Introduction
Childhood obesity remains a significant burden globally due to its high prevalence [30]. Obesity in children below five years of age exceed 40 million [30, 2] and those older than 5 years and adolescents has reached over 330 million [30]. The global challenge posed by obesity has prompted the World Health Organization to start a campaign called “no increase in childhood overweight by 2025” [31]. The initiative targets prevention of diseases associated with childhood obesity [8, 30]. The short-term effects of obesity in children include psychological conditions such as low self-esteem, anxiety, depression, and liver complications [32]. Furthermore, the potential long-term effects include heart diseases, type 2 diabetes, and some types of cancer [30]. The risks of these illnesses progress into adulthood and may cause premature deaths or musculoskeletal deformities [8, 19]. Therefore, curbing obesity prevalence is crucial in reducing the incidences of numerous chronic illnesses in adulthood.
The Middle East is one of the regions with high obesity prevalence globally [5]. In United Arab Emirates (UAE), an alarming upsurge has been observed in most schools [20]. Notably, in the last two decades, the overweight and obesity cases have increased by two folds in students aged 11 to 18 years [33]. The prevalence has dramatically escalated from 21.2-21.7% to 35.6-42.1% nationwide [20]. Moreover, studies indicate that the annual increase in childhood obesity countrywide is 2.36% in children and adolescents aged 3 to 18 years [3, 34, 35]. Furthermore, several studies have reported a high prevalence of childhood obesity in UAE students [3, 34, 35]. Bani-Issa et al. [5] revealed that the obesity prevalence in UAE schools is 34.7%. In Ras Al‐Khaimah public schools, students aged 11-18 years had a prevalence of 38-41.2 % [3]. Similarly, Pengpid and Peltzer [20] suggested that in students aged 8 to 14 years in UAE schools, the obesity prevalence in males (42.1%) was considerably higher compared to females (35.6%). Therefore, it is crucial to develop effective strategies for reducing childhood obesity in UAE.
Parents are instrumental in promoting healthy eating and dietary practices in children [36]. Moreover, they are the key determinants of the nutritional status of children and adolescents [4]. Parents’ knowledge and attitude towards healthy eating influence their food selection, meal pattern, and level of physical activity (6). Eventually, parent’s their food choices impact the children’s weight and nutritional status [13, 7]. Moreover, studies suggest that including parents in the prevention strategies can substantially improve the weight of their obese children [36, 6, 8]. Previous research identified obesity risk factors in children to include high consumption of fast foods and sugar, low intake of fruit and vegetable, sedentary lifestyle, as well as eating large portions of foods [4, 15]. Although there is a consensus globally that prevention is a crucial strategy of reducing the incidences, limited success has been achieved so far in implementing this approach in students alone [37]. Parents play a critical role in influencing the dietary habits of children in their early years [13, 9]. However, the suitable strategies for supporting parents in improving their children’s nutritional status remain unclear. Nonetheless, seeking parents’ opinion on how to promote healthy eating and exploring their attitude towards their children’s eating behavior and physical activity is crucial in developing effective prevention strategies [13, 4, 2].
This study explored views of parents on factors that contribute to childhood obesity and sought their suggestions on possible ways of overcoming barriers to weight management and healthy lifestyle.
Methods
Study Design
The research was a qualitative study involving in-depth interviews with parents of 9–13-year-old children with obesity who were attending government schools in Sharjah and Dubai, UAE. A qualitative research method was deemed to be most appropriate in studying parents’ perspectives on childhood obesity (opinions experiences, and suggestions) allowing themes to emerge. The parents were invited to obtain their views on factors that contribute to childhood obesity and sought their suggestions on possible ways of overcoming the barriers to weight management and adoption of healthy lifestyle among school children. The study was conducted to use the results in assisting the development of a planned intervention for overweight and obese 9-13-year-old children in Dubai and Sharjah.
Data was from September to November 2021.
Participants
The participants were parents of 19- to 13-year-old children with obesity attending public schools in the emirates of Dubai and Sharjah in the United Arab Emirates. Purposive sampling technique was used to recruit parents of 9-13 school children with obesity whose children were attending public schools in Dubai and Sharjah. Purpose sampling allows selection of participants based on predetermined criteria relevant to a particular research question (Huberman & Miles, 1994). The basis of sample size determination was data saturation. All eligible parents were contacted through emails explaining the purpose of the study and the main topics that will be discussed during the interview. They were invited to attend a single in-depth individual interview. Those interested were asked to confirm their willingness to participate by responding to the email and choosing their available date and time for the interview. Attached on the email was the consent form of which the participants were give verbal consent at the start of the interview.
Of those contacted, 35 parents accepted to participate in the interviews. However, after 26 interviews, data saturation was achieved, and the process of data collection was stopped.
Semi-Structured Interviews
A semi-structured interview guide (Supplementary Material: S1) was developed as a guide during the interview process. It contained questions 13 key questions focusing on three main areas: (1) the perception of the parents regarding their children’s weight and eating habits, (2) their attitude towards healthy eating and weight management through nutritional interventions, and lastly, (3) their suggestions on how the parents and the school administration can support the children in adopting a healthy eating pattern and effective weight management. The research team consisting of nutritionist and university faculty member developed 13 questions guided by related literature [9, 18, 26, 27]. Prior to initiating data collection, the interview guide was translated to Arabic and subjected to content validation [7]. It was subsequently pilot-tested with 6 parents of children aged 9-13 years with obesity (three females and three males). Necessary modifications to the questions before use for the study were made accordingly.
The interviews were conducted in Arabic over the phone which was their preference using the Arabic. Interview duration ranged between 45-60 minutes including the time used to explain the purpose of the interview. Additional probing questions were used to seek further information or clarifications when needed. All the interviews were collected by a native Arabic-speaking senior nutritionist trained to collect qualitative research data collection. All discussions were audio-recorded. At the beginning of each interview the interviewer obtained participants verbal consent, explained the purpose of the study and assured the participant the confidentiality of the discussions. The participants were also informed that they have the right not answer any question they do not want to answer or discontinue the interview at any time. In addition, they were assured that all the information collected will remain confidential and will be used only to meet the purpose of the study. The interview recordings were used to transcribe the discussions verbatim in Arabic. The transcripts were transcribed into English by the interviewer so that text-based analysis can be performed using the NVIVO software (NVIVO, 12, QSR International). Throughout data collection, the interviewer was reflecting on the interview guide and on her attitude during interviews in efforts to reduce interviewer bias [22, 29].
Table 1: Sample questions included within the parents’ interview guide
Data Analysis
Translated interview transcripts were imported into NVIVO 12 (NVIVO) to conduct the thematic analysis and facilitate the development of the codes using an inductive approach [6]. The constant comparison method [24] was used to identify recurring data, create categories, systematically compare them, and group them into themes. As the interviews progressed, data was analyzed (i.e., concurrent) and the interview questions refined with additional probes in line with the qualitative research methodology [21].
The codes were constantly compared and then grouped into categories/subthemes, which were later also grouped into themes. The NVIVO software was also used to determine interrelationships of themes and sub-themes, for example how multiple facilitators and barriers reported by the parents are affecting the children’s eating habits and consequently their body weight. The coding was performed by the first author (SZ) and coding assignment and appropriateness to the assigned themes and sub-themes was reviewed by the third author (HIA) who has extensive background in qualitative research (HIA). Any inconsistencies were resolved through discussion to reach a consensus.
Quality Assurance
Multiple approaches were employed to enhance the quality of the research. The equivalency of the Arabic transcriptions and English translations Arabic were checked by two in-dependent reviewers fluent in both Arabic and English. In addition, 15 recorded interviews were sent to external reviewer along with the translated transcript to check the consistency of the English translation against the Arabic recordings.
Finally, the translated summary of the interviews was sent to six parents who were fluent in English to confirm the accuracy of the translated text. Participant quotes that support the emerged themes and sub-themes are presented in the Results section.
To enhance credibility, the interviews were recorded, transcribed verbatim in Arabic. The interview transcripts were shared with the participants to confirm the accuracy and the English translation of the text underwent independent reviews.
Ethical considerations: The ethical approval for the study was obtained from the United Arab Emirates University Social Sciences Ethics (protocol number: ERSC_2022_744). All procedures were following the principles of the Declaration of Helsinki. Notably, the consent of the participants was obtained by first sending consent forms through the email and later verbal consent at the start of the interview.
Results
A total of 26 parents participated in the individual interviews. The majority of whom were females (88%). All interviewed parents were Emiratis, and the vast majority were working (92%). Only two interviewed parents reported being separated from their partners (8%). Table X below presents the demographic information of interviewed parents.
Table 2: Demographic information of interviewed parents
Results of the thematic analysis of conducted in-depth interviews transcripts identified 3 main themes: (1) Negative effects of obesity on children’s lives; (2) Barriers to weight management and healthy lifestyle, and (3) Facilitators to healthy lifestyle. There were 8 related subthemes related to the 3 major themes (Table 3). The themes are categorized into three groups, namely Individual/intrapersonal (child), interpersonal (peers, family, maids, etc.) and institutional/School environment)
Table 3: themes and sub-themes
Theme 1: Negative Effect of Obesity on Children’s Lives
Being overweight has various negative effects on children’s lives at the physical and psycho-social levels, as mentioned by interviewed parents. It was expressed that their children’s weight affects their ability to play with friends. One of the interviewees, a male father of an overweight child, stated: “My child’s weight is greatly affecting his life. He wishes he could run with his friends and ride a bike, but he can’t because of his weight.”
Individual/intrapersonal issues
Parents mentioned that obesity results in social isolation of children which can be attribute to an intrapersonal barrier of low self-esteem. Due to the presence of stereotypes concerning weight, children with obesity tend to develop self-esteem issues, thus, choosing to abstain from communicating with others. It leads to limited interactions with peers which negatively impacts the child’s development of social skills and adoption of healthy lifestyle. The mother of one of the children commented: “His weight stops him from playing with other kids, which means his social skills will not develop over time; and for sure, this will affect his psychological well-being. Therefore, he will not be motivated to achieve his goals.”
Interpersonal issues
In addition, similar social isolation can be caused by bullying from peers, as another woman points out: “He is being bullied at school and among his friends because of his extra weight, and this is what makes him hate going to school and hate studying and playing with his friends.” Some parents mentioned that their children’s weight is not affecting their children’s lives now. However, they expressed concern about their prospects: “While my child is a little bit overweight for his age, I believe his weight does not stop him from achieving his goals at the moment, but in the future, it may become a major limitation”. Therefore, peer pressure and bullying can be seen as major interpersonal barriers.
Institutional/School environment issues
Finally, one should mention the lack of support from educators in addressing the needs of children with obesity issues. While the parents acknowledged the need for exercise in the lives of their children, they noted that the children lacked the motivation to exercise due to obesity. The observed trend translates into children’s unwillingness to participate in PE, which is not addressed by teachers adequately. The weight gain has seriously affected the self-esteem of their children making them to socially isolate. One parent said, “My daughter hates any activity that is physical. Even with peers around, she would rather sit and play with her tablet than go running around with her peers. Due to their heavy weight, they are not as flexible as their peers making them feel different”. As another parent noted, most of the physical activity for children that age is mainly from play with peers: “It is impossible to make my child exercise, he’s only active around other kids.”
Theme 2: Barriers to a Healthy Lifestyle
During the interviews, parents discussed and highlighted various perceived barriers hindering their children from eating healthy and enjoying a healthy lifestyle which eventually caused them to unwanted weight gain. Barriers are described in this study as factors that make weight loss or sustaining a healthy lifestyle difficult for the children aged 9-13 years. The discussed barriers are segregated to three categories: Individual/intrapersonal (child), interpersonal (peers, family, maids) and institutional/School environment)
Individual/intrapersonal barriers
For the purpose of this study, individual/intrapersonal barriers are considered to be all barriers existing within the child. These barriers were reflected in the following sub-themes: (1) Sedentary lifestyle, (2) Personal food choices, (3) Lack of motivation to exercise and (4) low nutrition knowledge
Sedentary lifestyle
With the emergence of COVID-19, children had to stay at home and study there for long periods. It also drastically reduced their time out and their activities with their friends, hence, reducing their physical activities. As one of the mothers commented on her son’s behavior, “His weight is constantly increasing. He is less mobile due to sitting in front of the computer for long periods because of remote education”. In addition, parents discussed their concerns about their children’s preference to stay at home and engage in social media and video games: “I believe that the main reason my child is overweight is that he does not move enough, and his only activities involve watching TV and sitting in front of the computer.”
Personal food choices
Children’s tendency to love fast/junk and pre-prepared foods and their preference for some food items over others also influence their lifestyle. Parents reported that their children prefer fast foods over more healthy dishes. Moreover, some said that their children are not willing to decrease their consumption of unhealthy meals:
“His love for food that is full of calories, flavors, and harmful juices is the main issue. Most of the time, he refuses to eat healthy snacks.” The other personal barrier the parents revealed was the unwillingness of their children to reduce the consumption of unhealthy snacking. One of the parents pointed out that their children excessively love breakfast consisting of junk food: “He loves breakfast with biscuits and chips and loves to eat noodles and pastries daily”.
Low nutritional knowledge
The lack of a credible source continuously disseminating nutrition and food-related information hinders establishing healthy nutrition practices. Parents mentioned their need for credible sources of nutrition information: “I believe that my son’s lack of knowledge on how certain foods have to be consumed in moderation is the main problem that causes him to have such big portions of snacks that he consumes almost daily. More accessible knowledge about healthy eating could help to encourage children to eat more healthy food”.
Interpersonal barriers
For the purpose of this study, interpersonal (peers, family, maids) barriers are considered to be the factors that stem outside the child which include relationship with parents, family, maids and others. These external barriers were reflected in the following sub-themes: (1) Perceived bad influence of peers and social media, (2) Parent’s role in children’s lives and (3) Nannies engagement.
Perceived bad influence of peers and social media
The parents identified peers as the other critical areas of concern. One of the parents revealed that some children may tend to eat unhealthy foods when they are in the company of their friends: “My son often drinks sodas when he is with friends.” Moreover, the option of controlling what their children eat in the company of their friends elicited mixed reactions. Some of them admitted talking to the parents of the other children to discourage the unhealthy habits, whereas some were reluctant. Some parents also revealed that healthy traditional meals are rarely showcased on social media compared to unhealthy ones and attributed them to unhealthy eating habits. A mother of a slightly overweight child stated: “As I noted earlier, his sudden obsession with fast food is the main factor affecting his weight. Perhaps this new eating habit was influenced by the social media that and his school fellows.”
Limited parent engagement in healthy lifestyle: Parents’ pre-occupation with their jobs and careers, especially mothers, negatively affected the children’s healthy eating habits and, in some cases, gave them the chance to eat whatever they wanted without proper monitoring. An illustration of this is the statement of the father of one of the children: “I think that the fact our son is almost fully responsible for what he eats, and we cannot monitor him, is the main factor why he cannot control his portion sizes and the types of products he consumes.” Moreover, the majority of parents mentioned that their busy and demanding work schedule results in their inability to cook healthy food, feed their children healthy food or monitor their children’s eating habits and food portions. The mother of one of the children noted: “Since I am a working mother, I do not have much time to cook healthy meals daily. Most of our meals consist of frozen food or food filled with starchy foods such as rice and pasta, in addition to our heavy reliance on takeaway.”
Parents’ unhealthy eating habits were also identified among the underlying factors of children’s unhealthy eating patterns. One mother commented on her son’s behavior: “During the weekends, we often go out to fast-food restaurants or order food at home, so he sees me engaging in similarly bad dietary behavior. I believe that the fact that his dad and I have never been preoccupied with healthy eating has negatively influenced my child’s own eating preferences and led to his weight gain.” In addition, parents identified that buying their children sweets and sweetened juices and keeping these products at home is also one of the internal barriers hindering their children’s ability to have a healthy lifestyle.
Nanny’s engagement
The engagements of the nannies in children’s everyday life might affect their healthy lifestyles. According to some mothers, the nanny might be less strict with children than parents: “…The nanny usually gives him anything just to keep him quiet and safe, so he picked this habit of having whatever he desires without any restrictions. This behavior allows nannies to keep the child in a positive mood but significantly affects their eating habits”.
Institutional/School environment barriers
For the purpose of this study, institutional/School environment barriers are factors that originate from the school environment which limit healthy lifestyle or healthy weight maintenance among children aged 9-13 years old. The subthemes identified for this category include (1) Lack of nutrition education in schools and (2) School demands lead to stress eating and lack of time for physical activities
Lack of nutrition education in schools
Most parents noted that the children are not taught nutrition education in school. The school curriculum does not specifically focus on the need for healthy eating habits and how to achieve them. Parents cited that most of the children are not able to use the knowledge acquired in school in general science classes as they do not connect it to their daily lives. As stated by one parent, “My son knows different food categories and their functions but still cannot use it to control his food portion. The knowledge is too abstract.”
School demands lead to stress eating and lack of time for physical activities
The busy schedules in school and demand that school has on the children create anxiety for most students. One of the parents said, “My daughter instead of losing weight, gains more weight due to the stress of schoolwork. She tends to eat a lot of snacks when she comes from school and does not control her portions.” Another parent noted that her son comes home with a lot of homework he does not find time for physical activity or exercise: “Nowadays, teachers demand more from kids and the amount of homework is mind-blowing. My kid goes to school to study, then comes back to study even more. He doesn’t have any time for exercise.”
Identified Facilitators for a Healthy Lifestyle
Throughout the interviews, parents mentioned and discussed various perceived facilitators (enablers) that might affect positively their children’s attitudes and behaviors toward a healthy lifestyle. These facilitators are presented in three categories: intrapersonal, interpersonal and institutional facilitators
Intrapersonal facilitators: For the purpose of this study, intrapersonal facilitators are to be considered all the factors that children can do to optimize their healthy lifestyle. These facilitators were reflected in the following sub-themes: (1) Motivation to engage in physical exercise and (2) Healthy eating behaviors
Motivation to engage in physical exercise
Intrinsic motivation is an important facilitator of healthy lifestyle. Parents have reported that the children lose more weight when they are self-driven than when being pushed. Taking personal responsibility for their health makes the children to engage in physical exercise. Additionally, with motivation, they are not easily discouraged when things are difficult and the goal is not achieved instantly. As reported by one parent, her son had shown significant improvement when he was enthusiastic in the physical activities.
Healthy eating behaviors
Healthy eating habits are identified as one of the facilitators of healthy lifestyles. As reported by parents the healthy eating habits include eating patterns such as food portion control and food substitution. One of the parents accentuated that substituting healthy snacks like fruits and vegetables with refined sugar is important in weight loss and control journey. The parent commented that “sugar is essential for young children, yet candy with harmful ingredients can easily be replaced with fruits or foods cooked with organic ingredients.” The parents noted that despite it being hard for children to practice healthy eating behavior, once they acknowledge the importance, they can stick to it. According to the parents, “the children can learn the importance of healthy eating by watching documentaries or learning how the junk food is made.”
Interpersonal Facilitators
For the purpose of this study, interpersonal facilitators are to be considered all the factors that encourage and optimize children’s healthy lifestyles that are outside the control of the children. These interpersonal facilitators were reflected in the following sub-themes: (1) Parents’ perception of and knowledge about the importance of following a healthy and diversified diet (2) Parents positive attitude towards being engaged in the change and
(3) Advise from a Specialist.
Parents’ perception of and knowledge about the importance of following a healthy and diversified diet
Parents discussed their knowledge about the benefits of following a healthy lifestyle and highlighted their perception of the importance of adopting a healthy lifestyle for their children’s health in the future as adults. One of the mothers stated: “Nutritional and health fields are very important as they are responsible for our psychological and nutritional health. If our food is healthy, we will be in the best physical and psychological health.”
Parents’ positive attitude towards being engaged in the change
The parents expressed their positive attitude toward being involved with their children to be within their journey toward a healthy lifestyle. They mentioned being ready to change their eating habits to influence their children to positively change their unhealthy eating habits. One of the mothers also expressed their willingness to cook healthy food weekly for their children: “I can adopt a new healthy food plan by encouraging my son to eat food full of healthy vegetables and vitamins by buying an air fryer to cook with.”
In addition, parents mentioned that they are ready to engage with their children in conversations about healthy food and the importance of following healthy eating habits and a healthy lifestyle. As one of the parents noted, “the health of my child is really important to me and if it takes a great effort to help them understand the importance of healthy food, I am ready to engage in this process.” They further mentioned establishing a reward system for their children whenever they eat healthy foods: “I can support my child by making healthy meals for him consisting of fruits and vegetables, beautifully decorating them, and giving him material rewards when he eats healthy food”. Furthermore, parents expressed readiness to stop buying their children unhealthy snacks and bring home more fruits and vegetables. “I am a working mom who unfortunately doesn’t have much free time. For a long time, I chose the food that could be cooked in under an hour. However, now I realize how unhealthy this food is, which made me consider buying more fruits and vegetables.”
Advice from a specialist
Interviewed parents highlighted that receiving advice from a specialist would significantly impact their and their children’s eating habits and encourage them to have a healthy lifestyle. One of the fathers stated: “Having a specialist’s advice will contribute to educating my child about the importance of eating healthy and the ways to build a balanced meal plan.”
Institutional Facilitators
Potential involvement of the Emirates School Foundation
The parents suggested several ways the school management can follow to support the children’s journey toward a healthy lifestyle. One of the mothers suggested raising awareness: “The foundation can participate by publishing awareness campaigns in schools with the aim of reinforcing the conviction of children about the importance of healthy meals for their physical health.” Another suggestion included the provision of nutrition information in the school curriculum: “The foundation can add study materials and courses of a nutrition curriculum that will be designed for school students, teaching them about healthy food and encouraging them to eat it, especially from young ages such as kindergarten students. Thus, the child will grow up with healthy habits since childhood.”
According to parents, being overweight affects their children’s lives in various ways. It had negative effects on their children’s ability to play with friends; children’s social inclusion; and children’s health in the future.
Discussion
The issue of obesity exists in many countries, which necessitates the government to take actions. Multiple studies indicate that childhood obesity cases are highly prevalent in UAE [20]. Moreover, the number of obese school children has increased exponentially in the last two decades [1, 5, 3]. Furthermore, several studies have suggested that parents play a critical role in influencing their children’s nutritional [11]. In the present study, qualitative research involving in-depth individual interviews was used to explore parents’ perception on factors that contribute to childhood obesity and their suggestions for healthy lifestyle for prevention and management of overweight and obesity among school children. This method was considered the most appropriate in exploring and determining the attitude of parents towards healthy eating, and their perception of their children’s weight and nutritional status [25]. In addition, this method facilitated capturing parents’ recommendations and suggestions [25] on ways the parents, the school administration and specialists can support school children in adopting healthy eating habits.
Overall, the results of the analysis indicate that childhood obesity continues to be a major public health issue. Furthermore, the themes identified in the course of the analysis prove the necessity to involve parents actively in shaping the approach toward building a healthier lifestyle for their children. Specifically, unique nutritional requirements for each child must be integrated into the general nutritional plan for a school, therefore, providing the foundation for managing the issue directly. Furthermore, the efforts undertaken by the school must be aligned with the approaches that parents implement in order to keep the child healthy [25]. Specifically, the dieting options and food choices provided to the child at school must be correlated to those that the child receives at home, which is why active collaboration between schools and parents is required.
Conceptual Framework
Based on the initial results of the study, a preliminary conceptual framework based on the Social Ecological Model (SEM) [30] was developed. This framework focusses on 3 of the key elements of the SEM (individual level, interpersonal level and institutional/organizational level. The conceptual framework was continuously updated and expanded throughout the study and based on the findings of the study to better reflect emerging themes and sub-themes and their interrelationships.
The parents identified various factors that can affect school children adoption of healthy eating and regular physical activity (healthy lifestyle). Some of these factors were barriers to the children’s ability to live a healthy lifestyle and others were facilitators enabling children towards a healthier one. These factors act at the intrapersonal, interpersonal and institutional levels. The negative effects of the barriers from the three levels resulted children to adopt an unhealthy lifestyle and become overweight. The parents’ lack of engagement compounded by the negative effects of other interpersonal barriers (nannies and influence from peers and social media) lead to their children’s personal choices favoring energy-dense foods (s such as fast food and sweets). It also contributed to eating while playing video games and TV which leads to their lack of mindful eating. The parent also mentioned limited nutrition education in the school curriculum and physical activities while in the school has also contributed to unhealthy lifestyle of their children
The parents cited a number of negative effects of obesity on their children. These included how their children’s weights prevented them from engaging in physical activities and playing with other children. They also identified excess weight as a major obstacle to the development of their children’s social skills and psychological wellbeing. Moreover, some of the parents stated that their children faced bullying due to their body weight in the school, whereas some parents expressed fears of future physical and psychosocial implications of obesity on their children’s lives.
However, most of them did not mention the health risks associated with childhood obesity. The parents acknowledged that their busy schedule at work has adversely affected their children’s eating habits. Their demanding work schedules do not permit them to cook healthy meals at home; hence, they mostly rely on fast foods and cannot monitor their children’s eating habits. Moreover, the children are usually left under the care of nannies who provide them with whatever food they desire to eat. The findings corroborated Vittrup and McClure [28], who revealed that the key barrier to childhood obesity weight management is lack of time by parents. Furthermore, the study revealed that the parents lacked knowledge on portion sizes, healthy foods and health risks of childhood obesity. Importantly, Garzay [12] examined the perception of nannies towards children’s eating habits. Most of them indicated that the parents were the key determinants of their children’s eating habits. Additionally, they engaged the children in poor feeding habits due to limited nutritional knowledge. The researchers recommended provision of nutritional education for nannies to improve the children’s nutritional status.
The participants discussed negative influence from peers and social media, low nutrition knowledge, and sedentary lifestyle as some of the barriers. The findings were consistent with Ragelienė and Grønhøj [23], who found that family, peers and social media influence children’s eating behavior. Therefore, positive role modeling from parents, nannies and peers has the potential to promote healthy eating behaviors in children.
On the other hand, as mentioned by the parents a number of facilitators that can play an important role in helping their children to shift into a healthier lifestyle and overcome being overweight. These factors were mainly related to parents’ engagement and external factors. The parents have a perception and knowledge about the negative effect of being overweight and having an unhealthy lifestyle. In addition, parents mentioned that having proper awareness from the school management, and support from health and nutrition specialists would also help them and their children.
Creating parental concern through knowledge of obesity health risks was previously identified as key in controlling childhood obesity [17]. Moore and colleagues [17] found that concerned parents were more likely to initiate a healthy lifestyle in their children compared to the ones that were not concerned. Aljunaibi et al. [4] evaluated parental perceptions of school children in the UAE and found 63.5% of parents of overweight /obese children misclassified their children’s body weight status. The study suggested for parents recognize the challenges associated with childhood obesity, they will actively participate in managing the weight of their children. These findings are consistent with Etelson et al. [11], who reported that parents of overweight children mostly had inaccurate perceptions regarding their children’s weight. Therefore, creating more awareness on the potential adverse effects of obesity on health would contribute to efforts to reduce childhood obesity in UAE.
At the institutional (school level), parent s suggested that the administration for schools and experts promote a healthy lifestyle in their children. Overall, the suggestions provided by the parents were insightful and consistent with those previously reported in other studies. El-Sabban [10] suggested that children’s nutrition and general health require the support of parents, teachers, school administrators, nannies, and other directly or indirectly involved parties. Hinojosa et al. [14] revealed that modification of the school environment is crucial in childhood obesity weight management. The institutions can incorporate more programs that involve nutritional education and physical activities. Additionally, surveillance programs can be initiated in public schools to identify the students who are obese. Subsequently, they can be supported through various nutritional interventions.
Strengths and Limitations
A major strength of this study is that it is the first study that explored opinions of parents on factors affecting factors affecting adoption of healthy weights among school children with obesity in the UAE. The qualitative research methodology used in this study limits the ability to generalize the findings to parents with obesity in the UAE. The sample consisted of a small sample of parents who were motivated to attend the interviews and discuss their children’s eating habits and issues affecting their weights. However, data saturation was reached in line with qualitative research and thus the sample is considered sufficient to explore the topic.
The major limitation of the study is generalizations cannot be made since the sampling criteria was self-selection. Notably, some parents chose not to attend the interviews. Although only 26 parents participated in the interviews, data saturation was attained.
Conclusions and Recommendations
Obesity and lack of exercise among children remains one of the issues in modern society. The findings of this study facilitate development of future studies focusing on childhood obesity prevention and management. The barriers of healthy lifestyle identified by parents can be addressed through the recommendations, including: (1) Collaborative programs of nutritional education targeting the parents and children can be developed by relevant government agencies to support the children in adopting a healthy lifestyle; (2) Implementing training programs for nannies to enhance their nutritional knowledge. They can be trained on how to support the children in adopting a healthy lifestyle, especially in instances where the parents are busy at work. This can be achieved through collaborative efforts between relevant government institutions can improve access to nutrition specialists for families, including the nannies. Additionally, awareness campaigns can be initiated through television commercials and social media to counter the negative influence.
Furthermore, there is a need to implement more opportunities for students to be physically active at school. Additionally, surveillance programs to identify students at risk for obesity and intervening at an earlier stage must be developed. Addressing the negative peer influence from interpersonal category by implementing nutrition awareness programs in communities and the formation of social support groups to help students with obesity is vital as well.
The parents who participated in this study helped identify a number of barriers to children to adopt healthy lifestyles, including busy work schedules of the parents, they did not mention long term health risks associated with childhood obesity. Therefore, including more information on the health risks associated with the disease in the awareness campaigns will improve the support from parents. Additionally, increasing awareness on the benefits of healthy eating on social media and television can potentially counter the negative influence. Furthermore, positive influence from peers in school can promoted by including nutritional knowledge in the school curriculum. A collaborative effort from public health institutions and the school system can implement education resources for school children, parents. Moreover, public health entities and schools can consider the suggestions from parents and formulate policies designed to curtail the prevalence of childhood obesity in UAE.
As the conceptual framework derived from the interviews with parents reflects the identified barriers having negatively impacting the children’s healthy lifestyle and body and are contributing to obesity. Therefore, a focus on the facilitators and their implementation has the potential for adoption of healthy lifestyles and effective weight management among school children in the UAE.
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