A behavioural change intervention study for the prevention of childhood obesity in South Africa: protocol for a randomized controlled trial

A school-based food and nutrition education intervention increases nutrition-related knowledge and fruit consumption among primary school children in northern Ghana

BACKGROUND

Providing children with the opportunity to learn about nutrition is critical in helping them establish a healthy lifestyle and eating behaviours that would remain with them till adulthood. We determined the effect of a school-based food and nutrition education (SFNE) intervention on the nutrition-related knowledge, attitudes, dietary habits, physical activity levels and the anthropometric indices (BMI-for-age z scores, %Body fat and waist circumference) of school-age children in northern Ghana.

METHODS

Following a controlled before-and-after study design, we recruited school-age children in primary 4 and 5 from public and private schools and assigned them non-randomly to intervention and control groups (4 schools total). A SFNE intervention called 'Eat Healthy, Grow Healthy (EHGH)' was implemented in intervention schools. Components of the intervention included children, teachers, school officials, and the school environment. Nutrition education didactic sessions, active discussions, nutrition games, charades, art work, and physical activity sessions were among the teaching and learning activities implemented. At 0 and 6 months, primary (anthropometry) and secondary (fruit, vegetable, and breakfast consumption) outcomes were obtained.

RESULTS

Mean BMI-for-age z-scores did not differ significantly between intervention and control groups (F1,261 = 0.45, P = 0.503, η2 = 0.01). However, significantly greater nutrition-related knowledge scores were recorded in the intervention group than in the control group at post-intervention (M = 6.07 SD = 2.17 vs. M = 5.22 SD = 1.92; p = 0.002). Mean number of days intervention children consumed fruits differed across time (F1, 263 = 33.04, p = 0.002, η2 = 0.04) but not between the control and intervention groups (F1, 263 = 0.28, p = 0.60, η2 = 0.00).

CONCLUSIONS

The EHGH intervention had positive effects on the nutrition-related knowledge and the consumption of fruits among children although it did not impact their anthropometric indices.

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Interventions to prevent obesity in children aged 12 to 18 years old

BACKGROUND

Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect.

AUTHORS' CONCLUSIONS

The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

Child-directed marketing on packaged breakfast cereals in South Africa

OBJECTIVE

Childhood obesity is on the rise in South Africa (SA), and child-directed marketing (CDM) is one of the contributing factors to children's unhealthy food choices. This study assessed CDM on packaged breakfast cereals available in SA supermarkets and their nutritional quality.

DESIGN

Photographic images were examined in a descriptive quantitative study. A codebook of definitions of CDM was developed for this purpose. REDCap, an online research database, was used for data capturing, and SPSS was used for data analyses including cross-tabulations and one-way ANOVA.

SETTING

The current study was set in the Western Cape province of SA.

SUBJECTS

Photographic images of all packaged breakfast cereals sold in major retailers in the Western Cape province of SA in 2019 were studied.

RESULTS

CDM strategies were classified as direct (to the child) or indirect (through the parent). A total of 222 breakfast cereals were studied, of which 96·9 % had a nutritional or health claim, 95·0 % had illustrations, 75·2 % had product and consumption appeals, 10·8 % had characters, 10·8 % consisted of different appeals, 8·6 % alluded to fantasy and 7·7 % had role models. In breakfast cereals with direct CDM, the protein and fibre content was significantly lower than in breakfast cereals without direct CDM. This study found a significantly higher total carbohydrate and total sugar content in breakfast cereals with direct CDM than those without direct CDM.

CONCLUSION

CDM was highly prevalent in breakfast cereals sold in SA. Regulations to curb the marketing of packaged foods high in nutrients of concern is recommended.

Patients' views on health promotion and disease prevention services provided by healthcare workers in a South African tertiary hospital

BACKGROUND

Patients' views and experiences in healthcare institutions provide a means of assessing the quality of services patients receive from healthcare workers (HCWs). However, the views of patients on the health promotion (HP) and disease prevention (DP) services offered by HCWs and the delivery mode have not been adequately studied.

AIM

This study assessed the views of patients on HP and DP services provided by various categories of HCWs.

SETTING

The study was conducted at a tertiary hospital in the Nelson Mandela Bay Municipality, South Africa.

METHOD

An exploratory cross-sectional study was conducted among 500 patients. The questionnaire elicited responses from patients regarding the HP and DP services received from the different cadres of HCWs at three different admission phases: pre-admission phase (PAP), admission phase (ADP), and post-admission phase (POP). Descriptive, bivariate, and multivariate analysis was conducted.

RESULTS

In the PAP, most patients (83.33%, n = 5; 87.85%, n = 217; and 76.14%, n = 150) seen by the rehabilitation health workers, medical doctors, and nurses respectively were empowered to manage their health. Patients attended to by nurses were 0.45 (95% CI 0.27-0.74) times less likely than those attended to by medical doctors to receive information that that will help them address the physical and environmental needs. In the ADP, patients attended to by nurses were less likely, compared to those attended to by medical doctors to be empowered to have good control over their health. In the POP, patients attended to by nurses are more likely to have their health behaviours change for better compared to those not seen by any HCW.

CONCLUSION

Patients attending tertiary hospital received greater HP and DP services during the PAP and ADP of patient care. Greatest influence for behavioural change of patients on HP and DP were achieved from the medical doctors, nurses and rehabilitation service staff. Improving structural factors may prove beneficial in enhancing patients' experience from all HCW groups and phases of patient care.

The Multidimension of Malnutrition among School Children in a Rural Area, South Africa: A Mixed Methods Approach

To address childhood malnutrition, the use of multifaceted methodologies, such as mixed methods research, is required to inform effective and contextual interventions. However, this remains limited in studying malnutrition among school children in a South African context, notwithstanding its persistence. We adopted a convergent parallel mixed methods design to best understand the magnitude of malnutrition through multilevel influences in a rural area. A quantitative survey determined the magnitude of malnutrition and associated factors among school children and their mothers (n = 508), parallel to a qualitative study, which explored mothers' insights into the influences of child growth and nutrition in interviews using seven focus group discussions. Mixed methods integration was achieved through convergence of the quantitative constructs developed from measured variables for malnutrition and related factors with ten emergent qualitative themes using a joint display analysis to compare the findings and generate meta-inferences. Qualitative themes on food unavailability and affordability, poor feeding beliefs and practices, and decision to purchase foods were consistent with the quantified poor socio-demographic status of mothers. Furthermore, the qualitative data explained the high prevalence of undernutrition among children but did not corroborate the high estimated households' food security in the quantitative survey. The misperceptions of mothers on child growth agreed with limited food knowledge as well as lack of knowledge on child growth gathered during the survey. Moreover, mothers believed that their children were growing well despite the high presence of childhood undernutrition. Mothers further overrated the effectiveness of school feeding programmes in providing healthy food to children as compared to their household food. They reported high incidence of food allergies, diarrhea, and vomiting caused by food consumed at school which resulted in children not eating certain foods. This might have impacted on the nutritional status of children since mothers depended on the school feeding program to provide food for their children. The ambiguity of cultural influences in relation to child growth was evident and substantiated during qualitative interview. Mixed methods integration offered a better understanding of malnutrition from empirical findings on interrelated factors at child, maternal, household, and school levels. This study points to a need for multilevel, informed, and contextual multidimensional interventions to contribute towards addressing childhood malnutrition in South Africa.

Physical activity and sedentary behaviour of primary school learners in the Eastern Cape province of South Africa

Background

This study was designed to assess physical activity (PA) levels and sedentary behaviour amongst primary school learners in the Eastern Cape province of South Africa.

Methods

A cross-sectional study was adopted to assess the patterns and levels of PA and sedentary behaviour using the Physical Activity Questionnaire for Older Children (PAQ-C). The sample consisted of primary school learners, both boys and girls, aged 9–14 years. The learners were randomly selected from rural, urban and peri-urban areas in the Eastern Cape province of South Africa.

Results

Using a complete case analysis, 870 randomly selected participants (boys = 351 and girls = 519) aged 9–14 years were retained. Overall, the sample had a low mean PAQ-C score of 2.33 ± 0.43. The mean of PA in boys was significantly higher (p = 0.003) in comparison with the girls. The 13- to 14-age group had significantly higher PA levels (p = 0.014). Learners from urban areas (n = 136; 77.3%) engaged more in sedentary behaviour compared to those from rural areas (n = 252; 54.9%).

Conclusion

The findings demonstrated low levels of PA and high engagement of sedentary behaviour across the combined gender groups, which have negative implications on health, growth and development of children. The study, therefore, recommends relevant stakeholders to implement interventions aimed at promoting an increase in PA and a reduction in sedentary behaviours for primary school learners in the Eastern Cape province of South Africa.

Adolescents' understanding of obesity: a qualitative study from rural South Africa

Background

Levels of obesity are rising in South Africa, notably among adolescent females. Excessive energy-dense diets and physical inactivity are among the factors contributing to this increase. Given that these factors are largely behavioural, understanding young people’s views of obesity can contribute to more targeted behavioural interventions. Yet little is known of how rural South African adolescents view obesity.

Objectives

The aim of this study was to explore rural South African adolescents’ views of obesity, including their understanding of its causes, consequences, and solutions.

Methods

This qualitative study took place within the MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) study area, in rural northeast South Africa. Three focus group discussions were held with male (n = 16) and female adolescents (n = 15), aged 14–19 years in 2018. Data were analysed using thematic analysis and the Social Cognitive Theory used to frame the findings.

Results

Participants presented conflicting views of obesity, with both positive and negative opinions expressed. Causes of obesity were seen to be multifactorial, including genetics, diet, lack of physical activity, and HIV treatment. Adolescents proposed medication and hospitalisation as ways to address obesity. When discussing interventions to address obesity, adolescents expressed the need for more information, suggesting that providing information to both themselves and their family members as part of interventions would be important.

Conclusions

Rural South African adolescents have a complex perspective of obesity, likely driven in part by the current nutrition transition underway and do not inherently see individual behaviour as a driver or mitigator of obesity. Complex interventions including the involvement of other household members are needed to change adolescents’ views on the role of the individual, and ultimately, change both individual and household behaviour to prevent obesity.