Childhood Obesity and Nutrition Interventions in the UAE
Childhood obesity exhibits an alarming upward trend in UAE schools. Notably, unhealthy dietary habits significantly contribute to this increased incidence. Determination of efficient networks of delivering nutritional information can significantly curb the detrimental effects of obesity in UAE schools. This study aims to compare the effectiveness of delivering nutritional interventions using one to one sessions and family/peer support group methods in 9-14 year old students from cycle 2 in Sharjah and Dubai public schools. The anthropometric measurements, including weight, height, and waist circumference, will be collected from August to September 2021 (baseline) and 6 months after the intervention. Subsequently, the students will be divided into three groups, where the control (group 1) will not receive any treatment, whereas group 2 will receive nutritional knowledge one on one from trained personnel for about 30 minutes weekly. Similarly, group 3 will receive nutritional education together with their family members/peers.
The training sessions will also be for at least 30 minutes weekly. Additionally, various nutritional exposures will be given to the two intervention groups. Dietary practices will be enhanced through weekly monitoring by health coaches, awareness campaigns in schools, educational materials as posters and playing nutritional video games that encourage healthy eating. Moreover, self-efficacy support will healthy foods in school canteen and labelling them, as well as nutritional education on calorie count and portion control. Furthermore, in-depth interviews will be conducted on parents of the students in the intervention groups to support the change in lifestyle of their children. Control group will be used for comparison to determine the effectiveness of one to one sessions and family/peer support group methods on dietary practices, nutritional knowledge, and self-efficacy. The results of the study will be useful in identifying effective approaches of administering nutrition interventions to promote a healthy lifestyle among 9-14-year-old school children.
Obesity is a challenging threat to the public health of children and adolescents in United Arab Emirates (UAE). Moreover, a countrywide increase in prevalence of the condition has been reported in various schools. Particularly, the obesity/overweight cases in adolescents aged 11-18 years substantially increased from 21.2-21.7% in 2005, to 35.6-42.1% in 2016 (Pengpid & Peltzer, 2020). Furthermore, large-scale epidemiological research performed in Ras Al Khaimah, UAE, established that obesity incidence in schools exhibited an upward trend in students aged 3 to 18 years; the proportion of obese students increased steadily (2.36%) annually (Al-Blooshi et al., 2016).
In Abu Dhabi, the percentage of obese school students was 18.9% (Junaibi et al., 2012), and 26.7% in Dubai (Hussain et al., 2015). Nationally, Bani-Issa et al. (2020) reported a high prevalence of obesity/overweight (34.7%) in UAE public school students. Therefore, developing effective strategies for delivering nutrition interventions to students is critical, and can potentially limit the high prevalence of obesity in UAE schools.
The alarming increase of obesity cases in UAE schools is largely attributable to diet (Ng et al., 2011; Pengpid & Peltzer, 2020). As evident, the UAE students showed high snacking tendencies, and majority preferred consuming high-calorie fast foods as opposed to the healthy traditional diets. Additionally, most students reduced their thirst using soft drinks instead of water (Ng et al., 2011; Pengpid & Peltzer, 2020). Moreover, the intake of fruits among the students remarkably decreased from 68.7% (2005) to 61.6% in 2016, whereas the consumption of vegetables reduced from 81.0% (2005) to 78.4% (2016) (Pengpid & Peltzer, 2020).
Importantly, Abduelkarem et al. (2020) identified consumption of unhealthy foods as the key contributor of the high frequency of obesity in students (6-11years) from various schools in Sharjah, UAE. Furthermore, the study exposed that candy and fast-food intake was considerably higher in boys (54.6%) than in girls (47.8%), and the eating habits of students correlated with their body mass index (BMI). Hence, promoting healthy eating habits in schools through nutritional interventions is critical in alleviating the challenge of obesity in UAE schools.
Studies indicate that most UAE students lack the nutrition knowledge required for adopting healthy eating habits. Moreover, information on the efficient mode of delivering this information is limited (Bani-Issa et al., 2019). Notably, the high prevalence of obesity in children and adolescents may worsen the heavy burden of non-communicable diseases (NCDs) in UAE. Childhood obesity poses a high risk of developing type 2 diabetes, heart diseases, and some types of cancer (Abduelkarem et al., 2020). Primarily, prevention is perceived as a crucial approach of combating the illness in schools (Abduelkarem et al., 2020). Therefore, evaluating the effective mode of administering nutritional knowledge is crucial in reducing childhood obesity in UAE.
Social cognitive theory can be used to enhance the administration of nutritional interventions to obese/overweight school students. The theory states that human behavior is influenced by personal (cognitive), environmental, and behavioral factors. The critical elements of personal factors include a student’s emotions and thoughts, which drives his/her attitude and expectation. Primarily, environmental factors refer to the external social and physical components that influence a student’s dietary practices. Lastly, behavioral factors encompass the skills and interventions acquired, which enable a student to exercise self-control or act in a particular manner (Bagherniya et al., 2018; Schunk & DiBenedetto, 2020).
Notably, the theory suggests that developing and maintaining a healthy behavior is dependent on a student’s social environment. Additionally, a student’s experiences determine the likelihood of a behavioral change since his/her expectations are usually attached to beliefs (Bagherniya et al., 2018). Moreover, Social cognitive theory is used to promote healthy dietary behavior through goal-directed behavioral change. Bagherniya et al. (2017) and Rosario et al. (2013) successfully used nutritional interventions based on social cognitive theory to induce changes in the dietary behavior of students aged 6-18 years. Therefore, delivering nutritional interventions based on social cognitive theory is promising in encouraging healthy eating habits among UAE school children.
The main construct of Social cognitive theory is mutual, and the three inter-related factors include cognitive, behavior, and the environment. The cognitive factors refer to characteristics that one has learnt over time, whereas behaviour is the enhanced understanding and skill of acting in a particular manner. Additionally, the environment involves the components that induce or trigger a particular behavior. The crucial elements include self-efficacy, behavioral capacity, observational learning, expectations, and reinforcements (Bagherniya et al., 2018; Schunk & DiBenedetto, 2020). Primarily, self-efficacy is based on an individual believing that they have control over their actions.
Moreover, behavioral capacity refers to enhanced understanding and skill of behaving in a particular manner. Notably, expectations and expectancies focus on the outcome of a particular behavioral change and the value assigned to it. Typically, observational learning describes watching and conducting oneself based on the outcome of other people’s behavior, whereas reinforcements involve encouraging behavioral changes through rewards or incentives (Bagherniya et al., 2018; Schunk & DiBenedetto, 2020). Therefore, the various constructs of social cognitive theory can be used to induce behavioral changes in obese/overweight school children and adolescents in the UAE. The aim of this study is to determine the effects of nutrition interventions on food choices, self-efficacy, dietary practices, and anthropometric measurements (weight, waist circumference) of overweight and obese students aged 9-14 years old in UAE schools (Dubai and Sharjah). The study will test the following two hypotheses:
- School-based one-to-one intervention sessions will result in significantly greater improvements in body weight, waist circumference, nutrition knowledge, dietary behaviors and self-efficacy compared to a control group among 9-14 old children and adolescents
- Intervention involving family/ peer support will lead to greater improvements in body weight, waist circumference, nutrition knowledge, dietary behaviors and self-efficacy compared to an intervention delivered only to the participant among 9-14 old children and adolescents
The main objectives of this study will be to:
- Examine the effects of nutrition intervention program guided by Social cognitive theory on nutrition knowledge, on food choices, dietary practices, self-efficacy, and anthropometric measurements of overweight and obese students aged 9-14 years.
- Compare the impact of one-to-one participant intervention with that given through the family/peer support groups.
- How does administration of nutritional knowledge influence food choices, self-efficacy, healthy dietary practices, and anthropometric measurements of overweight/obese students in UAE?
- Is nutrition intervention involving family/peer support groups for 9–14-year olds more effective than that delivered one-to-one to the participating student?
The research will target overweight/obese students aged 9-14 years old in schools located in Dubai and Sharjah. The collection of data will be performed using ‘Atlas questionnaire (Al-Hazzaa et al., 2011),’ ‘nutrition knowledge and healthy lifestyle behavior (Kalender et al., 2011)’ questionnaire with additional questions related to self-efficacy and dietary practices (Becher, 2009; Voss et al., 2017). Moreover, individual, in-depth interviews will be conducted with parents of children in the intervention groups. The questionnaires will be distributed to the target students from August to September 2021.
At the same time, anthropometric measurements, including the weight, height, and circumference, will be taken. Subsequently, at the beginning of March, re-distribution of questionnaires and re-take of anthropometric measurements will be conducted simultaneously. Notably, the sample size will be stratified into three groups, including the control (group 1), the one who will be taught using one to one sessions (group 2), the students that will be educated by family and peers (group 3). At the end the questionnaires will be re-distributed and anthropometric data will be obtained again at the beginning of March 2022 from the three groups and used to assess the effectiveness of one to one session and family/peer support groups in delivering nutrition interventions.
Trends in Prevalence of childhood obesity/overweight in UAE
Childhood obesity presents a massive challenge to global public health since it aggravates the susceptibility of individuals to terminal illnesses such as cancer, heart diseases, and diabetes. In UAE schools, a dramatic upsurge of childhood obesity/overweight has been observed in the last two decades. AlBlooshi et al. (2016) examined the frequency of obesity cases in government schools located in Ras Al‐Khaimah. The study involved children and adolescents aged 3- 18 years. Certified school nurses measured the students’ height and weight, and their body mass index (BMI) was calculated using the formula: weight (kg)/height (m) 2. Moreover, WHO growth charts were used to classify the obese (BMI ≥95th to <99th percentile), overweight ((BMI ≥85th to <95th percentile), and extremely overweight (BMI ≥99th percentile) students. The average of BMI of individuals in the different age brackets was determined for the males and females. Age-wise, the 11-18 years group exhibited the highest overweight cases (38-41.2 %), whereas 3-6 years had the lowest occurrence (11.5%).
Notably, the 15-18 years students (41.2%) had a significantly higher proportion of extremely obese cases in males compared to females (9.6 folds). Overall, the trend in prevalence of extreme obesity increased with age and was highest in the 15-year-old students of both sexes (AlBlooshi et al., 2016). The findings indicate that the prevalence has almost doubled in both sexes based on the values obtained in a similar study conducted in 1999. Al‐Haddad et al. (2000) determined the prevalence of childhood overweight/obesity in students aged 6-16 years. The BMI (kg/m2) values were used to identify the obese/overweight students in Ras Al‐Khaimah using the CDC and WHO growth charts. The overweight/obese male students were 16.5%, whereas the females were 16.9%. Age-wise, obesity prevalence was highest in ages 13 to 16 year (18.2-24.7%) compared to ages 6-7 years (6.5-9.6%). Therefore, urgent measures should be undertaken to contain the severe increase of childhood obesity in UAE schools.
Several national surveys have corroborated the disturbing trend in obesity/overweight prevalence in UAE schools. Pengpid and Peltzer (2020) conducted three cross-sectional studies in UAE schools to examine the trend in occurrence of multiple health indicators, including obesity/overweight. The national surveys were performed in 2005, 2010, and 2016. The eligible participants were adolescent students in grades 8, 9, and 10 aged 9-14 years old. Notably, the median age of the students was 14 years, and data were collected using self-administered questionnaires. The students were stratified into different age-groups and their BMI values for 2005, 2010, and 2016 were used to observe the prevalence. The findings revealed that the overweight/obese male cases doubled from 21.2% in 2005 to 43.2% in 2010 and 42.1% in 2016. Moreover, in females, the occurrence in 2005 (21.7%) was slightly higher than in males. Conversely, the prevalence in girls was relatively lower than in boys in 2010 (36.0%), and 2016 (35.6%).
Age-wise, both male and female students aged 14 had the highest prevalence in 2005 (23.6%) and 2010 (31.8%), whereas 16 years and older were the highest in 2016 (41.0%). Overall, the prevalence increased with age, from 2005 to 2016 with the 16-year-olds and beyond exhibiting a sharp increase compared to the rest (Pengpid & Peltzer, 2020). The findings were consistent with Bani-Isa et al. (2020), who observed a widespread occurrence of childhood obesity in schools nationwide (34.7%). The research targeted 13 to 19-year-old adolescents from public schools. The anthropometric indices, including hip and waist circumference, weight, and height, were measured and used to determine the waist-to-height ratio (WHtR), waist-to-hip ratio (WHR) BMI. Additionally, the percent body fat was measured using a body composition analyzer.
The BMI value (34.7%) was primarily lower than the body fat one (40.6%). Moreover, the body circumference measurements, including waist circumference (47.3%), waist-to-hip ratio (22.7%), and waist-to-height ratio (27.1%), were relatively high. Therefore, the national incidences of childhood obesity in UAE have grown by almost two folds in the last 11 years and the older children are at greater risk compared to the younger ones.
Factors contributing to the high prevalence of childhood obesity and proposed intervention
Nutritional experts link the rise in childhood obesity prevalence to unhealthy dietary habits. Bin Zaal, (2009) examined the relationship between dietary habits, and heightened risk of obesity among students aged 12 -17 years in Dubai. The weight and height of the students were measured and used to calculate the BMI, whereas the dietary habits were determined using family study questionnaires. The findings revealed that the risk of obesity was higher in students who did not eat breakfast (38.7%) than regular consumers (22.6%). Additionally, the frequency of snacking between breakfast and lunch (31.8%) exhibited a lower risk of obesity compared to snacking at midnight (40.4%).
Moreover, the risk of obesity was higher (41.0%) in those who eat while watching TV and when they are bored (35.3%). Notably, the consumption of soft drinks, fast foods, sweets, and chocolates significantly correlated with high obesity risk in boys (38.7-42.2%). Therefore, frequent snacking at midnight and increased consumption of fast foods, candy, and soft drinks contribute to the high childhood obesity prevalence in UAE.
Lack of nutrition interventions is a critical factor that fuels the childhood obesity/overweight prevalence in UAE. Al Junaibi et al. (2013) investigated the potential determinants of childhood obesity in Abu Dhabi students aged 6-19 years. Anthropometric measurements of both the students and their parents were collected by qualified nurses. Notably, the height, weight, and circumference measurements were obtained to determine the prevalence of obesity in the students. Additionally, interviews were conducted with the parents, and their measurements were obtained as well and correlated with that of their children.
Moreover, the dietary habits of the students and socioeconomic status were examined. The findings revealed that the obese students had a lower score for consumption of fruits (2.7) and vegetables (2.9) daily compared to ones with normal weight (3.1-3.3). Furthermore, the obese students had a higher score of overweight fathers (6.2) than the regular weight students (4.7). Therefore, the low consumption of fruits and high BMI of parents may be attributable to the low level of nutritional interventions.
Nutritional education is a practical intervention that can promote healthy eating habits among students. However, limited information is available on the effective mode of delivering the information to UAE students. Bani-Issa et al. (2019) investigated the influence of schools and parents on the perception of students towards diet and exercise. The participants were students in grades 7-12, and information regarding their schools, parents, lifestyle, and socio-demographics were obtained within 6 months. Subsequently, self-efficacy was assessed based on exercise and eating habits. Generally, the participants had low self-efficacy in both exercise and healthy eating habits, which was attributable to lack of nutritional interventions and motivation. Moreover, the average score of students who never received support from parents on nutrition (3.54), was considerably higher than those who acquired it (2.44).
Notably, parental support was through regular meals and prohibiting soft drinks, whereas exercise was mostly performed through support from the school. Therefore, parents and schools play a critical role in influencing the perception of students towards a healthy lifestyle. Importantly, determining the effectiveness of delivering nutritional interventions through one to one session and family/peer support groups is crucial in promoting healthy eating habits in UAE students.
Theory-based nutrition intervention: Social Cognitive theory
Nutritional education based on social cognitive theory has been successfully applied in inducing dietary changes in obese adolescent students. Bagherniya et al. (2017) evaluated the effect of nutritional education based on social cognitive theory on the anthropometric measurements of adolescent students (12-18 years) from various Iranian schools. The study focused on inducing dietary changes in students and reduction of body weight through interventions that were founded on social cognitive theory constructs, including personal (self-efficacy, outcome expected), environment (parents and teachers), and behavioral factors (skills and interventions). Moreover, the nutritional education was administered through workshops and interactive seminars. The sessions were held for 60 minutes two times in a month.
Other interventions included healthy cooking workshops, text messages to students and parents, disseminating educational materials to parents, and individual counselling sessions monthly. Notably, questionnaires and anthropometric measurements of the students were collected at the beginning of the study and after 7 months. Notably, dietary behavior of the treated students significantly improved compared to the control group, and the anthropometric measurements of the treated group were lower than the control group (0.6-unit, kg/m2 reduction in BMI and 3.3cm in waist circumference). Therefore, nutritional interventions based on social cognitive theory can induce a healthy lifestyle in students and improve their anthropometric measurements.
Nutritional interventions delivery using social cognitive theory also significantly promotes healthy eating habits in students. Rosario et al. (2013) assessed the effect of providing nutritional education to students aged (6–12 years) on the consumption of healthy foods. The study was conducted on elementary school students in Portugal, and the administered nutrition interventions was based on social cognitive theory. The ‘interventions’ and ‘skills’ constructs of the theory were used in delivering the information. Firstly, the teachers were trained on healthy eating and nutrition. Subsequently, dietary assessments of the students were performed before and after the study.
Notably, the dietary intake of the students was collected after every 24 hours, and the unhealthy foods were categorized as low nutrient, energy-dense (LNED) foods and sugar-sweetened beverages (SSBs). The teachers were subjected to three hours of training by the health professionals. Subsequently, they delivered the content using creative approaches to the students, and each participant undertook 12 sessions of nutritional education. The findings indicated that the treated students significantly reduced their consumption of LNED compared to the control group. Primarily, the consumption of LNED foods reduced to 48.3% in the treated group compared to 55.9% in the control group, whereas the consumption of SSBs was 53.1% in the control group compared to 49.7% in the test group. Therefore, nutritional education based on social cognitive theory substantially induces positive changes in dietary behavior of school students and can potentially be used to promote healthy dietary behavior in obese/overweight students in UAE.
This is a six- month intervention. The sampling will be performed using stratified random selection method. The students will be overweight/obese students aged 9-14 years in Dubai and Sharjah. They will be classified into three groups: Group 1 will not receive any nutrition intervention (control group); Group 2 will be nutrition education activities involving only the participating child, and Group 3 will involve nutrition education for the participating child and his family/peer support groups. The intervention will be for 6 months and data will be collected at baseline and after 6 months.
Notably, the study will be conducted in 36 public schools in Sharjah and Dubai. The control group will include 5 schools in Sharjah and 7 in Dubai, whereas the intervention groups will be 10 schools in Dubai and 14 in Sharjah. The ethical approval for the study will be obtained, before the commencement of the study from Emirates schools establishments.
The study will be conducted in United Arab Emirates (UAE) public schools located in Dubai and Sharjah. The schools will be selected randomly from a map of the two regions, which will be divided into four sections, North, South, East and West. The two regions were selected due to their distinct differences in socio-economic factors, which will provide information on the effectiveness of different nutritional interventions since Social cognitive theory is based on the environmental setting. Therefore, the two regions will provide essential information on the interventions that are effective in multi-ethnic or highly urbanized regions and rural or countryside settings in UAE.
The participating students will be 9-14 years old males and females studying in public schools. They will be either overweight or in the obese category based on WHO BMI classification (WHO, 2021). The students will be screened at the baseline of the study and categorized as either obese/overweight or not after the first anthropometric measurements have been obtained. Moreover, the students from public schools will be selected since studies indicate that they are more affected by childhood obesity compared to those in private schools in UAE (Baniisa et al., 2020). Therefore, excluding private schools would provide a clearer picture on the effectiveness of the interventions that will be administered.
Sampling method and Sample size calculation
The sampling method for the study will be stratified random selection, and the sample size for the first questionnaire distribution and anthropometric measurements will be calculated using the formula by Gill et al. (2010) in equation 1 below.
n= P (100−P) Z2/E2 (equation 1)
Where n is the required sample size.
P is the percentage occurrence of a state or condition (also called variance of the population, and it is accepted at 50%).
E is the percentage maximum error required which is called margin of error (5% is acceptable).
Z is the value corresponding to level of confidence required (1.96 for 95% confidence or 2.57 for 99% confidence).
The sample size calculated using the formula is 378~400 at 95% confidence, 5% margin of error, and P=50%. Alternatively, it can be 643~650 at 99% confidence, 5% margin of error, and P=50%. Hence, the sample size will range from 400 to 650 if the margin of error utilized is reduced to 3% instead of the typical 5%. The sample size selected will be confirmed using Raosoft® (Raosoft Inc, 2004). The exact sample size will be determined after the first questionnaire is distributed to the students, and anthropometric parameters are obtained. Additionally, the ratio of obese and overweight students in Sharjah (39.25% and 23.75%) and Dubai (44.75% and 26.5%) will be considered during sampling.
Furthermore, the variation in the percent of students present in Sharjah (60.4%) and Dubai (39.6%) will also be considered. Therefore, the initial sample size will be 400 students, who will be selected and stratified randomly, and the number may be adjusted to 650 students to account for the ratio of obese and overweight students in Dubai and Sharjah schools. At the end of study, the G*power software, version 126.96.36.199, will be used to evaluate the power of the sample size, and the acceptable limit should be at least 80%.
The methodology will encompass distribution of questionnaires and measuring the anthropometric parameters two times within a duration of 6 months. The initial anthropometric measurements will be performed at the end of August to select children who fall in the overweight or obese categories. Next, they will be stratified into three groups, where the first group will be the control, while the others will receive nutritional interventions from one to one sessions (group 2) and family/peer support groups (group 3). Additionally, all the groups except the control will receive various nutritional interventions for a period of six months. Subsequently, at the beginning of March 2022, the questionnaires will be re-distributed, and anthropometric measurements will be obtained again. Data obtained in dietary practices, self-efficacy, level of nutritional interventions, food choices, and anthropometric measurements will be compared in control and test groups using statistical analyses. The collection of data will be consistent in all groups to ensure a high level of accuracy.
Data collection tools
Arab Teens Lifestyle (ATLS) questionnaire will be used in this study and the purpose will be to examine dietary behaviour (Al-Hazzaa et al., 2011). Additionally, nutrition knowledge and healthy lifestyle behavior’ (Kalender et al., 2011) questionnaire with additional questions related to self-efficacy and dietary practices (Becher, 2009; Voss et al., 2017) will be administered. The purpose of the questionnaire will be to examine nutrition knowledge and healthy lifestyle behavior (14 questions), attitude (3 questions), dietary practice (11 questions) and self-efficacy (10 questions). Moreover, the ‘nutrition knowledge and healthy lifestyle behavior’ questionnaire was successfully used in research involving UAE adolescents aged 9-13 years.
Importantly, Al-Yateem and Rossiter (2017) utilized the questionnaire to assess the nutrition interventions and lifestyle of the students in Sharjah, one of the study sites (Kalender, 2011). Notably, the questionnaires will capture the demographic details of the students; hence, the demographic proformas will not be required. Therefore, the two questionnaires are effective in assessing the effectiveness of nutritional interventions..
The anthropometric parameters of the students, including weight, height and waist circumference, will be measured. The weight will be measured in kilograms using Tanita BC730W, which has a sensitivity of 0.1 kg and a capacity of 150kg. The standardization procedure will involve taring clothing value (0.1) from the weight. Additionally, the readings will be collected without shoes, and the students will be required to remove extra clothing to a minimum of approximately 0.1 kg since the study will be conducted during winter (Al-Hazzaa et al., 2011). The height will be measured using ‘Seca 213 Portable Stadiometer,’ whose sensitivity is to the nearest 1cm and has a capacity of 205cm. The standardization procedure will include all students standing upright without shoes (Al-Hazzaa et al., 2011). Similarly, the waist circumference will be determined using ‘Seca Tape Measure.’ It is a flexible, non-stretching tape with a sensitivity of 1cm and a capacity of 150 cm. The students will also be required to stand upright, and their measurements will be taken at the umbilical cord level directly on the skin, which will be to the nearest 0.1 cm without pressing the skin inward (Al-Hazzaa et al., 2011).
The non-stretching element was included to enhance precision since the measurements will be conducted to the nearest 0.1 cm (Al-Hazzaa et al., 2011). Similarly, the flexible aspect was added to improve accuracy since the students’ skin will not be pressed inward during measurement. (Al-Hazzaa et al., 2011). Body Mass Index (BMI) WHO classification will be calculated from the weight and height in kilograms per square meters (Kg/m2). Notably, all measurements will be conducted by trained professionals, including trained school nurses and researchers. The dietary intake will be measured using the questionnaires at the baseline and at the end of the study. The consumption of fruits, vegetables and caloric intake will be used to assess changes in dietary practices.
The educational materials will cover various topics, including energy balance, myPlate, portion size, and eating healthy, which will be delivered using one to one sessions and family/peer support group methods. The source of nutrition information will include publications, online videos from education sites, WHO and CDC websites, and lecture materials used (Kalender, 2011).The education material will be in Arabic.
The parents will be invited for individual interview session, which will be conducted by a trained interviewer. The perceptions of parents about factors that influence food choices, eating behaviors, and physical activity patterns (facilitators and barriers) of their obese/overweight children will be discussed. These discussions will be audio-recorded to have a complete information for the data analysis.
The students will be stratified into three, including the control group, One-to-one intervention group (Group 2) and family/peer support group (Group 3) after screening using the anthropometric measurements collected at the baseline. Moreover, out of 450-600 obese/overweight students selected for the study, two-third of them will receive lectures virtually for 30 minutes on a weekly basis. One group will receive it one on one, while the other group will acquire it with their family and peers. The topics that will be covered include healthy eating lifestyle, energy balance, food portion control, healthy snacking, importance of physical activity and healthy eating, dietary practices, and nutrition related self-efficacy.
Moreover, all the students, except the control, will receive other nutritional exposures, including video games in school, health coach monitoring, educational materials as poster, and nutritional labelling of foodstuff in school canteen. Moreover, parents will be encouraged to offer incentives to their children to motivate them. Similarly, teachers will be encouraged to acknowledge the students with exceptional performance in class and applaud them, as this will create a sense of reward in them (Bagherniya et al., 2018; Schunk & DiBenedetto, 2020). Therefore, the nutritional interventions will be administered to promote healthy eating habits among the obese/overweight children.
The parents and family/peer intervention will be involved in weekly training on nutritional knowledge. Notably, the study will include one parent per student and the total number of sessions will be 4. The family members and peers of the students will support the students in adopting a healthier lifestyle. The 30- minute sessions will be conducted on daily bases for 1 week and they will cover the nutritional knowledge content assessed in the questionnaires and they will be similar to the ones that will be delivered one on one through trained professionals to the students. Additionally, each lecture will contain a 10-minute question and answer session to enhance the understanding of the nutritional knowledge delivered. There will be no specific format for the question-and-answer sessions as the family/peers will be allowed to seek clarification on areas that they did not understand during the lectures.
School level intervention
The school support system to promote healthier lifestyles for the participating children and adolescents will include nutrition education to the students, video games in school, and visual displays of healthy dietary practice in the schools’ bulletin boards or walls of the canteen (Gillies et al., 2020). Notably, the nutritional interventions will enable the students to develop the skills they require to adopt healthy dietary practices (Bagherniya et al., 2018; Schunk & DiBenedetto, 2020). The information is expected to enhance the student’s capacity to select healthier food options and control their calorie intake. Furthermore, the video games in school will induce ‘self-efficacy’ as the selected games will encourage eating fruits and vegetables. A summary school based nutritional interventions are shown in table 1.Therefore, the school support system and video games in school will facilitate change of dietary behavior in the students.
Table 1: Summary of school based nutritional tools and their expected outcome.
|Intervention tool||Outcome measure|
|Educational materials as posters||Nutritional knowledge|
|Nutritional video games||Self-efficacy based on improved fruit and vegetable consumption|
|Visual displays of healthy dietary practice in the schools’ bulletin boards or walls of the canteen||self-efficacy in selecting healthy food options|
|Stocking healthy food options in the school canteen and labelling them||Improved dietary practice by selecting healthy foods options and control of calorie intake.|
Health coach monitoring
For Health coach monitoring, the students will be enrolled in a program called “your food is your mirror” under the ministry of education. It is a health coach monitoring, which provides weekly coaching through videos and enables one to monitor their lifestyle virtually. The health coaches will be qualified and trained staffs to provide the services based on qualification. The inter-variability in health coaches will be minimized by ensuring that the same contents are administered by the different coaches within the same duration of time. Particularly, the health coaches will offer guidance to facilitate the adoption of a healthy eating lifestyle, monitor the process of diet changes. Primarily, the monitoring by health coaches will support the students in developing ‘self-efficacy’ habits that will promote behavioral change.
Importantly, ‘reinforcement’ aspect of the theory will be included by reviewing the short-term goals set by the students with the help of the health coaches and assigning them scores on their performance in weight loss, nutritional knowledge and diet improvement to induce a sense of reward or accomplishment (Bagherniya et al., 2018; Schunk & DiBenedetto, 2020). All the sessions will be conducted virtually and will be automatically recorded for data analysis purposes. Therefore, the intervention will be crucial in supporting the delivery of nutritional knowledge.
Nutritional labelling of foodstuff in school canteen
The nutritional labelling of foodstuff present in the school canteens will be performed to enhance the monitoring of calorie intake. The labelling of the foods will enable the students to develop self-efficacy by counting their calorie intake (Bagherniya et al., 2018; Schunk & DiBenedetto, 2020). The research team will collaborate with the municipalities of Sharjah and Dubai, as well as the school principals, to facilitate the labelling exercise as it was previously performed in Sharjah by Husein et al. (2017). The intervention will involve all the stakeholders to maximize the efficiency of the labelling exercise.
The statistical analyses of variation in nutritional interventions, food choices, attitudes, dietary practices, and barriers of healthy eating perceived by parents in control and intervention groups will be performed using social sciences (SPSS) computer software (version 27), IBM software, USA. Firstly, the questionnaire will be validated using Cronbach’s alpha to determine if the level is between 0.6-0.8 (Tavakol & Dennick, 2011). Next, the qualitative variables data, including nutritional interventions, attitudes, and response of parents’ interviews, will be expressed as count (n) and percent (%). The quantitative scores of dietary practices, food choices, and self-efficacy questions, which are in the Likert scale answers, will be expressed as weighted mean± Standard deviation (SD).
Moreover, for quantitative variables, normal distribution of data will be checked using Kolmogorov-Smirnov (Sample size>50 for each group) or Shapiro-Wilk test (Sample size =<50 for each group) in addition to checking homogeneity of variance (Mishra et al., 2019). Notably, the parametric statistical tests or non-parametric ones will be selected according to normality and homogeneity assumptions fulfilment (p>0.05, non-significant), or violation (p<0.05, significant) (McKight & Najab, 2010; Yusof et al., 2013). The statistical analysis for the data collected two times from the questionnaires will be performed separately. Subsequently, Chi square test will be used to compare the variation in qualitative variables (nutritional interventions, attitude, and response from parents’ interview) (McHugh, 2013). Additionally, independent t test (parametric test) or Mann Whitney test (non-parametric), will be used to analyze the effect of 2 level qualitative variables on quantitative variables, whereas one way ANOVA test (parametric test) or Kruskal Wallis test (non-parametric test) will be used to analyze the effect of more than 2 level qualitative variables on quantitative variables in each questionnaire stage (McKight & Najab, 2010; Yusof et al., 2013).
Additionally, the anthropometric measurements of the control and the intervention groups will also be compared using ANOVA test before and after nutritional education. Pearson’s correlation test will be used to determine the relationship between nutritional interventions, attitude, response from parents’ interviews, food choices, dietary practices, self-efficacy and anthropometric measurements. The correlation will be considered strong if it is near to 1 and far from 0 (weak when r <0.3, moderate when r >0.3 – 0.6, strong when r >0.6 – 0.85, and extremely strong when r >0.85 – 1). A positive value will imply it is directly proportional).
Conversely, a negative r value will imply it is inversely proportional (Akoglu, 2018; Bolboaca & Jäntschi, 2006). The outcome of the variables, including change in dietary practice, self-efficacy, food choices, and anthropometric measurements, will be clustered based on age, level of parental, and school support. Furthermore, graphical illustrations will be used to show the changes in the anthropometric measurements of the four groups, as well as the difference in mean scores of dietary practices, and self-efficacy.
The responses obtained from parents’ interviews will be analyzed qualitatively using Nvivo software. The data will be sort and classified based on the barriers of healthy eating habits perceived by the parents. The relationship between the barriers of healthy eating habits and nutritional interventions, food choices, and dietary practices will be assessed. The information will provide insights on the barriers of healthy eating among grade 5-8 students aged 9-14 years old, which can be addressed to curb the high childhood obesity prevalence in UAE.
The viability of the research method
The research approach is achievable and is likely to give positive results since a related study successfully used a similar approach. Demirozu et al. (2012) examined the effect of increasing nutritional interventions on dietary habits of school students aged 8-12 years. Firstly, questionnaires were used to measure initial nutritional interventions of students and collect the age of the students, their gender, education level and parents’ age. Additionally, the anthropometric characteristics of the students were obtained. Notably, the Nutritional education programs entailed 1.5 hours section of problem-solving sessions, brainstorming, and discussions.
The students were issued nutrition booklets and other materials that they were supposed to use with their families. After six weeks, the questionnaires were distributed, and the changes in nutritional interventions and habits were evaluated. The results revealed that there were significant differences between the trained students and the control group. Increase in nutritional interventions induced healthy dietary habits among the students. Therefore, the proposed methodology is effective and can potentially yield beneficial information regarding which approach is most suitable in delivering nutrition intervention. The involvement of the parents will also enhance the support required by the students to adopt the healthy lifestyle change.
Evaluation of success of the study
Evaluations will be conducted regularly, and the major focus will be the progress towards achieving the research objectives. Firstly, timelines will be set for the main tasks, including identification of the students from the chosen schools, seeking consent, the first round of filling questionnaires and obtaining anthropometric measurements, conducting one to one sessions and family/peer support groups training, and the second round of filling questionnaires and collecting anthropometric measurements. The six months period chosen for the study is based on findings by Demirozu et al. (2012), which revealed that children aged 8 to 12 years gained nutritional interventions within 6 weeks of training and exhibited lifestyle changes.
Similarly, Hussein et al. (2017) observed significant healthy lifestyle changes in school students aged 5-18 years after administering different nutritional interventions for 6 months. Importantly, the period of this study is approximately 6 months; hence, lifestyle changes are anticipated within this period. To evaluate and validate the results, the measurements of the treated students will be compared to the control group.
The sample size, nutritional interventions earned, and the effectiveness of one to one sessions and family/peer support group methods will also be evaluated and validated. Firstly, the number of students versus the calculated sample size will be compared to ensure it is within the required limit. Additionally, the nutrition knowledge gained by the students and lifestyle changes will be determined using sections of ‘nutritional interventions and healthy dietary behavior’ questionnaire and additional questions on dietary practices and self-efficacy from ATLS.
Afterwards, variation between the one to one sessions and family/peer support group methods of delivering nutrition interventions will be evaluated using the anthropometric measurements by taking into account the confounding factors such as natural growth. The effectiveness of the two methods will be validated using a graph showing the dimensions before and after treatment. The technique with the highest variation would be the most effective. Furthermore, it will be a channel of identifying and addressing the key challenges observed. Therefore, evaluating and validating the different channels of delivering nutritional interventions is critical in establishing the most effective approach of combating childhood obesity in UAE.
Motivation of the overall research
The administration of nutritional interventions to the students through various interventions is expected to change their dietary practices, and improve their anthropometric measurements. Notably, studies link the high occurrence of obesity in UAE schools to unhealthy dietary habits, which is motivated by lack of nutritional interventions (Bin Zaal 2009; Al Junaibi et al. (2013). Moreover, research indicates that delivery of nutritional interventions to children and their parents, especially mothers, yields greater lifestyle changes and significantly reduces waist circumference, weight and BMI of children. (Vereecken & Maes, 2010; Contento & Koch, 2020).
Studies indicate that administering nutritional education to children influences their choices of snacks. Majority tend to select healthy food options after gaining nutritional interventions (Yabancı et al., 2014; Vereecken & Maes, 2010). Therefore, the administration of a variety of nutritional interventions will considerably reduce the prevalence of childhood obesity in UAE.
Nutritional behavior change based on social cognitive theory will be primarily created on three crucial phases, including motivation (cognitive factors), action phase (behavioral capacity), and the environment (situational). Importantly, the motivational phase will focus on why the students should change their dietary behavior, which will be affected through in depth interviews of parents and students, awareness campaigns in schools, and educational materials. The action phase will include supporting the students to make the changes through nutritional food labelling in schools, visual displays of healthy dietary practice, and health coach monitoring. Lastly, the environmental factors will be evaluated using parents and peers. Once the research is concluded, the appropriate recommendations will be made to the relevant ministry of education or any policymaker.
The self-efficacy component will be addressed by examining the confidence to overcome unhealthy behavior and focusing on the ‘outcome expectations’ and the ‘benefits’ (Mohammed et al. 2017). Therefore, the programs are expected to cause significant reduction in anthropometric measurements of the students, including waist circumference, weight and BMI. Additionally, the students are expected to acquire high self-efficacy behavior that will enhance the maintenance of a healthy lifestyle even after the research is complete.
The proposal development and seeking of ethical approval will be conducted from January to August, 2021. Subsequently, sampling, data collection, administration of nutritional knowledge, and data analysis will be performed within a 6 months duration as outlined in the chart below.
The approval of the Ethical Review Committee will be sought from the Ministry of education in UAE before commencing the study. Subsequently, the approval will be communicated to the schools that will participate in the study. Next, the parental consent will be sort since the students are minors. The school protocol will be followed in communicating with the parents of the students, where in most cases, the school nurses will coordinate with the parents. The verbal consent of the students will also be required before the study, and careful examination will be performed to identify instances of pressure as the inclusion criteria will be strictly based on free will to participate. Notably, regular checks will be performed during the study to evaluate if the participation is voluntary, and the students will be allowed to discontinue at any point of the study. Importantly, parents will also be informed that the participation of their children is voluntary, and they can advise them to withdraw whenever they feel uncomfortable.
Moreover, the participant’s information will be protected through maximum privacy and confidentiality. No personal information that can allow future identification of the students will be collected. Furthermore, the students will be urged not to provide identifying information when completing the questionnaires. Lastly, the storage of all data will be secure and only accessible team. Incentives will be offered to parents and nurses who will participate to keep them motivated.
|Gifts||For parents and nurses to keep them motivated||3000 Dhs|
|Research assistants||To help in taking the measurements||4000 Dhs|
|Stationery||Educational materials |
Files for keeping the documentation
|Anthropometric measurement tools||Tanita, |
flexible non- stretchable fexible tapes
|Course in SPSS and Nvivo||To do the analysis||4000 Dhs|
|Total Budget||21,000 Dhs|
The high obesity prevalence in UAE schools poses an enormous challenge to public health and substantially elevates the risk of contracting non-communicable diseases. Notably, several studies have uncovered that nutrition intervention is one of the approaches that can effectively counter the disturbing trend in increase of the condition. However, limited information is available on the effective method of delivering nutritional interventions. In the proposed study, the administration of nutritional interventions based on social cognitive theory will include one to one sessions and family/peer support group methods. The one to one session method provides the merit of a greater learning opportunity to the student, whereas the family/peer support group one enables the students to ask questions without feeling self-conscious. Importantly, nutritional interventions will be based on social cognitive theory, which will enhance commitment to health recommendations. The interventions include motivational interviewing, school support system, posters, health coach monitoring and games in school. Primarily, after obtaining ministry approval and informed consent from parents and students.
Anthropometric measurements will be obtained from the students, and they will fill the questionnaires in the last week of August 2021, upon the ethics approval. Notably, the measurements will be obtained for one week both at the baseline and at the endline of the study. Subsequently, they will be categorized into three groups, where the control group will not receive any treatment, whereas the other two groups will receive nutritional interventions to support the administration of nutritional interventions. Subsequently, the anthropometric measurements will be obtained in the last week of February 2022 (upon completion of 6-months intervention period). Evaluation of the three groups will be affected using graphs that will compare the differences between the groups. I predict a significant improvement in anthropometric measurements of the students, including weight loss, reduction in BMI and waist circumference. Overall, the study will provide beneficial information on the suitable mode of delivering nutritional interventions based on social cognitive theory. The information can be used by the relevant stakeholders to reduce the incidence of obesity in UAE schools.
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We are conducting a research study about the XXXXXXX. You are invited to participate in this research.
Alongside this form is a questionnaire consisting of XXXXX easy and quick questions, which contains general questions regarding XXXXXXXXX. Once you have agreed to this, the questionnaire will be available, and it will not take much of your time to complete.
Your participation is entirely voluntary; the information provided will remain confidential. The results of this research will strictly be used for research purposes only and will only be accessed by the researchers and supervisors of the study.
This research is being conducted by: Students in United Arab Emirates University, College of Food and Agriculture
- I agree.
- I disagree.
I am a ⚪ Male, ⚪ Female
My Nationality ⚪ Emarati , ⚪ Others I am in year ⚪ 5 ⚪6 ⚪7 ⚪8
My age is
For each question, please fill the circle next to the answer you think is correct
- Balancing energy in and energy out is important to maintain a healthy body weight. Energy out is also known as:
- The goal for physical activity is to take steps every day.
- A unit of energy that comes from the food we eat and what we drink is called:
- A guide that helps us to balance what we eat with regular physical activity called:
- A guide that helps us to evaluate what are the nutritional contents of food products called:
- MyPlate recommends minutes of activity per day.
- According to MyPlate you should eat most from the group.
- Total number of servings of fruits and vegetables you should eat every day are:
|⚪||At least 2|
|⚪||At least 5|
|⚪||At least 10|
|⚪||At least 8|
- Every day you need cups of dairy.
- The healthiest choice from the following is to drink:
|⚪||100% fruit juice|
|⚪||Diet Soft drink|
- Which food is considered a healthy snack?
|⚪||Low fat yogurt|
|⚪||Lettuce and tomato salad|
|⚪||All of the above|
- How important is eating healthy to you?
|⚪||Very important||⚪||Somewhat important||⚪||Not important|
- How important is physical activity to you?
|⚪||Very important||⚪||Somewhat important||⚪||Not important|
- Did you perform any physical activity in the last 7 days?
- Did you do the physical activity or activities more than once in the last 7 days?
⚪ Yes ⚪ NO
- Did you perform the physical activity or activities for more than 30 minutes?
⚪ Yes ⚪ NO
For each Question, please fill the circle next to the answer that describes you best Dietary practices
Think about last week. How frequent did you eat food from a fast food restaurant?
|No, I didn’t eat any |
|⚪||Yes, I ate 1 time.||⚪||Yes, I ate 2 time.||⚪||Yes, I ate 3 time.|
|⚪||Yes, I ate 4 time.||⚪ Yes, I ate 5 time.||Yes, I ate 6 time.||⚪ Yes, I ate 7 time.||.|
Think about last week. How frequent did you skip eating breakfast?
|No, I didn’t skip breakfast.||⚪||Yes, I skipped breakfast once.||⚪||Yes, I skipped breakfast 2 |
|⚪||Yes, I skipped breakfast 3 times.|
|⚪||Yes, I skipped breakfast |
|⚪ Yes, I skipped breakfast 5 times||Yes, I skipped breakfast |
|⚪ Yes, I skipped |
Yesterday did you eat snacks like candy, chocolate, chips, cookies, cake or ice- cream?
|⚪||No, I didn’t eat any of the foods listed above |
|⚪||Yes, I ate 1 of these foods 1 time yesterday.||⚪||Yes, I ate 1 of these foods 2 times |
|⚪||Yes, I ate 1 of these foods 3 or more times yesterday.|
Yesterday, did you eat fruit? Do not count fruit juice.
|⚪||No, I didn’t eat any fruit |
|⚪||Yes, I ate fruit 1 time yesterday.||⚪||Yes, I ate fruit 2 times |
|⚪||Yes, I ate fruit 3 or more times |
Yesterday, did you eat any vegetables?
Vegetables are salads; boiled, baked and mashed potatoes; and all cooked and uncooked vegetables. Do not count French fries or chips.
|⚪||No, I didn’t eat any |
|⚪||Yes, I ate vegetables 1 time yesterday.||⚪||Yes, I ate vegetables 2 |
|⚪||Yes, I ate vegetables 3 or more times yesterday.|
Think about last week, how many times did you take milk, yogurt or cheese?
|No, I didn’t take any |
|⚪||Yes, I ate them |
|⚪||Yes, I ate them 2 |
|⚪||Yes, I ate them 3 times.|
|⚪||Yes, I ate |
|⚪ Yes, I ate |
|Yes, I ate |
|⚪ Yes, I ate |
Think about last week, how many times did you snack at night, especially midnight?
|No, I didn’t eat any |
|⚪||Yes, I snacked once||⚪||Yes, I snacked 2 |
|⚪||Yes, I ate snacks |
|⚪||Yes, I ate |
|⚪ Yes, I ate snacks |
|Yes, I ate |
|⚪ Yes, I ate |
How many times do you snack between morning and lunch time?
|⚪ No, I don’t eat any |
|⚪||Yes, I eat snacks once||⚪||I eat snacks 2 times |
|⚪||Yes, I eat snacks 3 times.|
Do you eat/snack when watching TV or a movie? If yes how many times per hour?
|⚪ No, I don’t eat any |
|⚪||Yes, I eat snacks once||⚪||I eat snacks 2 times |
|⚪||Yes, I eat snacks 3 times.|
Think about last week, how many times did you eat when you are bored at home?
|⚪ No, I didn’t eat any |
Food or snack.
|⚪||Yes, I ate once.||⚪||Yes, I ate 2 |
|⚪||Yes, I ate 3 times.|
For each Question, please fill the circle next to the answer that describes you best Self-efficacy
How confident are you in ordering a fruit or salad instead of pizza or chips?
|⚪||0%||⚪ 25%||⚪50%.||⚪ 75% ⚪100%|
Rate how you feel you are likely to adhere to the portion control recommendations?
|⚪||0%||⚪ 25%||⚪50%.||⚪ 75% ⚪100%|
How confident are in you in resisting eating when different types of foods are available?
|⚪||0%||⚪ 25%||⚪50%.||⚪ 75% ⚪100%|
How strong do you feel you can resist ordering an unhealthy meal your friends are ordering from the menu in a restaurant?
|⚪||0%||⚪ 25%||⚪50%.||⚪ 75% ⚪100%|
How confident are in you in choosing water as opposed high calorie drinks such as soda?
|⚪||0%||⚪ 25%||⚪50%.||⚪ 75% ⚪100%|
Outline of presentation
|Session 1||Healthy Eating Lifestyle|
|Target||Students and parents|
|Through||The classes will be conducted virtually|
|Education tools||PowerPoint presentation, video, posters.|
|Main objectives for students||To introduce them to the concept of energy balance using tools such as ‘My plate’ and provide knowledge on the nutritional content of various foods, healthy snacking, and measuring food portions.|
|Main Objective for the parent||To furnish them with crucial information on nutritional knowledge, which will enhance their capacity to support a healthy lifestyle in their obese/overweight children.|
|Learning outcomes|| |
|Session 2||Dietary Practices|
|Target||Students and parents|
|Through||The classes will be conducted virtually|
|Education tools||PowerPoint presentation, video, models for demonstration, mini cooking session to help them create their own healthy snacks.|
|Main objectives for students||To enlighten them on the importance of breakfast and selecting healthy food options for snacking at different times of the day or while watching television.|
|Main Objective for the parent||To prepare the parents with knowledge on healthy dietary practices that will enable them to guide their children in adopting healthy behavior.|
|Learning outcomes|| |
|Session 3||Nutritional Self-Efficacy|
|Target||Students and parents|
|Through||The classes will be conducted virtually|
|Education tools||PowerPoint presentation, video, models for demonstration.|
|Main objectives for students||To educate them on how to maintain a healthy lifestyle discipline in food choices even when faced with temptations from friends and enlighten them on the portion control recommendations.|
|Main Objective for the parent||To provide them with self-efficacy knowledge to support their children in eating healthy foods by either by cooking healthy food options or selecting low calorie meals in restaurants.|
|Learning outcomes|| |