Impact of health education program on knowledge, attitude and practices about obesity and overweight among Saudi girls in a primary school, Riyadh, Saudi Arabia, 2006

Childhood and adolescence overweight and obesity have doubled over the last decades in several developing and developed countries. This experimental study was conducted to investigate the prevalence of obesity and overweight among female grade five primary school studentsE¼ in Riyadh, Saudi Arabia. It also aimed to assess their knowledge, attitude, and practices towards obesity and eating habits, and to evaluate the impact of a health education program on their knowledge, attitude, and practices.

The study was carried out through the following steps: Firstly, an initial assessment (pretest) of knowledge, attitude and practices regarding overweight and obesity, carried out for the whole sample by using a pretest self-administered questionnaire. This initial assessment was considered as baseline evaluation of the program. Secondly, the educational intervention, which was launched as three sessions, and the topics presented included food groups, food pyramid, dietary guidelines, definition of obesity and overweight, the balanced diet, importance of breakfast, fast foods, exercise, benefits of maintaining ideal body weight, complications and risk factors of obesity and overweight and how to avoid them. The objectives of the health education intervention were to build awareness of the benefits of healthy eating, induce positive dietary and exercise behavioral changes, and increase knowledge about nutrition and obesity. Participatory active learning methods were used as educational games, discussion, posters, power point presentation, competitions and gifts, food pyramid model, food models, and prepared snacks. Thirdly, evaluation of the impact of the nutritional education intervention (posttest) was done by another questionnaire.

The questionnaire used in both the pretest and posttest was designed to elicit socio-demographic data, risk factors of obesity, family history, eating and drinking practices. Each item of the practices question was given a score from 1 to 5, where poor practice was given a score of 1, while good practice was given the maximum score. The alpha reliability of practice questions was 0.78. The total eating practices score ranged from 29-145 points and was leveled as follows: Good dietary practices (107-145), fair (68-106), and poor (29-67). Regarding drinking practices, the total score ranged from 5-25 points and was leveled as follows: Good (19-25), fair (12-18), and poor (5-11). Total score of dietary habits ranged from 12-60 points and was leveled as follows: Good (44-60), fair (28-43), and poor (12-27). Regular physical activity practices was assessed by 5 questions including walking to school; regular physical activity at home, its frequency and duration, as well as other types of activities. Each physical activity practice question was given a score from 1 to 5 with higher score for favorable practices. The alpha reliability of activity practice questions was 0.89. Score ranged from 5-20 points and was leveled as follows: Good (16-20), fair (11-15), and poor (5-10). Knowledge about obesity and overweight was assessed by 20 multiple-choice questions The alpha reliability of the knowledge questions was 0.85. A correct response was given a score of 1, and an incorrect or don€™t know response was given a score of 0. The total knowledge score ranged from 0-20 points and was leveled as follows: Good (16 €“ 20), fair (10 €“ 15), and poor (0 €“ 9).

Anthropometric measurements were used to assess the nutritional status of the studied sample, including weight, height, body mass index (BMI); fat percentage, predicted weight, fat gain and fat loss, by using Body Composition Analyzer measurements. This is a tool used for measuring weight, height, BMI, body fat content, predicted weight (ideal weight), amount of fat that should be gained (fat gain), and amount of fat that should be lost (fat loss). The BMI [weight in kg / (height in meters)²] was used as the measure of body fatness.

One hundred and fifty girls were included in the study. Their ages ranged between 10-12 years (mean 10.7, SD ± 0.5). All had not reached menarche. The majority of their parents were university graduates: 75.3% of mothers and 86% of fathers. Their weights ranged from 23.5-75.3 kg (mean 45.5, SD ±10.7), and heights ranged between 104.5-163 cm (mean 141.6, SD ± 11.4 cm). The fat percent ranged from 8.5-50.8% (mean 30.0, SD ± 1.0 %). The mean predicted weight was (44.7 ± 6.6 kg); 52% needed to gain fat between 0.5-10.4 kg (mean 4.3, SD ± 2.4 kg); 48% needed to lose fat between 0.1-18.6 kg (mean 6.3, SD ± 4.5 kg). The BMI ranged from 13.5-42.3 kg/m2 (mean 22.9, SD ± 6.13); 53.0% of the students were within normal BMI range (BMI 18.5€“24.9), and 21.0% were underweight (<18.5). The rest had different grades of obesity: 12% had grade I obesity (BMI 25.0€“29.9), 12% had grade II obesity (BMI 30.0€“39.9), and 2.0% had grade III obesity (BMI ≥ 40). About one third of the students (34%) had a positive family history of obesity, of which 60.8% among first-degree relatives and 39.2% among second-degree relatives.

Most (86.7%) showed fair score of total Eating Practices at pretest, and all (100%) showed fair level at posttest. Regarding sweets, the lowest mean score was for Chocolate in both pretest (1.83 ± 0.7) and posttest (2.29± 0.8). Little improvement in the mean scores for all sweet items was observed at posttest. Regarding meat products, fried chicken nuggets had the lowest mean practice score in both tests, with a mean score of pretest (2.09 ± 0.1) and posttest (2.42 ± 0.9). The mean scores for all meat product items improved at posttest.

For carbohydrate & starch products, the lowest mean score was for pies & Sambosak at pretest as well as posttest, with mean score pretest (1.44 ± 0.6) and posttest (1.73 ± 0.7). Regarding dairy products, the creamy cheese (Kraft) showed very poor practices with a mean score at pretest (2.03 ± 0.1) and posttest (2.41 ± 0.9). Regarding vegetables & fruits, leafy vegetables got the lowest mean score at pretest (3.65 ± 0.8) and posttest (3.37 ± 0.8), while the mean score of fruits was (1.95 ± 0.1) at pretest and (1.49± 0.6) at posttest. Fatty traditional foods mean score was (3.57± 0.1) at pretest and (3.73± 0.9) at posttest. Non Fatty traditional foods had means score of (3.43 ± 0.9) pretest and (3.42 ± 0.9) posttest. In general, there was little improvement in the mean scores for all food items at posttest. The score for drinking milk was (2.15 ± 1.3) at pretest, and (1.65 ± 0.1) at posttest.

Dietary-related habits revealed an improvement at posttest. Eating breakfast at home scored at pretest (2.33 ± 1.3) and at posttest (1.36 ± 0.1). Eating three main meals scored at pretest (2.36 ± 1.3) and at posttest (1.80 ± 0.8). The highest mean dietary-related habits score was for sleeping directly after the main meal at pretest (3.65 ± 1.2) and (3.93 ± 0.9) at posttest.

Concerning the impact of the health education program on the total scores of studentsE¼ eating and drinking practices and dietary-related habits, the mean practice scores of the posttest was higher than that of the pretest with a marked difference between pretest and posttest. This difference was statistically significant (all p-values < 0.001) for total eating practices, total drinking practices and dietary-related habits.

Regarding physical activity, 52.4% had poor level of physical activity, while 8.1% had good level scores at the pretest. Walking to school was not very common, and scored (4.94 ± 0.5) in both the pretest and posttest. The mean score of physical exercise at least three times a week was (3.45 ± 1.6) at pretest and (2.81 ± 1.5) at posttest .

Regarding knowledge about obesity and overweight, at pretest 38% of the students correctly knew the definition of obesity, increasing to 100% at posttest. Regarding good habits to avoid obesity, the most frequent correct answers reported by students were: increasing physical activity and regular exercise 56%, followed by avoiding carbonated beverages 53.3%, then avoiding fast foods 50.7%. The least frequent correct answers were for: dieting should be supervised by dietitian 35.3%, regularly weighing yourself 36.0%, and avoiding chocolates, sweets and nuts in snacks 36.0%. Regarding knowledge of complications of obesity and overweight, the percentage of correct answers ranged from 8.7 to 20% at pretest. After the intervention, the percentage of correct answers improved for all knowledge items, between 99.3 to 100%.

Regarding impact of the health education program on students€™ knowledge about obesity and overweight, the mean total knowledge score at posttest was higher than that of the pretest with a markedly statistically significant difference (p < 0.000).

More than half of the students were unsatisfied with their current weight at both pretest (56.7%) and posttest (57.3%). Most of the students (60%) had thought about reducing their weight. The major reason stated was to avoid teasing and bad comments from others (33.3%) at pretest, and (27.8%) at posttest. Only 3.3% of the students at pretest contemplated reducing their weight to avoid complications of obesity, as compared to 35.6% at posttest, where this was found to be the major reason for reducing weight. Most of the students were advised by their parents to reduce their weight (57%), while 8.3% only thought of reducing their weight following a doctor€™s advice. Almost half (47.8%) were reducing their weight by dieting, either on their own or by their families help.

In the multiple regression analysis of factors influencing total practices & Anthropometric Measurements after implementing the educational intervention, out of fourteen examined variables, only three were significant. The first was height; then weight, then BMI. For factors affecting total knowledge among the students before and after implementing the intervention, six factors entered the regression: age, mothers occupation, fathers occupation, educational level of mother, and educational level of father, but none were statistically significant.

Obesity is a public health problem worldwide and has been proposed as the most frequent cause of preventable deaths after smoking. Its increasing prevalence has compelled the WHO to include it on the list of the essential health problems in the world.[1,2] Development of obesity and excess weight in childhood are associated with a simultaneous increase in the chronic diseases risk profile.[3]

Economic development in the Kingdom of Saudi Arabia has influenced nutritional and lifestyle habits of the people. The combined prevalence of overweight and obesity has been estimated around 27.5% among boys (11.7% overweight and 15.8% obese) between 6-18 years of age in 1996, and 28.0% among girls between 12-19 years in 1999.[4] A study investigating the change in overweight and obesity among schoolchildren and adolescents in Jeddah using data from the years 1994 and 2000 showed a rise in the BMI for both sexes at the 50th percentile, and higher still at the 85th and 95th percentiles. The increases in BMI were marked for all age groups; with boys showing the largest increase among the 10€“16 years age group.[5]

The overall prevalence of obesity in our study was 26%, which is slightly lower than that previously reported.

The increase in obesity prevalence among Saudi children and adolescents reflects a population shift toward positive energy balance. Sedentary lifestyle and calorically dense food consumption have become increasingly popular, with physical activity and sports being substituted by television viewing and computer games.[6]

In the present study, family history of obesity was reported by 34%. It is well known that parental obesity is the most important risk factor of childhood obesity. More than half of the students (52.4%) had a good level of physical activity at pre and posttests. This can be attributed to the availability of lessons and facilities at this private school for physical training. This is not the case in most Saudi girls schools, particularly governmental schools.

The prevalence of obesity documented in this study cannot be generalized because of the limitation of its being conducted in one private school, which understandably suggests that the students are from a more affluent social and economic background. However, the study shows evidence that dietary changes are possible in the context of school based health education.

Primary prevention and successful treatment of obesity requires the extensive involvement of many sectors of society. A national prevention program with involvement of schools is recommended to increase knowledge among children and adolescents. A concentrated and sustained effort is needed to focus on broad environmental changes and community support for healthy behaviors; the commitment of families is critical.