rafamantanantsoa et al. (2002) reported
that the Lifecorder underestimated EE by 20% for adults,
while Yamada et al. (2009b) reported that the Lifecorder
underestimated EE by 11% for elderly people relative to 14day DLW method measurements. In children, Adachi et al.
(2007) reported correlations (r = 0.7090.828) between the
output of the Lifecorder and AEE (kcalkg1) measured by
the DLW method but did not mention any underestimation.
Therefore, we conducted an additional experiment in the
present study in which we measured the TEE using the
DLW method and the accelerometer simultaneously in 12
children (1113 years old) to obtain a correction factor. The
detailed DLW method was described in previous reports (Yamada et al. 2009a, 2009b).
Activity and dietary records for 24 h
The 5-day minute-by-minute activity record was used to
assess the level of PA (Noda et al. 2006). Participants used a
specially designed form to record each activity minute by minute to facilitate diary maintenance. They were instructed to
record only when there was a change in activity by drawing a
line at the end of one activity under the corresponding indicator of time. A detailed demonstration and an example of a
completed sample were given to the teachers, parents, and
children before the recording . We asked the teachers and parents to assist children in completing the activity records. The
activity records were checked and any missing information
was obtained. The literacy rate is 100% in Japan, and all
schools use similar textbooks approved by the Japan Official
Commission on Textbooks; therefore, there was no difference
in language capability between urban and rural areas. All participants were requested to continue with their regular daily
activities and to keep a record of all activities, assisted by
their parents or teachers if required.
Values for nutrient intakes were obtained from the food records that were maintained during the usual school hours
(MondayFriday). All participants received a detailed verbal
explanation and written instructions about keeping the food
record. The participants were requested to maintain their
usual dietary habits and to be as accurate as possible in recording the amount and type of food, fluid, and drinks consumed, excluding unsugared tea or water. Examples of
common household measures, such as cups, tablespoons, and
specific information about the quantity of each measurement
(grams, etc.) were given. After completion of the activity and
dietary logging period, the recording sheets were collected
and checked to reduce under recording. The administrator of
an urban school and a boy in a rural school refused to complete the food records because of the complexity. Therefore,
the numbers of participants for the dietary examination were
reduced to 60 urban and 70 rural children.
Statistical analysis
Analyses were conducted using PASW statistics (Windows
Version 18; SPSS Inc., Chicago, Illinois). The results are
given as mean SD. Differences in the physical characteristics, PA, and dietary intake values were analyzed using twoway ANOVA with region (rural or urban) and sex (boy or
Published by NRC Research Press

1192

girl) as between-subject factors. Differences in the distribution of weight status, rate of walking to school, and rate of
playing outdoors were examined using the c2 test. Significance was set at P < 0.05.

Results
The mean SD values for the childrens anthropometric
characteristics are shown in Table 1. The weight and BMI
were significantly higher in the rural children than in the urban children for both sexes. The prevalences of overweight
and obese children in the rural schools were 26.8%, 21.1%,
and 25.4%, using the IOTF, MEXT, and MHLW definitions,
respectively. These values were significantly higher than the
prevalences in the urban schools, which were 8.4%, 6.4%,
and 6.4%, using the IOTF, MEXT, and MHLW definitions,
respectively (P < 0.02).
The mean SD values for the childrens step count, estimated EE, and duration or engaged rate of activities are
shown in Table 2. There were no significant interactions for
region sex for any of the variables. Boys had significantly
higher step counts, TEE, AEE, and PAL than girls. The rural
children had significantly lower step counts, AEE, and PAL
than the urban children for both sexes (P < 0.001). TEE did
not differ significantly between the two regions because of
the higher weight and lower PA in the rural children compared with the urban children (P = 0.143).
The mean duration of walking to school was significantly
shorter for the rural children than for the urban children. The
percentage of children who walked to school was almost
100% in the urban region but was only 25% in the rural region. The majority of the rural children were taken to school
by car. The durations of playing indoors and studying were
significantly shorter in the rural region (P 0.001); in contrast, sleeping duration was significantly longer (P = 0.019).
The mean SD values for reported food intake are shown
in Table 3. The reported EI was significantly higher in the
boys than in the girls, but it did not differ significantly between the two regions (P = 0.631). The reported EI divided
by weight had a significant interaction for region sex. Specifically, the rural boys had a lower EI per weight than the
urban boys. The energy balance described as EITEE1 did
not differ between the two regions (P = 0.924). There were
significantnutritional differences in the two regions; specifically fat, iron, vitamin B2, vitamin C, eggs, sugar, and cooking oil were all consumed at lower levels in the rural region
compared with the urban region.
The children were divided into three categories (tertiles)
using step counts to examine the relationship between walking and BMI. For both sexes, the children who had lower
step counts per day had a higher BMI (Fig. 1). The children
of both sexes who demonstrated a shorter duration of walking to school also had a higher BMI.

Discussion
The purpose of the present study was to examine the differences in obesity prevalence, daily PA, active commuting,
and EI between rural and urban Japanese children. The rural
children had higher BMIs and obesity prevalence and lower
step counts, AEE, and PAL compared with the urban children. Fewer rural children walked to school, and they also

Appl. Physiol. Nutr. Metab. Vol. 37, 2012

had a lower mean duration of walking to school. In contrast,

the reported EI and EITEE did not differ significantly between the two regions, with a lower fat intake in the rural
children than in the urban children. Sleeping duration was
longer in the rural children than in the urban children. The
step count and duration of walking to school were significantly related to the weight status.
Several previous studies have examined the differences in
obesity prevalence and PA between urban and rural areas.
However, in those studies the obesity prevalence was calculated using BMI, and PA status was obtained by a questionnaire that is less accurate than accelerometer data or a 24 h
activity record. In contrast, the present study used an accelerometer and a 24 h activity record. Previous studies reported
that the TEE and AEE obtained by the Lifecorder are highly
correlated with TEE and AEE measured using the DLW
method but significantly underestimated TEE and AEE in
adults aged 1887 years (Kumahara et al. 2010; Rafamantanantsoa et al. 2002; Yamada et al. 2009b). In children, Adachi et al. (2007) found a high correlation between the
Lifecorder output and AEE measured using the the DLW
method but did not mention any underestimation. Therefore,
we examined the relationship between the DLW method and
the Lifecorder in 12 children. The TEE and AEE estimated
by the Lifecorder were highly correlated with the TEE and
AEE estimated by the DLW method, but the Lifecorder significantly underestimated EE, as expected. Therefore, using
the correction equation developed from this analysis, we recalculated the TEE, AEE, and PAL for the entire population.
In the present study, the rural children had a higher BMIs
and obesity prevalence and lower step counts and PA. Almost all the urban children, but only 25% of rural children,
walked to school. The other rural children commuted by car
or bus. Joens-Matre et al. (2008) reported that the prevalence
of overweight was higher among rural children than in children from urban areas and small cities. Urban children were
the least active overall, particularly around lunchtime while at
school. Children from small cities reported the highest levels
of physical activity. Sjolie and Thuen (2002) reported that
94% of children commuted by car or bus in a rural municipality in Rendalen, Norway. Similarly, Kobayashi and Ozawa
(2007) and Ozawa et al. (2006) reported that rural school
children commuted by car or bus more often than urban children in Japan. The primary underlying reason for these findings is that larger school districts now exist in the rural
regions. Previous studies reported that children who walked
to school had higher moderate to vigorous PA and step
counts compared with children who did not walk to school
(Cooper et al. 2003, 2005, 2010; Loucaides and Jago 2008;
Sirard et al. 2005). The present results are consistent with
these previous findings.
Tudor-Locke et al. (2004) recommended 15 000 and
12 000 steps per day for boys and girls, respectively. In the
present study, the children who reached the recommended
step counts were 83.1% and 13.3% for the urban and rural
boys (P < 0.001), respectively, and 79.7% and 17.7% for the
urban and rural girls (P < 0.001), respectively. The measured
step counts in the present study were 15003000 steps higher
in the urban children, but 40005000 steps lower in the rural
children, compared with previously reported values by Duncan et al. (2008) (16 100 and 14 200 steps for boys and girls,
Published by NRC Research Press

Itoi et al.

1193
Table 1. Physical characteristics of the children (n = 227).
Boys

Height (cm)
Weight (kg)
BMI (kgm2)

Urban
(n = 77)
146.56.3
38.47.3
17.82.7

Girls
Rural
(n = 45)
148.08.2
43.512.8
19.64.2

P value of two-way ANOVA

Urban
(n = 79)
148.06.8
39.37.3
17.92.5

Rural
(n = 26)
147.06.7
41.410.0
19.13.9

Region
0.817
0.006
0.001

Sex
0.807
0.662
0.614

Region
Sex
0.225
0.251
0.536

Note: BMI, body mass index.

Table 2. Physical activity levels of the children.

Item
Step count (stepday1)
TEE (kcalday1)
AEE (kcalday1)
PAL
Walking to school
(minday1)
No. of children walking
to school (%)
Playing outdoors
(minday1)
No. of children playing
outdoors (%)
Sports club (minday1)
Playing indoors
(minday1)
Watching TV
(minday1)
Playing video games
(minday1)
Studying (minday1)
Sleeping (minday1)

Boys

Girls

Urban
(n = 77)
197755277
2454387
764253
1.850.21
3723

Rural (n = 45)
121282306
2408508
457155
1.700.06
47

Urban
(n = 79)
155464643
2242404
592209
1.780.23
4225

Rural
(n = 26)
93432020
2108375
373158
1.650.06
26

P value of two-way ANOVA

Region
<0.001
0.143
<0.001
<0.001
<0.001

100

31.1

98.4

23.1

Boys P < 0.001, girls P < 0.001*

4639

3227

3529

3427

0.096

85.3

95.6

90.0

84.6

Boys 0.120, girls 0.482*

2641
4438

2740
2723

2936
4033

1322
2326

0.168
0.001

0.312
0.478

0.124
0.928

10759

11871

10267

12986

0.064

0.804

0.429

3038

3237

818

410

0.816

<0.001

0.491

6068
51846

2717
52137

7174
50643

4218
53332

<0.001
0.019

0.143
0.973

0.846
0.051

Sex
<0.001
<0.001
<0.001
0.022
0.537

0.364

Region
Sex
0.255
0.481
0.154
0.660
0.253

0.205

Note: TEE, corrected total energy expenditure using the accelerometer output with the equation established by the experiment with the DLW method;
AEE, corrected activity energy expenditure; PAL, corrected physical activity level.
*c2 test to compare the prevalence rate between urban and rural children.

respectively) and Toda et al. (2007) (16 657 and 13 690 steps
for boys and girls, respectively).
Pabayo et al. (2011) reported that urban settings were significant predictors of active transportation to school compared with rural settings in the Canadian National
Longitudinal Survey of Children and Youth (odds ratio 3.66
(95% confidence interval: 3.234.15)). van Sluijs et al.
(2009) reported that the proportion of active travelers decreased from 83.8% to 0.0% across the increasing distance
travelled to school from <0.5 miles (0.8 km) to 5 miles
(8.05 km) in the Avon Longitudinal Study of Parents and
Children (Bristol, UK). Cooper et al. (2005) reported that in
primary school aged children in Odense, Denmark, walking
to school is associated with higher levels of overall physical
activity compared with those who travel to school by motorized transport. McMurray et al. (1999) indicated that living in
a rural area in North Carolina, USA, is an independent risk
factor for obesity in third- to fourth-grade children. JoensMatre et al. (2008) found that the prevalence of being overweight was higher and PA was lower among rural children
compared with urban children in Iowa, USA. Therefore,

based on this evidence, we conclude that in developed countries, living in rural settings promotes less physical activity,
as well as overweight or obesity and that one reason for this
may be the reliance on motor vehicles for transportation.
In contrast, Bathrellou et al. (2007) reported that the
prevalence of being overweight or obese and the level of
questionnaire-derived vigorous or moderate to vigorous
physical activity did not differ between urban and rural
areas in Cyprus. Bassett et al. (2007) found that Old Order
Amish youth had higher daily physical activity levels and
that obesity prevalence was rare. In addition, Onywera et
al. (2011) reported that rural Kenyan children were more
physically active than their urban counterparts, with a mean
average steps per day (SE) of 14 700 521 and 11 717
561 (P < 0.0001) for rural and urban children, respectively.
Adamo et al. (2011) found that the rural children in Kenya
were not overweight or obese. However, 6.8% of boys and
16.7% of girls were overweight or obese in urban environments in Kenya. Therefore, the ruralurban differences in
the prevalence of overweight or obese children may be different between developed and developing countries.
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1194

Table 3. Food intake of the children.

Boys
Urban (n = 30)
2171333
80.419.0
73.319.3
288.756.5
727189
9.62.9
1087654
1.060.35
1.660.37
11158
8.12.6
15.11.9
27.04.3
56.14.0
57.36.0
51.39.2
36.020.3
42.67.5
9.69.7
21.26.1
34.07.4
35.18.8
6.57.0
3.25.0
71.066.4
174.9116.6
112.181.7
73.350.8
155.079.4
50.120.7
40.052.7
85.321.4
83.271.2
107.3103.5
106.098.4
0.0

Rural (n = 44)
2006433
76.521.5
59.823.7
278.056.3
707230
7.12.5
9451021
1.220.47
1.310.54
8036
8.52.8
15.52.1
26.26.2
56.46.2
55.510.3
46.716.8
24.612.8
44.39.6
6.17.1
22.29.2
37.19.4
33.010.7
3.96.3
3.97.0
60.453.9
158.7147.2
47.754.5
82.550.4
135.661.5
40.920.9
31.426.6
80.820.3
40.639.1
62.064.9
62.252.4
8.9

Urban (n = 30)
1864435
75.719.4
64.333.4
237.943.7
696210
10.03.9
1053508
0.940.30
1.460.37
10145
8.12.5
16.13.2
24.86.7
57.08.4
57.012.9
50.614.7
35.515.3
46.510.9
5.35.3
18.47.6
39.65.8
36.56.9
4.44.4
1.12.5
74.871.7
176.5205.2
114.679.6
102.158.2
140.764.7
53.029.6
32.030.1
69.419.2
94.573.4
91.1113.0
78.387.7
0.0

P value of two-way ANOVA

Rural (n = 26)
1960368
72.516.0
54.717.1
285.154.7
635140
7.02.1
1025913
1.200.44
1.340.75
8952
8.22.2
15.11.7
24.74.7
58.34.6
53.89.0
40.814.0
28.511.3
45.46.3
8.88.2
19.94.8
38.47.7
31.57.2
7.06.0
3.24.6
58.141.8
128.294.5
42.546.0
80.041.3
128.955.6
52.829.2
41.729.4
83.115.2
31.926.6
77.869.3
58.347.6
0.0

Region
Sex
0.631
0.015
0.355
0.253
0.010
0.114
0.062
0.026
0.269
0.161
0.000
0.809
0.565
0.874
0.004
0.345
0.015
0.378
0.014
0.953
0.581
0.837
0.488
0.561
0.752
0.136
0.547
0.277
0.247
0.660
0.030
0.311
0.005
0.596
0.884
0.195
0.985
0.654
0.461
0.122
0.595
0.057
0.074
0.992
0.981
0.698
0.262
0.251
0.235
0.948
0.235
0.594
0.000
0.912
0.485
0.159
0.197
0.384
0.304
0.108
0.931
0.856
0.198
0.056
0.000
0.898
0.076
0.991
0.021
0.249
Boys 0.565, girls N/A

Region
Sex
0.071
0.923
0.658
0.003
0.570
0.668
0.699
0.503
0.229
0.264
0.792
0.138
0.767
0.680
0.737
0.424
0.491
0.445
0.041
0.858
0.230
0.458
0.056
0.534
0.788
0.554
0.753
0.093
0.750
0.329
0.167
0.011
0.333
0.330
0.384

Appl. Physiol. Nutr. Metab. Vol. 37, 2012

Published by NRC Research Press

Item
Energy intake (kcalday1)
Protein (g)
Fat (g)
Carbohydrate (g)
Calcium (mg)
Iron (mg)
Vitamin A (g RE)
Vitamin B1 (mg)
Vitamin B2 (mg)
Vitamin C (mg)
Salt (g)
Energy rate of protein (%)
Energy rate of fat (%)
Energy rate of carbohydrate (%)
Animal protein ratio (%)
Animal fat ratio (%)
Green and yellow vegetables ratio (%)
Energy rate of grain (%)
Energy rate of confectionery and drink (%)
Energy rate of breakfast (%)
Energy rate of lunch (%)
Energy rate of dinner (%)
Energy rate of between-meal eating (%)
Energy rate of late-evening snacking (%)
Fish and seafood (%)
Meat (%)
Eggs (%)
Beans (%)
Milk (%)
Vegetables (%)
Fruits (%)
Grains (%)
Sugar (%)
Confectionery (%)
Cooking oil (%)
No. who did not eat breakfast (%)

Girls

Itoi et al.

1195

Fig. 1. (A) Body mass index (BMI) values of the children categorized by the daily step counts in boys (solid bars) and girls (open bars).
There was a significant main effect for each group, and the group with the lowest step counts had a BMI that was greater than the highest
tertile. (B) BMI values of the children categorized by the duration of walking to school in boys (solid bars) and girls (open bars). There was a
significant main effect for each group, and the group with the lowest duration of walking to school had a BMI that was greater than the
highest tertile. *, P < 0.05; **, P < 0.01; ***, P < 0.001.

Simen-Kapeu et al. (2010) reported a high prevalence of

obesity among rural children. These obese children had
higher PA levels but also had a poor diet characterized by
high fat intake. The authors noted that these results may
have been related to geographical factors and a lack of
knowledge regarding healthy diets. In contrast, the rural children in the present study consumed less fat than the urban
children. This was caused by significantly lower intake of
cooking oil with integrated effects of a slightly lower intake
of fish, seafood, meat, eggs, and milk. The animal fat to total
fat ratio was also significantly lower in the rural children.
The reasons for this are that (i) the Tohoku district is a major
rice production area and the frequency of eating rice as the
staple food is higher in this district than in metropolitan
areas, and (ii) the percentage of multigenerational households
is higher in the Tohoku district and the dietary habits are less
westernized than in metropolitan areas. Therefore, the higher
prevalence of obese children in this Japanese rural area cannot be accounted for by eating behavior, at least according to
the results of the reported dietary intake. Dietary intake is examined annually by the National Health and Nutrition Survey
in Japan (Ministry of Health Labour and Welfare Japan 2010)
and is reported as the averaged general population data for
each district. Total EI was almost the same for the urban
and rural districts, but fat intake was lower in rural districts
(Tohoku, Hokuriku, Shikoku, and South Kyushu) compared

with the urban districts (Greater Tokyo Area (Shuto-ken)

and Kansai Metropolitan Area (Kei-han-shin)). Although
district data were not reported for the children because of
the small sample size, the food intake results for the present
study are consistent with the National Health and Nutrition
Survey in Japan.
We recognize that the measurement of daily dietary intake
has limitations. Daily dietary intake cannot be examined accurately using unsupervised methods, whereas supervised
methods cause a modification in eating behavior. In particular, obese adults (Braam et al. 1998; Prentice et al. 1986) or
children (Bratteby et al. 1998; Livingstone et al. 1992;
OConnor et al. 2001) underreport their food intake. The fact
that the present study and the National Health and Nutrition
Survey showed no differences in reported EI between rural
and urban districts may not mean that there is no difference
in the actual EI between rural and urban districts. In addition,
the year-long accumulation of a small positive energy balance
(approx. 30100 kcalday1) can result in an increase in obesity (Hill et al. 2009). There are no field methods for measuring daily EI with this precision. Therefore, the results of the
reported dietary intake should be interpreted with caution.
Food frequency questionnaires, 24 h food records and 24 h
food recall methods were developed to examine food intake.
Black et al. (2000) reported that the EI calculated using a dietary record was significantly correlated with the EE measPublished by NRC Research Press

1196

ured by the DLW method (r = 0.48), but EI calculated using

the 24 h recall was not significantly correlated with the EE
(r = 0.11). Therefore, we used food records rather than a
food frequency questionnaire or food recall method. Recently,
Burrows et al. (2010) reviewed the validity of dietary assessment methods in children compared with the DLW method.
They concluded that there is a lack of data regarding the
most suitable methods for estimating EI in children.
Previous studies reported a negative association between
obesity and participation in sporting activities (Salbe et al.
2002) and a positive association between obesity and the duration of watching TV in children (Jackson et al. 2009). In
the present study, the duration of playing outdoors and the
duration of watching TV did not differ significantly between
rural and urban children. Previous studies found that sleep
duration was negatively associated with obesity and snacking.
The rural children slept longer than the urban children in the
present study. Japanese urban children go to private preparatory school more frequently and study for longer periods outside of school than rural children. Therefore, the higher
prevalence of childhood obesity in the Japanese rural areas
cannot be accounted for by sleep disturbance.
Previous studies reported that childhood obesity was related to higher food intake, a westernized diet pattern characterized by high intake of meats, fat, and oils (Aeberli et al.
2007; Gazzaniga and Burns 1993), lower PA (Abbott and
Davies 2004), and a shorter sleep duration (Padez et al.
2009; Shi et al. 2010). In contrast, in the present study, the
rural children did not demonstrate a westernized dietary pattern, had a longer sleep duration, and did not have a higher
food intake compared with the urban children. These habits
may not be related to obesity prevalence in rural children in
Japan. However, the rural children demonstrated a lower PA
level with fewer children walking to school compared with
the urban children. The promotion of walking to school or
being more active, rather than altering dietary or sleeping behaviors, may be useful for preventing childhood obesity in
Japanese rural areas. Previous studies have demonstrated the
effectiveness of a walking school bus program (Mendoza et
al. 2011a). Children joined the walking school bus at various
points along a set route. Students who lived far away were
dropped off along the route to join the walking school bus.
The program was effective in that it increased physical activity levels. One method of increasing walking to school in rural children would be to establish a walking school bus
program in those areas. Further studies are required to examine the effect of a walking school bus program on obesity
prevention in Japanese rural areas.
A limitation of the present study was that the schools were
selected using convenience sampling. However, the overweight
and obesity prevalences in the Tohoku and Kyoto regions are
similar to those provided in a government report (Ministry of
Education Culture Sports Science and Technology Japan
2010). Further large-scale research is required to examine
the issue in more depth using random sampling.

Conclusion
The overweight and obesity prevalences in Japan was significantly higher in rural regions than in urban regions. The
number of steps per day, AEE, PAL, and duration of walking

Appl. Physiol. Nutr. Metab. Vol. 37, 2012

to school were significantly lower in rural children than in

urban children. The PA and duration of the walk to school
were significantly correlated with BMI. In contrast, the
higher prevalence of overweight or obese children in the rural
area cannot be accounted for by eating or sleeping behaviors.
Rural children have a higher prevalence of overweight and
obesity, and this may be at least partly explained by lower
physical activity levels, especially less time spent walking to
school, in rural chidren than in urban children.

Acknowledgments
The authors thank Naoyuki Ebine and Satoshi Nakae (Doshisha University, Kyoto, Japan), Mami Fujibayashi (Kyoto
University, Kyoto, Japan), Soichi Ando (Kyoto Prefectural
University of Medicine, Kyoto, Japan), and Yoshiko Aoki
(Heian Jogakuin St. Agnes University, Osaka, Japan) for their
help in conducting the DLW experiments. This study was
supported by a research grant awarded to M.K. from the Japanese Ministry of Education, Culture, Sports, Science, and
Technology (23650408) and to A.I. (21500675).

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