Fruit and vegetable consumption, leisure‐time physical activity, and sedentary behavior among children and adolescent students in Uganda

Abstract Introduction Fruit and vegetable (FV) intake and participation in leisure‐time physical activity (PA) and in sedentary behavior in accordance with the recommendations are met in a minority of populations including children and adolescents. Objective To describe the frequency of FV intake, leisure‐time PA, and sedentary behavior, assess compliance with international recommendations, and how selected factors are associated with these recommendations. Methods The FV consumption and PA questionnaire items previously assessed for reliability in a Ugandan setting were used to gather information about FV consumption, PA, and sedentary behavior among 621 children and adolescents attending schools in Kampala Uganda. The results of FV consumption and PA were categorized as adequate or inadequate while sedentary behavior was categorized as adequate or excess. The relationship between FV consumption, PA, and sedentary behavior with selected independent variables was verified by chi‐square test statistic. Results Half of the participants (50%) reported inadequate fruit consumption, and 76% of them reported inadequate vegetable consumption. More children (68%) than young adolescents (52%) and older adolescents (44%) met their daily recommendation for fruit consumption. A similar trend was observed for vegetable consumption. Adequacy of FV intake was significantly associated with participant's age, level of education, school ownership, and type of school. Less of 8‐ to 17‐year‐olds (14%) than 18 years and above olds (41%) met their weekly recommendation for leisure‐time PA. Majority of participants (54%) participated in acceptable levels of sedentary behaviors. Leisure‐time PA was significantly associated with age category and school ownership while sedentary behavior was significantly associated with participant's age and education level. Conclusions The intake of FV and participation in leisure‐time PA was not adequate in the study population. A significant proportion of participants engaged in excess sedentary behavior. Developing and implementing strategies to increase FV intake and PA among children and adolescents in schools should be a national priority.

such as television viewing and playing video/computer games have increased, yet low-intensity physical activity is associated with obesity in adolescents (Li et al., 2007). World Health Organization (WHO) recommends that children and youth aged 5-17 years should accumulate at least 60 min of moderate-to vigorous-intensity PA daily (WHO, 2017b) while adults aged 18-64 should do at least 150 min of moderate-intensity aerobic PA throughout the week (WHO, 2017a). Increasing PA and reducing sedentary behavior play important roles in health promotion and prevention of lifestyle-related diseases in children and adolescents (Graf et al., 2014). However, PA among children and adolescents is believed to be insufficient, and low levels of PA seem to persist into adulthood.
This makes physical inactivity among young people a risk factor for cardiovascular disease, cancer, and osteoporosis in later life (van Sluijs, McMinn, & Griffin, 2007).
Sedentary lifestyle patterns in children and adolescents, that is, playing digital games, using computers and especially watching television, have been associated with obesity (Rey-López, Vicente-Rodríguez, Biosca, & Moreno, 2008). In children and adolescents, independent of PA levels, sedentary behaviors are associated with increased risk of cardio-metabolic disease, all-cause mortality, and a variety of physiological and psychological problems (Sisson et al., 2009;Tremblay et al., 2011). Therefore, to maximize health benefits, approaches to resolve the inactivity crisis should attempt to both increase deliberate PA and decrease sedentary behaviors.
However, to date, public health efforts have focused primarily on PA and have paid little attention to the mounting evidence to support sedentary behavior as a distinct behavior related to poor health. The American Academy of Pediatrics (AAP) recommends no more than 2 hr a day of screen-based activities (e.g., TV viewing, computer games, and console games) due to the relationship between screen time and health risk (Martínez Gómez et al., 2012;Sisson et al., 2009).
Given that food intake patterns established during childhood may track into adulthood and the potential associations of FV intake with other eating and health behaviors (e.g., physical activity and sedentary behavior) (Chong, Lee, Ng, Khouw, & Poh, 2017) and the importance of increasing PA and reducing sedentary behavior in health promotion and prevention of lifestyle-related diseases in children and adolescents (Graf et al., 2014), increasing the intake of FV, PA, and reducing sedentary behavior among children and adolescents should therefore be public health priorities. In 2003, 19.8% of Ugandan school children and adolescents ate fruits and vegetables five or more times per day during the past 30 days, only 15.3% were physically active all the previous 7 days for at least 60 min continuously, 27.5% spent 3 hr or more per day doing sitting activities such as watching TV/video or playing computer games (Twa-Twa & Oketcho, 2005). There is limited up-to-date published data available on FV consumption, PA, and sedentary behavior among children and adolescents, collected using reliable tools in Uganda. In addition, little is known about the extent to which the FV consumption, PA, and sedentary behavior comply with international recommendations and their association with selected factors. A better understanding of these associations is particularly important for providing insights toward the development of more effective strategies and approaches to target the double burden of malnutrition reported in many developing countries, including Uganda (Abdullah, 2015). Thus, the purpose of the current study was to determine the frequency of FV consumption, engagement in leisure-time PA, and sedentary behavior among children and adolescents aged 8-19 years attending schools in Uganda and subsequently assess compliance with international recommendations.

| Subjects
Students aged 8-19 years, attending primary and secondary schools in Kampala district, Uganda, were recruited as participants for this study. A representative sample of participants was obtained through multiple-stage sampling in the order of Kampala district division, school, and class. Twelve representative schools were eventually selected to reflect the population distribution in Kampala city schools.

| Sample size calculation
Sample size was calculated using Daniel's equation as illustrated below: Where: N is the required sample size, t is the confidence level at 95% (standard value of 1.96), p is the estimated prevalence of malnutrition in the project area.

| Design effect (D)
Since the study used cluster sampling methodology, D = 2 was assumed as this is the recommendation for nutrition surveys using cluster sampling methodology (IFAD, 1995).

| Contingency
The sample was increased by 25% to account for contingencies such as nonresponse n = 490+ (0.25 × 490) n = 612.5

| Assessment of FV consumption, PA, and sedentary behavior
The FV consumption and PA questionnaire items were adopted from the Uganda Global Schools' Health Survey questionnaire (Twa-Twa & Oketcho, 2005). These items had been previously assessed for reliability using test-retest reliability method in a Ugandan setting were used to gather information about FV consumption, leisure-time PA, and sedentary behaviors among 621 children and adolescents attending schools in Kampala, Uganda.
Slight modifications were made on the PA items. Demographic data including respondents' age, sex, level of education, class attended in school, school ownership, and type of school attended were also collected. The FV consumption tool had two items on frequency of FV consumption in the past 30 days: number of times per day that participants usually ate fruits such as ripe bananas, mangoes, oranges, guavas, avocado, or pawpaw in the past 30 days and number of times per day that participants usually ate vegetables, such as dodo, gobe, ntula, sekuma wiki, buga, or nakati in the past 30 days. The PA tool had seven items that captured: number of days on which respondents were physically active for at least 60 min per day in the past 7 days, number of days on which respondents were physically active for at least 60 min per day during a typical or usual week, time spent in sedentary behaviors, number of days the respondent walked or rode a bicycle to and from school during the past 7 days, time respondents usually spent to and from school each day during the past 7 days, number of days respondents did exercises to strengthen or tone their muscles during the past 7 days, and how respondents felt after PA.
Participants aged above 17 years were asked for number of minutes in a week they engaged in moderate-to vigorous-intensity instead of number of days on which they were physically active for at least 60 min per day in the past 7 days, to suit the WHO PA recommendations. The rest of the data were categorized based on WHO's standard age group categorization: 5-9, 10-14, and 15-19 years (Ahmad, Boschi-pinto, & Lopez, 2001).

| Data analysis
Participants characteristics and adequacy of FV intake, leisure-time PA, and engagement in sedentary behavior were presented as frequencies and proportions. Chi-square (χ 2 ) test statistic was used to determine the significance of association of selected factors with adequacy of FV intake, leisure-time PA, and engagement in sedentary behavior. All statistical analyses were performed using the STATA 12.0 software program at p < 0.05 level of statistical significance.

| Participants' socio-demographic factors
The study constituted of 621 respondents who completed the FV consumption tool (Table 1). Majority (54%) of participants were female, and most of the respondents (45.4%) were older adolescents (aged 15-19 years of age). There were more secondary (53%) than primary school participants. Majority (66%) of participants were from privately owned schools. The PA tool was completed by slightly more participants (652).
Half of the participants (50%) reported inadequate fruit consumption and did not meet their daily recommendation. That is, they had consumed fruits less than two times per day in the past 30 days prior to the interview ( Table 2). Majority of participants (25%) reported to consume fruits only once per day while 8% had not consumed fruit in the past 30 days prior to the interview.
Adequacy of fruit consumption significantly varied with age category, school ownership, type of school, and participant's level of education (Table 3). A higher proportion of children (68%) than young adolescents (52%) and older adolescents (44%) met their daily recommendation for fruit consumption. More primary (59%) than secondary school (42%) and more public (57%) than private (46%) school participants met their daily recommendation for fruit consumption. Acceptable level of sedentary behavior significantly varied with age category, gender, and level of education (Table 9). More of the older adolescents (85%) than young adolescents (80%) and children (52%) participated in excessive sedentary behaviors. More females (55%) than males (52%) and more students who attended secondary (62%) than primary (44%) schools engaged in excessive sedentary behaviors.

Levels of fruit consumption
When asked about what they felt after physical activity, majority of participants reported feeling refreshed and happy, some felt tired, and others did not do any PA while only 3% had other feelings (Table 10).

| D ISCUSS I ON
This study documents inadequate FV intake among the study population relative to international recommendations. Low intakes were observed both in fruits and vegetables and in all genders, in age groups, in primary and secondary, in public and private, and in day and day and boarding schools. Low-and middle-income countries and high-income countries have had the same trend of inadequate FV consumption levels among adolescents; for example, in seven African countries, 77.5% of adolescent students (Peltzer & Pengpid, 2012) and 78.6% of American high school students (Eaton et al., 2008) had eaten less than five servings of fruits and vegetables per day. This is similar to findings of other studies such as one conducted among Nigerian adolescents (Ilesanmi, Ilesanmi, & Ijarotimi, 2014). Up to a quarter of respondents had not taken fruits a month prior to the study and among those who had taken fruits, the intake was grossly inadequate (Ilesanmi et al., 2014). Findings are also similar to those obtained from school children aged 13 to 15 years from five Southeast Asian countries where the mean daily servings of fruits and/or vegetables per day was 3.2, far below the recommended five servings a day (Peltzer & Pengpid, 2012).
Inadequate fruit consumption could be attributed to participants' perception of adequate consumption and about fruit market prices. A study carried out in Austria reported that the greatest barrier to higher FV intake was the perception that current individual consumption was already sufficient (Schätzer, Rust, & Elmadfa, 2010). Ghanaian students considered fruits expensive (Mintah et al., 2012). The inadequacy could also be attributed to home   were also reported in a study that assessed leisure-time PA and sedentary behavior and substance use among in-school adolescents in eight African countries (Peltzer, 2010). These results compare with other reports from mainly low-and middle-income countries (Guthold, Cowan, Autenrieth, Kann, & Riley, 2010) (Peltzer, 2010).
Since there is a negative association between PA and body mass (Peltzer & Pengpid, 2016), the high prevalence of physical inactivity is likely to result into increased body mass among school children and adolescents in Uganda. In order to improve cardio-respiratory and muscular fitness, bone health, and cardiovascular and metabolic health biomarkers, children and youth should accumulate at least 60 min of moderate-to vigorous-intensity physical activity (WHO, 2017b). Therefore, the inadequacy of physical activity could negatively affect children and adolescents' health. The association between substance use and sedentary behavior has been reported by number studies (Iannotti, Janssen, Haug, Kololo, & Annaheim, 2010;Nelson, 2006;Peltzer, 2010). Association between loneliness and sedentary behavior and association between suicidal ideation and physical inactivity have been confirmed among girls (Peltzer & Pengpid, 2016). Generally, there is evidence of a protective association between physical activity and depression (Liu, Wu, & Yao, 2016). As a result of the high rates of physical inactivity and sedentary behavior reported among the in this study, there is a likelihood for loneliness, depression, substance use, and suicidal ideation in the study population and other similar populations.
On the other hand, a positive association between attending physical education classes and physical activity has also been found (Tassitano et al., 2010). Furthermore, the introduction of movable/recycled materials could have a significant, positive long-term intervention effect on children's physical activity (Hyndman, Benson, Ullah, & Telford, 2014).
Physical activity can possibly be increased by empowering and promoting physical education classes in schools and by introducing movable/ The authors declare that they do not have any conflict of interest.

I N FO R M E D CO N S E NT
The purpose and objectives of the study were carefully explained to each participant and their parents. Informed consent to the study was obtained from participants' parent/guardian to affirm their willingness or not. The parents or guardians of participants provided consent to allow their children to take part in the study while participants signed assent accepting to participate in the study. The study conforms to the Declaration of Helsinki, US, and European Medicines Agency Guidelines for human subjects.