Promoting healthy eating and physical activity among school children: findings from Health-E-PALS, the first pilot intervention from Lebanon

Overweight and obesity are serious problems posing one of the most difficult public health challenges of the 21st century in many countries. The Middle East and the Arabian Peninsula regions, which include Lebanon, are not exempt from the obesity epidemic, which has reached worrying levels both among children and adults [1].

Lebanon is a small middle-income country characterised by a high urbanisation rate (81%), a high literacy rate (85%) and a life expectancy close to 72 years [2]. A monitoring study reporting on overweight and obesity trends in Lebanon in 1997 and 2009 showed a rapid increase in body mass index (BMI) across sex and age groups, particularly 6–19 year olds [3]. This study also showed that childhood obesity which continues through adolescence occurs before age 11 [4]. Children aged 13 to 15 years reported poor eating habits including skipping breakfast, a low intake of fruits and vegetables, and a high consumption of high energy foods and beverages, compared with recommended [5]. Coupled with the low physical activity levels reported by these children, these risk factors help explain the increased prevalence of overweight and obesity in Lebanon [3, 6, 7].

In response, policies and strategies have been recommended to promote weight control and physical activity across Lebanon [8, 9]. But school-based interventions promoting healthy eating and physical activity are still lacking, and the Lebanese integrated health curriculum incorporates very little nutrition education. Several reviews have assessed the effectiveness of school-based interventions in preventing and reducing childhood obesity [10‐12]. However, most of the interventions have been conducted in North America, Australia and Europe; very little research in this area has been carried out in the Middle-Eastern region. Although certain key concepts and elements of the successful interventions identified in these reviews can be translated for the Lebanese population, such as the importance of using a whole school-based approach [10] which targets behaviour change at the individual level and also changing the school food environment, new or adapted interventions require pilot testing because of the distinct Lebanese cultural context.

In this realm, this study was undertaken to fulfil two objectives: (1) To develop a theory and evidence-based multi-component school intervention that is culturally appropriate, which takes a whole school-based approach, and is participatory-based (involving the school environment and parents), that aims to promote healthy eating and physical activity among children aged 9–11 years; and (2) by conducting a pilot study, to evaluate the feasibility and effectiveness of this multicomponent school-based intervention to promote healthy eating and physical activity (and prevent obesity) in school children aged 9–11 years in Lebanon.

This paper reports on the process and outcomes of the pilot study. A paper reporting on the development of the intervention is published elsewhere [13].

‘Health-E-PALS’ is the first school-based intervention in Lebanese schools for the promotion of healthy eating and an active lifestyle. It is also the first study to demonstrate the feasibility of undertaking a successful school-based intervention despite the many contextual challenges that may be faced in a politically unstable context, with security threats and social unrests. The absence of a similar study from the region made it difficult for us to set benchmarks for what could be feasible and reasonable to accomplish. Notwithstanding these challenges, however, our pilot study illustrated that the intervention was culturally-relevant, promising and effective in improving many students’ dietary behaviours and determinants of behavioural change.

Health-E-PALS significantly increased students’ nutritional knowledge. Group discussions with students and parents revealed that this was mainly due to the classroom component being an activity rather than a didactic lesson. While increasing knowledge may be an important initial step, whether knowledge alone can directly translate to changes in behaviours remains questionable [16], which is why efforts to increase students’ self-efficacy is a fundamental part in personal change, as it motivates people to act [17]. Students exposed to the Health-E-PALS intervention scored higher on self-efficacy compared with controls. Self-efficacy is a stronger predictor of behavioural change, and has also been found to be an important mediator of the relation between knowledge and behaviour [18, 19].

With respect to behavioural outcomes, Health-E-PALS was effective in increasing the odds of daily breakfast intake, mostly that skipping meals, particularly breakfast, is a major risk factor for becoming overweight or obese as they grow older [20]. Daily intake of breakfast has been consistently linked to decreased BMI among children and adolescents, and a reduced risk of being overweight or obese [21]. Even if our finding were partially due to the lower proportion of children eating breakfast daily in the control group at post-test, qualitative findings confirm that breakfast intake was among the main healthy changes students incorporated into their dietary habits. Students in fact reported trying to “wake up early” in order to have breakfast on a regular basis and parents noted that their children were preparing breakfast following the examples given during the class sessions.

The lack of increase of fruits intake in our study corroborates others’ findings [22] and as such greater efforts must be made to promote the intake of fruits as a snack, dessert or part of a meal; worth noting however that the majority of students had already reported having fruits as a snack between meals. Reviews of studies that demonstrated a positive and statistically significant increase in fruit consumption noted that the effect size was small compared to the required intake [23]. However, availability and motivation were constructs that have been shown to mostly determine successful increases in fruit and vegetables consumption among children [24].

In the present pilot study, perceived self-efficacy, personal skills and food preferences were enhanced through food tasting workshops and snacks preparation, in line with evidence-based recommendations favouring tasting sessions of new healthy foods and drinks [25]. Interventions with parents further secured accessibility of these food items at home, and qualitative results showed that students were encouraged by their parents to consume fruits and vegetables, and that students were less resistant when offered these food items. Unfortunately, Health-E-PALS was not successful in changing the school environment, and the lack of fresh fruits and juices at the school shop was brought up during focus group interviews as one of the barriers to increased fruit intake, especially that students were willing “to buy fruits and fresh juices if offered at the school shop”. Lack of availability of healthy food options at school was also pointed among the perceived barriers to eating healthy in other studies looking at insights into children’s views on food and nutrition [26, 27].

Our programme also significantly decreased students’ intake and purchase of soft drinks but not of other sweetened drinks, as others have also found [28]. One possible explanation is the availability of sweetened beverages at school shops and at home as “healthy” substitutes for soft drinks. Parents and health educators mistakenly perceive them as a healthier option. Studies showed that reducing easy access to energy dense drinks could limit the chances of overconsumption [29].

Snacking has lately been suggested as being one of the causes of the increased energy intake responsible for the observed growing epidemic of obesity in the world [30]. Health-E-PALS effectively reduced students’ consumption and purchase of some types of energy dense snacks namely potato chips, which itself has been strongly linked to long-term weight gain [31]. One possible factor for this positive finding in our study might be the educational games’ emphasis on added fats and sugars in the common energy dense snacks. Though not statistically significant, the consumption and purchase of chocolate and biscuits also decreased. While access to potato chips was restricted in some schools, it was more difficult to convince the shop staff to remove all types of candies, as reported in other studies [32, 33]. Efforts to decrease availability of energy dense snacks and drinks were only successful in few schools; as shop owners were concerned about reduced profit. A recent review article on the effectiveness of school-based interventions in low- to middle-income countries found that changing the nutritional environment in schools poses a real challenge in these countries [34]. The Ministry of Higher Education in Lebanon has recently issued a law restricting the sale of competitive foods in school shops; this will hopefully improve the food environment in Lebanese elementary schools.

Health-E-PALS was not successful in raising the frequency of organised sports in schools curricula, though was effective in getting students engaged in after school sports at least once a week. Interviewed parents were reluctant to enrol their children in extracurricular activities due to budget, time, schedule constraints and homework overload, all of which have been previously reported in other studies [35]. In Lebanon, free physical activity facilities are scarce. After school sports are offered in some schools for an extra fee or in private sports clubs usually at an elevated monthly membership cost. Moreover, increasing expectations about academic achievements have prompted many Lebanese schools to cut back on both recess time and gym classes. Health-E-PALS also emphasized the importance of unorganised physical activity through several means one of which is the pedometer workshop that proved to be successful in motivating children to move. Pedometer-based interventions are becoming more popular as a low-cost and effective method for promoting physical activity and increasing walking [36‐38]. Group discussions unanimously pointed towards pedometers being an incentive to increase daily physical activity, as others have found [39]. Health-E-PALS also positively influenced play during recess but not at home, probably due to unsafe neighbourhoods as explained by parents during the focus group discussions. The built environment in the city of Beirut prevents children from engaging in spontaneous physical activity and play. Improving the urban environments is not one of the Lebanese government’s priorities, which mainly revolves around economic and political problems. Thus, short-term solutions should focus on improving the school environments by regarding the PE session as a central part of the student’s wellbeing.

Mounting evidence shows that independent of physical activity levels; sedentary behaviours are associated with increased risk for many diseases and namely adiposity [40‐42]. Intervention studies which helped children decrease their sedentary time reported desirable changes in body weight and BMI [43]. Health-E-PALS did not achieve a decrease in students’ screen time habits, despite the strict rules at home for screen time during school days in some families, as reported during focus groups. Generally, parents perceived reducing their children’s TV viewing as a difficult task [44] and longer follow-ups are needed to observe changes [45].

The lack of any observed changes in students’ BMI and waist circumference measurements in the present study is probably due to the insufficient duration between pre- and post-test (i.e.12 weeks), making it difficult to detect any noticeable changes in adiposity. Systematic reviews [10] showed that the majority of studies targeting six to 12 year old children that proved effective on some indicators of adiposity, involved long-term intervention periods (>12 months). Nonetheless, our study positively impacted major mediating variables, as well as some behavioural habits.

Since parents are fundamental to the success of any child intervention, parents were involved in Health-E-PALS both through direct (via meetings and health fairs) and indirect exposure to the programme’s elements, by sending information packets and recipes home with the students. It is worth noting that direct methods to engage parents have proven to be more successful than indirect methods [46] although the best way to involve parents is yet unknown. Parents helped in the success of the Health-E-PALS intervention by ensuring the availability and accessibility of healthier food options at home, and through role modelling. One of the challenges faced with parents however is their attendance in meetings, which was poor in some schools. Inviting parents to attend their children’s’ performances, and providing meals and tokens helped secure parents’ participation in the present study, as suggested elsewhere [47].

Our pilot evaluation of the Health-E-PALS, including culturally sensitive and innovative components, proved successful in increasing students’ nutritional knowledge and self-efficacy, as well as improving various important behavioural risk factors to obesity. The traditional foods, rhymes, riddles and games helped children relate messages to their daily routine and local environment. Contextual influences such as social values and cultural norms were important parameters to include for the success of school-based interventions in low and middle income countries [34]. Holding parents’ meetings around breakfast and demonstrating how traditional foods can be served in a healthy way was key to this context since gathering around meals is intrinsic to the Lebanese culture. This secured better attendance during meetings especially with families of low socioeconomic status. Health-E-PALS was generally well accepted by students, teachers and their parents. The focus group discussions were fundamental for soliciting important feedback and verifying the intervention was indeed tailored to the Lebanese culture and context. This essential component was a driving force for the positive findings achieved in the present study. Furthermore, given this particular social and cultural context the applicability and transferability of the present study to other countries of the region ought to be considered.

Despite the positive findings and study’s contribution, the results must be interpreted in light of some limitations including: the purposeful sampling of schools who were keen to take part in the study, despite the fact they were matched and randomised to intervention and control group, may have increased compliance with the intervention; the relatively low number of schools (eight) that were randomised may have limited the likelihood of distributing potential confounders equally between the intervention and control schools; the relatively short study duration (three months), which may not have been sufficient to induce proper and sustained behaviour change; failure to succeed in modifying the school’s food environment due to lobbying and lack of support of some of the school authorities. Several challenges were also faced during implementation of the programme given Lebanon’s political and social unrest; extra sessions were necessary to make up for the missed ones that were canceled due to unpredicted strikes and security events prevailing in the country. The health fair event that was cancelled in one of the schools could not be rescheduled as end of year final exams had begun. Nonetheless, despite these field constraints, the Health-E-PALS programme was successfully delivered as designed: the 12 educational lessons and activities were all implemented in the intervention schools along with meetings with parents and the food service management.

Health-E-PALS showed that this culturally appropriate, theory-based intervention that used a whole school approach and included interactive learning was feasible and increased students’ nutritional knowledge and self-efficacy, and decreased their purchase and consumption of high energy dense snacks and beverages. Next steps entail planning for a larger scale evaluation of this intervention, to include a greater number of schools from different regions of Lebanon, for a longer duration period. The large scale trial should emphasise the physical education component, improve the quality of foods available to students in school shops, and be delivered by trained school personnel, for better sustainability of the programme.