1. PREVALENCE OF OBESITY AND ASSOCIATED FACTORS AMONG CHILDREN (3-6 YEARS). A COMPARATIVE STUDY OF URBAN AND PERI-URBAN MOMBASA, KENYA BY: CAROLYNE NEKESA WALUCHIO (BSC.FOND) REG NUMBER: A56/67371/2013 A RESEARCH PROPORSAL SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE DEGREE OF MASTER OF SCIENCE IN APPLIED HUMAN NUTRITION OF THE UNIVERSITY OF NAIROBI DEPARTMENT OF FOOD SCIENCE,NUTRITION AND TECHNOLOGY 2014 1

2. Supervisors 2 Professor J.K Imungi Dr. George Abong Ooko Dr. Cathrine Macharia Mutie

3. TABLE OF CONTENT 3 DECLARATION………………………………………………………………………………………………ii TABLE OF CONTENT………………………………………………………………………………………iii LIST OF ABBREVIATIONS……………………………………………………………………………….v OPERATIONAL DEFINITIONS………………………………………………………………………….vii CHAPTER ONE: INTRODUCTION……………………………………………………………………..1 1.1 Background Information……………………………………………………………………………….1 1.2 Statement of the Problem……………………………………………………………………………. 5 1.3 Justification………………………………………………………………………………………………6 1.4 Aim…………………………………………………………………………………………………………….7 1.5 Purpose………………………………………………………………………………………………………8 1.6 Objectives of the Study…………………………………………………………………………………8 1.6.1 General objective……………………………………………………………………………………….8 1.6.2 Specific objectives……………………………………………………………………………………..8 1.6.3 Research questions……………………………………………………………………………………8 1.7 Hypotheses………………………………………………………………………………………………….9 1.7.1Null Hypotheses…………………………………………………………………………………………9 1.8Assumptions and Limitations………………………………………………………………………..9 1.9 Benefits (For Nations, Study Community, Researchers)…………………………………..9

4. 2.0 CHAPTER TWO: LITERATURE REVIEW 4 2.1 Definition of Overweight and Obesity………………….10 2.2 Current status of Overweight and Obesity……………11 2.3 Health consequences of Overweight and Obesity….14 2.4 Predisposing factors of Overweight and Obesity…..15 2.4.1 Dietary factors………………………………………………..16 2.4.2 Environmental factors…………………………………….17 2.4.3 Cultural and Societal factors……………………………18 2.4.4 Television and advertising……………………………….18 2.4.5 Physical activity……………………………………………..19 2.4.6 Genetic Factors………………………………………………19 2.5 Assessment of overweight and obesity…………………21 2.6 Gaps in Knowledge……………………………………………23

5. CHAPTER THREE: RESEARCH DESIGN AND METHODOLOGY 5 3.1 Research Design………………………………………………………...........25 3.2 Research Methodology……………………………………………………….25 3.2.1 Study site……………………………………………………………………….25 3.2.1.1 Location and size………………………………………………………….25 3.2.1.2 Physical and topographic features………………………………….25 3.2.1.3 Ecological conditions……………………………………………………26 3.2.1.4 Climatic conditions………………………………………………………26 3.2.1.5 Administrative units…………………………………………………….27 3.2.1.6 Pre-school education…………………………………………………….28 3.2.1.7 Health care…………………………………………………………………..28 3.2.2 Study Population…………………………………………………………….28 3.3 Sampling Frame…………………………………………………………………29 3.3.1 Sampling procedures……………………………………………………….29 3.3.2 Sample size determination……………………………………………….30

6. 6 3.4 Data Collection…………………………………………………………30 3.4.1 Data collection tools……………………………………………….30 3.4.2 Development and pretesting of questionnaires…………30 3.4.3 Recruiting and training of the research assistants……..30 3.4.3.1 Socio-demographic and socio-economic information30 3.4.3.2 Anthropometric measurements…………………………….31 3.4.3.3 Food frequency questionnaire………………………………31 3.4.3.4 Physical activity profile………………………………………..31 3.5 Data Quality Control and Assurance…………………………..31 3.6 Data Analysis…………………………………………………………..31 3.7 Ethical Consideration………………………………………………..32

7. APPENDICES 7 APPENDIX 1: CHILDREN’S QUESTIONNAIRE....40 APPENDIX 2: TRAINING SCHEDULE FOR RESEARCH ASSISTANTS……………………………46 Appendix 3: BUDGET………………………………….47 APPENDIX 4: MOMBASA COUNTY MAP…….49 Appendix 5: SCHEDULE OF ACTIVITIES…….50 APPENDIX 6: LETTER SEEKING CONSENT FROM SCHOOLS…………………………………………………..51

8. Chapter 1.1 Background information 8 Malnutrition literally means “bad nutrition “and technically includes both over and under- nutrition (WHO, 2003). In the context of developing countries, under-nutrition is generally the main issue of concern, though industrialization and changes in eating habits have increased the prevalence of over-nutrition. The co existence of both over and under nutrition typifies the ‘ Double Burden of Malnutrition' (DBM) (FAO, 2006). The DBM is becoming of great concern for African countries (Thiam, 2006)and a real threat at the population, household and even individual level and it is now observed among schoolchildren.

9. 9 Urbanization is associated with the prevalence of Non Communicable Diseases( NCD) risk factors such as; Industrial pollution and Increased access to alcohol and tobacco. Energy dense, low fiber foods; screen invasion and sedentary lifestyles. All these lead to secondary risks such as overweight, obesity, hypertension, high cholesterol, raised blood sugar etc. (WHO, 2011).

10. Background information 10 Obesity is defined as a state in which there is generalized accumulation of excess adipose tissue in the body leading to more than 20% of the desirable body weight. Overweight is defined as a weight over a weight standard. Overweight and obesity in childhood (including adolescence) is associated with serious physiological, psychological, and social consequences. Obesity is measured using Body Mass Index BMI= weight (in kilograms) height (in metres)squared

11. Background information 11 Evidence suggests most childhood obesity is recognised during preschool years. This is when long-term dietary and physical activity habits are being established leading to lifetime effects on health (Lanigan, 2010) Globally, up to 200 million school aged children are overweight or obese and this represents a 10% of all the children with the Americans leading at 32%, followed by Europe 20%, and then the Middle East 16% (Ogden, 2012).

12. Background information 12 Prevalence rates of obesity in selected African countries was 13, 14 and 15% in Sudan, Egypt and Libya (North Africa) According to KDHS 2008/9 a total of 18% of preschool children are overweight and 4% are obese. The proportion of women aged 15-49 that are overweight and obese is 25%, with the highest proportion being reported in Nairobi at 41 %

13. 13 Other studies have also established that obesity rates among children 10 -14 years in Nairobi is 14.4 %(Githinji, 2009) In Nakuru the prevalence of overweight and obesity was 11.9% and 3.4% respectively with 16.7% and 10% in private and public schools respectively (Kigutha,2010). Further, the prevalence of obesity among school-aged children 7-10years was found to be 25.6% with more boys (27%) being obese than girls (26%) in Nairobi (Abdalla,2010). This rates are quite high which compares to rates in most developed countries. However, very little information is available on the prevalence rates of overweight and obesity among children in Mombasa hence the need for the study.

14. Background information 14 The Government and some NGOs have put strategies in place. They include; Creating awareness through training of health care providers and diabetic walks by(Diabetic Management and Information Centre (DMC) and Ministry of Health(MOH) School health policy and the recent Nutrition Action Plan 2012-2017 Screening of adults patients with BMI>26. AIHD a research institute in conjunction with the Mombasa Municipal Council (MMC) and the Ministry of Health (MOH) began its lifestyle change programs in Mombasa.

15. 15

16. 1.2 Statement of the problem 16 Kenya is facing the double burden of malnutrition. Many researchers have focused on under nutrition like the Nutrition Improvement in Chile and Kenya (NICK) study (Lan’go, 2013) thus little information is available on obesity prevalence in this age group. Most studies have been conducted in Nairobi and thus little information is available on the rising trends of obesity from areas outside Nairobi and particularly among children (Imungi,2013)

17. Statement of the problem 17 School tuitions where children spend long hours in school could be contributing to lack of physical activity. Physically, there is obesity among children especially 6- 12 years because from observation in every 3 children at least 1 is overweight. There is a lot of uncontrolled food hawking around the schools and an increased number of franchised food joints. Since there seems to be no control this could be contributing to high levels of obesity. Advertisement of junk foods(high energy drinks and foods) in the media without a strong policy can influence both the children and parents to make wrong choices.

18. Statement of the problem 18 Routine screening as recommended in the education health policy has not been emphasised since little information exist about routine screening and especially among school children unless they are sick. In addition, the indicator reported at the national level only captures adults with BMI >25 but how many adults will go to hospital unless they are unwell? The African Institute of Health and Development (AIHD) together with the municipality planned to come up with programs for lifestyle change. They include; advocacy, making walkways for pedestrians and cyclists, fixing street lights for security and encourage health seeking behaviour but so far very little has been achieved.

19. 1.3 Justification 19 Prevalence of obesity among children with 18% according KDHS, 2008/9. There is limited information on exact trends in child obesity and especially from studies that have been conducted outside Nairobi. Mombasa is one of the cities with limited data on the trends of obesity and is a fast growing city that harbours both periurban and urban populations The government policies and interventions in place need to be identified and strengthened

20. Levels at which public awareness has been done is still very low because populations are still not keen about what they eat and what they do and if they contribute to their being obese. The levels of awareness in the community is still low as because culturally people still see a “fat person” as being healthy. 20

21. 1.4 Aim The aim of this study is to contribute towards improving the health status of the children through tackling the determinants of over nutrition. 21

22. 1.5 Purpose The purpose is to provide data that can be used to create awareness on the prevalence of overweight and obesity among school children 3-6 years. The study will provide information to characterize the risks associated with being obese or overweight. Further, data from the study will enable the County and the policy makers to identify and strengthen available interventions that will help reverse the increasing trends of obesity and related complications among the preschoolers. Build a basis for future research. 22

23. 1.6 OBJECTIVE OF THE STUDY BROAD OBJECTIVE To establish the prevalence of obesity among preschoolers (3-6years) and the associated factors in urban and peri- urban schools in Mombasa, Kenya. SPECIFIC OBJECTIVES 1. To characterize the socio demographic composition of families of the children 3-6 years. 2. To determine the predisposing factors leading to over nutrition among preschoolers (3-6 years) 3. To assess anthropometric measures among the children 4. To establish the caloric intake and food frequency among the children 3-6 years 5. To assess physical activity levels among preschoolers 23

24. 1.6.3 Research questions What is the nutrition status of the children 3-6 years? What are their snacking habits? What do they carry in their bags from home or what they buy? How often? What do they eat in school, how often and who prepares the food? How often they have break and where do they play? What foods are sold around their school? Nutritive value and hygiene How is the school environment? How does it affect physical activity. 24

25. 1.7 Null Hypotheses There is high prevalence of overweight and obesity among children in Mombasa. There is a high prevalence of obesity among the urban than the periurban preschoolers There is no association between feeding practices and obesity among the children There is no association between physical activity and obesity 25

26. 1.8 Assumptions and limitations That the pupils and the teachers the children will cooperate and give correct information. The schools selected will be a true representative of the preschool population This study may not clearly establish if the obesity is genetic of due to diet. 26

27. 1.9 Benefits The study will provide data that will help increase advocacy and, help strengthen nutrition programs in the community and hence adapt healthy lifestyles. This study results will give insight to the nation/county on the trends of obesity and overweight among preschoolers, The results will further build a foundation for further research to establish the real baseline of obesity in the county The study may help evaluate if the government policies on school health are in place and being implemented. The research will help the researcher build management and research skills 27

28. 2.0 Chapter Two: Literature review 28 2.1 Definition of Overweight and Obesity………………….10 2.2 Current status of Overweight and Obesity……………11 2.3 Health consequences of Overweight and Obesity….14 2.4 Predisposing factors of Overweight and Obesity…..15 2.4.1 Dietary factors………………………………………………..16 2.4.2 Environmental factors…………………………………….17 2.4.3 Cultural and Societal factors……………………………18 2.4.4 Television and advertising……………………………….18 2.4.5 Physical activity……………………………………………..19 2.4.6 Genetic Factors………………………………………………19 2.5 Assessment of overweight and obesity…………………21 2.6 Gaps in Knowledge……………………………………………23

29. 2.6 Gaps in knowledge 29 Generally, in Kenya there has been an increase in levels of overweight and obesity as established by previous studies like the KDHS 2008 18% of preschoolers are overweight while 4% are obese. There is however limited information from other areas outside Nairobi and particularly in this age group (3-6) years. Studies done within Nairobi have concentrated on adolescents and teenagers from 8-18yrs and adults particularly women and not preschoolers. There is need to establish if the preschoolers’ obesity may be proceeding to increased adolescent prevalence and later to adults that end up with diabetes and later complications. The community still has little information as concerns the lifestyle changes and how this can influence their health and that of the children.

30. Gaps in knowledge 30 There is change in lifestyle and school tuitions may be consuming the children’s physical activity time hence the need to establish this association. The foods that are sold around our schools and the increased number of franchised food joints like;“ pizza inn ’’ could be influencing the choices of the children and there is limited information on their nutritive value and the hygiene. Most coastal dishes are deep fried or cooked with a lot of fat and coconut milk e.g mahamri,bhagia,pilau,biriani The Government together with NGO’s have set up strategies like the school health policy that is in place to address nutrition issues in particular but there is no information on how far they have been implemented.

31. 3.0 Chapter three: Research Design and Methodology 31 3.1 Research design A cross-sectional design will be used with an analytical component of the anthropometric data collected. Children will be proportionately sampled from rural and urban populations of Mombasa. 3.2 Research Methodology 3.2.1 Study site The study will be carried out in Mombasa County in two divisions purposively selected (Changamwe and Island) to represent the Peri-urban and urban population respectively.

32. 3.2.1.1 Location, size and topography 32 Mombasa county is located in the South Eastern part of the Coastal region of Kenya. It covers an area of 229.9 Km2 excluding 65 Km2 of water mass which is 200 nautical miles inside the Indian Ocean. The county lies within the coastal lowland which rises gradually from the sea level in the east to about 132 m above sea level in the mainland. The terrain is characterised by three distinct physiographic features, which includes the coastal plain, which is found along the shoreline, covering parts of the South Coast, the Island, parts of Changamwe and the North Coast.

33. 3.2.1.4 Climatic conditions 33 The County lies within the coastal strip in the hot tropical region where the climate is influenced by monsoon winds. Rainfall The rainfall pattern is characterized by two distinct long and short seasons corresponding to changes in the monsoon winds. The long rains occur in April - June with an average of average 1,040 mm and correspond to the South Eastern Monsoon winds. The short rains start towards the end of October lasting until December and correspond to the comparatively dry North Eastern Monsoons, averaging 240mm. The annual average rainfall for the county is 640mm.

34. 34 Temperature The annual mean temperature in the county is 27.9 0 C with a minimum of 22.7 0 C and a maximum of 33.1 0 C. Average humidity at noon is about 65 per cent. Administratively, the county is segregated into seven divisions, eighteen locations and thirty sub-location and hosts six constituencies namely Mvita, Changamwe, Jomvu Kuu, Likoni, Kisauni and Nyali. 3.2.1.6 Pre-school education There are 254 ECDE centres within the county with a population of 26,080 student and 612 teachers.

35. 3.2.1.7 Health care 35 The county hosts the coast level five hospital which is a referral facility serving the entire coast region. Other notable private hospitals include the Aga Khan Hospital, the Mombasa Hospital and Pandya Memorial Hospital which are all in the Island division. Other lower level hospitals include; Tudor district hospital found in island and Port Reitz in Changamwe. Level four hospitals are further complemented by fifteen private hospitals, four nursing homes, and nine health clinics of which two are public and seven privately managed. There are twenty seven dispensaries out of which twenty five are public and two private.

36. 3.2.2 Study Population 36 The population for under 5’s was 127,320 in 2009 and was projected to reach142, 694 in 2012, 159,925 and 172,553 in 2015 and 2017 respectively. The population in Early Childhood Development centres (ECDE) is 26,080 for both private and public schools. Changamwe division has 6025 while island division has 6508.

37. 3.4 Sampling frame 37 Mombasa County Urban All the children aged 3-6 years 208 children from urban schools random sampling of 4 schools 192 children from periurban schools random sample for 6 schools Periurban purposive randomproportionate

38. 3.3.1 Sampling procedures. 38 Purposive sampling was used to select the target geographical area as one of the county among the 47 in Kenya that is rapidly experiencing economic growth and harbours both urban and peri urban populations. Purposive sampling will be used to select Changamwe and island divisions out of the six to represent the urban and periurban. proportionate sampling will be used to allocate the number of children for urban and periurban. Simple random sampling will be used to identify 10 schools (6 periurban and 4 urban) Stratified sampling will be used to select the class levels (KG3 and class 1) while systematic sampling will be used to select the Nth

39. 3.3.2 Sample size determination 39 The national prevalence for preschoolers is 18%overweight and 4% obese according to KDHS 2008/9 This figures have changed and since coast region does not have a rate the study will calculated using 50% (Fisher et al.1998 ). N = Z 2.PQ D 2 Therefore N= (1.96x1.96) x0.5 (1-0.5) or 4pq=384 children 0 05 2 L 2 = 400 children Added~5 % to cater for attrition, then a sample of 400 children will be selected.

40. 3.4 Data Collection 40 3.4.1 Data collection tools Previously pretested structured questionnaires for demographic and socio economic information Food frequency questionnaires for dietary assessment Activity profile Question guide Anthropometric data sheet for weight and height Observation list

41. 3.5 Data Quality Control and Assurance 41 Equipment will be calibrated before the start of the activity. At the start of the day the scales will be calibrated using a standard measure like a 2kg flour packet to ensure accuracy. The filled questionnaires will be checked at the end of each day for completeness, consistency in answers and proper filling by the assistants.

42. 42 The research assistants will be recruited based on the level of education(form four or tertiary colleges) and will be thoroughly trained for three days. The whole data collection process will be supervised by the principle investigator and supervisors consulted for any assistance.

43. 43 TimeContentMethod Day 18.30 -9.00 9-10.30 Climate setting and introduction Overview of the topic, purpose of study and objectives Brainstorming Lecture and brainstorming 10.30-1100 Break Day 11100-1300Overview of data collection tools and sampling procedures Lecture and demonstration Lunch Break Day 21400-1600Review data collection equipment and calibration Lecture and demonstration 0830-0930 0930-1030 Recap Practice use of the research tools and equipment Role-plays discussion 1030-1100 Break 1100-1300Continue with practice Role play Day 30900-1300Pretesting the questionnaire in the nearby school 1400-1600Feedback and planning for data collection Way forward Brainstorming APPENDIX 2:RECRUITING AND TRAINING SCHEDULE FOR RESEARCH ASSISTANTS

44. 3.6 Data Analysis 44 Information from the questionnaires will be checked, verified and entered into the computer data base. Statistical Package for Social Sciences (SPSS) version 17 will be used for analysis. Descriptive analysis will be used to provide general information on the characteristics of the study population. This will be done by generating frequency tables, mean and ranges. Data on food frequency will be tabulated to show the frequency of consumption while Chi squares test will be used to compare the independent variables. BMI for age classification will be done using WHO referencing standards

45. 3.7 Ethical Consideration 45 Permission to collect data will be sought from; The University of Nairobi, Ministry of Education and Mombasa County Council. Participation will be voluntary through informed consent from the teachers. The researcher will explain the purpose of the study and assure the respondent that there will be no ill motives and confidentiality of their responses will be ensured.

46. 46 Year 2014Year 2015 ActivityJFMAMJJASONDJFMAMJJA Selection of research topic Proposal writing Proposal presentation Proposal correction Questionnaire pretesting Proposal correction and submission Data collection Data entry and analysis Project defence Project correction Project submission

47. 47 ItemQuantityUnit costNo. of days Total cost 1.0personnel 1.1 Researcher110 1.2 UON supervisor13 1.3 Research assistants 1.4 Enumerators Field guides 2222 10 1.5 Software expert consultation15000 Sub total5000 2.0 Stationery 2.1Proposal writing/ correction printing52005@2001000 2.2Research notebook11000 2.3Purchase statistical package12000 2.4Pens, notebooks, pencils, eraser sharpener clear bag 444444444444 20 50 25 10 15 45 4@20 4@50 4@25 4@10 4@15 4@45 620

48. 48 2.5Printing of questionnaires2x5pages44x1040 2.6Photocopying of questionnaires300x5page21500x23000 2.7Printing and binding proposal2250250x2500 2.8Printing and binding dissertation6300300x61800 subtotal 9960 3.0Logistics 3.1Accommodation for UON supervisor160003x 600018000 3.2Transport for UON(car hire)140003x400012000 3.3UoN Supervisor Return air ticket 12x750015000 3.4 Taxi to and from airport250002x25005000 3.5Researcher’s lunch allowance for pretesting 1500x1500 3.6Researcher’s lunch during data collection 1500x105000 3.7Refreshments in training51005x100x31500 3.8Hall hire500x31500 3.9Training the research assistants /Allowances 4200800x32400 3.10Salaries Research assistants2100010x1000x220000 Field guides250010x500x210000 Subtotal85400

49. 49 ItemQuantityUnit costNo on daystotal 4.0Equipment 4.1Scales hire Heightboard hire 2222 1500 2x1500 3000 Subtotal6000 5.0 Communication 5.1Airtime for modem13months2000 5.2airtime for research assistants210010x100x22000 5.3Ministry of Education permit1500 5.4Permission from schools1free 5.5permission from MOH1free Subtotal4500 6.0Data entry and analysis 5% Contigency5543 Grand total116403

50. 50 Anderson, P.M. and Butcher, K.F. (2006). Childhood obesity: trends and potential causes. Future Child. 16: 19-45. Approaches, ACT press Nairobi, Kenya. Bertoncello, C. Cazzaro, R. Ferraresso, A. Mazzer, R.and Moretti, G. (2008). Prevalence of overweight and obesity among school-aged children in urban, rural and mountain areas of the Veneto Region, Italy. Public Health Nutr; 11(9):887–890. [PubMed]PubMed

51. References Doak, C.M., Visscher, R.L.S., Renders, C.M. et al. (2006). The prevention of overweight and obesity in children and adolescents: A review of interventions and programs. Obesity Reviews,2006. 7, 111-136 KNBS(2008/9).Kenya Health Demographic Survey MOH(2013).Kenya Nutrition Bulletin. Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J. and Flegal, K. M. (2006). Prevalence of Overweight and Obesity in the United States, 1999-2004. The Journal of the American Medical Association, 296, 1549-155 51

52. 52 WHO(1998). Obesity; preventing and managing the global epidemic,Geneva:WHO. WHO ( 2000). Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 894:1 253[http://whqlibdoc.who.int/trs/WHO_TRS_894. pdf], (accessed September 1, 2010)