A randomized controlled trial for families with preschool children - promoting healthy eating and active playtime by connecting to nature

Proper nutrition and physical activity are essential for a healthy life [1]. Modern-day children practice unhealthy habits and routines; they play indoors, engage in sedentary activities, eat poorly and get insufficient sleep. Lifestyles are generally becoming unhealthier worldwide, and Hong Kong is no exception [2, 3]. The urban environment is criticised for being ‘toxic’, promoting the ‘nature-deficit’ phenomenon, and for stimulating less physical activity in young children [4, 5]. In Hong Kong, the majority of people live in densely populated areas, moving within a concrete labyrinth with little exposure to nature. The prevalence of overweight and obesity amongst Hong Kong children has become an increasingly prominent public health concern. A recent study of the Hong Kong population, conducted in 2013, reported that children as young as 6 months were overweight/obese and by the age of 2 years of age almost 5 % of the territory’s children were overweight/obese [2, 3, 6]. Any routines, healthy and unhealthy that get introduced in early childhood may stay for life, strongly suggesting that interventions promoting healthy living should start as early as possible [7]. For these reasons, we have chosen to target families with children aged 2 to 4 in our proposed research. It is widely accepted amongst the caregivers that preschool children are sufficiently active and as a result of this belief is that preschool children are often overlooked in physical activity research [7]. This belief, however, does not always reflect the real situation. The family setting provides the most powerful influence on preschool children; consequently, many of the risk factors for obesity in the preschool years are rooted in the family context [8]. Parents have the capacity to impact their children’s emerging food choices with their knowledge of nutrition, and their parenting style and modelling [9]. The strongest predictor of vegetable consumption in 2–6 year old children is parental consumption, and when it comes to negative eating behaviour in this age group, this can be modified if handled properly [10]. Furthermore, children with active parents also tend to be more active [11]. In Hong Kong, parents often adopt inappropriate strategies in managing the physical activities and dietary habits of their children, such as encouraging overeating i.e. "force feeding", and allowing children to watch TV while eating, etc. [2, 3, 6]. We therefore intend to conduct a family intervention, targeting children’s caregivers, as it is well-confirmed that they are responsible for introducing the lifestyle routines in young children and thus play one of the biggest roles in influencing their habits [12]. Although grandparents and domestic helpers and are also highly involved in taking care of the children of in Hong Kong, we targeted families with parents as the primary caregivers and not domestic helpers in order to test our hypothesis in a more controlled and homogenous group. The tools which are often utilised by parents to manage some problematic behaviour in children (e.g., food fussiness) [13] are documented to firstly improve general parenting and secondly, the parenting practices in specific situations [13]. A recent Cochrane review reported only a marginally significant improvement in body weight after some interventions and little to no effect on dietary or physical activity behaviours [14]. Hence, developing new lifestyle intervention programs for preschool children and testing these is highly relevant.

Time spent in nature has also proven to be beneficial for health and wellbeing. The systematic reviews conducted recently have pointed out that nature-related activities enhance general well-being and lead to increased physical activity, a healthier diet, improved sleep and reduced overall stress [15‐18]. Worldwide, the most current programmes promoting a healthy lifestyle for children focus almost exclusively on diet and physical activity [19], but few take into consideration a family’s interactions with nature. We suggest that this emerging research area, known as Connectedness to nature or Nature Relatedness [20], is highly related to healthy lifestyle. Unhealthy lifestyle is often explained by environmental factors, while more time spent outdoors in a natural environment is reflected in healthy life patterns [15, 21].

We recently conducted a pilot study in Hong Kong, Play & Grow learning, which is based on the most successful preschool interventions from Sweden and Australia [22, 23]. The results of the pilot work helped formulate the basis of the present project by incorporating the healthy eating and physical activity elements of Play & Grow to which we also included a third novel element; Connectedness to nature. The proposed project will examine this modified Play & Grow intervention aimed at promoting healthy lifestyle in preschool children (aged 2 to 4) through the combined intervention of healthy eating, active play and connectedness to nature habits to children and their families.

The strategies outlined in this study are particularly appropriate to Hong Kong for several reasons. First, most Hong Kong children in primary schools fail to reach the physical activity levels recommended by the health authorities, and moreover, their increased sedentary habits lead to deterioration in health [2, 3, 24]. Second, Hong Kong children’s food habits fail to meet recommended nutritional standards: the major source of energy intake derives from calorie-dense foods, saturated fats and sugar [6], negatively influencing the territory’s obesity levels [6]. Third, this unhealthy lifestyle has negative consequences not only on general well-being but also academic performance; an issue of great concern to Hong Kong parents. It is therefore hoped that the proposed project will bring sustainable health benefits to Hong Kong’s population in a long run. These positive changes and benefits will hopefully in turn lead to reduced prevalence of obesity amongst children in Hong Kong, and a concomitant decrease in healthcare related costs.

In addition, this pioneering project will have scientific value in development of several important protocols and measurement instruments, including our Nature Relatedness Scale. Existing instruments for nature relatedness are applicable only to adults and have not yet been tested in Asia; thus, our new instrument will contribute to international research in this field, which has been relatively sparse to date.

The objectives of the proposed project will be achieved in two stages over a 30-month period (Fig. 2) in Hong Kong. Firstly, to create a valid measurement tool for the novel Connectedness to nature intervention element, a Nature Relatedness Scale (NRS) will be validated and tested for reliability (Stage 1). To measure the effectiveness of the early-intervention Play & Grow programme, a RCT will be conducted (Stage 2). In order to investigate which particular components of the Play & Grow were most/least effective, the data from the RCT will be used to perform a mediator study at a later stage.

Firstly, this study will develop, test and validate in Hong Kong an instrument to measure Connectedness to nature in preschool children in Hong Kong. This scale could be the first promising tool for understanding and predicting health-related environmental attitudes and behaviours, and how these change over time. It has the potential to be used for establishing causal associations between an intervention and an outcome and evaluation of health-promoting interventions in general.

To the best of our knowledge, this type of intervention is novel in Hong Kong and internationally. The results are expected to contribute to the knowledge on physical activity and diet in preschool children and by introducing a new environmental element, Connectedness to nature, to the healthy lifestyle recommendations.

AGF, anticipatory guidance framework; BMI, body mass index; CFQ, child feeding questionnaire; IG, intervention group; INFANT, infant feeding activity and nutrition trial; MANOVA, multivariate analysis of variance; NKQ, nutrition knowledge questionnaire; NRS, nature relatedness scale; PCFQ, the preschool child feeding questionnaire; PCNS, Pliner’s child neophobia scale; RCT, randomised controlled trial; WLCG, waiting-list control group.