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

What is ToyBox Study Malaysia?

ToyBox Study Malaysia is an evidence based approach using behavioural models for the prevention of obesity in early childhood). Funded by the Medical Research Council-grant, this study aims to an examine an innovative and evidence-based obesity prevention programme for children between 4-6 years old.

The novel aspect of ToyBox Study Malaysia is the translation and assessment of the feasibility of an intervention programme which originated in Europe. The original ToyBox-Study (http://www.toybox-study.eu/) addresses issues with regards to childhood obesity from four key energy balance-related behaviours, namely drinking water, eating healthy snacks and meals, and reducing sedentary behaviour, and increasing physical activity. With the support of experts from the original ToyBox Study team, the team of experts from Malaysia have adapted the ToyBox Study to produce ToyBox Study Malaysia which is suitable for the Malaysian context and community. Similar to the original ToyBox Europe programme, the aim of the ToyBox Study Malaysia is also to improve four behaviours which impact on obesity. The intervention programme is targeted at children attending government-funded kindergartens (KEMAS) in Klang Valley and Sarawak, Malaysia.

Why age 4-6?

Early childhood is a critical period for addressing obesity prevention since behaviours, psychological traits, and physiological processes are largely developed or formed at this young age. The development and adoption of the desired behaviours will help to ensure optimum growth during childhood and increases the likelihood of long-term health in adulthood.

What will ToyBox Study Malaysia do?

The overall goal of ToyBox Study Malaysia is to promote healthy energy balance-related behaviour (EBRBs) in order to prevent obesity.  It also aims to guide the scientific community, health and education professionals, and policy makers in potentially expanding such initiatives throughout Malaysia.

ToyBox Study Malaysia will:

• Identify key behaviours and their determinants related to early childhood obesity; evaluate existing behavioural models and educational strategies that best support behavioural change in this age group; assess environments, policies and legislation affecting the implementation of preschool-based health promotion activities;
• Develop a preschool-based, family-involved intervention to influence obesity-related behaviours in 4-6 year olds, adjusting for cultural, legislative and infrastructural diversities in the participating locations in Malaysia;
• Implement the intervention program in Malaysia, assess its process, impact and outcomes and estimate its cost-effectiveness;
• Disseminate the results and make recommendations for Malaysian public health policy.

Study Partners

ToyBox Study comprises a multidisciplinary team of 15 partners across the EU (http://www.toybox-study.eu/): a variety of experts will be involved in this project such as public health experts, epidemiologists, nutritionists, physical activity experts, pedagogists, psychologists, behavioural scientists, paediatricians, early childhood psychologists and health economists. The consortium consists of 11 universities, 1 research institute, 2 advocacy groups, and an SME representing all regions of Europe, and all of them have ample experience in conducting and coordinating multi-centre international research as well as understanding dissemination activities to all relevant stakeholders.

ToyBox Study Malaysia consists of 2 universities, namely Universiti Kebangsaan Malaysia (UKM) and Universiti Malaysia Sarawak (UNIMAS). The adaptation of the ToyBox-Study programme for the use with the children in Malaysia is to change behaviours in children to prevent obesity and related diseases. The necessary first step towards a definitive trial of such an intervention which might lead to scaled-up and sustainable interventions in kindergartens across Malaysia. It will specifically target the KEMAS kindergartens funded by the Community Development Department which are set up to support underprivileged children and families.

Using and adapting the evidence-based ToyBox-Study intervention materials will be a cost-effective method to achieve healthier EBRBs in children, for lifelong health and welfare benefits, as well as healthier kindergarten environments and training of their staff to set healthy behaviour examples to their children and parents. In the long term, these changes should bring benefits to the economy through greater productivity and reduced healthcare costs.

Brief Guide of Intervention

ToyBox is a kindergarten-based, family-involved intervention, which targets key behaviours related to early childhood obesity i.e. drinking, eating and snacking, physical activity and sedentary behaviour and their determinants, in preschool children from Malaysia. The ToyBox intervention programme was implemented from January 2018 to August 2018 with a duration of 24 weeks. It focused on four stages:

• Setting environmental changes in the classroom (Level 1)
• Children implementing the actual behaviour (water consumption, healthy snacking, physical activity and interruption of sedentary time) in the kindergarten (Level 2)
• Teachers implementing fun classroom activities (e.g. stories, experiments, games.) with the active participation of the whole class (Level 3)
• Actively involving parents to apply environmental changes and implement these lifestyle behaviours together with their children at home (Level 4).

The ToyBox-intervention material included a kangaroo hand-puppet, a teachers’ general guide and four classroom activities guides, one for each of the targeted behaviours, which were used in the kindergarten. To involve parents in the intervention, nine newsletters, eight tip-cards and four posters, were included and were handed to the parents throughout the year. In addition, three training sessions for teachers were conducted throughout the year to train the teachers on how to implement the intervention.

About 48 kindergartens and over 1000 children with their parents and their teachers were recruited. The process, impact, outcome, and cost-effectiveness of the ToyBox-intervention were assessed via questionnaires and measurements of children’s anthropometric characteristics (height, weight, waist circumference) and physical activity levels (pedometers).