To develop and evaluate the effectiveness of nutrition and physical education (toolkit) materials to address childhood obesity among school age children (6-9 years old) in primary schools in UAE

Summary:

Childhood obesity has emerged as global public health problem. Evidence for this growing health hazard has been reported in the United Arab Emirates (UAE). Previous investigations have suggested the importance of nutrition education in the early years to tackle this public health concern. The aim of this project was to develop a nutritional education package (toolkit) targeting school children. This educational package will evaluate the increase in their awareness and attitude towards healthy diet and physical activity. This pilot targeted n=100 participants (n=50 males-n=50 females) aged 6-9 years old. The participants were randomly selected from the British school in Al Ain, UAE. Only sixty participants completed a pre-assessment questionnaire followed by the distribution of the developed booklet. The children’s knowledge was further advocated by nutrition/physical activity focused lecture. The post assessment questionnaire has been convened one week after the lecture and the distribution of the toolkit. The data from both questionnaires was analysed using SPSS version 16. The key findings of the pre-assessment questions showed that the participants had a fair (40-50, n= 20) to good (50-60; n=15) knowledge about nutrition and physical activity. These figures have been improved to excellent (scaled up to100% n=60). These key findings confirmed that the booklet was effective in raising the awareness of the targeted group towards healthy diet and physical activity.

Key words: Obesity, Nutrition education, Children, intervention

Introduction:
Recent scientific literature reveals a tremendous shift in the health status of children and adolescents caused by malnutrition (under and over nutrition) and changes in general lifestyle (WHO 1997;WHO 2000; Robert Koch-Institute 2002). In the past few decades, a steady increase in nutrition-associated problems such as being overweight and obesity have been recorded. From a life-span approach, the problem has its offset point in the early age of development (Wagner et al,2005). Nutrition education lays the groundwork for lifelong health habits (National Dairy Council, 2005). Studies have shown that the knowledge and skills children acquire at an early age help them choose more nutritious foods during childhood as well as adulthood (Resnicow, et al., 1998, Nicklas, et al., 1995, Aldinger et al, 1998, ADA, 1999). Other studies support that good nutrition contributes to improving the wellbeing of children and their potential learning ability, thus contributing to better school performance (Nicklas, et al., 1995, Aldinger et al, 1998, ADA, 1999). Accordingly goodnutrition and learning go hand in hand. When children’s nutritional needs are met, it’s easier for them to focus and learn. Well-nourished children have higher test scores, better school attendance and fewer classroom behaviour problems. Therefore children need the tools to make nutritious selections. Most children are making food choices daily in the school cafeteria. Many children are also deciding what they will eat for breakfast, snacks and even dinner. Nutrition education provides them with the tools they need to make smart food choices (National Dairy Council, 2005).

In the UK and many other parts of the world the problem has been clearly recognised and nutrition education targeting young children started to take place mainly in schools and settings where the main targeted audience is children. In other developing nations however, such as UAE, the problem is still not well recognised, and no significant preventive actions to battle childhood obesity epidemic have been taken, although childhood obesity is reaching epidemic trends (Malik, et al., 2006). Abduelkarem, 2005, identified a number of factors that have caused such an increase in the childhood obesity trends. Primarily the economic development of the past three decades and progress in the socio economic level has brought many benefits to the region, such as health care access, education and safe drinking water. However, this progress has generated a dramatic nutrition transition through the transformation of lifestyle and eating patterns in the region (Abduelkarem, 2005). Moreover, the relatively hot climate (40ºC during the majority of the year) limits outdoor activity. It is also worth mentioning the type of clothing dominant in the region, where the loose white and black robe for both males and females is the main reason why the weight gain goes unnoticed (Abduelkarem, 2005). The previously discussed factors are largely the main reasons why the childhood obesity trends in UAE are spreading.

This pilot study aimed mainly to develop and evaluate the impact of a nutritional educational package that employs a nutrition and physical activity booklet. The latter was designed for primary school children (6-9 years old) in UAE. One of the anticipated outcomes of this pilot study was to evaluate the gained knowledge about nutrition and physical activity among the school children in a typical nutrition transition location.

Methodology:
The study was based on a pilot intervention for changing behaviour without giving food. For this purpose a toolkit was developed from scratch that aimed to raise awareness and facilitate the message delivery among school children aged 6-9 years towards food and physical activity in the United Arab Emirates. The study targeted a sample size of 100 pupils selected from one of the schools in the UAE.

Booklet Development: The toolkit was developed at the beginning, containing four main chapters that describe the nutrients and food groups clearly and simply in addition to the main messages to be delivered to the targeted readers (consume five fruits and vegetables a day and reduce the consumption of high fat, sugar and salt food). The final chapter gave information about physical activity, and encouraged daily physical activity while limiting screen-viewing time to two hours per day. Pictures for the booklet were taken from the clipart store after a paid subscription of one month to the website and after asking permission to use the pictures in educational material for an academic purpose. After the collection of pictures and the development of the table of contents, the next step was starting the development of the booklet content itself. The development of the pre-intervention and post-intervention questionnaire was a subsequent step after the confirmation of the booklet content. As a part of the educational package a power point presentation was developed based on the information in the booklet, aiming at clarifying the booklet content and encouraging the participants to interact with the lecturer and take the most from it.

Project implementation: The British School in Al Ain was chosen as a good medium for the intervention mainly due to their highly appreciated collaboration. The chosen school principal was approached and met prior to receiving a formal letter from the University of Westminster. After the agreement about the collaboration and the intervention process, teachers were met to organise the dates and the time allocation for the intervention. Firstly children from grades three and four were given a consent form (100 forms were distributed) for their parents to sign and return to school. Those who brought the consent slip back were included in the intervention. In total, 29 girls and 31 boys (60 in total) were given a pre-assessment questionnaire to complete at school. One week later the children were collected at the PE hall where they were given a one-hour lecture about the developed booklet and given one copy of the booklet . The content was thoroughly explained and the main messages were promoted during the lecture and after one week the participants were allowed to half an hour to complete the post assessment questionnaire. It is worth adding that both the pre and post-assessments were invigilated, with two teachers of both grades three and four, in addition to the investigator, were available in the lecture hall during the questionnaires distribution, completion and collection.

Ethical considerations: All the ethical procedures were taken before the beginning of any fieldwork and implementation of the project. The ethical clearance part A was filled in and the collaborated school received an official letter from the university of Westminster. Moreover all the selected participants were given a consent form for their parents to sign it before the intervention.

Statistical analysis: The questionnaires collected were analysed using SPSS version 16 and the frequency tables were obtained.

Results:
Table 1 describes the demographic distribution of the sample size. The sample size age was concentrated between eight and nine years old where, 43.3% were eight years old, and 35% were nine years old. A few of the participants were aged 10 (6.7%) and seven years (15%). The gender distribution was largely equally distributed, with 52% of the participants girls and 48% boys. There was a largely equal distribution among the school years as well, with 45% of participants being in Year 3 and 55% in Year 4.

The pre and post-assessment questionnaires were divided into four main parts, the first part, which was concerned with general nutritional knowledge evaluation, is described in table 2. From this table it can be concluded that 47.5% of the participants reported a previous knowledge about the number of food groups, while 51.5% didn’t. Moving to the second question, 82% of the participants reported that we need food from all food groups for a healthy diet, compared to 17% who reported the wrong answer to this question.

Table 3 represents the second and third parts of the pre-assessment. The majority of the participants reported a good knowledge about the food items and food groups where 78.7%, 62.3%, 91.7% respectively chose the correct food items belonging to the milk group, fruits group and meat group. In the vegetables group only 20% reported correct answers. In the third part of the questionnaire, 41% of the participants reported correct answers for the food group that helps builds muscles (meats group), 75% reported correct answers for the food group that builds bones and teeth (milk group) and 68.3%,reported that the fats and sugars group is the one responsible for weight gain and tooth decay.

The last part of the pre assessment is described in table 4. This part was mainly concerned about the key messages delivered during the intervention. The results revealed that before the intervention 58.3% of the participants reported that screen viewing should be limited to two hours a day and that fruits and vegetables should be consumed five times a day. A total of 53.3% reported that they should be physically active for an hour a day at least and 45% reported correct proportional distribution of food groups on the healthy plate.

The post assessment has revealed 100% correct answers in all the parts of the questionnaire, for all the participants.

Discussion:
Demographic distribution:
The age disrtibution of the data as displayed earlier in the results section. The targeted age group of the study was children aged six to nine. A few participants were aged 10, but the rest ranged between seven and nine years old. Previous investigations targted the same age group in primary schools, ages 6 to 11 (Manios, et al., 1999, Anderson, et al., 2004, Brownell et al., 1982). Others, however, extended the targeted group to include adolescents up to 16 years old (Al Haddad et al., 2000, Malik et al., 2006). Some investigations have included various target groups, for instance, parents of the children and teaching staff of the setting schools were included in work by Wagner and colleagues (2005) previously, where they also did a pre and post-assessement to extract the impact of nutritional education intervention on the targeted groups (Wagner et al, 2005). On the other hand, Anderson and colleagues (2004) have included children seperately to investigate the increase of fruits and vegetables intake after the provision of several points of purchase (Anderson et al, 2004). Understandbly this investigation has included only children as a pilot study with limited assinged time to extract the impact of an educational booklet designed for primary level (six to nine years old) on their awarness towards nutrition and physical activity.

Pre and Post assessment:
From the results displayed previously in the results section, 67% of the participants reported their previous knowledge about food groups, which is relatively a large proportion of the sample size. But surprisingly only 47.5% of them reported the correct number of food groups, while the others reported wrong numbers in the following question. Another general question that all the participants reported a correct answer to about was the food groups needed to maintain a good health, with 82% of the participants giving the correct answer, which was food from all the food groups, while the rest of the participants answered wrongly. The results of this section of the questionnaire revealed a previous knowledge of the participants about general nutrition aspects. A good justification for these results is that the school where the intervention took place already had some fundamental nutrition information embedded in their curriculum. This was previously not evaluated, which has given even more potential to the implemented intervention, where the pre-assessment has thoroughly evaluated this pre-existing information, in order to avoid the bias and extract the typical impact of the intervention through the post assessment. Unsurprisingly the post assessment questionnaires revealed an excellent increase in their awareness, where all the participants reported their knowledge about the food groups and food guide pyramid and selected the correct number of food groups in the food guide pyramid. Similarly the pre-assessment reported 78.7% of the participants answered correctly when they were asked about the food items that belong to the milk group, 62.6% for the fruits group and 91.7% for the meats group. A good justification for these results was that some food groups nomenclature directly reveals the food items included in it, for instance the milk group directly reveals that yogurt and cheese and dairy products are included in this category of the food guide pyramid. The meat group is another good example, as what constitutes meat is common information that everyone knows, and as the questionnaire was simple and designed for primary level, it didn’t include some tricky food items that might confuse the reader in classifying them to a certain food group (beans, eggs, etc,). Surprisingly the vegetables group question came in with 80% wrong answers., A good reason for this result could be the great variety of vegetables, which can baffle the reader at a beginner level in addition to the great proportion of the participants who were not English native speakers. Therefore some terms and names of certain types of vegetables might be new to them. Generally the knowledge of food groups was directly raised to 100% correct answers for all the participants after the intervention and the post-assessment revealed the unified level of knowledge the participants acquired after the intervention.

The pre-assessment data in this part of the questionnaire aimed to assess the participants’ knowledge about the nutrients and their role in the body. 41% reported the correct answer for the role of meats and the protein content in building muscles, 75% reported the role of the milk group and its calcium content in building strong bones and teeth, and 68.3% reported correctly the role of fats and sugars in weight gain. As reported earlier in this section the impact of some fundamental nutrition knowledge might have had a direct impact on their pre- intervention knowledge. Moreover the role of certain nutrients in the body is obvious, such as milk and calcium for teeth and bones; it is commonly believed that milk is a key food for healthy bones and teeth, since this information is circulating via different types of media and advertisements. Similarly fats and sugars are commonly known to be the main reason of obesity and excessive weight gain; therefore the results are largely justified. However, the post- assessment results demonstrated correct answers by all the participants without exceptions, which indicate the effective impact of the intervention and the booklet on the targeted group.

As mentioned earlier the intervention booklet was promoting four main key messages; reducing screen viewing time, increasing physical activity, consuming five fruits and vegetables a day and reducing the high fat, sugar and salt in food items. The pre-assessment results for this section, revealed that almost half of the participants reported correct answers (58.3%, 53.3%, 45% and 58.3% respectively) to screen viewing time, daily physical activity, healthy plate components and five a day, and have reported correct answers for the four questions, while the second half have answered wrongly. The post-assessment results revealed a noticeable increase in general awareness, with all the participants reported correct answers.

Generally a noticeable increase in the knowledge about nutrition and physical activity was attained as revealed by the post intervention assessment results; all the participants reported their knowledge about all the issues covered by the booklet and the intervention, which reflects the potential of the piloted booklet and intervention in raising the awareness of the targeted group.

The results of this investigation are strongly supported by the similar results of previous investigations. Wagner and colleagues (2005) have concluded the same results comparatively in their similar intervention, with a statistically significant improvement of general nutrition related knowledge between the pre and the post-test across all the participants (Wagner, et al, 2005). Furthermore, other studies, which were based on practical evaluation of the outcomes such as biomedical tests and anthropometric measurements, strongly support these results, and according to Manios and colleagues (1999) the nutritional intervention results within three years had a direct impact on the behavioural change of the participants, which was mainly detected in the positive serum level changes, smaller BMI increase among the intervention group, recognisable increases in the nutritional and physical activity awareness and an improvement in fitness levels (Manios, et al, 1999). Similarly, on a practical basis, Brownell and colleagues (1982) have investigated the impact of educational intervention on weight loss. The results were encouraging, showing the intervention group lost more weight than the control group(Brownell, et al, 1982) For the same purpose, Anderson and colleagues (2004) have investigated the impact of the provision of more fruits and vegetables in the school premises on the consumption of these vital food items in school children, Anderson’s investigation resulted in an average increase in fruits intake and a general increase in nutrition related knowledge about fruits and vegetables, while the taste preferences remained unchanged (Anderson, et al, 2004).

Conclusion:
The evaluation of the intervention outcomes confirmed that the booklet was effective in raising the awareness of the targeted group towards a healthy diet and physical activity. The knowledge of the participants was raised to 100% in all parts of the questionnaire. The participants have demonstrated excellent interaction with the educational package.

Acknowledgement:
This work was highly supported by Dr. Ihab Tewfik, the supervisor of the research project, and Dr. Claire Robertson, the course leader, with special thanks to the project supervisor. Both are from the University of Westminster.

Tables:

Table 1 : demographic distribution of the sample

Table 2: the first part of the pre-assessment questionnaire (correct Vs wrong answers indicated)

Table 3: the second and third parts of the pre-assessment questionnaire, food groups and nutrients questions

Table 4: the last part of the questionnaire, key messages questions

References:

• Abduelkarem, A,R., (2005), Childhood obesity and type 2 diabetes:a growing public health challenge in UAE ,Diabetes voice,50( 3) 9-11.
• Anderson,A,S., Porteous,L,E,G., Foster,E., Higgins,C., Stead,M., Hetherington, M., Ha,M,A., Adamson,M,J., (2005), The impact of a school-based nutrition education intervention on dietary intake and cognitive and attitudinal variables relating to fruits and vegetables, Public health nutrition journal,8(6) 650–656.
• Agrawal.S.,(2008). Fluid Requirements of children. Complex child E-magazine.
• Aldinger CE, Jones JT, (1998), Healthy Nutrition: An essential element of a Health-Promoting School. WHO Information Series on School Health. Document four. Geneva: WHO
• ADA. Position of the American Dietetic Association, (1999), Dietary guidance for healthy children aged 2 to 11 years. J. Am. Diet Assoc, (99) 93-101.
• Amine.E.K., Samy. M., (1996)., Obesity among female university students in the United Arab Emirates, The Journal of the Royal Society for the Promotion of Health 116 (2) 91-96.
• Brownell, K,D., Kaye, F,S., (1982), A schools based behaviour modification, nutrition education, and physical activity program for obese children, The American journal for clinical nutrition 35:277-283.
• Malik,M., Balir,A., (2006), National Prevalence of Obesity: Prevalence of overweight and obesity among children in the United Arab Emirates, (8)15–20
• Marcus., B.H., Forsyth.L.H., Blair.S., (2003), Physical activity intervention series: motivating people to be physically active., Human kinetics.
• Mckenzie.J., Dixon.L.B., Smiciklas-Wright.H., Mitchell.D., Shannon.B., Tershakovec. A., (1996), Change in nutrient intake, number of servings, and contributions of total fat from food groups in 4-10 years old children enrolled in a nutrition education study, Journal of the American Dietetic Association, 96(9) 865-873.
• Ministry of Planning, Abu Dhabi, United Arab Emirates. National census Report, 1995
• Musaiger.A.O., Abuimeileh.N.M.,(1998) Food consumption patterns of adults in the United Arab Emirates. J R Soc Health, (118)146–150.

• Manios.Y., Moschandreas.J., Hatzis.C., Kafatos. A., (1999), Evaluation of a health and nutrition education program in primary school children of Crete over a three 3 years period, Preventive medicine journal, (28)149–159.
• My pyramid for kids, Eat right, exercise have fun, www. mypyramid.gov
• Nicklas.T.A, Webber.L.S, Johnson.C.C, Srinivasan.S.R, Berenson.G.S. (1995), Foundations for health promotion with youth: a review of observations from the Bogalusa Heart Study. J. Health Educ.; 26(2) S18-26.
• National dairy council. 2005, little nutrition expedition: nutrition backgrounder, Rosemont.
• Punnose .J, Agarwal .M.M., El Kadir . A, devadas. K, Mugamerit. (2002), Childhood and adolescent diabetes mellitus in Arabs residing in the United Arab Emirates. Diabetes Res Clin Pract (55) 29-33.
• Perez- Rodrigo, C., Aranceta,J., 2001, School-based nutrition education: lessons learned and new perspectives., Public Health nutrition, 4(1A), 131-139
• Picciano. M.F., 2009. Minerals. http//: Kidshealth.org
• Ramos.O.F., Andreas.M.E., Arce.L., (2003), Type 2 diabetes in youth, an increasing problem in Buenos Aires. Diabetes Metab, 29: 4S205.
• Resnicow .K., Smith .M., Baranowski .T., Baranowski .J., Vaughan .R., Davis .M., (1998), 2-year tracking of children’s fruit and vegetable intake. J. Am. Diet Assoc. 98: 785-9.

• Sweeting,H,N., (2007), Measurement and Definitions of Obesity In Childhood and Adolescence: A field guide for the uninitiated, Nutrition Journal, 6(32)1-8.
• Singh,R., Shaw,J., Zimmet,P., 2004, Epidemiology of childhood type 2 diabetes in the developing world, Blackwell: paediatric diabetes, 5: 154—168.
• Wagner,N., Meusel,D., kirch., (2005), Nutrition education for children—results and perspectives, Springer, (13)102–110
• Whitney, E,N., Rolfes,S,R. 2002., Understanding nutrition., Ninth edition., Wadsworth learning. United states of America.
• WHO 1997;WHO 2000; Robert Koch-Institute 2002