Dietary habits and physical activity levels amongst school going children and their parents in Bengaluru city: Resultsfrom a descriptive study in South India

Introduction

Childhood obesity rates have surpassed rates of undernutrition in Asia.^1,2 India has the secondhighest proportion of obese children in the world with the proclivity of acquiring cardiovascular diseases (CVDs) a decade earlier^3-6 and has the highest number of diabetics in the world as well.^7,8 Physical inactivity, low consumption of fruits, and vegetables (F&Vs) are major obesogenic factors.^9-11 Various studies have shown that lifestyle modifications like increasing physical activity, decreasing intake of processed foods, and increasing vegetable & fruit consumption can primarily reduce the risk of developing obesity and other ailments.^12-15

The NFHS-4 results indicate that 33.4% of the women and 27.5% of the men aged between 15- 49 years are overweight or obese in Bengaluru Urban district.¹⁶ Other studies done in the city indicate 7-13% and 4-6% are overweight and obese (O-O)respectively among adolescent children in Bengaluru.^17-19 A cross-sectional study of nearly 4000 schoolchildren found that 27.1% of them were overweight and 13.7% of them were obese.²⁰ Address Health, a pioneer in primary healthcare for school children, conducted a study along with Rainbow Hospitals, and found 20.7% of the schoolgoing children to be overweight or obese. ²¹ Nearly 1 in 7 children have a waist to hip ratio > 0.5, which puts them at risk for coronary heart diseases.²²

Increased TV viewing, decreased sleep duration, and increased fried food consumption have been associated with being overweight as per a study conducted among the city children by St. John's Hospital.²³ Another hospital-based observational study conducted in the city found that obese adolescents were more likely to belong to the higher socioeconomic strata, had a mixed diet and sleep disturbances.²⁴ Studies conducted across various cities in India found that children were consuming high levels of energy dense foods, had insufficient fruit and vegetable intake and, had inadequate physical activity levels.^25-28

Childhood obesity is a known risk factor for unfavourable health conditions, such as the development of chronic diseases during adulthood.^29,30 In Karnataka, the type 2 diabetes mellitus (T2DM) rates are 12.9% among females and 13.8% among males; well above the national median of 7.4% prevalence.³¹ CNNS reported that 4% of school-age children were overweight or obese (BMI-for-age >+1 SD), 8% of schoolage children were overweight as measured by SSFT (SSFT for-age >+1 SD).³² These numbers lay importance on developing interventions for school children in India.

A literature review of obesity prevention interventions for children found that healthy eating and physical activity were the most effective components. ³³ In recent years, it has been found that mindfulness-based interventions can be effective in preventing obesity as well. ³⁴ Unfortunately, we do not have sufficient literature regarding such intervention studies in India. To address the burden of the overweight-obesity epidemic in school-going children, it is important to understand theirreceptivity for potential strategies. The success of any intervention is mainly determined by the receptiveness of the target population towards the intervention. For this, we must be able to assess their health behaviours, perceptions, and interest inthe interventions.It is shown that parental engagement is necessary for any successful intervention in reducing childhood obesity. ¹² Hence, we decided to include parents in this survey study as well.

We conducted a pilot study to assess the health behaviours amongst school children and their parents. Also, we aimed to assess the receptivity of children and their parents towards a potential school-based intervention that encourages children to increase fruit and vegetable consumption and physical activity levels.

Materials and methods

We conducted a cross-sectional study among school children and, their parents to assess their eating behaviour, level of physical activity, and interest in school-based interventions. Our study was based in urban Bengaluru, India and our target study group included adolescent children enrolled in schools and their parents. The research team approached the students and parents through random selection and snowball sampling. Invitations to be a part of the study were sent to schools for the higher, middle, and lower socioeconomic strata. The schools which showed interest were further pursued. In addition to this, trained data collectors approached the target population at tuition centres, summer camps, and shopping malls. Secure online survey forms were forwarded via social media apps amongst parents and children. Our inclusion criteria were: 1) Residing in Bengaluru, 2) students belonging to the age group of 12-16 years 3) parents of students belonging to the age group of 12-16 years and, 4) informed assent and consent have been obtained from the participants. We ensured that participants from all socioeconomic strata were included in the study.

Study tool, data collection, and analysis:

The participants were first given a detailed explanation about the study and questionnaires and then, the interested participants were administered with the questionnaire. Informed consent was taken from the parents before administering the questionnaire to the students. Data were collected in March and April 2019 by trained data collectors and research assistants.

Students were administered a 40- items- survey questionnaire which was developed by the research team. It comprised of a student questionnaire developed and modified by University of California, Los Angeles (UCLA), the validated Child and Adolescent Mindfulness Measure (CAMM) questionnaire ³⁵, and questions from the Global School-based Student Health Survey (GSHS)³⁶, India 2006.

The student baseline questionnaire was initially developed by UCLA to study health-related behaviours and attitudes pertaining to diet and physical activity and, how this can reduce the risk of developing cancer. The CAMM questionnaire is a mindfulness questionnaire designed for children and adolescents. It helps assess their actions based on awareness and acceptance of internal experiences. It was translated to Kannada and back-translated to English before being administered to children. The GSHS questionnaire was developed by the World Health Organization (WHO) to measure and assess behavioural risk factors among children aged 13-17 years. Factors like alcohol use, dietary behaviours, drug use, hygiene, mental health, physical activity; protective factors, sexual behaviour, tobacco use, violence, and unintentional injury can be assessed using this tool. For the purpose of this study, questions about dietary behaviours and physical activity were used for developing the student questionnaire . The CAMM tool suggests that the higher the score, the higher is the mindfulness level of the child. The Cronbach’s alpha value for the CAMM questionnaire was 0.778 in our pilot study.

It took an average of 20 minutes to administer the student questionnaire on each participant. We developed the 19- item- parent survey questionnaire to capture parenting perceptions and attitudes towards the child’s dietary and eating habits, as well as physical activity. It took an average of 5 minutes for each parent to finish answering the questionnaire. Parents were approached at schools and other training institutes.

After cleaning the collected data, descriptive analysis was done using the statistical software, R Commander [R x64 3.4.1, R for Windows GUI front-end. R Core Team (2013).R a language and environment for statistical computing, R Foundation for Statistical Computing, Vienna, Austria].

Ethical Considerations:

The study was reviewed and approved by the institutional technical review and ethics committee at the Indian Institute of Public HealthHyderabad (Bengaluru Campus) (IIPHHB/TRCIEC/145/2019). It has been performed following the relevant guidelines and regulations for public health research in India. Only students and parents who voluntarily participated and provided informed assent and consent were considered for the study.

Results

We had a total of 458 students and 85 parents who took part in the surveys. Among the 458 students who participated in the survey, there were an equal number of boys and girls who took part in the study and their mean age was around 13.7 ± 1.73 years. Almost 83% of them belonged to the lower socioeconomic strata.

When it comes to dietary habits, almost half of the students (34%) consumed dairy products and 100% fruit juice once a day, 42% of them consumed sweetened juice and about 48% of them consumed carbonated drinks once a day. One-third of the children (33%) did not consume any fruits the previous day, and 26% of them did not consume any vegetables. While only 29-30% of the students consumed fruits and vegetables once a day, 22% of them consumed vegetables thrice a day, and 12 % consumed fruits thrice a day; 31-33% of them consumed fried food and sweets once a day. Over 40- 43% feel fruits and vegetables fill up onequarter of their average plates and yet, almost half of the student sample (46%) feels that they eat the right amount of fruits and vegetables.

Over20% of the students regularly had an intense level of physical activity, and 31% of them regularly had a moderate level of physical activity. Almost one-quarter of the group (24%) had physical activity during PE classes only once a week. Only 29% feel they require at least 60 minutes of physical activity and 27% feel they require at least 40 minutes of physical activity daily.Almost one-third of the students (31%) watch TV for 1 hour, and 12% of them watch TV for 3 hours on an average school day.

The students felt that almost one-third of the parents (31%) often consumed high-calorie food, 39% of the parents sometimes consumed highcalorie food once a week and 53% always eat a lot of fruits and vegetables. Only 28% of the parents always limit their TV viewing or gaming habits, and sometimes, 55% of them limit the consumption of carbonated drinks. Only 10-15% of the families exercise regularly/ often or are physically active. While 41-43% of the students watch TV or use the mobile phone while dining at home, a vast majority of the students (66%) do not sit with their family while eating dinner.

Out of a total score of 40, the mean CAMM score was 25.28 ± 6.91, and the median CAMM score was 26. Over 54% of them had CAMM scores equal to 26 or above.

About 49-50% of the students are actively interested in taking part in the fruit and vegetable tasting, gardening activities, and yoga activities if conducted in their school. Almost 10% are strongly not interested in any of the interventions.A vast majority suggested additional activities like sports, exercises, and dancing for improving their physical health.

Out of the 85 parents who took part in the survey, two-thirds of them (68%) were women, and the mean age of the sample was 37.03 ± 7.51 years. Only 30% of the respondents and their spouses were graduates/postgraduates, and 40% of the sample belonged to the middle socioeconomic strata.

Three-quarters of the sample live in nuclear families. More than two- thirds of the respondents (70%) buy groceries, regularly prepare meals, and pack their child's lunch box. However, only about 50% of them made most of the decisions regarding their child's lifestyle; 40% of the spouses and 10% of other elders in the family made most of the decisions.

About half of the children (55%) were served fruits and vegetables once a day, and 25% were served vegetables twice a day and fruits less than one time per day. Almost 30% of them consume processed food 2-3 times per week and carbonated drinks once a week. 20% of them consume junk food daily, consume meat 2-3 times per week, and consume packaged fruit juice once a week.

A vast majority of 95% of the parents encourage their children to be physically active, but only 80% of the children are active. Only half of the parents are physically active, and one-fourth of them practice yoga at home. More two- thirds (70%) of the parents have a garden at home and encourage their kids to take part in supervised gardening/ cooking activities. However, only 50% of the children help in maintain the plants at home.

Students reported that almost two-thirds of the parents (57- 59%) sit with their child and watch TV while having dinner at home and a third of the sample (34%) checks their phone while eating.

bout 60% of the parents are actively interested in letting their children take part in the intervention and playing a vital role in the intervention as parents. A small percentage of 5% were firmly disinterested in it. Parents have suggested additional activities such as exercises, sports, dancing, health education, improving the child's mental health, and initiating discussions on health in the family.

Discussion

Overall, we found that a third of the children consumed fried food and sweetsregularly, did not consume fruits and vegetables daily, and had moderate levels of physical activity. Our results are in accordance with other studies conducted on the same age group across India. A study conducted in a private school in Kolkata among adolescent children found that almost 45% of the children did not consume fruits daily and 30% did not consume vegetables daily. There was high consumption of energy-dense food instead. ²⁵ A Chennai based study on teenagers found that moderate levels of consumption of fast food and sweetened beverages were more than that of fruits and vegetables. The students reported moderate levels of physical activity as well. ²⁶ Another school-based study conducted in a city in Karnataka found that there was high consumption of energy-dense food and low consumption of fruits, vegetables, and dairy products when compared to the dietary guidelines. ²⁷A study conducted amongst adolescent children in Anand, India found that that they had inadequate physical activity levels and many of the students were overweight or obese. ²⁸ The results in our study support studies conducted in other cities in India.

Over the past few decades, India has witnessed an epidemiological transition, with the increase in the prevalence of risk factors for chronic diseases which include an increase in consumption of saturated fat and processed foods.³⁷ Traditional Indian diets predominantly focused on whole grains such as millet, barley and amaranth; unpolished brown rice, pulses, roots, tubers, curd, unsaturated cooking oils, and occasionally, ghee³⁸. However, the contemporary diet has transited to low consumption of proteins and overconsumption of refined carbohydrates by replacing lentils, fruits vegetables, unrefined whole grains, nuts, and seeds.³⁹ An increase in the consumption of processed food that is high in salt and fatty acids is a vital component of the nutritional transition in India.^{38, 40}

Mindfulness has been introduced added into the curriculum of various schools in developed countries.⁴¹ This has been initiated to teach children the importance of mental health and how to take care of it.⁴¹ We had assessed mindfulness through the CAMM questionnaire and almost half of the students had scored lower than the median value. This sheds light on the need for mental health and well- being sessions for children to cope with every day and academic stress.Although the CAMM questionnaire has been validated in English and Spanish, no data has been reported in the Indian context. ^35,42 To our knowledge, this is the first study in India to validate the CAMM questionnaire in a local language (Kannada).

The main weakness of this study is that it has not assessed the BMI of the children. If this was collected, we could study its relationship with dietary habits and physical activity. We were unable to do so due to time constraints. Also, the study is vulnerable to recall bias. Students and parents might have understated or overstated their health practices during the survey, which can affect our results. Alcohol and tobacco consumption could not be recorded as most students do not reveal the truth as they fear that if their school and parents get to know, strict action would be taken against them.

In conclusion, our pilot study results confirm to the existing studies in other cities in India and help in validating the necessity for nutrition-based interventions to control the NCD epidemic in the country. Early life interventions are always more favourable than adult life interventions due to their effectiveness and cost benefits.⁴³ Most health behaviours get established by adolescence and hence, developing interventions targeting this age group would be appropriate.⁴⁴ The students and their parents are interested in interventions that aim at improving their health such as regular fruit and vegetable tasting, fruit and vegetable gardening, yoga, and other exercises aimed at improving one’s mindfulness. The proposed interventions should focus on improving their physical activity levels and liking for fruits and vegetables.

Declarations

Not applicable.

Availability of data and information

The datasets used and analysed during the study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The study was funded by an Intermediate Fellowship by the Wellcome Trust DBT India Alliance (Clinical and Public Health Research Fellowships) to Dr.Giridhara R Babu. (Grant Number: IA/CPHI/14/1/501499).

Authors’ contributions

SK developed the research tools, collected certain sections of the data, analysed the results, and wrote the manuscript. DR developed the research tools, collected certain sections of the data, and edited the manuscript. NKR collected and analysed certain sections of the data. GRB conceptualised the study, developed the research tools, and edited the manuscript.