Improving healthy energy balance- and obesity-related behaviours among preschoolers in Malaysia: feasibility of adapting the ToyBox-Study

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This research addresses the urgent need to tackle the rise of childhood obesity; Malaysia is suffering more than other Southeast Asian countries in terms of increasing numbers of young children becoming overweight or obese. There are many adverse consequences of obesity, including development of non-communicable diseases such as Type-2 diabetes, cardiovascular disease and some cancers. These diseases will occur at younger ages and increase in prevalence in the population if obesity levels continue to grow. In addition, obesity can harm both physical and mental development and function, thus harming both individual wellbeing and national welfare and economy. A recent report from the World Health Organisation recognises that ending childhood obesity will require multiple and multifaceted interventions, involving changes to policy, education and the environment, in order to deliver sustained changes in behaviours related to obesity risk. Since many of these behaviours rapidly become habitual, key recommendations include targeting early childhood to encourage healthy eating, physical activity, less sedentary behaviour and reduced intake of sugar-sweetened beverages. However, to do this successfully requires not just education, but also removal of environmental barriers to these behaviours, and engagement of the young children's families. The ToyBox-Study programme (www.toybox-study.eu) is one intervention that incorporates these facets and has already been trialled in 4-6 year-old kindergarten children across six European countries. The intervention is designed to be carried out in kindergartens, involving the kindergarten teachers encouraging healthy behaviours in the children, by educating through specially focussed activities, and by changing the kindergarten environments. This permits hands-on learning to instil healthy habits, such as drinking water as the main fluid in place of sweetened drinks, healthier snacking, enjoying more physical activity, and avoiding prolonged periods of sedentary behaviour. The kindergarten setting is also a relatively inexpensive and less disruptive, than a school setting for such an intervention. The ToyBox-Study programme has a complete set of materials to guide kindergarten teachers, and the primary caregivers of the children, in achieving these healthier behaviours. However, it is recognised that some adaptation of the materials, as well as translation, may be necessary for the Malaysian sociocultural context. Thus, the primary aim of this research is to conduct a feasibility study of the adaptation and application of the ToyBox intervention in Malaysian kindergartens, in sites in both Peninsular Malaysia, and in Sarawak. The intervention will run for 24 weeks across a kindergarten year. Similar measurements will be taken at baseline and post-intervention as in the original study, including height and weight of the children, so that comparisons can be made with published evidence from the ToyBox-Study. These will evaluate whether the intervention has altered the health-related behaviours, as well as the acceptability of the intervention to stakeholders, teachers and families of the children. In addition, a follow-up set of measurements will be made 6 months later, to determine how sustainable any behavioural changes have been. Comparison will be made to kindergartens not enrolled in the intervention but whose children will be measured in the same way over the same period. The kindergartens will be recruited from the KEMAS pool of kindergartens, so that a greater number of underprivileged children and families can benefit. The research will be conducted by experienced University staff with expertise in obesity, nutrition, behaviour and education: a separate team will be based at each site. The local teams will be strongly supported by UK experts, two of whom worked on the original ToyBox-Study programme. Guidance and training will be provided at every stage.