A Study of Overweight and Obesity among Secondary School Students in Dubai : Knowledge , Attitude , and Practice

The prevalence of overweight and obesity among children and adolescents in UAE was dramatically increased in the last few years, which has major public health implications. The aim of the present study was to assess knowledge, attitude, and practice towards overweight and obesity among secondary school students in Dubai. A cross sectional study was carried out in private secondary schools in Dubai using a multistage stratified random sample technique. Self administrated questionnaire was utilized to collect data about socio-demographic characteristics, knowledge, and attitude towards obesity, perception of the students about their weight, methods, and barriers of practicing weight reduction. Results revealed that 33.5% of the students had good knowledge about obesity and its complications while 44.8% had poor level. Positive attitude towards obesity and its treatment was found among 57.0% of the students with no significant gender difference. More than half of the students (56.7%) agreed that obesity is a disease and 72.1% agreed that obesity needs treatment. Self perception of being obese was found among 58.5% of the students, and the majority (72.6%) did not practice any weight reduction before. Females had significantly higher rate of practicing weight reduction compared to males. The most common barriers against practicing weight reduction were lack of knowledge about the methods (47%), lack of time (25%), and lake of interest or support (23.2%). Female gender and higher education of the mother were independent predictors of good knowledge about obesity, while higher education of the mother was an independent predictor for student's positive attitude towards obesity. Utilization of the mass media to enhance the level of community knowledge about obesity and its complications was recommended. Health education materials should be delivered to present and future mothers. School health programs should include interventions to improve knowledge, attitude, and practice of the students towards obesity.


INTRODUCTION
successfully. (1,2)ver the past 3 decades, the prevalence of overweight and obesity has more than tripled for children aged 6-11 years and more than doubled for youth 12-19 years. (3)e increase in obesity has been well documented in developed as well as developing countries and can be attributed to a range of factors such as changes in eating behavior and exercise patterns, shifts in food production, and an increasingly obesogenic environment designed to encourage overeating and sedentary lifestyle. (4)e prevalence of overweight and obesity among UAE children and adolescents was dramatically increased in the last few years as reported from different studies.At 2000, a study carried in Ras Al-Khaimah found that the prevalence of overweight in school children boys and girls was 16.5% and 16.9%, respectively and about 8% of them were obese. (5)Five years later, a study carried out in four regions in UAE, found that the overall prevalence of overweight and obesity in school students was 33.6% (6) .This high prevalence of overweight and obesity is a cause of concern, as it was estimated that between 40% and 70% of obese children will become obese adults.This precursor condition for adult obesity is a critical public health threat because of the associations with several chronic diseases including hypertension, type 2 diabetes, coronary heart disease, stroke, osteoarthritis, and sleep apnea (7) .
It has been found that deficiencies exist in regard to knowledge, attitudes, and behaviors in relation to obesity and weight control among adults. (8)Moreover, several studies, (9,10) have shown low level of obesity knowledge among adolescents and high school students and most students presented negative attitudes towards obesity and overweight people (10) .Despite the desire to have appropriate body weight, physical exercise and dietary measures tocontrol body weight are lacking both among adults and school students. (11,12)e management of obesity is problematic with much research showing that although the most complex interventions may produce weight loss, this reduction in weight is often only short-term, with many studies showing that weight returns to baseline levels by follow up (13) .Little is known about the knowledge, attitude, and practice of the school students in UAE towards obesity problems.Getting enough knowledge about these factors may help in planning for intervention programs to deal with this important public health problem.

AIM OF THE STUDY
The aim of the present study was to assess knowledge, attitude, and practice towards overweight and obesity among secondary school students in Dubai.

Data collection plan
All students were subjected to a self administrated questionnaire (Arabic and English forms) using closed ended questions that included the following data: •

Statistical analysis
The statistical analysis was carried out using computer program SPSS version "13".The following statistical analyses were performed: (14,15) • Descriptive statistics using mean and standard deviation.
• Chi-square test was used for categorical data.
• Student t test was used for comparison of mean knowledge and attitude score for two independent groups.
• ANOVA was used for comparison of mean knowledge and attitude score for three independent groups with post hoc pair wise comparison "Scheffe's test".
• Stepwise multiple regression was used to delineate the predictors for knowledge and attitude scores.The independent variables included were age, gender, grade, nationality and educational level of the mother.
• P<0.05 was used as cut off level of significance.

RESULTS
The present study comprised 1186 secondary school students.Table (1)   shows that the sample included nearly equal percentages of males and females,     (16) Student's knowledge about obesity varied from study to another.In a sample of 1271 eighth and ninth grade students from six Latin American cities, (9) the mean test scores reflected a low level of obesity knowledge among male and female adolescents from higher and lower SES groups in all study sites.Another study, (10) revealed that students' knowledge of food and nutrition, the risk of obesity, and the danger of excessive diets was insufficient.This is consistent with the results of the present study, where around two-thirds of the students had fair or poor knowledge about obesity (figure 1).The results also revealed that the worst level of knowledge was that regarding complications of obesity (table 2).Similarly, adolescents in the study by Nowak and Crawford (17) attached a great deal of importance on the impact that food has on their current looks, weight, appearance, and energy compared to the importance that they placed on the prevention of future illness or complications.On the other hand, another study (12) demonstrated that students were aware of the seriousness of obesity to a certain extent; however, there was no difference in knowledge of obesity between normal-weight and obese students.
It was also found that most of the information concerning nutrition was obtained through the media; school education about food and nutrition only amounted to 28.3% of the total. (10)reover, in a study done in USA, (18) it was noticed that medical school curricula do not address obesity as a disease.It was suggested that medical school curricula should be changed to reflect the growing epidemic of obesity and enhance students' knowledge about obesity as a disease.The Bull High Inst Public Health Vol.38 No. 3 [2008]   present study also portrayed that female students had significantly better knowledge about obesity than males (tables 3 and 7).
This may be explained by the desire of females to be lesser in weight than males; hence they are trying to get more knowledge about obesity.This was also previously found, (10) where girls expressed the desire to be thinner four times more than boys and practiced weight reduction diets three times more than them.This is also consistent with the present study, where females showed a significantly higher level of practicing weight reduction than males (figure 5).On the other hand, Kim et al., (12) found no significant difference between knowledge level of obesity in either boys or girls.Another socio-demographic variable which was found to be significantly associated with student's better knowledge about obesity in the present study, both in the univariate and multivariate analyses is the higher education of the mother (tables 3 and 7).
Different studies, (19,20) have found a significant association between lower education of the mother and higher prevalence of obesity among children.
Moreover, mother education was the only independent predictor of the attitude of the students towards obesity in the present study (table 7).Researches suggest that parents are still considered by children and adolescents to be the gate keepers of the family food supply and that parents act as important role models for children's eating behaviors. (21,22)esearchers in diverse disciplines have noted that more educated persons are more aware of health risks and more likely to initiate actions to reduce these risks. (23)The present study also demonstrated that more than half of the students had a positive attitude towards obesity and its treatment (figure 3) and considers it as a disease (table 4).It also revealed that there was no significant gender difference regarding this attitude towards obesity (figure 4).In another study, (10) it was observed that 31% of the students regarded obesity as a handicap.
On the other hand, a study done in Jamaica (24) revealed that most of the students who participated in the focus group sessions did not think of obesity as a nutritional disease, but rather regarded it as a sign of wealth, good living, or access to an abundance of food.Socio-economic and cultural factors may explain difference of the student's believes in the last study.
The present study also showed that 58.5% of students consider themselves overweight or obese.This is much higher than the actual prevalence of overweight and obesity (38.9%) as measured in the first part of this study. (25)This was also found by Brook and Tepper, (10) where forty-  6).This was also previously found in Jamica, (24) where students' knowledge about the causes of obesity and prevention measures were not very consistent with their dietary patterns.
Also in Korea, (12) there was no relationship between knowledge of obesity and healthy eating habits or the presence or absence of regular exercises.This may be due to the general perception that obesity is difficult to be managed.The present study also demonstrated that near to half of the Bull High Inst Public Health Vol.38 No. 3 [2008]   students (47.3%) didn't agree that obesity is easy to be treated (table 4).Also, it showed that the main barriers for not practicing weight reduction methods among the students were lack of knowledge, lack of time, and lack of interest (table 6).These cross sectional study was carried out in private secondary schools in Dubai.The private sector was chosen because the Department of Health and Medical Services supervises only private schools.However the private schools include all social categories (high and low) & national and international schools.A Multistage stratified random sample with equal allocations was carried out.The stratification was based upon region (Bur Dubai, Deira; the two main geographic areas of Dubai), gender (males, females) and spoken language in schools (Arabic & English).The total number of the school was 20.One class from each grade of education was selected randomly and all the students were invited to participate in the study, the sample amounted to 1186 students (as calculated using the computer program EPI-INFO version "6.04" and mentioned in the first part of this research).Most of the students were non-local and this represents approximately the actual distribution within the community.
Figure(5):Percent distribution of secondary school students according to practice of weight reduction and sex three barriers were tackled by The WAY program (27) which was offered by the Institute for America's Health (IAH).Under the program, teachers let students take 10minute daily breaks to exercise along with a videotaped program.There were also incorporated lessons on nutrition, calories, goal setting and stress management into core subject areas -math, language arts, science, and social studies.Resources also provided for parents to participate in efforts to encourage the students in life-long healthy behaviors.Teachers and parents reported positive shifts in students' lunch and snack choices, eating habits at home and physical activity rate at and outside school within two weeks of beginning the WAY program.CONCLUSION AND RECOMMENDATIONS It could be concluded that knowledge of the secondary school students in Dubai about obesity and its complications is insufficient.Female gender and higher education of the mother were independent predictors of good knowledge about obesity, while only higher education of the mother was an independent predictor for student's positive attitude towards obesity and its treatment.The majority of the students perceived themselves as overweight or obese, had a positive attitude towards obesity but did not do any practice towards reduction of their weight.The most common barriers against practicing weight reduction were lack of knowledge, time, and interest.It is recommended to utilize the mass media to enhance the level of community knowledge about obesity, its complications, and methods to combat it.Health education materials about obesity which is simple, self explanatory, and culturally oriented to be suitable for those with lower educational level should be delivered to present and future mothers in any site of contacts like health centers, workplaces, and shopping centers.School health programs should include interventions to improve knowledge, attitude, and practice of the students towards obesity.Such programmes should include health education about obesity, sound dietary habits, increase supervised physical education and physical exercise sessions, competition and prizes, and active involvement of teachers and parents.

Table ( 1): Distribution of the secondary school students according to socio-demographic characteristics
•

Table ( 3): Mean knowledge score of secondary school students in relation to socio-demographic data
• The level of education was not recorded for 18 mothers.* P <0.05  Significantly different from those of preparatory or secondary educated mothers.

Table ( 5): Mean attitude score of secondary school students according to sociodemographic data
• The level of education was not recorded for 18 mothers.* P <0.05 º Statistically significant different from illiterate/read & write or primary