Healthy Youth, Healthy Community

Running Title: Healthy Youth, Healthy Community (HYHC): School-based intervention efforts towards obesity-related messages in Fiji Poe E, Morse Z, Pryor Z. Abstract: Background: Overweight and obesity prevalence rates in Pacific Island Countries are among the highest in the world. The Healthy Youth Healthy Community (HYHC) was a school-community project aimed in reducing pediatric overweight and obesity in Fiji. Data on obesity-related messages in secondary students in Fiji are limited.

Objective: To identify the degree of acceptance of key obesity-related messages among adolescents participating in the HYHC Project.

Methods: We conducted a cross-sectional comparative quantitative study based on a self-reported questionnaire design. Questions included obesity-related behaviors: breakfast consumption, sugar-sweetened beverages, and physical activity. The sample comprised of secondary school students (n=720) participating in the HYHC enrolled in form levels 4, 5, and 6 as well as adult mothers (n=180) of children enrolled in the HYHC Project. This study investigated responses from adolescents and mothers whom had participated in the HYHC Project and were compared to adolescents and mothers, respectively, whom had not received any intervention.

Results: Student results indicate that 89.4% children in the intervention consume breakfast and 18.3% are physically active after lunch which is five and ten percent greater than comparative group (p<0.047, p<0.01) respectively. When adjusted for ethnicity, Fijian children in the intervention were 5% more likely than Indian children (66.2%) to show a higher frequency (in the last 5 school days) of breakfast consumption before school (p<0.03). Ten percent more participants in the intervention reported drinking water most often than the comparison group (46.4%, p<0.01).

Introduction: Overweight and obesity prevalence rates in Pacific Island Countries (PICs) are among the highest in the world. 1 Public health concerns in the Pacific have shifted from preventing and controlling infectious diseases to preventing and controlling chronic non-communicable diseases (NCD).2 According to a recent report supported by the World Health Organization (WHO) and the Secretariat of the Pacific Community (SPC), NCDs were the leading causes of death in all PICs; these accounted for 70%-75% deaths, with the exception of Papua New Guinea where these conditions accounted for 58% deaths. 3 Data from the WHO Global InfoBase show that obesity rates (Body Mass Index (BMI) ≥ 30 kg/m2) are 47.9%, 68.4%, 70.2%, and 81.0% in Samoa, Tonga, Cook Islands, and Nauru respectively.1 Between modifiable behaviors such as poor eating habits and excessive physical inactivity and the development of NCDs is the development of overweight and obesity. 4 Globalization, adopting Westernized lifestyles, and improved living standards have disrupted the energy balance resulting in increased consumption of energy-dense, high-fat/lownutritive foods and sedentary lifestyle. 5 Behaviors that contribute to obesity, such as avoiding breakfast are established in childhood. 6-7 An inverse relationship has been found between BMI and breakfast consumption. 8-9 Moreover, skipping breakfast increases the likelihood of being overweight or obese. 10 A recent study analysis found that persons who skip breakfast have a higher mean BMI even after adjustment for gender, age, race, socioeconomic status and other lifestyle factors. 11 Eating breakfast every day is associated with an improved overall diet quality12 and having a healthy body weight. 13 Other behaviors such as the intake of sugar-sweetened beverages (SSB) and physical inactivity are determinants of obesity in school-aged children. With SSB contributing to more than 40% of total added sugar in an average diet in the United States, the consumption of SSB have increased in all ages. 14-15 One prospective study of pre-adolescents aged 11 to 12 years found becoming overweight increased by 60% for each sugar-sweetened beverage consumed daily. 16 Data from the Longitudinal Study of Child Development in Quebec suggest that children who regularly consumed SSB from ages 2-4 were more than twice as likely to be overweight at 4.5 years. 17 In terms of physical inactivity, a Cochrane Review meta-analysis on exercise for overweight and obesity supports the usage of exercise in combination with a diet change as effective measures in a weight lost intervention. 18 Fortunately, even if no weight loss is achieved, exercise is associated with improved cardiovascular disease risk factors, diastolic blood pressure, triglycerides, HDL, and glucose levels.

Socialization of health-related behaviors occurs within the family, with parent’s knowledge, attitudes and behaviors substantially affecting children’s health behavior. 19 However, maternal misperceptions of child’s actual weight have been documented in the literature. 20-21 In a recent review, 19 out of 23 studies found that more than half of parents cannot recognize their child is overweight. 22 For parents and adolescents, underestimating the adolescents’ weight was associated with poorer diet behaviors and more perceived barriers to following healthy diet or exercise behaviors.

23 Mothers are of particular interest on children’s eating behavior as they have been

shown to spend significantly more time than fathers in direct interactions with their children. 24 The Healthy Youth Healthy Community (HYHC) was an on-going schoolbased project in Fiji aimed in reducing pediatric overweight and obesity. The goal of the interventional study was to develop and implement HYHC activities that promote healthy eating and healthy activities in secondary schools targeting adolescents (13-18 years old). Few studies that have documented school-based obesity prevention interventions in the USA have shown to be effective at improving knowledge but with limited effects on influencing health behavior in children and adolescents. 25-29 Little or no information is available about obesity prevention interventions among secondary school students in the Pacific. Breakfast consumption, intake of sugar-sweetened beverages (SSB), and a decrease in physical activity (PA) have all been associated with overweight and obesity. Each of these behaviors have been promoted in the HYHC Project in the effort to reduce overweight and obesity among Fijian adolescents.

This study investigated the effectiveness of relaying key messages among students and mothers on the prevention of obesity in the HYHC Project. Three messages were examined: 1) breakfast consumption, 2) sugar-sweetened beverages (fruit drinks versus regular fizzy drinks); and 3) physical activity. The purpose of this study was to investigate the degree of acceptance of key messages among adolescents participating in the HYHC Project.

Methods Setting and Overview The Healthy Youth Healthy Communities (HYHC) Project was a schooldirected, community-based, pediatric obesity intervention among adolescents in the school year of 2006 in Fiji. Adolescents (13-18 years old) enrolled in seven secondary schools encompassed within a localized community participated in the study and served as the intervention. These intervention schools were based in the urban area of Nasinu in the eastern division of Fiji. Matched comparative secondary schools were primarily located in the western division of Fiji These schools did not receive intervention and served as the control. The goal of the HYHC Project was to develop and implement a school-based community intervention program on overweight and obesity prevalence in young people.

The HYHC Project is part of a larger project, The Obesity Prevention in Communitiesâ&#x20AC;&#x2122; (OPIC) Project, which includes similar interventions being conducted simultaneously throughout the Pacific. Efforts are being mobilized with over 15,000 adolescents in Fiji, Tonga, New Zealand and Australia from 2005-2009 to reduce the prevalence of pediatric obesity.

Study Design This cross-sectional study was based on a questionnaire designed to evaluate the behavior among adolescents participating in the HYHC Project. Data collection involved administering questionnaires to students at school by way of sample of

convenience. Stratified data was used to match demographics between investigation groups. During the on-going implementation of the HYHC Project, data collection for this study was collected once mid-way of the HYHC Project in 2006. Data analysis compared responses from intervention adolescents that were enrolled in the intervention schools participating in the HYHC compared to adolescents enrolled in comparative schools that did not receive the intervention.

This study also investigated responses from mothers of children enrolled in their respective groups. The questionnaire designed for mothers was similar to the questionnaire designed for students. Data collection involved administering questionnaires to mothers in selected supermarkets located in the community that were within school zones of children enrolled in both groups. The purpose was to investigate mothers’ perceived responses of their children’s behavior of the three key messages and to identify any differentiation between groups. The HYHC study has received a variety of ethical clearances including from the Fiji National Research Ethics Review Committee.

Participants Students in either Forms 4, 5 and 6 (n=720) were invited to participate in this study. This study collected data from an equal number of Indo-Fijians and Indigenous Fijians, referred here as Indians and Fijians respectively with both males and females equally represented. Students in the intervention group were enrolled in one of the following six participating schools from the HYHC Project: Ahmadiyya Muslim College, The Assembly of God High School, Bhawani Dayal Arya College, Nasinu Muslim College, Nakasi High School and Rishkul Sanatan College. In the control group, students were also in forms 4, 5 and 6 and enrolled in a school in the western division of Fiji.

Mothers of children (n=180) with a child in forms 4, 5 and 6 with a child enrolled in a secondary school in either the intervention or control schools were invited to participate . Sample of convenience was used to screen for eligible mothers.

Oral consent was obtained from all participants in addition to any previous written consents that may have been provided.

Measures Questionnaires were self-reported and addressed main concepts from the HYHC Project, i.e. breakfast consumption, sugar-sweetened beverages (fruit drinks versus fizzy drinks), physical and sedentary activity. Questions used for the student participants were derived from questionnaires used in the HYHC Project and the questions for the adult participants addressed mothers’ perception of child behavior with almost identical questions.

Determining breakfast consumption with students was assessed with questions such as: ‘Do you usually eat breakfast before school starts?’, ‘In the last 5 school days, on how many days did you have something to eat for breakfast before school started?’, and ‘In the last 5 days, on how many days did you eat at morning recess interval?’.

SSB refers to carbonated, regular fizzy soft drinks (i.e. Coke, Sprite, and Fanta) and sugar-added fruit drinks with similar questions posed separately for fruit drinks and regular fizzy drinks. Questions in the surveys included: ‘In the last 5 school days, on how may days (including time spent at home), did you have at least one

‘regular’ soft drink?’, ‘In the last school day, how many glasses or cans of soft drinks did you have?’ and ‘In the last school day, how many glasses fruit drinks or cordial did you have?’ Another question addressed what type of beverage do students most oftenly drink between: water, fruit drinks, regular fizzy drinks (sodas and soft drinks), diet fizzy drinks, and others. Option choices of brand drinks were relevant and appropriate for the area.

The physical activity component of this study composed of two questions that examined energy expenditure during lunchtime and afterschool. One aspect of physical activity was assessed in the following question, ‘In the last 5 school days, what did you do most of the time at lunchtime (apart from eating)?’ Response choices for the former question were: ‘mostly just sat down’, ‘mostly stood or walked around’ or ‘mostly played active games’ The other question assessed after school physical activity with the following question: ‘In the last 5 school days, on how many days after school did you do sports, dance cultural performances or play games or any activity in which you were active?’

Analysis This study adjusted for ethnicity, age, gender and student form level covariates. Statistical analyses were performed with Epi Info (version 3.4.3, 2007) software. Demographics for ethnicity, gender, and student form level were described with univariate statistics. Cross-tabulations using chi-square tests were performed between groups and variable questions to determine statistical significance which was defined in this study as P<0.05.

Results: Demographics A total of 720 students and 180 adults participated in the study. There was an equal proportion of students in terms of gender, ethnicity and class grade. The average age of the student participants was 16.1 years (range 14-19). Mothers were also represented equally in terms of ethnicity and had an average age 42.2 years (range 3466).

Breakfast Consumption Results of the study indicate that 89.4% of intervention students usually eat breakfast before school, as opposed to 84.4% of controls (p<0.047). More females (90.5%) in the intervention group eat breakfast than females in the control (79.3%)(p<0.01). There were no significant difference in males, or according to ethnicity. When asked the same question of their children, no significant difference was found between what mothers perceived and what the children reported.

There was no difference in the frequency of breakfast consumption in the last 5 school days between intervention and control groups. This data was also consistent with the mothers’ perceptions. In terms of ethnicity, more Fijian students in the intervention group eat breakfast more frequently than Fijian students in the control group (p<0.03). Results show that 71.6% of Fijians in the intervention eat breakfast 5 out of 5 days compared to 60.1% of Fijians in the control. Similarly with the Indian

population, more Indian students in the intervention group (66.2%) eat breakfast 5 out of 5 days than Indians in control (55.9%) p<0.0377. No significant difference was found for both male and female student participants.

Adult surveys also included questions to mothers that addressed the frequency of taking food from home to recess and to lunch in the last 5 school days. No difference was found with the frequency of taking food from home to recess between groups. However 17.7% more children in the control take food from home to school for lunch 5 out of 5 school days than children in the intervention (p<0.04).

Beverage Intake When student participants were asked what particular beverage they most often drink: water, fruit drinks, regular fizzy drinks, diet fizzy drinks, and others, close to half of both groups chose water. More participants (p<0.01) in the intervention area (56.4%) reported water consumption than the comparison group (46.4%). Fruit drinks, diet fizzy drinks, and others were relatively similar between groups, approximately 20%, 3%, and 2% respectively. For those who chose soft drinks as their number one preference, 30.6% of control participants chose regular fizzy drinks compared to 18.9% of intervention participants. When mothers were asked the same question about their children, they reported that more of their children in the intervention group chose fruit drinks 18.9% and fizzy drinks 8.9% than control (p<0.01 Indian mothers, reported that their children in the intervention group consume 13.3% more fruit drinks and 8.9% more soft drinks than controls (p<0.04). On the other hand with Fijian adults, more Fijian kids drink fruit drinks 24.4% and soft drinks 8.9% than control (p<0.01).

With the frequency of soda consumption in the last 5 school days, 28.6% of control participants compared to 16.4% of intervention participants drank at least one soft drink 4-5 days in the last 5 school days (p<0.01). Adult data also suggest that more children in the control (6.7%) drink at least one soft drink 5 out of 5 school days than intervention children (p<0.01). According to Fijian adults, 6.7% in the control drink at least one soft drink 5 out of 5 school days than control. With the amount of sodas consumed (i.e. cans) in the last school day, no difference was found between groups. Our study found no difference in the amount of fruit drinks consumed or the frequency of fruit drink consumption between groups. There was also no significant difference in the amount of water consumed on the last school day between groups.

Physical Activity: When students were asked what was the type of usual physical activity during lunchtime, 15.3% of the control students “mostly just sat down” as opposed to 12.8% found in the intervention group (P=_). 8.1% of control students “mostly played active games” whereas 18.3% of intervention students “mostly played active games” (p<0.01). Physical activity in terms of sports, dance cultural performances or any active games after school showed the participants in the intervention group were less actively involved than in the control group (p<0.01).

Discussion:

According to the results from the student analysis, close to 90% of intervention students usually eat breakfast before school. Although the parent data found no difference between groups when asked the same question about their children, suggest that students in the intervention group are usually eating breakfast away from home.

Students may either be attaining breakfast in school from limited funded HYHC activities or in town before school. Unlike developed countries where fast food chains offer a quick option for breakfast with increasingly healthy alternative menus, bakeries are the popular source for breakfast in Fiji. Common breakfast meals in Fijian urban areas consist of bakery products rich in carbohydrates and fat such as bread, cream buns, meat pies, and sausage rolls. Fiji does not have allocated school buses for primary or secondary children and thus children are resorted to using city buses as their primary mode of transportation. Schools in both treatment groups are relatively near or within central town where these bakeries reside, increasing the availability of unhealthy foods to children. Students in urban areas are therefore more likely to eat breakfast and also more prone to consume carbohydrates, fried, and other processed foods compared to students in isolated rural areas.

This study found that when looking at students attending schools in two similar urban areas, more students in the intervention arm are eating breakfast than those in the comparative group, suggesting a heightened awareness of the importance of breakfast consumption. However, the data does not differentiate whether breakfast consumed from student respondents were “healthy” or “unhealthy” nor eaten in town or in school, an opportunity for future studies to address.

No difference was found with the frequency of breakfast consumption among student participant groups nor with the parent’s perception of children’s frequency of eating breakfast. Although time could be the most common factor for this outcome, another factor could be of financial stability with families such as costs for breakfast, meals/snacks and bus fare. Unlike the education system in most developed countries where public schools are free, Fijian schools require an incurred cost to attend, which may provide Fijian families a financial strain to conserve money where deemed necessary. Access to healthy foods is another factor in maintaining good health and daily breakfast consumption. It has been documented that food insecurity and nonaccess to healthy foods in households, have been associated with increased BMI in the 85th-95th percentile with children. 30 This study did not obtain BMI from students or parents, but future studies that collect BMI may provide insight on the link between theory and action. Future research may also look into finding correlations with specific parent-child dyads, rather than a random parent with a child enrolled in one of the intervention schools. Additional questions may also address annual family income to determine whether finance is a factor in obtaining healthy foods.

Increasing efforts in promoting water consumption seems to be an area that needs further attention. According to the student participants, study found no difference in the amount of fruit drinks consumed in the last day, the amount of soda consumed in the last day, nor the frequency of fruit drinks consumed in the last 5 school days. Water was also found to have no statistical difference between groups.

On the other hand, study did find that students in the comparative group drink at least one soda a day in 4-5 days, 12.2% more than intervention students. One question

asked what particular beverage they most often drink between water, fruit drinks, regular fizzy drinks, diet fizzy drinks and others. Findings were that more students in the control chose regular fizzy drinks than students in the intervention. Interestingly, according to parents, more kids in the intervention chose fruit drinks and fizzy drinks than the comparative group. It is possible that awareness of these key messages are being accepted by target adolescents and behavior change is being recognized at home. Thus parents would also gain awareness of the detrimental effects of fizzy drinks and its contribution to weight gain, thereby responding with higher numbers than parents whom are unaware.

Expediting energy through physical activity is the second part of the energy balance that maintains homeostasis of proper weight levels. Results found that more students in the intervention seem to be more active than students in the control. On the other hand, more students in the comparative group responded in higher numbers in physical activity after school. After school athletic programs and clubs are dependent on individual school policy, this study did not address the number of programs available for students after school.

Parents were asked the level of encouragement to physical activity that they express to their children, results found that more parents in the control consider encouraging their children â&#x20AC;&#x153;a lotâ&#x20AC;? than parents in the intervention. Emphasizing the importance of physical activity from parents, teachers, and other school personnel is imperative for the proper growth of children.

Strengths of this study included a cross-sectional view of targeted adolescents in the HYHC Program, where no data had been provided before. School-based interventions are limited in PICs, evaluation is essential towards sustainability and feasibility of programs, especially in a region that is closely affected by the obesity epidemic. The report of the Healthy People 2010 program in the US state that overweight and obesity is a top priority as life expectancy is expected to decrease 2-5 years in the next generation. 31-32 Furthermore, a progress report on the Millennium Development Goals (MDGs) in the Pacific region showed that PICs are unlikely to achieve the health-related goals by 2015 without significant additional external investment in health and related sectors. 3 Limitations included that selective schools from HYHC were already considered as the intervention, comparative schools may not have been matched equally. Although sample size within the intervention were randomized, sample of convenience was used to identify participants in the comparative group, as well as the adult sample. Continuing efforts could be directed in further promotion of daily breakfast at home, fruit and water consumption, and promotion of physical activity as alternatives to media time. Nevertheless, this study provides evidence basis that suggests that HYHC intervention has been effective in changing childrenâ&#x20AC;&#x2122;s attitudes in breakfast consumption and physical activity in a cohort of adolescents.

Acknowledgements:

We would like to acknowledge Jimaima Schultz, and Gade Wade with their primary insight on this study and thank Drs. Shari Barkin and Sabina Gesell for their constructive criticism of this manuscript. This study was funded by the Wellcome Trust, National Health and Medical Research Council of Australia, Health Research Council of New Zealand, and The World Health Organization.

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Table 1: Student Demographics, Children aged 14 to 19 Years in 2006

Age

Ethnicity Indigenous Fijian Indo-Fijian Gender Male Female Student Form Level Form 4 Form 5 Form 6 † Mean § Standard Deviation € Range

Control (n=360) Intervention (n=360)

Combined (n= 720)

p-values

16.05† ± 1.05§ (14-19) €

16.09±1.04 (14-19)

0.7505

16.13± 1.04 (14-19)

0.1172 50.8% (183/360) 49.2% (177/360)

45.0% (162/360)

47.9% (345/720)

55.0% (198/360)

52.1% (375/720) 0.7093

51.7% 50.3% (181/360) (186/360) 48.3% (174/360) 49.7% (179/360)

51.0% (367/720) 49.0% (353/720) 0.8166

34.2% (123/720) 34.4% (124/720) 31.4% (113/720)

33.1% (119/720)

33.6% (242/720)

33.3% (120/720)

33.9% (244/720)

33.6% (121/720)

32.5% (234/720)

Table 2: Adult Demographics in 2006

Age

Ethnicity Indigenous Fijian Indo-Fijian Student Form Level Form 4 Form 5 Form 6 † Mean § Standard Deviation € Range

Control (n= 90)

Intervention (n=90 )

Combined (n= 180 )

p-values

43.22† ± 5.85§ (34-65) €

41.27 ± 4.98 (31-66)

42.24 ± 5.51 (34-66)

0.2518

1.0000 50% (45/90)

50% (45/90)

50% (90/180)

50% (45/90)

50% (45/90)

50% (90/180) 1.0000

50% (30/90) 50% (30/90) 50% (30/90)

50% (30/90) 50% (30/90) 50% (30/90)

33.3% (60/180) 33.3% (60/180) 33.3% (60/180)