FACTOR CONTRIBUTING TO PARENTAL AWARENESS OF CHILDHOOD OBESITY AMONG THAI PRESCHOOL CHILDREN

Jittima Rodsawad, Lertchai Charerntanyarak, Benjawan Tawatsupa Health Impact Assessment Division, Department of Health, Ministry of Public Health Tiwanon Road, Muang District, Nonthaburi 11000,Thailand jrodsawad@gmail.com Faculty of Public Health, Department of Epidemiology, Khon Kaen University 123 Mittrapap Road, Amphur Muang, Khon Kaen Province 42000, Thailand lertchai@kku.ac.th, lertchai2499@gmail.com Health Impact Assessment Division, Department of Health, Ministry of Public Health Tiwanon Road, Muang District, Nonthaburi 11000,Thailand ben_5708@hotmail.com


INTRODUCTION
In the past few decades the prevalence of childhood overweight and obesity has escalated dramatically in developing countries (Sakamoto, Wansorn, Tontisirin, & Marui, 2001). Thailand has also been faced with this problem due to social and economic transition (Kosulwat, 2001). Children aged 0 -72 months with overweight and obesity were 2.9 % in 2009 and up to more than three times (9.7 %) in 2011. Moreover children aged between 6 and 18 years with overweight and obesity were 6.9 % in 2010 and rapidly increase to 9.0 % in 2011.
As the prevalence of childhood obesity is associated with a significant risk of adverse health consequences and comorbidities in adulthood early prevention or intervention is therefore required to decrease the health implications (Dietz & Robinson, 2005;Reilly et al., 2003). The cultural and family environment can often be seen as responsible for the development of childhood overweight and obesity (Golan & Crow, 2004).
Parents play a critical role in influencing family attitude towards healthy eating and physical activity. Increasing parental awareness can help to prevent overweight and obesity in children (Arredondo et

METHODS
The study was conducted during 2012 in a kindergarten school located in an urban area of Nakon Prathom Province, Thailand. The subjects were the parents or guardians of kindergarten students aged 4-6 years at level 1 and level 2, and written informed consent was completed prior to their participation. This study was approved by the Ehics Committee for Research in Human Subjects, Department of Disease Control.
A self-administered questionnaire was distributed to the parents or guardians of the children by a classroom teacher and completed questionnaires were collected one were later, The participants were asked to provide information about demographic characteristics (sex, status, age, education level, household monthly income and family caregiver). They were also asked about the frequency (often, sometimes, never) of skipping breakfast, eating junk food and beverages and spending family time outdoor activities. Additional items were included to assess beliefs about approached to combating childhood obesity. This involved asking participants whether they agreed or disagreed (yes, no) with each of four statements: 'a healthy child refers to child those who is healthy only in physical aspects', 'Monitoring child growth development is a teacher responsibility', 'healthy practices in children should be encouraged in their preschool years rather than later when they are at school', and 'rewarding child with candies can make them prefer these to vegetables'. The dependent variable of parental awareness of the problems of overweight and obesity was assessed by asking participants to agree or disagree with two statements. 'excess weight in childhood will not persist in adulthood' and 'overweight or obesity in childhood is not a serious problem'.
The data were analysed using SPSS version 19.0 for Windows and Stata 12. Cross tabulation and chi-square were used in an initial exploration of factors related to parental awareness. The associations between each of potential contributing factors and parental awareness were assessed by a univariate analysis, which yielded crude odds ratios (ORs) were then adjusted for the influence of all contributing factors (sex, marital status, age, education level, household monthly income, family caregiver, skipping breakfast, eating junk food and beverages and spending family time in outdoor activity, and the four variables about beliefs related to combating childhood obesity). Finally, using a stepwise logistic regression was performed included on significant contributing factors (p-value ≤ 0.05)

RESULTS
Of the 588 parents or guardians who agreed to participated in this study, 495 (84.2%) completed the questionnaires. The characteristics of the respondents are summarized in Table 1. The majority (74.3%) were female and 37.6% reported a household income in the range of 10,001-20,000 baht per month. Not many (8.8%) of them were educated beyond the bachelor degree level. More than half of respondents (63.4%) believed that excess weight in childhood will persist in adulthood. There was a strong statistically significant association between education level and parental awareness of this (p < 0.001). Furthermore, a large majority of respondents (88.3%) reported disagreement with the statement that childhood overweight or obesity is not a serious health problem. Similarly, education level was found to be significantly related to parental awareness (p < 0.05). However, there were no statistically significant associations between demographic variables (age, household monthly income, family caregiver) and parental awareness. Parental beliefs about ways to combat overweight and obesity were found to have strong statistically significant relationship with both the two measures of parental awareness. Interestingly, the belief that healthy practices should be encouraged in preschoolers rather than when the children have reached school age was held by only 15.2% of the respondents and was significantly associated (p ≤ 0.001) with low levels of awareness. F e b rua r y 1 6 , 2 0 1 5  Table 2 shows association between potential contributing factors and parental awareness. Crude ORs were computed for the associations between each measure of parental awareness about childhood obesity and each of the contributing factors. The results revealed that females were less likely than males to disagree with 'excess weight gain persist into adulthood' which means that, compared with males, females have less awareness regarding to excess weight gain persisting into adulthood (crude OR = 0.54). Parents who graduated with bachelor and higher degrees were more likely than parents with a lower educational attainment to disagree (or have more awareness) regarding excess weight gain persisting into adulthood when compared parents who have lower education level (crude ORs =1.90 and 3.25, respectively). In addition, parents who never or only sometimes spent family time in outdoor activity were more likely to disagree with the statement 'overweight or obesity in childhood is not a serious problem' which means they had more awareness about childhood obesity compared with those who often spent family time in outdoor activity (crude ORs = 4.47 and 4.41, respectively). Moreover, parents who had correct beliefs about ways of combating childhood obesity had higher parental awareness than those with incorrect beliefs. F e b rua r y 1 6 , 2 0 1 5  Table 3 shows the associations between all contributing factors and parental awareness using multivariate logistic regression. Adjusted ORs were computed for the associations between each measure of parental awareness and each covariate. Overall, the results revealed that sex, parent's education level and spending family time in outdoor activity were important factors which can influence awareness of excess weight gain persisting into adulthood. In additions, marital status and spending family time in outdoor activity can influence awareness that overweight or obesity in childhood is a serious problem.
Finally, Table 4 shows the associations between contributing factors and parental awareness using stepwise logistic regression. Only the factors found to have statistically significant associations with parental awareness in the previous analysis (adjusted ORs) were included in the stepwise analysis. This final models confirms our previous results that sex, education level, and two variables about beliefs related to combating childhood obesity ('a healthy child refers to child those who is health only in physical aspects' and 'healthy practices in children should be encouraged in their preschool years rather than later when they are at school' can influence the parent's awareness that 'excess weight in childhood will not persist in adulthood' The stepwise model also showed the same pattern regarding education level. The parents who had higher education were more likely to disagree with the statement that 'excess weight in childhood will not persist in adulthood' (they have higher awareness). Marital status, education level, spending family time in outdoor activity, and the three variables about beliefs related to combating childhood obesity were all factors which had a significant association with parental awareness about 'overweight or obesity in childhood is not a serious problem'. Rewarding child with candies can make them prefer these to vegetables Yes -1 No 3.36*** <0.001 1.71 -6.59 † The stepwise odds ratios (Stepw ORs) for estimating the significant contributing factors on 'Excess weight in childhood will not persist in adulthood' includes all statistically significant factors (sex, education level, and two variables about belief related to measure combating childhood obesity:; 'A healthy child refer to child those who is healthy only in physical aspects' and 'Healthy practices in children should be encouraged in their preschool years rather than later when they are at school'). † † The stepwise odds ratios (Stepw ORs) for estimating the significant contributing factors on 'Overweight or obesity in childhood is not a serious problem' includes all statistically significant factors (marital status, education level, spending family time in outdoor activity, a nd three variables about belief related to measure combating childhood obesity).

DISCUSSION
In this study, it was found that a respondent's education level was significantly associated with parental awareness about childhood obesity. The ORs showed that the higher the educational level of the parent/guardian the more likely that he or she was to reject the idea that excess weight in children does not persist into adulthood. This finding confirms those of previous studies which show that education level impacts on the awareness of parents about overweight and obesity in their children (Birch & Fisher, 2000;Clark, Goyder, Bissell, Blank, & Peters, 2007). Many studies have reported that low awareness among parents may be a risk factor for childhood obesity (Clark et al., 2007;Golan & Crow, 2004;Hesketh et al., 2005). Additionally, the present study found a relationship between parental beliefs regarding combating obesity in children and parental awareness about childhood obesity. Incorrect beliefs about combating were risk factors for a low awareness about childhood obesity. This may be due to the fact that Thailand has been faced with a nutritional transition in only recent decades (2), and that parental beliefs and awareness regarding childhood obesity have not been given much attention in the wider society. Hence, in order to deal with the obesity problem and help to maintain healthy weights in children, it suggested that health education should be provided to increase the knowledge of parents who have low awareness.
Various limitations in this study should be considered. Firstly, the study population was recruited using a convenience sample of participants and selection biases may therefore have effected the results. Secondly, no attempt was made to measure the weight status of the children of the respondents as was done in previous studies. These data would have strengthened the conclusions about factors related to parental awareness. Thirdly, this research was undertaken in an urban area of Nakhon Prathom Province, and the results may not generalize to other populations of preschool children. Fourthly, this was a cross-sectional study, and the results can therefore only be interpreted as those applying at the single point of time when the data were collected. Nevertheless, only a few previous studies were found which investigated culture aspects regarding childhood obesity in a Thai context, and most of these focused on school age children. The findings of this study may be beneficial for the planning of further studies of preschool children in Thailand.

CONCLUSION
This study explored the factors contributing to parental awareness regarding childhood obesity. A statistically significant association was found between parental beliefs and awareness. Increasing public awareness and health education may help parents understand health issues related to childhood obesity and in particular, their role in the establishment of healthy behaviors in their children. Effective approaches to the solutions to the problem of overweight and obesity in early childhood are needed for the successful long term maintenance of healthy weight in older children.