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JNFS 2023, 8(4): 654-662 |
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Sheikhi M, Tabatabaei S M, Eftekharinia M, Zaboli M. The Effects of a Nutritional Education Package Titled "Eat a Rainbow Every Day" on Eating Behaviors and Physical Activity of Elementary School Children. JNFS 2023; 8 (4) :654-662
URL: http://jnfs.ssu.ac.ir/article-1-552-en.html
URL: http://jnfs.ssu.ac.ir/article-1-552-en.html
Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
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1 Department of Community Nutrition, National Nutrition and Food Technology Research Institute; Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2 Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran; 3 Health Deputy, Zahedan University of Medical Sciences, Zahedan, Iran.
Introduction
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The Effects of a Nutritional Education Package Titled "Eat a Rainbow Every Day" on Eating Behaviors and Physical Activity of Elementary School Children
Mahdieh Sheikhi; PhD1, Seyed Mehdi Tabatabaei; PhD*2, Monir Eftekharinia; BSc3 &
Maryam Zaboli; MD, MPH3
Mahdieh Sheikhi; PhD1, Seyed Mehdi Tabatabaei; PhD*2, Monir Eftekharinia; BSc3 &
Maryam Zaboli; MD, MPH3
1 Department of Community Nutrition, National Nutrition and Food Technology Research Institute; Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 2 Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran; 3 Health Deputy, Zahedan University of Medical Sciences, Zahedan, Iran.
| ARTICLE INFO | ABSTRACT | |
| ORIGINAL ARTICLE | Background: In school age children, a healthy nutritional behavior can prevent double burden of malnutrition and chronic diseases. Nutritional education has a key role in adopting a healthy lifestyle. This study aims to evaluate the effectiveness of an educational package on the nutritional knowledge and practices, physical activity (PA), and body mass index (BMI) of elementary school children in Zahedan, southeast Iran. Methods: In this quasi-experimental before-after study, a total of 734 elementary school children, aged 10–14 years, recruited by census sampling method completed the survey. Each student received 8 hours of training and they were provided with a booklet that included a weekly chart for recording intake of food groups and PA by students for 3 months. A semi-structured questionnaire that included questions on the students' nutritional knowledge, eating behavior, PA performance, and BMI before and after the intervention was used for data collection. Paired t-test, McNemar's, and Friedman tests were used for data analysis. Results: Before the intervention, the mean score of nutritional knowledge was 7.5 and the prevalence of underweight and overweight/obesity was 17.4% and 0.4%, respectively. After the intervention, the results showed a significant increase in the nutritional knowledge scores, the number of days with 30 min PA per week, and the frequency of consumption of dairy products, animal protein, and fruits. Also, in comparison with before intervention, a significant decrease was found in the prevalence of underweight and overweight/obesity of school children after the intervention. Conclusion: This multifaceted nutritional education intervention was associated with improved nutritional knowledge score, PA, and being underweight in elementary school children. Keywords: Body mass index; Eating behavior; Knowledge; Physical activity; Elementary school |
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| Article history: Received: 4 Jan 2022 Revised: 9 Apr 2022 Accepted: 10 May 2022 |
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| *Corresponding author: zu.healthdeputy@gmail.com Health Deputy, Zahedan University of Medical Sciences, Zahedan, Iran. Postal code: 9816913181 Tel: +98 5433372013 |
Introduction
Malnutrition is considered a major public health problem especially in developing countries (Ali et al., 2022). Being underweight as well as overweight and obese in childhood
and adolescence negatively affects physical, psychological, and social health throughout life (Murtagh and Collaboration, 2017). Globally, it is estimated that 75 million girls and 117 million boys aged 5-19 years are underweight. Correspondingly, 50 million girls and 74 million boys are obese (Murtagh and Collaboration, 2017). The overall prevalence of underweight, overweight, and obesity in school children in Iran is estimated to be 6.6%, 11.9%, and 9.7%, respectively (Azizi-Soleiman et al., 2020, Khashayar et al., 2018). The highest
rate of food insecurity in the country has been reported in Sistan and Baluchistan Province, where 21.3% and 9.6% of elementary school children suffer from underweight and overweight/obesity, respectively (Maddah et al., 2010). High prevalence of underweight in elementary school children
as well as an increase in the prevalence of overweight/obesity in this age group is a major public health concern (Maddah et al., 2010).
Healthy nutrition has a key role in improving and maintaining health status of the individuals. In school-aged children, a healthy eating behavior not only is associated with health and growth promotion, but also may prevent childhood malnutrition and chronic diseases (Nasreddine et al., 2019). Healthy nutrition is also associated with improved mental and physical ability, leading to increased self-confidence and a positive body image. Lifestyle and many core nutritional behaviors are subject to major chnages during school years. Social factors, experiencing a new environment, and peer pressure can affect dietary intake of children during school years (Scaglioni et al., 2018). Independence can be manifested via increasing consumption of fast food and carbonated soft drinks, decreasing vegetables and fruit consumption during the time spent out of the home or at school (FAO 2019). Due to various psychological, social, and environmental factors affecting food preferences, school-aged children are exposed to adverse health effects of malnutrition and poor eating behavior. Therefore, targeted interventions to promote healthy nutrition should be carried out early in childhood and adolescence (Wells et al., 2020).
Education is an effective way to improve nutritional behavior and physical activity (PA). Education must focus on promoting children’s nutritional knowledge and subsequently correcting their attitudes towards unhealthy eating behaviors (Naqibi et al., 2015). The effectiveness of education on health and nutritional promotion in children has been well established in different studies (Naqibi et al., 2015, Wright et al., 2012). For example, the effect of nutritional education by lecture and distributing pamphlets on breakfast consumption in school-aged children, showed beneficial effects on knowledge, attitude, and performance scores in children (Naqibi et al., 2015). In another study, nutrition and PA trainings along with school health program couldimprove nutritional behavior and it was also associated with a reduced risk of obesity in school children (Wright et al., 2012).
School-based intervention to increase knowledge, attitude, and practice with a focus on reducing malnutrition are necessary for proper growth and development of school age children (Bouchard et al., 2018, Hennessy et al., 2019, Shapu et al., 2020). The aim of this study was to evaluate the effectiveness of an educational package on the nutritional knowledge and practices, PA, and body mass index (BMI) among school age children in Zahedan, southeast of Iran.
Materials and Methods
Participants and study setting: The current quasi-experimental before-after study was conducted between September to December 2018 and included grades 5 and 6 primary school in Zahedan city, Sistan and Baluchistan Province, southeast of Iran. To calculate the sample size, a pilot study was conducted on 20 students and the standard deviation (SD) of knowledge score was used in the formula: n= ((Z1-α ̸2 + Z1-β)2× δ2/∆2), where δ is the variance of knowledge score and ∆ is the differences in mean score of knowledge. Given the Z1-α/2 =1.96, Z1-β = 0.85 and ∆=1.08, the sample size needed for the study was estimated at 200 participants. Considering the effects of study design and sampling method, the estimated sample size was doubled. Therefore, the final estimated sample size was 800 students (400 girls and 400 boys). The list of all elementary schools in Zahedan district was obtained from the Zahedan Department of Education. Then according to the provided information from Zahedan Health Center and definition of marginalization given by the Iranian Ministry of Health, elementary schools were divided into two categories; those located in the outskirts of the city and those located in the central part. From each category one boys' and one girls' school, in total 4 schools were randomly selected. Finally, students at grades 5 and 6 from each school were selected to participate in the study. The inclusion criteria were no existence of any acute or chronic diseases such as diabetes, cardiovascular, hepatic, and renal diseases, cancer and no adherence to a specific diet. The failure to follow the study protocol was considered for excluding the student from the study.
Ethical considerations: Ethical approval for this study was obtained from Zahedan University of Medical Sciences Ethics Committee (code IR.ZAUMS.REC.1395. 254(. All participants of the study gave written informed consent.
Development of the educational package: Each student was provided with a booklet in Persian titled "Eat a Rainbow Every Day'', developed based on the booklet published by Advocating the Right of Children (ARC) (Advocating the Right of Children (ARC), 2010). The booklet introduced the food pyramid and health benefits of different food groups and each food group corresponded to one color of the rainbow, encouraging children to consume each group on a daily basis. The booklet also included weekly charts for recording the daily intake of food groups and the level of PA. The booklet was divided into 4 sections and each section was taught in a 2-hour session by trained health care professionals. Also, these nutritional educational sessions were held for parents to encourage their children to observe and improve their nutritional behaviors. The topic of each educational session was presented through the lecture and discussed by questioning and answering at the end of each session.
A star chart was included in "Eat a Rainbow Everyday" booklet to be used by parents to encourage children to record their daily food group intake and PA. A color coding system was used for recording the students daily eating behavior and PA. If the student consumed a food group according to recommended daily intake, less than the recommended amount, or did not use a food group at all during the day, they were asked to paint the star of that group with a green, yellow or red pencil, respectively. In addition to food groups, if the student did not use fast foods and/or sweetened beverages, he or she was asked to paint the star of those forbidden foodstuff with a green pencil. Similary, if the studnet did at least 30 minutes of PA and sports during the day , the star was painted green. The parents kept the track of their children's eating behavior and PA by counting the number of green, yellow, and red stars at the end of each week. The parents were urged to encourage their children to improve their eating behavior. This was assessed by an increase in the total number of green stars obtained during the week, according to the food pyramid recommendations, and by a decrease in the number of yellow and red stars.
Measurements: A 69-item semi-structured questionnaire was used by a team of trained health care professionals for data collection before and after intervetion. The questionnaire included four sections: 1) demographic and medical information, 2) height and weight and PA measurements, 3) nutritional knowledge, and 4) eating behavior and dietary intake of participants.
The validity of the questionnaire was estimated by calculating the validity content ratio (CVR) and content validity index using the feedback from a panel of 10 experts including nutritionists, public health professionals, maternal and child health experts, and medical doctors. The questions with a CVR less than 0.62 were either modified or removed (Lawshe, 1975). The reliability of the questionnaire was evaluated by pre-tests and post-tests conducted one month apart among a sample of 35 elementary school children. An Alpha Cronbach’s coefficient of 0.902 for knowledge scores and Kuder-Richardson20 coefficient of 0.73 for other dichotomized questions established the reliability of the questionnaire.
Weight was measured to the nearest 100 g in lightly dressed and barefoot condition using a digital scale (Seca, Germany). Height was measured using a non-elastic tape. BMI was calculated as weight (kg) divided by height squared (m2). The WHO growth charts were used to categorize the BMI into underweight BMI z-score < –2, normal z-score ≥−2 to <1, overweight BMI z-score ≥+1 to <+2, and obese BMI z-score > +2 (Al-Thani et al., 2018).
Nutritional knowledge was assessed with 26 questions that were designed as ‘Yes’ or ‘No’ questions. Each correct answer was scored as 1, and the sum of the scores (maximum 26) was calculated as the total nutritional knowledge score.
The dietary intake of students was determined by a standard Food Frequency Questionnaire (FFQ) adapted from the Childhood and Adolescence Surveillance and Prevention of Noncommunicable disease (CASPIAN) study (Motlagh et al., 2009). The duration of the intervention was 3 months. After educational sessions, at the end of each month, students were asked to bring their booklets back and their dietary and PA performance recorded in the booklets was assessed by an expert nutritionist.
Data analysis: The continuous variables were presented as mean ± SD. Categorical variables were presented as counts and percentages. Paired t-test was used to compare the mean scores of continuous variables. McNemar's and Friedman tests were used for comparing paired categorical variables. A p-value < 0.05 was considered as significant for all analyses. SPSS version 20 statistical software package (Chicago, IL) was used for data analysis.
Results
A total of 800 elementary school children were selected in this study, out of which 734 students including 362 (49.3%) girls, and 372 (50.7%) boys aged 10-14 years completed the study. The mean family size was 6.35±2.24. The father's and mother's education levels in 55.7% and 65.7% of participant were less than high school, respectively. Overall, 28.1% of fathers had government job, 61% were workers or self-employed, and the rest were unemployed. Also, 68.8% of mothers were housewives.
Table 1 compares the overall knowledge score, PA and eating behaviors, before and after the intervention. Statistically significant changes in knowledge scores were observed after the intervention (P≤0.001). A significant increase was also found in the number of days with at least 30 minnutes of PA per week (P<0.001). Regarding having meals during school days, the number of school days having breakfast, lunch, and dinner significantly increased. Similarly, the proportion of children who had breakfast and dinner on the weekends increased significantly after the intervention (P< 0.001).
Table 2 describes the frequency of consumption of food groups based on times per week in elementary school children before and after intervention. The consumption of dairy products, animal proteins, and fruits significantly increased. The frequency of consumption of fast foods showed a significant reduction (P<0.001). No significant effectwas found on the frequency of intaking grains, vegetables, salty/fatty snacks, and sweets.
The proportion of underweight in the study population decreased from 17.4% to 11.9% after the intervention. The percentage of elementary school children with a normal BMI also changed from 82.2% to 88.0% after the intervention. The fraction of overweight and obesity in the participants decreased from 0.4% to 0.1%. All differences observed in the BMI after intervention were statistically significant.
and adolescence negatively affects physical, psychological, and social health throughout life (Murtagh and Collaboration, 2017). Globally, it is estimated that 75 million girls and 117 million boys aged 5-19 years are underweight. Correspondingly, 50 million girls and 74 million boys are obese (Murtagh and Collaboration, 2017). The overall prevalence of underweight, overweight, and obesity in school children in Iran is estimated to be 6.6%, 11.9%, and 9.7%, respectively (Azizi-Soleiman et al., 2020, Khashayar et al., 2018). The highest
rate of food insecurity in the country has been reported in Sistan and Baluchistan Province, where 21.3% and 9.6% of elementary school children suffer from underweight and overweight/obesity, respectively (Maddah et al., 2010). High prevalence of underweight in elementary school children
as well as an increase in the prevalence of overweight/obesity in this age group is a major public health concern (Maddah et al., 2010).
Healthy nutrition has a key role in improving and maintaining health status of the individuals. In school-aged children, a healthy eating behavior not only is associated with health and growth promotion, but also may prevent childhood malnutrition and chronic diseases (Nasreddine et al., 2019). Healthy nutrition is also associated with improved mental and physical ability, leading to increased self-confidence and a positive body image. Lifestyle and many core nutritional behaviors are subject to major chnages during school years. Social factors, experiencing a new environment, and peer pressure can affect dietary intake of children during school years (Scaglioni et al., 2018). Independence can be manifested via increasing consumption of fast food and carbonated soft drinks, decreasing vegetables and fruit consumption during the time spent out of the home or at school (FAO 2019). Due to various psychological, social, and environmental factors affecting food preferences, school-aged children are exposed to adverse health effects of malnutrition and poor eating behavior. Therefore, targeted interventions to promote healthy nutrition should be carried out early in childhood and adolescence (Wells et al., 2020).
Education is an effective way to improve nutritional behavior and physical activity (PA). Education must focus on promoting children’s nutritional knowledge and subsequently correcting their attitudes towards unhealthy eating behaviors (Naqibi et al., 2015). The effectiveness of education on health and nutritional promotion in children has been well established in different studies (Naqibi et al., 2015, Wright et al., 2012). For example, the effect of nutritional education by lecture and distributing pamphlets on breakfast consumption in school-aged children, showed beneficial effects on knowledge, attitude, and performance scores in children (Naqibi et al., 2015). In another study, nutrition and PA trainings along with school health program couldimprove nutritional behavior and it was also associated with a reduced risk of obesity in school children (Wright et al., 2012).
School-based intervention to increase knowledge, attitude, and practice with a focus on reducing malnutrition are necessary for proper growth and development of school age children (Bouchard et al., 2018, Hennessy et al., 2019, Shapu et al., 2020). The aim of this study was to evaluate the effectiveness of an educational package on the nutritional knowledge and practices, PA, and body mass index (BMI) among school age children in Zahedan, southeast of Iran.
Materials and Methods
Participants and study setting: The current quasi-experimental before-after study was conducted between September to December 2018 and included grades 5 and 6 primary school in Zahedan city, Sistan and Baluchistan Province, southeast of Iran. To calculate the sample size, a pilot study was conducted on 20 students and the standard deviation (SD) of knowledge score was used in the formula: n= ((Z1-α ̸2 + Z1-β)2× δ2/∆2), where δ is the variance of knowledge score and ∆ is the differences in mean score of knowledge. Given the Z1-α/2 =1.96, Z1-β = 0.85 and ∆=1.08, the sample size needed for the study was estimated at 200 participants. Considering the effects of study design and sampling method, the estimated sample size was doubled. Therefore, the final estimated sample size was 800 students (400 girls and 400 boys). The list of all elementary schools in Zahedan district was obtained from the Zahedan Department of Education. Then according to the provided information from Zahedan Health Center and definition of marginalization given by the Iranian Ministry of Health, elementary schools were divided into two categories; those located in the outskirts of the city and those located in the central part. From each category one boys' and one girls' school, in total 4 schools were randomly selected. Finally, students at grades 5 and 6 from each school were selected to participate in the study. The inclusion criteria were no existence of any acute or chronic diseases such as diabetes, cardiovascular, hepatic, and renal diseases, cancer and no adherence to a specific diet. The failure to follow the study protocol was considered for excluding the student from the study.
Ethical considerations: Ethical approval for this study was obtained from Zahedan University of Medical Sciences Ethics Committee (code IR.ZAUMS.REC.1395. 254(. All participants of the study gave written informed consent.
Development of the educational package: Each student was provided with a booklet in Persian titled "Eat a Rainbow Every Day'', developed based on the booklet published by Advocating the Right of Children (ARC) (Advocating the Right of Children (ARC), 2010). The booklet introduced the food pyramid and health benefits of different food groups and each food group corresponded to one color of the rainbow, encouraging children to consume each group on a daily basis. The booklet also included weekly charts for recording the daily intake of food groups and the level of PA. The booklet was divided into 4 sections and each section was taught in a 2-hour session by trained health care professionals. Also, these nutritional educational sessions were held for parents to encourage their children to observe and improve their nutritional behaviors. The topic of each educational session was presented through the lecture and discussed by questioning and answering at the end of each session.
A star chart was included in "Eat a Rainbow Everyday" booklet to be used by parents to encourage children to record their daily food group intake and PA. A color coding system was used for recording the students daily eating behavior and PA. If the student consumed a food group according to recommended daily intake, less than the recommended amount, or did not use a food group at all during the day, they were asked to paint the star of that group with a green, yellow or red pencil, respectively. In addition to food groups, if the student did not use fast foods and/or sweetened beverages, he or she was asked to paint the star of those forbidden foodstuff with a green pencil. Similary, if the studnet did at least 30 minutes of PA and sports during the day , the star was painted green. The parents kept the track of their children's eating behavior and PA by counting the number of green, yellow, and red stars at the end of each week. The parents were urged to encourage their children to improve their eating behavior. This was assessed by an increase in the total number of green stars obtained during the week, according to the food pyramid recommendations, and by a decrease in the number of yellow and red stars.
Measurements: A 69-item semi-structured questionnaire was used by a team of trained health care professionals for data collection before and after intervetion. The questionnaire included four sections: 1) demographic and medical information, 2) height and weight and PA measurements, 3) nutritional knowledge, and 4) eating behavior and dietary intake of participants.
The validity of the questionnaire was estimated by calculating the validity content ratio (CVR) and content validity index using the feedback from a panel of 10 experts including nutritionists, public health professionals, maternal and child health experts, and medical doctors. The questions with a CVR less than 0.62 were either modified or removed (Lawshe, 1975). The reliability of the questionnaire was evaluated by pre-tests and post-tests conducted one month apart among a sample of 35 elementary school children. An Alpha Cronbach’s coefficient of 0.902 for knowledge scores and Kuder-Richardson20 coefficient of 0.73 for other dichotomized questions established the reliability of the questionnaire.
Weight was measured to the nearest 100 g in lightly dressed and barefoot condition using a digital scale (Seca, Germany). Height was measured using a non-elastic tape. BMI was calculated as weight (kg) divided by height squared (m2). The WHO growth charts were used to categorize the BMI into underweight BMI z-score < –2, normal z-score ≥−2 to <1, overweight BMI z-score ≥+1 to <+2, and obese BMI z-score > +2 (Al-Thani et al., 2018).
Nutritional knowledge was assessed with 26 questions that were designed as ‘Yes’ or ‘No’ questions. Each correct answer was scored as 1, and the sum of the scores (maximum 26) was calculated as the total nutritional knowledge score.
The dietary intake of students was determined by a standard Food Frequency Questionnaire (FFQ) adapted from the Childhood and Adolescence Surveillance and Prevention of Noncommunicable disease (CASPIAN) study (Motlagh et al., 2009). The duration of the intervention was 3 months. After educational sessions, at the end of each month, students were asked to bring their booklets back and their dietary and PA performance recorded in the booklets was assessed by an expert nutritionist.
Data analysis: The continuous variables were presented as mean ± SD. Categorical variables were presented as counts and percentages. Paired t-test was used to compare the mean scores of continuous variables. McNemar's and Friedman tests were used for comparing paired categorical variables. A p-value < 0.05 was considered as significant for all analyses. SPSS version 20 statistical software package (Chicago, IL) was used for data analysis.
Results
A total of 800 elementary school children were selected in this study, out of which 734 students including 362 (49.3%) girls, and 372 (50.7%) boys aged 10-14 years completed the study. The mean family size was 6.35±2.24. The father's and mother's education levels in 55.7% and 65.7% of participant were less than high school, respectively. Overall, 28.1% of fathers had government job, 61% were workers or self-employed, and the rest were unemployed. Also, 68.8% of mothers were housewives.
Table 1 compares the overall knowledge score, PA and eating behaviors, before and after the intervention. Statistically significant changes in knowledge scores were observed after the intervention (P≤0.001). A significant increase was also found in the number of days with at least 30 minnutes of PA per week (P<0.001). Regarding having meals during school days, the number of school days having breakfast, lunch, and dinner significantly increased. Similarly, the proportion of children who had breakfast and dinner on the weekends increased significantly after the intervention (P< 0.001).
Table 2 describes the frequency of consumption of food groups based on times per week in elementary school children before and after intervention. The consumption of dairy products, animal proteins, and fruits significantly increased. The frequency of consumption of fast foods showed a significant reduction (P<0.001). No significant effectwas found on the frequency of intaking grains, vegetables, salty/fatty snacks, and sweets.
The proportion of underweight in the study population decreased from 17.4% to 11.9% after the intervention. The percentage of elementary school children with a normal BMI also changed from 82.2% to 88.0% after the intervention. The fraction of overweight and obesity in the participants decreased from 0.4% to 0.1%. All differences observed in the BMI after intervention were statistically significant.
| Table 1. Knowledge score, phsical activity (PA), and eating behaviors in elementary school children, aged 10–14 years, before and after the intervention. | |||
| Variables | Before | After | P-value |
| Knowledge score | 7.5±5.6c | 17.1±6.4 | <0.001a |
| Days with 30 min PA per week | 2.6±2.0 | 3.4±2.2 | <0.001a |
| No. of school days having breakfast | 5.9±1.9 | 6.1±1.8 | 0.009a |
| No. of school days having lunch | 6.4±1.3 | 6.6±1.1 | 0.002a |
| No. of school days having dinner | 6.3±1.4 | 6.6±1.1 | <0.001a |
| Having breakfast on the weekends Yes |
651 (88.7)d |
698 (95.1) |
<0.001b |
| No | 83 (11.3) | 36 (4.9) | |
| Having lunch on the weekends Yes |
710 (96.7) |
717 (97.7) |
0.324b |
| No | 24 (3.3) | 17 (2.3) | |
| Having dinner on the weekends Yes |
694 (94.6) |
721 (98.2) |
<0.001b |
| No | 40 (5.4) | 13 (1.8) | |
| a: Paired t-test; b: McNemar test; c: Mean±SD; d: N(%) | |||
| Table 2. Mean (SD) of abundance of consumption (times/week) of food groups in elementary school children, aged 10–14 years, before and after intervention. | |||
| Food groups | Before | After | P-valuea |
| Grains | 12.93±3.60b | 13.12±3.35 | 0.268 |
| Dairy products | 4.30±2.75 | 4.78±2.49 | 0.0001 |
| Animal protein | 8.64±4.24 | 9.18±4.11 | 0.001 |
| Plant protein | 4.09±3.32 | 4.93±3.46 | 0.0001 |
| Vegetables | 3.77±2.70 | 3.91±2.68 | 0.291 |
| Fruits (fresh, dried, juice) | 5.80±3.61 | 6.47±3.41 | 0.0001 |
| Fast foods | 1.67±2.28 | 1.34±2.10 | 0.001 |
| Salty/fatty snacks | 2.73±2.81 | 2.65±2.87 | 0.520 |
| Sweets/candies | 13.00±5.70 | 13.01±5.74 | 0.970 |
| a: Paired t-test; b: Mean±SD | |||
| Table 3. Weight status in elementary school children aged 10–14 years, before and after the intervention. | |||
| Weight status | Before | After | P-valuea |
| Underweight | 128 (17.4)b | 87 (11.9) | 0.0001 |
| Normal | 603 (82.2) | 646 (88.0) | |
| Overweight/Obese | 3 (0.4) | 1(0.1) | |
| a: Friedman test; b: N(%) | |||
Discussion
In this study, the effects of a nutritional educational intervention on the nutritional knowledge and performance, phisical activity, and BMI status of elementary school children were evaluated. Results indicated that this 3-month intervention improved the nutritional knowledge and physical performance of the participants. In line with these findings, a study conducted in Qom, Iran reported that a 3-month nutritional education program via lecture and an educational booklet improved the nutritional knowledge, attitude, and performance of junior high school students (Vahedian et al., 2014). Another study showed that two nutritional education methods (lecture with teaching aid and without teaching aid) with a focus on fast food intake among grade 5 elementary school children, increased mean score of knowledge and practice (Pourabdollah et al., 2005). Other similar studies also indicated the beneficial effects of nutritional education on knowledge and attitudes of children (Hamulka et al., 2018, Murimi et al., 2018).
Regarding PA, the intervention improved the number of days with 30 minutes of PA. The role of PA education in improving PA level and consequently promoting health outcomes has been well established (Dudley et al., 2012). Students who received PA education trainings over a six months period showed an increase in the levels of PA and the majority of subjects performed moderate and vigorous PA (Dudley et al., 2012). However, PA training in high school students of deprived areas failed to reach the international recommendations after the intervention. Its has been proposed that the differences in teaching method and teacher gender might affect the students’ PA levels. In fact male teachers tend to teach more moderate and vigorous PAs (Sutherland et al., 2016).
Meal skipping is common among children and adolescents (Azemati et al., 2018). The increasing risk of chronic diseases due to meal skipping has been demonstrated in some studies (Moschiano et al., 2012, Zilberter and Zilberter, 2014). In a study conducted on Iranian adolescent, the prevalence rate of breakfast, lunch, and dinner skipping was estimated 32.1%, 8.9%, and 10.9%, respectively (Kelishadi et al., 2017). It was found that educational intervention could improve the number of school days having breakfast, lunch, and dinner. The intervention also improved the frequency of breakfast and dinner consumed on the weekends. A study conducted among low income adults in 14 counties of Indiana, reported that two methods of education (online and in-person education) improved most nutrition-related behaviors including breakfast consumption (Neuenschwander et al., 2013). A randomized-controlled trial on 590 participants showed that nutrition education was effective in improving breakfast-related knowledge and reducing breakfast skipping (Chaudhary et al., 2016).
The findings of this study also highlighted the improving effects of the intervention on the frequency of consuming dairy product, animal and plant protein, and fruits. However, for fast food intake, an incraese was observed in the consunption after the intervention. A quasi-experimental study evaluated the effectiveness of an 8-month integrated nutritional education through a peer-led approach, health promotion via school media and health clubs on dietary behaviors of 1000 school adolescents from Southwest of Ethiopia (Tamiru et al., 2016). Consistent with the present study results, their findings showed improvement effects of education on animal source dietary consumption of students. In another study, dietary diversity and dietary practice of adolescent students improved after implementation of a school based nutritional education and this improvement was associated with the duration of the intervention (Tamiru et al., 2016). The improving effects of a whole school nutritional education on dietary intake and attitudes of students toward fruits and vegetables have been reported in other studies (Morgan et al., 2010).
The household economic status and the parents’ occupation also can affect the nutritional behaviors and dietary diversity of children (Tamiru et al., 2016). In the current study, parents’ education and occupation were in a low status, which can result in consumption of a less diversified diet. Maternal education can affect food choices of children via shifting their attitude from unhealthy food to more healthy and nutrient-dense food (Nguyen et al., 2013). Currently, most school interventions focus on preventing overweight and obesity (Abdollahi et al., 2019, Niknam et al., 2021), while in underprivileged areas, underweight is a still a nutritional problem and the findings of this study showed that educational interventions can have a good effect on reducing the proportion of underweight school children.
The following limitations should be considered in interpreting the study findings. The duration of this intervention was 3 months, but most studies in the field of nutritional education have indicated that longer durations of intervention can have more beneficial effects (Murimi et al., 2017, Verjans-Janssen et al., 2018). Therefore, conducting studies with longer duration is required to obtain more beneficial effects of nutritional education. Another limitation of the study was self-assessment conducted by students, which may lead to reporting bias. The strengths of this study included the study design (a quasi-experimental before-after study) and good compliance of the participants, using weekly schedule as a good way for recording dietary and PA of the students, and also involving parents in nutritional education and feedback.
Conclusion
This multifaceted nutrition education intervention was associated with improving the nutritional knowledge score and healthy lifestyle
in elementary school children. Continued professional education and implementation of educational package to improve nutrition and health behavior in elementary school children are suggested.
Acknowledgement
The authors thank all the elementary school children and their parents for participating in this study.
Funding/Support
This study was supported by Zahedan University of Medical Sciences, Zahedan, Iran.
Authors' contributions
Sheikhi M and Tabatabaei SM designed and performed the study and analyses, and wrote the main paper. Eftekharinia M and Zaboli M helped performed and interpret the data. All authors read and approved the final manuscript.
References
Abdollahi Z, et al. 2019. Effect of educational intervention on healthy lifestyle in Iranian children and adolescents: The IRAN-Ending Childhood Obesity (IRAN-ECHO) program. Journal of nutritional sciences and dietetics. 32-39.
Advocating the Right of Children (ARC) 2010. HEAL Campaign: promoting Healthy Eating and Active Lifestyles for children
Al-Thani M, et al. 2018. The prevalence and characteristics of overweight and obesity
among students in Qatar. Public health. 160:
143-149.
Ali MS, Kassahun CW, Wubneh CA, Mekonen EG & Workneh BS 2022. Applied nutritional investigation Determinants of undernutrition among private and public primary school children: A comparative cross-sectional study toward nutritional transition in northwest Ethiopia. Nutrition. 96: 111575-111575.
Azemati B, et al. 2018. Association of meal skipping with subjective health complaints in children and adolescents: the CASPIAN-V study. Eating and weight disorders-studies on anorexia, bulimia and obesity. 241-246.
Azizi-Soleiman F, Sharifi H & Zamanian M 2020. Comparison of the prevalence and trend of malnutrition between 0–6 years and 7–11 years old Iranian children: A systematic review and meta-analysis. International journal of preventive medicine. 11 (182).
Bouchard C, Blair SN & Haskell WL 2018. Physical activity and health. Human Kinetics.
Chaudhary NS, Grandner MA, Jackson NJ & Chakravorty S 2016. Caffeine consumption, insomnia, and sleep duration: Results from a nationally representative sample. Nutrition. 32 (11-12): 1193-1199.
Dudley DA, Okely AD, Cotton WG, Pearson P & Caputi P 2012. Physical activity levels and movement skill instruction in secondary school physical education. Journal of science and medicine in sport. 15 (3): 231-237.
FAO, IFAD, UNICEF , WFP and WHO 2019. The state of food security and nutrition in the world 2019: Safeguarding against economic slowdowns and downturns. Rome, FAO. Licence: CC BY-NC-SA 3.0 IGO.
Hamulka J, Wadolowska L, Hoffmann M, Kowalkowska J & Gutkowska K 2018. Effect of an education program on nutrition knowledge, attitudes toward nutrition, diet quality, lifestyle, and body composition in Polish teenagers. The ABC of healthy eating project: Design, protocol, and methodology. Nutrients. 10 (10): 1439.
Hennessy E, Korn AR & Economos CD 2019. A Community-Level Perspective for Childhood Obesity Prevention. In Global Perspectives on Childhood Obesity, pp. 287-298. Elsevier.
Kelishadi R, et al. 2017. Is snack consumption associated with meal skipping in children and adolescents? The CASPIAN-IV study. Eating and weight disorders-studies on anorexia, bulimia and obesity. 22 (2): 321-328.
Khashayar P, et al. 2018. Childhood overweight and obesity and associated factors in iranian children and adolescents: a multilevel analysis; the CASPIAN-IV study. Frontiers in pediatrics. 6: 393.
Lawshe CH 1975. A quantitative approach to content validity 1. Personnel psychology. 28 (4): 563-575.
Maddah M, Shahraki T & Shahraki M 2010. Underweight and overweight among children in Zahedan, south-east Iran. Public health nutrition. 13 (10): 1519-1521.
Morgan PJ, et al. 2010. The impact of nutrition education with and without a school garden on knowledge, vegetable intake and preferences and quality of school life among primary-school students. Public health nutrition. 13 (11): 1931-1940.
Moschiano F, et al. 2012. Headache, eating and sleeping behaviors and lifestyle factors in preadolescents and adolescents: preliminary results from an Italian population study. Neurological sciences. 33 (1): 87-90.
Motlagh ME, et al. 2009. Rationale, methods and first results of the Iranian national programme for prevention of chronic diseases from childhood: CASPIAN Study. EMHJ-Eastern Mediterranean health journal 15 (2):
302-314.
Murimi MW, et al. 2017. Factors influencing efficacy of nutrition education interventions: a systematic review. Journal of nutrition education and behavior. 49 (2): 142-165. e141.
Murimi MW, et al. 2018. Factors that contribute to effective nutrition education interventions in children: a systematic review. Nutrition reviews. 76 (8): 553-580.
Murtagh E & Collaboration NRF 2017. Worldwide trends in children’s and adolescents’ body mass index, underweight, overweight and obesity, in comparison with adults, from 1975 to 2016: A pooled analysis of 2,416 population-based measurement studies with 128.9 million participants (Pre-published version). Lanset.
Naqibi MB, Karami K & Shakerinezhad Q 2015. Effect of nutritional education through lecture and pamphlet methods on breakfast consumption behavior among primary school girls in Ahvaz. International journal of bioassays. 4 (6): 3973-3979.
Nasreddine L, Taktouk M, Dabbous M & Melki J 2019. The extent, nature, and nutritional quality of foods advertised to children in Lebanon: the first study to use the WHO nutrient profile model for the Eastern Mediterranean Region. Food & nutrition research. 63.
Neuenschwander LM, Abbott A & Mobley AR 2013. Comparison of a web-based vs in-person nutrition education program for low-income adults. Journal of the academy of nutrition and dietetics. 113 (1): 120-126.
Nguyen PH, et al. 2013. Maternal and child dietary diversity are associated in Bangladesh, Vietnam, and Ethiopia. Journal of nutrition. 143 (7): 1176-1183.
Niknam M, Omidvar N, Amiri P, Eini-Zinab H & Kalantari N 2021. Community readiness for childhood obesity prevention programs: findings from an urban population in Iran. Health promotion international. 36 (3): 824-835.
Pourabdollah P, et al. 2005. The effect of nutrition education on the knowledge and practice of elementary school children regarding junk food intake. Journal of advances in medical and biomedical research. 13 (51): 13-20.
Scaglioni S, et al. 2018. Factors influencing children’s eating behaviours. Nutrients. 10 (6): 706.
Shapu RC, Ismail S, Ahmad N, Lim PY & Njodi IA 2020. Systematic review: Effect of health education intervention on improving knowledge, attitudes and practices of adolescents on malnutrition. Nutrients. 12 (8).
Sutherland R, et al. 2016. Physical education in secondary schools located in low-income communities: Physical activity levels, lesson context and teacher interaction. Journal of science and medicine in sport. 19 (2): 135-141.
Tamiru D, et al. 2016. Improving dietary diversity of school adolescents through school based nutrition education and home gardening in Jimma Zone: Quasi-experimental design. Eating behaviors. 23: 180-186.
Vahedian M, et al. 2014. Effect of Educational Booklet and Lecture on Nutritional Behavior, Knowledge and Attitude on Third-Grade Male Guidance School Students. Journal of health research 3(1): 1-12.
Verjans-Janssen SR, van de Kolk I, Van Kann DH, Kremers SP & Gerards SM 2018. Effectiveness of school-based physical activity and nutrition interventions with direct parental involvement on children’s BMI and energy balance-related behaviors–A systematic review. PloS one. 13 (9): e0204560.
Wells JC, et al. 2020. The double burden of malnutrition: aetiological pathways and consequences for health. Lancet. 395 (10217): 75-88.
Wright K, Norris K, Newman Giger J & Suro Z 2012. Improving healthy dietary behaviors, nutrition knowledge, and self-efficacy among underserved school children with parent and community involvement. Childhood obesity. 8 (4): 347-356.
Zilberter T & Zilberter EY 2014. Breakfast: to skip or not to skip? Frontiers in public health. 2: 59.
In this study, the effects of a nutritional educational intervention on the nutritional knowledge and performance, phisical activity, and BMI status of elementary school children were evaluated. Results indicated that this 3-month intervention improved the nutritional knowledge and physical performance of the participants. In line with these findings, a study conducted in Qom, Iran reported that a 3-month nutritional education program via lecture and an educational booklet improved the nutritional knowledge, attitude, and performance of junior high school students (Vahedian et al., 2014). Another study showed that two nutritional education methods (lecture with teaching aid and without teaching aid) with a focus on fast food intake among grade 5 elementary school children, increased mean score of knowledge and practice (Pourabdollah et al., 2005). Other similar studies also indicated the beneficial effects of nutritional education on knowledge and attitudes of children (Hamulka et al., 2018, Murimi et al., 2018).
Regarding PA, the intervention improved the number of days with 30 minutes of PA. The role of PA education in improving PA level and consequently promoting health outcomes has been well established (Dudley et al., 2012). Students who received PA education trainings over a six months period showed an increase in the levels of PA and the majority of subjects performed moderate and vigorous PA (Dudley et al., 2012). However, PA training in high school students of deprived areas failed to reach the international recommendations after the intervention. Its has been proposed that the differences in teaching method and teacher gender might affect the students’ PA levels. In fact male teachers tend to teach more moderate and vigorous PAs (Sutherland et al., 2016).
Meal skipping is common among children and adolescents (Azemati et al., 2018). The increasing risk of chronic diseases due to meal skipping has been demonstrated in some studies (Moschiano et al., 2012, Zilberter and Zilberter, 2014). In a study conducted on Iranian adolescent, the prevalence rate of breakfast, lunch, and dinner skipping was estimated 32.1%, 8.9%, and 10.9%, respectively (Kelishadi et al., 2017). It was found that educational intervention could improve the number of school days having breakfast, lunch, and dinner. The intervention also improved the frequency of breakfast and dinner consumed on the weekends. A study conducted among low income adults in 14 counties of Indiana, reported that two methods of education (online and in-person education) improved most nutrition-related behaviors including breakfast consumption (Neuenschwander et al., 2013). A randomized-controlled trial on 590 participants showed that nutrition education was effective in improving breakfast-related knowledge and reducing breakfast skipping (Chaudhary et al., 2016).
The findings of this study also highlighted the improving effects of the intervention on the frequency of consuming dairy product, animal and plant protein, and fruits. However, for fast food intake, an incraese was observed in the consunption after the intervention. A quasi-experimental study evaluated the effectiveness of an 8-month integrated nutritional education through a peer-led approach, health promotion via school media and health clubs on dietary behaviors of 1000 school adolescents from Southwest of Ethiopia (Tamiru et al., 2016). Consistent with the present study results, their findings showed improvement effects of education on animal source dietary consumption of students. In another study, dietary diversity and dietary practice of adolescent students improved after implementation of a school based nutritional education and this improvement was associated with the duration of the intervention (Tamiru et al., 2016). The improving effects of a whole school nutritional education on dietary intake and attitudes of students toward fruits and vegetables have been reported in other studies (Morgan et al., 2010).
The household economic status and the parents’ occupation also can affect the nutritional behaviors and dietary diversity of children (Tamiru et al., 2016). In the current study, parents’ education and occupation were in a low status, which can result in consumption of a less diversified diet. Maternal education can affect food choices of children via shifting their attitude from unhealthy food to more healthy and nutrient-dense food (Nguyen et al., 2013). Currently, most school interventions focus on preventing overweight and obesity (Abdollahi et al., 2019, Niknam et al., 2021), while in underprivileged areas, underweight is a still a nutritional problem and the findings of this study showed that educational interventions can have a good effect on reducing the proportion of underweight school children.
The following limitations should be considered in interpreting the study findings. The duration of this intervention was 3 months, but most studies in the field of nutritional education have indicated that longer durations of intervention can have more beneficial effects (Murimi et al., 2017, Verjans-Janssen et al., 2018). Therefore, conducting studies with longer duration is required to obtain more beneficial effects of nutritional education. Another limitation of the study was self-assessment conducted by students, which may lead to reporting bias. The strengths of this study included the study design (a quasi-experimental before-after study) and good compliance of the participants, using weekly schedule as a good way for recording dietary and PA of the students, and also involving parents in nutritional education and feedback.
Conclusion
This multifaceted nutrition education intervention was associated with improving the nutritional knowledge score and healthy lifestyle
in elementary school children. Continued professional education and implementation of educational package to improve nutrition and health behavior in elementary school children are suggested.
Acknowledgement
The authors thank all the elementary school children and their parents for participating in this study.
Funding/Support
This study was supported by Zahedan University of Medical Sciences, Zahedan, Iran.
Authors' contributions
Sheikhi M and Tabatabaei SM designed and performed the study and analyses, and wrote the main paper. Eftekharinia M and Zaboli M helped performed and interpret the data. All authors read and approved the final manuscript.
References
Abdollahi Z, et al. 2019. Effect of educational intervention on healthy lifestyle in Iranian children and adolescents: The IRAN-Ending Childhood Obesity (IRAN-ECHO) program. Journal of nutritional sciences and dietetics. 32-39.
Advocating the Right of Children (ARC) 2010. HEAL Campaign: promoting Healthy Eating and Active Lifestyles for children
Al-Thani M, et al. 2018. The prevalence and characteristics of overweight and obesity
among students in Qatar. Public health. 160:
143-149.
Ali MS, Kassahun CW, Wubneh CA, Mekonen EG & Workneh BS 2022. Applied nutritional investigation Determinants of undernutrition among private and public primary school children: A comparative cross-sectional study toward nutritional transition in northwest Ethiopia. Nutrition. 96: 111575-111575.
Azemati B, et al. 2018. Association of meal skipping with subjective health complaints in children and adolescents: the CASPIAN-V study. Eating and weight disorders-studies on anorexia, bulimia and obesity. 241-246.
Azizi-Soleiman F, Sharifi H & Zamanian M 2020. Comparison of the prevalence and trend of malnutrition between 0–6 years and 7–11 years old Iranian children: A systematic review and meta-analysis. International journal of preventive medicine. 11 (182).
Bouchard C, Blair SN & Haskell WL 2018. Physical activity and health. Human Kinetics.
Chaudhary NS, Grandner MA, Jackson NJ & Chakravorty S 2016. Caffeine consumption, insomnia, and sleep duration: Results from a nationally representative sample. Nutrition. 32 (11-12): 1193-1199.
Dudley DA, Okely AD, Cotton WG, Pearson P & Caputi P 2012. Physical activity levels and movement skill instruction in secondary school physical education. Journal of science and medicine in sport. 15 (3): 231-237.
FAO, IFAD, UNICEF , WFP and WHO 2019. The state of food security and nutrition in the world 2019: Safeguarding against economic slowdowns and downturns. Rome, FAO. Licence: CC BY-NC-SA 3.0 IGO.
Hamulka J, Wadolowska L, Hoffmann M, Kowalkowska J & Gutkowska K 2018. Effect of an education program on nutrition knowledge, attitudes toward nutrition, diet quality, lifestyle, and body composition in Polish teenagers. The ABC of healthy eating project: Design, protocol, and methodology. Nutrients. 10 (10): 1439.
Hennessy E, Korn AR & Economos CD 2019. A Community-Level Perspective for Childhood Obesity Prevention. In Global Perspectives on Childhood Obesity, pp. 287-298. Elsevier.
Kelishadi R, et al. 2017. Is snack consumption associated with meal skipping in children and adolescents? The CASPIAN-IV study. Eating and weight disorders-studies on anorexia, bulimia and obesity. 22 (2): 321-328.
Khashayar P, et al. 2018. Childhood overweight and obesity and associated factors in iranian children and adolescents: a multilevel analysis; the CASPIAN-IV study. Frontiers in pediatrics. 6: 393.
Lawshe CH 1975. A quantitative approach to content validity 1. Personnel psychology. 28 (4): 563-575.
Maddah M, Shahraki T & Shahraki M 2010. Underweight and overweight among children in Zahedan, south-east Iran. Public health nutrition. 13 (10): 1519-1521.
Morgan PJ, et al. 2010. The impact of nutrition education with and without a school garden on knowledge, vegetable intake and preferences and quality of school life among primary-school students. Public health nutrition. 13 (11): 1931-1940.
Moschiano F, et al. 2012. Headache, eating and sleeping behaviors and lifestyle factors in preadolescents and adolescents: preliminary results from an Italian population study. Neurological sciences. 33 (1): 87-90.
Motlagh ME, et al. 2009. Rationale, methods and first results of the Iranian national programme for prevention of chronic diseases from childhood: CASPIAN Study. EMHJ-Eastern Mediterranean health journal 15 (2):
302-314.
Murimi MW, et al. 2017. Factors influencing efficacy of nutrition education interventions: a systematic review. Journal of nutrition education and behavior. 49 (2): 142-165. e141.
Murimi MW, et al. 2018. Factors that contribute to effective nutrition education interventions in children: a systematic review. Nutrition reviews. 76 (8): 553-580.
Murtagh E & Collaboration NRF 2017. Worldwide trends in children’s and adolescents’ body mass index, underweight, overweight and obesity, in comparison with adults, from 1975 to 2016: A pooled analysis of 2,416 population-based measurement studies with 128.9 million participants (Pre-published version). Lanset.
Naqibi MB, Karami K & Shakerinezhad Q 2015. Effect of nutritional education through lecture and pamphlet methods on breakfast consumption behavior among primary school girls in Ahvaz. International journal of bioassays. 4 (6): 3973-3979.
Nasreddine L, Taktouk M, Dabbous M & Melki J 2019. The extent, nature, and nutritional quality of foods advertised to children in Lebanon: the first study to use the WHO nutrient profile model for the Eastern Mediterranean Region. Food & nutrition research. 63.
Neuenschwander LM, Abbott A & Mobley AR 2013. Comparison of a web-based vs in-person nutrition education program for low-income adults. Journal of the academy of nutrition and dietetics. 113 (1): 120-126.
Nguyen PH, et al. 2013. Maternal and child dietary diversity are associated in Bangladesh, Vietnam, and Ethiopia. Journal of nutrition. 143 (7): 1176-1183.
Niknam M, Omidvar N, Amiri P, Eini-Zinab H & Kalantari N 2021. Community readiness for childhood obesity prevention programs: findings from an urban population in Iran. Health promotion international. 36 (3): 824-835.
Pourabdollah P, et al. 2005. The effect of nutrition education on the knowledge and practice of elementary school children regarding junk food intake. Journal of advances in medical and biomedical research. 13 (51): 13-20.
Scaglioni S, et al. 2018. Factors influencing children’s eating behaviours. Nutrients. 10 (6): 706.
Shapu RC, Ismail S, Ahmad N, Lim PY & Njodi IA 2020. Systematic review: Effect of health education intervention on improving knowledge, attitudes and practices of adolescents on malnutrition. Nutrients. 12 (8).
Sutherland R, et al. 2016. Physical education in secondary schools located in low-income communities: Physical activity levels, lesson context and teacher interaction. Journal of science and medicine in sport. 19 (2): 135-141.
Tamiru D, et al. 2016. Improving dietary diversity of school adolescents through school based nutrition education and home gardening in Jimma Zone: Quasi-experimental design. Eating behaviors. 23: 180-186.
Vahedian M, et al. 2014. Effect of Educational Booklet and Lecture on Nutritional Behavior, Knowledge and Attitude on Third-Grade Male Guidance School Students. Journal of health research 3(1): 1-12.
Verjans-Janssen SR, van de Kolk I, Van Kann DH, Kremers SP & Gerards SM 2018. Effectiveness of school-based physical activity and nutrition interventions with direct parental involvement on children’s BMI and energy balance-related behaviors–A systematic review. PloS one. 13 (9): e0204560.
Wells JC, et al. 2020. The double burden of malnutrition: aetiological pathways and consequences for health. Lancet. 395 (10217): 75-88.
Wright K, Norris K, Newman Giger J & Suro Z 2012. Improving healthy dietary behaviors, nutrition knowledge, and self-efficacy among underserved school children with parent and community involvement. Childhood obesity. 8 (4): 347-356.
Zilberter T & Zilberter EY 2014. Breakfast: to skip or not to skip? Frontiers in public health. 2: 59.
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Received: 2022/01/4 | Published: 2023/11/20 | ePublished: 2023/11/20
Received: 2022/01/4 | Published: 2023/11/20 | ePublished: 2023/11/20
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