KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING HEALTHY DIET AND PHYSICAL ACTIVITY AMONG OVERWEIGHT OR OBESE CHILDREN IJPHCS

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International Journal of Public Health and Clinical Sciences e-ISSN : 2289-7577.Vol. 5:No. 4 July/August 2018

Suriani et. al. 254

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Open Access: e-Journal

KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING HEALTHY DIET AND PHYSICAL ACTIVITY AMONG

OVERWEIGHT OR OBESE CHILDREN

Azrin Shah AB¹, Aishath N¹, Al Oran HM¹, Hani Farhana N¹, Azreena MB¹, Fatima Dahiru M¹,Saba Babeli Y¹, Suwanmanee S¹, Hassan I¹, Alsharif Mohammed K¹, Sahar Saeed B¹, Mohamed Osman A¹, Suriani I², Ahmad Iqmer Nashriq MN², NorAfiah MZ², Rosliza AM²

1 Postgraduate student in the Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia

2 Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia

*Corresponding author: Suriani Ismail, [email protected]

ABSTRACT

Background: Inculcating healthy life style such as the habit of consuming balanced diet and performing physical activity among children could prevent them from becoming overweight or obese and thus avoid the risk of chronic diseases related with obesity. Such efforts are challenging yet crucial. This study assessed the immediate effect on children’s knowledge, attitude and practices regarding healthy diet and physical activity following an awareness programme.

Materials and Methods: A half-day childhood obesity awareness programme was conducted to encourage the practise of healthy diet and physical activity, and persuade against unhealthy food consumption and sedentary life style. The programme was carried out among 30 children aged 8-11year old in an international school in Putrajaya who were overweight or obese. A pre- and post-test design was carried out to evaluate their knowledge, attitude, and practice toward healthy diet and physical activity using pretested questionnaire. Comparison of pre- and post-test’ scores were carried out using paired t test.

Result: Over half of the respondents were female (63.3%) and obese (70.0%). The mean(sd) knowledge and attitude scores for healthy diet were 2.00(0.91) and 2.33(0.84). The mean knowledge score for physical activity was better i.e., 3.10(1.32) but the attitude scores was very low 0.87(1.07). After the programme, although not statistically significant there were slight increases in all scores, except ‘intend to practise’ physical activity after the programme.

Conclusion: The knowledge, attitude and practices regarding healthy diet and physical exercise among these children were low. A series of improved and validated programmes are recommended for greater impact.

Keywords: childhood obesity, awareness, knowledge, attitude, practice

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1.0 Introduction

Childhood obesity is a major public health issue globally affecting both developed and developing countries. The World Health Organization (WHO) estimated that over 340 million children and adolescents aged 5-19 years are classified as overweight or obese worldwide (WHO, 2018). In the United States of America (USA) the Centre for Disease Control and Prevention (CDC) reported that the rate of obesity, which is currently at 18.5%, has tripled since 1970s (CDC, 2018). In the United Kingdom (UK), data showed that the current rate of childhood obesity is 20% (NHS Digital, 2017). The prevalence of childhood and adolescent obesity has also increased significantly in developing countries such as India and China. In India it raised from 16.3% in 2001-2005 to 19.3% in 2010, and in China, the results of trend analyses for the 25-year period revealed a significant trend in obesity prevalence between 1985–2010 in males (RR, 1.59; 95% CI, 1.58–1.60) and in females (RR, 1.49; 95% CI, 1.48–

1.50) (Ranjani et al., 2016; Sun, Ma, Han, Pan & Sun, 2014).

Malaysia is another developing country that experiences a similar rise in the prevalence of childhood obesity. According to Malaysian National Health and Morbidity Survey 2017, the overall prevalence of overweight and obesity children in Malaysia in 2017 was 11.9%. The prevalence was higher in boys, (13.6% (95% CI: 12.2, 15.2)) and among urbanite (12.1%

(95% CI: 10.9, 13.5)). By ethnics group it is highest among the Chinese, (13.0% (95% CI:

10.0, 16.8)) followed by the Indians and Malays (NHMS, 2015). Since childhood obesity is often linked to chronic conditions that carry into adulthood, high obesity rates will definitely hinder the fight against illnesses such as cardiovascular disease and Type 2 diabetes (Mozaffarian, 2016; Sahoo et al., 2015). Moreover, childhood obesity has shown to cause social and psychological problems that compromised the ability of the child to interact freely.

Children with obesity are often stigmatized, bullied and teased and thus more likely to suffer from social isolation, depression and lower self-esteem (Al-Agha, Al-Ghamdi, & Halabi, 2016)

Excessive calorie intake and/or insufficient physical activities are two major predictive factors associated with childhood obesity (Hruby & Hu, 2015; Kar & Kar, 2015). Excessive calorie intake could be due to uncontrolled consumption of sugary beverages, unhealthy snacks and big portion size meal (Sahoo et al, 2015). Insufficient physical activities on the other hand were mainly attributed to sedentary lifestyle contributed by the increasing screen time among children (Saliba, 2015). Governments across the world including Malaysia have been devising strategic policies and interventions to countermeasure these issues by engaging education authorities as well as governmental and non-governmental schools. Such efforts include awareness and education campaigns in school aiming at improving student’s knowledge and attitude towards good health particularly in practicing healthy diet and being physically active (Wang et al., 2015, Hatta, Rahman, Rahman, & Haque, 2017).

There have been several studies highlighting the prevalence of overweight and obesity of school-aged children in Malaysian local schools (Hoque, Megat Ahmad, Ahmad Zabidi &

Afiq Athari,2016, Naidu et al., 2017), however studies focusing on children attending Malaysian international school is scarce. The aim of this study was to assess knowledge, attitude and practice regarding healthy diet and physical activity among a group of overweight and obese children in an international school and to evaluate the effect of an obesity awareness programme on improving these components.

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2.0 Materials and Methods

2.1 Study design and study location

This was a pre-post one group intervention study in conjunction with an awareness programme titled ‘Childhood Obesity’. It was carried out in April 2018 in an international school in Putrajaya. The school is a non-profit institution founded in 2007 that offers lessons in Arabic and English. It is currently accommodating about 2000 students from various nationalities across the globe, some of whom are refugees from war-torn countries.

2.2 Study Participants

This study involved 30 children aged 8-11 years who were either overweight or obese. They were selected by the school nurse and their body mass index (BMI) was measured prior to the programme. The cut-off point was BMI reading of 23 (de Wilde, van Dommelen &

Middelkoop, 2013). Invitation was extended to the student and their parents, of which, consent was granted.

2.3 The programme

The intervention programme was designed following the recommendations endorsed by the American Academy of Paediatrics to promote optimum health during primary school years (Hassink, 2010; Spear et al., 2007). It was based on the ‘5-2-1-0 rule’ where ‘5’ refers to five or more servings of vegetables and fruit per day, ‘2’ refers to not more than two hours of screen time per day, ‘1’ refers to one hour of physical activity or more per day, and 0 refers to zero sugar sweetened beverages per day (refer Table 1 for summary of flow of sessions). The educational activities were split into five sessions. The first session was a drama about ‘5-2-1- 0’ rules while the second session was designated for physical activity emphasizing on the fun aspect of being active. BMI of each child was calculated in the third session and results were later plotted by each child on the BMI chart (prepared according to gender) to illustrate the category they were in. In the fourth session, the healthy dietary habit was introduced through demonstration of the ‘half (vegetable and fruits), quarter (grains), quarter (protein)’ plate concept. The last slot was reserved for interactive session that included games and quizzes to consolidate the children’s knowledge, attitude and practices regarding healthy diet and physical activity. Prizes were given out to children to encourage participation and sustaining their attention.

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Table 1: Contents of the health promotion programme on awareness of childhood obesity

2.4 Study instrument and data collection

The data were collected using a structured self-administered questionnaire. Data were collected at the start of the programme and again after the programme conclusion. The questionnaire was in English and was divided into two main sections. Section A consisted of questions on demographics and frequency of eating out. Section B measured the participants’

level of knowledge, attitude and practice toward healthy diet and physical activity. There were 15 questions in each diet and physical activity domain (i.e. 5 for knowledge, 5 for attitude and 5 for practices). Additional phrases were added (i.e. ‘intend to’) for the post intervention questionnaire to assess the intention to change relevant practices. Changes level of knowledge, attitude and practice on the diet and physical activity were outcomes for the effect of the programme.

2.5 Data analysis

Data were organized and analysed using the Statistical Package for Social Sciences (SPSS) version 22. Both descriptive and inferential statistical tests were used. Descriptive analysis of frequencies, percentages and mean (sd) were used to assess respondents’ characteristics. The responses to knowledge questions were dichotomized into ‘correct’ and ‘incorrect’ while the responses to attitude questions into ‘appropriate’ and ‘inappropriate’. For knowledge, one (1) mark was given for a correct answer and zero (0) mark for an incorrect answer while for attitude(1) mark was given for a appropriate attitude and zero (0) mark for inappropriate attitude. Scores for questions that were written as negative statements were reversed accordingly. Thus, the score range for both knowledge and attitude was 0-5.

As for practice, the phrase ‘intend to practice’ were added to the post programme evaluation statements. The choice for practice responses were ‘everyday’, ‘3 times per week’ and ‘once a week’. For positive practices a score of ‘3’ was given for ‘everyday’, ‘2’ for ‘3 times per

Session Main activity Components Time

minutes 1. Introduction 1. Introduced goal of the programme.

2. Drama/sketch about "5-2-1-0" rule.

5 minutes 15 minute 2. Physical

activity

1. Introduction to fun physical activity.

2. Zumba dance session.

3. Three other songs were played for warming up, intense fitness and cooling down session

15 minutes 15 minutes 20 minute Break Milk, water, and banana was served 10 minutes 3 Measurement 1. Measured weight and height.

2. Calculated body mass index (BMI).

4. Self-check BMI category according to gender

20 minute 20 minutes 15 minutes 4 Healthy diet 1. Introduction to ‘healthy plate’ concept

(half plate for fruits and vegetables, quarter plate for protein and quarter plate for grains) (using power point, video and poster)

2. Jigsaw puzzle; Arranged images according to the healthy plate recommendations

20 minutes

10 minutes 15 minutes 5 Interactive

session

Quiz and game related to content delivered in session 2 and 4.

30 minutes

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week’, and ‘1’ for ‘once a week’ while a reverse score was adopted for the negative practices.

The score range for practice was 5-15.

The knowledge, attitude, and practice toward healthy diet and physical activity scores were summed up for respective domains and paired sample t-test was used to test the pre and post- programme score differences. Level of significant was set at p< 0.05.

3.0 Result

3.1 Characteristics of the children

Table 2: Socio demographic characteristics of the children and frequency eating out (N=30)

Variable Mean (sd) Frequency (n) Percentage(%)

Age (years) 9.5(0.8)

BMI kg/m² BMI category Overweight Obese Gender

23.3(3.2)

9 21

30.0 70.0

Male 11 36.7

Female 19 66.3

Father’s highest educational level

No formal education 2 6.7

Primary school 3 10.0

Secondary school 2 6.7

Degree/Diploma 23 76.6

Mothers’s higest educational level

No formal education 13 43.3

Primary school 2 6.7

Secondary school 4 13.3

Degree/Diploma 11 36.7

Thirty children aged 8-11 years participated in this programme. Table 2 shows that the students mean age was 9.5 (0.8) years with two-thirds of them being female (66.3%). Most of their father had tertiary education (76.6%) while most mothers had no formal education (43.3%). In terms of dietary habit, 66.7% eat out 1-2 times per week. Also, most of the respondent are obese (70%) and their mean BMI was 23.2(3.2) kg/m².

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3.2 Knowledge, attitude and practices regarding healthy diet

Table 3: Responses to knowledge, attitude and practice toward healthy diet before programme (N=30)

Statement

n(%) n(%)

Knowledge statements Correct Incorrect

K1. Drinking sugary drink frequently can lead to obesity 10 (33.3) 20 (66.7) K2. Eating fruits and vegetables can help prevent diseases 5(16.7) 25(83.3)

* K3. Milk is not needed in daily diet 21(70.0) 9(30.0)

K4. Protein is needed for growth 4(13.3) 26(86.7)

* K5. Eating two plates of rice during lunch is acceptable 20(66.7) 10(33.3

Attitude statements

Appropriate attitude

Inappropriate attitude

* A1. I think sweet food and drinks are good for health 27(90.0) 3(10.0)

* A2. I think children can eat more than 1 plate of food. 19(63.3) 11(36.7) A3. I think it is very important to drink lots of water everyday 2(6.7) 28(93.3) A4. I think eating fruits can help protect me form diseases 2(6.7) 28(93.3)

* A5. I think snack such as potatoes chips is good for children 20(66.7) 10(33.3)

Practices Statements

>3 times per week

< 3 times per week

P1. I eat fruits and vegetables 3-5 times per day 5(16.7) 25(83.3)

* P2. I eat fried food/fast food 5(16.7) 25(83.3)

P3. I drink at least 8 glasses/2 liters of plain water per day 2(6.7) 28(93.3)

* P4. I have a second plate during lunch/dinner 17(56.7) 13(43.3)

* P5. I eat snacks such as potatoes chips. 20(66.7) 10(33.3)

* negative statements or statements for reverse scoring

Table 3 shows the responses for knowledge, attitude and practice toward healthy diet statements before the programme. Although the questions were set in reverse statements, most of the children knew that they should include milk in their daily diet (70%), while 66.7%

knew that they should not eat more than a plate of served food (main dish such as rice, noodles etc.). Similarly, despite attitude’s reverse statements most of the children had appropriate attitude toward ‘sweet food and drinks’ (90%), ‘snacks such as potatoes chips’

(66.7%) and ‘eating more than 1 plate of food’ (63.3%). Unfortunately, in term of practices, most of the children ‘eat snacks such as potatoes chips’ (66.7%) and have ‘second plate during lunch or dinner’ (56.7%) every day.

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3.3 Knowledge, attitude and practice regarding physical activity

Table 4: Responses to knowledge, attitude and practice toward physical activity before programme (N=30)

Statement n(%) n(%)

Knowledge statements Correct Incorrect

1. Regular exercise can help build strong bones and muscles 27(90.0) 3(10.0) 2. Regular physical activity could prevent obesity 18(60.0) 12(40.0) 3. Regular exercise leads to lesser diseases risk 13(43.3) 17(56.7)

4. Exercise can reduce stress 13(43.3) 17(56.7)

5. Sitting more than 2 hours is bad for bone and muscle. 22(73.3) 8(26.7)

Attitude statements Positive Negative

1. People who exercise regularly is healthy 2(6.7) 28(93.3) 2. Most people who do not exercise are lazy 6(20.0) 24(80.0))

3. The whole family should exercise 2(6.7) 28(93.3)

4. Doing physically activity is fun 1(3.3) 29(96.7)

* 5. Doing exercise is tiring and painful 15(50.0) 15(50.0)

Practices Statements >3 times per

week

< 3 times per week

1. I walk slowly 20 minutes. 14(46.7) 16(53.3)

2. I walk fast for 20 minutes. 7(23.3) 23(76.7)

3. I play sports (such as badminton, bicycling, football, running and etc). 8(26.7) 22(83.3) 4. I play video games/watch TV for less than 2 hour. 12(40.0) 18(60.0)

* 5. I play video games/watch TV for more than 2 hours 18(60.0) 12(40.0)

* negative statements or statements for reverse scoring

Table 4 shows the responses to knowledge, attitude and practice toward physical activity statements before the programme was conducted. Most of them know that ‘regular exercise can help build strong bones and muscles‘(90%) but ‘sitting more than 2 hours is bad for bone and muscle‘(73.3%). Thus, in general, most of the children grasp the basic principle that they need to be physically active to stay healthy. The attitude toward physical activity was not that promising where the highest percentage was recorded for statement ‘doing exercise is tiring and painful (50%) with only 1 child agree that ‘doing physically activity is fun’. In term of practices, all children ‘play video games/watch TV everyday’, 60% for ‘more than 2 hours’

and 40% ‘less than 2 hours per day’.

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3.4 Changes in knowledge, attitude and practices

Table 5: Mean total knowledge, attitude and practices score toward healthy diet and physical exercise pre and post programme (N=30)

Variable Pre Programme Post

programme

p value 95%CI

Mean(sd) Mean(sd)

Healthy diet

Knowledge score 2.00(0.91) 2.13(0.81) 0.55 (-0.59,0.32)

Attitude score 2.33(0.84) 2.57(0.89) 0.15 (-0.55,0.09)

Practice score 10.30(1.39) 10.57(1.83)# 0.43 (-0.95,-0.80 ) Physical activity

Knowledge score 3.10(1.32) 3.50(1.38) 0.19 (-1.00,0.21)

Attitude score 0.87(1.07) 1.03(1.06) 0.36 (-0.53,-0.92)

Practice score 10.06(2.07) 10.06(1.92)# 1.00 (-0.70,-0.67)

Paired t test, significant p <0.05

# ‘intend to practice’

Table 5 shows that the mean score for knowledge and attitude towards healthy diet and physical activity and ‘intend to practice’ healthy diet increased slightly after the programme although not statistically significant. However, the mean score for ‘intend to practice’

physical activity did not change at all.

4.0 Discussion

This was an awareness programme developed based on a set of known principles used in similar programme for children in USA (Hassink, 2010; Spear et al., 2007). We evaluated the baseline knowledge, attitude and practices of 30 overweight and obese children regarding healthy diet and physical activity, and the effect of the awareness programme on these three factors afterwards.

From the baseline data, it was found that their overall knowledge on healthy diet was limited.

Analysis of the individual statements showed that most knew milk is important to be included in their daily diet and they should not eat more than the quantity of a plate of main dish.

However, most do not know the importance of consuming fruits, vegetable and protein, and the consequences of drinking sugary drinks. These findings should be a cause for concern among all stakeholders of children’s health, as limited dietary knowledge was found to impede children’s ability to consume a well-balanced diet and is associated with child obesity (Trichesa & Giuglianib, 2005).

Attitude towards the importance of consuming fruits and vegetables was also poor which corroborated their pre-programme dietary practices. This finding is supported by studies from Europe and USA which reported that approximately 80-90% of children aged 4-13 years old failed to meet the recommended fruits and vegetables servings (Vereecken, Keukelier &

Maes, 2004, Guenther, Dodd, Reedy & Krebs Smith, 2006). It is also consistent with the local study that found most children in Malaysia do not like vegetables (Norimah & Lau, 2000).

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Attitude towards the importance of consuming adequate water was also poor among the children and this concurred with their practices. Similarly, a study in USA showed that most children failed to meet water intake recommendations (Drewnowski, Rehm, & Constant, 2013). This is worrying because inadequate water intake is related to adverse health effects such as headache, urolithiasis, and impaired cognition (Goodman et al, 2013), and could also cause one to experience higher burden of chronic disease in the long run (D’Anci, Constant &

Rosenberg, 2006; Stookey, 2010). Furthermore, in the context of this study, increasing water consumption may also help limit excess weight gain among children and adolescents (Muckelbauer et al., 2009; Daniels & Popkin 2010).

Snacking practices are common among these children. Snacking in this research refers to potato chips that were high in salt and sugar which contribute greatly to obesity epidemic.

Despite knowing that they shouldn’t eat more than the quantity of a plate, most of them do.

These are negative signs since several studies had indicated that the consumption of unhealthy snacks and uncontrolled portion size are contributors to being overweight (de Graaf, 2006, Romieu et al., 2017, Sahoo et al.,2015).

Knowledge regarding physical activity among these children was quite good but the attitude and practices toward physical activity were poor. Most of the children find that physical activity is not fun, tiring and painful and naturally are more likely to participate in a more fun and less painful activities such as watching television and playing video games. The element of fun is sometimes lost in sports as it focuses on technical aspects, leading to less opportunity for free expression and fun. Studies had showed that children who spent more than 2 hours per day on viewing television or using a computer are more likely to be obese (Arluk, Branch, Swain, Dowling, 2003). This is in line with many other studies which reported that among perceived barriers to leisure-time physical activity is preference to do other things that is more fun and less tiring and that the continuity of doing physical activity is mediated by

‘fun’ experiences (Dias, Loch & Vaz Ronque, 2015, Visek et al, 2015).

Assessment of the pre- and post- knowledge, attitude and practice’s scores of both healthy diet and physical activity revealed no significant improvement. This could be attributed to the limitations of this study which includes the small sample size and the fact that improved knowledge does not necessarily bring positive changes. The children’s academic level was not assessed prior to recruitment. There is a possibility that academically weaker students were unable to fully comprehend the questions being asked of them especially the reversed statements given their intelligence level. Also, the study period was short and only focused on immediate learning instead of long term retention. Moreover, this study did not look into parents’ influences, gender and cultural biases which effects not only dietary preferences but also physical activity practices. Despite the findings of this research, school and health programmes at school were found to be one of the key element in inculcating a health- conscious culture among students and should be advocate continuously (Hoque, Megat Ahmad, Ahmad Zabidi & Afiq Athari , 2016, Wang et al,2015).

One of the main limitations of this study was the small sample size which compromises its statistical power to detect an effect. Also, the study did not assess the associations of knowledge, attitude and practices of healthy diet and physical activity of the children with sociodemographic characteristic of their parents. Studies had reported that children’s eating habits are always influenced by factors such as family socioeconomic status and mothers who prepare food for the family. For example, a study among Malaysian primary school children

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found that guardians with tertiary education background reported higher overweight prevalence and was found to have the highest prevalence in having an overweight child (Naidu et al, 2017). A review of similar associations in 12 countries showed mixed results where there was a positive relationship between maternal education and child overweight in Colombia and Kenya but a negative relationship between paternal education and child overweight in Brazil and USA (Muthuri et al., 2016). Lastly, this study did not explore confounders such as country of origin and the children’s ethnicity. Obesity perception and diet practices varies in different culture. In Malaysia for example, a study among Chinese family suggested that overweight is a sign of prosperity, success and good health and thus children were encouraged to eat more (Soo, Wan Abdul Manan, Abdul Manaf & Lee, 2011).

5.0 Conclusion and recommendation

Knowledge, attitude and practices on healthy diet and physical activity among the children in this study were poor. The awareness programme however, did not show significant improvement. Nevertheless, it is still recommended that health programmes should be carried out at schools to encourage healthy diet and active lifestyles among school children especially those who are overweight and obese. However, the content and method of delivery of health education materials should be improved, validated and tailored appropriately to the target population. Duration of the programme should also be longer and preferably conducted in multiple sessions.

Acknowledgement

Ethical approval was obtained from the Ethical Committee of Universiti Putra Malaysia (UPM/TNCPI/RMC/JKEUPM/1.4.18.2 (JKEUPM). The authors wish to thank the Modern Arabic International School, Precinct 14 and all the children who had participated in this programme and their parents who has consented their participation. The article reflects the research findings, and do not necessarily represent the official views of affiliated organization.

Declaration

The authors declare that there is no conflict of interest regarding publication of this article.

Authors’ contribution

Author 1-3 - prepare of manuscript, Author 1-12 - prepare programme and collect data, Author 13-16 –supervise, review and edit manuscript.

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