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Adolecent Obesity and Its Determinants: Basis For Learners' Wellness Program

This document presents a study that evaluated the effectiveness of a school-based intervention for overweight and obese adolescents. The intervention consisted of school nurse-delivered cognitive behavioral counseling sessions and an after-school exercise program. 126 overweight or obese adolescents from 8 public high schools participated. The adolescents were randomly assigned to the intervention or a control group that received information only. Measures of diet, activity, and BMI were collected at baseline and 8-month follow-up and analyzed to examine differences between the groups. The study aimed to develop and test a model for implementing expert-recommended weight management interventions for adolescents through readily accessible school-based programs.

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100% found this document useful (1 vote)

843 views28 pages

Adolecent Obesity and Its Determinants: Basis For Learners' Wellness Program

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beverly

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ADOLECENT OBESITY AND ITS DETERMINANTS:

BASIS FOR LEARNERS’ WELLNESS PROGRAM

A Thesis Paper Presented to the Faculty of the School of Graduate Studies of Western
Colleges, Inc. Naic, Cavite

In Partial Fulfillment for the Degree Master of Arts in Education major in Administration
& Supervision

(Your Name)
October 2021
APPROVAL SHEET

This thesis entitled _________ prepared and submitted by in

partial fulfillment of the requirements for the degree of Master of Arts in Education Major
in _____, has been examined and is recommended for acceptance and approval for
Oral Examination.

PANEL OF EXAMINERS

Approved by the Committee on Oral Examination with a grade of _ on

Accepted and approved in partial fulfillment of the requirements for the degree
Master of Arts in Education major in Administration & Supervision.

Comprehensive Examinations passed on ___________.

Abner V. Pineda, PhD, EdD, DPA, DBA

Dean, School of Graduate Studies
Title :
Researcher :
Adviser :
School :
Degree :
Date of Completion :
ABSTRACT
TABLE OF CONTENTS
Page
Title Page
Approval Sheet
Abstract
Table of Contents
List of Figures
List of Tables
INTRODUCTION
METHOD
Initial Stage
Final Stage
RESULTS
Development Stage
Conduct of Exploratory Factor Analysis
Final Results
DISCUSSION
REFERENCES
APPENDICES
Appendix
A. Letter to the Schools Division Superintendent
B. Informed Consent Form
C. Copy of the First Draft of the Instrument
D. Matrix for Development and Validations of the Proposed Instrument on ______
E. Copy for the Instrument Validators
F. Content Validity Index Results
G. Table
H. Figures
I. Semi – Final Draft of the Developed and Validated Instrument :
J. Copy of the Final Instrument
K. Certificate of PlagScan Review (Revised Final Manuscript)
L. Researcher’s Curriculum Vitae
LIST OF TABLES

Table Title/Description Page

LIST OF FIGURES

Figure Title/Description Page

INTRODUCTION
(This part presents in an APA format and IMRaD style of writing which includes
the reason why the study is undertaken, purpose of the research and the research
questions together with the tested hypothesis/es)
Obesity can be defined as having excessive body fat. Williams et al. in their
study that involved 3320 children aged between 5 and 18 years stated that; risk factors
for cardiovascular disease was more common in case of having at or above 25% fat in
males and at or above 30% fat in females even after adjusting for age, race, fasting
status, and truncal fat pattern (D. P. Williams et al., 1992).
For children aged between 2 and 19 years having a BMI ≥85th percentile but
<95th percentile is defined as being overweight. Being obese is defined as having a
BMI ≥95th percentile (Barlow, 2007).
Obesity is a global pandemic (WHO, 1998). It a matter of public health burden
and spreading to all the age groups, including children and adolescents. A global
epidemic of obesity occurred in recent years among adolescents, and prevalence of
obesity is continuing to rise in this population (Reilly, 2006). Given the high prevalence
and chronic nature of obesity, coordinated models of care for health-service delivery for
the management of pediatric obesity are needed (Baur et al., 2011).
In a study conducted by Freedman et al, (1999) the rate of being overweight was
10.8% in examined school children, while a 10.5% obesity prevalence was found in
more recently studied school population in Greece (Elastoplast et al., 2012).
Age- standardized prevalence of overweight was 17.8% among boys and 15.8%
among girls in a study conducted in India (Ramachandran et al., 2002).
Though obesity prevalence increases as a global problem; a study based on data from
1998 through 2011 conducted in Denmark, showed that the prevalence rates of
overweight and obesity in infants, children and adolescents were largely still on a
plateau with tendencies for a decline among children and adolescents (Schmidt Morgen
et al., 2013). But this may be far from representing the global picture.
In the Elastoplast et. al (2012) study which was conducted in Greece, it was found that
the prevalence of overweight and obesity in the studied population of 10–13-year-old
children it was 32% and 10.5%, respectively, while in children with parents of lower
educational level, the odds of being overweight/obese was higher.
In all pediatric age groups, there is an increasing prevalence of being overweight and
obese. National Health and Examination Surveys (NHANES) in the US showed
constant increases in the prevalence of overweight among children and adolescents at
age 2 to 18 years. According to the data approximately %14 of children aged 2 to 5
years and 19% of Obesity is a complex condition that interweaves biological,
developmental, environmental, behavioral, and genetic factors; it is a significant public
health problem. The most common cause of obesity throughout childhood and
adolescence is an inequity in energy balance; that is, excess caloric intake without
appropriate caloric expenditure.
In the Philippines, the prevalence of overweight and obese is observed to be
higher than the national estimate across all population groups in the 80 highly-urbanized
cities (HUCs) in the National Capital Region (NCR),” Dr. Imelda Angeles-Adept,
Scientist II, Officer-in-Charge, Office of the Deputy Director and Chief Science Research
Specialist of the Department of Science and Technology – Food and Nutrition Research
Institute (DOST-FNRI) said during the Dissemination Forum on the Expanded National
Nutrition Survey (ENNS) Year 1 Results at the Dusit Thani Manila on August 20, 2019.
Undernutrition particularly underweight, stunting and wasting among children and
chronic energy deficiency (CED) among adults still exist in the HUCs but glaring is the
result for overweight and obese in all population groups compared with national
estimates.
Among school-age children, 5-10 years old, the prevalence of overweight and
obese at the national level more than doubled among preschool children at 11.6% or
about 1 in every 10 school-age children, based on the World Health Organization
(WHO) Growth Reference body mass index (BMI) for-age. The prevalence is even more
glaring looking at each of the eight HUCs in NCR and all were significantly higher than
the national estimate, except Caloocan. Noteworthy is that about 1 in every 4 school-
age children can be found in the cities of Mandaluyong (26.2%) and Makati (24.5%).
Also based on BMI-for-age, about 1 in every 5 adolescents in Makati (23.6%),
Mandaluyong (19.7%), Manila (19.2%), San Juan (18.4%), Caloocan (17.6%) and Las
Piñas (16.3%) were overweight/obese and these were significantly higher than the
national prevalence of 11.6% or 1 in every 10.
Given the dramatic increase in adolescent overweight and obesity, models are
needed for implementing weight management treatment through readily accessible
venues. We evaluated the acceptability and efficacy of a school-based intervention
consisting of school nurse-delivered counseling and an after-school exercise program in
improving diet, activity, and body mass index (BMI) among overweight and obese
adolescents.

METHODS AND PROCEDURES

(This part of the paper includes the when, where and how was the study done,
materials being used, and who were / are the respondents / participants of the study.)
A pair-matched cluster-randomized controlled school-based trial was conducted
in which 8 public high schools were randomized to either a 12-session school nurse-
delivered cognitive-behavioral counseling intervention plus school-based after school
exercise program, or 12-session nurse contact with weight management information
(control). Overweight or obese adolescents (N = 126) completed anthropometric and
behavioral assessments at baseline and 8-month follow-up. Main outcome measures
included diet, activity, and BMI. Mixed effects regression models were conducted to
examine differences at follow-up.
Adolescent overweight and obesity have increased dramatically in recent
decades, with 34% of adolescents currently overweight or obese.1 Adolescent obesity
has negative physical and mental health consequences,2–4 and is strongly linked with
obesity during adulthood.5 Adolescence provides an opportunity to promote healthy
lifestyles affecting physical and psychosocial outcomes during adolescence and into
adulthood, yet adolescent obesity has been understudied compared with adults and
preadolescents.6 One systematic review7 found that comprehensive behavioral
interventions including diet and physical activity counseling and behavioral management
training8 are efficacious for decreasing youth body mass index (BMI), but they were
focused on preadolescents and conducted in specialty clinics with limited access by
youth.
Models for implementing expert recommendations for weight management
interventions9 with adolescents require development and testing. The school A pair-
matched cluster-randomized controlled school-based trial was conducted with a
convenience sample of 8 public high schools in Massachusetts. The total student
enrollment at these schools ranged from 673 to 1467; the student populations were
predominately white (61.8% to 94.4%) in 7 schools, and Hispanic (42.7%) in 1 school.
The percent of students considered low income ranged from 5.7% to 59.7%. Schools
were pair matched on enrollment, and 1 school from each pair was randomly assigned
to the intervention or control condition. Data were collected from September 2012 to
June 2013. Clinical Trial Registration # NCT01463124.
Adolescents in grades 9 to 12 were eligible to participate if they had a BMI ≥ 85th
percentile for age and sex, provided assent and had parental consent, and had at least
1 English-speaking parent. Exclusions included plans to move out of the area; a medical
condition that precluded adherence to the intervention;

RESULTS
(This part includes the answer/s found for the research questions / findings of the
study and whether the tested hypothesis/es are / were true or not.)
The results of this research provide evidence of a statistically significant,
although very small positive effect of school wellness policies on adolescent BMI that is
contrary to my hypothesis. Dominance analysis showed that of the four wellness policy
factors considered in the principal component composition of the wellness policy
measure, policy components that met state requirements rather than those meeting
health screen criteria, state recommendations, and national standards were most
important in explaining the overall variance of the regression model. Interestingly, the
public-school attendance rate itself was also associated with a substantial decrease in
adolescent BMI.
Understanding the determinants of adolescent obesity and how to effect change
in the rising trend is a national concern. Obese adolescents are at significant risk of
becoming obese adults and previous research has already shown the high economic
costs associated with adult obesity and its comorbidities. Policies implemented in
school, where adolescents consume a considerable portion of their daily calories and
participate in physical activity, can help to build healthy habits that have the potential to
lower the probability of an adolescent becoming an obese adult. Over time, a healthier
adult population may result in lower economic costs associated with medical care and
lost productivity.

DISCUSSION
(This part of the study presents the implication/s of the study, what does the it
matters, how does it fit with other researches and the perspective/ for future
researchers.)

Obesity is a serious epidemic that is increasing rapidly worldwide, especially in

developing countries. The global prevalence of overweight children ages 5 to 17 years
is 10%. Obesity is one of the most important health concerns of the Philippine
government, with the prevalence of childhood and adolescent obesity becoming a major
problem. The prevalence of obesity is associated with the rapid increase of wealth and
the dramatic impact of economic development during the oil boom in the 1930s. Studies
show that adult obesity can be predicted from childhood obesity. Therefore, the
increase in childhood and adolescent obesity may play an important role in the
increasing occurrence of cardiovascular diseases and diabetes in adults, which are the
leading causes of death.
According to the Department of Health, body mass index (BMI) is a measure of
body fat for adult men and women based on height and weight ("Calculate Your Body
Mass Index," 2016). The term “overweight” is defined as a body mass index (BMI)
between 25.0 to 29.9 kg/m2, and “obesity" is defined as a BMI at or above 30.0 kg/m2.
Additionally, there are grade categories of obesity as follows: a BMI of 30-34.9 is class I
obesity, a BMI of 35.0-39.9 is class II obesity, and a BMI of 40.0 or greater is class III
obesity ("Defining Adult Overweight and Obesity ", 2012). The BMI measurement is
frequently used in clinical and research settings to identify persons with excess
adiposity, since a high BMI can be predictive of high body fat.
Fundamentally, an effective school nutritional intervention makes positive
changes to nutrition- related behavior or an aspect of the health status for an individual,
target group, or even an entire community ("Nutrition Care Process", 2010). It is
comprised of two parts: the transmission and application of information. The disconnect
between what people know and what they practice is referred to as the “know-do gap”
(Pablos-Mendez, Chunharas, Lansang, Shademani, Tugwell, 2005)
By studying 9- to 13-year-old students, Brown, Teufel, and Birch (2007) highlight
the difficulties in both aspects of an intervention. Using surveys, they assessed over
1,000 students’ interest, understanding, and application of the presented health
information. The results suggest that knowledge does not imply application, confirming
the existence of the “know-do gap”.
In addition to emphasizing this discrepancy, one-fourth of the surveyed students
confessed difficulty in understanding the majority of the information presented to them
regarding health (Brown, Teufel, and Birch, 2007). Lacking a firm grasp of the nutritional
information taught is a key issue leaving students unmotivated or unsure of how to
adopt healthy lifestyle changes.
Early adolescents less interested in health information, and therefore unlikely to
modify their behaviors, confessed that they either did not understand or believe in the
power their current actions could have on their health later in life. Brown and colleagues'
sample included students from seven different states; this large, diverse geographical
sample allowed them to conclude that poor nutritional instruction was not a localized
problem.
Although Brown, Teufel, and Birch highlight the importance of providing
education in an accessible manner, others argue that the main challenge in nutritional
interventions is not providing information but rather motivating learners to utilize this
knowledge (Thalictrum, 2006).
Anderson, Stanberry, Blackwell, and Davidson (2001) evaluated an existing
curriculum, revealing the existence of a “know-do gap”. This study conducted a pre and
post-test among high school students, measuring the impact that 14 hours of nutritional
education had on the students’ knowledge and their food consumption. The students
were evaluated prior to taking Comprehensive Family and Consumer Sciences, a class
within the curriculum encompassing a unit on nutrition taught by a certified teacher.
After completion of the course, the students were assessed with a survey including a
57-item test and a one-day food analysis chart. The results from this intervention
indicated that while students exhibited increased knowledge after completing the
course, they failed to incorporate this information into their diets. It is worth noting that
because a 24-hour food recall technique was employed, the results may not have
accurately captured the students’ eating habits. This example suggests that it is
possible for schools to have nutritional education programs that fail to bridge the “know-
do gap”, and thus, may be ineffective in promoting change. Because increased
knowledge does not necessarily lead to healthier behaviors, my study will focus on
evaluating students’ application of information.

Barriers to Successful Interventions

To begin closing the “know-do gap,” it is important to identify any barriers that
might hinder an individual’s desire or ability to implement changes. Facilitating a focus
group comprised of 19 parents with obese children, Sonneville isolated barriers
preventing the application of healthier lifestyle recommendations. The range of
explanations offered by the parents included: a lack of information regarding how to
make appropriate changes, little support from other family members, difficulty
monitoring child behavior, economic obstacles such as time and dollar costs, difficulty
with changing habits, and child preferences (Sonneville, 2009).
Although this list seems rather lengthy, it can be condensed into a few
overarching issues. Sonneville suggests that interventions should try to involve the
entire family rather than only individuals, motivate the children to be proactive with their
own health, and implement programs at a young age. While Sonneville’s focus groups
involved adults, Gosling, Stanistreet, and Sawmi (2008) used focus groups with 32
younger students to reveal student-identified barriers.
The research assessed students’ understanding of healthy foods and the
benefits of physical activity to gauge their level of knowledge. Afterwards, students
acknowledged factors affecting the application of this knowledge; they specifically
highlighted the considerable impact parents have on their dietary patterns.
This sentiment is echoed by Surgeon General Benjamin, who has commented
that, “…the parents are the first teachers” (2010). Parents make the decisions about the
food their children eat and the amount of time spent doing physical activity; they are role
models. The barriers identified by the focus groups can be categorized as follows:
individual motivation to change, available resources, and environmental support. While
these focus groups concentrate on an array of obstacles in adopting healthy lifestyle
practices, the focus groups in my study will differ because I place the majority of the
emphasis on environmental support from the students’ school.
This strategy was adopted because the food that individual eats is determined by
an intersection of various factors, some under an individual young person's control and
others not. “In addition to personal preferences, there are cultural, social, religious,
economic, environmental, and even political factors” that affect food consumption
(Rodriguez, 2010). To reduce the gap between knowledge and application, all factors
that may hinder the intervention’s success should be taken into consideration. Focusing
on conditions existing at each middle school, and the experience of the students at a
particular school as a collective group.
Personal Motivation to Change

When delving into the elements potentially impeding the effectiveness of an

intervention, the study will start on the most basic level, the individual. One of the
leading issues with nutrition programs is that while they impart knowledge to students,
they may fail to instill a sense of responsibility for eating habits and the consequences
of these choices. Providing information does not guarantee that students are learning.
Even if they acquire knowledge, the program is not successful unless it spurs positive
changes in their lives. Not fully comprehending the role that they play in their own
health; students are unlikely to enact changes in established patterns. Therefore,
nutritional information should be taught in a manner that raises awareness and
develops a sense of empowerment in children regarding their health (Brown, Teufel,
and Birch, 2007).
Many researchers argue that it is important to have a successful intervention
when students are young because dietary habits are difficult to change once they are
established (Douglas, 1998). Mikkila, Rasanen, Raitakari, Pietien and Viikari (2005)
conducted research studying dietary patterns from childhood to adulthood. Their
findings “suggest that food behavior and concrete food choices are established already
in childhood or adolescence and may significantly track into adulthood.” Dr. David
Ludwig, Director of the Child Obesity Program at Children’s Hospital in Boston echoes a
similar view, stating: “Childhood is the ideal time to address this problem for a lot of
reasons. The lifestyle habits that cause the problem [poor diet and lack of exercise]
haven’t been entrenched as long with children as they have with adults” (Parker-Pope,
2008). Patterns in food consumption and physical activity are enormously relevant
because both are learned at a young age and major contributors to being overweight
and obese (Boyle, Maria, 2000).
The literature advocates for early health education but also recognizes that many
people lack motivation to transform knowledge into action. To better comprehend this
inconsistency, it is helpful to have a basic understanding of human motivation. Curtis
and Aunger define motivation as the distance we will go to get something we need
(2007). This definition immediately elicits the question: what do we need? Adopting an
evolutionary lens to comprehend motivation, Curtis and Aunger state that humans have
two basic needs: to survive and to reproduce. They argue that to successfully motivate
an individual, one must exploit our desire to meet these needs through our drives,
emotions, and aspirations to learn. Therefore, existing health promotion strategies may
need to be modified. Many interventions fail to recognize the significance of motivation
and are founded on the idea that individuals are rational beings with a conscious cost-
benefit analysis approach to behavior change, which it not necessarily the case. If some
interventions do incorporate motivation, Curtis and Aunger contend they isolate the
desire to be healthy, thus omitting the spectrum of motivational tools that could be used.
Because humans are able to compare the anticipated reward of future acts,
health promotion should focus on motivating individuals by emphasizing reasons to be
healthy that will resonate with our instinctual needs. One example is increasing an
individual’s physical activity; addressing the motivation of thirst and cooperation, one
might focus on how refreshing water is after exercise and the enjoyment of being part of
a team. Many of these motivations interact with the individual on a subconscious level;
therefore, the decision maker is often unaware of the exact reasons behind making their
choice (Curtis and Aunger, 2007).

Gender
When considering an individual’s decision to make healthier choices, it is
important to appreciate the moderating role that gender plays in the process.
Worldwide, females have a greater frequency of obesity than males (Kumanyika, 2007).
This higher prevalence of obesity in females is an overarching factor suggesting the
importance of looking beyond an individual to understand why people make unhealthy
choices. Kirchengast and Marosi explored this relationship using questionnaires to
study gender differences in behaviors among adolescents; in addition to examining
eating behaviors, they included questions regarding physical activity and body image
(2008). Their study included 354 females and 280 males between the ages of 11 and 18
years old. To assess changes over time, both genders were divided into a younger (11-
14) and older age group (15-18). One aspect of the study was body image; females
were significantly more likely than males to describe “their own body as unattractive and
non-athletic” (Kitching’s and Marosi, 2008). Along with poor body image, the findings
also suggested that both age groups of females were more likely to use weight loss
methods. In regard to physical activity, males were more active at all ages. It is
interesting to note, however, that the females’ physical activity decreased as they
became older while the males’ slightly increased.

Cultural and Environmental Influences

Beyond gender, it is evident that other patterns exist in society; not only does
obesity have a higher prevalence in women but also among Black, Hispanic, and Native
American populations (Benjamin, 2010). This tendency can be partially explained by
cultural influences within different societal groups, such as traditional foods, food-related
rituals, norms surrounding body image, and attitudes toward physical activity
(Kumanyika, 2007). It is important to note that “food deserts” also play a significant role
in creating racial differences in health.
African American women, specifically, have an extremely high prevalence of obesity;
data gathered from 1988-1994 revealed that 65.8 percent of black women over 20 years
of age were obese or overweight compared to 49.2 percent of white women
(Kumanyika, 2007). Baturka, Hornsby, and Schorling employed a qualitative approach
to study this trend examining African American women's perceptions of body image
(2007). They conducted 24 interviews with women 21 to 47 years of age, including a
mix of obese, overweight, and healthy weight women.
Their results indicated that the women felt a strong cultural pressure to be self-
accepting and that having a larger body was a norm encouraged by their family
members and significant others. One respondent noted that: "Most of the girls I see now
[are] just as big as I am, that’s why I don't feel bad… I look at them and feel better"
(Baturka, Hornsby, and Schorling, 2007).
The women expressed an understanding of the relationship between weight and
health; however, they frequently compared themselves to their peers and as a result did
not feel inclined to make lifestyle changes. Additionally, they vocalized a lack of social
support and resources to successfully achieve a healthier weight. A majority of the
women attributed being over-weight to factors outside of their control including family
history, traditional eating habits, and poor exercise programs or facilities in their area.
The authors suggest that health promotion can be improved by encouraging programs
to consider cultural and environmental variations in order to better address the needs of
individuals.
Beyond race, an examination of the prevalence of obesity on a global scale
indicates that cultural and environmental influences contribute to the epidemic. Among
countries in the same region, large variations in obesity rates exist suggesting that
geographical location is not a large influence on the occurrence but rather separate
factors are involved (Kumanyika, 2007).
Another study suggests the importance of environmental factors by studying
trends concerning obesity rates within a cohort of immigrants upon arriving in the United
States. After living in the United States for fifteen years, the proportion of obesity among
the immigrants had increased significantly, becoming remarkably similar to obesity rates
of individuals born in the U.S. Additionally, the immigrants' ability to maintain a normal
weight slowly declined with the duration of their time in the U.S. (Kumanyika, 2007).
This study highlights the extensive influence culture has on the obesity epidemic.

Socioeconomic Status

From 1985 to 2000, fresh fruit and vegetable prices have increased at a faster
rate than prices for high fat and high sugar food items (Food CPI and Expenditures,
2010). This common complaint is echoed often in the literature: implementing a
healthier diet is more expensive (Rawlins, 2009). Drewnowski’s research supports this
reality by comparing the prices of 370 foods sold at Seattle area supermarkets in 2007.
“The study showed that ‘energy dense’ junk foods, which pack the most calories and
fewest nutrients per gram, were far less expensive than nutrient-rich, lower-calorie
foods like fruits and vegetables. The prices of the most healthful foods surged 19.5
percent over the two-year study period, while the junk food prices dropped 1.8 percent”
(Parker-Pope, 2008). Although this suggests it is cheaper to buy less nutritious foods,
the Nutrition Services affiliated with the Schools of Health Sciences at the University of
Pittsburgh provides guidelines to avoid sacrificing good nutrition on a tight budget.
Some recommendations include: eating at home, planning meals in advance, and
making food from scratch (Eating Healthy on a Budget, 2010). While these guidelines
exist to assist people in eating healthy diets at a low cost, the implementation of these
changes is contingent on having sufficient time to do so. Buying raw materials demands
more preparation time and for a family in a troubled financial situation, money and time
might both be limited resources (Parker-Pope, 2008).
Martikainen and Marmot's research involving over 10,000 men and women
evaluated the large-scale impact socioeconomic status has on BMI (1999). Placing
participants into three categories based on salary, the study drew comparisons between
the groups. The questionnaire used included self-reports of four health-related
behaviors including smoking habits, alcohol consumption, assessment of diet, and
physical activity. Participants also answered questions measuring their work decision
authority, skill discretion, and the degree they felt in control over their health. Physical
measurements such as blood pressure, cholesterol, and body mass index were also
taken. The results reveal that for both men and women, socioeconomic status was
strongly related to BMI and, furthermore, individuals with lower salaries gained
considerably more weight than those with higher incomes over the three-year time span
of the study. While the determinants of these differences are not fully known, the study
does provide evidence that this relationship exists (Martikaninen and Marmot, 1999).
While this relationship has been well established among adults, it “appears weaker and
less consistent in children”; the overlapping nature of socioeconomic status and
race/ethnicity on the pervasiveness of childhood obesity creates difficulty in separating
the confounding variables (Bishop, Middendorf, Babin, Tilson, 2005).

Accessibility
Regardless of knowledge, motivation, financial resources and time, there is still
the issue of availability. In order to make nutritious meals, people need to be able to
purchase fresh fruits and vegetables at a reasonable cost. A "food desert" is the term
used to describe an area where supermarkets are typically nonexistent, fresh produce is
unavailable or extremely expensive, and the area is heavily populated with convenient
stores and fast-food chains.
Asian, and African American adolescents while white children consumed at a
much lower rate of 38 percent (Hastert, Babey, Allison, Diamant, and Brown, 2005).
This study underlines the reality that without adequate alternatives, unhealthy meals
become the only convenient and viable option for families living in food deserts.
Another factor to consider is "recreational deserts". Similar to food deserts, these
are areas that lack resources to provide a safe opportunity to be physically active
whether due to inadequate facilities, poor outdoor lighting, or a limited amount of open
space (Duncan, 2010). When considering nutritional education programs on a national
level, these are principal issues.

Supportive Environment: Home and School

Though the literature highlights a whole host of societal influences that impact an
individual’s decision to make healthy choices, we should not resign ourselves to
believing that childhood obesity is inevitable. Through collaboration between an
individual, their family, and community, a supportive environment can be created where
adoption of a healthy lifestyle is an easy option (Satcher, 1996). Children participating in
focus groups with Gosling, Stanistreet, and Sawmi (2008) highlight this reality. When
asked how they might be helped to eat healthier, several children identified parents as
having ultimate authority regarding their diets, determining what and where they eat.
Parent-based focus groups vocalized a similar appreciation for the influence they held
over their child's diets (Sonneville, 2009). Variyam, Lin, Ralston, and Smallwood who
utilize quantitative surveys reveal further support for this relationship. Their findings
indicate that mothers’ general knowledge and health has a significant influence on their
children’s diets (1999). Knowing that young children’s consumption is a reflection of the
knowledge and patterns of their parents, a successful intervention program needs to
target both parents and the young children (Variyam, Lin, Ralston, Smallwood, 1999).
While parents have a large responsibility concerning the health of their children,
schools also need to acknowledge their influence. Outside of their homes, children
spend more time in school than any other environment (Babey, Hones, Yu, Goldstein,
2009). Snelling and Kennard reveal how the items a school cafeteria offers can impact
the purchases made by students (2009).
Using a three-category labeling method, they analyzed the nutritional value of
competitive foods offered both before and after the installment of stricter cafeteria
standards. Nutritious, low-calorie foods that are rich in vitamins, minerals, and fiber
were labeled green; these items should be eaten with every meal. Foods moderate in
calories and generally lower in fat were labeled yellow because although healthy, they
should still be consumed in moderation. Lastly there were red foods, which have a large
number of calories and minimal nutrient value; some examples include fried foods, full-
fat potato chips and foods with rich sauces. After comparing the rate that these foods
were offered and purchased, Snelling and Kennard reevaluated the amounts two years
later once stricter regulations were installed. Once the standards had been
implemented, only 30 percent of the items offered were red foods compared to the
previously higher figure of 48 percent. This correlated with a considerable decline in the
number of red foods purchased, from 83 to 47 percent. The purchase of yellow foods
also increased from 6 to 34 percent. It is unknown the exact number of students that
purchased the exact number of healthier options and it is also unknown how much of
these purchases were consumed. Another limitation of the study is that it was not
known if changes in the health curriculum occurred during the two-year time period.
Regardless, Snelling and Kennard (2009: 545) argue that offering healthier foods in
cafeterias: "…appears to have a direct and immediate impact on the nutritional value of
the foods purchased by students."
The Centers for Disease Control asserts that for nutrition programs to be
successful the schools need to integrate the nutritional education with the food service
in order to reinforce the messages of healthy eating (1996). Snelling and Kennard have
provided an example of an effective policy change that enabled schools to become a
supportive environment for healthy dietary patterns. This suggests that with 31 million
children eating school lunch every day and 11 million consuming school breakfast, it is
important that schools are providing nutritious options (Merrigan, 2010).
A study conducted by Project Healthy School staff analyzing the behaviors and
physical measurements of over 1,000 sixth graders found that students who purchased
the school lunch regularly were 29 percent more likely to be obese compared to their
peers who brought lunch from home (2010).
Schools have the ability to create supportive environments for the
implementation of nutritional programs. One approach adopted by a school in Alabama
suggests that increased teacher involvement and school support results in a higher
success rate of the program. The goal of the “experimental learning approach” was to
“increase fruit and vegetable knowledge, preference, and consumption among second-
grade students” (Parmer, 2009). In order to properly assess the achievement of this
goal, students were divided into three categories. The first group received nutritional
education and was involved with the garden, the second group only received the
nutritional education, and the control was not exposed to either component.
The nutrition lessons were taught every other week for one hour and garden
lessons were also one hour on the alternative weeks for students participating in both.
The duration of the intervention program was 28 weeks and measurements were taken
with self-reported questionnaires and lunchroom observations both before and after the
program. Students also had a tasting session rating their preference of selected fruits
and vegetables. The results of this study revealed that students who were taught
nutrition in the classroom and involved with the gardens ate significantly more
vegetables compared with their consumption prior to the program. This intervention
reveals that the more exposure to nutrition lessons the students had, the more likely
they were to implement the changes into their own lives. The school utilized in-class
instruction concomitantly with gardening to create a supportive environment for the
students to learn and understand the material presented. This learning experiment
encapsulates the Centers for Disease Control recommendation for school health
programs to involve fun participatory activities that incorporate social learning strategies
(Satcher, 1996).

REFERENCES:

LETTER ASKING PERMISSION

Ma’am:
Greetings of Love, Peace & Respect!
The undersigned is presently on the last stage of her Master of Arts in Education
major in Special Education. She / He is conducting research entitled
________________________________________________________.

In order for the researcher to finish the said paper, a survey questionnaire has to
be floated to the respondents.

In this regard, may the researcher seek your approval for the conduct of the
study at (your school).

The researcher conveys his/her utmost gratitude for the support you accord to
him / her with regard to his / her study.

Respectfully yours,

Noted By : (Your Name)

Student – Researcher
Dr. Abner V. Pineda
Dean

LETTER TO THE PARTICIPANTS / RESPONDENTS

Dear __________:

Greetings of Love, Peace & Respect !

The undersigned is presently on the last stage of her Master of Arts in Education
Major in Special Education. She is conducting a research entitled ____
_____________________________________________________________.

In order for the researcher to finish the said paper, a survey questionnaire has to
be floated.

In this regard, may the researcher seek your ample time to answer the attached
survey.
The researcher conveys her utmost gratitude for the support you accord to her
with regards to her study.

Respectfully yours,

(Your name)
Student – Researcher
Appendix D

MATRIX FOR DEVELOPMENT AND VALIDATIONS OF (title)

Part l. Profile of the obese / overweight pupils in terms of :

1.1 Name ______________________________________________ (optional)

1.2 Grade and Section :
1.3 Socio economic Status

Part ll. This set of questions is about your children’s eating habits and physical
activity. The first few questions ask about food, and the rest of the questions
should be answered for each of the children in your household. Your
participation in this survey is voluntary and all answers will be kept confidential.
If there is a question that you do not wish to answer, you can skip it and move on
to the next question. We are hoping that the information we get from this survey
will help us understand the eating behaviors of children in our community.

Thank you for completing this survey.

Please indicate whether you strongly agree, somewhat agree, somewhat

disagree, or strongly disagree with the following statements:

2.1 Some people are born to be fat and some thin; there is not much you can do
to change this.

01 Strongly agree; 02 Somewhat agree; 03 Somewhat disagree; 04 Strongly disagree

2.2 What you eat can make a big difference in your chance of getting a disease,
like heart disease or cancer.