PREVALENCE OF OBESITY AND ASSOCIATED FACTORS AMONG CHILDREN (3-6
YEARS).
A COMPARATIVE STUDY OF URBAN AND PERI-URBAN MOMBASA, KENYA
BY:
CAROLYNE NEKESA WALUCHIO (BSC.FOND)
REG NUMBER: A56/67371/2013
A RESEARCH PROPORSAL SUBMITTED IN PARTIAL FULFILMENT OF THE
REQUIREMENT FOR THE
DEGREE OF MASTER OF SCIENCE IN APPLIED HUMAN NUTRITION OF THE
UNIVERSITY OF NAIROBI
DEPARTMENT OF FOOD SCIENCE,NUTRITION AND TECHNOLOGY
2014
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Supervisors
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 Professor J.K Imungi
 Dr. George Abong Ooko
 Dr. Cathrine Macharia Mutie
TABLE OF CONTENT
3
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DECLARATION……………………………………………………………………………………………… ii
TABLE OF CONTENT……………………………………………………………………………………… iii
LIST OF ABBREVIATIONS………………………………………………………………………………. v
OPERATIONAL DEFINITIONS………………………………………………………………………….vii
CHAPTER ONE: INTRODUCTION……………………………………………………………………. .1
1.1 Background Information………………………………………………………………………………. 1
1.2 Statement of the Problem ……………………………………………………………………………. 5
1.3 Justification……………………………………………………………………………………………… 6
1.4 Aim……………………………………………………………………………………………………………. 7
1.5 Purpose……………………………………………………………………………………………………… 8
1.6 Objectives of the Study………………………………………………………………………………… 8
1.6.1 General objective………………………………………………………………………………………. 8
1.6.2 Specific objectives…………………………………………………………………………………….. 8
1.6.3 Research questions…………………………………………………………………………………… 8
1.7 Hypotheses…………………………………………………………………………………………………. 9
1.7.1Null Hypotheses………………………………………………………………………………………… 9
1.8Assumptions and Limitations……………………………………………………………………….. 9
1.9 Benefits (For Nations, Study Community, Researchers)………………………………….. 9
2.0 CHAPTER TWO: LITERATURE REVIEW
4
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2.1 Definition of Overweight and Obesity…………………. 10
2.2 Current status of Overweight and Obesity…………… 11
2.3 Health consequences of Overweight and Obesity…. 14
2.4 Predisposing factors of Overweight and Obesity….. 15
2.4.1 Dietary factors……………………………………………….. 16
2.4.2 Environmental factors……………………………………. 17
2.4.3 Cultural and Societal factors…………………………… 18
2.4.4 Television and advertising……………………………….18
2.4.5 Physical activity…………………………………………….. 19
2.4.6 Genetic Factors……………………………………………… 19
2.5 Assessment of overweight and obesity………………… 21
2.6 Gaps in Knowledge…………………………………………… 23
CHAPTER THREE: RESEARCH DESIGN
AND METHODOLOGY
5
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3.1 Research Design………………………………………………………........... 25
3.2 Research Methodology………………………………………………………. 25
3.2.1 Study site………………………………………………………………………. 25
3.2.1.1 Location and size…………………………………………………………. 25
3.2.1.2 Physical and topographic features…………………………………. 25
3.2.1.3 Ecological conditions…………………………………………………… 26
3.2.1.4 Climatic conditions……………………………………………………… 26
3.2.1.5 Administrative units……………………………………………………. 27
3.2.1.6 Pre-school education……………………………………………………. 28
3.2.1.7 Health care………………………………………………………………….. 28
3.2.2 Study Population……………………………………………………………. 28
3.3 Sampling Frame…………………………………………………………………29
3.3.1 Sampling procedures………………………………………………………. 29
3.3.2 Sample size determination………………………………………………. 30
6
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3.4 Data Collection………………………………………………………… 30
3.4.1 Data collection tools………………………………………………. 30
3.4.2 Development and pretesting of questionnaires………… 30
3.4.3 Recruiting and training of the research assistants…….. 30
3.4.3.1 Socio-demographic and socio-economic information 30
3.4.3.2 Anthropometric measurements……………………………. 31
3.4.3.3 Food frequency questionnaire……………………………… 31
3.4.3.4 Physical activity profile……………………………………….. 31
3.5 Data Quality Control and Assurance………………………….. 31
3.6 Data Analysis………………………………………………………….. 31
3.7 Ethical Consideration……………………………………………….. 32
APPENDICES
7
 APPENDIX 1: CHILDREN’S QUESTIONNAIRE....40
 APPENDIX 2: TRAINING SCHEDULE FOR
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RESEARCH ASSISTANTS……………………………46
Appendix 3: BUDGET………………………………….47
APPENDIX 4: MOMBASA COUNTY MAP……. 49
Appendix 5: SCHEDULE OF ACTIVITIES……. 50
APPENDIX 6: LETTER SEEKING CONSENT FROM
SCHOOLS…………………………………………………..51
Chapter 1.1 Background information
8
 Malnutrition literally means “bad nutrition “and technically
includes both over and under- nutrition (WHO, 2003).
 In the context of developing countries, under-nutrition is
generally the main issue of concern, though industrialization
and changes in eating habits have increased the prevalence of
over-nutrition.
 The co existence of both over and under nutrition typifies the ‘
Double Burden of Malnutrition' (DBM) (FAO, 2006).
 The DBM is becoming of great concern for African countries
(Thiam, 2006)and a real threat at the population, household
and even individual level and it is now observed among
schoolchildren.
9
 Urbanization is associated with the prevalence of
Non Communicable Diseases( NCD) risk factors such
as; Industrial pollution and Increased access to
alcohol and tobacco.
 Energy dense, low fiber foods; screen invasion and
sedentary lifestyles.
 All these lead to secondary risks such as overweight,
obesity, hypertension, high cholesterol, raised blood
sugar etc. (WHO, 2011).
Background information
10
 Obesity is defined as a state in which there is generalized
accumulation of excess adipose tissue in the body leading
to more than 20% of the desirable body weight.
 Overweight is defined as a weight over a weight
standard.
 Overweight and obesity in childhood (including
adolescence) is associated with serious physiological,
psychological, and social consequences.
 Obesity is measured using Body Mass Index
BMI= weight (in kilograms)
height (in metres)squared
Background information
11
 Evidence suggests most childhood obesity is
recognised during preschool years.
 This is when long-term dietary and physical activity
habits are being established leading to lifetime
effects on health (Lanigan, 2010)
 Globally, up to 200 million school aged children are
overweight or obese and this represents a 10% of all
the children with the Americans leading at 32%,
followed by Europe 20%, and then the Middle East
16% (Ogden, 2012).
Background information
12
 Prevalence rates of obesity in selected African
countries was 13, 14 and 15% in Sudan, Egypt and
Libya (North Africa)
 According to KDHS 2008/9 a total of 18% of
preschool children are overweight and 4% are obese.
 The proportion of women aged 15-49 that are
overweight and obese is 25%, with the highest
proportion being reported in Nairobi at 41 %
13
 Other studies have also established that obesity rates among
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children 10 -14 years in Nairobi is 14.4 %(Githinji, 2009)
In Nakuru the prevalence of overweight and obesity was 11.9%
and 3.4% respectively with 16.7% and 10% in private and
public schools respectively (Kigutha,2010).
Further, the prevalence of obesity among school-aged
children 7-10years was found to be 25.6% with more boys
(27%) being obese than girls (26%) in Nairobi (Abdalla,2010).
This rates are quite high which compares to rates in most
developed countries.
However, very little information is available on the prevalence
rates of overweight and obesity among children in Mombasa
hence the need for the study.
Background information
14
 The Government and some NGOs have put strategies in
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place. They include;
Creating awareness through training of health care
providers and diabetic walks by(Diabetic Management
and Information Centre (DMC) and Ministry of
Health(MOH)
School health policy and the recent Nutrition Action Plan
2012-2017
Screening of adults patients with BMI>26 .
AIHD a research institute in conjunction with the
Mombasa Municipal Council (MMC) and the Ministry of
Health (MOH) began its lifestyle change programs in
Mombasa.
15
1.2 Statement of the problem
16
 Kenya is facing the double burden of malnutrition.
 Many researchers have focused on under nutrition
like the Nutrition Improvement in Chile and Kenya
(NICK) study (Lan’go, 2013) thus little information
is available on obesity prevalence in this age group.
 Most studies have been conducted in Nairobi and
thus little information is available on the rising
trends of obesity from areas outside Nairobi and
particularly among children (Imungi,2013)
Statement of the problem
17
 School tuitions where children spend long hours in
school could be contributing to lack of physical activity.
 Physically, there is obesity among children especially 612 years because from observation in every 3 children at
least 1 is overweight.
 There is a lot of uncontrolled food hawking around the
schools and an increased number of franchised food
joints. Since there seems to be no control this could be
contributing to high levels of obesity.
 Advertisement of junk foods(high energy drinks and
foods) in the media without a strong policy can influence
both the children and parents to make wrong choices.
Statement of the problem
18
 Routine screening as recommended in the education health
policy has not been emphasised since little information exist
about routine screening and especially among school children
unless they are sick.
 In addition, the indicator reported at the national level only
captures adults with BMI >25 but how many adults will go to
hospital unless they are unwell?
 The African Institute of Health and Development (AIHD)
together with the municipality planned to come up with
programs for lifestyle change .
 They include; advocacy, making walkways for pedestrians and
cyclists, fixing street lights for security and encourage health
seeking behaviour but so far very little has been achieved.
1.3 Justification
19
 Prevalence of obesity among children with 18%
according KDHS, 2008/9.
 There is limited information on exact trends in child
obesity and especially from studies that have been
conducted outside Nairobi.
 Mombasa is one of the cities with limited data on the
trends of obesity and is a fast growing city that
harbours both periurban and urban populations
 The government policies and interventions in place
need to be identified and strengthened
20
 Levels at which public awareness has been done is
still very low because populations are still not keen
about what they eat and what they do and if they
contribute to their being obese.
 The levels of awareness in the community is still low
as because culturally people still see a “fat person” as
being healthy.
1.4 Aim
21
 The aim of this study is to contribute towards
improving the health status of the children through
tackling the determinants of over nutrition.
1.5 Purpose
22
 The purpose is to provide data that can be used to
create awareness on the prevalence of overweight
and obesity among school children 3-6 years.
 The study will provide information to characterize
the risks associated with being obese or overweight.
 Further, data from the study will enable the County
and the policy makers to identify and strengthen
available interventions that will help reverse the
increasing trends of obesity and related
complications among the preschoolers.
 Build a basis for future research.
1.6 OBJECTIVE OF THE STUDY
23
BROAD OBJECTIVE
To establish the prevalence of obesity among preschoolers (3-6years)
and the associated factors in urban and peri- urban schools in
Mombasa, Kenya.
SPECIFIC OBJECTIVES
1.
To characterize the socio demographic composition of families of
the children 3-6 years.
2. To determine the predisposing factors leading to over nutrition
among preschoolers (3-6 years)
3. To assess anthropometric measures among the children
4. To establish the caloric intake and food frequency among the
children 3-6 years
5. To assess physical activity levels among preschoolers
1.6.3 Research questions
24
 What is the nutrition status of the children 3-6 years?
 What are their snacking habits? What do they carry in
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their bags from home or what they buy? How often?
What do they eat in school, how often and who prepares
the food?
How often they have break and where do they play?
What foods are sold around their school? Nutritive value
and hygiene
How is the school environment? How does it affect
physical activity.
1.7 Null Hypotheses
25
 There is high prevalence of overweight and obesity
among children in Mombasa.
 There is a high prevalence of obesity among the
urban than the periurban preschoolers
 There is no association between feeding practices
and obesity among the children
 There is no association between physical activity and
obesity
1.8 Assumptions and limitations
26
 That the pupils and the teachers the children will
cooperate and give correct information.
 The schools selected will be a true representative of
the preschool population
 This study may not clearly establish if the obesity is
genetic of due to diet.
1.9 Benefits
27
 The study will provide data that will help increase
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advocacy and, help strengthen nutrition programs in the
community and hence adapt healthy lifestyles .
This study results will give insight to the nation/county
on the trends of obesity and overweight among
preschoolers,
The results will further build a foundation for further
research to establish the real baseline of obesity in the
county
The study may help evaluate if the government policies
on school health are in place and being implemented.
The research will help the researcher build management
and research skills
2.0 Chapter Two: Literature review
28
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2.1 Definition of Overweight and Obesity…………………. 10
2.2 Current status of Overweight and Obesity…………… 11
2.3 Health consequences of Overweight and Obesity…. 14
2.4 Predisposing factors of Overweight and Obesity….. 15
2.4.1 Dietary factors……………………………………………….. 16
2.4.2 Environmental factors……………………………………. 17
2.4.3 Cultural and Societal factors…………………………… 18
2.4.4 Television and advertising……………………………….18
2.4.5 Physical activity…………………………………………….. 19
2.4.6 Genetic Factors……………………………………………… 19
2.5 Assessment of overweight and obesity………………… 21
2.6 Gaps in Knowledge…………………………………………… 23
2.6 Gaps in knowledge
29
 Generally, in Kenya there has been an increase in levels of
overweight and obesity as established by previous studies like
the KDHS 2008 18% of preschoolers are overweight while 4%
are obese. There is however limited information from other
areas outside Nairobi and particularly in this age group (3-6)
years.
 Studies done within Nairobi have concentrated on adolescents
and teenagers from 8-18yrs and adults particularly women
and not preschoolers.
 There is need to establish if the preschoolers’ obesity may be
proceeding to increased adolescent prevalence and later to
adults that end up with diabetes and later complications.
 The community still has little information as concerns the
lifestyle changes and how this can influence their health and
that of the children.
Gaps in knowledge
30
 There is change in lifestyle and school tuitions may be
consuming the children’s physical activity time hence the
need to establish this association.
 The foods that are sold around our schools and the increased
number of franchised food joints like;“ pizza inn ’’ could be
influencing the choices of the children and there is limited
information on their nutritive value and the hygiene.
 Most coastal dishes are deep fried or cooked with a lot of fat
and coconut milk e.g mahamri,bhagia,pilau,biriani
 The Government together with NGO’s have set up strategies
like the school health policy that is in place to address
nutrition issues in particular but there is no information on
how far they have been implemented.
3.0 Chapter three: Research Design and
Methodology
31
3.1 Research design
 A cross-sectional design will be used with an analytical
component of the anthropometric data collected.
 Children will be proportionately sampled from rural and
urban populations of Mombasa.
3.2 Research Methodology
3.2.1 Study site
 The study will be carried out in Mombasa County in two
divisions purposively selected (Changamwe and Island)
to represent the Peri-urban and urban population
respectively.
3.2.1.1 Location, size and topography
32
 Mombasa county is located in the South Eastern part of
the Coastal region of Kenya.
 It covers an area of 229.9 Km2 excluding 65 Km2 of
water mass which is 200 nautical miles inside the Indian
Ocean.
 The county lies within the coastal lowland which rises
gradually from the sea level in the east to about 132 m
above sea level in the mainland.
 The terrain is characterised by three distinct
physiographic features, which includes the coastal plain,
which is found along the shoreline, covering parts of the
South Coast, the Island, parts of Changamwe and the
North Coast.
3.2.1.4 Climatic conditions
33
 The County lies within the coastal strip in the hot tropical
region where the climate is influenced by monsoon winds.
Rainfall
 The rainfall pattern is characterized by two distinct long and
short seasons corresponding to changes in the monsoon
winds.
 The long rains occur in April - June with an average of
average 1,040 mm and correspond to the South Eastern
Monsoon winds.
 The short rains start towards the end of October lasting until
December and correspond to the comparatively dry North
Eastern Monsoons, averaging 240mm.
 The annual average rainfall for the county is 640mm.
34
Temperature
 The annual mean temperature in the county is 27.90C
with a minimum of 22.70C and a maximum of 33.10C.
Average humidity at noon is about 65 per cent.
 Administratively, the county is segregated into seven
divisions, eighteen locations and thirty sub-location and
hosts six constituencies namely Mvita, Changamwe,
Jomvu Kuu, Likoni, Kisauni and Nyali.
3.2.1.6 Pre-school education
 There are 254 ECDE centres within the county with a
population of 26,080 student and 612 teachers.
3.2.1.7 Health care
35
 The county hosts the coast level five hospital which is a
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referral facility serving the entire coast region.
Other notable private hospitals include the Aga Khan
Hospital, the Mombasa Hospital and Pandya Memorial
Hospital which are all in the Island division.
Other lower level hospitals include; Tudor district
hospital found in island and Port Reitz in Changamwe.
Level four hospitals are further complemented by fifteen
private hospitals, four nursing homes, and nine health
clinics of which two are public and seven privately
managed.
There are twenty seven dispensaries out of which twenty
five are public and two private.
3.2.2 Study Population
36
 The population for under 5’s was 127,320 in 2009
and was projected to reach142, 694 in 2012, 159,925
and 172,553 in 2015 and 2017 respectively.
 The population in Early Childhood Development
centres (ECDE) is 26,080 for both private and public
schools.
 Changamwe division has 6025 while island division
has 6508.
3.4 Sampling frame
37
purposive
Mombasa
County
Urban
Periurban
purposive
All the children aged 3-6 years
208 children from
urban schools
random sampling of 4
schools
192 children from
periurban schools
random sample for 6 schools
proportionate
random
3.3.1 Sampling procedures.
38
 Purposive sampling was used to select the target geographical area
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as one of the county among the 47 in Kenya that is rapidly
experiencing economic growth and harbours both urban and peri
urban populations.
Purposive sampling will be used to select Changamwe and island
divisions out of the six to represent the urban and periurban.
proportionate sampling will be used to allocate the number of
children for urban and periurban.
Simple random sampling will be used to identify 10 schools (6
periurban and 4 urban)
Stratified sampling will be used to select the class levels (KG3 and
class 1) while systematic sampling will be used to select the Nth
3.3.2 Sample size determination
39
 The national prevalence for preschoolers is 18%overweight and 4%
obese according to KDHS 2008/9
 This figures have changed and since coast region does not have a
rate the study will calculated using 50% (Fisher et al.1998 ).
N = Z2.PQ
D2
Therefore N= (1.96x1.96) x0.5 (1-0.5) or 4pq=384 children
0 052
L2
= 400 children
 Added~5 % to cater for attrition, then a sample of 400 children will
be selected.
3.4 Data Collection
40
 3.4.1 Data collection tools
 Previously pretested structured questionnaires for
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demographic and socio economic information
Food frequency questionnaires for dietary
assessment
Activity profile
Question guide
Anthropometric data sheet for weight and height
Observation list
3.5 Data Quality Control and Assurance
41
 Equipment will be calibrated before the start of the
activity.
 At the start of the day the scales will be calibrated
using a standard measure like a 2kg flour packet to
ensure accuracy.
 The filled questionnaires will be checked at the end
of each day for completeness, consistency in answers
and proper filling by the assistants.
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42
 The research assistants will be recruited based on
the level of education(form four or tertiary colleges)
and will be thoroughly trained for three days.
 The whole data collection process will be supervised
by the principle investigator and supervisors
consulted for any assistance.
APPENDIX 2:RECRUITING AND TRAINING SCHEDULE FOR RESEARCH ASSISTANTS
Day 1
10.30-1100
Day 2
Content
Method
8.30 -9.00
9-10.30
Climate setting and introduction
Overview of the topic, purpose
of study and objectives
Brainstorming
Lecture and brainstorming
1100-1300
Overview of data collection
tools and sampling procedures
Lecture and demonstration
1400-1600
Review data collection equipment
and calibration
Lecture and
Recap
Practice use of the research tools
and equipment
Role-plays discussion
1100-1300
Continue with practice
Role play
0900-1300
Pretesting the questionnaire in the
nearby school
1400-1600
Feedback and planning for data
collection
Way forward
Break
Day 1
Lunch
Time
Break
0830-0930
0930-1030
1030-1100
Day 3
demonstration
Break
43
Brainstorming
3.6 Data Analysis
44
 Information from the questionnaires will be checked,
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verified and entered into the computer data base.
Statistical Package for Social Sciences (SPSS) version 17
will be used for analysis.
Descriptive analysis will be used to provide general
information on the characteristics of the study
population. This will be done by generating frequency
tables, mean and ranges.
Data on food frequency will be tabulated to show the
frequency of consumption while Chi squares test will be
used to compare the independent variables.
BMI for age classification will be done using WHO
referencing standards
3.7 Ethical Consideration
45
 Permission to collect data will be sought from;
 The University of Nairobi, Ministry of Education
and Mombasa County Council.
 Participation will be voluntary through informed
consent from the teachers.
 The researcher will explain the purpose of the study
and assure the respondent that there will be no ill
motives and confidentiality of their responses will be
ensured.
Year 2014
Activity
J FM A
Year 2015
M J J A S O N D J
Selection of
research topic
Proposal writing
Proposal
presentation
Proposal correction
Questionnaire
pretesting
Proposal correction
and submission
Data collection
Data entry and
analysis
Project defence
Project correction
Project submission
46
F
M A
M J
J
A
Item
1.0
1.1
Quantity
Unit cost
No. of
days
personnel
Researcher
1
10
1.2
UON supervisor
1
3
1.3
Research assistants
1.4
Enumerators
Field guides
Software expert consultation
2
2
1
10
10
1.5
5000
Sub total
2.0
Total cost
5000
Stationery
2.1
Proposal writing/ correction printing
5
200
2.2
Research notebook
1
1000
1000
2.3
Purchase statistical package
1
2000
2000
2.4
Pens,
notebooks,
pencils,
eraser
sharpener
clear bag
4
4
4
4
4
4
20
50
25
10
15
45
47
5@200
4@20
4@50
4@25
4@10
4@15
4@45
1000
620
2.5
Printing of questionnaires
2x5pages
4
4x10
40
2.6
Photocopying of questionnaires
300x5page
2
1500x2
3000
2.7
Printing and binding proposal
2
250
250x2
500
2.8
Printing and binding dissertation
6
300
300x6
1800
9960
subtotal
3.0
Logistics
3.1
Accommodation for UON supervisor
1
6000
3x 6000
18000
3.2
Transport for UON(car hire)
1
4000
3x4000
12000
3.3
UoN Supervisor
Return air ticket
Taxi to and from airport
1
2x7500
15000
2x2500
5000
1
500x1
500
1
500x10
5000
3.7
Researcher’s lunch allowance for
pretesting
Researcher’s lunch during data
collection
Refreshments in training
5x100x3
1500
3.8
Hall hire
500x3
1500
3.9
Training the research assistants
/Allowances
Salaries
4
200
800x3
2400
Research assistants
2
1000
10x1000x2
20000
Field guides
2
500
10x500x2
10000
3.4
3.5
3.6
3.10
Subtotal
2
5
5000
100
48
85400
Item
4.0
Equipment
4.1
Scales hire
Heightboard hire
Quantity
Unit cost
No on days
total
2
2
1500
1500
2x1500
2x1500
3000
3000
Subtotal
6000
5.0
Communication
5.1
Airtime for modem
1
5.2
airtime for research assistants
2
5.3
Ministry of Education permit
1
500
5.4
Permission from schools
1
free
5.5
permission from MOH
1
free
100
Subtotal
6.0
3months
2000
10x100x2
2000
4500
Data entry and analysis
5% Contigency
5543
Grand total
116403
49
50
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