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Studies that report dietary behaviours indicated people in risk of obesity and overweight engage in on a regular basis. Inappropriate dietary behaviours are typically characterised by low consumption of fruits and vegetables with and high prevalence of fast food and sweetened drinks consumption (Kain, 2014; Habib-Mourad, 2013; Xu et al, 2012; Levy, et al, 2012; Shama & Abdou, 2009). Skipping meals is frequently cited as a common dietary behaviour (Kain, 2014; Habib-Mourad, 2013; Xu et al, 2012). Such behaviours are regarded as one of the major culprits of the prevalence of obesity and overweight among school children as well as being key factors in developing dietary inadequacies.

The reviewed studies reported different findings in regards to the effectiveness and feasibility of the implemented interventions in instilling behavioural and attitude changes towards food and eating habits. These studies further sought to measure the impact of the interventions on the students’ body mass index (BMI) (Shama & Abdou, 2009; Levy et al, 2012). In Kain et al. (2014), 50% of the children brought only healthy snacks to school post-intervention, this finding was described as “the greatest improvement” of the intervention. The importance of this finding becomes apparent when we consider the initial behaviour of the children pre- intervention as almost all of the participating students (90%) brought to school a combination of cookies or crackers and juice as their snack of choice. Healthy food choices amounted to only 33% of all the food items brought by the children in the intervention.

Such a salient progress is best explained by the amount of information pertaining to healthy eating they were exposed to throughout the duration of the intervention. This finding proves that nutrition education is indispensable and crucial in achieving behaviour change which can result in dietary improvements. A similar result was concluded previously in Xu et al (2012) arguing that awareness of the potential risks (i.e. accumulating excess body fat) brought about by certain detrimental behaviours (e.g. frequent consumption of unhealthy snacks and soft drinks, reduced intake of vegetable and fruits, physical inactivity and prolonged screen time) means that the students are less likely to engage in them. This conclusion was

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consistent with the behavioural pattern of the students who were identified as overweight or obese in the as they practiced healthier choices, including the consumption of fewer fried snacks and soft drinks coupled with an increased likelihood in spending more time being physically active and take active transport mode to/from schools in comparison to students identified as having normal body weight, the authors attribute this to the increased knowledge of children with excess body fat about the risk factors associated with unhealthy eating and physical inactivity and their implications on their overall weight health.

Despite this heightened awareness exhibited by the children with excess body weight, the significant influence of parents on their children’s eating habits meant that these children continued to consume excessive amounts of fatty meat. This finding is important as it shows that changes in the child’s behaviour cannot only be improved and maintained on the individual level but also extends to the society and eating practices prevalent on the cultural level. Albeit the fat that the authors raise the possible link between the fashion in which food is served to children in China and their persistent consumption of fatty meat, they do not elaborate beyond this point to make a case about the influence of culture on the individual’s perception, attitude and consumption of food.

This was dealt with more seriously and thoroughly in Habib-Mourad (2013) where the author discusses the significance of cultural sensitivity and accordingly implements a school-based intervention which is described as culturally appropriate in that considerations were made to help the children relate the messages of the educational materials and activities to their daily life and foods found in their immediate cultural environment (referencing traditional foods and dishes, communicating in Arabic for all the purposes of the intervention, culture-specific rhymes and riddles, etc.). Given the unpopularity of integrating cultural elements specific to the population under study in the author’s chosen context, her designed intervention can be regarded as a reaction to the widespread practice of adapting and translating health promoting initiatives from Western sources.

Habib-Mourad’s (2013) intervention programmes were designed with a Lebanese target population in mind and thus were developed to meet the dietary health requirements of this particular group, however, the findings from her study are reflective of the effectiveness of culturally sensitive interventions to obtain the desired outcomes and objectives. The behaviour changes were noticeable across the entire category of dietary habits, including reported attempts to have breakfast regularly (e.g. waking up earlier); increased efforts to take the recommended intake of fruits and vegetables, and less resistance when offered these

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kinds of food; significant decrease in the consumption and buying of carbonated drinks and artificial juice; significant decrease in consumption and buying of energy dense snacks (i.e. potato chips and chocolates).

Although, Habib-Mourad’s (2013) study does not evaluate the success of integrating cultural sensitivity in the intervention programme, nor explicitly cites thee incorporated cultural elements as determinants of behavioural change (aspects such as child’s nutritional knowledge, self-efficacy, parental involvement, school environment, etc. were used as outcome measures). It is worth mentioning that this study is the only reviewed study which overtly presents the role of culture in behaviour changes in relation to the consumption of food. The study by Shama & Abdou (2009) has shown that intervention initiatives in health promoting schools were effective in helping children adopt healthy dietary habits, this is represented mainly by a high percentage of breakfast intake (6-7 times per week) and regular consumption of fruits and vegetables (3 times or more per week). Nevertheless, the changes reported in this study are apparently significant only for breakfast and fruits and vegetables consumption, meaning that the remaining aspects in the dietary habits category did not see any major changes; these are namely, soft drinks and fast foods. The study detected no significant changes in the consumption of these items, as male students were found to drink soft drinks on a daily basis (up to three times) and eat fast foods more than once a week, female students on the other hand consumed less amounts of soft drinks but exhibited no great differences with the consumption of fast food. The reasons stated by the authors for school children to drink soft drinks are similar to those given in other studies (Habib-Mourad, 2013; Xu, et al, 2012) these are taste preference, being influenced by parents and peers’ consumption habits, ease of availability in the home and school environments and television viewing. The study shows an overall positive dietary behaviour and that the health promoting interventions did indeed have an impact on dietary behaviour both on male and female students.

The effectiveness of the health promoting initiative in schools presented in Shama & Abdou (2009) is in line with the study by Levy et al., (2012) which also sought to implement environmental changes within a wider school based nutrition focused programme. Providing such intensive and comprehensive experiences in school setting (and home setting) is anticipated to maximise the strength of interventions. The intervention in this study is called "Nutrition on the Go" and was designed with the aim to reduce the energy contents of school breakfasts and to increase the amounts of fruits and vegetables and encourage more

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consumption of water. After duration of over 6 months, the study recorded a slight yet statistically significant effect on reducing the probability of shifting from the overweight to the obesity category. This study also reported a decreasing effect on the shift from the normal to the overweight categories.

Rather than claiming to be effective in decreasing excess body weight, the intervention was concluded to be more effective for the purpose of maintaining BMI in schoolchildren. Quantitative data from the pre- and post- intervention behavioural and anthropometric measures in Lloyd, et al., (2012) showed a significant self-reported decrease in the consumption of energy dense snacks. Like most of the other studies this study incorporated a multi-component school-based intervention programme with a special focus on the following behaviours i) reduction of the consumption of sweetened soft drinks, ii) increase in the proportion of healthy snacks consumed and iii) reduction of TV viewing and other screen- based activities, within the context of a wider attempt to improve diet and increase physical activity.