Facilitators of Weight Management and Healthy Eating Among School Children

Abstract

Parents play a critical role in influencing the eating habits of their children. This study examined parents’ perceptions of factors that contribute to childhood obesity and sought their suggestions on various modalities of overcoming barriers to healthy eating in children. Semi-structured in-depth interviews were undertaken with 26 parents of 9-13 years old school children with obesity from the United Arab Emirates. Three key areas the interviews covered were: (1) Parents’ perceptions of their children’s weight and eating habits; (2) Attitudes towards healthy eating and weight management, and (3) Suggestions on how their children can adopt a healthy lifestyle. Interview transcripts were thematically analyzed using the NVIVO software to identify the emerging main themes and sub-themes. Parents identified individual/intrapersonal (child), interpersonal (peers, family, maids) and institutional/school environment) barriers and facilitators to a healthier lifestyle. The three major themes that emerged were: (1) Negative effects of obesity on children’s lives; (2) Barriers to weight management and healthy lifestyle, and (3) Facilitators to healthy eating. Nutritional education and a supportive home and school environment were suggested in the adoption of healthy lifestyles by children.

Introduction

The prevalence of childhood and adolescent obesity remains a significant burden globally. [30]. Obesity in children below five years of age exceeds 40 million [30, 2] and those older than 5 years and adolescents have reached over 330 million [30]. The global challenge posed by obesity has prompted the World Health Organization to start a campaign called “no increase in childhood overweight by 2025” [31]. The initiative targets prevention of various diseases associated with childhood and adolescence obesity [8, 30]. The short-term effects of obesity in school children include psychological conditions such as low self-esteem, anxiety, depression, and liver complications [32]. Furthermore, the potential long-term effects include heart disease, type 2 diabetes, and some types of cancer [30]. The risks of these illnesses progress into adulthood and may cause musculoskeletal deformities and even premature deaths [8, 19]. Therefore, curbing obesity prevalence is crucial in reducing the incidences of chronic illnesses in adulthood.

The Middle East is one of the regions with high adolescent obesity prevalence globally [5]. In the United Arab Emirates (UAE), an alarming upsurge has been observed in most schools [20]. Notably, in the last two decades, overweight and obesity cases have increased by two folds in adolescents aged 11 to 18 years [33]. The prevalence of obesity has dramatically escalated from 21.2 to 35.6-42.1% nationwide [20]. Moreover, studies indicate that the annual increase in childhood obesity nationwide is 2.36% in children and adolescents aged 3 to 18 years [3, 34, 35]. Furthermore, several studies have reported a high prevalence of adolescent obesity in UAE students [3, 34, 35]. Bani-Issa et al. [5] revealed that the obesity prevalence in UAE schools is 34.7%. In Ras Al‐Khaimah public schools, students aged 11-18 years showed an obesity prevalence of 38-41.2 % [3]. Similarly, Pengpid and Peltzer [20] suggested that in pre-teenagers and teenagers aged 8 to 14 years in UAE schools, the obesity prevalence in males (42.1%) was considerably higher compared to females (35.6%). Therefore, it is crucial to develop effective strategies for reducing adolescent obesity in the UAE.

Parents are instrumental in promoting healthy eating and dietary practices in school children aged 9 to 13 [36]. Moreover, these are parents who form the eating habits of pre-teenagers and teenagers. [4]. Parents’ knowledge and attitude toward healthy eating influence their food selection, meal pattern, and level of physical activity (6). Eventually, parents’ food choices impact the children’s weight and nutritional status [13, 7]. Moreover, studies suggest that including parents in the prevention strategies can substantially improve the weight of their obese children [36, 6, 8]. Previous research identified obesity risk factors in children to include high consumption of fast foods and sugar, low intake of fruit and vegetable, sedentary lifestyle, as well as eating large portions of foods [4, 15]. Although there is a consensus globally that prevention is a crucial strategy of reducing the obesity rate, limited success has been achieved so far in implementing this approach in school children alone [37]. Parents play a critical role in influencing the dietary habits of children in their early years [13, 9]. However, the suitable strategies for supporting parents in improving their children’s nutritional status remain unclear. Nonetheless, seeking parents’ opinions on how to promote healthy eating and exploring their attitudes towards their children’s eating behavior and physical activity is crucial in developing effective prevention strategies [13, 4, 2].

This study explored the views of parents on factors that contributed to childhood obesity and sought their suggestions on possible ways of overcoming barriers to weight management and the adoption of a healthy lifestyle.

Materials and Methods

Study Design

This is a qualitative study involving in-depth interviews with parents of 9–13-year-old children with obesity who attended government schools in the Emirates of Sharjah and Dubai in the UAE. A qualitative research method was deemed to be the most appropriate in studying parents’ perspectives on childhood obesity (opinions, experiences, and suggestions), allowing themes to emerge. The parents were invited to obtain their views on factors that contributed to childhood obesity and sought their suggestions on possible ways of overcoming the barriers to weight management and the adoption of a healthy lifestyle among school children. The study was conducted to use the results in assisting the development of a planned intervention for overweight and obese 9-13-year-old children in Dubai and Sharjah. Data was collected from September to November 2021.

Participant Recruitment

The purposive sampling technique was used to recruit parents of 9-13 school children with obesity whose children were attending public schools in Dubai and Sharjah. Purpose sampling allows the selection of participants based on predetermined criteria relevant to a particular research question (Huberman & Miles, 1994). The basis of sample size determination was data saturation. Parents of overweight/obese 9-13-year-olds participating in a school-based intervention were contacted through emails explaining the purpose of the study and the main topics that will be discussed during the interview. They were invited to attend a single in-depth individual interview. Those interested were asked to confirm their willingness to participate by responding to the email and choosing their available date and time for the interview. Of those contacted, 35 parents accepted to participate in the interviews.

Semi-Structured Interviews

A semi-structured interview guide (Supplementary Material: Table S1) was developed as a guide during the interview process. It contained 13 key questions focusing on three main areas: (1) the perception of the parents regarding their children’s weight and eating habits, (2) their attitude towards healthy eating and weight management through nutritional interventions, and lastly, (3) their suggestions on how the parents and the school administration can support the children in adopting a healthy eating pattern and effective weight management. The research team consisting of a nutritionist and a university faculty member developed the 13 questions guided by related literature [9, 18, 26, 27]. Prior to initiating data collection, the interview guide was translated to Arabic and subjected to content validation [7]. This was subsequently pilot-tested with 6 parents of children aged 9-13 years with obesity (three females and three males). Necessary modifications to the questions before use for the study were made accordingly. In-depth semi-structured individual interviews were conducted with parents of 9-13-year-old school children with overweight or obesity.. The interviews were conducted in Arabic over the phone which was their preference using Arabic. The interview duration ranged between 45-60 minutes including the time used to explain the purpose of the interview. Additional probing questions were used to seek further information or clarifications when needed. All the interviews were collected by a female native Arabic-speaking senior nutritionist trained in qualitative research data collection techniques. All discussions were audio-recorded. At the beginning of each interview the interviewer obtained the participant’s verbal consent, explained the purpose of the study, and assured the participant of the confidentiality of the discussions. The participants were also informed that they have the right not to answer any question they do not want to answer or discontinue the interview at any time. In addition, they were assured that all the information collected will remain confidential and will be used only to meet the purpose of the study. Throughout the data collection, the interviewer was reflecting on the interview guide and on her attitude during interviews in effort to reduce interviewer bias [22, 29]. Probing questions were used to obtain additional details when necessary The recordings were listened to as the interviews progressed to identify topics to explore in subsequent interviews. After 26 interviews, data saturation was achieved, and the process of data collection was concluded.

Data analysis

The interview recordings were used to transcribe the discussions verbatim in Arabic. The transcripts were translated into English by the interviewer so that the text-based analysis can be performed using the NVIVO software (NVIVO, 12, QSR International). Translated interview transcripts were imported into NVIVO 12 to conduct the analysis and facilitate the development of the codes using an inductive approach [6]. The constant comparison method [24] was used to identify recurring data, create categories, systematically compare them, and group them into themes. As the interviews progressed, data was analyzed (i.e., concurrent data collection and analysis) and the interview questions were refined with additional probes in line with the qualitative research methodology [21]. The transcripts were read multiple times to familiarize with the data and to identify initial codes. The codes were constantly compared and then grouped into categories/subthemes, which were later also grouped into themes [6]. The coding was performed by the first author (SZ) and the coding assignment and appropriateness of the codes to the assigned themes and sub-themes were reviewed by the third author (HIA) who has an extensive background in qualitative research (HIA). Any inconsistencies were resolved through discussion to reach a consensus.

Quality Assurance

Multiple approaches were employed to enhance the quality of this research. The equivalency of the Arabic transcriptions and the translations of Arabic into English were checked by two in-dependent reviewers fluent in both Arabic and English. In addition, 15 of the recorded interviews were sent to external reviewers along with the translated transcript to check the consistency of the English translation against the Arabic recordings. Finally, the translated summary of the interviews was sent to six parents who were fluent in English to confirm the accuracy of the translated text with the discussions during their interviews. Participant quotes that support the emerged themes and sub-themes are presented in the Results section. To enhance credibility, the interviews were recorded, transcribed verbatim in Arabic and participant quotes are provided in the Results. The interview transcripts were shared with the participants to confirm the accuracy and English translation of the Arabic transcripts and the transcription of the Arabic from the recordings underwent independent reviews.

Results

A total of 26 parents participated in the individual interviews, with the majority (88%) being females. All interviewed parents were Emiratis, and the vast majority were working (92%). Only two interviewed parents reported being separated from their partners (8%). Table X below presents the demographic information of interviewed parents.

Table 2: Demographic information of interviewed parents

Results of the thematic analysis of conducted in-depth interviews transcripts identified 3 main themes: (1) Negative effects of obesity on children’s lives; (2) Barriers to weight management and healthy lifestyle, and (3) Facilitators to healthy lifestyle. There were 8 related sub themes related to the 3 major themes (Table 3). The themes are categorized into three groups, namely Individual/intrapersonal (child), interpersonal (peers, family, maids, etc.) and institutional/School environment)

Table 3: Themes and sub-themes

Theme 1: Negative Effect of Obesity on Children’s Lives

Being overweight has various negative effects on children’s lives at the physical and psycho-social levels, as mentioned by interviewed parents. The parents were informed that their children’s weight affects their ability to play with friends. One of the interviewees, a male father of an overweight child, stated,

“My child’s weight is greatly affecting his life. He wishes he could run with his friends and ride a bike, but he can’t because of his weight.”

Individual/intrapersonal issues

Negative effect on Self-esteem: Parents mentioned that obesity results in social isolation of children which can be attributed to an intrapersonal barrier of low self-esteem. Due to the presence of stereotypes concerning weight, children with obesity tend to develop self-esteem issues, thus, choosing to abstain from communicating with others. It leads to limited interactions with peers which negatively impacts the child’s development of social skills and adoption of a healthy lifestyle. The mother of one of the children commented,

“His weight stops him from playing with other kids, which means his social skills will not develop over time; and for sure, this will affect his psychological well-being. Therefore, he will not be motivated to achieve his goals.”

Interpersonal issues

Social isolation and Poor social skills: Social isolation can be caused by bullying from peers, as another woman points out:

“He is being bullied at school and among his friends because of his extra weight, and this is what makes him hate going to school and hate studying and playing with his friends.”

Some parents mentioned that their children’s weight is not affecting their children’s lives now. However, they expressed concern about their prospects,

“While my child is a little bit overweight for his age, I believe his weight does not stop him from achieving his goals at the moment, but in the future, it may become a major limitation”. Therefore, peer pressure and bullying can be seen as major interpersonal barriers.

Institutional/School environment issues

Bullying by schoolmates: A lack of support from classmates addressing the needs of children with obesity issues needs to be considered. Indeed, the cases of bullying and harassment are becoming more common as children grow and begin to compete for their status in class or other school groups. One mother noted,

“My son is constantly insulted by his classmates who call him a lame duck and a loser. The bullying intensifies after physical education classes when other school children make jokes out of his inability to do some exercises”.

Poor academic performance and Lack of interest in school: These two can also be conducive to weight gain. Indeed, bad marks serve as stress factors that may trigger overeating to suppress anxiety. Three parents noted that getting bad marks at school made their children eat more at home to curb the feeling of failure.

Lack of interest in school may also serve as a trigger of weight gain. Indeed, two parents noted that their children have no interest in classes and have snacks to fill in the time. One mother said,

“My daughter complains of being bored at school with no interesting subjects or teachers who can inspire her in her studies. She claims that the dining room during the breaks is the only place she gladly visits since the snacks they offer there are delicious”.

Theme 2. Barriers to a Healthy Lifestyle

During the interviews, parents discussed and highlighted various perceived barriers hindering their children from eating healthy and enjoying a healthy lifestyle which eventually caused them unwanted weight gain. Barriers are described in this study as factors that make weight loss or sustaining a healthy lifestyle difficult for children aged 9-13 years. The discussed barriers are segregated into three categories: Individual/intrapersonal (child), interpersonal (peers, family, maids), and institutional/School environment).

Individual/intrapersonal barriers

In this study, individual/intrapersonal barriers are considered to be all barriers existing within the child. These barriers were reflected in the following sub-themes:

1. Sedentary lifestyle,
2. Personal food choices,
3. Lack of motivation to exercise,
4. Low nutrition knowledge.

Sedentary lifestyle: With the emergence of COVID-19, children were bound to stay and study from home for long periods. It also drastically reduced their time out and their activities with their friends, hence, reducing their physical activities. As one of the mothers commented on her son’s behavior:

“His weight is constantly increasing.” He is less mobile due to sitting in front of the computer for long periods because of remote education”.

In addition, parents discussed their concerns about their children’s preference to stay at home and engage in social media and video games,

“I believe that the main reason my child is overweight is that he does not move enough, and his only activities involve watching TV and sitting in front of the computer.”

Personal food choices: Children’s tendency for fast/junk and pre-prepared foods and their preference for some food items over others, also influence their lifestyle. Parents reported that their children prefer fast foods over more healthy dishes. Moreover, some said that their children are not willing to decrease their consumption of unhealthy meals,

“His love for food that is full of calories, flavors, and harmful juices is the main issue. Most of the time, he refuses to eat healthy snacks.”

The other personal barrier the parents revealed was the unwillingness of their children to reduce the consumption of unhealthy snacking. One of the parents pointed out that their children excessively love breakfast consisting of junk food,

“He loves breakfast with biscuits and chips and loves to eat noodles and pastries daily”.

Low nutritional knowledge: The lack of a credible source continuously disseminating nutrition and food-related information hinders establishing healthy nutrition practices. Parents mentioned their need for credible sources of nutrition information:

“I believe that my son’s lack of knowledge on how certain foods have to be consumed in moderation is the main problem that causes him to have such big portions of snacks that he consumes almost daily. More accessible knowledge about healthy eating could help to encourage children to eat more healthy food”.

Interpersonal barriers

For the purpose of this study, interpersonal (peers, family, maids) barriers are considered to be the factors that stem outside the child which include a relationship with parents, family, maids, and others. These external barriers were reflected in the following sub-themes: (1) Perceived bad influence of peers and social media, (2) Parent’s role in children’s lives and (3) Nannies’ engagement.

Peer pressure: The parents identified peers as the other critical areas of concern. One of the parents revealed that some children may tend to eat unhealthy foods when they are in the company of their friends,

“My son often drinks sodas when he is with friends.”

Moreover, the option of controlling what their children eat in the company of their friends elicited mixed reactions. Some of them admitted talking to the parents of the other children to discourage the unhealthy habits, whereas some were reluctant. Some parents also revealed that healthy traditional meals are rarely showcased on social media compared to unhealthy ones and attributed them to unhealthy eating habits. A mother of a slightly overweight child stated,

“As I noted earlier, his sudden obsession with fast food is the main factor affecting his weight. Perhaps this new eating habit was influenced by the social media and his school fellows.”

Limited parent engagement: Parents’ preoccupation with their jobs and careers, especially mothers, negatively affected the children’s healthy eating habits and, in some cases, gave them the chance to eat whatever they wanted without proper monitoring. An illustration of this is the statement of the father of one of the children,

“I think that the fact our son is almost fully responsible for what he eats, and we cannot monitor him, is the main factor why he cannot control his portion sizes and the types of products he consumes.”

Moreover, the majority of parents mentioned that their busy and demanding work schedule results in their inability to cook healthy food, feed their children healthy food or monitor their children’s eating habits and food portions. The mother of one of the children noted,

“Since I am a working mother, I do not have much time to cook healthy meals daily. Most of our meals consist of frozen food or food filled with starchy foods such as rice and pasta, in addition to our heavy reliance on takeaway.”

Parents’ unhealthy eating habits were also identified among the underlying factors of children’s unhealthy eating patterns. One mother commented on her son’s behavior,

“During the weekends, we often go out to fast-food restaurants or order food at home, so he sees me engaging in similarly bad dietary behavior. I believe that the fact that his dad and I have never been preoccupied with healthy eating has negatively influenced my child’s own eating preferences and led to his weight gain.”

In addition, parents identified that buying their children sweets and sweetened juices and keeping these products at home is also one of the internal barriers hindering their children’s ability to have a healthy lifestyle.

Unsupportive Nannies: The engagements of the nannies in children’s everyday life might affect their healthy lifestyles. According to some mothers, the nanny might be less strict with children than parents,

“…The nanny usually gives him anything just to keep him quiet and safe, so he picked this habit of having whatever he desires without any restrictions. This behavior allows nannies to keep the child in a positive mood but significantly affects their eating habits”.

Institutional/School environment barriers

This study defines institutional/School environment barriers as factors that originate from the school environment which limit healthy lifestyle or healthy weight maintenance among school children aged 8-14 years old. The sub themes identified for this category include:

1. Lack of nutrition education in schools
2. School demands lead to stress eating and lack of time for physical activities

Lack of nutrition education in schools: Most parents noted that the children are not taught nutrition education at school. The school curriculum does not specifically focus on the need for healthy eating habits and how to achieve them. Parents cited that most of the children are not able to use the knowledge acquired in school in general science classes as they do not relate it to their daily lives. As stated by one parent,

“My son knows different food categories and their functions but still cannot use it to control his food portion. The knowledge is too abstract.”

School demands limited time for physical activities: The busy schedules in school and the demand that school has on the children, create anxiety for most students. One of the parents said,

“My daughter, instead of losing weight, gains more weight due to the stress of schoolwork. She tends to eat a lot of snacks when she comes from school and does not control her portions.”

Another parent noted that her son comes home with a lot of homework he does not find time for physical activity or exercise,

“Nowadays, teachers demand more from kids and the amount of homework is mind-blowing. My kid goes to school to study, then comes back to study even more. He doesn’t have any time for exercise.”

Theme 3. Identified Facilitators for a Healthy Lifestyle

Throughout the interviews, parents mentioned and discussed various perceived facilitators (enablers) that might positively affect their children’s attitudes and behaviors toward a healthy lifestyle. These facilitators are presented in three categories: intrapersonal, interpersonal and institutional facilitators

Intrapersonal facilitators

For the purpose of this study, intrapersonal facilitators are to consider all the factors that children can do to optimize their healthy lifestyle. These facilitators were reflected in the following sub-themes:

1. Motivation to engage in physical exercise
2. Healthy eating behaviors.

Motivation to engage in physical exercise: Intrinsic motivation is an important facilitator of healthy lifestyle. Parents have reported that the children lose more weight when they are self-driven than when being pushed. Taking personal responsibility for their health makes the children more engaged in physical exercise. Additionally, with motivation, they are not easily discouraged when things are difficult and the goal is not achieved instantly. As reported by one parent, her son had shown significant improvement when he was enthusiastic about his physical activities.

Healthy eating behaviors: Healthy eating habits are identified as one of the facilitators of healthy lifestyles. As reported by parents, healthy eating habits include eating patterns such as food portion control and food substitution. One of the parents indicated that substituting healthy snacks like fruits and vegetables for snacks with refined sugar is important in weight loss and control journey. The parent commented,

“Sugar is essential for young children, yet candy with harmful ingredients can easily be replaced with fruits or foods cooked with organic ingredients.”

The parents noted that despite it being hard for children to practice healthy eating behavior, once they recognize the importance, they can stick to it. According to the parents,

“The children can learn the importance of healthy eating by watching documentaries or learning how junk food is made.”

Interpersonal Facilitators

In this study, interpersonal facilitators are considered as all the factors that encourage and optimize children’s healthy lifestyles that are outside the control of the children. These interpersonal facilitators were reflected in the following sub-themes: (1) Parents’ perception of and knowledge about the importance of following a healthy and diversified diet (2) Parents positive attitude towards being engaged in the change and (3) Advice from a Specialist in nutrition and health.

Parents’ healthy lifestyle perception: Parents discussed their knowledge about the benefits of following a healthy lifestyle and highlighted their perception of the importance of adopting this behavior for their children’s health in the future as adults. One of the mothers stated,

“Nutritional and health fields are very important as they are responsible for our psychological and nutritional health. If our food is healthy, we will be in the best physical and psychological health.”

Parents’ positive attitude: The parents expressed their positive attitude toward being involved with their children to be within their journey toward a healthy lifestyle. They mentioned being ready to change their eating habits to influence their children to positively change their unhealthy eating habits. One mother also expressed their willingness to cook healthy food weekly for their children,

“I can adopt a new healthy food plan by encouraging my son to eat food full of healthy vegetables and vitamins by buying an air fryer to cook with.”

In addition, parents mentioned that they are ready to engage with their children in conversations about healthy food and the importance of following healthy eating habits and a healthy lifestyle. As one of the parents noted,

“The health of my child is really important to me and if it takes a great effort to help them understand the importance of healthy food, I am ready to engage in this process.”

They further mentioned establishing a reward system for their children whenever they eat healthy foods,

“I can support my child by making healthy meals for him consisting of fruits and vegetables, beautifully decorating them, and giving him material rewards when he eats healthy food”.

Furthermore, parents expressed readiness to stop buying their children unhealthy snacks and bring home more fruits and vegetables. One mother said,

“I am a working mom who unfortunately doesn’t have much free time. For a long time, I chose a meal that could be prepared in under an hour. However, now I realize how unhealthy this food is, which made me consider buying more fruits and vegetables.”

Advice from a specialist in nutrition and health: Interviewed parents highlighted that receiving advice from a specialist in nutrition and health would significantly impact their and their children’s eating habits and encourage them to have a healthy lifestyle. One of the fathers stated,

“Having a specialist’s advice will contribute to educating my child about the importance of eating healthy and the way to build a balanced meal plan.”

Institutional Facilitators

Active school involvement : The parents suggested several ways the school management can follow to support the children’s journey toward a healthy lifestyle. One of the mothers suggested raising awareness, saying that

“The school administration can participate by publishing awareness campaigns in schools with the aim of reinforcing the conviction of children about the importance of healthy meals for their physical health.”

Another suggestion included the provision of nutrition information in the school curriculum,

“The school administration can add study materials and courses of a nutrition curriculum that will be designed for school students, teaching them about healthy food and encouraging them to eat it, especially from young ages such as kindergarten students. Thus, the child will grow up with healthy habits from childhood.”

According to the parents, being overweight affects their children’s lives and wellbeing in various ways. It had negative effects on their children’s ability to play with friends; children’s social inclusion; and children’s health in the future.

Discussion

The issue of childhood obesity exists in many countries, which necessitates the governments to take action. Multiple studies indicate that childhood obesity cases are highly prevalent in the UAE [20]. Moreover, the number of obese school children has increased exponentially in the last two decades [1, 5, 3]. Furthermore, several studies have suggested that parents play a critical role in influencing their children’s nutritional behavior [11]. In the present study, qualitative research involving in-depth individual interviews was used to explore parents’ perception on factors that contribute to childhood obesity and their suggestions for healthy lifestyle in the prevention and management of overweight and obesity among school children. This method was considered the most appropriate in exploring and determining the attitude of parents towards healthy eating, and their perception of their children’s weight and nutritional status [25]. In addition, this method facilitated capturing parents’ recommendations and suggestions [25] on ways the parents, the school administration and professionals can support school children in adopting healthy eating habits.

Overall, the results of the analysis indicate that childhood obesity continues to be a major public health issue. Furthermore, the themes identified in the course of the analysis prove the necessity to involve parents actively in shaping the approach toward building a healthier lifestyle for their children. Specifically, unique nutritional requirements for each child must be integrated into the general nutritional plan for the school, therefore, providing the school administration to manage the issues directly. Furthermore, the efforts undertaken by the school must be aligned with the approaches that parents implement in order to keep the child healthy [25]. Specifically, the dieting options and food choices provided to the child at school must be correlated to those that the child receives at home, which is why active collaboration between schools and parents is required. The results from our study led to the development of a preliminary conceptual framework based on the Social Ecological Model (SEM) [30 (Fig. 1). This framework focuses on 3 key elements of the SEM (individual level, interpersonal level and institutional/organizational level). The conceptual framework was continuously updated and expanded throughout the study based on the findings to better reflect emerging themes and sub-themes and their interrelationships.

The parents identified various factors that can affect school children adoption of healthy eating and regular physical activity (healthy lifestyle). Some of these factors were barriers to the school children’s ability to adopt healthy eating habits and others were facilitators enabling school children towards healthier eating style. These factors act at the intrapersonal, interpersonal and institutional levels. The negative effects identified as barriers on the above-named levels push school children towards adopting unhealthy eating habits and become overweight. The parents’ lack of engagement, compounded by the negative effects of other interpersonal barriers (nannies and influence from peers and social media), lead to their children’s personal choices favoring energy-dense foods (such as fast food and sweets). It also contributed to eating while playing video games and TV which leads to lack of mindful eating. The parents also mentioned limited nutrition education in the school curriculum and physical inactivity while at school has also contributed to unhealthy eating habits of their children. The parents cited a number of negative effects of obesity on their children. This includes their children’s weights preventing them from engaging in physical activities and playing with other children. They also identified excess weight as a major obstacle in the development of their children’s social skills and psychological well being. Moreover, some of the parents stated that their children faced bullying due to their body weight in school, whereas some parents expressed fears of future physical and psychosocial implications of obesity on their children’s lives.

However, most of them did not mention the health risks associated with childhood obesity. The parents acknowledged that their busy schedule at work has adversely affected their children’s eating habits. Their demanding work schedule does not permit them to cook healthy meals at home; hence, they mostly rely on fast foods and cannot monitor their children’s eating habits. Moreover, the children are usually left under the care of nannies who provide them with whatever food they desire to eat. The findings corroborated by Vittrup and McClure [28], who revealed that the key barrier to childhood obesity weight management is lack of time by parents. Furthermore, the study revealed that the parents lack knowledge on portion sizes, healthy foods and health risks of childhood obesity. Importantly, Garzay [12] examined the perception of nannies towards children’s eating habits. Most of them indicated that the parents were the key determinants of their children’s eating habits. Additionally, they engaged the children in poor feeding habits due to limited nutritional knowledge. The researchers recommended provision of nutritional education for nannies to improve the children’s nutritional status.

The participants discussed negative influence from peers and social media, low nutrition knowledge, and sedentary lifestyle as some of the barriers. The findings were consistent with Ragelienė and Grønhøj [23], who found that family, peers and social media influence children’s eating behavior. Therefore, positive role modeling from parents, nannies and peers has the potential to promote healthy eating behaviors in children. On the other hand, as mentioned by the parents, there are a number of facilitators that can play an important role in helping their children to shift into a healthier lifestyle and overcome being overweight. These factors were mainly related to parents’ engagement and external factors. The parents have a perception and knowledge about the negative effect of being overweight and having unhealthy eating habits.

Creating parental concern through knowledge of obesity health risks was identified as a key factor in controlling childhood obesity [17]. More and colleagues [17] found that concerned parents were more likely to instill the desire to adopt a healthy eating in their children compared to the parents who paid no special attention to forming healthy eating habits. Aljunaibi et al. [4] evaluated parental perceptions of school children in the UAE and found 63.5% of parents of overweight /obese children misclassified their children’s body weight status. The study suggested parents recognize the challenges associated with childhood obesity and actively participate in managing the weight of their children. These findings are consistent with Etelson et al. [11], who reported that parents of overweight children mostly had inaccurate perceptions regarding their children’s weight. Therefore, creating more awareness on the potential adverse effects of obesity on health would contribute to efforts to reduce childhood obesity in the UAE.

At the institutional (school level), parents suggested that the administration for schools and experts in promoting healthy eating in their children. Overall, the suggestions provided by the parents were insightful and consistent with those previously reported in other studies. El-Sabban [10] suggested that children’s nutrition and general health require the support of parents, teachers, school administrators, nannies, and other directly or indirectly involved parties. Hinojosa et al. [14] revealed that modification of the school environment is crucial in childhood obesity weight management. The institutions can incorporate more programs that involve nutritional education and physical activities. Additionally, surveillance programs can be initiated in public schools to identify the students who are obese. Subsequently, they can be supported through various nutritional interventions.

The barriers of a healthy lifestyle identified by parents can be addressed through the recommendations, including: (1) Collaborative programs of nutritional education targeting the parents and children can be developed by relevant government agencies to support the children in adopting a healthy lifestyle; (2) Implementing training programs for nannies to enhance their nutritional knowledge. They can be trained on how to support the children in adopting a healthy lifestyle, especially in instances where the parents are busy at work. This can be achieved through collaborative efforts between relevant government institutions that can improve access to nutrition specialists for families, including the nannies. Additionally, awareness campaigns can be initiated through television commercials and social media to counter the negative influence.

Furthermore, there is a need to implement more opportunities for students to be physically active at school. Additionally, surveillance programs to identify students at risk for obesity and intervene at an earlier stage must be developed. Addressing the negative peer influence from the interpersonal category by implementing nutrition awareness programs in communities and the formation of social support groups to help students with obesity is vital as well.

The strengths of the study lie in the fact that this is the first study in the UAE on school children’s body weight management using the Social Ecological Model (SEM). Moreover, all the information used to determine the barriers and facilitators of weight gain in school children is first-hand. Indeed, the results of the research are largely based on interviews with parents, a fact that minimizes the possibility of prejudice or manipulation of facts. In addition, school children’s parents who took part in the interview received no other benefits from this research except contributing to the knowledge about the formation of obese children’s eating habits. This fact minimizes the possibility of purposeful distortion of facts and makes the given interviews highly credible in what they disclose about school children’s eating habits. On the other hand, this study has some limitations. The fact that only 35 parents were interviewed indicates that the results have limited representation for larger groups of obese children’s parents.

Obesity and lack of exercise among children remain one of the issues in modern society in the UAE. The study has revealed that only the combined efforts of schools, parents and children themselves will be conducive to the proper management of body weight index in schoolchildren. Parent control, support from teachers and classmates, and personal determination to lose weight remain the key drivers to manage the issue of extra weight in school children. While this research has indicated the main factors instrumental in extra weight management, further research will be needed to develop specific programs for tackling obesity at the national level.

Supplementary Materials: The following are available online at www.mdpi.com/xxx/s1, Figure S1: title, Table S1: title, Video S1: title.

Author Contributions: For research articles with several authors, a short paragraph specifying their individual contributions must be provided. The following statements should be used “Conceptualization, X.X. and Y.Y.; methodology, X.X.; software, X.X.; validation, X.X., Y.Y. and Z.Z.; formal analysis, X.X.; investigation, X.X.; resources, X.X.; data curation, X.X.; writing—original draft preparation, X.X.; writing—review and editing, X.X.; visualization, X.X.; supervision, X.X.; project administration, X.X.; funding acquisition, Y.Y. All authors have read and agreed to the published version of the study.”

Funding: This research received no external funding.

Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. The ethical approval for the study was obtained from the United Arab Emirates University Social Sciences Ethics (protocol number: ERSC_2022_744). All procedures followed the principles of the Declaration of Helsinki.

Conflicts of Interest: The authors declare no conflict of interest.

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