A COMPARATIVE STUDY OF OVERWEIGHT AND OBESITY AMONG BASIC SCHOOL PUPILS FROM SELECTED SCHOOLS IN THE ASANTE AKIM CENTRAL MUNICIPALITY. THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY IN HOME SCIENCE DEGREE. BY MICHAEL OPUNI-FRIMPONG JUNE, 2015. DECLARATION I, Michael Opuni-Frimpong, hereby declare that with the exception of cited references, all the information in this document is a presentation of my original research work which was supervised by Professor Clara Opare-Obisaw and Professor Christina A. Nti, at the Department of Family and Consumer Sciences, University of Ghana, Legon. This dissertation has never been presented in part or in whole to any institution for the award of any degree. ………………………………….. Michael Opuni-Frimpong (Student) …………………………………. Prof. Christina A. Nti (Ph.D.) (Supervisor) ………………………………….. Prof. Clara Opare-Obisaw (Ph.D.) (Supervisor) i DEDICATION This thesis is dedicated to my mother Mrs. Mercy Hemaa Frimpong and my Uncles; Mr. Kofi Opuni-Frimpong, Mr. Emmanuel Danso Frimpong and Mr. Ebenezer Frimpong who have been instrumental in my education. ii ACKNOWLEDGEMENT I am grateful to God for giving me good health, knowledge and understanding to complete this thesis. My heartfelt gratitude to my supervisors, Prof. Christina A. Nti and Prof. Clara Opare- Obisaw for their support, professional guidance and encouragement to effectively complete this study. I am very thankful to my family for their motivation and financial assistance to complete this thesis. I am grateful to the A.G. Leventis Fund and The Jean Steckle Foundation for their financial support for the study. I acknowledge the time and participation of all the wonderful pupils who participated in this study. I thank the head teachers of the participating schools for granting me permission to undertake the study in their schools. Finally, my sincere and heartfelt gratitude to everyone whose support saw me through this study. iii LIST OF ACRONYMS BMI Body Mass Index CAT Computer Axial Tomography CDC Centers for Disease Control and Prevention EU European Union FFQ Food Frequency Questionnaire FRAC Food Research and Action Center IOTF International Obesity Task Force MRI Magnetic Resonance Imaging NOO National Obesity Observatory OECD Organization for Economic Co-operation and Development OSA Obstructive Sleep Apnea PAQ-C Physical Activity Questionnaire for Children PE Physical Education SES Socio Economic Status SPSS Statistical Package for Social Sciences USA United States of America WHO World Health Organization iv TABLE OF CONTENTS CONTENT PAGE DECLARATION……………………………………………………………................i DEDICATION ………………………………………………………………………...i ACKNOWLEDGEMENT ...…………………………………………...…………….iii LIST OF ACRONYMS ………………………………….…………………………..iv TABLE OF CONTENTS ……………………………….……………………………v LIST OF APPENDICES …………………………….……………………………..viii LIST OF TABLES …....................................................................................................ix LIST OF FIGURES ………………………………….……………………………....xi ABSTRACT ………. …………………………………………....………………….xii CHAPTER ONE ……………………………………………….…………………....1 1.0 INTRODUCTION …………………………………………………...…........1 1.1 Statement of the Problem…………………..……..………………………4 1.2 Aim of the Study ……………………………………….…………………..…5 1.3 Objectives of the Study …………………………………….………….............5 1.4 Hypotheses ………………………………………………….………...….........5 1.5 Significance of the Study …………………………………….……….…........6 v CHAPTER TWO…………………………………………………………….…….7 2.0 REVIEW OF LITERATURE………………………………………...…7 2.1 Concept of Obesity ……………………………………………………......7 2.2 Prevalence of Obesity ……….. …………………………………………10 2.3 Causes of Childhood Obesity…………………………………………….14 2.4 Effects of Childhood Obesity…………………………………………….19 2.5 Obesity and Socio-economic Status ………………………………….….24 2.6 Prevention of Childhood Obesity …………………………………….….27 2.7 Management of Childhood Obesity ……………………………………..32 2.8 Nutritional Assessment Methods ………………………………………..33 2.9 Anthropometric Assessment Methods …………………………………..34 2.10 Dietary Assessment Methods ………………………………………..…..36 CHAPTER THREE …………………………………………………………......37 3.0 METHODOLOGY …………..…………………………………………37 3.1 Study Design …… ……………………………………………………...37 3.2 Study Location …………………………………………………………..37 3.3 Target Population ………………………………………………………..38 3.4 Sample and Sampling Procedure ………………………………………..38 3.5 Instruments for Data Collection …………………………………………39 3.6 Pre-test …………………………………………………………………...43 3.7 Procedure for Data Collection …………………………………………...44 vi 3.8 Data Analysis and Presentation …………………………………………..44 3.9 Limitations of the Study ………………………………………………….45 3.10 Ethical Clearance ........................................................................................46 CHAPTER FOUR ……………………………………………………................47 4.0 RESULTS AND DISCUSSIONS …………..………………………….47 4.1 Description of Sample…… ……………………………………………...47 4.2 Meal Patterns of Pupils…..........................................................................52 4.3 Frequency of Food Consumption Patterns of Pupils ……….…………...56 4.4 Leisure Activities................... …………………………………………...62 4.5 Physical Activities of Pupils........................................... ………………..66 4.6 Pupils Knowledge of Obesity …………………………………………...80 4.7 Assessment of Nutritional Status of Pupils & Testing Hypothesis………82 CHAPTER FIVE ………………………………………………………………..89 5.0 SUMMARY, CONCLUSION AND RECOMMENDATIONS……...89 6.0 SUMMARY …………………………………………………….............89 7.0 CONCLUSION …………………………………………………………92 8.0 RECOMMENDATIONS ………………………………………………93 REFERENCES…………………………………………………………………..94 APPENDICES…………………………………………………………………..115 vii LIST OF APPENDICES APPENDIX PAGE 1. Questionnaire for Data collection ……………………………….........................115 2. Frequency of Consumption of Foods from the Ghana Six Food Group ………..124 3. Physical Activity ………………………………………………………………...136 4. WHO BMI-for-age Boys..................………………………………....................138 5. WHO BMI-for-age Girls ......................................................................................139 6. Ethical Clearance Approval……………………………………………...............140 viii LIST OF TABLES TABLE PAGE 1. Definition of Obesity by Different Organisations.........................................................11 2. Scoring of SES based on occupations of parents/guardians of pupils...........................40 3. Classification of Socio-Economic Status......................................................................41 4. Classification of Level of Physical Activity................................................................43 5. Age of Pupils................................................................................................................47 6. Persons Pupils Lived With............................................................................................48 7. Person in Charge of Preparing Meals...........................................................................48 8. Ethnic Background of Pupils........................................................................................49 9. Occupations of Pupils' Parents/Guardians....................................................................50 10. Amount of Pocket Money Given to School Pupils.....................................................51 11. Types of Snacks Pupils Consumed.............................................................................55 12. Time Spent Watching TV by Private and Public School Pupils.................................62 13. Number of Times Pupils Engaged in Activities for Exercise......................................69 14. Activities During Break Time.....................................................................................73 15. Activities During Lunch Time.....................................................................................74 16. Self-Reported Description of the Previous Weekend's Physical Activities by Pupils75 17. Frequency of Physical Activity Done by the Private School Pupils...........................76 18. Frequency of Physical Activity by Public School Pupils ...........................................77 19. Overall Classification of Physical Activity Levels of Pupils ......................................78 20. Mean Weights, Heights and BMIs of Pupils...............................................................82 21. Classification of Pupils' BMIs.....................................................................................83 ix 22. Socio-Economic Status of Pupils' Parents...................................................................86 23. Nutritional Status and SES of Private School Pupils...................................................87 24. Nutritional Status and SES of Public School Pupils....................................................88 x LIST OF FIGURES FIGURE PAGE 1. Number of Meals Eaten Daily..................................................................................52 2. Number of Snacks Eaten Daily................................................................................53 3. Duration of Video Games Play................................................................................64 4. Involvement in Physical Education..........................................................................72 5. Pupils Knowledge of the Causes of Obesity............................................................80 6. Pupils' Views on Obesity..........................................................................................81 xi ABSTRACT The purpose of this study was to determine and compare the prevalence of obesity among private and public basic school pupils in the Asante Akim central municipality using a cross sectional survey. A total of 200 children from private and public schools were selected using the simple random sampling technique. Data were collected using a structured questionnaire, a food frequency questionnaire, the Physical Activity Questionnaire for Children (PAQ-C) and anthropometry. The data obtained from the structured and food frequency questionnaires were analyzed using the Statistical Package for Social Sciences software (SPSS version 20) to generate frequency and percentage distributions. Data from the PAQ-C was analysed using the PAQ-C scoring manual to determine the physical activity levels of the school pupils. BMIs of the pupils were computed using the Microsoft Excel software. The WHO BMI-for-age reference chart was used to classify the nutritional status of pupils. The Pearson correlation coefficient was used to test five hypotheses at 5% level of significance (p=0.05). The age of the pupils ranged between 9 and 15 years with a mean age of 11.9±1.46. Almost all (95%) the parents or guardians of pupils were employed with 40% of them being traders. Over three quarters of the pupils in both private and public schools (91% vs 81%) ate at least 3 meals daily. Foods consumed on daily basis included corn, rice, bread, meat, fish, gari, plantain, oranges, bananas, tomatoes, onions, pepper and refined vegetable oil. Seventy three percent (73%) of private pupils and 83% of public pupils ate at least one snack a day. Snack foods consumed were biscuits, ice cream, pastries and sugar flavored drinks. The main physical activities pupils engaged in for exercise weekly were walking, jogging, dance, skipping, soccer xii and ‘‘ampe’’. Even though public school pupils had a higher physical activity level than the private school pupils, the level of physical activity was generally low among the study sample. Only 22% achieved the recommended moderate activity level. The study revealed an overall obesity prevalence of 5.5%, overweight prevalence of 17% and a thinness rate of 3%. Overweight and obesity were higher among private pupils than in public pupils. From the study, 74.5% of the study sample were classified as normal. From the hypotheses tested, there was a significant difference in the physical activity levels of the pupils, there was no significant difference between obesity and the socio- economic status of private and public pupils. Also, there was no significant difference between the socio-economic status of parents of pupils in private and public schools and finally, there was a statistically significant difference between obesity rates of private and public school pupils. Based on the findings of the study it was concluded that, the combined prevalence of overweight and obesity was 22.5%. The types of physical activities usually engaged in by school pupils were walking, jogging, dance, skipping, soccer and ‘‘ampe’’. Though public school pupils had higher physical activity levels than the private school pupils, physical activity levels among both groups was generally low. It was therefore recommended that parents and school authorities assist pupils through the formation of nutrition clubs to make practical efforts to achieve normal body weights by improving their dietary practices through the eating of balanced meals and exercise. xiii CHAPTER ONE 1.0 INTRODUCTION Childhood obesity has increased considerably over the past decades and currently noted as one of the World’s major public health concerns. Worldwide, obesity has risen from 4.2% in 1990 to 6.7% in 2010 (Muhihi et al., 2013). Initially believed to be a condition associated with Western countries, childhood obesity is now increasing in developing parts of the World. Obesity can be defined as a serious degree of overweight caused by excessive storage of fat and usually measured using the Body Mass Index. The World Health Organization defines it as “abnormal or excessive fat accumulation that presents a risk to health” (WHO, 2012). In a report by the International Obesity Task Force (IOTF) to the World Health Organization in the year 2000, it was documented that 155 million school-aged children can be classified as overweight or obese (Ahmad et al., 2010) and that more than one in every four children in the world is overweight or obese ( Karnik and Kanekar, 2012; McAllister, 2009). Genetic and environmental factors have been identified as potential causes of obesity. Obesity develops when food consumption outweighs the physiological need of the body. In today’s world where leisure time activities for children are becoming more sedentary coupled with the growing westernization evidenced in the increased preference for energy-dense western diets and fast foods, a gloomy picture is painted for Ghana’s public health in combating childhood obesity (Ben-Sefer et al., 2009).The prevalence of childhood obesity has increased steadily in developed countries. The number of overweight children has more than doubled, with most of the increases recorded in the last decade. 1 Nationally representative surveys carried out in developing countries have also shown a high prevalence of overweight in Primary School pupils. Mexico, India, Argentina and Brazil reported prevalence rates greater than 15% between 2008 and 2011 (Gupta et al., 2012). The estimated prevalence in Africa as at 2010 was pegged at 8.5%. This is expected to increase to as high as 12.7% by 2020 (Onis et al., 2010) . In Ghana, Abachinga (2001) recorded 19.3% prevalence in his study of school aged children in Legon and Achimota, suburbs of Accra. Watara et al. (2008) reported obesity prevalence of 4% among adolescents of the University of Ghana Staff Village School and University of Ghana Basic Schools. Mogre et al. (2013), in a study of school aged children in the Northern region of Ghana also recorded a combined prevalence of 8.5% for overweight and obesity. However, a study conducted in basic schools in Accra by Mohammed and Vuvor (2012) found a higher prevalence of obesity among children at the University of Ghana Primary School which was 10.9 % . In that same study, a combined prevalence of overweight and obesity was 26.7%. These findings confirm the existence of obesity in Ghanaian school children and thus the need for intervention by stakeholders. Obesity is of significant importance, especially to developing countries such as Ghana, because of its association with morbidities such as diabetes, hypertension, hyperlipidemia, renal, liver diseases and certain cancers and the stress on public budget to meet the treatment cost of such diseases (Gupta et al., 2012). To stress the serious dimension the subject of obesity has taken, the American Medical Association has officially classified obesity as a disease. This is in a quest to get doctors, insurance companies and other stakeholders to place more emphasis on the condition to minimize its deleterious effects 2 (Wabitsch et al., 2014). The high rise in the average BMI’s identified in WHO Global Burden of Diseases Study emphasizes the challenge diet-induced chronic diseases pose if preventive and treatment mechanisms are not put in place (Branca et al., 2007). Childhood obesity has serious effects not only on the child, but also on the society and the government’s purse in general. The effects on the child are comparable to that seen in adults who are obese. Ebbeling et al. (2002) postulated that childhood obesity can have both physical and psychological effects on a child. The physical effects of childhood obesity include type 2 diabetes, sleep apnoea, high blood pressure (hypertension) and orthopaedic complications. Similar to adults, these conditions in childhood are likely to increase the risk of developing coronary heart diseases. The psychological effects include low self-esteem, depression, loneliness and social discrimination. According to the American Heart Foundation (2010) development of overweight and obesity in children can contribute to lower life expectancy later in life. The increasing staggering statistics of obesity in developed countries precipitated the need for interventions. A few of such interventions are the “Let’s Move” childhood obesity campaign launched by the First lady of the United States in 2010 with the aim to solve “the childhood obesity problem within a generation”. The United Kingdom government had earlier on in 2009 launched a similar campaign to reduce the cases of overweight and obesity in children to 2000 levels by the year 2020. Some of these interventions are showing promising signs with the rate in increase of childhood obesity slowing or having reached a “plateau” (Lakshman et al., 2012). Unfortunately there is paucity of data on information on such interventions in Ghana. 3 There is documented evidence that obesity may persist through adulthood and lifestyle modification in children seems to yield more results compared to adults, therefore interventions to prevent or manage obesity should make children a top priority (Roberts et al., 2012; Zwiauer, 2000; Ahmad et al., 2010). It is thus imperative to know the prevalence of obesity and interventions rolled out to prevent or manage it. Most studies on childhood obesity in Ghana have concentrated on urban communities. It would be interesting to know the situation in rural and semi-urban communities as well. 1.1 Statement of the Problem In the traditional Ghanaian set up, a fat child is thought of as the epitome of a healthy child. However, research has proven this may not be so. Excess fat in the body with its associated complications has become a primary childhood concern in developed countries and gradually becoming a public health concern in developing countries. A developing country such as Ghana stands the risk to the dangers childhood obesity poses. Several research findings indicate childhood obesity is becoming prevalent in urban areas in Ghana. Nonetheless, there is very little information available in the literature on the prevalence of obesity among basic school pupils living in rural and semi-urban communities in Ghana and interventions to help address the issue, if any. This research was undertaken to investigate the prevalence of obesity among school-aged children in rural and semi-urban community settings as this can help in the development of policies to prevent or manage the condition nationwide. 4 1.2 Aim of the Study The aim of the study was to determine and compare the prevalence of obesity among private and public basic school pupils in the Asante Akim central municipality. 1.3 Objectives of the study The Specific objectives of the study were to: 1. Determine the prevalence of obesity in basic school pupils in both public and private schools. 2. Establish the dietary patterns of the pupils. 3. Find out the physical activity levels of pupils. 4. Determine the nutritional status of the pupils. 5. Ascertain if a relationship exists between socio-economic status of parents and the incidence of obesity in the child. 1.4 Hypotheses Five null hypotheses were tested; Ho1: There is no statistically significant difference between physical activity levels of private and public school pupils. Ho2: There is no statistically significant difference in prevalence rates of obesity among private and public school pupils. Ho3: There is no statistically significant difference between Socio-Economic Status of parents of pupils in private and public schools. Ho4: There is no statistically significant difference between prevalence of obesity and socio-economic status of the private school children. 5 Ho5: There is no statistically significant difference between prevalence of obesity and socio-economic status of public school children. 1.5 Significance of the Study 1. The results of this study would add to the existing literature on obesity and physical activity of Ghanaian school children in rural and semi-urban communities and also serve as reference material for students and researchers. 2. The findings of the study when published would be useful to key stakeholders (schools, NGOs, health workers, policy makers) in planning effective programmes for obesity control and prevention. 3. The findings will give an insight into the role(s) schools are playing to either prevent or manage obesity in primary schools in Ghana. 6 CHAPTER TWO 2.0 REVIEW OF LITERATURE The literature reviewed covered the following major topics:  Concept of Obesity  Prevalence of Childhood Obesity  Causes of Childhood Obesity  Effects of Childhood Obesity  Obesity and Socio-Economic Status  Prevention of Obesity  Management of Obesity  Nutritional Assessment Methods 2.1 Concept of Obesity Generally, when excess adipose tissues in the body rise to levels that are considered hazardous to one’s health, it may be referred to as obesity (Prentice et al., 2001; Rossner, 2002; WHO, 2000). The condition has a high likelihood of development when the consumption of food outweighs the body’s physiological needs especially if it continues over a long period of time. It becomes particularly tricky when parents and other caregivers have to feed school-aged children whose energy and nutrient needs are increased at this time. Historically, obesity has been a topic of discussion as early as the fourteenth century. Stolberg (2012) reported on works by some scientists in the fourteenth and fifteenth centuries like that of Jean Fennel, (1497-1555) in his work entitled ‘Universa medicina’ 7 which espoused the disadvantages of overeating. Again, reference was made to Giovanni Argenterio’s work in 1566 which postulated that people with too much fat tend to live shorter lives. Obesity has been mainly associated with developed countries over the years however, due to the nutrition transition and changing lifestyles, it is now considered one of the major health concerns in developing countries. Several methods can be used to determine obesity. Whilst some employ the relationship between weight and height involving the Body Mass Index (BMI) (Speiser et al., 2005), other methods such as underwater weighing, magnetic resonance imaging (MRI) and computerised axial tomography (CT or CAT) are used based on the measurement of body fat (Reinehr & Wabitsch, 2011). The method used may depend on the setting and available resources among other things. It must be noted that the use of BMI has been critiqued by some authorities. Martorell (2002) did an extensive discussion on why it might not be the best method to assess body fat and by extension obesity. He argued that, athletes who have developed huge body frames from rigorous physical activities may be wrongly classified as overweight/obese which in fact may not be so. Secondly, for populations with predominantly high levels of early childhood stunting, growth failure occurs with greater intensity in the first two years of life. This growth of the extremities is faster than of the trunk. As a result BMI may be overestimated among adults who suffered malnutrition during childhood and who may therefore have “high sitting height to stature proportions” (i.e. shorter legs) as he puts it. Finally he explained that at high altitudes, the body adapts to housing relatively large cardiovascular and respiratory capacities resulting in large chest dimensions and this may also alter the relationship between BMI and fatness. Bray (2006) though acknowledging 8 that BMI may be a good measure of overall fatness in adults, the inability of the method to provide information regarding patterns of fat which carries health risk independent of overall fatness makes it a limitation. However, Reilly et al. (2003) and Lobstein et al. (2004) have suggested that since BMI is largely associated with relative fatness in childhood, it is the most convenient way to measure adiposity in children. In addition, The National Obesity Observatory (NOO), an executive agency of the Department of Health in England also recommends BMI as a convenient technique for assessing weight status of children (NOO, 2009). The observatory believes BMI is a good indicator of fat levels in the body. Furthermore the relatively quick and easy ability to use BMI’s in these estimates especially in large population surveys confirms their endorsement (Han et al., 2010), as such that was the method employed in this study. Knowing the BMI of a child itself, doesn’t paint a clear picture of his/her nutritional status unless it is marched against a threshold/cut off developed from a reference population. Flegal et al. (2011) explained that a cut off value is arrived at from an angle of statistics rather than its relationship with health risk or degree of fatness making it a screening tool rather than a diagnostic one. Several countries have developed their own cut off points based on certain criteria. The British 1990 growth reference also known as the UK90 is normally used in population studies in the UK (NOO, 2011) while the United States Centres for Disease Control and Prevention (CDC) 2000 growth reference is primarily used in the United States (Kuczmarski et al., 2002) . There are a couple of international cut-offs as well, notable are The International Obesity Task Force (IOTF) cut-offs developed from nationally representative cross sectional surveys in 6 countries 9 and the World Health Organization (WHO) 2007 growth reference data also developed from an international sample from Brazil, Ghana, India, Norway, Oman and the United States. Dinsdale et al. (2011) thus suggests that prevalence rates should be compared in cases where similar cut offs were used. 2.2 Prevalence of Childhood Obesity. The World Health Organization, U.S. Centers for Disease Control and Prevention, and International Obesity Task Force classify overweight and obesity in children differently. The criteria given by these organizations portray a difference in the estimation of the prevalence of overweight and obesity at different ages. Table 1 below gives the different definitions of childhood obesity by different organisations. Generally the obesity prevalence worldwide has increased astronomically during the last couple of decades. Several studies using different cut-off points have confirmed this assertion (Airhihenbuwa et al., 1995; Whitaker et al., 1997; Onis, 2000; Rhee, 2008; WHO, 2010). The rise in the obesity prevalence may likely have a role to play in the increase of non-communicable diseases (NCD’s) that accompany this scourge. The WHO describes this scourge as “one of the most serious public health challenges of the 21st century”. However, some developed countries who set up interventions are beginning to churn out positive results (Wabitsch et al., 2014). The worldwide prevalence of childhood obesity and overweight increased from 4.2% to 6.7% between 1990 and 2010. Per these happenings, the total number of children expected to be overweight and obese by 2026 is estimated to be about 60 million according to Malik et al, (2013). The WHO (2015) also confirms a rapid worldwide increase of the rate of childhood obesity with the number of overweight and obese 10 children under age 5 projected to rise from more than 42 million in 2013 to 70 million by 2025 signifying an increase in prevalence of about 67%. Table 1. Definition of Obesity by Different Organisations. Organisation Definition of Childhood Obesity World Health Organization WHO Child Growth Standards (birth to age 5 years) •Obese: Body mass index (BMI) > 3 standard deviations above the WHO growth standard median •Overweight: BMI > 2 standard deviations above the WHO growth standard median •Underweight: BMI < 2 standard deviations below the WHO growth standard median WHO Reference 2007 (ages 5 to 19 years) •Obese: Body mass index (BMI) > 2 standard deviations above the WHO growth standard median •Overweight: BMI > 1 standard deviation above the WHO growth standard median •Underweight: BMI < 2 standard deviations below the WHO growth standard median U.S. Centers for Disease Control CDC Growth Charts and Prevention In children aged 2 to 19 years, BMI is assessed by age- and sex-specific percentiles: •Obese: BMI ≥ 95th percentile •Overweight: BMI 8 ≥ 5th and < 95th percentile •Underweight: BMI < 5th percentile In children from birth to age 2, the CDC uses a modified version of the WHO criteria International Obesity Task Force Provides international BMI cut off points by age and sex for overweight and obesity for children age 2 to 18 years. •The cut off points correspond to an adult BMI of 25 (overweight) or 30 (obesity) Source: Harvard T. H. Chan School of Public Health, Obesity Prevention 11 2.2.1 Prevalence rates in Developed countries. In the developed world, childhood obesity is a subject of everyday conversation and mounting public concern. The European Union (EU) in its Action Plan on Childhood Obesity spanning 2014-2020 revealed that out of every three children selected from an EU country in 2010 between the ages 6-9 years, one is overweight or obese. In Canada, using the WHO cut off points, close to one third (31.5%) of 5 to 17year olds, an estimated 1.6 million, were classified as overweight (19.8%) or obese (11.7%) in 2009 to 2011. The percentage that was overweight was similar across age groups. In the United States, about 16.9 percent of children aged between 2 and 19 were obese in 2011 to 2012, and 31.8 percent were either overweight or obese. Europe is one of the continents hardest hit by the rise in prevalence rates of childhood obesity. Countries such as The United Kingdom, Finland and Germany have obesity rates more than 20% (Stamatakis et al., 2010). The Organization for Economic Cooperation and Development (OECD), a group of 30 member democratic countries that discuss and develop economic and social policies report countries such as Greece, Italy, New Zealand and Slovenia have obesity prevalence rates among children aged 5-17years that is higher than that of the USA. In 2014, Greece recorded 44% of boys and 38% of girls being either overweight or obese. In Italy, 36% boys and 34% girls are either overweight or obese. New Zealand and Slovenia all recorded childhood overweight and obesity prevalence rates above 32% (OECD, 2014). 12 Countries that have staggering obesity prevalence rates did not get them by accident. Nguyen and El-Serag (2010) reported that as at 1990 no one state in the USA had an obesity rate above 15% but as at 2005, 15 states had rates above 25%. According to Malik et al. (2013), in the next 20 years the proportion of adults who are overweight and obese is expected to rise in Lower Middle Income countries. 2.2.2 Prevalence of Childhood Obesity in Developing Countries. Developing countries have not been spared the brunt of childhood obesity and its associated conditions. Gupta et.al, (2012) reported that fast changing dietary practices and decrease in physical activities have contributed to the scourge in developing countries recently: 41.8% in Mexico, 22.1% in Brazil, 22.0% in India, and 19.3% in Argentina. In Africa, though there is little to report regarding surveys on childhood obesity, the available data points to an increase in this age bracket. South Africa recorded 1% of school aged children between 8 and 11 years to be obese in 1994. This figure had risen to about 17% by 2006 (Snell et al., 2007). Blössner et al. (2010), also presented childhood overweight and obesity prevalence rate in Africa as at 2010 as 8.5% and projected a rise up to 12.7% in 2020 if current trends continue. In Asia, surveys in India and Kuwait among school aged children recorded prevalence rates of 14% and 45% respectively (Chusilp, 2003). Oceania also has prevalence rate in double digits (Olds et al., 2010). 13 2.3 Causes of Childhood Obesity Childhood obesity is a complex theme to look at as far as its causes are concerned. There are physiological, race/ethnic, environmental, socio-economic, education, cultural factors and regional considerations when addressing this condition in a populace. Obesity usually results from consumption of foods in excess of physiological needs (Guillaume, 1997). The imbalance between caloric intake of the child and the calories utilized for growth, development, metabolism and physical activities bring about the development of obesity (Center for Disease Control and Prevention, 2009). Childhood obesity can also be brought on by a range of factors which often act in combination (Ebbeling et al., 2002). “Obesogenic environment” is the medical term set aside for this mixture of elements (McBride, 2010). Factors causing childhood obesity include genetic, family and social practices, low or lack of physical activities and eating habits. (Field, 2004). 2.3.1 Genetics Genetic factors may influence metabolism, by changing the body fat content, energy intake and energy expenditure. Heritability of obesity from parents also influences obesity in children (Stamatakis et al., 2010). One study found that 80% of the offspring of two obese parents were obese in contrast to less than 10% of the offspring of two parents who were of normal weight (Kopelman, 2005). The percentage of obesity that can be attributed to genetics varies from 6% to 85% depending on the population examined (Yang et al., 2007). A child born into a family of overweight people may be predisposed to the condition, especially if there is high-calorie food consumption and decreased physical activity. Some scientists argue that there exists a determinist view of 14 genes and as such nothing can be done to alter the course of fate of something which is written in one’s genetic code. Recent studies have however debunked that view to be overly simplistic. Genes may predispose one to weight gain, but this weight can be lost by extra physical activity. Patterns of the prevalence of obesity are normally identified in certain families even if the family members do not live together or share the same patterns of exercise and food intake (Lyon and Hirschhornm, 2005). According to Lyon and Hirschhornm (2005), estimates of heritability range from 30 to 70% with more specific estimates at 50% meaning about half of the variation in body mass within a population is a result of inherited factors. The predictable pattern of common forms of obesity doesn’t follow the patterns seen in cases of cystic fibrosis and Huntington’s disease rather it shows a ‘complex pattern of segregation’ which may indicate that multiple factors are involved. Each of the obesity genes is likely to make a small contribution to body weight and by extension obesity. However, these obesity genes together with inherited variations play a large role in determining how an individual responds to the environmental factors of diet and physical activity. Veerman (2011) explains that genes may co-determine who becomes obese, but the environment determines how many become obese. 2.3.2 Family and Social Practices In children, growing evidence suggests that a child’s risk of being obese may begin even before birth. Children born to women who used tobacco and gained excessive weight during pregnancy have an increased risk of being obese even in their pre-school days (Al Mamun et al., 2006) . 15 In a home, the parent-child interaction is very crucial as parents can influence the food choices of children and motivate them to have a healthy lifestyle as children tend to learn habits of their parents or care takers especially in their formative years. (Centers for Disease Control and Prevention, 2009). The changes in environmental and social factors are the two likely explanations for severe childhood obesity rates doubling over the last three years (Ahmad et al., 2010). Family practices have significantly changed, and several of these can contribute to childhood obesity. With a decreasing number of mothers who breast-feed, more infants become obese children as they grow up (Birch & Fisher, 2000). Rather than walking to nearby schools, more school-age children are driven to school by their parents, reducing physical activity (Berger, 2014).This development is due to the rapid industrialisation and urbanisation rate in the 20th and 21st centuries. Schneider (2000) and Kohl et al. (2000) explained that children’s diminishing access to sporting activities and other physical exercises, coupled with increased access to television, video games, and energy-saving appliances greatly increased their susceptibility to obesity. This comes about because of the creation of an energy expenditure imbalance as energy consumed often outweighs energy utilized. The school is also another major stakeholder in teaching children proper dietary practices to promote healthy food choices and physical activities since children spend most of their time at school (Center for Disease Control and Prevention, 2009). 2.3.3 Eating Habits Calorie-rich drinks and foods are readily available to children across the world (Dietz, 1998). Consumption of at least one sugar-laden soft drink daily may contribute to 16 childhood obesity. In a study of 548 children over a 19 month period from public schools in Massachusetts, USA, the likelihood of obesity increased two times for every additional soft drink consumed in a day (James and Kerr, 2005). Energy-dense snacks are available in many locations such as restaurants, retail food stores, schools and other locations frequented by children. According to Davis & Carpenter (2008) the increase in availability of junk foods in schools can account for increases in average BMI among United States school children over the last decade. Lobstein and Dibb (2005) and Berger (2014) reported that advertisement of unhealthy foods correlates with childhood obesity rates. In some countries, advertising of candy, soft drinks and fast-food restaurants is illegal or limited on children's television channels and the media usually defends itself by blaming the parents for yielding to their children's demands for unhealthy foods (Lobstein and Dibb, 2005). According to Kulkarni (2004), a study carried out at Grady Memorial Hospital in the United States found that the fundamental rationale for patients not following food recommendations given was that the recommended diet was not familiar to them and contained unfamiliar food choices. As an example, the African-American diet is partially based on certain health beliefs that have been passed down from generations and are still observed presently thus they are likely to patronise specific meals and methods of cooking. He further explained that, socioeconomic status and educational level have been identified to play very significant roles in the meal planning and nutrition education of African-Americans. Financial and physical constraints, available cooking facilities, and family support are all taken into cognisance when dietary practices are involved. These 17 point to the fact that family practices are dearly adhered to and as such if there is a ‘shortcoming’ this will be transferred from one generation to the other. Industrialized agro-food systems established by global corporations have made cheap calorie-dense foods, fats, and oils widely available across the world and have caused a “nutrition transition” (Sobal, 2001). This new global diet has led to increases in fat consumption worldwide (Sobal, 2001). Brody (2002) and Viana et al. (2008) postulate that the new global diet rich in fats and calorie-dense foods and the increasingly sedentary nature of urban children provide the material conditions necessary for the onset of obesity. Children snack more in front of television and spend most of their time sitting without any physical activity (Lee et al., 2006). The fast food industry is a major contributor to the rise in childhood obesity. This industry spends about $3 million annually on advertisements aimed at young children (Thompson et al., 2004). The website of McDonald's alone was viewed by 365,000 children and 294,000 teenagers each month. In addition, fast food restaurants in several countries give out toys in children's meals, which serve as an enticement to children to patronize the fast food (Thompson et al., 2004). Davis & Carpenter (2008) found that 40% of children in the USA asked their parents to take them to fast food restaurants on a daily basis. The advertisements of energy-rich and sugar-rich foods influence children to make unhealthy choices. These unhealthy food choices may lead to weight gain and obesity. In Ghana, children belong to all members of the family. It is a regular sight to see relatives buying gifts for children during festive seasons and when they return from journeys. Unfortunately, these gifts often come in the form of foods such as chocolate, 18 ice cream, toffees, drinks which are typically high in sugar and occasionally fat. Regrettably, these components of food are some of the major culprits of childhood obesity (Steele-Dadzie and Dogbe, 2014). Furthermore food is used as rewards for children in most instances. Gradually these make children eventually develop the appetite for these foods and in most cases prefer more of these fat and sugary foods more than well-balanced meals served at home. Obesity develops one pound per time as such this lifestyle over a long period of time contributes to the surge in the prevalence of childhood obesity. Malhotra et al. (2015) admonishes that promoting physical activity over recommendation to eat healthily is a wrong approach to combat obesity as one cannot over run a bad diet and the junk food industry is to blame largely for the high rise in obesity rates. 2.4 Effects of Childhood Obesity Childhood obesity is a serious concern with both immediate and long term repercussions on health and general wellbeing of the child and the society as a whole. It has far reaching health, psychological, social and economic consequences. Health Consequences Obese children are more prone to many health conditions, experience health-related limitations and require more medical care than normal weight children. Notable among these life-threatening conditions are diabetes, high blood pressure, heart disease and eating disorders such as anorexia and bulimia (Dietz, 1998; Bessesen, 2008). In a surveillance programme of children under 17years carried out in the United Kingdom, 95% of those diagnosed with Type 2 diabetes were overweight and obese (Public Health England, 2015). Dabelea et al. (2014) in a similar study among different 19 sexes, ages, and race/ethnic subgroups across the United States between 2001 and 2009, reported that the prevalence of Type 1 and Type 2 Diabetes among children had shot up considerably and suggested that the increase is as a result of a rise in the frequency of obesity in pediatric populations. Additionally, the findings of a recent meta-analysis carried out in the UK revealed that overweight and obese children are at a 40-50% increased risk of asthma compared to children of normal weight (Egan, 2013). A study carried out in the U.S by Fritz et al. (2010) reported that childhood obesity may contribute to the development of asthma which if not well managed can escalate into very severe asthma later in life. Overweight children are also more likely to grow up to be overweight adults. The Center for Disease Control and Prevention (2009) reported that approximately 80% of children in the U.S who were overweight at age 10–15 years were obese adults at age 25 years. There is ample data to confirm that obese children stand the risk of developing Obstructive Sleep Apnea (OSA) as argued by Narang and Mathew (2012). Kang et al. (2012) reports that the prevalence of OSA among obese children could be as high as 60% when compared with non-obese children. Recent data also seek to prove that obese children have up to 46% prevalence of OSA when compared with children seen in general children’s clinics in the United States (Somers et al., 2010). The CDC (2015) reports that children who are obese are at a higher risk of developing bone and joint problems. In a study carried out in the Netherlands by Krul et al. (2009) involving 2,459 children aged 2 to 17 years, it came to light that overweight and obese children are almost twice as likely to suffer from musculoskeletal problems than children of normal weight. 20 Psychological Consequences Childhood obesity is more than a physical problem. Obese children face an enormous amount of psychological stress. They are more likely to suffer from anxiety disorder as most of them are over pampered and are likely to face separation anxiety when they face situations in the absence of their parents. They are also likely to harbour anxiety towards food and food habits in their bid to stop putting on extra weight at meal times (Kalra et al., 2012). Depression has been identified to be associated with obese children. This may manifest through aggressive behaviour, resentment, conduct problems, bullying (the obese child can either be the bully because of his/her size or be a victim of bullying) and oppositional defiant symptom (Goodman and Whitaker, 2002). It is worth noting that obesity may have subtle cognitive impairment in children. Zhang et al. (2008) established that childhood overweight/obesity is associated with low cognitive functioning in a study carried out among 2,519 school-age children of African American and Mexican American descent in the United States. Social Consequences In addressing the effects of childhood obesity on the child, it is of equal importance to have a look at the negative social ramifications including being liked to a lesser extent by peers, being rejected by peers, and being the victims of different forms of peer belligerence such as bullying. The consequences such hostilities may bring about to the overweight and obese school aged child may impair their social development. This is because school aged children especially those crossing into adolescence are extremely reliant on their peers for social support, identity, acceptance and self-esteem (Janssen et al, 2004). 21 In a study of school aged children between ages 11 and 16 years in Canada, Janssen et al. (2004) reports that the prevalence of social problem is quite high which can have both short-term and long-term psychological outcomes. The prevalence of bully-perpetrators, and victims/bullies in their study of youth were 8.8%, and 3.1%, respectively. The prevalence of victims increased with increasing BMI. The study also established a positive association between BMI category and verbal victimization limited to being called names, made fun of and being teased. A survey of 1,520 children in the USA, aged 9–10 years with a four-year follow up, discovered a positive correlation between obesity and low self-esteem in the four-year follow up. It was also discovered that low self-esteem led to 19% of obese children feeling sad, 48% of them feeling bored, and 21% of them feeling nervous. In comparison, 8% of normal weight children felt sad, 32% of them felt bored, and 10% of them felt nervous (Strauss, 2000). Ben-Sefer et al. (2009) reiterated that obese children who develop a negative body-image are likely to develop lower self-esteem. Such children get depressed, they feel socially discriminated against and stigmatized by their peers and sometimes adults, are nervous about their obesity issue and this is not a good environment for a child to grow into adulthood. This in the long run may negatively affect the child’s academic and social progress. Economic Consequences Literature on the analysis of the economic consequences of childhood obesity has largely been limited to the USA. However, globally obese people spend 42 percent more on healthcare costs than healthy weight people (Trust for America's Health, 2008). 22 According to the Harvard T.H. Chan School of Public Health (2014), there are two types of costs associated with the treatment of obesity and other obesity related conditions namely direct costs and indirect costs. (http://www.hsph.harvard.edu/obesity-prevention- source/obesity-consequences/economic/.) Direct costs are costs incurred from health services rendered to obese patients. Such services may include surgery, laboratory and radiological tests, and drug therapy. Cawley and Meyerhoefer (2012) reported that a study by Finkelstein and colleagues (2006) in the USA found that the per capita medical spending for obese individuals was an additional $1,429 (42 percent higher) compared to individuals of normal weight. Meanwhile Cawley and Meyerhoefer (2012) between 2000 and 2005 using the method of instrumental variables (IV) established that Finkelstein and co- workers may have underestimated the costs. The former found out that the per capita medical spending was $2,741 higher for obese individuals than for individuals who were not obese signifying a 150 percent increase compared to the works by the latter. Indirect costs, are explained as “resources forgone as a result of a health condition,” and may include the following categories: Value of lost work. : Caregivers and parents of obese children who may miss days from work are a cost to both employees (in lost wages) and employers (in work not completed). Parents/Caregivers of obese employees miss more days from work due to short-term absences, long-term disability of their children and premature death than employees whose children are not obese (Colditz, 1992). Insurance: Employers pay higher life insurance premiums for workers’ whose children are obese in cases such insurance cover them (Finkelstein et al, 2008). 23 Wages: A parent/care giver who spends time catering for an obese child with associated complications may have to cut down working hours as such resulting in reduced wages. Childhood obesity is associated with lower wages and lower household income (Colditz, 2008). 2.5 Obesity and Socio-Economic Status Socio-economic status (SES) has two closely related dimensions. The economic aspect is represented by financial wealth while the social aspect can incorporate education, occupational prestige, authority and community standing. These are, however, incomplete explanations for the relationships between societal inequalities and obesity (Ulijaszek, 2012). Socioeconomic factors are likely to exert a profound influence on health mainly due to the unequal distribution of privileges among population subgroups. For example, neighborhood of residence influences access to healthy foods, opportunities for physical activity and the quality of schools (Braveman et al., 2005). In industrialized societies, obesity is a characteristic of lower social and economic classes, having been associated with higher classes prior to widespread economic prosperity (Ulijaszek, 1995). Obesity in Western societies has been explained by generally increased purchasing power, decline in food price and low quality of food available to people of low Socio- economic status (Darmon and Drewnowski, 2008). Some studies have shown that obesity is greater in low income than in higher income populations (Wang & Zhang, 2006). Data from the National Health and Nutrition Examination Survey, from 2005-2008 in the USA revealed that children and adolescents in low income families were more likely to be obese than their higher income 24 counterparts, but the relationship was not consistent across race groups. Children and adolescents living in households where the head of household had a college degree were less likely to be obese compared with those living in households where the household head has less education, but the relationship again was not consistent across race and ethnicity groups (Ogden et al., 2010). Obesity rates increased by 10% for all U.S. children aged 10 to 17years old between 2003 and 2007, but by 23% during the same time period for low-income children (Singh et al., 2010). This national study of more than 40,000 children also found that in 2007, children from lower income households had more than two times higher odds of being obese than children from higher income households. Rates of severe obesity were approximately 1.7 times higher among poor children and adolescents in a nationally representative sample of more than 12,000 children aged 2 to 19 years (Skelton et al., 2009). The Food Research and Action Center (FRAC) (2015) attempted to explain the positive association between lower SES and childhood obesity in developed countries. The center explained that this association arises because of the following: i. Families with lower socio-economic status have limited resources and lack of access to healthy and affordable foods. In developed countries, such as the U.S, low income areas may lack full-service grocery stores and farmers’ markets and as such may not have access to a variety of foods from the different food groups to choose from. This is because they tend to shop from neighborhood malls and corner/convenience stores where fresh produce and low-fat items are either absent or present in limited quantities. Even in cases where variety is available it may be too expensive for them to afford. Citing Bowman & Vinyard (2004) and Pereira et al. (2005), the FRAC 25 explained that such neighbourhoods have a lot of restaurants or fast food joints where energy-dense, nutrient-poor meals can be purchased at relatively low prices. ii. Fewer opportunities for physical activity. Parks, green spaces and bike paths are fewer in lower income neighborhoods’ thus limiting the opportunity for outdoor physical activities. It is also a known fact that incidence of crime are high in such places and as such parents tend to discourage their children from going out thereby encouraging sedentary activities among their children which in the long term contribute to development of obesity. iii. Cycles of food deprivation and overeating. The center citing works by Bruening et al. (2012) and Dammann and Smith (2010) explain that, those who are eating less or skipping meals to stretch food budgets may overeat when food become available. A result of these chronic ups and downs in food intake can contribute to weight gain. iv. High levels of stress. As a result of financial and emotional pressures of food insecurity, low-wage jobs, lack of access to health care etc., persons in low income Neighborhoods are likely to develop high stress levels. Some studies have also postulated stress may lead to overweight and subsequently obesity (Adam & Epel, 2007; Torres & Nowson, 2007) thus its contribution to the association to the positive correlation of obesity and SES. v. Limited access to health care. Many low-income people lack access to basic health care and in places where it is available it may be of lower quality. This results in lack 26 of early diagnosis and treatment of chronic health problems like obesity that is emerging. Contrastingly, in developing countries obesity is associated with those with higher socio- economic status. A study by Dinsa et al. (2012) revealed that in low-income countries, the association between SES and obesity appears to be positively correlated among both sexes. The higher the SES and/or level of education, the more likely it is for one to be obese. Obesity in children appears to be predominantly a problem of the rich in low- and middle-income countries. Mohammed and Vuvor (2012), in a study among basic school pupils in Ghana, revealed that the prevalence of obesity increased with socio-economic status. Gupta et al. (2012) identified high SES as one of the important determinants of childhood obesity in developing countries. Findings by Bovet et al. (2010) in a study in the Seychelles also suggests that the type of school attended may be a useful indicator for assessing the association between socio-economic status and overweight in children emphasising that overweight affects more often wealthy children than others in developing countries. 2.6 Prevention of Childhood Obesity Evidence shows that prevention is potentially more efficient than treatment alone in reducing obesity and thus should be addressed with priority in the public health sector (Doak et al., 2006). Reviews on the effectiveness of childhood obesity prevention interventions suggest that those that are successful must include changes in dietary behavior, a reduction in time spent in sedentary activities, and an increase in the time devoted to physical activity (Doak et al., 2006). This review takes a look at some important stakeholders and proposed strategies to help in combating childhood obesity: 27 2.6.1 Household and School Environment After birth, breast-feeding for example may protect against obesity in later life as the duration of breast-feeding has been identified to be inversely associated with the risk of being overweight later on in life (Birch & Fisher, 2000). A cohort study carried out across 12 sites in the United States of America on 19,397 babies from birth to seven years discovered that fat babies at four months were 1.38 times more likely to be overweight at seven years old compared to normal weight babies. A child's weight may be influenced during infancy. Fat babies at the age of one were 1.17 times more likely to be overweight at age seven compared to normal weight babies (Stettler et al., 2002). At home, parents can help prevent their children from becoming overweight by changing the way the family eats and exercise together. The best way children learn is by example, so parents need to lead by example by living healthy lifestyles (Falciglia et al., 2004). Hence, effective interventions in a family setting can be beneficial to change children's behavior of overeating and unhealthy choice of food. Schools also play an important role in the life of children therefore schools can encourage children to make healthy food choices like reducing the intake of carbonated sugary drinks and foods, encourage children to drink healthy fruit juices, water, eat more vegetables and fruits. Those who provide meals during school hours should prepare them from healthy nutritious food items with emphasis on balanced diets (Rahman et al., 2011). Classroom-based health education can make older children and teens aware of eating nutritious diets and engaging in regular physical activities (Rahman et al., 2011). 28 Child care providers are also important stakeholders in preventing childhood obesity. They are placed in a unique position to provide excellent nutrition education to parents and other caregivers, encourage activity habits, and also to provide a healthy environment for children to eat, play, and grow. These when replicated at home by parents can, to a large extent, assure the best chance of a child growing into a healthy weight. The WHO (2012) in a document on childhood obesity prevention suggested that, the area, region or country where childhood obesity is being tackled, is critical in choosing an appropriate combating approach. Some actions or policy options will be more important, appropriate and feasible than others. Therefore, it is imperative that decisions regarding steps to curb the surge are made locally. Potential areas for action must be carefully analyzed, and given a locally designed approach taking into consideration local, regional or country-specific factors. Such factors must include historical, political, cultural, social and economic factors, available resources and existing policies. Recognizing the important role government(s) plays in addressing the childhood obesity epidemic, The Institute of Medicine (IOM) in the U.S.A after reviewing several studies worldwide produced a set of guidelines for “Local Government Action to Prevent Childhood Obesity”. Broadly the recommendations hinged on healthy eating and physical activity strategies. (IOM, 2009) With reference to healthy eating their recommendations were:  The need to create incentive programs that will attract supermarkets and grocery stores to set up in underserved lower income neighbourhoods. 29  The requirement for menu labelling in chain restaurants so as to provide consumers with calorie information regarding available menus in these restaurants.  The need to propose and effectively implement strong nutrition standards for foods and beverages available in government school feeding programs, recreation centers, parks, and child-care facilities, including limiting access to unhealthy foods and beverages.  Implement a tax strategy to discourage consumption of foods and beverages that have minimal nutritional value, such as sugar sweetened beverages.  Using the mass media (print, radio, social media, TV, bill boards etc.) to promote healthy eating and physical activity using consistent messages. 2.6.2 Phyical Activity Physical activity is a process which involves the repetitive movement of body parts performed to maintain physical fitness. Children who fail to engage in regular physical activity are at greater risk of obesity. Researchers studied the physical activity of 133 children in the United States to measure each child's level of physical activity. They discovered that obese children were 65% less active on weekends compared to non-obese children (McBride, 2010). A physically inactive child is more likely to become a physically inactive adult. In a fitness survey of 5,000 adults in Sweden, researchers discovered that 25% of those who were considered active at ages 14 to 19 were also active adults, compared to 2% of those who were inactive at ages 14 to 19, who were then said to be active adults (Ortega et al., 30 2007). Staying physically inactive leaves unused energy in the body, most of which is stored as fat leading to excessive weight gain (Allen and Myers, 2006). Many children fail to exercise because they spend time doing immobile activities such as computer usage, playing video games or watching television. Technology has a large influence on a child’s activeness. Although quiet time for reading and homework is encouraged, television watching, video games and internet use should be limited to not more than two hours a day. Children need to be encouraged to engage in moderate- intensity physical activity such as brisk walking, skipping, playing football, swimming and dancing (Robinson, 2001; Allen and Myers, 2006; Epstein et al., 2008). Researchers provided a technology questionnaire to 4,561 children aged 14 to 17 and after analyzing the results they discovered that children were 21.5% more likely to be overweight when they watched 4 hours or more of TV per day and 4.5% were more likely to be overweight when they used a computer for two or more hours per day (Epstein et al., 2008). Robinson (2001) conducted a study of children in the United States which demonstrated a relationship between hours of television watched per day and childhood obesity. The findings showed that children who watched more than 4 hours of television per day made poorer food choices, led more sedentary lifestyles, and participated in less rigorous physical activity than children who watched television less than 4 hours daily and are likely to be obese. Schools also play an important role in establishing an environment that supports healthful lifestyle habits. Policies within schools can be established to encourage regular physical activity (Allen and Myers, 2006). Schools can involve children in physical activities with 31 strategies like games and dance groups with more emphasis on non-competitiveness Children should be taught that physical activity has health benefits like: strengthening bones, decreasing blood pressure, reducing stress and anxiety and helps with weight management. 2.7 Management of Childhood Obesity Treatment interventions attempt to reduce the degree of adiposity in overweight patients and generally are administered in a clinical setting. Most clinical approaches to the treatment of childhood and adolescent overweight include a combination of calorie restriction, exercise promotion, and behavioural therapy (Amador et al., 1990). To address the problem of overweight, experts recommend that physicians determine the BMI for all children and adolescents in their practices and offer appropriate interventions to those who are overweight or at risk of overweight. The treatment goal should be on weight maintenance or weight loss (Dietz, 1998; Summerbell et al., 2005). Weight maintenance allows children to maintain current weight over time so that their BMI will gradually decrease as they grow taller. Weight maintenance is appropriate for: a) All children who are at risk of being overweight (BMI in the 85th to 95th percentile) who are between two and seven years of age, and those older than seven years without medical complications. b) Overweight children (BMI in the 95th percentile or higher) between two and seven years of age without medical complications (Summerbell et al., 2005). 32 Weight loss is recommended for: a) All overweight children (BMI in the 95th percentile or higher) who are older than seven years and those between two and seven years of age with medical complications. b) Children at risk for being overweight (BMI in the 85th to 95th percentile) who are older than seven years with medical complications. Finally children and adolescents with a BMI below the 85th percentile are not considered overweight or at risk of being overweight. Physicians should however reinforce healthy behaviors and monitor BMI periodically (Summerbell et al., 2004). Although surgical and pharmaceutical therapies are effective treatments, they are reserved for use in severely obese children (James and Kerr, 2005). 2.8 Nutritional Assessment Methods Nutritional assessment is the evaluation of the nutritional status of an individual or populations through measurement of food and nutrient intakes and nutrition-related health indications (Lee and Nieman, 1996). Four different methods are used to collect data in assessing nutritional status. These are anthropometric, biochemical, clinical and dietary methods (Gibson, 2005). Clinical and biochemical methods of nutritional assessment are not routinely used because they involve a lot of expertise, time and cost. Therefore in this study anthropometric and dietary methods were used in assessing the nutritional status of school aged pupils. 33 2.9 Anthropometric Assessment Methods According to Gibson (2005), nutritional anthropometry is the measurement of the variations of the physical dimensions and the gross composition of the human body at different age levels and degree of nutrition. Anthropometric evaluation is essential for determining malnutrition, overweight and obesity in populations. Anthropometric indicators are used to evaluate the diagnosis of chronic and acute diseases, and the conclusion is useful in designing nutrition care plans for individuals (Forster and Gariballa, 2005). Anthropometric measurements of nutritional status are divided into two main categories: the assessment of growth and the assessment of body composition. The assessment of growth includes the analysis of head circumference, arm circumference, weight and height measurements. Nutritional status assessment of body composition involves the measurement of muscle and fat components in an individual’s body (Gibson, 2005). In this study weight and height measurements were used to determine the Body Mass Indices (BMI’s) of the children. 2.9.1 Weight measurement Body weight may be obtained using a digital/electronic or analogue weighing scale. Subjects should be weighed with minimal clothing with shoes removed. The subject should stand with both hands by the sides and both feet in the center of the scale before recording body weights to the nearest 0.1 kilogram (Gibson, 2005). 34 2.9.2 Height measurement A stadiometer is used to measure heights. The clothing of the subject should be minimal when measuring height so that posture can be clearly seen. Shoes and socks should be removed and the subject must stand straight with feet together, knees straight, and heels, buttocks and shoulder blades in contact with the vertical surface of the stadiometer with the subject’s head in the Frankfurt plane (Gibson, 2005). The arms of the subject should hang loosely at the sides with palms facing the thighs. The Subject should be asked to take a deep breath and stand tall to straighten the spine. The moveable head piece of the stadiometer is firmly placed on the crown of the subject’s head. Height measurement should be taken at maximum inspiration, with the examiner's eyes level with the head piece to avoid parallax errors. The height of the subject is then recorded to the nearest millimeter (Gibson, 2005). 2.9.3 Body Mass Index (BMI) BMI is useful in evaluating the benefits of intervention programmes, as this index is more sensitive to changes in nutritional status. BMI refers to the ratio between current weight and current height and is derived by dividing weight in kilograms by height in meters 2 squared (Gibson, 2005). Mathematically BMI is calculated as weight (kg) / [height (m)] . The WHO’s (2007) BMI-for-age chart provides a reference for categorizing children and adolescents as underweight, severe thinness, thinness (thinness and thinness constitute underweight), normal, overweight and obese. 35 2.10 Dietary Assessment Methods According to Gibson (2005) quantitative and qualitative methods are used in dietary assessment of individuals. The quantitative methods consist of recalls and records and are designed to measure the quantity of foods consumed by individuals. Qualitative dietary assessment methods include the food frequency questionnaire used to obtain retrospective information on the patterns of food use during longer, less precisely defined time. The dietary assessment method used in this study was the food frequency questionnaire. A Food Frequency Questionnaire (FFQ) is a checklist of foods and beverages. In using the food frequency approach, respondents are asked to report their usual frequency of consumption (daily, weekly, fortnightly, monthly, occasionally or never) of each food (Willett, 1998). The FFQ is used to obtain retrospective information on the frequency of usage of foods from the food groups rather than the intakes of specific nutrients. A FFQ provides a general picture of food intake which may be more representative of the usual food intake of the individual. FFQ is said to be the most accurate method used in evaluating usual dietary intakes (Lee and Nieman, 1996; Gibson, 2005). The FFQ is relatively quick to administer, can be self-administered, has modest respondent burden and may be more representative of usual food intake. A limitation of the FFQ is that it is a retrospective method that relies upon the respondent’s memory (Lee and Nieman, 1996). To address this concern, Brantsæter (2014) suggested that food frequency questionnaires are better suited for ranking individuals than for precise numeric estimation. 36 CHAPTER THREE 3.0 METHODOLOGY 3.1 Study Design The study design was a cross sectional survey. This approach is used when the aim of the study is to find out the frequency or prevalence of an attribute, for the population or subgroups within the population at a given point in time. In other words, cross-sectional studies can be considered as providing an overview of the frequency of an attribute or other related characteristics in a population at a given point in time. The data collected can then be used to make inferences about the population. 3.2 Study Location The study was conducted in the Asante Akim Central Municipal Assembly of the Ashanti region of Ghana. Until July 2012, it used to be Asante Akim North Municipal Assembly but with the carving out of Asante Akim North District Assembly, the name was changed to Asante Akim Central Municipal Assembly. The Municipal vegetation is mostly semi- deciduous forest. The Ghana Statistical Service puts the population of the erstwhile Asante Akim North Municipality at 140,694 per the 2010 Population and Housing Census. There are 47 communities in the municipality, out of which 8 have assumed urban status using a population of 5,000 as a basis. (About Asante Akim Central Municipal Assembly, 2006). School pupils in two of these communities namely Konongo and Nyaboo were used in the study. 37 Konongo, a mining town, is the capital of the municipality and one of the major urban communities in the Ashanti region. The revamping of the mining industry in Konongo since 2011 has attracted many West African nationals as well as other ethnic groups from other parts of the country, making it an important commercial hub. Nyaboo, on the other hand, is predominantly a farming community. A survey carried out by the Ghana Statistical Service in the village in 2006, pegged average household expenditure at GH₵180 per annum whilst the Ghana Living Standards Survey (GLSS 5) in 2008 revealed that of Konongo as GH₵682. 3.3 Target Population All school aged pupils between 6 and 16 years in the Asante Akim Central Municipality were targeted. The normal age range for children in Primary schools in Ghana is 6-12 years, however the upper age limit was scaled up to 16 years because most children in the rural areas either start schooling at relatively older ages or tend to spend longer years in school because they may have to repeat their classes due to academic deficiencies. 3.4 Sample Size and Sampling Technique A sample size of 200 from the target population was used for the study with boys and girls having equal representation. The sample size of 200 school pupils was used because of time and financial constraints. 3.4.1 Sampling Procedure The sampling procedure involved a multiple stage approach. At the first stage, the schools were categorised into public and private owned after obtaining a list of all primary schools in Konongo and Nyaboo from the municipal directorate of education. A 38 private and a public school each were chosen from Konongo and Nyaboo. Fifty pupils were then selected from each school chosen. Class registers for Classes 4 to 6 were obtained and compiled into a list of males and females in the schools selected. Only pupils in classes 4 to 6 were included in the study because they were considered old enough and were more likely to understand the questions posed. Using the ballot system, 25 males and 25 females from the list of combined classes were drawn till the required sample size was obtained in each school. 100 pupils from private and public schools were thus drawn from each of the selected urban and rural settings. 3.5 Instruments for Data Collection Four instruments were used to collect the data. 3.5.1 A structured questionnaire A structured questionnaire was administered to gather information on background of the children as well as the occupational backgrounds of the parent(s). A socio-economic status (SES) score was computed based on the main occupation of parents/guardians of the respondents and the amount of money given to respondents to take to school. 39 The Scoring of SES based on occupation was as follows: Table 2a. Scoring of SES based on occupations of parents/guardians of pupils Occupation Score Professionals 5 Pastors 4 Artisans/Farmers 3 Traders 2 Unemployed 1 The scoring of Socio-Economic Status based on the amount of pocket money given to school pupils was as follows: Table 2b. Scoring of SES based on Amount of Pocket Money Given to School Pupils Amount of Pocket Money Score ≥GH₵ 7 5 GH₵ 5-6 4 GH₵3-4 3 GH₵ 1-2 2 < GH₵ 1 1 *Scoring system developed by the researcher. In creating a composite wealth score, scores for occupation of parents/guardians and amount of pocket money given to school pupils were summed up. The results from the pretest was used to arrive at the upper and lower limits. 40 The socio economic status (SES) was then classified as shown in Table 3 below: Table 3. Classification of Socio-Economic Status Socio Economic Status Composite Wealth Score High 8-10 Medium 5-7 Low < 5 Classification developed by the researcher. 3.5.2 A Food Frequency Questionnaire (FFQ) A food frequency questionnaire was used to obtain information on the food choices and frequency of consumption of foods by the pupils. The FFQ used in this study comprised 71 commonly consumed food items from the Ghana Six Food Groups (Appendix 1). The responses were used to provide descriptive information about respondents’ habitual food consumption patterns. 3.5.3 The Physical Activity Questionnaire for Children (PAQ-C). The Physical Activity Questionnaire for Children developed by Kowalski et al. (2004) is a self-administered, 7-day recall instrument. It was used to estimate the physical activity levels of the school pupils. This questionnaire has been validated and used in nationally representative epidemiological studies in Canada (Anderson et al., 2009). However, it was modified for use in this study in Ghana to reflect the different types of physical activities carried out by children in both countries. 41 A section of the PAQ-C obtains information on the frequency at which school pupils engaged in physical activities during their spare time seven days prior to the study. Activities such as baseball, softball, skateboarding, street hockey, floor hockey, ice skating, cross-country skiing and ice hockey/ringette which are not popular in Ghana, were not included in the list. ‘Ampe’ and ‘chaskele’ two very popular activities among Ghanaian school pupils were however included in the list. Ampe is a game best played by a group of four or more people though only two people can play it. It is an active game, with so much clapping, singing and jumping involved that it almost resembles a dance. A leader is chosen and the rest of the group either stand in a semicircle or split into groups of two. The leader begins by jumping, and places one leg forward as he/she lands from the jump. Points are earned depending on which leg (left or right) meets the opposite leg of an opponent first. Everyone gets a chance to be the leader and usually the first person to reach ten points wins. The game ‘Chaskele’ is the Ghanaian rendition of cricket or baseball. It can be played by at least two people or two teams with equal team numbers. The ball here is a crushed empty tin or can with a suitable narrow plank of wood for a bat. The game involves the throwing of ‘the ball’ into a designated bowl or bucket. Those who achieve this also have the task of preventing the other team from doing same by hitting ‘the ball’ with sticks. When the last person finally lands his ball in the bowl the game is restarted. The one with most balls in the basket at the end of the game wins. For this study the items used in computing the physical activity levels included physical activities 7 days prior to the study, physical education involvement, activities during 42 break time, activities during lunch time, self-reported description of physical activities and frequency of physical education. Scores from 1 to 5 for each of the six items (Sections 4.5.1 – 4.5.7) was used to obtain the physical activity composite score. The mean of these six items gave the final PAQ-C activity summary score. The levels of physical activity classifications are presented in Table 4 below: Table 4. Classification of Level of Physical Activity Level of total physical activity Summary Score Very high 5 High 4 Moderate 3 Low 2 Very low 1 The PAQ-C classification of levels of physical activity. Source: Kowalski et al.( 2004). 3.5.4 Instruments for anthropometric measurements A standardised UNICEF electronic scale and a stadiometer produced by SECA were used to take weight and height measurements of the school pupils respectively following standard procedures outlined by Gibson (2005). Heights were recorded to the nearest millimeter while weights were recorded to the nearest 0.1 kilogram. 3.6 Pre-test A pre-test of the instruments for data collection was carried out at the Dwease Local Primary and Peace & Love Preparatory Schools using five pupils from each school. This was to test the procedures outlined above and to check the reliability of the weighing 43 scale and the stadiometer used. The pretest also helped in rectifying problems of ambiguity of the questions asked in the structured questionnaire. 3.7 Procedure for Data collection A letter of introduction from the Department of Family and Consumer Sciences was submitted to the Municipal Director of Education and Head Teachers of the schools visited to seek permission to carry out the study. The researcher introduced himself and the purpose of the study was explained to school authorities and pupils. After the school authorities agreed for the study to be undertaken, consent letters were sent to parents of all pupils in classes 4 to 6 through their children. This was to seek the parents’ approval for their wards to participate in the study. Those who agreed had their children included in the study. The researcher distributed copies of the questionnaire to the school pupils to complete. 3.8 Data Analysis and Presentation 3.8.1 Questionnaire The data were hand-coded and analyzed using the Statistical Package for Social Sciences computer software (SPSS version 20.0) to generate frequency and percentage distributions. 3.8.2 Anthropometric data Microsoft Excel software was used to calculate the BMIs using the heights and weights 2 of the pupils. BMI was calculated as weight (kg)/height (m ). The World Health 44 Organization's (2007) BMI-for-age chart (Appendix 4) was used to classify the nutritional status of the pupils. 3.8.3 Dietary data The Statistical Package for the Social Sciences computer software (SPSS version 20.0) was used to analyze the data obtained from the Food Frequency Questionnaire to generate percentage distributions. Frequencies of consumption of the various food items were then tabulated and used to make inferences about the dietary patterns of pupils. 3.8.4 Testing Hypotheses The hypotheses were tested at 5% level of significance using the Pearson Chi square statistic. If the computed probability value (p) is 0.05 or less, the relationship between variables was considered significant. 3.8.5 Presentation of data The data were hand-coded and analyzed using the Statistical Package for the Social Sciences computer software (SPSS version 20.0) to generate frequency and percentage distributions tables. The results were presented using tables and charts where necessary. 3.9 Limitations of the study The study had a couple of limitations. The study did not investigate other factors such as maternal obesity, weight gain during pregnancy and birth weight which have been documented to have the tendency of positively influencing the risk of childhood obesity. As a result, this study excludes the potential influence of these factors on the etiology of childhood overweight and obesity. 45 Secondly, the FFQ relied on the memory of pupils therefore it is possible that foods consumed more frequently may be over or under reported. This may affect inferences made regarding the pattern of food consumption by the pupils in the study and how food intakes may be used to identify dietary predictors of childhood obesity. The third limitation involves reliance on memory to recall physical activity levels seven days prior to the study; self-reported physical activities on the weekend preceding the study and frequency of physical activities from Monday to Sunday. This may affect the accuracy of information provided by the pupils. Notwithstanding these limitations, the results provide some ideas on childhood overweight and obesity among school pupils in the Ashanti Akim central municipality. On the whole, one may use the results to make inferences with regards to childhood obesity among private and public basic school pupils in semi-urban and rural Ghana. 3.10 Ethical Clearance Ethical approval for the study was granted by Noguchi Memorial Institute for Medical Research (NMIMR) Institutional Review Board (IRB), University of Ghana, Accra. (Reference number: NMIMR-IRB CPN 110/13-14) (Appendix 6). 46 CHAPTER 4 4.0 RESULTS AND DISCUSSION 4.1 Description of the Sample A total of 200 school pupils (100 each from public and private schools) participated in the study. Gender was equally represented by100 boys and 100 girls. 4.1.1 Age of Pupils Table 5 presents the ages of pupils. Table 5. Age of Pupils Total Age (years) Private (%) Public (%) No. % < 12 82 64 146 73 13 16 14 30 15 14 2 17 19 9.5 >14 0 5 5 2.5 Total 100 100 200 100 In the public schools, pupils were aged from 9-15 yrs with a mean age of 12±1.40 years. In the private schools, pupils were aged from 9-14 years with a mean age of 11.3±1.28 years. Overall, majority of the pupils (88%) were aged between 9 and 13 years. Only a few (12%) mainly in the public schools were aged 14 years and above. The mean age was 11.9±1.46. 47 4.1.2 Persons Pupils Lived With Table 6 shows the care givers of the pupils. Table 6. Persons Pupils Lived With Persons pupils lived with Private Public Total % % No. % Both parents 68 47 115 57.5 Mother 22 38 60 30.0 Grandparents 7 11 18 9.0 Father 3 4 7 3.5 Total 100 100 200 100 Over half (58%) of the pupils lived with both parents while almost a third stayed with their mothers and the rest stayed with grandparents or fathers. Since the pupils were primary school pupils, it was not surprising that they all stayed with guardians. 4.1.3 Persons in Charge of Preparing Pupils’ Meals Table 7 shows the persons responsible for preparing meals. Table 7. Person in Charge of Preparing Meals Person in charge of Private Public Total preparing meals. % % No. % Mother 87 84 171 85.5 Grandparent 5 9 14 7.0 Myself 5 6 11 5.5 Others (house help) 2 1 3 1.5 Father 1 0 1 0.5 Total 100 100 200 100 48 Generally, mothers (86%) were responsible for preparing meals for the pupils. In Ghana, mothers are primarily responsible for preparing family meals and this information clearly confirms that. 4.1.4 Ethnic Background of Pupils Table 8 presents’ ethnic background of pupils. Table 8. Ethnic Background of Pupils Ethnic Private Public Total Background % % No. % Ashanti 79 82 161 80.5 Northern Origin 9 10 19 9.5 Fante 5 2 7 3.5 Ga 4 0 4 2.0 Ewe 3 6 9 4.5 Total 100 100 200 100.0 Most of the pupils (81%) were Ashantis in both the private and public schools. The study area was in the Ashanti region which is predominately occupied by Ashantis hence the greater percentage of Ashantis. 4.1.5 Occupation of Head of Household. Table 9 presents the occupations of head of households of pupils. In the private schools, 94% of household heads were employed while 6% were not. In the public schools, 96% of household heads were employed while 4% were not. 49 Table 9. Occupations of Pupils’ Parents/Guardians. Parents/Guardians Private Public Total Occupation % % No. % Petty Trader 38 41 79 39.5 ** Artisan/Vocational 25 45 70 35.0 * Professional 30 10 40 20.0 Unemployed 6 4 10 5.0 Pastors 1 0 1 0.5 Total 100 100 200 100.0 *Doctors, Administrators, Lawyers, Teachers, Bankers, Government workers **Farmers, drivers, cleaners, Tailor, Seamstress, Barber, Carpenter, Mason, Caterer Three quarters (75%) of the parents were employed in the informal sector mainly as traders (40%) and artisans (35%) while 20% were employed in the formal sector as doctors, teachers, bankers etc. Only (5%) of the parents/guardians were unemployed. This finding is in line with the report of the Ghana Living Standards Survey 6 (2014) which reported the unemployment rate in Ghana as 5.2%. This means 95% of parents were involved in some sort of income generation work and as a result they may have the ability to provide at least 3 meals a day for their children. 4.1.6 Amount of Pocket Money Given to School Pupils Table 10 indicates the amount of money given to pupils as pocket money during school hours. The amount of pocket money for the pupils ranged between less than GH¢1 and GH¢10 but majority (86%) of them were given GH¢1 or less to spend during school hours. The money given was little and might not be meant for feeding because the pupils admitted eating meals at home before they left for school. Since their homes were not far 50 from the school, most pupils returned home to eat lunch when school closed. (GH¢1 as at June, 2014 was equivalent to 32cents) Table 10. Amount of Pocket Money Given to School Pupils. Amount of Pocket Private Public Total Money Given (GH¢) % % No. % < 1 39 55 94 47.0 1 39 39 78 39.0 2-3 17 4 21 10.5 4-5 3 0 3 1.5 6-7 1 1 2 1.0 8-9 1 0 1 0.5 10 0 1 1 0.5 Total 100.0 100.0 200 100.0 Some pupils admitted that their parents were too poor to give them pocket money for school on regular basis and risk having to give up schooling to follow their parents to the farm or help them in trading should they push for it. However, this is not necessary if pupils ate at home before leaving for school. More than 22% of pupils in private schools as against 6% in public schools were given above GH¢ 1 for food which seems to agree with Nsiah-Peprah’s (2004) view that parents who took their children to private schools often had more disposable income at hand and belonged to the higher income bracket in the community. 51 4.2 Meal Patterns of Pupils. Fig. 1 shows the number of meals pupils ate daily. Fig 1. Number of Meals Eaten Daily. 90 81 80 76 70 60 50 40 Private Public 30 20 15 9 10 8 4 5 2 0 0 0 1 2 3 4 5 Number of meals Over three quarters of the pupils in both private and public schools ate at least 3 meals daily while 14% ate less than 3 meals a day. The latter is not recommended because it leads to inadequate energy and nutrient intakes for the pupils and has the potential to affect their growth. Overtime, this group of pupils eating less than three meals may end up becoming undernourished. Brady et al. (2000) recommends that children need three meals a day plus snacks for proper growth and development. 52 Percentage About 10% of private school pupils against 5% of public school pupils consumed more than 3 meals in a day. Snacking once or twice during the day may have accounted for this number. There is a need for caregivers to monitor the snacking habits of these pupils as excess calories consumed could contribute to development of obesity later in a child’s life. 4.2.1 Number of Snacks Eaten Daily Fig.2 presents the number of times pupils snacked daily. Fig. 2. Number of Snacks Eaten Daily 50 45 40 40 39 35 30 30 30 25 23 Private 20 Public 17 15 14 10 5 4 3 0 0 None 1 2 3 4 Number of Snacks Most private school pupils (77%) said they ate snacks while 23% did not. Among public schools, majority of the pupils (83%) ate snacks but 17% did not. 53 Percentage Most of the pupils (70% vrs 69%) had 1 or 2 snacks a day which is in line with Brady et al. (2000) who stated that children require snacks in addition to meals for growth and development. The snacking habits of children in this study was slightly higher (80%) than that of Mogre et al. (2013) who found 72% of children in Tamale eating at least one snack a day. The Ghana Health Service (2009) recommends 3 main meals and 2 in between snacks for children (6 to 11 years) and adolescents (12 to 17 years of age). Childhood is a time of rapid growth and meeting nutritional needs is critical to a child's well-being. On the other hand, snacking too many times in a day can contribute to excess weight gain which overtime can result in obesity. Obesity develops one pound per time and as such attention should be given to the number of times snacks are eaten. The snacking habits of pupils in this study are commendable since only a few (7% vs14% ) ate snacks more than twice daily. As such, it is expected that eating of snacks will not be a major contributing factor to the development of obesity among the study sample. 4.2.2 Types of Snacks Consumed by Pupils Table 11 shows the types of snacks eaten by pupils. Various food items were eaten as snacks however except for fruits, the rest of the snacks were all high-calorie foods. Popular snacks among both private and public school pupils were biscuits (46% vs. 39%), ice cream (23% vs. 29%), and “sobolo” drink (21% vs. 37%). These snacks are high in calories and when consumed in large quantities they could provide a high source of extra energy which can contribute to undesirable weight gains. Very few pupils (11% vs. 13%) ate fruits or drank fruit juices as snacks which was not encouraging because 54 healthy snack foods such as fruits should be emphasized to provide essential vitamins and minerals that promote good nutrition and health in children (Pamplona-Roger, 2006). Table 11. Types of Snacks Pupils Consumed Private Public Total Type of snacks % % No. % Biscuits 46 39 82 41 Ice cream 23 29 52 26 Sobolo 21 37 58 29 Pastries (cakes, meat pie) 15 17 32 16 Iced kenkey 15 19 34 17 Fruits 11 13 24 12 Soft drinks 7 5 12 6 Toffees 2 3 5 2.5 Fruit juice 2 0 2 1 Asana/corn drink 1 3 4 2 Energy drink 1 0 1 0.5 Total 144* 165* 306** * n> 100 due to multiple responses. ** n>200 due to multiple responses. 55 4.3 Frequency of Food Consumption Patterns of Pupils Appendix 2 shows the frequency of consumption of foods from the Ghana Six Food Groups which include Cereals and Grains; Starchy Roots and Plantain; Animal Products; Legumes, Nuts and Oil Seeds; Fruits and Vegetables; Fats and Oils. 4.3.1 Cereals and Grains Among the private school pupils, rice (67%), bread (56%), biscuits (50%) and corn (49%) were the most frequently consumed cereals on a daily basis. Among the public school pupils, rice (37%), corn (18%), biscuits (24%) and bread (23%) were the most frequently consumed cereals on a daily basis. The findings among private school pupils where bread was the most frequently consumed among the cereals and grains is contrary to findings by Nti (2008) which revealed that corn was the main staple frequently consumed in the Manya Krobo district of Ghana. The ready availability of bread on school compounds, the ease of carriage in very convenient packages could explain the variation as pupils who even ate at home were sometimes given bread to take to school as snacks. Corn was eaten primarily in the form of kenkey, banku, or as porridge. Bread was eaten for breakfast and rice was mainly eaten as boiled plain rice, jollof or waakye (a meal of rice and beans boiled together). Biscuits were consumed as snacks in both groups of pupils with the percentage of consumption significantly higher among private school pupils (46% vs 39%). Närvänen et al. (2013) citing Viinisalo et al. (2008) using Finland as a reference stated that the consumption of convenience foods such as biscuits have increased by four fold over the past two decades. The findings of this study with 41% of pupils consuming biscuits appear to suggest a high patronage of convenience foods among the study sample. 56 Cereals and grains such as maize, unpolished rice and wheat are high in fiber and a rich source of energy. 4.3.2 Starchy Roots and Plantain The main starchy staples usually consumed by private school pupils on a daily basis were gari (47%), cassava (46%), yam (45%) and plantain (36%). Among public school pupils, gari (56%), cassava (42%), plantain (31%), cocoyam (27%) and yam (21%) were the starchy roots consumed on a daily basis. Consumption of cassava and plantain were similar, however consumption of gari was higher among public school pupils and yam consumption was higher among private school pupils. Starchy roots and plantain are rich in carbohydrate which provides energy for growth and development. 4.3.3 Animal Products In the private schools meat (62%), fish (40%), milk (24%) and eggs (24%) were the main animal products consumed on a daily basis. In the public schools meat (31%), fish (24%), eggs (18%) and milk (15%) were the main animal products consumed on a daily basis. Meat and fish were consumed in stews and soups as accompaniment to dishes such as rice, yam, kenkey and banku. More children in the private schools consumed milk than those in the public schools (24% vrs 15%) although the consumption of milk daily was low among both groups. These findings differ significantly from that of Triches and Giugliani (2005) who found that 95% of school children in Southern Brazil consumed milk every day. The difference was because milk is not a significant component of the Ghanaian diet and besides, milk is expensive. A sachet of powdered milk (20 grams) costs between GH¢1.20 and GH¢1.50 57 so based on the Ghanaian minimum wage of GH¢7 as at 2015 , it will be expensive for a family of at least 3 people to spend almost half that amount on milk alone in the preparation of a meal. Animal products are nutritionally essential as they serve as body- building foods. 4.3.4 Legumes, Nuts and Oil Seeds The most frequently consumed legumes and oil seeds on a daily basis by private school pupils were beans (36%), groundnuts (33%), and palm fruits (30%). Among public pupils, the legumes consumed were groundnuts (20%), beans (19%), soya beans (13%) and palm fruits (11%). Private school pupils’ consumption of beans was almost twice that of public school pupils (36% vrs 19%). Beans were consumed as a component of waakye (rice and beans dish) or in the form of boiled beans with ripe fried plantain. Beans are nutrient-dense making them an important addition to one’s diet. They are low in fat, high in fiber and packed with protein. Beans provide a rich source of vitamins, minerals and plant phytochemicals. Regular consumption of beans enhances health-promoting aspects of diets as they play major roles in reducing risk for chronic diseases such as obesity, cancer, diabetes and heart disease (Raatz, 2015) Groundnuts were consumed roasted for snacks or eaten in the form of groundnut soup. Palm fruits were mainly used for preparing palm fruit soup and palm fruit oil. Legumes, nuts and oil seeds are rich sources of plant proteins which are needed to build and repair worn out body tissues. The high fat content also provides enough energy in a small volume of food to meet the needs for growth. 58 4.3.5 Fruits Among the private school pupils, the main fruits consumed daily were oranges (47%), bananas (39%), apples (31%), pawpaw (26%) and pineapple (25%). Among the public school pupils, the main fruits consumed were oranges (33%), bananas (21%), pineapples (15%) and apples (12%). More private school pupils consumed fruits daily than public school pupils. Oranges and bananas were mostly consumed likely because they are cheaper and readily available throughout the year unlike other fruits which are seasonal such as mangoes and watermelons. Generally, the consumption of fruits among the pupils was low (12%) as shown in Table 11. This was surprising since the study location is noted for abundant supply of fruits and as such one would expect pupils to patronize fruits on a daily basis. This might not be happening because pupils might not recognize the importance of fruits or may have under reported consumption of fruits as snacks. Similarly, Steiner-Asiedu et al. (2012) also found that the fruit consumption among children in the Ga East district of Accra was low. In their study, 60% reported consuming no fruits or vegetables at all. However, Triches and Giugliani (2005) in their study reported that 93% of school children in Brazil ate fruits every day. The difference between this study and that of the Brazilian study may be because fruits are not major menu items for Ghanaians. Fruits provide essential vitamins, minerals and fiber that promote good nutrition and health (Pamplona-Roger, 2006), as such children should be encouraged to eat fruits regularly. 59 4.3.6 Vegetables Onions (77%), Tomatoes (71%), pepper (70%), garden eggs (54%) and okro (41%) were consumed on daily basis by the private pupils. Tomatoes (50%), onions (44%), pepper (43%) and garden eggs (34%) were consumed on daily basis by the public pupils. These vegetables were consumed in soups, stews or as hot pepper sauce eaten with staple dishes. The consumption of vegetables was higher among private school pupils than in public school pupils. Vegetables provide rich sources of vitamins and minerals. 4.3.7 Fats and Oils Among the private school pupils, refined vegetable oil (31%), margarine (26%) and palm oil (22%) were the oils consumed daily. Among the public school pupils palm oil (23%), margarine (13%) and vegetable oil (10%) were the oils consumed daily. Generally, consumption of fats and oils was not encouraging among both groups. A difference was identified in the consumption of margarine where double the number of private school pupils consumed margarine than their counterparts from public schools. This probably is because parents/caretakers of pupils in public schools considered margarine as expensive. This is similar to what Nti (2008) found in her study of household dietary practices and family nutritional status in Manya Krobo district of Ghana where margarine was consumed less frequently because it was expensive. Palm oil which is a rich source of Vitamin A which is required for good vision was also consumed less frequently among pupils. Much as excess consumption of fats and oils is undesirable, they are needed to reduce dietary bulk by supplying sufficient energy in 60 smaller quantities of food to meet the needs of primary school pupils who have smaller stomach capacities than adults. 4.3.8 Beverages The beverages consumed on daily basis were Milo (42%), tea (37%), cocoa powder (19%) and soft drinks (21%) by the private school pupils. The public school pupils consumed Milo (23%), tea (21%), cocoa powder (11%) and soft drinks (11%) daily. Milo and tea were normally drunk for breakfast with bread or biscuits. There was a difference in the consumption of soft drinks among private and public school pupils. Almost twice the number of private school pupils consumed soft drinks compared to that of public school pupils (21% vrs 11%). Most of the private school pupils reported they bought the soft drinks at school while others said they were readily available in their homes. On the other hand, 45% of public school pupils reported they consumed soft drinks occasionally (especially on festive occasions or on their birthdays). Earlier in Table 11 however, only 6% of the sample said they consumed soft drinks so this section paints a clearer picture indicating an under estimation of the earlier responses. 4.3.9 Summary An adequate diet is one which is diversified; this means the diet contains food items from all the Six Ghana Food groups which provide energy and nutrients needed for growth. The pupils from both private and public schools consumed food items from all the 6 food groups. Although this study didn’t solicit for information on quantities consumed, if pupils were consuming foods from the groups in the right quantities, their diets could be considered adequate. 61 4.4 Leisure Activities 4.4.1 Time Spent Watching TV by Pupils Table 12 presents the time spent watching TV by Private and Public School Pupils. A little over half (57%) of private school pupils spent <30 minutes watching TV on weekdays while 38% of them did same on weekends. On the other hand, 41% and 34% of public school pupils also spent <30 minutes watching TV on weekdays and weekends respectively. A little over one third, (35%) of private school pupils spent between 1-3 hours daily watching TV on weekdays and 46% did same on weekends. Findings in this study differ from that of Vaida (2013) who found that 94% of school children in private schools in India spent 1 – 3 hours daily on TV. Table 12. Time Spent Watching TV by Private and Public School Pupils Time spent watching <30 30 – 59 1-2 2-3 4-5 >5 None Total TV Mins Mins Hrs Hrs Hrs Hrs % % % % % % % % Weekdays Private 57 0 30 5 3 2 3 100 Public 41 0 36 5 4 0 14 100 Weekends Private 38 0 29 17 4 6 6 100 Public 34 0 25 19 2 6 14 100 62 Likewise, Steiner-Asiedu et al. (2012) reported that 80% of children in the Ga-East district of Accra spent more than 1 hour daily watching television. This is higher than the findings of this study which found that among private school pupils, 40% spent more than 1 hour watching television on weekdays and 56% on weekends. Comparing the findings of Steiner-Asiedu et al. to that of public school pupils in this study, once again the findings differed as 45% and 52% of public school pupils spent more than 1 hour watching TV on weekdays and weekends respectively. Vaida (2013) found that 100% of school children in public schools in India spent 1–3 hours daily on TV. The findings from this study also differed from Vaida’s. The difference in the television viewing time of this study sample and that of Vaida (2013) could be due to lifestyle differences among the samples and also at the time of collecting data for this study, the power situation in Ghana had households enjoying only 12 hours of power daily. According to Robinson (2001), watching television can be useful however television hours should be moderated because children who consistently spend more than 4 hours per day watching TV are more likely to be overweight or obese. It is therefore commendable that majority of the study group spent 3 hours or less watching television daily. 4.4.2 Time Spent Playing Video Games Fig. 3 indicates the time pupils spent playing video games. Among private school pupils, 79% played video games whiles only 29% played video games among public school pupils. Some of the pupils (18% vs 7%) spent more than an hour daily playing video games. Table 10 showed that public school pupils were given 63 less pocket money than their counterparts from the private schools. As such, they might not have extra money to patronize public video game centers and this may explain why almost three quarters (71%) did not play video games. A few of the private school also reported owning a video game console. Fig. 3 Duration of Video Games Play. 80 71 70 61 60 50 Private 40 Public 30 21 22 20 12 10 4 5 1 1 2 0 None 30mins - 1 hr 2 - 3 hrs 4 - 5 hrs 6 hrs Duration In the study by Steiner-Asiedu et al. (2012), 60% of children studied in Ghana played video games for more than one hour a day with 40% playing video games for less than one hour. Although video games have been available for more than 30 years worldwide, 64 Percentage they were once the preserve of the rich and developed societies but now video games have flooded the markets of both developed and developing countries. This study and that of Steiner-Asiedu et al. (2012) confirm that children in Ghana are not excluded from the playing of video games which over time could contribute to the development of obesity as a result of the lack of physical activities. According to Anderson and Sakamoto (2008) because of the popularity of video games, eliminating them from a child's life might be difficult. However, parents can help decrease the negative impact such games have on children by setting limits on how long children are allowed to play video games and also encourage children to exercise. This is because playing video games is a sedentary activity and when children do not exercise regularly, this can lead to undesirable weight gain, an unwelcome phenomenon emerging among children in Ghana. 65 4.5 Physical Activities of Pupils 4.5.1 Physical Activities 7 Days Prior to the Study Table 13 shows the various physical activities pupils did for exercise 7 days prior to the study. Walking, jogging, dancing, skipping, soccer and ampe were the most popular physical activities engaged in by pupils. Walking Walking was the most popular physical activity engaged in by pupils. Seventy nine percent of students walked at least once in the seven days prior to the study. Thirty four percent (34%) of the total sample walked 1-2 times a week for exercise while 26% walked 3-4 times weekly. Eighty five percent (85%) of public school pupils walked at least once a week compared to seventy eight (78%) of private school pupils. A couple of the private school pupils mentioned they were driven to school by their parents. Some of the private school pupils from neighbouring towns who schooled in Konongo came to school by public transport during school days. Walking is one of the best forms of physical activity. It does not put stress on the joints, it is weight-bearing as a result, it can improve bone density and a 60kg individual walking briskly will burn about 300kcal an hour, so it can assist with physical wellbeing. Additional benefits include stress reduction and improved sleep (Hu et al., 1999). Jogging Sixty two percent (62%) jogged at least once weekly, 26% did so 3-4 times weekly while 38% did no jogging. Some of the male pupils said they belonged to soccer clubs and as a routine jogged in the mornings before going to school. 66 Dancing Fifty six percent (56%) danced at least once a week. Thirty two percent (32%) danced for exercise 1-2 times weekly, 15% did so 3-4 times a week with close to half (45%) not dancing. During the period data was collected, pupils were preparing for interschool’s traditional dance competition and this explains why about a third reported dancing at least once a week. Skipping Fifty six (56%) played skipping at least once a week. Forty one percent (41%) played skipping 1-2 times a week, 13% played skipping 3-4 times a week while 44% did not play skipping at all. If such pupils are not participating in any other physical activity, it will be encouraged they are introduced to skipping. Soccer Fifty three percent (53%) of pupils played soccer at least once a week while the rest (47%) did not. Soccer is one of the popular sports in Ghanaian schools and has recently gained further popularity with the introduction of female soccer even among primary schools to feed Ghana’s female soccer teams. One of the main benefits of having children participate in soccer is staying active. The Centers for Disease Control and Prevention recommends that children should have at least an hour of physical activity each day in order to maintain good health. A typical soccer player runs about seven or eight miles during a game, and there is ample opportunity for children to get the exercise they need (Park, 2014) . It is therefore commendable that many of the pupils engaged in playing soccer so as to keep active and maintain desirable weights. 67 Ampe Half of the pupils (51%) played ‘‘ampe” at least once a week. ‘‘Ampe’’ is a local inexpensive game normally played by females. Many Ghanaian indigenous games have a lot of benefits including physical fitness and perceptual motor development. ‘‘Ampe” as a sport develops cardio-respiratory endurance according to Chepyator-Thomson et.al (2013). This makes ‘‘ampe’’ a good activity for physical exercise that could prevent the development of obesity. Volley ball Twenty percent (20%) of pupils played volley ball at least once a week while 80% did not. This could probably be because the facilities and equipment needed for this game is relatively expensive so it is not surprising the game is not popular. Swimming Majority (90%) of pupils did not swim for exercise. This may be because there are no community swimming pools in Ghana. The swimming pools available are in hotels and cost GH¢20 to GH¢ 150 for children to use depending on the class of hotel. Swimming stimulates the burning of excess fat, prevents the deposition on fat on the thighs, abdomen and hips. It normalizes the function of endocrine glands and also has the superior advantage over other means of physical exercise as part of energy is also used in maintaining a stable body temperature (Ganciu, 2015). Basketball Only a few (8%) played basketball at least once a week. This wasn’t surprising as basketball isn’t very common in Ghana and as such facilities absent in all schools visited and within most communities in the municipality. 68 Aerobics Very few pupils (6%) did any aerobics, which is an active exercise routine accompanied with music, often in a group. Aerobic exercises provide overall health benefits, including fat loss and an increase in daily energy levels. Chaskele Just 5% of pupils played “chaskele” at least once a week. This is mainly an inexpensive game for pupils and hence it was surprising that a lot more pupils didn’t play it. It helps build muscles and as such help to reduce fat deposition in the arms. Badminton Almost all the pupils (99%) did not play badminton. This was not surprising because badminton, a game similar to lawn tennis is not popular in Ghana. Summary Pupils in the study were actively engaged in a variety of physical activities. Only a few of them did not engage in any physical activity which should be discouraged because of the associated health implications later in life. The lack of physical activity results in fewer calorie loss each day and as a result weight gain increases the risk for high blood pressure, heart disease and type 2 diabetes among such pupils. However, for this study , provided the engagement in physical activities by the majority of pupils are regular, they could be considered as having adequate physical activity levels. 69 Table 13. Number of Times Pupils Engaged in Activities for Exercise Weekly None 1-2 3-4 5-6 7 Total Activity for Exercise times times Times times or more Private 22 38 19 8 13 100 Walking Public 15 30 32 13 10 100 Total No. 37 68 51 21 23 200 Total % 18.5% 34% 22.5% 10.5% 11.5% 100% Private 27 36 22 9 6 100 Jogging Public 49 33 11 3 4 100 Total No. 76 69 33 12 10 200 Total % 38% 34.5 16.5% 6% 5% 100% Private 34 34 17 7 8 100 Public 54 29 12 4 1 100 Dancing Total No. 88 63 29 11 9 200 Total % 44% 31.5% 14.5% 5.5% 4.5% 100% Private 30 52 14 3 1 100 Skipping Public 58 30 11 0 1 100 Total No. 88 82 25 3 2 200 Total % 44% 41% 12.5% 1.5% 1% 100% Private 46 20 16 7 14 100 Public 47 13 23 7 10 100 Soccer Total No. 93 33 39 14 24 200 Total % 46.5% 16.5% 19.5% 7% 12% 100% 70 Ampe Private 41 7 15 17 20 100 Public 57 10 24 6 3 100 Total No. 98 17 39 23 23 200 Total % 49% 8.5% 19.5% 11.5% 11.5% 100% Private 85 12 2 1 0 100 Public 75 16 7 2 0 100 Volley Ball Total No. 160 28 9 3 0 200 Total % 80% 14% 4.5% 1.5% 0% 100% Private 87 10 1 0 2 100 Public 93 3 1 3 0 100 Swimming Total No. 180 13 2 3 2 200 Total % 90% 6.5% 1% 1.5% 1% 100% Private 92 5 1 1 1 100 Public 93 4 2 0 1 100 Basketball Total No. 185 9 3 1 2 200 Total % 92.5% 4.5% 1.5% 0.5% 1% 100% Private 95 2 2 1 0 100 Public 93 3 1 3 0 100 Aerobics Total No. 188 5 3 4 0 200 Total % 94% 2.5% 1.5% 2% 0 100% Private 93 4 1 2 0 100 Public 96 2 2 0 0 100 “Chaskele” Total No. 189 6 3 2 0 200 Total % 94.5% 3% 1.5% 1% 0% 100% 71 4.5.2 Physical Education (PE) Involvement 7 days Prior to Study Fig.4 presents physical education (PE) involvement 7 days prior to the study. In Ghanaian primary schools, PE involves various activities such as jogging, soccer, “ampe”, basketball, running, aerobics and other forms of physical exercise. Seven days prior to the study, almost 8 times the number of public school pupils engaged in PE quite often compared to private school pupils (38% vs 5%). However, more private school pupils (35%) reported engaging in PE always compared to 26% of the public school pupils. Fig 4. Involvement in Physical Education 40 38 35 35 31 Private 30 26 Public 25 20 17 17 14 15 12 10 5 5 5 0 PE involvement 72 Percentage Twenty nine (29%) of the private school pupils did no PE or hardly engaged in PE, whereas 19% of the public school pupils did no PE or hardly did PE. Overall, 24% did no PE or hardly did it. This is worrisome since pupils need PE for physical and social development. Studies and reports by Haskell et al. (2007) and Penedo and Dahn (2005) support the positive impact of physical activity on the prevention and control of obesity and its effects particularly on cardiovascular diseases and type 2 diabetes. 4.5.3 Activities During Break Time Table 14 shows the activities during break time. Table 14. Activities during break time Private Public Total Activities % % No. % Ran or played a little bit 29 44 73 36.5 Ran and played hard most of the time 26 11 37 18.5 Sat down 24 9 33 16.5 Stood around or walked 16 18 34 17.0 Ran and played quite a bit 5 18 23 11.5 Total 100 100 200 100.0 Break time is a period during the school hours when pupils took time away from classroom activities to rest and eat meals or snacks. During break time 83% of the pupils engaged in some form of activity such as running or playing which is enough to achieve 73 desirable physical activity levels. Seventeen percent (17%) just sat down signifying a lack of physical activity which is not healthy. It was however commendable that a little over one third (36%) ran or played a little during their break time. According to the Council on School Health of the U.S, even minor movements during break time counterbalances sedentary time during teaching periods and at home and help the child achieve the recommended 60 minutes of moderate to vigorous activity per day, a standard strongly supported by the American Academy of Pediatrics (AAP) policy as this can contribute to lowering the risk of development of obesity (Council on School Health, 2013). 4.5.4 Activities During Lunch Time Table 15 shows the activities pupils engaged in during lunch time. During lunch time 73% of the pupils engaged in some form of physical activity such as running or playing. This is encouraging though it is recommended that pupils who didn’t engage in any form of activity are encouraged to so. Table 15. Activities During Lunch Time Private Public Total Activities % % No. % Ran or played a little bit 31 29 60 30 Sat down 38 16 54 27 Stood around or walked 18 27 45 22.5 Ran and played hard most of the time 11 10 21 10.5 Ran and played quite a bit 2 18 20 10 Total 100 100 200 100.0 74 4.5.5 Self-Reported Description of Physical Activities Engaged in by Pupils During the Weekend Prior to Study. Table 16 presents comments of pupils regarding physical activities. Table16. Self-Reported Description of the Physical Activities by Pupils the Weekend Preceding Study. No. of activities Private (%) Public (%) Total (%) All or most of my time spent doing things which involve little physical 32 9 41 20.5 effort Sometimes did physical activities in 41 34 75 37.5 my free time (1-2times) Often did physical activities in my 11 32 43 21.5 free time(3-4 times) I quite often did physical activities 14 15 29 14.5 in my free time (5-6 times) I very often did physical activities in 2 10 12 6.0 my free time (7 times or more) Total 100 100 200 100 Majority of the pupils (63%) described themselves as having done at least three physical activities during the weekend prior to the study. The rest (37.5%) engaged in physical activities just once or twice during their free times. 75 4.5.6 Frequency of Physical Activity – Private School Pupils Table 17 indicates the frequency of physical activity done by the Private School Pupils. From Table 17, 62% of the private school pupils were active often or very often on Fridays and 42% of them were active often or very often on Saturdays. Normally on Fridays, the schools closed earlier and Saturdays were “no school days” hence the pupils had time to engage in physical activity. Table 17. Frequency of Physical Activity by Private School Pupils Days of the week (%) Frequency Monday Tuesday Wednesday Thursday Friday Saturday Sunday None 15 13 7 12 4 13 25 Little bit 43 31 33 26 11 18 30 Medium 26 32 34 34 22 26 27 Often 9 20 21 18 18 21 10 Very often 6 3 4 7 44 21 7 4.5.7 Frequency of Physical Activity by Public School Pupils Table 18 shows the frequency of Physical Activity by Public School pupils prior to the study. From Table 18, a total of 75% of the public school pupils were active often or very often on Fridays while 42% of public pupils were active often or very often on Saturdays. These findings point to the fact that public school pupils were a little bit more active often than that of their private school counterparts. 76 Table 18. Frequency of Physical Activity by Public School Pupils Days of the week (%) Frequency Monday Tuesday Wednesday Thursday Friday Saturday Sunday None 16 6 5 9 1 14 26 Little bit 16 18 18 6 12 18 33 Medium 29 36 34 35 12 26 26 Often 32 39 41 42 30 21 12 Very often 7 1 2 8 45 21 3 4.5.8 Teaching Periods on Eating Habits and Physical Activity in Participating Schools All the participating schools indicated that they had teaching periods on physical activity and healthy eating habits. The difference however was in the length of time allocated for such lessons. While the public schools spent an hour each week on physical activities, the private schools spent between 30 and 45 minutes per week. However, on periods for teaching eating habits both private and public schools spent between 30 minutes to an hour a week. However, in both categories of schools the teachers said during regular lessons (teaching periods not directly related to food/eating habits) when there was opportunity to educate children on eating habits they did so accordingly. Schools play an important role in establishing an environment that supports healthy eating and regular physical activity which are useful in reducing the incidence of childhood obesity (Allen and Myers, 2006). As such this information regarding all schools having teaching periods for physical activity and teaching on healthy eating 77 habits points to the fact that schools are playing their roles to some extent , though it will be recommended they go into details on overweight and obesity topics. 4.5.9 Classification of Pupils’ Physical Activity Levels The overall physical activity levels of the pupils were classified as outlined in the Methodology based on the PAQ-C. Table 19 shows the classifications of physical activity levels of pupils. Table 19. Overall Classification of Physical Activity Levels of Pupils Physical activity* Private Public Total Classification % % No. % Very High 0 0 0 0.0 High 0 0 0 0.0 Moderate 18 25 43 21.5 Low 53 36 89 44.5 Very Low 29 39 68 34.0 Total 100 100 200 100.0 2 * PAQ-C Classification X =5.857, df = 2, p = 0.053 Over three quarters (79%) of the pupils had low or very low levels of physical activity. This is not encouraging since lack of physical activity is a major contributory factor to undesirable weight gain leading to obesity. The pupils in this study per the PAQ-C have less physical activity compared to Indian pupils studied by Vaida (2013) though the latter used a different instrument (questionnaire) instead of the PAQ-C. In the Indian study, 89% of school children spent 1–3 hours on physical activity daily. Specifically, 92% of private school children spent 1–3 hours on physical activity daily while 86% of the public school children spent 1–3 hours on physical activity daily (Vaida, 2013). 78 In a controlled study carried out in the Czech Republic, it was revealed that one year after increasing physical activity among 6 to 9 year olds in a group of intervention pupils, the odds of being overweight or obese were almost three times lower than that of controlled children. Furthermore, these odds steadily decreased when the duration of the physical activities were increased (Sigmund et al., 2014). Badawi et al. ( 2013) in a study of Egyptian children also established that low levels of physical activity was significantly associated with pupil’s BMIs. Similarly, a study carried out among 375 schools in Spain by Galan et al. (2013) reported that as the frequency of moderate to vigorous physical activity increased the association with health benefits became stronger. The study revealed that among males, health benefits were detected from even very low levels of physical activity. The study however was carried out among government school pupils only. In this current study the first hypothesis stated that: Ho1: There is no statistically significant difference between physical activity levels of private and public school pupils. There was a statistically significant difference between the physical activity levels of the private and public school pupils. The null hypothesis was therefore rejected since the p- value of 0.053 is higher than 0.05 (Table 19). This means public school pupils had higher physical activities than that of the private school pupils. This is not surprising since results in earlier sections of this study revealed private school pupils led a more sedentary lifestyle and engaged less in physical activities compared to their colleagues in public schools. 79 4.6 Pupils Knowledge of Obesity Fig. 5 shows the pupils’ knowledge of the causes of obesity. A number of questions were asked to solicit pupils’ ideas on the causes of obesity. Generally, pupils’ had a fair knowledge of the causes of obesity. About half (52% vs. 43%) mentioned only bad eating habits and over a third (40%) mentioned only the lack of exercise as causes of obesity. Fig. 5. Pupils’ Knowledge of the Causes of Obesity. 70 60 52 50 43 40 31 26 Private 30 24 24 Public 20 10 0 Bad eating Lack of exercise Heredity habits Causes of obesity As per the answers given, over 40% of pupils had the notion that only bad eating habits or only the lack of physical activity contributed to obesity development. However, it is not entirely correct as just a particular factor does not cause obesity but these factors 80 Percentage work in combination to bring it about. It is however commendable pupils knew these major causes of obesity. A follow up on the course content with teachers in the participating schools revealed that the syllabus didn’t go into details on obesity and its associated effects. As such, it is recommended that the content of nutrition education at the basic school level goes a little more into details with practical teaching methods such as the use of pictures, videos and inviting health care personnel to enlighten pupils on the topic of overweight and obesity. 4.6.2 Pupils Views on Obesity Fig. 6 gives the pupils’ views on obesity Fig. 6. Pupils’ Views on Obesity 100 88 90 75 80 70 Private 60 50 Public 40 21 30 20 9 3 4 10 0 Rich Poor Rich&Poor Views on Obesity From Fig.6 most of the pupils (88% vrs 75%) were aware of the fact that obesity is a condition that afflicted both the rich and the poor. This is good because pupils would then be aware that they were not immune to obesity and would have to make efforts to prevent it regardless of their status. 81 Percentage 4.7 Assessment of Nutritional Status of Pupils and Testing Hypotheses. 4.7.1 Mean Weight, Height and BMI of Pupils Table 20 shows the mean weights, heights and BMIs of Pupils. Table 20. Mean Weights, Heights and BMIs of Pupils Measurements Private ±SD Public ±SD Total ±SD Weight (kg) 35.36 7.82 36.55 8.16 35.95 7.76 Height (m) 1.37 0.09 1.42 0.11 1.40 0.10 2 BMI (kg/m ) 18.69 3.45 17.91 2.38 18.30 3.37 The heights of pupils ranged between 1.13m and 1.76m while their weights ranged between 21.0 kg and 80.0 kg. The mean BMI of public school pupils were lower than that of private school pupils, though their mean weights and heights were higher. This points to the fact that, relatively shorter pupils need to make extra efforts to have desirable weights. The mean BMI of 18.30±3.37 kg/m2 is lower than the BMI of 27±5 kg/m2 reported by Steiner-Asiedu et al. (2012) probably because the children they studied in Accra had access to more food and inappropriate eating patterns hence the higher BMI. However, the mean BMI of public school pupils of 17.91kg/m2 in the present study is similar to the 17.4±2.6kg/m2 reported by Danquah et al. (2013) for public school pupils in Atwima-Nwabiagya District, Ghana. This may be because the pupils in the latter setting and those in the current study have similar characteristics because they were in the same geographic region. 82 4.7.2 Nutritional Status of Pupils. Table 21 presents the nutritional status of the pupils. Table 21. Classification of Pupils’ BMIs. BMI * Private Public Total Classification % % No. % Severe thinness 1 0 1 0.5 Thinness 0 5 5 2.5 Normal 69 80 149 74.5 Overweight 20 14 34 17 Obesity 10 1 11 5.5 Total 100 100 200 100.0 *Classification based on WHO (2007) BMI-for-Age Z scores. 2 X =15.235, df = 4, p = 0.040 The overall prevalence of obesity among the study pupils aged 9 to 15 years was 5.5% while the overall prevalence of overweight was 17%. In two separate studies carried out in Enugu, Nigeria and rural India, obesity prevalence rates of 4.1% and 4.5% were recorded respectively (Ani et al, 2013; Ramachandran et al, 2002). This is not surprising as Ghana like these developing countries, are all experiencing the nutrition transition when changes in diet and physical activity patterns gradually fuel the incidence of obesity. This calls for an urgent need to address this menace from escalating further. However, Danquah et al. (2013) found that 4% of the public school pupils studied in Atwima-Nwabiagya District also in the Ashanti region of Ghana were obese which is lower than the current findings implying that the causes, prevention and approach to management of the menace may have to differ from one area to the other even within the same region. 83 The second hypothesis tested was that: Ho2: There is no statistically significant difference in prevalence rates of obesity among school aged pupils in private and public schools. However, there was a statistically significant difference between obesity rates of pupils as the chi-square indicated a significant level of 0.04 which is less than the acceptable p- value of 0.05 so the null hypothesis was rejected (Table 21). This means that obesity was higher among the private school pupils than the public school pupils. Tables 17 and 18 reveal that on average, 17% of private school pupils were often active throughout the seven days of the week compared to an average of 31% of public school pupils. In Table 19, 82% of private school pupils had low and very low levels of activity; it is thus not surprising that 10% of private school pupils were obese as physical inactivity plays a major role in the development of overweight and obesity. Findings of this study are similar to a study in Uyo, Nigeria where 11% of private and 0% of public school children were obese respectively (Opara et al., 2010). Similarly, Vaida (2013) found obesity rates among private and public Indian school children to be 6% and 0% respectively. Likewise, Kyallo et al. (2013) reported that 11% of private and 2% of public school children in Nairobi, Kenya were obese. In the studies mentioned above, it was observed that obesity was always higher among the private than public schools pupils. This was probably because families/parents in the middle to upper economic classes usually enrolled their wards in private schools. The wards also had access to long periods of playing video games and generally had low physical activity levels. These sedentary activities if not done in moderation coupled with increased physical activities can lead to undesirable weight gain. 84 Another interesting observation was that, the prevalence of overweight among girls was 2 higher in private schools than in public schools (χ = 1.329, df=1, p=0.249) though not statistically significant. This finding is in line with Kyallo et al. (2013) who found that girls in private schools were more likely to be overweight than those in public schools. 2 (χ =7.0, df=1, p= 0.008). There wasn’t any gender differences in other BMI classifications in the schools (p>0.05) This present study revealed a combined overweight and obesity rate of 22.5%. Findings from this study were a little higher than the childhood overweight and obesity rate of 17.4% reported by Mogre et al. (2013) in their study of children in Tamale, Ghana and the 17% reported among children in Greece and Italy (Janssen et al., 2005). Another study by Peltzer and Pengpid (2011) among a sample of children from Ghana and Uganda found a childhood overweight and obesity rate of 8% which is much lower than what this study found. This may be because the Ghana/Uganda study used the IOTF age-gender specific child BMI cut points to define overweight and obesity instead of the WHO cut off point used in the current study. Rates of overweight and obesity in this study were lower compared to a study of children in Chicago, USA where 41% of 6-12 year old children were overweight and obese (Margellos-Anast et al., 2008). It is a fact that childhood obesity is the fastest growing health crisis in the United States due to a lack of energy balance arising from inactive lifestyles. The United States has observed the rate of childhood obesity more than triple over the past thirty years, (CDC, 2015) which serves as a warning signal for Ghana to give the menace all the attention it deserves so not to have a repeat of the USA situation few years from now. 85 Overall, 3% of the pupils in this study were thin or severely thin, which was far lower than the 30% rate of thinness reported by Mogre et al. (2013) in their study in Tamale, the 33% reported by Opara et al.(2010) in Nigeria and 6% thinness reported by Kyallo et al. (2013) in Kenya. The 3% rate in this study may be due to pupils eating inadequate diets since 28% reported eating less than three meals daily (Fig.1).This leads to inadequate energy and nutrient intakes for the pupils and has the potential to affect their growth. Both thinness, overweight and obese conditions are undesirable and conditions that must be prevented. Normal weight is what is recommended and 75% of pupils were in this range. The overweight and obese pupils should keep to healthy diets and engage in regular physical activity in order to maintain their weights. The overweight rate of 17% is a matter of concern as overweight children tend to be obese if they are not well managed. Therefore, efforts should be made to manage the incidence of overweight to prevent its transition into obesity. 4.7.3 Obesity and Socio-economic Status A third hypothesis tested was that: Ho3: There is no statistically significant difference between Socio-Economic Status of parents of pupils in private and public schools. Table 22. Socio-Economic Status (SES) of Pupils’ Parents. SES Private Public Total % % No. % High 3 3 6 3 Medium 82 90 172 86 Low 15 7 22 11 Total 100 100 200 100 2 X =3.281, df = 2, p = 0.194 86 The null hypothesis was accepted because there was no significant difference between the socio-economic status of parents of pupils in private and public schools in this study. This means that the socio-economic status of parents of both groups were similar as depicted in Table 22. This may suggest that socio-economic status may not be responsible for the difference in the overweight and obesity rates among the groups. Findings from this study indicate the low levels of physical activity among private school pupils which probably was the major factor responsible for the difference in the overweight and obesity rates among the groups. The fourth hypothesis tested stated that: Ho4: There is no statistically significant difference between prevalence of obesity and socioeconomic status of the private school children. In Table 23, the p-value of 0.770 is greater than 0.05 so the null hypothesis is accepted. This means that the obesity rates among the private school pupils did not differ according to their socio economic status. Although the relationship was not significant, Table 23 indicates that the 10% of pupils, who were obese, were from medium and high SES households. Table 23. Nutritional Status and SES of Private school Pupils. Socioeconomic status (SES) % Obesity Low Medium High Total Obese 0 8 2 10 Non obese 3 74 13 90 Total 3 82 15 100 2 X =0.524, df = 2, p = 0.770 87 The fifth hypothesis tested stated that: Ho5: There is no statistically significant difference between prevalence of obesity and Socioeconomic status of public school pupils. Table 24. Nutritional Status and SES of Public School Pupils.. Socioeconomic status (SES) Obesity % Total Low Medium High Obese 0 1 0 1 Non obese 3 89 7 99 Total 3 90 7 100 2 X =0.112, df = 2, p = 0.945 The p-value of 0.945 is greater than 0.05 therefore the null hypothesis is accepted. This means that the obesity rates among the public school pupils did not differ according to their socioeconomic status. 88 CHAPTER FIVE 5.0 SUMMARY, CONCLUSION AND RECOMMENDATIONS 5.1 SUMMARY The aim of this cross sectional survey was to determine the prevalence of obesity in school aged children in the Ashanti region. A total of 200 pupils from private and public schools were selected using the simple random sampling technique. A structured questionnaire, food frequency questionnaire (FFQ), anthropometric measurements and the Physical Activity Questionnaire for Children (PAQ-C) were used to obtain information from the pupils. Data obtained from the structured questionnaire and FFQ were analyzed using the Statistical Package for Social Sciences software (SPSS version 20.0). Physical activity was determined using the PAQ-C. BMIs of pupils were computed using the Microsoft Excel software. The WHO BMI-for-age reference chart was used to classify the nutritional status of pupils. The presentation of data was mainly descriptive using frequency tables and charts where appropriate. The chi-square statistics was used to test the null hypotheses. The mean age of pupils was 11.9 ±1.46 years. A little over half (58%) of the pupils lived with both parents. Almost all (95%) the parents or guardians of pupils were employed with a little under half (40%) of them being traders. Over three quarters of the pupils in both private and public schools (91% vs 81%) ate at least 3 meals daily. Foods consumed on daily basis included corn, rice, bread, meat, fish, gari, plantain, oranges, bananas, tomatoes, onions, pepper and refined vegetable oil. Seventy three percent (73%) of private pupils and 83% of public pupils ate at least one snack a day. Food items mainly consumed as snacks were biscuits, ice cream, soft drinks and pastries. 89 A little over half (57%) of private school pupils spent <30 minutes watching TV on weekdays while 38% of them did same on weekends. 41% and 34% of public school pupils also spent <30 minutes watching TV on weekdays and weekends respectively. About one third (35%) of private school pupils spent between 1-3 hours daily watching TV on weekdays and 46% did same on weekends. More private pupils (61%) than public pupils (22%) played video games 30 minutes to 1 hour daily. The main physical activities pupils did for exercise weekly were walking, jogging, dance, skipping, soccer and ‘‘ampe’’. All the participating schools indicated that they had teaching periods for physical activity and healthy eating habits. The difference however was in the length of time allocated for such lessons where the public schools spent relatively longer periods per week. Generally, pupils’ had a fair knowledge of the causes of obesity. Most pupils (88% vs 75%) agreed that obesity was a disease of both the rich and the poor. Walking was the most popular physical activity engaged in by pupils. Seven days prior to the study, almost 8 times the number of public school pupils engaged in PE quite often compared to private school pupils (38% vs 5%). During break time 83% of the pupils engaged in some form of activity. Based on the PAQ-C over three quarters (78%) had low physical activity while 22% achieved the recommended moderate activity level. The study revealed an overall obesity prevalence of 5.5% and a thinness rate of 3%. Obesity was higher in private pupils (10%) than in public pupils (1%). There was a statistically significant (p < 0.05) difference in the prevalence of obesity between private and public school pupils. There was no significant difference between obesity and the socio economic status of private and public pupils. There was a significant difference in the physical activity levels of the pupils. 90 5.2 CONCLUSION Based on the findings of the study, it was concluded that the combined prevalence rate of overweight and obesity among the study sample was 22.5% with overweight and obese rates being 17% and 5.5% respectively with higher rates in private school pupils than in public school pupils. Most of the pupils ate 3 meals a day with more than half eating a snack as well. Although public school pupils had higher physical activity levels than the private school pupils, physical activity levels among both groups were generally low. 91 5.3 RECOMMENDATIONS Based on the findings of the study, the following recommendations are made: 1. A little over a quarter (25.5%) of the pupils were obese, overweight or thin due to physical inactivity and inadequate diets. It is therefore recommended that private school pupils are assisted to make efforts to achieve normal body weights by the formation of ‘Nutrition clubs’ which will educate pupils on the importance of good nutrition and regular physical activities. 2. Generally, the consumption of fruits among the pupils was low while most pupils patronised snack foods such as biscuits, ice cream, pastries and soft drinks most of which are energy-dense and nutrient-poor. Consumption of these snacks overtime could lead to development of overweight and obesity. School authorities in collaboration with food sellers on school compounds could present cut fruits in attractive packages and encourage sale of fresh fruits juice extracts in place of these snacks on school compounds. 3. 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Vol. 159: pp.56-68. 114 APPENDIX 1 QUESTIONNAIRE FOR DATA COLLECTION ON A COMPARATIVE STUDY OF OBESITY AMONG BASIC SCHOOL PUPILS FROM SELECTED SCHOOLS IN THE ASANTE AKIM CENTRAL MUNICIPALITY. Respondent Code ……………………………….. School code: ………… SECTION A: Background Information 1) Sex of respondent a. Male b. Female 2) Age of respondent a. below 12 years b.13 years c.14years d. Above 14 years 3) Who do you live with? a. Mother b. Father c. Both Parents d. Grandparents e. Others (specify) ……………………………………………………. 4) Who is in charge of preparing your meals? a. Mother b. Father c. Grandparent d. Myself e. Others (Specify)…………… 5) Ethnic Background a. Asante b. Ewe c .Fante d. Ga e. Northerner f. Others (specify)………. 6) Is your parent/Guardian employed? a. Yes b. No 7) If Yes, what is his/her occupation? ………………………………… 8) How much food money are you given to take to school daily? a. GH¢10 SECTION B: Eating patterns 9) How many meals do you regularly eat in a day? a. One b. Two c. Three d. Four e. More than 4 115 10) On a day you eat three meals, how many of them is (are) prepared at home a. None b. One c. Two d. Three 11) Do you normally eat snacks? a. Yes b. No 12) If yes how many times in a day? a. Once b. Twice c. Thrice d. More than thrice 13) Kindly list some of the snacks you normally eat if you answered yes above. SECTION C: Leisure and physical Activity 14) How much time do you spend watching TV on a weekday? a. Less than 30 minutes b. 1-2 hours c. 2-3 hours d. 4-5 hours e.>5 hours 15) How much time do you spend watching TV on a weekend? a. <30 minutes b. 1-2 hours c. 2-3 hours d. 4-5 hours e.>5 hours 16) Do you play video games? a. Yes b. No 17) If Yes, how many hours in a day? a. Less than 1 hour b. 2-3 hours c. 4-5 hours d. 5-7 hours e. More than 8 hours 18) Do your school have teaching periods when you are taught healthy eating habits and eating healthy foods? a. Yes b. No 19) Do you have periods allocated solely for physical exercise? A. Yes b. No 20) If Yes, how often in a week do you have these periods? a. Never b. Once a week c. Twice a week d. Thrice a week e. More than thrice a week f. Once in a while SECTION D: Knowledge of causes of obesity 21) What do you think causes obesity? a. Eating habits b. Lack of exercise c. Hereditary d. Others e. I don’t have an idea f. Others ………………….. 116 22) Do you think obesity is a condition for the rich or poor? …………………………….. SECTION E: Physical Activity Questionnaire (Elementary School) Under this section, I am trying to find out about your level of physical activity from the last 7 days (in the last week). These includes sports or dance that make you sweat or make your legs feel tired, or games that make you breathe hard, like tag, skipping, running, climbing, and others. 23). Physical activity in your spare time: Have you done any of the following activities in the past 7 days (last week)? If yes, how many times? (Tick only one box per row.) Activity Frequency (times per week) 1-2 times 3-4 times 5-6 times ≥7 times Skipping Tag Walking for exercise Jogging/ running Aerobics Swimming Dance Football Soccer Volleyball Basketball Ampe Chas-ke-le Badminton Others: 24) In the last 7 days, during your physical education (PE) classes, how often were you very active 117 (Playing hard, running, jumping, throwing)? (Check one only.) a. I don’t do PE b. Hardly ever c. Sometimes  d. Quite often e. Always  25). In the last 7 days, what did you do most of the time during break time? (Check one only.) a. Sat down (talking, reading, doing schoolwork) b. Stood around or walked around c. Ran or played a little bit d. Ran around and played quite a bit e.  Ran and played hard most of the time 26). In the last 7 days, what did you normally do at lunch (besides eating lunch)? (Check one only.) a. Sat down (talking, reading, doing schoolwork) b. Stood around or walked around c. Ran or played a little bit d. Ran around and played quite a bit e. Ran and played hard most of the time 27). In the last 7 days, on how many days right after school, did you do sports, dance, or play games in which you were very active? (Check one only.) a. None ............................................... b. 1 time last week ........................... c. 2 or 3 times last week ................. d. 4 times last week......................... e. 5 times last week......................... 118 28). In the last 7 days, on how many evenings did you do sports, dance, or play games in which you were very active? (Check one only.) a. None .............................................. b. 1 time last week ............................ c. 2 or 3 times last week ................... d. 4 or 5 last week .............................. e. 6 or 7 times last week.................... 29). Last weekend, how many times did you do sports, dance, or play games in which you were very active? (Check one only.) a. None.................................................... b. 1 time............................................... c. 2 — 3 times ......................................... d. 4 — 5 times ......................................... e. 6 or more times..................................... 30). Which one of the following describes you best for the last 7 days? Read all five statements before deciding on the one answer that describes you. A. All or most of my free time was spent doing things that involve little Physical effort B. I sometimes (1 — 2 times last week) did physical things in my free time (E.g. played sports, went running, swimming, bike riding, did aerobics) C. I often (3 — 4 times last week) did physical things in my free time D. I quite often (5 — 6 times last week) did physical things in my free time  E. I very often (7 or more times last week) did physical things in my free time  31). M a r k how often you did physical activity (like playing sports, games, doing dance, or any other physical activity) for each day last week. FREQUENCY OF PHYSICAL ACTIVITY DAY None Little bit Medium Often Very often Monday Tuesday 119 Wednesday Thursday Friday Saturday Sunday 32).Were you sick last week, or did anything prevent you from doing your normal physical activities? (Check one.) a. Yes ........... b............ If Yes, what prevented you? SECTION F: Frequency of consumption of foods In this section, the objective is to assess your habitual diet by knowing the frequency with which you consume food items or specific food groups over the past 6 months or a year. No answer is wrong I will be happy if you answer the questions as honestly and accurately as you can — this is very important. How often do you eat the following food items? Please tick the appropriate box Food items Daily Weekly Monthly Occasionally Never ANIMAL PRODUCTS Meat Fish Eggs Milk Poultry Game Snails Shrimps Crabs Others LEGUMES, NUTS AND OIL SEEDS Beans Groundnuts Agushie Soya beans 120 Dawadawa Palm fruits CEREALS AND GRAINS Corn Rice Millet Sorghum Wheat Oats Bread Biscuits Cakes Weanimix Indomie ( pasta) Others FRUITS Oranges Banana Pineapple Pawpaw Lime/lemon Grapefruit Watermelon Apple Mango Soursop VEGETABLES Leaves Okro Garden eggs Tomatoes Pepper Onions Carrots Cabbage Others STARCHY ROOTS AND PLANTAIN 121 Cassava Yam Cocoyam Sweet potato Plantain Kokonte Gari Others OILS Refined vegetable oil Coconut oil Palm kernel Oil Margarine Butter Cheese Shea butter Others BEVERAGES Milo Cocoa powder Bournvita Chocolim Richoco Tea Coffee Soft Drinks Alcohol Pito Others MISCELLANEOUS Toffees Ice cream Tiger nut milk Others SECTION D Anthropometric measurements Date measured Age Weight Height BMI 2) (years) (kilograms) (meters) ( kg/m 122 APPENDIX 2. FREQUENCY OF CONSUMPTION OF FOOD ITEMS FROM THE GHANA SIX FOOD GROUPS. Table 25. Private School Respondents’ Consumption of Animal Products Food items Daily Weekly Monthly Occasionally Never ANIMAL PRODUCTS Meat 62 20 13 4 0 Fish 40 34 15 8 1 Eggs 24 38 28 6 3 Milk 24 27 24 20 4 Poultry 13 28 22 27 9 Game 12 15 19 34 18 Snails 7 9 16 23 44 Shrimps 5 12 17 26 39 Crabs 4 13 22 28 32 123 Table 26. Public School Consumption of Animal Products Food items Daily Weekly Monthly Occasionally Never ANIMAL PRODUCTS Meat 31 16 18 32 3 Fish 24 43 21 11 1 Eggs 18 24 32 25 18 Milk 15 20 29 25 11 Poultry 8 18 20 39 14 Game 8 8 19 30 35 Snails 5 11 10 27 47 Shrimps 3 8 10 19 60 Crabs 4 8 8 26 54 Table 27. Private Consumption of Legumes, Nuts and Oil Seeds Food items Daily Weekly Monthly Occasionally Never LEGUMES, NUTS AND OIL SEEDS Beans 36 30 15 8 10 Groundnuts 33 42 17 5 2 Agushie 19 26 18 19 17 Soya beans 17 18 18 20 25 Dawadawa 18 14 17 14 36 Palm fruits 30 46 9 10 4 124 Table 28. Public School Pupils Consumption of Legumes, Nuts and Oil Seeds Food items Daily Weekly Monthly Occasionally Never LEGUMES, NUTS AND OIL SEEDS Beans 19 34 31 14 2 Groundnuts 20 29 36 12 3 Agushie 9 15 24 32 20 Soya beans 13 7 17 35 28 Dawadawa 5 11 8 20 55 Palm fruits 11 41 25 17 6 Table 29. Private School Pupils Consumption of Cereals and Grains Food items Daily Weekly Monthly Occasionally Never CEREALS AND GRAINS Corn 49 31 11 7 1 Rice 67 21 8 2 1 Millet 17 25 27 15 15 Sorghum 5 12 9 10 63 Wheat 24 22 21 8 2 Oats 32 28 19 17 3 Bread 56 34 10 0 0 Biscuits 50 22 17 7 3 Cakes 23 27 13 31 5 Weanimix 11 14 10 31 30 Indomie ( pasta) 22 25 10 24 18 125 Table 30. Public School Pupils Consumption of Cereals and Grains Food items Daily Weekly Monthly Occasionally Never CEREALS AND GRAINS Corn 18 44 30 8 0 Rice 37 48 13 2 0 Millet 7 22 23 34 14 Sorghum 2 2 9 14 73 Wheat 11 13 24 40 12 Oats 11 29 32 19 9 Bread 23 40 22 14 1 Biscuits 24 23 19 31 3 Cakes 9 5 18 43 25 Weanimix 4 4 8 22 62 Indomie ( pasta) 3 15 9 24 48 126 Table 31. Private School Pupils Consumption of Fruits Food items Daily Weekly Monthly Occasionally Never FRUITS Oranges 47 27 17 7 1 Banana 39 25 26 9 0 Pineapple 25 23 30 16 3 Pawpaw 26 24 27 19 2 Lime/lemon 10 15 15 22 37 Grapefruit 13 14 8 16 48 Watermelon 19 24 34 19 3 Apple 31 11 22 29 4 Mango 15 15 27 38 3 Soursop 6 3 21 36 33 127 Table 32. Public School Pupils Consumption of Fruits Food items Daily Weekly Monthly Occasionally Never FRUITS Oranges 33 28 32 7 0 Banana 21 39 24 16 0 Pineapple 14 30 30 26 0 Pawpaw 14 21 28 28 9 Lime/lemon 6 7 14 17 56 Grapefruit 7 10 7 21 55 Watermelon 8 18 29 39 6 Apple 12 4 22 47 14 Mango 6 13 26 49 6 Soursop 6 5 15 37 37 128 Table 33. Private School Pupils Consumption of Vegetables Food items Daily Weekly Monthly Occasionally Never VEGETABLES Leaves 30 30 20 12 5 Okro 41 20 23 6 7 Garden eggs 54 18 22 2 1 Tomatoes 71 17 7 2 1 Pepper 70 19 3 2 2 Onions 77 15 3 2 2 Carrots 23 32 21 20 1 Cabbage 20 20 24 30 3 Table 34. Public School Pupils Consumption of Vegetables Food items Daily Weekly Monthly Occasionally Never VEGETABLES Leaves 15 33 35 13 4 Okro 32 42 19 4 3 Garden eggs 34 22 33 11 0 Tomatoes 50 27 18 5 0 Pepper 43 40 12 5 0 Onions 44 28 14 14 0 Carrots 17 15 25 38 5 Cabbage 14 12 22 41 11 129 Table 35. Private School Pupils Consumption of Starchy Roots and Plantain Food items Daily Weekly Monthly Occasionally Never STARCHY ROOTS AND PLANTAIN Cassava 46 33 13 4 4 Yam 45 39 10 3 0 Cocoyam 33 28 27 7 5 Sweet potato 15 18 23 35 6 Plantain 36 27 24 9 4 Kokonte 18 20 18 29 12 Gari 47 31 10 4 8 Table 36. Public School Pupils Consumption of Starchy Roots and Plantain Food items Daily Weekly Monthly Occasionally Never STARCHY ROOTS AND PLANTAIN Cassava 42 35 13 6 4 Yam 21 41 30 5 0 Cocoyam 27 36 27 7 3 Sweet potato 8 20 21 45 6 Plantain 31 36 28 1 2 Kokonte 23 32 25 15 5 Gari 56 31 9 2 2 130 Table 37. Private School Pupils Consumption of Oils Food items Daily Weekly Monthly Occasionally Never OILS Refined vegetable oil 31 31 26 5 4 Coconut oil 15 23 24 18 17 Palm kernel Oil 22 26 27 11 11 Margarine 26 28 13 22 8 Butter 23 18 14 25 17 Cheese 15 18 11 13 40 Shea butter 5 14 10 11 57 Table 38. Public School Pupils Consumption of Oils Food items Daily Weekly Monthly Occasionally Never OILS Refined vegetable oil 10 27 30 29 3 Coconut oil 11 22 33 27 5 Palm kernel Oil 23 21 37 13 6 Margarine 13 17 11 34 24 Butter 12 7 11 32 37 Cheese 8 7 5 16 63 Shea butter 2 12 6 14 65 131 Table 39. Private School Pupils Consumption of Beverages Food items Daily Weekly Monthly Occasionally Never BEVERAGES Milo 42 14 16 18 7 Cocoa powder 19 24 10 26 18 Bournvita 8 7 11 27 44 Chocolim 17 7 10 28 35 Richoco 14 17 9 30 26 Tea 37 18 20 15 7 Coffee 15 11 16 37 18 Soft Drinks 21 26 28 18 4 Alcohol 0 0 0 0 100 Pito 0 0 0 3 97 132 Table 40. Public School Pupils Consumption of Beverages Food items Daily Weekly Monthly Occasionally Never BEVERAGES Milo 23 15 15 31 15 Cocoa powder 11 10 18 35 24 Bournvita 5 5 9 35 45 Chocolim 5 7 8 28 51 Richoco 5 10 6 35 43 Tea 21 9 25 36 8 Coffee 8 6 15 40 30 Soft Drinks 11 11 25 45 7 Alcohol 0 0 0 2 98 Pito 0 0 1 8 91 133 Table 41. Private School Pupils Consumption of Miscellaneous Items Food items Daily Weekly Monthly Occasionally Never MISCELLANEOUS Toffees 50 22 14 7 4 Ice cream 34 34 17 12 1 Tiger nut milk 4 13 17 13 50 Table 42. Public School Pupils Consumption of Miscellaneous Items Food items Daily Weekly Monthly Occasionally Never MISCELLANEOUS Toffees 32 21 29 15 2 Ice cream 24 29 18 23 3 Tiger nut milk 5 11 14 69 5 134 APPENDIX 3. PHYSICAL ACTIVITY 1.0 Number of Times Activities (Sports, Games, Dance) Were Done Right After School Table 43. The number of times activities (sports, games, dance) were done right after school No. of times activities Private Public Total were done (per week) % % No. % None 27 24 51 25.5 1 time last week 35 33 68 34 2 or 3 times last week 24 26 50 25 4 times last week 10 6 16 8 5 times last week 4 11 15 7.5 Total 100 100 200 100 2.0 Number of Evenings Pupils Did Sports, Dance, Or Played Games. Table 44. Number of Evenings Activities Were Done. No. of evenings Private Public Total activities were done (per week) % % No. % None 47 48 95 47.5 1 time last week 25 35 60 30 2 or 3 times last week 14 12 26 13 4 times last week 10 2 12 6 5 times last week 4 3 7 3.5 Total 100 100 200 100 135 3.0 Number of Times Activities (Sports, Games, Dance) Were Done Last Weekend Prior to Study. Table 45. Number of times activities (sports, games, dance) were done last weekend No. of times activities Private Public Total were done (per week) % % No. % None 18 31 49 24.5 1 time last week 66 47 113 56.5 2 or 3 times last week 6 7 13 6.5 4 times last week 5 6 11 5.5 5 times last week 5 9 14 7 Total 100 100 200 100 136 137 138 APPENDIX 6 139 140 \ 141