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Childhood obesity is a public health problem associated with high risk of onset of non-communicable diseases in the adult years. Preschool is a crucial phase in the development and growth of physical, social, and mental well-being. Thus, a South African childhood obesity prevention program was developed to promote healthy eating behavior in young children aged two to five years. The programme is aimed at caregivers and mothers of preschool children. This programme is multi-faceted and focuses on basic principles of healthy eating, such as increasing the consumption of fruits and vegetables, as well as strengthening physical activity in preschool environments. Healthy family environments are essential to the growth and development of children, and they should include healthy family meals and physical activities.
Department of Human Nutrition and Dietetics, Sefako Makgatho Health Sciences University, Pretoria, South Africa
Mashudu Manafe
Department of Human Nutrition and Dietetics, Sefako Makgatho Health Sciences University, Pretoria, South Africa
Lindiwe Ncube
Division of Hospitality and Tourism, University of Mpumalanga, City of Mbombela, South Africa
*Address all correspondence to: suzan.mokone@smu.ac.za
1. Introduction
More than 42 million children under the age of five are overweight or obese around the world, 35 million of whom live in low- or middle-income countries [1]. Obesity is on the rise worldwide and has been ranked as the fifth leading cause of death among children [2]. Consequently, the World Health Organization (WHO) identified childhood obesity as one of the highest priorities. The United Nations Children’s Fund (UNICEF) estimates that 3 million children under the age of five die every year in the world from malnutrition, and the cost of treating malnutrition is estimated at $3.5 trillion annually [3]. Childhood obesity is a public health problem that involves the high risk of non-communicable diseases (NCDs) that affect people’s physical, mental and health status [1]. In the United States, children under five years of age in Latin America had the highest weight and obesity prevalence (40%), followed by Australian children with an obesity prevalence of 28 per cent, which put them at high risk of metabolic syndrome [4, 5]. The 2013–2020 World Health Organization’s World Action Plan for the Prevention and Control of Childhood Obesity is a global priority, and recommendations have been made to countries to prevent childhood obesity [1]. WHO recommends that countries should encourage that processed, nutrient-poor foods and beverages be reduced in favor of healthier alternatives and promote physical activity to prevent childhood obesity [6].
Children under five years of age, who consume high-energy sugary foods and live a sedentary lifestyle, are more likely to develop type 2 diabetes and cardiovascular disease in early childhood, and this is associated with higher likelihood of disability and premature death [7]. Energy-rich, nutrient-poor, high-sugar, high-salt snacks, and sugar-sweetened beverages (SSBs) contribute to childhood obesity [5, 8]. Preschool children eat high-fat, high-fat energy-dense foods such as fries, crisps, bread, and processed foods [7]. In addition, some studies show that most children around the world eat a large amount of energy-intensive foods, saturated fats from animals, which increases the risk of overweight and obesity [9, 10]. Intake of fatty foods with high trans fats and saturated fats, high energy density foods, is associated with childhood obesity [11]. Moreover, diets high in trans fatty acids were found to increase risk of obesity and cardiovascular disease by 27% [12].
High-protein diets such as fatty lamb, beef, and fried chicken are a risk factor for childhood obesity, as high protein content stimulates insulin-releasing amino acids, resulting in weight gain and obesity [13, 14]. Most working parents and those who do not have time to cook at home buy fast foods, which are convenient and affordable, but high in calories, with unhealthy fats, sugars, salt [12].
In rural and urban areas in North West province, South Africa, the consumption of sugar and sweet beverages (SSBs) is increased among children under five years of age, thus increasing the risk of childhood obesity [15, 16]. Increased consumption of SSB leads to an increase in calories, which in turn leads to weight gain and causes children to become overweight and obese [17]. High intake of sugar beverages among children from low-income households may be related to low prices and this becomes a risk factor for childhood obesity [12]. High-sugar drinks are less filling than food and can be consumed in greater quantities, increasing the calorie intake. According to a 2014 Economic Research report, the average daily consumption of calories in the United States has increased by 459 over the past 40 years [18].
Most overweight children have been reported to eat snacks between meals, especially pastries, and few children consumed healthy snacks, such as fruit or nuts [17]. Large portions lead to high calories and a 30% increase in energy was noted when children were offered large portion sizes [18]. In addition, a study conducted in the United States showed that less children had smaller portion of food and most children ate larger portions [19]. WHO recommends that preschoolers consume a smaller proportion of nutritious food which has lower energy density as an important strategy for prevention and management of childhood obesity (Table 1) [6].
Food group
Recommended cooked portion size
Portions/day
Starches
Mealie meal/maltabella/Oats porridges-: 125–250 ml Samp/pap: 250–300 g Rice:65 g Potatoes:80 g Sweet potatoes: 80 g Pasta: 200–300 g Bread: 2 slices
1 cup starchy porridge 60–80 g potatoes/ 200 g pasta/ 2 slices bread
Proteins
Mince: 50–100 g Beef/chicken/lamb/pork/fish: 60 g Soya:80 g Cheese: 30 g Egg: 30 g
50–60 g protein dish/ 30 g cheese/1 egg
Dairy
Milk: 250 ml Maas: 250 ml Yoghurt:250 ml t
1–2 cups milk Or 1 cup milk & 250 ml yoghurt
Fruits & vegetables
Cooked vegetables:150–200 g Salads (e.g., cucumbers/tomatoes): 60 g Fruits: 2–3 medium fruits Fruit juice: ½ cup
150-200 g vegetables/60 g salad 1 fruit/1/2 cup fruit juice
Fats
Oil: 1tsp Margarine: 1tsp
1tsp oil 1tsp margarine
Table 1.
Recommended food group portion sizes for children 2-5 years of age (Source: [6]).
Children with excessive weight are less likely to exercise as they are exposed to the risk of being ridiculed by other children and thus spend most of their time watching television and eating fatty snacks [20, 21, 22]. Children who regularly exercise are less likely to develop NCDs such as type 2 diabetes and heart diseases [23].
The prevalence of obesity and obesity is rising in South Africa, causing burdens such as type 2 diabetes, asthma, liver fatty disease, cardiovascular disease, high cholesterol, sleep disorders, insulin intolerance and insulin resistance [24]. According to a study conducted by Hayes et al. [25] in Sydney, Australia, hospitalization, and medical expenditure for obese children was higher. The global obesity costs accounted for 2–7% of annual medical costs, and in the USA, the cost of treating obesity-related diseases, particularly diabetes, imposed pressure on health services, accounting for 26% of medical costs [26]. A study in Cape Town found that 13 percent of children admitted to the Red Cross War Memorial Hospital were obese and suffer from chronic diseases such as diabetes, hypertension, and heart disease [27]. Despite the Department of Social Development’s efforts to provide menus for implementing adequate nutritional meals in ECDs, it was found that the food offered to pre-schoolers was mainly starchy, with little animal products and little fruit and vegetables. Inadequate pre-school menus can lead to high consumption of saturated fats, sugars, and low fibers, and can put children at risk of becoming obese [27, 28].
The National Health and Nutrition survey in South Africa showed a 13 per cent obesity rate among children aged one to five, twice the global average of 6.1 per cent [29, 30]. Despite efforts at national level, childhood obesity remains a problem in children aged 3 to 9, with the highest prevalence of obesity in Gauteng province [31]. Quality of care, including adequate food supply and participation in physical activities in preschools, has an impact on the growth and development of social, intellectual, physical, and psychological characteristics of preschool children. Consequently, it is necessary to develop and implement a pre-school obesity prevention intervention. Instigating healthy lifestyle programs in pre-schools contributes to the introduction of healthy diets and improvement of the quality of life. In South Africa, there are currently no specific programmes to prevent obesity among children aged two to five. The current obesity strategy in South Africa targets all age groups, however, the prevalence of obesity and obesity in children is increasing. The developed programme includes a healthy lifestyle strategy for children, preschools, and families.
4. South African-based childhood obesity prevention programme (SABCOPP) for preschool children
SABCOPP is a multi-component program (Figure 1) that was developed based on children’s nutritional status (before and after interventions) and nutritional knowledge (before and after interventions) and food preparation practices of the caregivers [32]. ECDs are ideal for preventing childhood obesity because children’s eating habits between the ages of two and five can be influenced by the size of the portions and food types served in ECDs and in a home setting. Sustainable Development Goal 3 (SDG 3) calls for the promotion of strategies to improve the health and quality of life of infants and young children [24]. Consequently, the SABCOPP framework has been developed to prevent childhood obesity in children aged two to five by improving the nutritional knowledge and food practice of ECD caregivers and mothers. The SABCOPP framework proposes three strategies for preventing obesity in children attending ECD.
Figure 1.
South African based childhood obesity prevention programme for children 2–5 years.
4.1 Pre-school setting
Children spend 28 to 40 hours a week and consume three quarters of their daily nutritional needs at a preschool, therefore, pre-schools become an important environment to promote healthy lifestyles including eating healthy foods and exercising [31]. The pre-school caregivers prepare food for children and impact their nutritional conditions, laying the foundations for accurate knowledge of healthy food, positive attitudes to food, and a healthy lifestyle [24]. Preschools should provide nutritious meals to children to promote their health and physical well-being. Addressing overweight and obesity among children below the age of 5 years is very important for the prevention of NCDs [33].
4.2 Healthy eating
Preschool children’s caregivers should provide nutritious meals, beverages, and snacks to children and a variety of foods (Figure 2). Five servings of fruits and vegetables should be consumed daily as they are high in fiber, low in energy, and helps with satiety [34]. Most meals should include starch foods, such as refined maize, samp (starch from dried corn) and brown bread. Lean meat and lean chickens, fish and eggs should be eaten daily. Dry beans, split beans, lentils, and fiber-rich soybeans should be consumed regularly. Children should be given clean and safe water to drink from a cup daily [35].
Figure 2.
Variety of foods for children according to the food based dietary guidelines for south Africans. Source: [15].
4.2.1 Practical tips for healthy eating
Children should be fed meals five times a day, including a greater variety of foods from all food groups.
Include at least one serving of food from each of the four key food groups each day.
Include one serving of liver, fish, chicken, meat, or eggs every day.
Use at least one vegetable or fruit rich in vitamin A such as dark green leafy vegetables, orange fleshed vegetables, and fruits.
Use dry beans, split peas, or lentils as an ingredient in meals or as a side dish.
Foods that are not recommended are as follows:
Instant porridges or cereals are high in sugar and salt.
Children should avoid low-nutrient foods such as cakes, biscuits, sweets, and chips.
Processed meat products such as Polon, vienna, grilled fish, chicken nuggets, beef patties or sausages may be avoided as they are high in fats, preservatives, and salt.
Milk from a cow or goat that has not been boiled, pasteurized, or heat-treated should be avoided.
Sweetened yoghurt and some drinking milk contain a lot of sugar.
Tea and coffee creamers, condensed milk or milk mixtures should be avoided because they do not provide important nutrients (proteins, calcium, riboflavins) or do not contain much of any nutrients.
Cold drinks, juices, and squash are rich in sugar Frequent consumption of fruit juice can cause tooth decay, especially during meals. Children may not get enough fiber from food when they drink juice instead of fruit. Beverages may obstruct their appetite and they do not eat enough food during meals.
Children should avoid foods that are high in fat content, sugar, and salt (Figure 3).
In the preparation of food for children, high-salt ingredients/seasonings such as stock cubes must not be used [24, 35].
Figure 3.
High-saturated foods that should be avoided.
4.3 Nutrition education for preschool children
Children should learn about healthy eating and balanced eating, including various food groups.
Fresh foods are energy-rich and protein-rich foods, enabling bodybuilding.
Vitamins and minerals such as fruits and vegetables help prevent infection and strengthen the immune system.
Eat various foods by combining different groups of foods to make food healthy, including healthy snacks.
Five small meals a day (children have a small stomach and cannot eat enough for a long time).
Children should avoid drinking sugary beverages, rather than drinking a lot of water. Choose healthy fats and oils and avoid saturated fatty foods.
4.3.1 Portion sizes
Children should smaller portions of nutritious foods as an important strategy for preventing and managing child obesity [6]. Smaller plates and bowls should be used in order to control the portion size of a food item (Figure 4).
Figure 4.
Examples of small plates recommended for children.
Children should eat a healthy breakfast to provide nutrients for mental growth and development [36]. Eating a healthy breakfast in pre-school will induce a good breakfast behavior, which will be lasting even during adulthood. Children should be offered a taste of foods to let them try new fruits and vegetables they may not have tried before. (e.g., kiwi, blackberries, broccoli, cauliflower, etc.).
4.3.2 Healthy snacks
Children should eat healthy snacks, such as fruits and vegetables, and avoid high-energy, fat, and trans-fat snacks. Energy-rich desserts, chips, cakes, cakes, cakes and sweets should be avoided.
4.3.3 Food preparation methods
Cooked foods and raw foods such as fish, meat and chicken should be separated to avoid cross-contamination. Food must be cooked and stored well [6].
4.3.4 Hygiene and sanitation
Hand washing with soap and clean water before cooking or eating is necessary.
The surfaces and types of equipment used in food preparation should be regularly cleaned and protected against insects, pests, and other animals.
Food and kitchen equipment clean to prevent infection.
Raw and raw food should be separated to avoid cross-contamination.
Cooked food should not stay at room temperature for more than two hours, but should be served hot, and the leftover food should be covered and stored at room temperature [24].
4.3.5 Physical activities
Children should be given the opportunity to increase their physical activity by becoming more active. Children should exercise for one hour a day to develop motor and physical abilities, promote healthy lifestyles, and prevent obesity [37, 38]. Physical activity increases ECD energy expenditure and fitness. One hour of exercise a day, including dance, soccer, netball, walking and dancing. During the rainy season, caregivers should provide classroom physical activities and inexpensive equipment (jump ropes, hoops, balls, etc.) in local shops, but encourage physical activities outside as much as possible and include free games.
4.4 Food gardening
Children should be taught and observe how to grow food in food gardens, which will increase awareness and promote the consumption of vegetables and fruits [36].
Families play an important role in the way children eat in a household. Children should be taught about the health effects of obesity. Families should be aware of the importance of healthy food and role of physical activities for children.
5.1 Healthy family eating
Children should eat a variety of foods to provide nutrients needed by the body such as carbohydrates, protein, as well as vegetables and fruits. High-fiber foods such as lentils and beans should be included in children’s diet. Children should consume five portions of fruits and vegetables a day to protect them from childhood diseases [37]. Limit the intake of sugar and sugar-sweetened beverages and fruit juice to 1/2 glass per day. Water should be the beverage of choice for children. Parents should put as much time aside for family meals as possible and provide nutritious food to children. Eating family meals regularly together is encouraged because it provides an opportunity for children to learn about healthy food. Families have a role to play in shaping and guiding children towards healthy food and the importance of physical activities [37]. Family meals are a way of teaching children the benefits of healthy eating, and children should be encouraged to try different foods to learn different textures and tastes, and to experience different foods from different food groups. The portion size of the food items given to children should be controlled. A good snack to give to your child includes fresh fruits, cooked vegetables, low-fat yoghurt, or milk. Children should not be exposed to food served in restaurants as they are energy dense. Children should be encouraged to participate in the preparation of healthy meals, they should be taught to sit with other family members during mealtimes, and not be distracted by watching TV or playing games during meals.
5.2 Physical activities
Parents should engage their children in physical activities, as different music and movements help children build fitness and increase their energy utilization at home. Physical activities improve gross motor skills and promote self-confidence and self-confidence [38]. According to the 24-hour movement guideline in South Africa, children should exercise at least 60 minutes a day [39]. Regular physical activity will improve health and weight management in the short and long term [40, 41, 42, 43]. Encourage children to play indigenous activities such as running, football, and most importantly, take a walk with your children (Figure 5).
Figure 5.
Promoting physical activities among children.
Active parental participation includes repeated participation in workshops, advice or education sessions; passive participation (such as reading brochures or newsletters) does not involve parent or guardian.
5.3 Routine sleeping for children
Children should sleep 10 to 13 hours a day, which will help them recover energy. Sufficient sleep promotes good health and the development of children’s nervous system. Parents must ensure that their children sleep for sufficient time [39].
5.4 Children’s screen time
According to the 24-hour movement guidelines in South Africa, children should watch television less than one hour a day because longer-term television encourages children to consume high-energy snacks such as chips, pizzas, and sugary beverages [39]. Parents should limit children’s time viewing television, playing computer games, and watching films to 30 minutes or less each day [44].
5.5 Hygiene and sanitation
To prevent infection, keep food and kitchen utensils clean. Always wash your hands and children’s hands with soap and water before eating, and after using the toilet.
Preschool nutrition intervention can promote healthy eating and the adoption of healthy lifestyles. Preventing childhood obesity reduces health care costs and economic burdens by preventing chronic diseases later in life and improving the overall quality of life [26]. Caregivers with good nutrition knowledge contribute to healthy eating for their children [36]. Improvements in caregiver nutrition knowledge and good food preparation practices promote healthy weight for children [36, 45]. Physical activities such as outdoor and indoor play are very important for children because they promote the maintenance of healthy weight [42]. UNICEF’s nutrition conceptual framework states that caregivers play an important role in promoting healthy diet and participation in physical activity among children. Nutrition education is essential to improve children’s nutrition and nutrient status and promote healthy growth and development [36]. Parents at home are the model of healthy behavior, so it is important for parents to be educated about healthy foods and the benefits of physical activity so that they can teach their children. Family meals and physical activities in the family are important opportunities to educate children on healthy behavior [42, 43, 46].
SABCOPP, a developed programme incorporates the basic principles of healthy eating with emphasis on high consumption of fruits and vegetables and increased physical activity. The programme emphasizes the family component as it influences eating and general lifestyle behavior of a child.
The authors thank the preschools’ caregivers and mothers of the preschools who participated in the study. The opinions and views expressed in this chapter are those of the authors.
There is no conflict of interest in writing this chapter.
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Written By
Suzan Mokone, Mashudu Manafe and Lindiwe Ncube
Reviewed: 07 September 2023Published: 13 October 2023
Open access peer-reviewed chapter
