PREVALENCE OF OBESITY AND ASSOCIATED FACTORS AMONG CHILDREN (3-6 YEARS). A COMPARATIVE STUDY OF URBAN AND PERI-URBAN MOMBASA, KENYA BY: CAROLYNE NEKESA.

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 THEUNIVERSITY OF NAIROBI

DEPARTMENT OF FOOD SCIENCE,NUTRITION AND TECHNOLOGY   

2014   

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Supervisors 2

Professor J.K ImungiDr. George Abong OokoDr. Cathrine Macharia Mutie

TABLE OF CONTENT3

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

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2.1 Definition of Overweight and Obesity…………………. 102.2 Current status of Overweight and Obesity…………… 112.3 Health consequences of Overweight and Obesity….142.4 Predisposing factors of Overweight and Obesity….. 152.4.1 Dietary factors……………………………………………….. 162.4.2 Environmental factors……………………………………. 172.4.3 Cultural and Societal factors…………………………… 182.4.4 Television and advertising………………………………. 182.4.5 Physical activity…………………………………………….. 192.4.6 Genetic Factors……………………………………………… 192.5 Assessment of overweight and obesity………………… 212.6 Gaps in Knowledge…………………………………………… 23

CHAPTER THREE: RESEARCH DESIGN AND METHODOLOGY

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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

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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

APPENDICES7

APPENDIX 1: CHILDREN’S QUESTIONNAIRE....40APPENDIX 2: TRAINING SCHEDULE FOR RESEARCH

ASSISTANTS…………………………… 46Appendix 3: BUDGET…………………………………. 47APPENDIX 4: MOMBASA COUNTY MAP……. 49Appendix 5: SCHEDULE OF ACTIVITIES……. 50APPENDIX 6: LETTER SEEKING CONSENT FROM

SCHOOLS………………………………………………….. 51 

Chapter 1.1 Background information8

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.

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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 information10

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 information11

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 information12

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 %

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Other studies have also established that obesity rates among 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 information14

The Government and some NGOs have put strategies in 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.

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1.2 Statement of the problem16

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 problem17

School tuitions where children spend long hours in school could be contributing to lack of physical activity.

Physically, there is obesity among children especially 6-12 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 problem18

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 Justification19

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

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.

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1.4 Aim

The aim of this study is to contribute towards improving the health status of the children through tackling the determinants of over nutrition.

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1.5 Purpose

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.

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1.6 OBJECTIVE OF THE STUDY

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 OBJECTIVES1. 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

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1.6.3 Research questions

What is the nutrition status of the children 3-6 years?What are their snacking habits? What do they carry in

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 hygieneHow is the school environment? How does it affect

physical activity.

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1.7 Null Hypotheses

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

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1.8 Assumptions and limitations

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.

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1.9 Benefits

The study will provide data that will help increase 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

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2.0 Chapter Two: Literature review28

2.1 Definition of Overweight and Obesity…………………. 102.2 Current status of Overweight and Obesity…………… 112.3 Health consequences of Overweight and Obesity….142.4 Predisposing factors of Overweight and Obesity….. 152.4.1 Dietary factors……………………………………………….. 162.4.2 Environmental factors……………………………………. 172.4.3 Cultural and Societal factors…………………………… 182.4.4 Television and advertising………………………………. 182.4.5 Physical activity…………………………………………….. 192.4.6 Genetic Factors……………………………………………… 192.5 Assessment of overweight and obesity………………… 212.6 Gaps in Knowledge…………………………………………… 23

2.6 Gaps in knowledge29

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 knowledge30

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 designA 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 siteThe 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 topography32

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 conditions33

The County lies within the coastal strip in the hot tropical region where the climate is influenced by monsoon winds. 

RainfallThe 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.

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TemperatureThe 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 educationThere are 254 ECDE centres within the county

with a population of 26,080 student and 612 teachers.

3.2.1.7 Health care

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The county hosts the coast level five hospital which is a 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 Population36

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 frame37

3.3.1 Sampling procedures.38

Purposive sampling was used to select the target geographical area 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 determination39

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

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3.4.1 Data collection toolsPreviously pretested structured questionnaires

for demographic and socio economic informationFood frequency questionnaires for dietary

assessmentActivity profileQuestion guideAnthropometric data sheet for weight and heightObservation 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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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.

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Time Content Method

Day 1 8.30 -9.009-10.30

Climate setting and introductionOverview of the topic, purpose of study and objectives

BrainstormingLecture and brainstorming

10.30-1100 Break

Day 1 1100-1300 Overview of data collection tools and sampling procedures

Lecture and demonstration

Lunch Break

Day 2 1400-1600 Review data collection equipment and calibration

Lecture and

demonstration

0830-09300930-1030

RecapPractice use of the research tools and equipment

Role-plays

discussion

1030-1100 Break

1100-1300 Continue with practiceRole play

Day 3 0900-1300 Pretesting the questionnaire in the nearby school

1400-1600 Feedback and planning for data collectionWay forward

Brainstorming

APPENDIX 2:RECRUITING AND TRAINING SCHEDULE FOR RESEARCH ASSISTANTS

3.6 Data Analysis

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Information from the questionnaires will be checked, 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.

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Year 2014 Year 2015

Activity J F M A M J J A S O N D J F M A M J J A

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

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Item Quantity Unit cost

No. of days

Total cost

1.0 personnel1.1 Researcher 1 10

1.2 UON supervisor 1 3

1.3 Research assistants

1.4 EnumeratorsField guides

22

1010

1.5 Software expert consultation 1 5000

Sub total 5000

2.0 Stationery

2.1 Proposal writing/ correction printing 5 200 5@200 1000

2.2 Research notebook 1 1000 1000

2.3 Purchase statistical package 1 2000 2000

2.4 Pens,notebooks,pencils,erasersharpenerclear bag

444444

205025101545

4@204@504@254@104@154@45

620

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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

subtotal 9960

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 SupervisorReturn air ticket

1 2x7500 15000

3.4 Taxi to and from airport 2 5000 2x2500 5000

3.5 Researcher’s lunch allowance for pretesting

1 500x1 500

3.6 Researcher’s lunch during data collection

1 500x10 5000

3.7 Refreshments in training 5 100 5x100x3 1500

3.8 Hall hire 500x3 1500

3.9 Training the research assistants /Allowances

4 200 800x3 2400

3.10 Salaries

Research assistants 2 1000 10x1000x2 20000

Field guides 2 500 10x500x2 10000

Subtotal 85400

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Item Quantity Unit cost No on days total

4.0 Equipment

4.1 Scales hireHeightboard hire

22

15001500

2x15002x1500

30003000

Subtotal 6000

5.0 Communication

5.1 Airtime for modem 1 3months 2000

5.2 airtime for research assistants 2 100 10x100x2 2000

5.3 Ministry of Education permit 1 500

5.4 Permission from schools 1 free

5.5 permission from MOH 1 free

Subtotal 4500

6.0 Data entry and analysis

5% Contigency 5543

Grand total 116403

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Anderson, P.M. and Butcher, K.F. (2006). Childhood obesity: trends and potential causes. Future Child. 16: 19-45. Approaches, ACT press Nairobi, Kenya.

Bertoncello, C. Cazzaro, R. Ferraresso, A. Mazzer, R.and Moretti, G. (2008). Prevalence of overweight and obesity among school-aged children in urban, rural and mountain areas of the Veneto Region, Italy. Public Health Nutr; 11(9):887–890. [PubMed]

References

Doak, C.M., Visscher, R.L.S., Renders, C.M. et al. (2006). The prevention of overweight and obesity in children and adolescents: A review of interventions and programs. Obesity Reviews,2006. 7, 111-136

KNBS(2008/9).Kenya Health Demographic SurveyMOH(2013).Kenya Nutrition Bulletin.Ogden, C. L., Carroll, M. D., Curtin, L. R.,

McDowell, M. A., Tabak, C. J. and Flegal, K. M. (2006). Prevalence of Overweight and Obesity in the United States, 1999-2004. The Journal of the American Medical Association, 296, 1549-155

51

52

WHO(1998). Obesity; preventing and managing the global epidemic,Geneva:WHO.

WHO ( 2000). Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser 894:1 253[http://whqlibdoc.who.int/trs/WHO_TRS_894.pdf], (accessed September 1, 2010)