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Abstract
- Background: Parents play a critical role in influencing the eating habit of children from an early stage. Hence, ensuring they have a positive perception towards healthy eating is crucial in reducing childhood obesity. The study examined the parents’ perception on factors that contribute to childhood obesity and sort their suggestions on the possible ways of overcoming the barriers.
- Method: Semi-structured in-depth interviews were undertaken for 26 parents with obese children aged 9-13 years. A total of 13 open-ended questions focusing on the three nutritional aspects were utilised. They included (1) perception of the parents regarding their children’s weight and eating habits, (2) their attitude towards healthy eating and weight management and lastly, (3) their suggestions on how their children can adopt a healthy lifestyle. The data was analysed using the Nviro software based on themes and sub-themes developed.
- Results: The parents identified the internal barriers as their preoccupation with work, nannies allowing their children to consume an unlimited quantity of unhealthy foods, children’s lack of mindful eating, and unhealthy personal food choices. The external barriers were negative influence of peers and social media, sedentary lifestyle, lack of awareness and unified dietary information. The suggested internal facilitators were parents’ change of attitude and willingness to stop buying unhealthy foods, whereas the external ones were support from Emirates School Foundation for their children, and advice from specialists.
- Conclusion: The internal barriers identified can be overcome by providing nutritional education to nannies, conducting awareness campaigns through TV commercials and on social media, including nutritional education into the curriculum at an early age, developing surveillance systems in schools to identify obese/overweight students and support them in weight management and providing unified information through government websites.
- Keywords: Obesity, parent’s perception, healthy lifestyle, UAE, weight management, barrier.
Introduction
Childhood obesity remains a significant burden globally due to its high prevalence. Notably, the cases of the condition in children below five years exceed 40 million. Moreover, the incidences in those above five years and adolescents are over 330 million. Importantly, the global challenge posed by the disorder has prompted the World Health Organization to start a campaign called “no increase in childhood overweight by 2025.” The initiative targets prevention of diseases associated with childhood obesity [1, 2]. Primarily, the short-term effects of obesity in children include psychological conditions such as low self-esteem, anxiety, depression, and liver complications. Furthermore, the potential long term effects include heart diseases, type 2 diabetes, and some types of cancer. The risks of these illnesses progress into adulthood and may cause premature deaths or musculoskeletal deformities [1]. Therefore, curbing obesity prevalence is crucial in reducing the incidences of numerous chronic illnesses.
The Middle East is one of the regions with high obesity prevalence globally. In United Arab Emirates (UAE), an alarming upsurge has been observed in most schools. Notably, in the last two decades, the overweight and obesity cases have increased by two folds in students aged 11 to 18 years. The prevalence has dramatically escalated from 21.2-21.7% to 35.6-42.1% nationwide [3]. Moreover, studies indicate that the annual increase in childhood obesity countrywide is 2.36% in children and adolescents aged 3 to 18 years (Al-Blooshi et al., 2016). Furthermore, several publications have reported a high prevalence of childhood obesity in UAE students. Bani-Issa et al. [4] revealed that the obesity prevalence in UAE schools is 34.7%. In Ras Al‐Khaimah public schools, students aged 11-18 years had a prevalence of 38-41.2 % [5]. Similarly, Pengpid and Peltzer [3] suggested that in students aged 8 to 14 years in UAE schools, the obesity prevalence in males (42.1%) was considerably higher compared to females (35.6%). Therefore, it is crucial to develop effective strategies for reducing childhood obesity in UAE.
Parents are instrumental in promoting healthy eating and dietary practices in children. Moreover, they are the key determinants of the nutritional status of children and adolescents. Primarily, the parents’ knowledge and attitude towards healthy eating influence their food selection, meal pattern, and level of physical activity. Eventually, their food choices impact the children’s weight and nutritional status [6, 7]. Moreover, studies suggest that including them in the prevention strategies can substantially improve the weight of their obese children. Importantly, the identified obesity risk factors in children include high consumption of fast foods and sugar, low intake of fruit and vegetable, sedentary lifestyle, as well as eating large portions of foods [7-9]. Although there is a consensus globally that prevention is a crucial strategy of reducing the incidences, limited success has been achieved so far in implementing this approach in students alone. Notably, parents play a critical role in influencing the dietary habits of children in their early years [6, 9]. However, the suitable strategies for supporting parents in improving their children’s nutritional status remains unclear. Nonetheless, seeking parents’ opinion on how to promote healthy eating and exploring their attitude towards their children’s eating behaviour and physical activity is crucial in developing effective prevention strategies [6, 7, 9]. The study assessed the attitude, perception and nutritional knowledge of parents using in-depth interviews to determine how they contributed to the nutritional status of their children.
Methods
The aim of this study is to explore the attitude, perception, and knowledge of parents of public schools’ students, aged between 9 to 13 years, studying in the United Arab Emirates (UAE) and Sharjah about their children’s weight, eating habits, and healthy eating.
Study Design
This was a qualitative study design involving in-depth interviews with parents of 9-13 year children attending government schools in Sharjah and Dubai, UAE. The parents were invited to obtain their perceptions on factors that contribute to childhood obesity and sort their suggestions on the possible ways of overcoming the barriers. The collection of data was conducted through in-depth interviews from September to November 2021. This information was collected to use for a planned intervention for overweight and obese students.
Participants and Sampling
The participants were parents of obese children aged 19 to 13 years attending the selected public schools in UAE and Sharjah. The purposive sampling technique was utilized in selecting the parents. The basis of sample size determination was data saturation.. Firstly, all eligible parents were contacted through emails containing essential information on the study, and its purpose. Additionally, the email included information about the means that will be adopted to conduct the interview and its estimated duration. The interested parents were requested to issue a positive response. Eventually, a total of 35 parents consented and were included in the study. However, after 26 interviews, data saturation was achieved, and the process of data collection was halted.
Semi-structured interviews
A semi-structured interview template (Attachment X) was developed as a guide during the interview process. It contained questions focusing on three main nutritional aspects, including (1) the perception of the parents regarding their children’s weight and eating habits, (2) their attitude towards healthy eating and weight management through nutritional interventions, and lastly, (3) their suggestions on how they and the Emirates School Foundation can support their children in adopting a healthy eating pattern and effective weight management. The 13 questions in the interview guide were obtained from [10-13]. Prior to initiating data collection, the interview guide was translated to Arabic and subjected to content validation [14] before testing it in both languages with 6 parents of random obese and overweight children aged between 9 to 13 years living in the UAE (three females and three males), and necessary modifications were made accordingly. Table 1 below presents main asked questions:
The semi structured interviews were all conducted over the phone using the Arabic language based on the preference of the contacted parents. The interviews lasted between 45 to 60 minutes each, including the time used to explain the purpose of the interview. Throughout data collection, it was reflecting on the conducted interviews and on her attitude during interviews in efforts to reduce interviewer bias [16, 17]. During the interviews, verbal probing techniques were adopted to better understand the point of view of the participants [18, 19]. In-depth interviews were conducted by a researcher with vast knowledge on nutrition Additionally, it was taking verbatim notes of the responses in Arabic on word documents. Notably, the parents were probed, and on-the-spot questions were included whenever clarifications and details were required. The added questions were recorded by the interviewer as part of the transcript, which were later translated into English by the author. Eventually, the text was imported into the NVivo software (NVivo 12; QSR International, Doncaster, Australia) for analysis.
Table 1: Sample questions included within the parents’ interview guide
Recruitment
The recruitment criteria of the sample were all parents of overweight and obese public schools students in the UAE and Sharjah aged between 9 to 13 years in the selected public schools. Before the excercise, we first obtained the approval of the concerned ministry of education in the UAE and approached the schools directors. Based on this approval, the requested for appointment with school directors to be able to visit and record the height and weight of their students aged between 9 to 13 years. Next, their BMI was calculated and plotted on the growth chart. Then, all eligible parents were contacted through email entailing all essential information about the study, and purpose. In addition, the email included information about the means that will be adopted to conduct the interview and the estimated time of the interview. Also, within the email, interested parents to participate in the study were requested to respond back positively to the email so that we can contact them back with further details about the interview and schedule a date and time for the interview.
Data Analysis
Imported the transcripts generated after each interview to Nvivo software. After reading the interview transcript various times, then started by assigning codes to each input using an inductive approach [20]. This was done by using Nvivo software-related command. Assigned codes were based on the participants’ responses rather than directly linked to the specific question asked [20]. In case a code was emerging many times, the Nvivo software reselected it and later showed its frequency. The codes were constantly compared and analyzed using Nvivo Query and then grouped into categories/subthemes, which were later also grouped into themes. The Nvivo software was also used through one of its query to find how concluded themes were inter-related and how multiple facilitators and hindering factors were reported by the parents as affecting their children eating habits and eventually their weight. All identified themes and sub-themes were organized and illustrated in tables.
Quality Assurance
Multiple approaches were employed to enhance the quality of the research. Language equivalence was assured through in-dependent reviews by other researchers fluent in both Arabic and English. Moreover, 15 recorded interview were sent to different person along with the translated transcript to check if both are aligned together. In addition, the translated manuscripts were sent back to parents who speak English to verify the translated text almost all replied that it was accepted. Additionally, the Nvivo software was used to facilitate thematic analysis and coding of data into themes and sub-themes based on the qualitative data research methods. Prior to importing transcribed data, created a specific project for this study on Nvivo software. We adopted the constant comparison method [18] to identify recurring data, create categories, systematically compare them, and group them into themes. Accordingly, in line with the qualitative research methodology [19], data collection and analysis were concurrent.
Ethical consideration
The ethical approval for the study was obtained from the United Arab Emirates University social sciences ethics ERSC_2022_744.Notably, their consent to participate in the study was obtained prior to the date of the interview by email. Additionally, the parents were informed that they could discontinue at any time or decline to answer any question. In addition, they were assured that all shared information would only be used in the study.
Results
As mentioned within the methodology section, 26 parents were interviewed. The majority of whom were females (88%). All interviewed parents were Emiratis, and their vast majority were working (92%). Only two interviewed parents reported being separated from their partners (8%). Table X below presents the demographic information of interviewed parents.
Table 2: Demographic information of interviewed parents
Results of the thematic analysis of conducted in-depth interviews transcripts identified 3 main themes and 11 related subthemes, as detailed below. The first topic is “Negative effect of overweight on students’ life”, which describes the physical, psychological, and social factors associated with overweight status and affecting a person’s life. This theme does not distinguish any categories or sub-themes, containing various reactions and perspectives of parents on their child’s condition.
The second topic is “Identified barriers for a healthy lifestyle”, which consists of two categories according to the type of barriers: internal and external. Among the internal obstacles, four sub-themes were identified related to the involvement of parents and the nanny in the child’s life, as well as the child’s personal choices and deficiencies in mindfulness. Among the external factors, three sub-themes stand out: the negative impact of the environment, a sedentary lifestyle, and a lack of awareness and awareness. The last theme is formulated as “Identified facilitators for a healthy lifestyle”, and within it, two similar categories are also distinguished: internal and external facilitators. The first and second categories consist of two sub-themes related to the knowledge and behavior of parents in the first case and the involvement of specialists and the Emirates School Foundation in the second.
Table 1: The themes and sub-themes used in the thematic analysis
Negative Effect of Overweight on Students’ Lives
Being overweight has various negative effects on children’s lives at the physical and psycho-social levels, as mentioned by interviewed parents. It was expressed that their children’s weight affects their ability to play with friends. One of the interviewees, a male father of an overweight child, stated: “My child’s weight is greatly affecting his life. He wishes he could run with his friends and ride a bike, but he can’t because of his weight.” Childhood obesity was also reported by parents that results in social isolation. The reasons for such behavior may be, firstly, the initiative of the child himself, associated with low self-esteem. The mother of one of the children commented: “His weight stops him from playing with other kids, which means his social skills will not develop over time. And for sure, this will affect his psychological well-being. Therefore, he will not be motivated to achieve his goals.”
In addition, similar social isolation can be caused by bullying from peers, as another woman points out: “He is being bullied at school and among his friends because of his extra weight, and this is what makes him hate going to school and hate studying and playing with his friends.” Some parents mentioned that their children’s weight is not affecting their children’s lives now. However, they expressed concern about their prospects: “While my child is a little bit overweight for his age, I believe his weight does not stop him from achieving his goals at the moment, but in the future, it may become a major limitation”.
Identified Barriers to a Healthy Lifestyle
During the interviews, parents discussed and highlighted various perceived barriers hindering their children from eating healthy and enjoying a healthy lifestyle which eventually caused them to gain unwanted weight. These discussed barriers are presented below and segregated to two categories: Internal and External barriers.
Internal barriers
For the purpose of this study, internal barriers are considered to be all barriers within the control of the children and their parents. These barriers were reflected in the following sub-themes:
- Parents’ engagement in their children’s daily life;
- Nannies engagement;
- Lack of mindful eating;
- Children’s personal food choices.
Parents’ engagement in their children’s daily life
Parents’ pre-occupation with their jobs and careers, especially mothers, negatively affected the children’s healthy eating habits and, in some cases, gave them the chance to eat whatever they wanted without proper monitoring. An illustration of this is the statement of the father of one of the children: “I think that the fact our son is almost fully responsible for what he eats, and we cannot monitor him, is the main factor why he cannot control his portion sizes and the types of products he consumes.” Moreover, the majority of parents mentioned that their busy and demanding work schedule results in their inability to either/or: (1) cook; (2) cook healthy food; (3) feed their children healthy food; and (4) monitor their children’s eating habits and food portions. The mother of one of the children noted: “Since I am a working mother, I do not have much time to cook healthy meals daily. Most of our meals consist of frozen food or food filled with starchy foods such as rice and pasta, in addition to our heavy reliance on takeaway.”
Parents’ unhealthy eating habits were also identified among the underlying factors of children’s unhealthy eating patterns. One mother commented on her son’s behavior: “During the weekends, we often go out to fast-food restaurants or order food at home, so he sees me engaging in similarly bad dietary behavior. I believe that the fact that his dad and I have never been preoccupied with healthy eating has negatively influenced my child’s own eating preferences and led to his weight gain.”. In addition, parents identified that buying their children sweets and sweetened juices and keeping these products at home is also one of the internal barriers hindering their children’s ability to have a healthy lifestyle.
Nannies’ engagement
Nannies’ engagement in children’s everyday life might affect their healthy lifestyles. According to some mothers, the nanny might be less strict with children than parents: “…The nanny usually gives him anything just to keep him quiet and safe, so he picked this habit of having whatever he desires without any restrictions.” This behavior allows nannies to keep the child in a positive mood but significantly affects their eating patterns.
Lack of mindful eating
Lack of mindful eating and distracted eating habits contribute to children’s tendency to eat junk foods and have uncontrolled food portions. Some parents note the child’s excessive connection with electronic devices as one of the causes of obesity: “My child does not understand that he is distracted when he watches TV or plays video games, so he eats more than his appetite tells him to, resulting in his inability to lose weight.”
Children’s personal food choices
Children’s tendency to love fast/junk and pre-prepared foods and their preference for some food items over others also influence their lifestyle. Parents reported that their children prefer fast foods over more healthy dishes: “His love for food that is full of colorings, flavors, and harmful juices is the main issue. Most of the time, he refuses to eat healthy snacks.” The other personal barrier the parents revealed was the unwillingness of their children to reduce the consumption of unhealthy snacking. Notably, one of the parents pointed out that their children excessively love breakfast consisting of junk food: “He loves breakfast with biscuits and chips and loves to eat noodles and pastries daily”.
External barriers
For the purpose of this study, external barriers are considered to be the factors that are outside the control of the children or their parents. These external barriers were reflected in the following sub-themes:
- Perceived bad influence of peers and social media;
- Sedentary lifestyle;
- Lack of awareness and unified dietary information.
Perceived bad influence of peers and social media
The parents identified peers as the other critical areas of concern. One of the parents revealed that some children may tend to eat unhealthy foods when they are in the company of their friends: “My son often drinks sodas when he is with friends.” Moreover, the option of controlling what their children eat in the company of their friends elicited mixed reactions. Some of them admitted talking to the parents of the other children to discourage the unhealthy habits, whereas some were reluctant. Some parents also revealed that healthy traditional meals are rarely showcased on social media compared to unhealthy ones and attributed them to unhealthy eating habits. A female mother of a slightly overweight child stated: “As I noted earlier, his sudden obsession with fast food is the main factor affecting his weight. Perhaps this new eating habit was influenced by the social media that and his schoolfellows.”
Sedentary lifestyle
With the emergence of COVID-19, children had to stay at home and study there for long periods. It also drastically reduced their time out and their activities with their friends, hence, reducing their physical activities. As one of the mothers commented on her son’s behavior, “His weight is constantly increasing. He is less mobile due to sitting in front of the computer for long periods because of remote education”. In addition, parents discussed their concerns about their children’s preference to stay at home and engage in social media and video games: “I believe that the main reason my child is overweight is that he does not move enough, and his only activities involve watching TV and sitting in front of the computer.”
Lack of awareness and unified dietary information
The lack of a credible source continuously disseminating nutrition and food-related information hinders establishing healthy nutrition practices. Parents mentioned their need for credible sources of information: “I believe my and my son’s lack of knowledge on how certain foods have to be consumed in moderation is the main problem that causes him to have such big portions of snacks that he consumes almost daily.” More accessible knowledge about healthy eating could help to encourage children to eat more healthy food.
Identified Facilitators for a Healthy Lifestyle
Throughout the interviews, parents mentioned and discussed various perceived facilitators that might affect positively their children’s attitudes and behaviors toward a healthy lifestyle. As done for the identified barriers, these noted facilitators are presented below in two categories: Internal and External facilitators.
Internal facilitators
For the purpose of this study, internal facilitators are to be considered all the factors that children and their parents can do to optimize their healthy lifestyle. These facilitators were reflected in the following sub-themes:
- Parents’ perception of and knowledge about the importance of following a healthy and diversified diet.
- Parents positive attitude towards being engaged in the change.
Parents’ perception of and knowledge about the importance of following a healthy and diversified diet
Parents discussed their knowledge about the benefits of following a healthy lifestyle and highlighted their perception of the importance of adopting a healthy lifestyle for their children’s health in the future as adults. One of the mothers stated: ” Nutritional and health fields are very important as they are responsible for our psychological and nutritional health. If our food is healthy, we will be in the best physical and psychological health.”
Parents positive attitude towards being engaged in the change
The parents expressed their positive attitude toward being involved with their children to be within their journey toward a healthy lifestyle. They mentioned being ready to change their eating habits to influence their children to positively change their unhealthy eating habits. One of the mothers also expressed their willingness to cook healthy food weekly for their children: “I can adopt a new healthy food plan by encouraging my son to eat food full of healthy vegetables and vitamins by buying an air fryer to cook with.”
In addition, parents mentioned that they are ready to engage with their children in conversations about healthy food and the importance of following healthy eating habits and a healthy lifestyle. They further mentioned establishing a reward system for their children whenever they eat healthy foods: “I can support my child by making healthy meals for him consisting of fruits and vegetables, beautifully decorating them, and giving him material rewards when he eats healthy food”. Furthermore, parents expressed readiness to stop buying their children unhealthy snacks and bring home more fruits and vegetables.
External Facilitators
For the purpose of this study, external facilitators are to be considered all the factors that encourage and optimize children’s healthy lifestyles that are outside the control of the children and/or their parents. These external facilitators were reflected in the following sub-themes: (1) Potential involvement of the Emirates School Foundation and (2) Advise from a Specialist.
Potential involvement of the Emirates School Foundation
The parents suggested several ways the Emirates School Foundation can follow to support the children’s journey toward a healthy lifestyle. One of the mothers suggested raising awareness: “The foundation can participate by publishing awareness campaigns in schools with the aim of reinforcing the conviction of children about the importance of healthy meals for their physical health.” Another suggestion included the provision of nutrition information into the school curriculum: “The foundation can add study materials and courses of a nutrition curriculum that will be designed for school students, teaching them about healthy food and encouraging them to eat it, especially from young ages such as kindergarten students. Thus, the child will grow up with healthy habits since childhood.”
Advise from a specialist
Interviewed parents highlighted that receiving advice from a specialist would significantly impact their and their children’s eating habits and encourage them to have a healthy lifestyle. One of the fathers stated: “Having a specialist’s advice will contribute to educating my child about the importance of eating healthy and the ways to build a balanced meal plan.”
Conceptual Framework
Based on the conducted study and its findings and emerging themes and sub-themes the study’s preliminary conceptual framework was further developed and extended as reflected in the figure below. This conceptual framework reflects the inter-relationships between the concluded themes and subtheme and their relationship with the children’s healthy lifestyle.
Based on the findings of the study, various factors affected the children’s healthy lifestyle. Some of these factors were barriers to the children’s ability to live a healthy lifestyle and others were facilitators enabling children to improve their lifestyle towards a healthier one.
As reflected within the developed conceptual framework parents identified the following to be barriers hindering their children to live a healthy lifestyle. These factors were external barriers, barriers related to the parents/family, and barriers related to the children themselves. These barriers are all interrelated and their effects were compounded which led children to shift into an unhealthy lifestyle and become overweight. Parents’ lack of engagement, compounded by the negative effect of external barriers (lack of proper awareness and bad influence from peers and social media) lead to their children’s personal choices favoring unhealthy food items such as fast food and sweets and gave them the chance to eat while playing or watching which leads to their lack of mindful eating.
According to parents, being overweight affect their children’s lives in various ways. It had negative effects on their children’s ability to play with friends; children’s social inclusion; and children’s health in the future.
At the same time, parents discussed a series of facilitators that might play an important role in helping their children to shift into a healthier lifestyle and overcome being overweight. These factors were mainly related to parents’ engagement and external factors. The parents have a perception and knowledge about the negative effect of being overweight and having an unhealthy lifestyle. This induced their positive attitude and willingness to be more engaged in their children’s lives and influence them to follow healthier eating habits. Similarly, parents mentioned that having proper awareness from the Emirate Schools Foundation, and support from specialists would also help them and their children to engage in a healthy lifestyle and to follow healthy eating habits based on science and supported facts.
Thus, within the aforementioned themes, nutritional facilitators could theoretically influence obesity in several ways. First of all, they can significantly improve the psychological and physiological state of the child, which positively affects a person’s future health. As part of these changes, healthier eating habits are formed. In addition, crucial nutritional knowledge can be disseminated, which creates the correct worldview for the child from childhood. These actions can be carried out both through educational institutions through various awareness campaigns and through direct interaction with specialists. However, all these influence measures require significant efforts, which limits their practical implementation.
As the conceptual framework reflects currently the barriers are having a greater effect on children’s lives compared to the facilitators. And they are leading to children’s overweight and its related effects. Yet, with proper focus on the facilitators and on implementing needed actions this conceptual framework might shift with more effect of facilitators and positive impact on children’s weight and their lives.
Discussion
Multiple studies indicate that childhood obesity cases are highly prevalent in UAE. Moreover, the number of obese school children has increased exponentially in the last two decades [21, 5, 3]. Furthermore, several studies have suggested that parents play a critical role in influencing their children’s nutritional [22-24]. Notably, Aljunaibi et al. [7] revealed that parental participation is crucial in preventing childhood obesity. Additionally, the incorrect perception of parents contributes to the unhealthy weight in their children. Importantly, the article proposed that if parents recognize the challenges associated with childhood obesity, they will actively participate in managing the weight of their children.
In the present study, qualitative research methods were utilized in determining the parents’ perception on factors that contribute to childhood obesity. Additionally, the research sort their suggestions on how to overcome the barriers. The method was considered the most appropriate in exploring and determining the attitude of parents towards healthy eating, and their perception of their children’s weight and nutritional status [25]. In addition, this method facilitated capturing parents’ recommendations and suggestions [25] on ways the parents, the Emirates School Foundation, and specialists can support their children in adopting healthy eating habits.
The parents were generally conversant with the negative effects of obesity or being overweight on their children. However, most of them did not mention the health risks associated with childhood obesity. Notably, they admitted that their children’s weights prevented them from engaging in physical activities and playing with other children. Additionally, they identified excess weight as a major obstacle to the development of their children’s social skills and psychological wellbeing. Moreover, others stated that their children faced bullying in school, whereas some parents expressed fears of future physical and psychosocial implications. Creating parental concern through knowledge of obesity health risks was previously identified as key in controlling childhood obesity. Moore et al. [23] examined the relationship between parental concern and weight management of their children. The findings revealed that concerned parents were more likely to initiate a healthy lifestyle in their children compared to the ones that were not concerned. The findings were consistent with Etelson et al. [22], who reported that parents of overweight children mostly had inaccurate perceptions regarding their children’s weight. Therefore, creating more awareness on the potential adverse effects of obesity on health would substantially reduce childhood obesity in UAE.
The parents were aware of the barriers that were preventing their children from adopting a healthy lifestyle. They admitted that their preoccupation with work and careers has adversely affected their children’s eating habits. Notably, their demanding work schedules do not permit them to cook healthy meals at home; hence, they mostly rely on fast foods and cannot monitor their children’s eating habits. Moreover, the children are usually left under the care of nannies who provide them with whatever food they desire to eat. The findings corroborated Vittrup and McClure [24], who revealed that the key barrier to childhood obesity weight management is lack of time by parents. Furthermore, the study revealed that the parents lacked knowledge on portion sizes, healthy foods and health risks of childhood obesity. Importantly, Garzay [26] examined the perception of nannies towards the children’s eating habits. Most of them indicated that the parents were the key determinants of their children’s eating habits. Additionally, they engaged the children in poor feeding habits due to limited nutritional knowledge. The researchers recommended provision of nutritional education for nannies to improve the children’s nutritional status.
The parents also indicated that their children are not mindful of what they are eating. Additionally, they avoid healthy foods and eat junk/fast food instead. Moreover, some said that their children are not willing to decrease their consumption of unhealthy meals. Additionally, they cited negative influence from peers and social media, lack of unified dietary information, and sedentary lifestyle as some of the barriers. The findings were consistent with Ragelienė and Grønhøj [27], who found that family, peers and social media influence children’s eating behaviour. Therefore, the parents, nannies and peers should be involved in weight management programs that promote healthy eating behaviour in children.
The parents mentioned facilitators that they believed could change their children’s perceptions. They included parents, schools and specialists’ advice. The parents expressed their willingness to change their attitude towards healthy eating, adopting healthy eating habits and teaching their children the importance of healthy habits. Furthermore, some were ready to stop buying unhealthy snacks and stock more fruits and vegetables. They further suggested that Emirates School Foundation and advice from experts promote a healthy lifestyle in their children. Overall, the suggestions provided by the parents were insightful and consistent with those previously reported in other studies. El-Sabban [28] suggested that children’s nutrition and general health require the support of parents, teachers, school administrators, nannies, and other directly or indirectly involved parties. Hinojosa et al. [29] revealed that modification of the school environment is crucial in childhood obesity weight management. The institutions can incorporate more programs that involve nutritional education and physical activities. Additionally, surveillance programs can be initiated in public schools to identify the students who are obese. Subsequently, they can be supported through various nutritional interventions.
Framework
Based on the results of the conducted literature review and in efforts to guide the data collection and analysis of the research findings, a preliminary conceptual framework was developed. This framework has at its focus four elements: Children’s Healthy Lifestyle; Children’s Personal Factors; Parents/Family; and External Environment. This conceptual framework was continuously updated and expanded throughout the study and based on the findings of the study to better reflect emerging themes and sub-themes and their interrelationships (Figure X).
The research provides crucial information that can be utilized in formulating strategies for prevention and decreasing childhood obesity in UAE schools. The information will be disseminated to the relevant government authorities. Moreover, the findings will facilitate development of future studies focusing on childhood obesity prevention and management. The barriers of healthy lifestyle identified by parents can be addressed through the recommendations below.
- Collaborative programs of nutritional education targeting the parents and children can be developed by relevant government agencies to support the children in adopting a healthy lifestyle.
- Moreover, the government should implement training programs for nannies to enhance their nutritional knowledge. They can be trained on how to support the children in adopting a healthy lifestyle, especially in instances where the parents are busy at work.
- Nutritional education can also be incorporated into the school curriculum in the early years to provide a unified source of information. Additionally, awareness campaigns can be initiated through television commercials and social media to counter the negative influence.
- The government can improve access to nutritional experts, where the parents and nannies can receive advice on healthy eating at subsidized costs.
- The schools can also provide more physical activity programs and develop surveillance programs for identifying obese students and administering nutritional interventions to them.
- The barriers of peer influence can be addressed by implementing nutritional awareness programs in communities and the formation of social support groups to help in the weight management of obese children.
Limitations
The major limitation of the study is generalizations cannot be made since the sampling criteria was self-selection. Notably, some parents chose not to attend the interviews. Although only 26 parents participated in the interviews, data saturation was attained.
Conclusion
The study examined the parents’ perceptions on barriers of childhood obesity weight management and ways of overcoming them. The internal barriers that the parents identified were the lack of time due to busy work schedules, nannies permitting the children to eat unhealthy foods without restrictions, the unwillingness of the children to eat healthy meals and lack of mindful eating. However, the parents did not mention the short term or long term health risks associated with childhood obesity. Therefore, including more information on the health risks associated with the disease in the awareness campaigns will improve the support from parents. Additionally, increasing awareness on the benefits of healthy eating on social media and television can potentially counter the negative influence. Furthermore, influence from peers may be resolved in school by including nutritional knowledge in the school curriculum. Similarly, the government can develop a website that the parents can use as a source of reference for information on healthy eating, the portions required, and the types of food one can consume. Similarly, the Emirates School Foundation can support in identification of obese/overweight children in different public schools, enrolling them in weight management programs. Overall, the government can utilize the barriers identified by parents to formulate policies that will curtail the prevalence of childhood obesity in UAE.
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Bani-Issa, W, Radwan, H, Rossiter, R, Fakhry, R, Al-Yateem, N, Al-Shujairi, A, Hasan, S, Macridis, S, Farghaly, A.A, Naing, L. and Awad, M.A. Prevalence and determinants of overweight/obesity among school-aged adolescents in the United Arab Emirates: a cross-sectional study of private and public schools.BMJ Open, 2020, 10(12), e038667. Web.
AlBlooshi A, Shaban S, AlTunaiji, M, Fares N, AlShehhi L, AlShehhi H, AlMazrouei, A. and Souid, A.K. Increasing obesity rates in school children in the United Arab Emirates. Obesity Science & Practice, 2016, 2(2), 196-202. Doi: 10.1002/osp4.37
Golan, M. Parents as agents of change in childhood obesity–from research to practice. International journal of pediatric obesity, 2006, 1(2), 66-76. DOI: 10.1080/17477160600644272
Aljunaibi A, Abdulle A, and Nagelkerke N. Parental weight perceptions: a cause for concern in the prevention and management of childhood obesity in the United Arab Emirates. PloS one, 2013, 8(3), e59923. Web.
Lindsay AC, Sussner, KM, Kim J, and Gortmaker S. (2006). The role of parents in preventing childhood obesity.The Future of children, 2006, 169-186. Web.
Akhtar‐Danesh, N, Dehghan, M, Morrison, KM, and Fonseka, S. Parents’ perceptions and attitudes on childhood obesity: A Q‐methodology study.Journal of the American Academy of Nurse Practitioners, 2011, 23(2), 67-75. Web.
DiLillo, V, Siegfried, NJ, and West, DS. Incorporating motivational interviewing into behavioral obesity treatment. Cognitive and Behavioral Practice, 2003, 10(2), 120-130. Web.
Pakpour, AH, Gellert P, Dombrowski SU, & Fridlund B. Motivational interviewing with parents for obesity: an RCT. Pediatrics, 2015, 135(3), e644-e652. DOI: 10.1542/peds.2014-1987
University of Connecticut. Motivational Interviewing for Diet, Exercise and Weight. Web.
Vansteenkiste M, and Sheldon, KM. There’s nothing more practical than a good theory: Integrating motivational interviewing and self‐determination theory. British Journal of Clinical Psychology, 2006, 45(1), 63-82. DOI:10.1348/014466505X34192
Brod, M, Tesler, LE, and Christensen, TL. Qualitative research and content validity: developing best practices based on science and experience.Qual Life Res, 2009, 18, 1263. Web.
Pannucci, C.J, and Wilkins, EG. (2010). Identifying and avoiding bias in research. Plastic and reconstructive surgery, 2010, 126(2), 619–625. Web.
Qu, SQ and Dumay, J.The qualitative research interview. Qualitative Research in Accounting & Management, 2011, 8(3), 238-264. DOI 10.1108/11766091111162070
Willis, GB. Cognitive interviewing in practice: think-aloud, verbal probing, and other techniques. In Cognitive interviewing(pp. 42-65). SAGE Publications, Inc. 2005.
Strauss, A, Corbin, J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage, 1990.
Pope, C, and Mays N. Reaching the Parts Other Methods Cannot Reach: An Introduction To Qualitative Methods In Health And Health Services Research. BMJ. 1995, 311(6996), 42–5. Web.
Braun V, and Clarke V. Using thematic analysis in psychology.Qual Res Psychol, 2006, 3(2), 77–101. Web.
Abduelkarem, AR, Sharif, SI, Bankessli, FG, Kamal, SA, Kulhasan, NM., and Hamrouni, AM. Obesity and its associated risk factors among school-aged children in Sharjah, UAE. PloS one, 2020, 15(6), e0234244. Web.
Etelson, D, Brand DA, Patrick, PA, and Shirali, A. Childhood obesity: do parents recognize this health risk?. Obesity research, 2003, 11(11), 1362-1368. Web.
Moore LC, Harris CV, and Bradlyn AS. Exploring the relationship between parental concern and the management of childhood obesity. Maternal and child health journal, 2012, 16(4), 902-908. Web.
Vittrup B, and McClure D. Barriers to Childhood Obesity Prevention: Parental Knowledge and Attitudes. Pediatric Nursing, 44(2), 2018.
Tenny S, Brannan, GD, Brannan, JM, and Sharts-Hopko NC. Qualitative Study. In StatPearls. StatPearls Publishing, 2021.
Garza, M. Knowledge, behaviors, and beliefs of nannies regarding nutrition for children in their care. FIU Electronic Theses and Dissertations. 3590, 2010. Web.
Ragelienė, T, and Grønhøj, A. The influence of peers′ and siblings′ on children’s and adolescents′ healthy eating behavior. A systematic literature review.Appetite, 2020, 148, 104592. Web.
El-Sabban, F. Child nutrition and general health require nutritional knowledge of parents and others. EC Nutrition, 2016, 3, 653-658.
Hinojosa AMO, Macleod K E, Balmes J, and Jerrett M. Influence of school environments on childhood obesity in California. Environmental research, 2018, 166, 100-107. Web.
Footnotes
- Di Cesare M, Sorić M, Bovet P, Miranda JJ, Bhutta Z, Stevens GA, Laxmaiah A, Kengne AP, Bentham J. The epidemiological burden of obesity in childhood: a worldwide epidemic requiring urgent action. BMC medicine. 2019;17(1):1-20. Web.
- World Health Organization. (2021). Obesity and overweight. Web.
- Pengpid S, and Peltzer, K. Trends in the prevalence of twenty health indicators among adolescents in the United Arab Emirates: cross-sectional national school surveys from 2005, 2010 and 2016. BMC Pediatrics, 2020. 20(1), 1-11.
- Bani-Issa, W, Radwan, H, Rossiter, R, Fakhry, R, Al-Yateem, N, Al-Shujairi, A, Hasan, S, Macridis, S, Farghaly, A.A, Naing, L. and Awad, M.A. Prevalence and determinants of overweight/obesity among school-aged adolescents in the United Arab Emirates: a cross-sectional study of private and public schools. BMJ Open, 2020, 10(12), e038667. Web.
- AlBlooshi A, Shaban S, AlTunaiji, M, Fares N, AlShehhi L, AlShehhi H, AlMazrouei, A. and Souid, A.K. Increasing obesity rates in school children in the United Arab Emirates. Obesity Science & Practice, 2016, 2(2), 196-202. Doi: 10.1002/osp4.37
- Golan, M. Parents as agents of change in childhood obesity–from research to practice. International journal of pediatric obesity, 2006, 1(2), 66-76. DOI: 10.1080/17477160600644272
- Aljunaibi A, Abdulle A, and Nagelkerke N. Parental weight perceptions: a cause for concern in the prevention and management of childhood obesity in the United Arab Emirates. PloS one, 2013, 8(3), e59923. Web.
- Lindsay AC, Sussner, KM, Kim J, and Gortmaker S. (2006). The role of parents in preventing childhood obesity. The Future of children, 2006, 169-186. Web.
- Akhtar‐Danesh, N, Dehghan, M, Morrison, KM, and Fonseka, S. Parents’ perceptions and attitudes on childhood obesity: A Q‐methodology study. Journal of the American Academy of Nurse Practitioners, 2011, 23(2), 67-75. Web.
- DiLillo, V, Siegfried, NJ, and West, DS. Incorporating motivational interviewing into behavioral obesity treatment. Cognitive and Behavioral Practice, 2003, 10(2), 120-130. Web.
- Pakpour, AH, Gellert P, Dombrowski SU, & Fridlund B. Motivational interviewing with parents for obesity: an RCT. Pediatrics, 2015, 135(3), e644-e652. DOI: 10.1542/peds.2014-1987
- University of Connecticut. Motivational Interviewing for Diet, Exercise and Weight. Web.
- Vansteenkiste M, and Sheldon, KM. There’s nothing more practical than a good theory: Integrating motivational interviewing and self‐determination theory. British Journal of Clinical Psychology, 2006, 45(1), 63-82. DOI:10.1348/014466505X34192
- Brod, M, Tesler, LE, and Christensen, TL. Qualitative research and content validity: developing best practices based on science and experience. Qual Life Res, 2009, 18, 1263. Web.
- Pannucci, C.J, and Wilkins, EG. (2010). Identifying and avoiding bias in research. Plastic and reconstructive surgery, 2010, 126(2), 619–625. Web.
- Qu, SQ and Dumay, J.The qualitative research interview. Qualitative Research in Accounting & Management, 2011, 8(3), 238-264. DOI 10.1108/11766091111162070
- Willis, GB. Cognitive interviewing in practice: think-aloud, verbal probing, and other techniques. In Cognitive interviewing(pp. 42-65). SAGE Publications, Inc. 2005.
- Strauss, A, Corbin, J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage, 1990.
- Pope, C, and Mays N. Reaching the Parts Other Methods Cannot Reach: An Introduction To Qualitative Methods In Health And Health Services Research. BMJ. 1995, 311(6996), 42–5. Web.
- Braun V, and Clarke V. Using thematic analysis in psychology. Qual Res Psychol, 2006, 3(2), 77–101. Web.
- Abduelkarem, AR, Sharif, SI, Bankessli, FG, Kamal, SA, Kulhasan, NM., and Hamrouni, AM. Obesity and its associated risk factors among school-aged children in Sharjah, UAE. PloS one, 2020, 15(6), e0234244. Web.
- Etelson, D, Brand DA, Patrick, PA, and Shirali, A. Childhood obesity: do parents recognize this health risk?. Obesity research, 2003, 11(11), 1362-1368. Web.
- Moore LC, Harris CV, and Bradlyn AS. Exploring the relationship between parental concern and the management of childhood obesity. Maternal and child health journal, 2012, 16(4), 902-908. Web.
- Vittrup B, and McClure D. Barriers to Childhood Obesity Prevention: Parental Knowledge and Attitudes. Pediatric Nursing, 44(2), 2018.
- Tenny S, Brannan, GD, Brannan, JM, and Sharts-Hopko NC. Qualitative Study. In StatPearls. StatPearls Publishing, 2021.
- Garza, M. Knowledge, behaviors, and beliefs of nannies regarding nutrition for children in their care. FIU Electronic Theses and Dissertations. 3590, 2010. Web.
- Ragelienė, T, and Grønhøj, A. The influence of peers′ and siblings′ on children’s and adolescents′ healthy eating behavior. A systematic literature review. Appetite, 2020, 148, 104592. Web.
- El-Sabban, F. Child nutrition and general health require nutritional knowledge of parents and others. EC Nutrition, 2016, 3, 653-658.
- Hinojosa AMO, Macleod K E, Balmes J, and Jerrett M. Influence of school environments on childhood obesity in California. Environmental research, 2018, 166, 100-107. Web.
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