CHAPTER ONE

INTRODUCTION

Background to the Study

Nutrition is the science that links food to health and diseases. It includes the processes by

which the human body deals with the intake of food and how the body processes the

substances (nutrients) in the food consumed for growth, development and maintenance of

life. The food eaten and those avoided have much to do with the quality of life. Healthy

eating means eating nutritious diets in acceptable proportion at all times. Studies have

shown that through healthy eating habits, certain diseases and disorder such as heart

diseases, cancer, high blood pressure, diabetes, dental complications and gastrointestinal

disorder can be prevented.

Children in the age group of 10-19 years are referred to as adolescents (WHO, 1998) as

they are still within the age bracket of schooling. School age is a period of rapid growth

in human development when nutritional demand is increased and dietary habit is

established. This period is one of the most dynamic and complex transitions in the human

lifespan. The physical, developmental and social changes that occur during adolescence

can markedly affect eating habits and nutritional health. Their rapid physical growth

creates an increased demand for energy and nutrients. Total nutrient needs during this

period are higher than any other time in the lifecycle, and failure to consume an adequate

diet during the time can potentially affect growth and sexual maturation. The importance

of developing healthful eating habits is obvious as this has been emphasized in the Home

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Economics Education curriculum, because malnutrition during this period can decrease

not only physical and mental developments but also increases risk for a number of

immediate health problems such as iron deficiency, obesity, type 2 diabetics, eating

disorder as well as impaired learning ability. Unfortunately, the diets of adolescent often

fail to meet dietary recommendation both in terms of specific nutrient intake and on the

level of food consumption despite their nutrition knowledge in Home Economics from

the nursery, primary and secondary school levels. The influx of eateries has further

worsened dietary practices of the adolescent as their rate of consuming these foods often

referred to as junk food is alarming. The increase in consumption of such food in recent

years has increased the incidences of major non-communicable diseases such as

cardiovascular diseases, diabetes, high blood pressure and obesity (WHO, 2002).

Secondary education is the bridge between primary and tertiary education levels. The

primary goal is to prepare students for tertiary learning and self employment as designed

by the 9 – 6- 4 system. In the curriculum of senior secondary school education in Nigeria,

subjects such as English language, Mathematics, biology, chemistry, health science, and

building construction, Foods and Nutrition, Catering Craft amongst others are mainly

offered (FRN, 2004). Foods and nutrition, catering craft, provides numerous teaching

topics for acquiring knowledge and skills in nutrition practices. Salami & Uko-Aviomoh

(2004) defined Home Economics as a professional field which attempts to serve the

society through its effort to solve immediate family problems and of the larger society

which infringes on the family. Home Economics is a field of study which when properly

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taught will help in producing well adjusted and healthy individuals. In the senior

secondary school, food and nutrition has the following objectives; understanding the

principles of nutrition, the relationship between nutrition and health, the methods of

planning, preparing and serving balanced meals for different occasions and to meet

family needs, the importance of sanitation in food preparation and service, the

appropriate manipulative skills in food preparation amongst others. While Catering craft

objectives includes; understanding food commodities, method of food preparation,

service of food and drinks, dietary adequacies and procedure for producing dishes and

meal planning procedures amongst others. This programme content has the capacity of

equipping students with the knowledge of healthy food choices, but unfortunately the

adolescents still engage in wrong dietary practices perhaps, as a result of inadequate

nutrition knowledge and lack of basic skills of healthy food practices, which may be as a

result of poor learning/teaching methods utilized in teaching food and nutrition at that

level and types of family meal services.

Empirically, researchers have discovered strong relationship between nutrition education

and nutrition knowledge/dietary practices. For instance, Schinders (2011) in a study

designed to enhance student’s nutrition knowledge and dietary practices, found that

students who were exposed to nutrition education performed slightly higher than those

not exposed to it. By virtue of this, it is therefore important to device innovative

learning/teaching approaches that will enable students improve on their comprehension of

nutrition ideas, which will enhance learning outcome in nutrition education. In the

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nursery and primary education, pictorial device is a major means of instruction, this

account for their ability to recall all they learn.

Pictorial Nutrition intervention seems to be needed to promote nutrition knowledge and

healthy dietary practices among secondary school students. Globally, schools have been

requested to participate in combating the mortality and morbidity rate of adolescents by

promoting the practice of healthy lifestyles and equipping them with skills necessary for

adopting healthy lifestyles (WHO, 2004). Schools can be an effective and efficient

medium to influencing the health of school children and have been identified as a system

that can have a high penetration rate due to the number of children attending the sessions.

Pictorial nutrition education package (PNEP) is an innovative learning/teaching approach

that utilizes personalized visual cues in increasing students’ retention of nutrition ideas in

enhancing behavioral change in dietary practices. PNEP provides a level of interaction

and individualized attention that distinguishes it from the traditional approach method of

teaching. PNEP may be used to bridge the gap between theory and practice. Research has

shown that visual aids can increase students’ understanding. Visual cues accompanied by

oral instructions have increased students’ recall more than oral instructions alone (Houts,

Doak, Doak, & Loscalzo, 2006). Pictorial nutrition education package serves as an

adjunct aid for “reading to learn” that is the processing of which includes perceiving,

understanding, and remembering text information. PNEP is a graphic package used to

create, manage, and exchange information and knowledge. The use of interactive

pictorial education may increase students’ understanding of nutrition instructions when

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compared to the traditional method of teaching/learning nutrition especially, when the

pictorial cues represent information and knowledge via the spatial organization of

concepts, according to the education contents. Pictures can also improve comprehension

when they show relationships among ideas or when they show spatial relationships

(Hughes & Huby, 2002).

Improving students nutrition behavior through Interventional Education Programme

(IEP), such as school lunch programmes, food supplement programme, nutrition

education have been shown to benefit the health of children now as well as in the future

(WHO, 2003). Nutrition education (NE) refers to the planned use of any educational

processes such as Pictorial nutrition education to modify food and nutrition behavior in

the pursuit of improved health. NE is a means by which functional and scientific nutrition

is transmitted to the student in a manner that leads to reasonable nutrition behavior; it is

geared towards a positive change in food habits of an individual. Contento (1995) defined

nutrition education (NE) as any set of learning experiences designed to facilitate

voluntary adoption of eating and other nutrition related behavior conducive to health and

well-being.

Nutrition knowledge is the comprehension of basic nutrition principles and concept and

its application for healthy living irrespective of gender. Research has shown that, people

who are aware of the connection between poor nutrition and certain health conditions are

more likely to follow a nutritious diet and avoid excessive weight gain or being

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underweight. Empirically, it has been discovered that there is strong relationship between

Nutrition knowledge and gender. Studies have consistently shown superiority of female

in Nutrition knowledge when compared with their male counterpart. Gender has proved

to be the most significant demographic variable on nutrition knowledge.

Socio-economic status (SES) is commonly conceptualized as a social standing of class of

an individual or group. It is often measured as a combination of education, income and

occupation. When viewed through a social lens, privileges, power and control are

emphasized. SES is postulated to be a major predictor of dietary intake and nutrition

related knowledge in adult. A strong association between SES and healthy eating habits

has being documented in literature (Convey 2004). Studies have revealed that individual

from higher and medium SES demonstrates higher nutrition knowledge, habits and

healthy life styles as compared to individuals from lower SES. This means that

nutritional knowledge in Edo South Senatorial Schools can be a good strategy to employ

in achieving healthy life styles. Houts, Sharada, Klassen, Robinson & Mccarthy, 2006 in

Oldewage-Theron and Egal (2009) reported that both in research and clinical

experiments, the incorporation of problem-solving techniques in nutrition education

should increase long-term change in nutrition behaviors. Nutrition education tools can

therefore provide interactive and problem solving activities such as food plate puzzle

where children can replace food items in the same food group to construct a balanced

meal. It has also been observed that effective nutrition interventions for students should

have a behavioral focus that will minimize the targeted risk factors, and utilize theoretical

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framework. However, to achieve the desired behavioral changes related to health and

nutrition will require the attainment of adequate knowledge, attitudes, skills and self-

efficacy.

Dietary practices refer to an established habit of feeding. Eating practices can be good or

bad and measured through dietary intake data which includes information about usual

daily food intake, eating pattern and usual nutrient intake, using the 24 hour recall. Good

eating practices are those that encourage the consumption of a healthy and nutritious diet

that provides the right amount of energy to keep body weight in the desirable range.

According to Whitney, (2007) eating practices that supply all the nutrients required in life

can be achieved through the six basic diet-planning principles which include: adequacy,

balance, energy control, nutrient density, moderation and variety. Consistent poor dietary

practices are a leading contributor to the development of chronic diseases. A positive

association between dietary practices and body mass index has been established. Body

mass index is a simple index of weight for height that is frequently used in the assessment

of nutritional status.

In Edo state, typical food intake of the people consists of cereals, tubers, grains, fries,

meat pies, doughnut, chips and candies which may not meet with the recommended

dietary intake. It has been observed that the rate of malnutrition among the students in

Edo State is high, particularly in Edo South Senatorial District with its intensity being

stronger among the 10-19 age groups located in 136 public secondary schools which are

also taught Home Economics. Malnutrition trend in Nigeria is indicative that there is

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increase in underweight, wasting and stunting (UNCEF, 2011), and factors that could

influence an adolescent eating habit for healthy living include nutrition knowledge,

physiological needs, food preferences, parental meal practices, peers group influence,

media, social norms, and fast-foods outlets.

Statement of the Problem

The relatively high level of malnutrition among secondary school students in Edo State

may be attributed to poor nutritional knowledge which to a large extent influences the

pattern of their food consumption. It has been observed that a number of secondary

school students suffer from health and nutrition related problems which may be resulting

from factors such as lack of knowledge and poor nutrition practices (Abah,

Aigbiremolen, Duru, Amunor, Asogun, Enahoro & Akpede, 2012). It may be assumed

that since schools provide nutrition education through Home Economics, Health and,

Physical education, it is expected that students should possess basic necessary nutritional

knowledge and dietary practices for their maximum benefits and lifelong application,

however this seems not to be the case because of the long standing conventional method

used in teaching that is not activity based and learner centered. There appears to be a

strong correlation between good nutrition, wellness, growth and academic performance

among others. Researchers have shown that students with good nutritional practices

manifest alertness and zeal towards various activities in school and perform academically

better than poorly fed children (WHO, 2004). There are emerging problems related to

poor nutrition among students such as over nutrition (obesity) on one hand, under

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nutrition (thinness) on the other, impaired vision, dental caries, kidney failure, and

cardio-vascular disease amongst others. These conditions are becoming worrisome to all

health related professionals especially when these are or could be assured to be related to

advance age. The general assumption is that such bad nutrition practices are probably

enhanced by the proliferation of eateries and high access to junk foods

Nutrition education, as an interventional programme may facilitate voluntary adoption of

proper eating and other nutrition related behaviors endocentric to health and wellbeing.

Nutrition knowledge has been recommended as a strategy to employ so that the

population, especially youth can enjoy a healthy diet. Nutrition education is not new as it

is a part of Home Economics Curriculum, but what may be new is using pictorial

nutrition education packages as against the traditional method of instruction. Pictorial

nutrition education may therefore, be an avenue for students’ healthy eating habits. In

spite of the fact that Home Economics is a necessary experience for students in JSS level,

it appears eating habits of students is still poor. Consequently there is the need to device

innovative methods of teaching and learning nutrition knowledge. This leads to the

question; will pictorial nutrition education packages help advance students nutrition

knowledge and lead to good dietary practices, in Edo South Senatorial District of Edo

State? This study seeks to answer this question.

Purpose of the Study

The major purpose of the study was to develop pictorial nutrition education packages

(PNEP) and investigate the effect on Nutrition knowledge and Dietary practices of Senior

Secondary Schools Students in Edo State, specifically the study:

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1. determine the instructional objectives of the pictorial nutrition education

packages;

2. determine the content of the pictorial nutrition education packages;

3. determine the delivery system (materials and methods) for teaching

nutrition concepts;

4. determine the evaluation methods for teaching nutrition using pictorial

nutrition education packages;

5. determine if there was any difference in nutrition knowledge between the

group exposed to pictorial nutrition education packages and the group not

exposed to it;

6. determine if there was any difference in dietary practices of students

exposed to pictorial nutrition education packages and the group not

exposed it;

7. determine the body mass index of students as a result of exposure to the

pictorial nutrition education packages;

8. examined the effect of gender on nutrition knowledge of students exposed

to pictorial nutrition education packages;

9. examined the effect of gender on dietary practices of students exposed to

pictorial nutrition education packages;

10. examined the effect of socio-economic status on nutrition knowledge of

students exposed to pictorial nutrition education packages;

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 11. the effect of socio-economic status on dietary practices of students

exposure to pictorial nutrition education packages;

12. the interactive effect of group by gender, on nutrition knowledge of

students;

13. the interactive effect of group by gender, on dietary practices of students;

14. the interactive effect of group by socio-economic status in nutrition

knowledge of student; and

15. the interactive effect of group by socio-economic status in dietary

practices of student.

Research Questions

The following research questions were raised to guide the study:

1. What are the Instructional objectives of the pictorial nutrition education

packages?

2. What are the contents of the pictorial nutrition education packages?

3. What delivery systems (materials and methods) are utilized in the use of pictorial

nutrition education packages?

4. What are the evaluation activities used in the use of pictorial nutrition education

packages?

5. What is the difference in nutrition knowledge of students exposed to pictorial

nutrition education packages and those not exposed to it?

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6. What is the difference in dietary practices of students exposed to pictorial

nutrition education packages and those not exposed to it?

7. What is the difference between the pre and post body mass index measure of

students as a result of exposure to pictorial nutrition education packages?

8. What is the difference in nutrition knowledge of male and female students as a

result of exposure to pictorial nutrition education?

9. What is the difference in dietary practices of male and female students as a result

of exposure to pictorial nutrition education?

10. Is there a difference in nutrition knowledge among students of different socio

economic status as a result of exposure to pictorial nutrition education?

11. Is there a difference in dietary practices among students of different socio

economic status as a result of exposure to pictorial nutrition education?

12. Will gender have any interactive effect on nutrition knowledge of students as a

result of exposure to pictorial nutrition education?

13. Will gender have any interactive effect on dietary practices of students as a result

of exposure to pictorial nutrition education?

14. Will socio-economic status have any interaction effect on nutrition knowledge of

students as a result of exposure to pictorial nutrition education?

15. Will socio-economic status have any interaction effect on dietary practices of

students as a result of exposure to pictorial nutrition education?

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Hypotheses

Research questions 5- 14, were formulated to hypotheses and tested at 0.05 alpha level of

significance.

1. There is no significant difference in nutrition knowledge between students’

exposed to Pictorial Nutrition Education Packages and those not exposed to it in

Edo south senatorial district.

2. There is no significant difference in dietary practices between students’ exposed

to Pictorial Nutrition Education Packages and those not exposed.

3. There is no significant difference between pre and post Body Mass Index measures

of students as a result of exposure to Pictorial Nutrition Education Packages.

4. There is no significant difference in nutrition knowledge of male and female

students’ as a result of exposure to Pictorial Nutrition Education Packages.

5 There is no significant difference in dietary practices of male and female students’

as a result of exposure to Pictorial Nutrition Education Packages.

6 There is no significant difference in nutrition knowledge among students’ of high,

medium and low socio-economic status as a result of exposure to Pictorial

Nutrition Education Packages.

7 There is no significant difference in dietary practices among students’ of high,

medium and low socio-economic status as a result of exposure to Pictorial

Nutrition Education Packages.

8 There is no significant Group by gender interaction effect in students’ nutrition

knowledge.

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 9 There is no significant Group by gender interaction effect in students’ dietary

practices.

10 There is no significant Group by socio- economic status in students’ nutrition

knowledge.

11 There is no significant Group by socio- economic status in students’ dietary

practices.

Significance of the Study

The findings of this study will be beneficial to all stakeholders in Education namely,

students, health workers, nutrition educators, researchers, Food and nutrition curriculum

planners and policy makers.

The findings of this work will go a long way in providing useful information as regards

nutrition education as a tool for improving nutrition knowledge amongst students in

making better food choices. The study will be beneficial to students as it will improve

their nutritional knowledge and dietary practices as a result of the intervention

programme. This will help in correcting their poor dietary habits as well as help them

develop lifelong eating patterns using the dietary guideline and food guide pyramid. The

study will also improve on the competencies of students in the area of food choices and

lifestyles, through the knowledge and skills acquired.

Findings from this study will equip health workers with skills in combating nutritional

related diseases of the adolescent while advising them through seminars and workshop on

best food choices for healthy living.

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The information from the study will help reposition nutrition educators to be more

dedicated and improve on their traditional method of teaching nutrition by imbibing some

of the interventions strategy used in the study in teaching effectively, this will also help

them identify areas that need more attention and ensure competence in the teaching of the

subject.

The study will provide curriculum planners/policy makers the required information that

could improve matters in the curriculum content for teaching and learning nutrition

education effectively in the designated areas in the country.

The findings of this study will also provide materials for researchers who are interested in

working on nutrition education and other related topics, serving as a baseline for future

studies. Finally, the study will benefit the generality of the society through the impact on

the students’ feeding habits which may show off on the homes.

Scope and Delimitation of the Study

This study focused on the development of Pictorial Nutrition Education Packages and the

effect on nutritional knowledge and dietary practices of senior secondary school students

in Edo State. The study covered the objectives, contents, methods and packages

employed for implementing the developed PNEP and investigating the effectiveness on

students’ nutrition knowledge and dietary practices

The study was restricted to all public senior secondary school students one (SS1) in Edo

south senatorial district. Senior secondary students were chosen for the study, because of

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their previous knowledge in nutrition through Home Economics and Health Science at

the Junior Secondary levels (1-111). Only government owned schools were chosen from

two local government areas in Edo South senatorial district. Edo south senatorial district

is made up of seven (7) local government areas and two (2) representative local

government areas were used in the study.

The schools used for the study satisfied the following criteria: They were:-

 school that have enrolled students in SSS for Foods and Nutrition in

WASSCE. This was to ensure that they were not new schools;

 school that are co-educational (mixed). This gave room for gender

assessment; and

 school had at least a graduate teacher (B.Sc Ed) in Home Economics

Education.

Operational Definition of Term

Visual Cues: Visual cues help students to understand spoken words. It is a signal and an

object aiming to be self explanatory and pre attentive, it creates a framework for its own

interpretation.

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 CHAPTER TWO

REVIEW OF RELATED LITERATURE

This chapter deals with the review of the literature. It examines the theoretical framework

for the study as well as the major concept of the study. It also reviews findings of some

empirical studies that have been carried out on nutrition education. The related literature

is discussed under the following sub- headings:

 Theoretical Framework of the Study

 Conceptual Framework of the Study

 Adolescent and Nutrition Knowledge

 Nutrition Education/ Pictorial Nutrition Education

 Dietary/Eating Practices and Assessment

 Review of Related Empirical Studies

 Summary of Literature Reviewed

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Theoretical Framework of the Study

Social Learning Theory (SLT)

The theoretical framework of the study was based on the social learning theory,

developed by Albert Bandura in 1977. Bandura, born December 4, 1925 is

a psychologist and a Professor of Psychology. He believed that behavior is learned from

the environment through the process of observational learning and modeling. The theory

originally evolved from behaviorism but now includes many of the ideals the cognitive

also hold; as a result it is sometimes referred to as social cognitive learning. The social

learning theory emphasizes the importance of observing and modeling the behaviors,

attitudes, and emotional reactions of others.

The SLT states that there is an interrelationship between an individual, the environment

and their behaviours. Human behavior is learned and regulated by stimuli within the

environment (Bandura, 1999). Humans are able to recognize important information

expressed through various medium, including observational learning. Behaviorial

theories, like the Social leaning Theory (SLT), are used to promote and evaluate behavior

changes. This Theory explains how people acquire and maintain certain behavioral

patterns, while also providing the basis for intervention strategies (Bandura, 1997;

Baranowski & Stables, 2000). Within social learning theory, human behavior is explained

in terms of a dynamic model in which behavior, personal factors and environmental

influences all interact. Bandura (1986) stated that learning would be exceedingly

laborious, not to mention hazardous, if people had to rely solely on the effects of their

own actions to inform them what to do.

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Several theoretical approaches could be used in behavioral changes of dietary practices of

the adolescent in nutrition education. However, for the purpose of this study, the Social

learning Theory of Bandura (SLT) is particularly useful with emphasis on the concept of

observational learning and self-efficacy. Previous research findings have shown that, this

theoretical framework has been used for nutrition interventions among adolescents and it

has helped in understanding and describing the multiple influences that have impact on

food behaviors’ of adolescence. Among the crucial personal factors are an individual’s

capabilities to symbolize behavior, to anticipate the outcomes of behavior, to learn by

observing others, to have confidence in performing a behavior, to self-determine or self-

regulate behavior, and to reflect on and analyze experience (Bandura, 1997).

Interventions derived from social cognitive theory focus on the importance of the

individual ability to control their own behavior and how changes in the individual and/or

environment produce changes in behavior. Social cognitive theory maintains that

adolescents learn from observation (Parcel, 1995). Adolescents tend to imitate parent,

adults, peers and older siblings food patterns. This theory proposes that relationships exist

among behavioral factors, personal factors (those coming from within an individual) and

environmental factors (those coming from the contest in which behavior takes place). In

this study, the SLT is relevant as Pictorial Nutrition Education (environmental factor)

interacted with the personal factor (nutrition knowledge) producing good dietary

practices (behavior) in students.

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The Concept of Observational Learning

Observational learning also known as vicarious learning, social learning or modeling is a

learning that occurs as a function of observing, retaining and replicating novel behavior

executed by others. Observational learning has been used to assist in modifying child

behavior. In the use of observational learning, two participants are essential, the observer

and the model. Research has shown that children are not born equipped with sets of

bahaviour, but instead learn through various experiences which often involve observing

(Colledge, 2002). Thus viewing various behaviours is an important tool in acquiring new

skills (Jahr & Eldevik, 2002), hence eating habits are established as the child observes the

parents, siblings and others.

Observational learning can be done through live, symbolic or electronically portrayed

modeling (Schunk, 2000).Live observational modeling involves the observer watching

the behaviours being performed such as an observer watching parents, siblings or peers

mode of eating and eating habits, such eating habit will definitely be modeled. Symbolic

(Pictorial) or non human modeling involves learning with toys or cartoon character and

pictures. This involves observing others choose food in their right proportion from the

food grouping for healthy living. The pictorial view of the food pyramid and the eat well

plate modeled by the students will enable them eat varieties of food proportionately for

healthy living.

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The Concept of Self-Efficacy

Self-efficacy is the confidence a person feels about performing a particular activity,

including overcoming barriers in performing that behavior. It is the judgment of one’s

ability to achieve a certain level of performance (Bandura, 1999). Self-efficacy helps

influence how complicated the observer finds the tasks, for instance a student who has

been classified as obsessed according to his BMI of above 25 and has been given a

pictorial view of what he should consume daily, may perceive the task as less difficult if

the student believes the task can be accomplished without much difficulty. Self-efficacy

is important to the observer who must believe that the model can accomplish a specific

goal.

Self-efficacy facilitates a child motivation. The theory suggest that after watching a

model, the child will believe in the capability of achieving the same level of success and

will be more motivated to confront it with less fear and anxiety. The greater the degree of

self-efficacy, the greater ability the child has to process tasks that are more difficult.

Efficacy beliefs create a sense of confidence regardless of the degree of difficulty in the

task (Bandura, 1990).

In the light of the above, the social learning theory is relevant to the study as it

emphasizes that human behavior is explained in terms of a three way dynamic reciprocal

process in which personality, environmental influences and behavior continually interact.

Bandura (2004) opined that behavior and the environment are reciprocal systems and the

influence is in both directions. Pictorial Nutrition Education (environmental factor) on

nutrition knowledge (personal factor) and dietary practices (behavior) of students. That is

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 dietary changes result from interaction between nutrition knowledge and pictorial

nutrition education (Figure 1).

Behaviourial Factor
(Dietary Changes)

Personal Factor
Environmental Factor
(Nutrition Knowledge)
(Pictorial Nutrition Education)

Figure 1: Reciprocal interaction between personal factors, environmental influence and

   behaviour. Adapted from the Social Learning Theory of Albert Bandura
(2001)

Conceptual Framework of Pictorial Nutrition Education

The conceptual framework for the study is presented in figure 2. The framework helps to

rationalize the effectiveness of interventional education (pictorial nutrition education

packages) on nutrition knowledge and dietary practices of senior secondary school

students in Edo south senatorial district. The conceptual framework for this study

includes independent variables (predictor) and dependent variables (outcome), which is

predicated on behavioral paradigm of stimulus-organism-response (S-O-R).

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 Interventional Education (Pictorial nutrition education packages) constitutes the treatment

programme which is the independent variable while Nutrition knowledge and dietary

practices resulting in healthy eating represent the dependent variables. Some personal or

organism factors that are presumed to mediate between the treatments (stimulus) and the

treatment outcomes are known as intervening variables or secondary independent

variables and can be fairly measured. They are gender, body mass index (BMI) and

socio- economic status. They represent the organism (O). These variables will be studied

along with the treatment in order to measure their effects on the behavioral paradigm.

Stimulus-Organism-Response allows for consideration of variables in an orderly manner

when analysizing the effectiveness’ of a programme (Oloruntegbe, 2000).

Intervening variables
Dependent variables
Independent Variable Gender: Male and Female
Nutrition Knowledge and Dietar
Pictorial Nutrition Education packages
Instructional objectives, Socio Economic Status (SES)
Contents of the package, High, Medium and Low
Delivery system (Methods and materials)
Evaluation Method

Body Mass Index Healthy eating practice

(BMI)

S O R
Figure 2: Conceptual frame work for this study. Source: Adapted from Oloruntegbe (2000)

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Concept of Human Nutrition

Nutrition describes the processes whereby cellular organelles, cells, tissues, organs,

systems, and the body as a whole obtain and use necessary substances obtained from

foods (nutrients) to maintain structural and functional integrity (Vorster, 2009). Nutrition

is the science of food values. It is relatively a new science, which has evolved from

chemistry and physiology. The effect of food in our body is explained in nutrition. Food

plays paramount role in one’s life and there is a strong correlation between good food and

development (Salami & Uko-Aviomoh, 2004). In other words, nutrition is defined as

food at work in the body. In a broader sense nutrition is defined as “the science of foods,

the nutrients and other substances their action, interaction, and balance in relationship to

health and diseases, the process by which the organism ingests, digests, absorbs,

transports and utilizes nutrients and disposes off their end products, in addition nutrition

must be concerned with the social, economic, cultural and psychological implications of

food and eating.”

Nutrition science will often be necessary to put new knowledge, or new applications of

old knowledge, into the perspective of the holistic picture. On a genetic level it is now

accepted that nutrients dictate phenotypic expression of an individual’s genotype by

influencing the processes of transcription, translation, or post-translational reactions. In

other words, nutrients can directly influence genetic (DNA) expression, determining the

type of RNA formed (transcription) and also the proteins synthesized (translation). For

example, glucose, a carbohydrate macronutrient, increases transcription for the synthesis

of glucokinase, the micronutrient iron increases translation for the synthesis of ferritin,

24
while vitamin K increases post-translational carboxylation of glutamic acid residues for

the synthesis of prothrombin. Nutrients, therefore, influence the synthesis of structural

and functional proteins, by influencing gene expression within cells.(Voster, 2009).

Nutrients also act as substrates and cofactors in all of the metabolic reactions in cells

necessary for the growth and maintenance of structure and function. Cells take up

nutrients (through complex mechanisms across cell membranes) from their immediate

environment, also known as the body’s internal environment.

The composition of this environment is carefully regulated to ensure optimal function and

survival of cells, a process known as homeostasis, which gave birth to a systems

approach in the study of nutrition.

Nutrients and oxygen are provided to the internal environment by the circulating blood,

which also removes metabolic end-products and harmful substances from this

environment for excretion through the skin, the kidneys, and the large bowel.(Voster,

2009) The concerted function of different organs and systems of the body ensures that

nutrients and oxygen are extracted or taken up from the external environment and

transferred to the blood for transport and delivery to the internal environment and cells.

The digestive system, for example, is responsible for the ingestion of food and beverages,

the breakdown (digestion and fermentation) of these for extraction of nutrients, and the

absorption of the nutrients into the circulation, while the respiratory system extracts

oxygen from the air. These functions are coordinated and regulated by the endocrine and

central nervous systems in response to the chemical and physical composition of the

blood and internal environment, and to cellular needs. The health or disease state of the

25
different organs and systems will determine the nutrient requirements of the body as a

whole.

During the first renaissance of nutrition, emphasis was placed on the study of nutrients

and their functions. A medical, natural science or biological model underpinned the study

of the relationships between nutrition and health or ill-health. During the second

renaissance, these aspects are not neglected, but expanded to include the study of all other

external environmental factors that determine what and how much food and nutrients are

available on a global level. These studies are underpinned by social, behavioral,

economic, agricultural, and political sciences.

According to Vorster, (2009), the study of human nutrition therefore seeks to understand

the complexities of both social and biological factors on how individuals and populations

maintain optimal function and health, how the quality, quantity and balance of the food

supply are influenced, what happens to food after it is eaten, and the way that diet affects

health and well-being. This integrated approach has led to a better understanding of the

causes and consequences of malnutrition, and of the relationship between nutrition and

health

Relationship between nutrition and health

Individuals can be broadly categorized into having optimal nutritional status or being

undernourished, overnourished, or malnourished. The major causes and consequences of

these nutritional states are indicated. It is important to realize that many other lifestyle

and environmental factors, in addition to nutrition, influence health and well-being, but

26
 nutrition is a major, modifiable, and powerful factor in promoting health, preventing and

treating disease, and improving quality life. (Fig 3)

Nutritional situationHealth Consequences, outcomes

Optimum nutritionhealth, well-being, normal
Food secure individuals with adequate development, high quality life
nutritious and prudent diets
Deceased physical and mental development
Under nutrition: hunger Compromised immune systems
Food-insecure individuals living in poverty, Increased infectious diseases
Ignorance, politically unstable environments, Vicious circle of under nutrition, underdevelopment, poverty
Disrupted societies, war

Obesity, metabolic syndrome, cardiovascular disease, typ

Over nutrition
Over consumption of food, especially macronutrients, plus:
Low physical activity
Smoking, stress, alcohol abuse

Malnutrition
Double burden
Nutrition transition: individuals and communities previously food insecure- of infectious
confronted diseases of
with abundance plus NCDs often
palatable char
foods- so

Figure 3: Relationship between nutrition and health. Adapted from Vorster, 2009.

Concept of Malnutrition

Malnutrition is a group of pathological disorders resulting from imbalance between

intake of essential nutrients and the body’s demand for them (Grisby & Shashidar, 2004).

Malnutrition is a global problem but the prevalence and pattern differ between nations

and even within regions in the same country. Malnutrition remains a major health and

development issue in Nigeria and contributes to as much as 50 per cent of the deaths of

children under five in the country. The global prevalence of adolescent, maternal and

27
child malnutrition is devastatingly high, and is a major contributing factor to the high

mortality rate and burden of infectious diseases seen in developing countries. Proper

nutrition is necessary for good health and well-being, but is not easily attainable by all.

Malnutrition can involve both over- and under-nutrition. Over-nutrition involves

overweight and obesity. In the developed countries over-nutrition (obesity and

overweight) is a major concern while in most developing nations under-nutrition

predominates (Prentice, 2006).

Malnutrition in all its forms amounts to an intolerable burden not only on the health

systems, but the entire socio-cultural and economic fabric of the society and is the

greatest obstacle to the fulfillment of human potentials. Malnutrition increases the risk of

infection and infectious disease, and moderate malnutrition weakens every part of the

immune system (Schaible & Kaufmann, 2007).  For example, it is a major risk factor in

the onset of active tuberculosis (Stillwaggon, 2008). Protein and energy malnutrition and

deficiencies of specific micronutrients (including iron, zinc, and vitamins) increase

susceptibility to infection. Malnutrition affects HIV transmission by increasing the risk of

transmission from mother to child and also increasing replication of the virus (Lakhan &

Vieria, 2008). In communities or areas that lack access to safe drinking water, these

additional health risks present a critical problem. Lower energy and impaired function of

the brain also represent the downward spiral of malnutrition as victims are less able to

perform the tasks they need to in order to acquire food, earn an income, or gain an

education Child malnutrition is a huge public health problem in Africa that is not

properly given the priority that it deserves Malnutrition is largely a preventable and

28
treatable cause of childhood morbidity and mortality that can be dealt with for less than

USD 20 per child per year (Chiabi, Tchokoteu,Takou, & Tchonne, 2008). According to

WHO malnutrition accounts for 6.6 million out of 12.2 million deaths among children

under five (54% of child mortality) in developing countries.

In Nigeria and elsewhere about 35.7% and 47.5% of children under five years of age are

moderately to severely undernourished respectively (Solomon, 1985; Roy, Jolly,

Shafique, Funhs, & Mahmud, 2007). It is known that almost any illness will impair a

child’s growth, however in practice in developing countries, growth deficits are caused

by interplay of two preventable factors: inadequate food and infections. Infections

influence body size and growth through their effects on metabolism and nutrition.

Additionally, UNICEF conceptual framework also recognizes poor caring practices as

equally important cause of malnutrition (UNICEF, 1990). Environmental factors have

profound effect on health and can make nutritional problems worse. A child who is well

fed but drinks contaminated water and lives in polluted environment will not grow up

healthy (UN, 2004). Identified nutritional problems among adolescents include wasting,

stunting, overweight, obesity and micronutrient deficiencies (Prentice, 2006; Olumakaye,

2008). Adolescence, characterized by rapid growth and development, is therefore

accompanied by increase requirements for nutrients. When these increase needs are not

met under-nutrition results. A previous report of World Health Organization (WHO)

showed that under-nutrition was widespread among Nigerian adolescents. Sixteen percent

(16%) of adolescents in rural area were reported to be wasted compared to 8% in the

urban area. Stunting was also reported to be more frequent in rural area (WHO, 2005).

29
Nigeria is the country with the 3rd highest absolute number of children who are stunted,

41% of children under the age of five are stunted, 23% are underweight, and 14% are

wasted, 14% of infants are born with a low birth weight (UNICEF, 2009) Significantly

higher prevalence of under-nutrition was reported in many other developing countries,

23% in Benin, 36% in Nepal and 56% in India. (Verhoef, West, Veenemas,Beguin &

Kokf, 2002).

Globally there are reports of increasing prevalence of obesity and overweight and the

association with non-communicable disease especially cardiac deaths and morbidity

(Olumakaye, 2008). Growing percentages of adolescents are overweight, mostly caused

through a combination of a lack of exercise and eating too much fat and sugar. However,

under-nutrition involving eating disorders like anorexia and bulimia, especially amongst

females, remains the predominant concern during this stage of life. Over- and under-

nutrition can become related and can turn into an emotional problem, becoming a vicious

circle - eating, or starving, to cope with unhappiness (Sobo & Oguntona, 2006) Some

determinants of malnutrition include area (rural versus urban), socioeconomic status,

lifestyle including alcohol and tobacco use, eating habits and level of physical activity in

an individual (Prentice, 2006; Olumakaye, 2008; Blake & Davis, 2006; WHO,2005). The

association of malnutrition with increased mortality and morbidity in childhood is well

understood (Ulasi, & Ebenebe, 2007). In adulthood, there is a higher burden of Type II

Diabetes Mellitus, hypertensive heart diseases, coronary heart diseases, colonic cancers

and other disorders in obese and overweight individuals (WHO, 2005). Malnutrition in

childhood through adolescence may progress to adult life

30
There is a dearth of data on nutritional status in Nigerian adolescents. The global

economic recession, adoption of sedentary lifestyle, the advancement in technological

development and changing eating habits are some of the reasons believed to have brought

changes in the nutritional status of Nigerian adolescents.

The nutritional status is defined as an evident state of nutrition of an individual and is

assessed through dietary, anthropometric, biochemical and physical observation for signs

of malnutrition. These methods of measurement are usually done in combination for

more accurate results. When there is a deficiency in the amount and nutritional value of

the food consumed, the growth pattern of a child becomes disrupted owing to nutrient

deficiencies (Faber & Wenhold, 2007; Labadarios 2005

The dilemma of malnutrition can be understood and addressed with the aid of the

framework, shown in Figure 4, developed by the United Nations Children’s Fund

(UNICEF, 2004). The framework recognizes that poor household access to sufficient,

safe and nutritious food; inadequate maternal and child care and feeding practices; and

poor household access to health care services and unhealthy environment are the

underlying causes of maternal and child undernutrition (including both chronic and acute

malnutrition) in developing countries. The framework further identified the underlying

and basic causes of malnutrition, including environmental, economic and sociopolitical

contextual factors with poverty playing a central role. The framework also acknowledges

that shocks, trends and season likely have considerable effects on undernutrition and its

causal pathways. It is a major tragedy that millions of people currently live with hunger,

and fear of starvation. This is despite the fact that food security or “access for all at all

31
times, to a sustainable supply of nutritionally adequate and safe food for normal physical

and mental development and healthy productive lives” is a basic human right embedded

in the constitution of most developing countries. It is also despite the fact that sufficient

food is produced on a global level. Food insecurity is an obstacle to human rights, quality

of life, and human dignity. It was estimated that, during the last decade of the twentieth

century, 826 million people were undernourished: 792 million in developing countries

and 34 million in developed countries. In developing countries, more than 199 million

children under the age of five years suffer from acute or chronic protein and energy

deficiencies. An estimated 3.5–5 billion people are iron deficient, 2.2 billion iodine

deficient, and 140–250 million vitamin- A deficient (UNICEF, 2004)

Malnutrition death & Disability

Figure 4: Framework showing causes of malnutrition. Adapted, from UNICEF 2004 as in Black et al,
32
Increasing cases of malnutrition problems in adolescent in Nigeria is worrisome because

inadequate nutrition could take its toils on their ability to learn and productivity level,

(Oguntola, 2010). She reported that some cases of malnutrition in adolescents is as a

result of increased intake of carbonated drinks, which invariably provides empty calories

and as such insufficient to meet the body’s requirement for proper growth.

Oyedokun (2012) gave the projected figures of persons at risk of malnutrition as 18.7

million, children at risk of severe acute malnutrition (SAM) as 1.1million and children at

the risk of moderate acute malnutrition (MAM) as 3 million. According to the nutrition

specialist, "Poor nutrition jeopardizes children's survival, health, growth and development

which slow down national progress towards developmental goals. The prevalence of

global acute malnutrition (GAM) was found between 5 to 15 percent in all surveys across

all states in Nigeria and when the situation is beyond 10%, it is regarded as emergency

situation. Without any intervention, severe acute malnutrition has up to 60% mortality

risk and children with severe acute malnutrition are nine times likely to die from any

causes than those who are not".

Nutritional Problems of Adolescent

Adequate nutrient intake during adolescence is very important for many reasons.

Adolescence is a particularly unique period of life because it is a time of intense physical,

psychological and cognitive development. Adolescence is a transition phase to adulthood.

The age of adolescence encapsulates a window of time when bodies are metamorphosing

and evolving into that of an adult. It is a time when the adolescent tries to establish his

own identity yet desperately seeks to be socially accepted by his peers (Lulinski, 2001).

33
During adolescence hormonal changes accelerate growth in height. Growth is faster than

at any other time in the individual’s life except the first year (Brasel, 1982). Increased

nutritional needs at this juncture relate to the fact that adolescents gain up to 50% of their

adult weight, more than 20% of their adult height and 50% of their adult skeletal mass

during this period (Brasel, 1982). The adolescents therefore face series of serious

nutritional challenges which would impact on this rapid growth spurt as well as their

health as adults. However, the adolescents remain a largely neglected, difficult-to-

measure, hard-to-reach population. Consequently, their needs, particularly those of

adolescent girls are often ignored (Kurz and Johnson -Welch, 1994).

The main nutritional problems affecting adolescent populations worldwide and Nigeria in

particular include under-nutrition in terms of stunting and wasting. Others are

deficiencies of micronutrients such as iron and vitamin A, obesity and other specific

nutrient deficiencies (Kurz and Johnson- Welch, 2001).

 One of the major global health problem faced by the developing countries, today is

malnutrition (UNICEF,1990; WHO, 1985) Of course, Nigeria too, is not an exception to

this problem of malnutrition (Odunayo,& Oyewole, 2006; Abidoye & Ihebuzor, 2001)

With the epidemiological and nutritional transition, coupled with globalization of

economies, nutritional problems of industrialized countries become increasingly

prevalent in low and middle income countries, notably obesity. Obesity, diabetes and

hypertension are present in wealthy, middle-income and poor groups. It is recognized that

the extremes of overnutrition and undernutrition are oftentimes concurrent problems in

adolescent populations (Odunayo & Oyewole, 2006). Deficiencies can be found in poor

34
societies because of poverty and in better-off groups because of poor eating patterns. The

overall nutritional status is better assessed with anthropometry, in adolescence as well as

at other stages of the life cycle. Anthropometry is the single most inexpensive, non-

invasive and universally applicable method of assessing body composition, size and

proportions (De Onis & Habicht, 1997). However, because of important changes in body

composition during adolescence, and particularly during the puberty-related growth spurt

which varies in its timing, assessment of obesity, or undernutrition, is more complex in

adolescents than in adults or younger children.

Undernutrition in Adolescent

Undernutrition is a form of malnutrition. (Malnutrition also includes overnutrition.

Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired

metabolism, loss of nutrients due to diarrhea, or increased nutritional requirements (as

occurs in cancer or infection) (Morley, 2012). Undernutrition progresses in stages; it may

develop slowly when it is due to anorexia or very rapidly, as sometimes occurs when it is

due to rapidly progressive cancer-related cachexia. First, nutrient levels in blood and

tissues change, followed by intracellular changes in biochemical functions and structure.

Ultimately, symptoms and signs appear. Diagnosis is by history, physical examination,

body composition analysis, and sometimes laboratory tests (such as albumin).

The 2003 Nigeria Demographic and Health Survey revealed that 38% of under-five

children in Nigeria are stunted, 29% underweight and 9.2% wasted (Ajieroh, 2010). The

2004 Food Consumption and Nutrition Survey reported similar trends with 42% stunted,

35
25% underweight and 9% wasted (Ajieroh, 2010). These surveys indicated significant

variation between the rural and urban areas with children from rural areas worse affected

by malnutrition. Undernutrition encompasses stunting, wasting, and deficiencies of

essential vitamins and minerals (collectively referred to as micronutrients).

Micronutrient deficiency is caused by poverty, food insecurity, lack of knowledge, and

lack of distribution of adequate resources (Nagati, Mansour, Alouane, 2003).

Undernutrition (stunting and wasting) in adolescents has detrimental effects, as it affects

their ability to learn and work at maximal productivity. It affects their sexual maturation,

increases the risk of poor obstetric outcomes for females and jeopardizes the healthy

development of future children (WHO, 2005). The relationship between food insecurity

and undernutrition is synergistic. In a food-insecure environment, nutrient losses due to

energy expenditure, menstruation in girls and disease can increase risk for undernutrition.

Undernutrition during adolescence may compromise health status across generations,

because undernourished young women are most likely to have low-birth weight infants

(Delisle, 2005; Black, Allen, Bhutta, Caulfied, De Onis, Ezzati, Mather & Rivera 2008),

who in turn are likely to experience poor health and have fewer chances for survival

(Black et al, 2008; Caulfied, De Ohis, Blossner, Black, 2004).

Undernutrition is a major public health concern for adolescents in developing countries

(Delisle, 2005), with negative implications for growth (Dreizen, & Spirakis 2000; Abu-

Jaad & Fraser, 2010; Black et al., 2008), and long-term health (Van-

Abeelem,Elias,Bossuyt,Grobbee,Vander-\Schoun & Roseboom, 2010). Poor nutritional

36
status lowers productive capacity compromises resistance to disease, and adversely

affects cognitive development (Baranowski & Stables, 2000). Children entering

adolescence chronically undernourished can experience delayed pubertal development

and prolonged growth (Ahamed, Zareem, khan 1998).

Body mass index (BMI) for age, is used to classify the nutritional status of an adolescent.

BMI is calculated by dividing the weight, in kilograms (kg), by the height squared (²), in

metres (m) (WHO 1998). The WHO (2007) developed standards to assess the growth of a

child. Under-nutrition is associated with deficit in behaviour and development of the

brains anatomy, neurochemistry, and metabolism (Black, Hess, & Papas 2005). In most

studies allowing comparisons of boys and girls, there was twice as much undernutrition

in boys as in girls. One possibility is a differential maturation in boys and girls; another

one, which warrants further investigation, is connected with the high rates of anaemia,

which could affect body weight of boys more than girls because the former put on more

muscle than the latter

In Nigeria, a study among adolescent girls (Brabin, Lkimalo & Dollimore, 1997) showed

that undernutrition was more widespread in rural areas than in urban areas: 10% of rural

and 5% of urban girls were stunted.

Based on available information, a general profile of adolescent girls’ nutritional status

was sketched in the South-East Asia Region (WHO Regional Office for South-East Asia,

2005):

“They are undernourished, indicating a chronic energy deficiency. Most

often, the BMI of adolescent girls of 13 and above is below 18.5. The girls
are usually physically stunted, a manifestation of chronic protein energy

37
 malnutrition and have a narrow pelvis indicating that the full growth of
the pelvis has yet to take place.[...] Iron deficiency anaemia is the most
glaring nutritional deficiency,[....] with no less than 25-40% of adolescent
girls as victims of moderate and sometimes severe anaemia. [....] In all
countries of the region, at least 40-50% of adolescent pregnant girls are
anaemic”.

Severely undernourished adolescents may be at lower risk of death or opportunistic

infection.

Malnutrition trend in Nigeria is indicative that there is increase in underweight, wasting

and stunting (UNICEF, 2012) as is indicated in figure 5

Figure 5: Malnutrition in Nigeria (adapted from UNICEF 2012)

38
Stunting

Stunting results from chronic undernutrition, which retards linear growth, whereas

wasting results from inadequate nutrition over a shorter period, and underweight

encompasses both stunting and wasting (Caulfied ,Richard, Riveria ,Misgrove & Black

2004). Stunting is a major public-health problem in low and middle-income countries

because of its association with increased risk of mortality during childhood (UNICEF,

2008). Apart from causing significant childhood mortality, stunting also leads to

significant physical and functional deficits among survivors (WHO, 1995; Unicef, 2008;

WHO, 2000). According to the latest reports, stunting contributes 14.5% of annual deaths

and 12.6% of disability-adjusted life-years (DALYs) in under-five children (UNICEF,

2008). Children who are stunted complete fewer years of schooling. This may be due to

the fact that stunted children are known to enroll late in school, perhaps because they are

not grown enough to enroll. It may also be because they drop out earlier. This may lead

to fewer years of education of stunted children when compared with tall children.

Stunting hinders cognitive growth, thereby leading to reduced economic potential.

Stunting is known to be highly prevalent in environments that are characterized by a high

prevalence of infectious diseases (De Onis, & Blossner, 2003). On the other hand,

stunting impairs host immunity, thereby increasing the incidence, severity, and duration

of many infectious diseases (Verhoef et al., 2002). In countries where malaria infection is

endemic, stunting increases the degree to which malaria is associated with severe

anaemia causing considerably higher likelihood of mortality due to malaria (Verhoef et

al., 2002). The long-term consequences of stunting include short stature, reduced capacity

39
of work, and increased risk of poor reproductive performance (WHO 1995; UNCEF,

2008). There is a positive association among stunting, central obesity, and cardio-

metabolic disorders (Schroeder, Martorell & Flores, 1999). The burden of these chronic

diseases is daunting as they remain significant causes of morbidity and mortality even in

the tropics and subtropics. This could stretch health facilities which are either non-

existent or ill-equipped to cope with the yet-to-be resolved problems of undernutrition

and infections.

Micronutrient deficiencies

The three most prevalent micronutrient deficiencies include Iodine Deficiency Disease

(IDD), Iron (Fe) Deficiency Anemia (IDA) and Vitamin A Deficiency (VAD) (Nagati et

al. 2003; Faber & Wenhold 2007). According to the WHO, World Food Programme

(WFP) and UNICEF (2007), estimated that two billion people across the globe are

deficient in key minerals and vitamins.

Iodine Deficiency Disease (IDD)

Iodine is a natural salt found in seaweed and certain animal proteins, such as eggs, meat

and milk. It is a nutrient that assists in synthesizing the thyroid hormone, and regulates

the metabolism of the body. Clinical detection of Iodine deficiency occurs with the

presence of goitre, which is a swelling of the thyroid. Sub-clinically, IDD is tested

through urinary iodine (Kennedy, Nantel, Shetty, 2002). In severe form, IDD can cause

stillbirth and miscarriages (UNICEF, 2009).

40
Currently, approximately 741 million people globally are affected by goitre (WHO 2001)

in comparison with 1997, when 1500 million people globally were reported to have IDD

(Food and Agriculture Organization (FAO). In developing countries, about 37 million

children remain unprotected from the lifelong consequence of brain damage associated

with IDD (UNICEF, 2009). The 2005 NFCS in South Africa indicated that four out of ten

women and five out of ten children had urinary iodine (UI) levels higher than standard.

Six out of nine provinces reflected values above normal rate, with the Northern Cape

(NC) having a higher prevalence of 95 percent of children and 83.3 percent of women

(Labadarios, Smart, Maunder, Kruger, Gerricke, Kuzwayo, Ntsie, Steyn, Scholass,

Dhansay, Jooste, Dannhauser, Nel, Molefe, Kotze, 2008).

Irreversible mental retardation can develop during the first and second trimester of

pregnancy if the mother has IDD. The WHO recorded in 2002 that 50 million people

including adolescent worldwide were mentally handicapped owing to iodine deficiency

(WHO 2002). Iodine deficiency is the most preventable cause of brain damage, and

requires only the addition of a small quantity of salt to the diet (Kennedy et al. 2002). In

1994 UNICEF and the WHO recommended universal iodization of salt as a safe and cost-

effective strategy to address IDD (UNICEF, 2009).

Iron Deficiency Anemia (IDA)

When a deficiency in oxygen-carrying red blood cells occurs, it is defined as IDA. It is

the most common cause of anemia and related to vitamin B12 or folate deficiency. IDA

also occurs during periods of higher Ferrous (Fe) requirements, such as pregnancy and

menstrual loss, and severe losses occur during illnesses such as malaria and parasite

41
infections, also referred to as hookworms (Kennedy et al., 2002). IDA is more prevalent

in women, young children and the elderly. Children of pre-school age, adolescents and

women of childbearing age account for 2000 million victims of IDA (FAO, 1997).

Approximately two billion people globally are affected by IDA (Kennedy et al. 2002).

Tuberculosis and HIV infection are other etiological factors of iron deficiency (Van den

Broek & Letsky, 1998), and it is known that sexually active adolescents are at increased

risk of HIV infection. In Nigeria, Brabin et al (1997) found that adolescent girls who had

low Hb (<10g/dl) were more likely to have a low BMI than those who had higher Hb

levels, suggesting that overall malnutrition is associated with anemia. Nationally, poor

iron status occurs amongst one out of five women and one out of seven children.

Prevalence is higher than in previous recordings in 1999 (Labadarios et al., 2008). Heavy

menstrual blood loss may be an important factor of iron deficiency anaemia, as observed

in Nigerian girls, and it might also be related to vitamin A deficiency (Barr, Brabin,

Agbaje, 1998). A 12% menorrhagia rate was found among nulliparous, menstruating girls

aged less than twenty. Menorrhagia was suspected to be an important contributor to the

high rate of anemia (40%).

During infancy and in children of pre-school age, IDA causes impaired psychomotor and

physical development, as well as poor immune structure. In adults, IDA diminishes

stamina and work capacity by as much as 15-20 percent (Faber & Wenholf, 2007). Iron

deficiency may alter cognitive function in children and even in adolescents (Ballin, Berar,

Rubinstein, 1992) and the effects may be only partly reversible in severe and prolonged

deficiency.

42
Vitamin A Deficiency (VAD)

Vitamin A is needed for growth of all body tissues and repair. The immune and visual

system is dependent on vitamin A for normal functioning. VAD is most recognized

clinically through Bitots spots and complete blindness, and can be prevented in children

(Mason, Lotfi, Dalmiya, Sethuraman, Deitchler, Geibel, Gillenwater, Gilman, Mason,

and Mock, 2001). The risk of vitamin A deficiency tends to decline with age, it is now

apparent that it often extends in adolescence and early adulthood (Henning, Foster,

Shrestha, & Pokhrel,1991), Evidence of high deficiency rates in adolescents in

Bangladesh and Malawi female factory workers (Ahmed, Hassan & Kabir, 1997), found

that 56.2% had low serum retinol (<1.05 mmol) and 14.2% were deficient (serum retinol

<0.7 mmol/l). After adjusting for potential confounders, it was found that serum retinol

was significantly higher in girls who consumed milk and dark green leafy vegetables

more frequently. Here again, serum retinol and Hb were correlated. Nearly half (44%)

were anemic, which is twice as high as in upper-level-school adolescent girls this again

suggest that vitamin- A deficiency(VAD) is extremely low (Ahmed, Khan &, Karim,

1996).VAD can cause complete blindness and a decline in the functioning of the body’s

immune system and its resistance to disease; (Unnevehr, Pray, Paarlberg 2007;

Rodriguez-Amaya, 2000). VAD can cause ailments such as measles, diarrhoea or malaria

before causing complete blindness. UNICEF suggests fortification and dietary

diversification as a solution to address VAD (UNICEF, 2009).

43
Overnutrition in Adolescent (Obesity)

Obesity and overweight are rapidly becoming a health risk within the poor economic

strata of industrialized countries. Obesity is increasing in most high-income countries, in

developing countries undergoing nutrition transition, and even in poor countries with

current food insecurity and undernutrition problems. In Nigerian adults, for instance,

underweight (BMI <18.4) is only slightly more prevalent than overweight (BMI>25). The

Obesity and under-nutrition coexist within families (UNICEF, 2006). The consequence of

inappropriate diets leads to mortality amongst children and adults. Childhood obesity has

become a severe health problem in some developing countries, especially during the last

few decades (Ribeiro, Guerra, Pinto, Olivera, Durtte & Mota, 2003). The most

prominent issues related to over-nutrition include obesity, allergies, and chronic disease

such as cardiovascular disease, diabetes and cancer. The nutrition transition is regarded as

causing a double burden of obesity and inactivity (UNICEF 2007; UNICEF, 2006).

Overweight is classified as BMI>+1 Standard Deviation (SD), which is equivalent to

BMI 25 kg/m² at 19 years; obesity >+2SD, which is equivalent to BMI 30 kg/m² at 19

years; thinness is <-2SD and severe thinness is <-3SD (WHO 2007). ). In Nigeria, in a

study conducted by Olumakaye and Funke (2006), oberseved that the prevalence of

underweight was higher among boys than girls while the prevalence of overweight was

higher among girls than boys. In Europe, the prevalence of adult obesity has reportedly

increased by about 10%-40% in the last 10years, and the most dramatic increase (50%

since 1980) has been observed in the UK. Interestingly factors in Italian adolescents

attending junior high schools according to Rabbia,Veglio & Pinna 1994, was

44
significantly higher in boys than in girls, which is at variance with most studies. In the

Minnesota, Adolescent Health Survey (Neumark-Sztainer, Story, Resnick & Blum,

1998), there was a strong inverse relationship between socioeconomic status and weight

status in girls, but not in boys.

The situation in developing countries varies widely according to urbanization and

income, but obesity is not merely a problem of high-income groups. In the Middle East,

there have been several reports of increasing obesity among adolescents and adults.

Based on a BMI cut-off of 25 for overweight or obesity, 16% of boys and 17% of girls in

secondary schools in Bahamas were positive (Abdulrahman, 1993). While obesity

increased with age in girls, it declined in boys. A family history of obesity was a

significant factor associated with obesity in both boys and girls. An interesting

observation is that boys who ate alone were three times more likely to become obese than

those who ate with family members. The health consequences of overweight and obesity

in adolescence have been thoroughly reviewed (WHO, 2005). Obesity-related symptoms

in children and adolescents include psychosocial problems, increased cardiovascular risk

factors, abnormal glucose metabolism, hepatic gastrointestinal disturbances, sleep apnoea

(in children) and orthopedic complications. Obesity in adolescence may have serious

health and psychosocial consequences. For some, the greatest hazards of adolescent

obesity are the social and psychological difficulties that also may persist into the adult

years (Lifshitz, Tarim and Smith, 1993), although for others, obesity in adolescence may

have limited emotional implications (Elster and Kuznets, 1995). Adolescents are sensitive

about body image and obese teenagers are especially vulnerable to social discrimination.

45
Poor self-esteem and body image are consistently associated with obesity in adolescents,

but not in younger children (French, Story and Perry, 1995). In women, obesity at

adolescence may even affect future socioeconomic and marital status, according to a

longitudinal study in the USA (Gortmaker, Must&, Perrin, 1993). The major long-term

health problems associated with adolescent obesity are its persistence in adult life and its

association with cardiovascular disease risk in later life. The highest prevalence of

obesity in South Africa amongst children occurs between the ages of one and three years,

at 19.3 percent in rural areas and 15 percent in urban areas. A comparison between the

National food Consumption Survey (NFCS) of 1995 and that of 2005 shows that there

was a decrease in the prevalence of overweight based on weight-for-height.

The prevention of obesity amongst children has been highlighted by the WHO, and links

such as the frequency of meals, distribution throughout the day (Maffeis, Provera, Filippi,

Idoti, Schena, Pinelhi & Tato, 2000), meals of adults and parents provided to the children

and quantity consumed, have an impact on obesity (Smiciklas-Wright, et al., 2003).

Tooth decay, a nutrition problem in adolescence

Tooth decay and periodontal disease may result from a combination of poor oral hygiene

and poor eating habits. At this time, dental problems are more widespread in

industrialized than developing countries. Education for dental hygiene and health and

fluoridation of drinking water and toothpastes, and to a certain extent the use of sugar

substitutes, are contributing to a reduction in numbers of cavities, filled and missing

teeth. However, in developing countries, dental health may deteriorate rapidly as a

46
consequence of dietary changes (WHO, 1994). Sucrose (table sugar) is the main

cariogenic food ingredient, particularly when in a form that sticks to the teeth. Other

mono- and disaccharides are also cariogenic, but to a lesser extent; lactose is the least.

Starch is not, so that diets high in starch and poor in sugar have a very low-caries

producing potential. It is also possible that high carbohydrate, unrefined foods have anti-

decay properties (Rugg-Gunn, 1993). These are typical features of traditional dietary

patterns of many developing countries. However, partly hydrolysed starch as found in

highly processed snack foods may have an increased cariogenicity (Grenby, 1990). With

increasing consumption of sugar, processed foods and snack items by children, tooth

decay may increase. The effects of dietary changes, such as those that occur in

adolescence, combined with alcohol and tobacco consumption, may affect dental health.

Another factor that may contribute to tooth decay is malnutrition during tooth formation

(Grenby, 1990). It has been demonstrated in animals that early malnutrition affects tooth

development and eruption, and increases tooth decay later in life. There is increasing

evidence of similar effects in humans. Cross-sectional and longitudinal studies in

Peruvian children showed that malnutrition, as evidenced by anthropometric status, not

only delayed tooth development and affected the age distribution of dental caries, but was

also associated with a higher number of carious deciduous and permanent teeth. Even

mild or moderate malnutrition during infancy was associated with increased caries in

both deciduous and permanent teeth. Dental enamel hypoplasia is also associated with

malnutrition in the early years, although it is not a highly specific indicator of nutritional

status (Goodman and Rose, 1991). Finally, periodontal disease may also be associated

47
with undernutrition, in particular ulcerative gingivitis of infectious origin (Enwonwu,

1994). Thus, early malnutrition and dietary changes associated with adolescent lifestyles

and socioeconomic development may lead to increasing prevalence of dental decay in

adolescents and adults.

Nutritional Requirement of Adolescents

The phenomenal growth that occurs in adolescence, can only be compared to that in the

first year of life, creates increased demands for energy and nutrients. Total nutrient needs

are higher during adolescence than any other time in the lifecycle. Nutrition and physical

growth are integrally related; optimal nutrition is a requisite for achieving full growth

potential (Story & Stang, 2005) Failure to consume an adequate diet at this time can

result in delayed sexual maturation and can arrest or slow linear growth. (Story et al,

2005) Nutrition is also important during this time to help prevent adult diet-related

chronic diseases, such as cardiovascular disease, cancer, and osteoporosis.

Prior to puberty, nutrient needs are similar for boys and girls. It is during puberty that

body composition and biological changes (e.g., menarche) emerge which affect gender-

specific nutrient needs. Nutrient needs for both males and females increase sharply

during adolescence. Nutrient needs parallel the rate of growth, with the greatest nutrient

demands occurring during the peak velocity of growth. At the peak of the adolescent

growth spurt, the nutritional requirements may be twice as high as those of the remaining

period of adolescence (Forbes, 1992). Many adolescent do not follow the

recommendation of the Dietary Guidelines or the Food Guide Pyramid. According to

Deveney, Gordon & Burghardt in Floyd (2003), average adolescents consume too much

48
fat, saturated fat, sodium and not enough fruits, vegetable, or calcium. Adolescents obtain

about 35% of their calories from fat and 13% from saturated fat (above the recommended

levels of 30% and 10% respectively) only 15% of adolescent’s age 12-19 meet the

recommendation for total fat intake; and seven (7%) percent of adolescents meet the

recommendation for saturated fat intake.(Daveney, et al, 1995)

Adolescent appears to be familiar with the general relationship between nutrition and

health but are less aware of the relationship between specific foods and health. For

example, adolescent understand the importance of limiting fat, chocolate, and sodium in

one’s diet. But they do not know which food is high in fat, cholesterol, sodium, or fiber.

A study indicated that adolescents were well informed about good nutrition and health

but did not use their knowledge to make healthy food choices.

Energy Intake

Energy needs of adolescents are influenced by activity level, basal metabolic rate, and

increased requirements to support pubertal growth and development. Basal metabolic rate

is closely associated with the amount of lean body mass. Adolescent males have higher

caloric requirements since they experience greater increases in height, weight, and lean

body mass than females (Story & Stang, 2005). An imbalance of energy intake (food

consumption) and energy output (physical activity and energy cost of metabolic process)

could result in condition of overweight, obesity and underweight in adolescent. Since the

incidence of obesity and overweight in children and adolescents seems to be increasing,

globally energy intake on the whole, would appear to be inadequate; nevertheless, energy

49
restriction in children may be problematic for certain populations, such as young

adolescents from minority subgroup, adolescent of low socioeconomic status and

adolescent with disabilities. Restricted energy intake has been found to stem from a

chronic marginal deficiency of food quality, which has been identify more recently as a

form of food insecurity (Campbell, 1991).The recommended energy intake for the

adolescent is approximately 2,368 kilocalories.

Protein Intake

Protein needs of adolescents are influenced by the amount of protein required for

maintenance of existing lean body mass and accrual of additional lean body mass during

the adolescent growth spurt. Protein requirements per unit of height are highest for

females in the 11 to 14 year age range and for males in the 15 to 18 year age range,

corresponding to the usual timing of peak height velocity (Unicef, 2011).

When protein intakes are consistently inadequate, reductions in linear growth, delays in

sexual maturation, and reduced accumulation of lean body mass may be seen. During

adolescence, protein needs correlate more closely with the growth pattern than with age

(Floyd, 2003). The daily protein recommendation for adolescents is approximately

0.85g/kg of a body weight (Kulas, 2011). Average intake of proteineous foods in

adolescent, is well above the recommendation. There is little evidence to show that

insufficient protein intakes occur in the adolescent population in Nigeria (UNICEF,

2011). Protein metabolism is particularly sensitive to energy restriction in adolescents

during the growth spurt.

50
Calcium

Calcium needs during adolescence are greater than they are in either childhood or

adulthood because of the dramatic increase in skeletal growth. Because about 45% of

peak bone mass is attained during adolescence, adequate calcium intake is important for

the development of dense bone mass and the reduction of the lifetime risk of fractures

and osteoporosis. At age 17, adolescents have attained approximately 90% of their adult

bone mass. Thus, adolescence represents a “window of opportunity” for optimal bone

development and future health.

The DRI for calcium for 9 to 18 year olds is 1300 mg/day. Only 19% or about 2 out of 10

adolescent girls meet their calcium recommendations. Milk provides the greatest amount

of calcium in the diets of adolescents, followed by cheese, ice cream and frozen yogurt.

Calcium-fortified foods are widely available (e.g., orange juice, breakfast bars, bread,

cereals) and can be excellent sources of calcium; many of these foods are fortified to the

same level as milk (300 mg/serving). Soft drink consumption by adolescents may

displace the consumption of more nutrient-dense beverages, such as milk and juices. In

one study, adolescents in the highest soft drink consumption category were found to

consume less calcium and vitamin C than non-soft drink consumers(Harnack, Stang &

Story, 2002) Adolescence need adequate calcium for adequate growth and to achieve

peak bone mass, which reduces the risk of developing osteoporosis as an adult (Brown,

2005). Inadequate calcium consumption has also been associated with the development of

other adult chronic disease such as colon cancer and hypertension (Somlin and

Grosvenor, 2008).

51
Calcium requirement vary throughout the lifetime in accordance with growth patterns.

The current recommended daily allowance (RDA) of calcium for adolescents is 1,200mg

(Brown, 2005) although the National Institutes of Health Consensus Development

Conference Statement on Optimal Calcium Intake recommended 1,200 to 1,500 mg

calcium per day for adolescent aged 11 to 24 years. Dietary survey data indicate that

adolescent particularly girls, are at greatest risk for inadequate calcium intake (Anderson,

2004). Calcium intake tends to decline among girls from 10 to 17 years of age. The

average intake is from 800 to 920 to range from 780 to 820mg per day. In boys, the

average intake is from 800 to 920 mg per day (Albertson, Belmann. Loenard & Floyd,

1997:2003). In addition, there is evidence to suggest that high drink consumption

contributes to low calcium intake in this age group because adolescent may substitutes

soft drinks for milk. It is estimated that 14% of total energy intake in boys and 15% of

total energy intake in girls can be attributed to soft drink consumption (Alberston et al.,

2003).

Iron

Iron is vital for transporting oxygen in the bloodstream and for preventing anemia. For

both male and female adolescents, the need for iron increases with rapid growth and the

expansion of blood volume and muscle mass. The onset of menstruation imposes

additional iron needs for girls. Iron needs are highest during the adolescent growth spurt

in males and after menarche in females. The RDA for iron is 8 mg/day for 9-13 year olds,

11 mg/day for males’ ages 14-18 and 15 mg/day for females ages 14-18. Iron deficiency

52
anemia is the most common cause of anemia in adolescents. Iron deficiency hampers the

body’s ability to produce hemoglobin, which is needed to carry oxygen in the blood. This

deficiency can increase fatigue, shorten attention span, decrease work capability, reduce

resistance to infection and impair intellectual performance (O’ Brein & Davis, 2006).

Dallman in Floyd 2003 noted that in boys there is a sharp increase in the requirement for

iron for approximately 10 to 15 mg/day. Female adolescents are at greatest risk for iron

deficiency, particular African American females aged 12-19. The prevalence of iron

deficiency anemia range from 0.6% among males and 4% females 12-19 years old

(WHO, 2005).Reports from dietary surveys indicate that iron intakes of adolescents with

normal dietary patterns are between 12.5 and 14.2 mg/day for girls compared with 13.4 to

18.0 in boys (NHANES III). Iron deficiency was found in 14. 2% of the girls aged 15 to

18 years and 12.1% of the boys aged 11 to 14 years (Alaimo, McDowell, & Briefel,

1994). Estimates of iron deficiency among adolescents are 3-4% for males and females

ages 11-14, 6-7% for females ages 15-19, and 0.6% for males ages 15-19.27 Rates of iron

deficiency tend to be higher in adolescents from low-income families.

Vitamins

Vitamin A

Besides being important for normal vision, vitamin A plays a vital role in reproduction,

growth, and immune function. To ensure adequate body stores of vitamin A, boys and

girls ages 9-13 should consume 600 μg/day, females ages 14-18, 700 μg/day and males

ages 14-18, 900 μg/day. In the CSFII survey about 30% of adolescents had inadequate

intakes of vitamin A. The most obvious symptom of inadequate vitamin A consumption

53
is vision impairment, especially night blindness, which occurs after vitamin A stores have

been depleted (Russell, 2001). Vision impairment caused by inadequate vitamin A is

rarely seen in the US. However, up to 500,000 children in developing countries go blind

each year because of vitamin A deficiency. The top five dietary sources of vitamin A in

the diets of adolescents are ready-to-eat cereal, milk, carrots, margarine, and cheese.

Beta-carotene, a precursor of vitamin A, is most commonly consumed by teens in carrots,

tomatoes, spinach and other greens, sweet potatoes, and milk. The low intake of fruits,

vegetables and milk and dairy products by adolescents contributes to their less than

optimal intake of vitamin A.

Vitamin E

Vitamin E is well known for its antioxidant properties, which become increasingly

important as body mass expands during adolescence. The RDA for vitamin E for 9-13

year olds is 11 mg/day and 15 mg/day for 14-18 year olds. There are few data available

on the vitamin E status of adolescents. National nutrition surveys suggest that dietary

intakes of vitamin E are below recommended levels (WHO, 2005).

Among adolescents the five most commonly consumed sources of vitamin E are

margarine, cakes/cookies/quick breads/donuts, salad dressings/mayonnaise, nuts/seeds,

and tomatoes (Blake et al., 2005). Increasing adolescent intakes of vitamin E through

dietary sources is a challenge, given that many of the sources of vitamin E are high fat

foods. Fortified breakfast cereals and nuts are good sources of vitamin E to recommend

for youth.

54
Vitamin C

Vitamin C is involved in the synthesis of collagen and other connective tissues. For this

reason, vitamin C is an important nutrient during adolescent growth and development.

The RDA for vitamin C is 45 mg/day for 9-13 year olds, 75 mg/day for males’ ages 14-

18 and 65 mg/day for females ages 14-18. Almost 90% of vitamin C in the typical diet

comes from fruits and vegetables, with citrus fruits, tomatoes and potatoes being major

contributors. The five most common sources of vitamin C among adolescents are orange

and grapefruit juice, fruit drinks, ready-to-eat cereals, tomatoes, and white potatoes

(Krebs-Smith, Look, Subar, Cleveland, Friday, & Kahle, 2001). Evidence suggests that

smokers have poorer vitamin C status than nonsmokers, even with comparable vitamin C

intakes. Because smoking increases oxidative stress and metabolic turnover of vitamin C,

the requirement for smokers is increased by 35 mg/day. On average, adolescents who use

tobacco and other substances have poorer quality diets and consume fewer fruits and

vegetables, which are primary sources of vitamin C.

Folate: Folate plays an integral role in DNA, RNA and protein synthesis. Thus,

adolescents have increased requirements for folate during puberty. The RDA for folate is

300 μg/day for 9-13 year olds and 400 μg/day for 14-18 year olds. National data suggests

that many adolescents do not consume adequate amounts of folate. The top five sources

of dietary folate consumed by adolescents include ready-to-eat cereal, orange juice,

bread, milk, and dried beans or lentils. Teens who skip breakfast or do not commonly

consume orange juice and ready-to-eat cereals are at an increased risk for having a low

55
consumption of folate. Severe folate deficiency results in the development of

megaloblastic anemia, which is rare among adolescents. There is evidence, however, that

a number of adolescents have inadequate folate status. In a study, 12% of adolescent

females were mildly folate-deficient, based on low serum folate levels, while 8-48% of

female teens had been shown to have low red cell folate levels indicative of subclinical

folate deficiency (Clake, Mossholder & Gates, 1987) Adequate intakes of folate prior to

pregnancy can reduce the incidence of spina bifida and select other congenital anomalies,

and may reduce the risk of Down syndrome among offspring. The protective effects of

folate occur early in pregnancy, often before a teen may know she is pregnant.

Thus, it is important that female adolescents who are sexually active consume adequate

folic acid. In view of the evidence linking folate intake with neural tube defects in the

fetus, it is recommended that all women capable of becoming pregnant consume 400

μg/day from supplements or highly fortified breakfast cereals in addition to food folate

from a varied diet that includes fruits, vegetables, and whole grains.

Fruits and vegetable Intake

Higher intake of fruits and vegetable are consistently associated with lower risk of

cancer. It has also been suggested that the antioxidant vitamins such as vitamin E, found

in fruits and vegetables reduce the risk of coronary heart diseases, (Beech, Rice, Myers,

Johnson & Nicklas, 1999) The existing evidence provides strong support for a protective

effect on a diet rich in vitamins, minerals, or nutrient responsible for the effects. Very few

56
adolescent consume five serving of fruits and vegetables per day, as recommended for

optimal health and prevention of cardiovascular disease and cancer.

Researches into fruits and vegetable consumption by the adolescents also have found that

intake of fruit and vegetable among children was consistently less than the recommended

five serving per day. In all of the available data support the probability that adolescents

consume only about half of the recommended number of serving of fruits and vegetable

per day.

Fiber Intake

Dietary fiber is important for normal bowel function, and may play a role in the

prevention of chronic diseases, such as certain cancers, coronary artery disease, and type

2 diabetes mellitus. Adequate fiber intake is also thought to reduce serum cholesterol

levels, moderate blood sugar levels, and reduce the risk of obesity. Presently, there are no

accepted guidelines for optimal fiber intake in adolescents. The Dietary Guidelines

suggest six serving of grain product per day, but do not specify the amount to consume.

Smolin et al., (2008) proposed that the minimum daily intake of dietary fiber for children

3 to 18 –years-old equal their age plus 5 grams. Using this guide, recommended fiber

intake would be about 30 grams per day among adolescents of 18-years old.

In the general, for almost all adolescents with the possible exception of the very youngest

age groups, current dietary fiber intake is well below the suggested recommendation

made by Smolin et al., (2008). Significant sources of fiber in the diet of adolescents

include whole grain breads, ready-to-eat cereal, potatoes, popcorn and related snack

foods, tomatoes, and corn (Krebs-Smith et al., 2001). The low intake of fruit, vegetables,

57
and whole grains among adolescents is the greatest contributing factor affecting fiber

intake among adolescents. Adolescents who skip breakfast or do not routinely consume

whole grain breads or ready-to-eat cereals are at high risk for having an inadequate

consumption of fiber.

Fat Intake

Intake of total fat in adolescent has been a public health concern for a number of years,

largely because of the association between excessive fat intake and subsequent

development of chronic diseases, such as cardiovascular disease and certain cancers

(Grafova, 2006). An excessive intake of fat, especially saturated fat, has been found to

increase blood lipid level, a major risk factor for cardiovascular disease. The

development of cardiovascular disease begins early in life; in fact, plaque formation has

been noted in the arteries of adolescents (Strong, Newman, Freedman, Grad, Tracey, &

Solberg, 1986).

Limiting total fat intake to 30% or less of total kilocalories has been hallmark of many

national dietary recommendations, including the dietary Guidelines for American (United

States Department of Agriculture, 1990)

Adolescent’s intake of saturated fat has increased somehow over the last 20 years, most

of these foods are highly processed, often stripped of key nutrients and the result of this is

malnutrition. Higher fat dietary products, hamburgers, doughnut, meat pies and

carbonated drinks are the major contributions of saturated fat to adolescents’ diets

(Konwea, 2012) with baked goods, such as cookies, cakes and pies, also providing a

58
significant share of saturated fat intake. The higher the consumption of junk food, the less

likely they would have an adequate intake of essential vitamins and minerals. National

School Lunch Program (NSLP) and the School Breakfast Program (SBP) also may have

contributed to the higher intakes of saturated fat reported in adolescents.

Factors Influencing Adolescent Food Choices

Adolescence is a vulnerable period during which dietary habits are established that persist

into adult life (Savige, Ball, Worsley, & Crawford, 2007). As children move into

adolescence, they may have more freedom to select foods, in accordance with their own

individual preferences. Such independence is exhibited within the home, school and

social environments and may fuel the apparent lack of nutritionally balanced food

behavior exerted by these consumers. Thus adolescents’ independence may affect

personal decisions about when, where and what they eat. Many adolescents may seek

and develop their own individual food preference behavior, particularly apparent through

the number and styles of meals eaten outside the home, and within the school and social

environments. Rapid physical growth creates an increased demand for energy and

nutrients. Total nutrient needs during adolescence is higher than at any other time in the

lifecycle, and failure to consume an adequate diet during this time can potentially affect

growth and delay sexual maturation (Story, 1992; Parker & Fox, 2000; Okeyo, 2009).

In addition to the impact on the growth and development, eating practices affect young

people’s risk for a number of immediate health problems, such as iron deficiency, eating

59
disorders, obesity, under-nutrition, bone health, and dental caries (Story, 1992). Dietary

practices during adolescence may have long-term health implications. For example,

being overweight as an adolescent is associated with overweight as an adult, high fat

intake during adolescence and into adulthood is associated with an increased risk for

heart disease, and low calcium intake during adolescence is associated with low bone

density and increases risk for osteoporosis later in life. Furthermore, because adolescents

are becoming more autonomous, behavior patterns acquired during this period are likely

to influence long-term behaviors (Neumark-Sztainer, Rock, Thornquist, Cheskin,

Neuhouser, & Barmett, 2000).

Despite the importance of healthy eating patterns during adolescence, studies have

consistently shown that adolescents as a group have poor eating habits that do not meet

current dietary recommendations (Neumark-Sztainer & Story, 1999). Nutrition related

practices include unhealthy dieting; high intake of fast foods and other foods high in fat;

low intake of fruits, vegetables, fiber, dairy foods and erratic eating behaviors, such as

skipping meals (Neumark-Sztainer et al., 2000). Recent national data show that only 1%

of adolescent males and females meet nutritional recommendations for all the Food

Guide Pyramid groups (Human Nutrition Information Service, 2000), and 18% of girls

and 7% of boys do not meet any of the recommendations.

There is also evidence that dietary quality declines from childhood to adolescence. Intake

of fruits, vegetables, milk, and fruit juices decreases whereas intake of some drinks

increases during this time (Lytle, Varnell & Murray, 2009). Reasons for the shift in

eating patterns as children move into adolescence are likely because of lifestyle,

60
development, social, and environment changes (Story & Neumark-Sztainer, 1999).

Growing independence and eating away from home with physical appearance and body

weight, the need for peer acceptance and busy schedules all have an effect on eating

patterns. Food preferences are formed as a result of the complex interactions of many

factors in a person’s environment, including early childhood experiences with food and

eating, positive or negative conditioning, exposure, and genetics. Birch, (1999) in Floyd,

reported that food preferences have been found to be one of the strongest predictors of

food choices (Drewnowski & Hann, 1999). Adolescents may be more reluctant to eat

healthy foods, because of the fear of being different from their friends. These adolescents

may be identified as generally eating foods, which are familiar, and indeed they may

actively avoid new foods. This is defined as: The fear of new food (neophobia), which

has to be balanced with a desire for variety (neopilia) which is increasingly manifested in

a systematic search for new and inexperienced pleasurable tastes (Marshall, 1995). In

essence, the food behaviour of adolescents is portrayed as exerting the characteristics

from early childhood years with notoriously wary of unidentified eating objects, children

invariably go for the familiar (Lydecker, 1998; Dryen, 2005). Also, adolescents appear

to have a higher tolerance for repetition than adults and this can mean an unremitting diet

of hamburger, hot dogs, pizza, chili, barbecued ribs, fried chicken, doughnut and cakes

(Lydecker, 1998).

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Individual Influences

Studies with adolescents have shown that taste is one of the most important influences on

food choices (French, Story, Hannan, Breitlow, Jeffrey, Baxter & Snyder, 2007). In

focus groups with adolescents, taste and the appearance of food were frequently

discussed as primary factors influencing food selection (Neumark-Sztainer et al., 2000).

Lifestyle

According to Neumark-Sztainer & Story (1999), perceived that time constraints and

convenience influences strongly adolescent food choices. In focus groups with

adolescents from low-income families in Califonia, convenience was a major driving

factor in determining food choices (Lin, Guthrie, & Blaylock, 1999). In another study,

adolescents discussed wanting to sleep longer in the morning instead of taking the time to

eat or prepare breakfast, not wanting to wait on a long lunch line, eating at fast food

restaurants because the food is served quickly (Neumark-Sztainer et al, 2000). Evidence

reflects that fast food options appear to have overshadowed the proper meal (Eboh et al.,

2006) which encompasses a cooked meal, usually evening dinner and consisting of meat,

potatoes and vegetables eaten at a properly set dinner table. Lack of time is also

perceived as a major barrier to eating healthier. Adolescents often believe they are too

busy to worry about food and eating well. Common remarks were “people of our age are

so busy we don’t have time to make healthful foods” and “we have too many pressures

on us” (Story & Resnick, 1996).

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Skipping meals adversely affects dietary quality. Breakfast is the most commonly missed

meal among adolescents (Lin et al., 1999). Dieting is a common and widespread practice

among adolescents, especially girls (French, Perry, Leon, Fulkerson, 2001). In 1999,

59% of high school girls and 26% of high school boys nationwide reported trying to lose

weight during 30 days preceding the survey (Centers for Disease Control and Prevention,

2000). Almost 20% of girls had gone without eating for 24 hours or more to lose weight,

11% had taken diet pills to lose weight, and 8% had vomited or taken laxatives to lose

weight during the past 30 days. The few studies that have examined adolescent weight

control behaviors and associations with dietary intakes have had inconsistent results.

This may be because adolescent dieters are not alike (Neumark-Sztainer et al., 2000). In

interviews, however, many girls said this meant “watching what they eat” and mentioned

positive behaviours, such as cutting down on high fat foods and eating more fruits and

vegetables. French et al., (2001) also found that many adolescent girls who dieted

reported using healthful eating behaviour changes to lose weight.

It may be that adolescents who use unhealthful weight-control methods may have poorer

diets. Data from the national Youth Risk Behaviour Survey found adolescent girls

engaging in extreme weight-loss behaviors were less likely to eat fruits and vegetables

compared with non-dieters and dieters using more moderate methods of weight control

(Story, & Neumark-Sztainer, 1996). Another large population based study found that

adolescents who reported frequent dieting were at greater risk for inadequate dairy food

intake than were non-dieters (Neumark-Sztainer et al., 2000).

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Family Influences

Parents are a major influence on adolescents eating behavior. Parents tailored

adolescents’ dietary patterns in two ways: Parents are providers of food, and the family

influences food attitudes, preferences, and values that affect lifetime eating habits. As

they transit towards greater independence, food habits of adolescents reflects the

changing role of parental influence on food choices. The increase in dining out that

occurs during adolescence is related to the decline in dietary quality from childhood to

adolescent (Raats & Lumbers 2004). Research has shown that adolescents eat 68% of

their meals and 78% of their snacks outside the home and obtain 65% of total energy

from these, younger teens (aged 12 to 14-years) are more likely to eat at home compared

with older teens (aged 15 to 17-years). United States families as well as some families in

Nigeria have undergone profound social changes in family structure and maternal

employment. There has also been substantial growth in maternal employment in the past

few decades. Currently, 74% of mothers with children aged 6 to 17 years are employed

in the labour force. Of these, mothers 77% work full time and 23% work part time

Parents in two-earner households and single parents have less time to prepare meals

(Bowers, Esmond & Jacobson 2000).

Food preparations have largely been the work of women, and cooking trends over the

past 100 years reveal interesting patterns. In the early 1900’s only a small number of

women were in the work force. In 1998, 60% of women were in the workforce and less

than 10 hours a week were spent on food preparation and clean up (Bowers et. al., 2000).

64
Family meals

Family meals, provides a larger proportion of intake of energy and key nutrients than

other meals or snacks (Floyd, 2003). A contemporary notion is that the family meal is

becoming less important to most families; however, surveys indicate that majority of

parents as well as the adolescent view family dinners to be very important. Despite the

importance placed on the family dinner by both parents and adolescents, survey data

indicate that the proportion of youth eating dinner with their families on a regular basis is

not high (Zollo, 1999). Two recent studies found that only about one-third of adolescents

ate dinner with their family every day (Gillman, Rifas-Shiman, Frazier, Rockett,

Camargo, Field, Berkey, & Colditz, 2000; Neumark-Sztainer, Story, Ackard, Moe &

Perry, 2000). About 22% to 32% of adolescents reported eating dinner with their family

rarely or only a few days each week (Gillman, et. al. 2000; Neumark-Sztainer et al.,

2000). Among 252 junior and senior high school students, the average number of days

that families ate dinner together was 4.7% (Neumark-Sztainer et al., 2000).They, found

out that the major reasons cited by adolescents for not having family meals included

parent and teen schedules, teen desire for autonomy, dissatisfaction with family relations,

and a dislike of food served at family meals. Population trends of fewer family meals as

well as the increasing popularity of fast food preparation have again affected the

adolescent quality diet; a study found that maternal employment was not associated with

consistency of meal patterns among adolescents; however adolescents living in single-

parent households were more likely to eat fewer meals and more snacks (Siega-Riz,

65
Carson, & Popkin, 1998). Majority of adolescents thought they would eat more healthful

food if they ate more often with their parents.

Little data exist on the nutritional impact of family dinners. Using a national sample of

16,202 children and adolescents aged 9 to 14-year olds, Gillman et al., (2000) examined

the association between frequency of eating family dinner and dietary quality. They

compared food and nutrient intakes of children who ate family dinner most days with

those who do not eat family dinner. Those who ate family dinner was associated with

more healthful dietary intake patterns, including fruits and vegetables, less fried food and

soft drinks, less saturated and trans fat, and more fiber and micronutrients from food.

The influences of peers and conformity to group norms are often considered hallmarks of

adolescence, especially middle adolescence. Peers exert a major influence on overall

adolescent behavior. They help to create the norms concerning behavior, particularly

whether the behavior is acceptable to the peer group. Adolescents spend a substantial

amount of time with friends, and eating is an important form of socialization and

recreation. Because adolescent seek peer approval and social identity, it is assumed that

peer influence and group conformity are important determinants in food choices has

rarely been explored and the few studies done have not found a strong associations

(French et al., 2000; Neumark-Sztainer et al., 2000).

French et al., (2000) examined 13 motivations regarding vending machine snack

selections among ‘419 adolescents.’ Influence of friends was rated as the least important

motivation for snack choice; however, results from qualitative focus group research have

66
been inconsistent (Zollo, 1999). Adolescents are seeking individuation, autonomy, and

independence, and may not want to believe that others influence their behavior.

67
Physical Environmental Influences

One third of all teen-eating occasions take place outside the home. More than half of out

of home eating occasions take place at school, followed by fast food restaurants, other

locations, and vending machines. The physical environment in the community has a

large impact on adolescent eating.

Schools: The school food environment can have a large impact on adolescents’ food

choices and dietary quality because adolescents consume a large proportion of their total

daily energy at school. National data show that foods eaten at lunch compose 35% to

40% of students’ total daily energy intake (Burghardt, Gordon, Chapman, Gleason, &

Fraker, 1993). Compared with the food environment in elementary schools, students in

secondary school and high schools are faced with a huge array of high-fat and high-sugar

food choices to the detriment of their health and given little, guidance about these

choices. Many schools sell candy, chips, and soft drinks at school to raise money for

programmes and activities (Griffith, Sackin & Bierbauer, 2000). Food and beverage

machines are nearly universal in secondary school and attract lots of money annually in

adolescent snack spending.

A recent study found that the majority of foods available in high school vending

machines and school stores were high fat and high sugar items, such as chips, candy, and

sodas (Arulogun & Owolabi, 2011). Another survey assessed the availability of a la carte

food items in junior and senior high classes and found that more than half (52%) of the a

la carte items were high in fat, according to the Food and Drug Administration dietary

criteria (3g fat of fewer per 100g for entrees; 3g fat or fewer per serving for all other

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foods). Fewer than 10% of the items in the cookie and entrée categories met the fat

criteria (Hamack, Snyder, Story, Holliday, Lytle, Neumark-Sztainer, 2000). The growing

trend of commercialism and aggressive marketing in schools is not limited to food and

beverage items in vending machines, school stores, or snack bars. However direct

advertising in school has expanded. Examples include school bus advertising for soft

drinks and fast food establishments; “free” textbook covers advertising candy, chips and

soft drinks; advertisements for high sugar/high fat products on wall boards and in

hallways, in student publication such as newspapers and yearbooks, and on sports

scoreboards.

Fast-Food Restaurants

The number of fast-food outlets in both developed and developing countries has risen

steadily over the past twenty-five years. In United States of America, according to

Jekanowski (1999) in Floyd (2003) noted that fast food restaurants has risen from about

75,000 outlets in 1972 to almost 200,000. Konwea, (2011) reported that fast food eating

has become part of the lifestyle of the people of Nigeria, and is spreading across major

cities of the country. Expanding the number of outlets increases accessibility, making it

more convenient for the consumer to purchase fast food. Fast-food restaurants hold great

appeal among the adolescent population. Adolescents want quick, good tasting,

convenient, and low cost meals, which are the main features of fast food. Unlike many

other restaurants, fast-food restaurants welcome adolescents and provide a clean,

friendly, brightly lit atmosphere and a socially acceptable place to spend time with

69
friends. Fast-food outlets are also a prime employer of adolescents, and this increases

their exposure to fast food.

Fast-food outlets provide almost (64%) of away from home meals to adolescents. The

average adolescent visits a fast-food restaurants 2-3 times a week and spends more than

one thousand naira a visit. On Saturdays and Sundays fast food composes of higher

percentage of all meals for adolescents aged 12 to 17-years. Fast-food consumption is

greatest among older adolescents (aged 15 to 17-years) as they have greater freedom

mobility, and income, as well as for youth who have part-time jobs. Fast-food

consumption can have a negative impact on the nutritional quality of the adolescent diet

(Konwea, 2011)

Stress Factors

Compass (1987) in Floyd (2003), reported that the adolescent years are associated with

numerous biological, psychological, and social changes. The family, school, peers, and

other interpersonal domains can all be sources of stress. Prior research indicates that

when adolescents are under stress, they sometimes act in ways that prevent them from

receiving social and family support and, in turn, may actually increase the stress level in

their lives. Some of the most complex transitions in life occur during adolescence (Elliot

& Feldman, 1990; Oldewage-Theron & Egal, 2009). The child is growing into an adult,

relationships with others take on new meaning and complexity, and independence is

increasing. This period can bring about stress in the form of depression, loneliness, and

other psychological difficulties (Vohs & Heatherton, 2000).

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The relationship of stressful life events and distress has received much research interest.

Many studies have shown a positive relationship between stressful life events and

depression, loneliness, anxiety, and other symptoms of psychological distress Ward &

Mann (2000). Depression is probably the most common type of psychological distress

among adolescents. Studies suggest that high levels of loneliness are common during the

developmental period of adolescence. Psychological stress is a risk factor for obesity. In

adolescents, stress precedes weight gain (Tarofsky-Kaaff, Wilfley & Spurrell 2000).

According to Lissau and Sorenson (1994), in their study, found that stress precedes

weight gain. Stress can influence obesity by stimulating energy intake and adolescents

may use snacking as a stress coping mechanism (Shimai, Kawabata, Nishioka, & Haruki,

2000). Frequent stress may then result in excess energy intake, weight gain, and obesity

or a relapse of obesity in children attempting to maintain a healthy weight.

The effects of stress on eating are not consistent. For some individuals, stress may

reduce energy intake, whereas for others, it can increase energy intake. In adolescents,

stress is thought to reduce the inhibition produced by dietary restraint leading to

increased energy intake. Theories that have been proposed to explain the reduction in

inhibition include depletion of self-regulatory resources theory (Vohs & Heatherton,

2000), escape theory (Tanofsky-Kraff et al., 2000), and distraction from worries (Ward &

Mann, 2000). Self-regulatory resources theory proposes that an individual has limited

amount of resources that are being allocated to maintaining dietary restraint. These self-

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regulatory resources can be depleted by stress resulting in hyperphagia which occurs

when emotional distress and aversive self-awareness produce a negative effect, resulting

in disinhibition of restraint (Tanofsky-Kraff et al., 2000). Ward et al (2000) have

suggested that stress may increase eating in restrained eaters by distracting the individual

from attempts to inhibit food intake.

Stressful circumstances have been shown to be strongly related to psychological and

emotional problems, drug use, stress-induced eating, and behavioral problems at home

and school (Compass, 1987).

Nutrition Education

Nutrition Education (NE) is any combination of educational strategies, accompanied by

environmental supports, designed to facilitate voluntary adoption of food choices and

other food- and nutrition-related behaviors conducive to health and well-being (Contento,

2007). Nutrition education is delivered through multiple avenues and involves activities

at the individual, community, and policy levels (Contento, 2007). NE is classified as a

food-based strategy, which allows for community empowerment through information. It

is a change process whereby beliefs, attitudes and influences are changed to encourage

improved nutritional practices consistent with individual needs and available resources

(Oosthuizen, 2010). Nutrition Education programmes (NEPs) allow for the

communication of information which can ultimately improve the quality of life. NE is a

means of promoting lifelong healthier eating habits by educating people in making the

right food choices and in carefully preparing and preserving foods which have a good

nutritional value (FAO, 2008).

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Nutrition Education is vital as it ensures a better and more diversified food supply.

Decision making is encouraged at all levels when the intervention covers various levels

of the population, i.e. parents, children and the elderly, and must address the needs of the

school, scholars and teachers (FAO, 2008). It takes into account current knowledge and

how to improve that knowledge and involves promoting healthier eating habits within

cultural boundaries. Attitudes, knowledge and skills of youngsters can be changed so

that they understand the link between food and nutrition. The people who will benefit

from NE can act as change agents by spreading the message to a larger segment of the

population (Vijayapushpam, Rao, Antony &, Rao, 2008). NE communicates information

which must be understood, and the best approach is through schools: children attend

schools, which are nested within neighborhoods’ and are the existing connection between

families and communities (Blom-Hoffman, Kelleher, Power and Leff, 2004). The aim of

NE is to encourage movement from a knowledge orientation to a behavioural orientation

(Contento, Randel, Basch, 2002). NE involves not only imparting information or

submitting messages, but also getting people to do something different to improve

nutrition (Contento et al. 2002). Nutrition education is effective only when it is based on

adequate analysis of the nutritional problems and clear and concise definition of the

objectives and the methods of communications.

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Goals of Nutrition Education

Goals describe in broad terms what the programme will achieve. The overall goal of

school-based nutrition interventions is the elimination of nutrition-related health

problems among students. Other goals might be:

 To reinforce specific nutrition-related practices or behaviors’ to change habits that

contribute to poor health; this is done by creating a motivation for change among

the people

 To establish desirable food and nutrition behavior for promotion and protection of

good health.

 To provide people with correct information on the nutritional value of foods, food

quality and safety, methods of preservation, processing and handling, food

preparation and eating to help them make the best choice of foods for an adequate

diet.

 To educate and train teachers to integrate nutrition education in an

interdisciplinary approach.

 To promote and disseminate resource information related to integration of

nutrition education into curriculum.

 To promote nutrition awareness throughout school environment by disseminating

resources for nutrition education that can be displayed, (via posters in cafeteria,

hallways, and classrooms, among others). Such posters can assist students to

make healthy food choices.

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  To promote nutrition awareness to parents and communities through any of the

following methods: offering healthy eating seminars, sending nutrition

information home, through handbills posting nutrition tips on websites and

providing nutrient analyses of school menus..

 To initiate school-based marketing that is consistent with nutrition education and

health promotion. As such, we will limit food and beverage marketing to the

promotion of foods and beverages that meet the nutrition standards for meals or

for foods and beverages sold individually.

 To understand the strong relationship between nutrition and health,

 To improve their food choices and eating habits by showing them how to use the

foods pyramid and other healthy foods.

Nutrition Education in Schools

One of the goals of nutrition education is to motivate participants to eat a healthy diet.

Children are a very important audience for nutrition education because a healthy diet is

essential for their normal growth and development, and because children are establishing

food patterns that carry into adulthood (Story, Mays, Bishop & Perry, 2000). Good

nutrition promotes not only better physical health and reduced susceptibility to disease,

but has been demonstrated to contribute to cognitive development and academic success.

Schools provide a special medium for nutrition education and for intervention to improve

children's health and nutritional status. The basic aim is to help children acquire nutrition

knowledge and to develop and encourage desirable eating habits and food choices.
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Children can also help change the eating habits of their families by demanding desirable

food, and when they also become parents in the future, they can impart good dietary

habits to their children. Therefore, a common maxim about how to bring about a real

change in dietary habits is "Go to school". Effective nutrition education helps shape these

environmental factors and assist students in developing the skills needed to select healthy

diets (Stang & Story, 2005).

Available evidence on the effectiveness of nutrition education programmes in schools

shows that nutrition knowledge is most effective if there is a supportive environment and

if nutrition education is linked with practical food- and nutrition-related activities. Lunch,

feeding, gardening and health programmes in schools offer special opportunities for

practical teaching in nutrition. Student participation in school gardening, menu planning,

food selection (ideally from locally grown and processed foods) and food preparation

offers pupils first-hand experience in learning nourishing and hygienic dietary practices.

The classroom can thus serve as a "laboratory" where proper eating habits can be

demonstrated and reinforced in practice. Another important way to build a supportive

environment for nutrition education in schools is to involve the parents. The Child to

Child Programme, for example, is based on the concept of children as social educators

and as effective intermediaries for messages directed at their parents

Children are also effective change agents; transferring what they learn at school to the

communities they live in. Providing children with nutrition education in schools is,

therefore, an effective investment that should be supported by governments and funding

76
agents, as this can address the nutritional problems of communities over the short and

long term (David, Kimiywe, Waudo & Orodho, 2008).

Effective Nutrition Education Programme

The aim of NE is to encourage change through a learning process with the outcome of

voluntary action towards changing eating patterns (Contento et al., 2002). NE becomes

effective when participation occurs through the school especially if there is a bridge

between theory and practical learning. Improvement is further encouraged through family

and community involvement. Focus must be placed on behavior and active learning

(Sherman & Muehlhoff, 2007). Another possible approach is the involvement of the

family and/or community in NE. It is important to consider improving the knowledge of

nutrition and health practices of parents and children, and incorporating community

members within these strategies (UNICEF, 2007). According to Roy, Bilkes, Islam, Ara,

Tanner, Wosk, Rahman, Chakraborty, Jolly, Khatun (2008), providing nutrition

education and guiding participants with correct food practices may assist in reducing the

critical situation of malnutrition, which is further worsened by cultural norms, including

early marriages and discrimination against girls in food. A further suggestion was made

in a study by Ritchie, Whaley, Spector, Gomez and Crawford (2010) to consider a co-

ordinate approach within nutrition education, as this could enable significant changes

resulting in healthier food choices.

Participation is the ultimate goal for achieving positive changes of attitude towards health

care, hygiene practices, nutrition, water and sanitation, and is a rights-based approach to

77
human progress (UNICEF, 2007). Participation throughout the household ensures

effectiveness of the programme amongst younger children. Gaining support from parents

and community members encourages change (Pérez-Rodrigo & Aranceta, 2001).

Community participation can be seen as a mechanism which can alleviate the causes of

malnutrition by bridging the gap between knowledge, policy and action.

To be effective, a NEP must also be creative, engaging, and inexpensive and widely

disseminated (Pérez-Rodrigo et al., 2003; Pérez-Rodrigo & Aranceta, 2001).

Effectiveness is also achieved through appropriate NE messages, which are reinforced

through school, community and home-based food and nutrition interventions. This

enables a desirable behavioural change (Sherman et al., 2007).

Pictorial Nutrition Education (PNE)

Pictorial nutrition education is an innovative learning/teaching approach that utilizes

visual cue to behavioral change in nutrition. It provides a level of interaction and

individualized attention that distinguishes it from the traditional approach. Research has

shown that visual aids can increase student’s understanding. Visual cues accompanied by

oral instructions have increased student’s recall more than oral instructions alone (Houts,

Doak, Doak, & Loscalzo, 2006). Pictorial nutrition education serves as adjunct aids for

“reading to learn” that is, the processing of which includes perceiving, understanding,

and remembering text information. A pictorial is a graphic tool used to create, manage,

and exchange information and knowledge. The use of interactive pictorial education may

increase student’s understanding of nutrition instructions, especially, when the pictorial

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cues represents information and knowledge via the spatial organization of

concepts/topics, ideas, words, or other items, linked to and arranged in an ordinal pattern

according to the education contents. Visual mapping diagrams of ideas and concepts are

widely acknowledged as a very powerful and fun learning tool. The pictorial map and

cards can incorporate meaningful pictograms to present the flow of ideas. As graphic

knowledge representation tools, they provide written, visual, and spatial information and

this combination is more likely to be retrievable from memory than written information

alone. Pictures can also improve comprehension when they show relationships among

ideas or when they show spatial relationships (Houts et al 2006; Hughes & Huby, 2002).

Pictorial information delivery is an important theory-based element of an intervention,

contributing to four components; engagement, comprehension, information retention and

behavioral change. When compared to text alone, pictures closely linked to written or

spoken text can markedly increase attention to and recall of health education information.

An informative calendar on anaemia depicting etiology, prevention, control, signs and

symptoms of anaemia, and a video film in which various aspects of anaemia were

explained in a drama form were the media used for nutrition education. Content of

calendar and video film was tailored specifically for young and middle-aged women who

had grown up in low-resource rural environments. As culturally tailored pictures help

make information personally salient, a professional artist was used to create nutrition

education materials featuring rural hill families with a positive attitude toward iron rich

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food consumption. The images in the calendar were also designed to communicate key

points with minimal reliance on the written language.

Nutritional Knowledge

Nutrition knowledge is the comprehension of basic nutrition principle and concepts.

Psychologists have described two different types of knowledge: declarative and

procedural. Declarative knowledge is knowledge of what is knowledge of things and

processes (Worsley, 2002). One can know that vitamins are essential in one’s diet; that

too much fat is not good in one’s diet. Procedural knowledge is knowledge involving

how to do something. This type of knowledge involves application of declarative

knowledge. Knowing how to cook well is an example of procedural knowledge. One

takes the declarative knowledge and converts it to procedural knowledge. Choosing the

healthier snack is another example of procedural knowledge. Many people may realize

that they need to reduce their energy intakes, but how do they go about doing so?

Nutrition behavior obviously involves both types of knowledge. This knowledge is

applicable when a consumer learns how to benefit from the knowledge of nutrients. The

question is how much of this knowledge does each person need to know in order to apply

the knowledge to his or her daily life? The answer to this question depends on the person.

The nutritionist obviously has certain scientific needs and interests that require a larger

amount of knowledge. A nursing mother will have different nutritional knowledge needs.

A college student will be more concerned about what nutritional requirements are needed

for people of his age and gender. An athlete will need other types of nutritional

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knowledge. There are so many nutritional facts that are known to nutritionist and

dieticians. How much does an average consumer need to know about nutrition in order to

apply it to his or her every day eating habits? Some areas, in which consumers seem to be

interested in, include: the energy content of food, the roles of fat, the sources of vitamins

and minerals, the sources of phytochemicals, and the links between food production and

ecology and sustainability (Worsley, 2002). Other interests certainly depend on the

person and his specific needs.

Kruger,Venter,Vorster & Margetts (2002) believes that nutritional knowledge is an

important factor in promoting healthier eating habits, and consequently, maintaining an

appropriate body weight, thus, preventing overweight and obesity. People who are aware

of the connection between poor nutrition and certain health conditions are more likely to

follow a balanced diet and avoid excessive weight gain (Grafova, 2006). Applying this

knowledge to eating habits is the next step. What is eating habit and what does it involve?

Eating habits combines a variety of choices involving food. It can range from choosing

certain foods because of their nutritional values to cooking certain food in a certain way.

What influences these eating habits, and how much impact does the person’s knowledge

about nutrition affect the eating habits? Research has shown that nutritional knowledge is

only one among many influential factors that influence eating habits. These factors

include the perceived consequences of a certain behavior, beliefs about a certain

behavior, skills that are required, the social and physical environments of consumer, and

most importantly, motivators. Motivators can contribute a very significant amount of

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influence on food behaviors. These motivators include cultural values, social influences,

or different environmental rewards (Worsley, 2002).

Many consumers value taste, convenience, and price much more than nutrition, despite

knowing that certain food is not very healthy, many still consume the food because it

provides immediate gratification. Other consumers are reluctant to change their present

eating habits merely to prevent future problems (Frazao & Allshouse, 2003). Other

studies, however, showed that knowledge does, in fact, influence eating habits. A study

was performed by Wardle et al. on a group of 1040 subjects who were 18-75 years of

age. The study assessed and surveyed the participants and determined accordingly the

link between knowledge and application. After careful analysis, the authors were able to

see the correlation between knowledge and healthy eating habits. The participants with

more nutrition knowledge were twenty-five percent more likely to consume sufficient

amounts of fruits and vegetables daily. Another study conducted by the USDA’s

economic Research Service revealed that the mothers’ knowledge about food and

nutrition directly affected their children’s diets. Still another study conducted on an adult

population in the US revealed a direct correlation between cancer-prevention knowledge

and adequate consumption of healthy foods. The more knowledgeable adults consumed

vegetables, fruits, fiber, and fat in amounts closer to the recommended daily values than

the less knowledgeable participants did (Worsley, 2002). Another question is what

factors influence a person’s nutrition knowledge? A study conducted by Chew and

Palmer found that one of the main reasons there are differences in nutrition knowledge is

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because there are differences in nutrition interests among people (Worsley, 2002). For

example, elderly people generally consume more fruits and vegetables than the younger

people do. As people age, they tend to care more about eating healthy since benefits of

healthy eating will be more apparent and noticeable (Frazao et al., 2003). A study

conducted on ninety-seven middle aged women revealed that there was a positive

association between knowledge of fats and consumption of low fat diets. In another

survey of 475 elderly participants, it was found that there was a direct link between

nutrition knowledge and reading of nutrition information panels. Reviews have shown

that children who are educated regarding nutrition have shown a healthier change in their

dietary behavior that lasted for about two years (Worsley, 2002). All these studies reveal

that nutrition interest, which leads to nutrition knowledge does, in fact, influence in some

way eating behaviors and habits.

Adolescent and Nutrition Knowledge

Currently, there is conflicting research about how well nutrition knowledge precipitates

change in healthy lifestyle behaviors. School-based programs have been shown to have a

significant impact on the nutrition knowledge of adolescents. Abood, Black & Coaster

(2008) , conducted an obesity prevention study on 551 teens in 14 schools and found that

nutrition knowledge increased from 64.1% to 71.8% in the experimental group, as

measured by a 22-item multiple choice pre- and post-test. This program also positively

changed adolescents’ behavioral intentions, including maintaining a healthy body weight,

eating fewer fried foods and sweets, reading food labels and limiting television watching.

Reinhardt and Brevard (2002) developed a curriculum that integrated the Food Guide

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Pyramid and the Physical Activity Pyramid in order to promote healthy dietary and

physical activity habits among adolescents. During this 5-week course, 192 students

participated in 18 lessons given during health and physical education classes. Nutrition

knowledge was measured in a 34-question survey and physical activity knowledge was

assessed in a 30-question survey. The study revealed that nutrition knowledge increased

by 17% from pre- to post-assessment while physical activity knowledge increased by

19%. Fahlman, Dake, McCaughtry & Martain, (2008) conducted a pilot study to examine

the effects of a nutrition intervention on nutrition knowledge, behaviors, and efficacy

expectations in 783 middle school students. This quasi-experimental study was conducted

in intact classrooms and consisted of eight lesson plans related to nutrition knowledge,

including the food groups, food pyramid, food labels, advertising, and body image.

The course also contained components sought to target healthy eating patterns, including

increasing consumption of fruits, vegetables, and dairy products. A pre/post-assessment

was comprised of 33 questions relating to a 24-hour food recall, 20 questions determining

nutrition knowledge and 8 questions assessing healthy eating efficacy expectations.

Students in the experimental group demonstrated a significant improvement in post-test

and also scored significantly higher on the post-test compared to students in the control

group. Not only did nutrition knowledge increase, students were also more likely to

report making positive changes to their diet, such as increasing their consumption of

fruits, vegetables, and dairy products. Little information is available regarding nutrition

knowledge and behavior of children and adolescents; however, some studies from other

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populations found that nutrition knowledge is unlikely to affect eating habits (Shepard

and Towler 2007). Parmenter, Wardle, & Waller, (2000) examined individuals 18-75

years old in England, and found that nutrition knowledge was linked to healthy eating,

the more knowledgeable individuals being, the more likely to eat the daily

recommended amounts of fruits and vegetables. Nutrition knowledge significantly

increased in a group of low-income fourth and fifth graders who participated in a 12-

week school wellness program compared to the control group (Tuuri, Zanovec,

Silverman, 2009). The theory-based multi-component program aimed to increase the

knowledge of healthy nutrition practices, encourage fruit and vegetable consumption and

assess the psychosocial variables associated with fruit and vegetable consumption. The

program consisted of an interactive wellness assembly followed by a classroom

curriculum that emphasized consumption of fruits and vegetables. Fifth graders scored

higher than fourth graders on the pre/post test, and there was no difference in scores

between boys and girls.

Furthermore, children who participated in the program also expressed more confidence

that they could eat a fruit instead of a favorite dessert, drink fruit juice and consume the

recommended number of fruit and vegetable servings each day. Overall, the students who

participated in this school-based program demonstrated improved nutrition knowledge

and psychosocial variables associated with consuming fruits and vegetables Nutrition

knowledge scores were significantly lower in low-income boys and girls compared to

higher-income peers. On an eight-item multiple choice test, students were asked to

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identify foods that were high in fat, carbohydrate, dietary fiber and iron as well as choose

snacks, fast-food and home-cooked meal choices with the lowest fat content. Apart from

the nutrition knowledge scores, low-income boys and girls had a significantly higher

BMI than middle-high income boys and girls, respectively. A study by Beech, Rice,

Myers, Johnson & Nickolas (1990) assessed 2,213 high school students’ nutrition-related

knowledge using questions about fruits and vegetables on a 22-item nutrition

questionnaire. The average score on the questionnaire was 39% correct, suggesting low

nutrition knowledge among high school students, which is consistent with earlier studies.

Kolodinsky, Harvely-Berino ,Berlin, Johson, & Reynolds (2007) found that higher

nutrition knowledge translated into better eating behaviors in college students. For each

food group, the more knowledgeable the more healthful food choices they made. When

asked about individual food choices, participants based the decision to choose healthy

foods on their nutrition knowledge.

Nelson, Lytle & Pasch (2009) assessed adolescent and parental knowledge related to

energy intake and expenditure using a 15-item questionnaire. From the 349 adolescent-

caregiver pairs, the mean score on the 15-item questionnaire was 7.5 (±2.6) for

adolescents and 10.7 (±2.5) for caregivers. These results demonstrate poor nutrition and

physical activity knowledge related to energy intake and expenditure among adolescents.

Although the 19 adults possessed higher levels of knowledge, there is still much room for

improvement. Previous studies have revealed that there is a positive association of

adolescent nutrition knowledge with food choices. The study also revealed that parental

86
knowledge was a significant predictor of adolescent knowledge. As more and more

adolescents are becoming obese, they are experiencing diseases, such as metabolic

syndrome, once only seen in adults. Increasing their nutrition knowledge becomes

imperative. Previous research has identified a need for effective educational programs to

help combat this disease. Therefore, this research aims at teaching students the skills

needed to lead a healthy lifestyle, with specific objectives to enhance nutrition

knowledge.

Intervening Variables and nutrition knowledge

Gender and Nutritional Knowledge

Gender has become a contemporary concern to most researchers as gender can have

strong influence on nutritional knowledge and eating behavior. Studies have consistently

shown superiority in nutrition knowledge of females when compared to their male

counterparts. Adler, (2000) submitted that determinants of nutritional practices are those

factors or variables responsible for adoption of the nature of food consumed. Such

variables, in his view include sex, family income, environmental conditions, religious

affiliation, availability of food items, knowledge of food value and cultural significance,

among others. Rodger (1998), in his analysis; the impact of socio-demographic and

attitudes as well as dietary and health knowledge variables on dietary quality indicator

with respect to gender reported that German females had better dietary knowledge than

the males.

A study that focused on sixth, seventh, and eighth grade adolescents in a middle school

was conducted to determine nutritional knowledge based on gender, eating behavior

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based on gender, and the correlation of nutritional knowledge and eating behavior based

on gender. The results showed that there was no significant difference in eating behavior

among the sixth graders based on gender. Differences in eating behaviors, however,

among the seventh and eighth graders were highly significant. Girls tended to be more

knowledgeable and health-conscious than the boys. A possible explanation to this

difference may be that girls tend to become more occupied with their physical appearance

at an earlier stage than boys do of the same age. This, in turn, results in higher nutritional

knowledge and application (Pirouznia, 2001).

Another study was conducted on college female athletes to determine the effectiveness of

a nutrition education intervention on improving dietary intakes .Control and experimental

groups were selected, nutritional knowledge was assessed based on a questionnaire and a

three-day diet analysis was recorded. There was not a significant difference between

results from the experimental and the control group. The experimental group was treated

with an eight-week nutrition education program. The athletes in the experimental group

experienced a significant increase in nutrition knowledge and they reported a significant

increase in confidence regarding choosing healthier foods. This study supported the

significance and efficacy of a nutrition education. The female athletes did in fact,

positively change their eating behaviors (Abood, Black, & Birnbaum, 2004) In another

study which Compares nutrition knowledge between males and females adolescent by

Ruamsup and Charoenchai (2012), it was discovered that females had more food

knowledge than males with statistical significance of 0.01 because female adolescent

were more interested in themselves, fond of dressing and careful with diet. Kiefer,

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Rathmanner,& Kunze 2005; Lynn, 2005 in a study, investigated sex differences in

general knowledge and reported that women’s gained higher scores in nutrition

knowledge in comparison to men’s who gained higher score in sport, finance and science.

He also suggested women’s higher interest in nurturing as a possible explanation for the

observed variation. Nayga (2000) reported that males are less likely to perceive nutrition

as important when food shopping than females. An earlier study also revealed that males

are less likely to use food labels than females (Nayga, 2000).A possible explanation for

this pattern is that females find risk reducing search strategies more useful than males.

However, several studies have alluded to the apparent disparity between the health

behavior of males and females. Another study carried out to evaluate the nutritional

adequacy of student eating habits and to determine the influence of nutrition knowledge,

socio-demographic factors and weight status on students’ diets showed that socio-

demographic variables have an influence on nutrient intake, particularly gender, socio-

economic status and ethnicity. Gender proved to be the most significant socio-

demographic variable, followed by socio-economic status and ethnicity. However, the

strength of the association between ethnicity and nutrient intake was very weak. There

were significant differences in nutritent intake between genders represented by the

sample. Males had a higher-nutrient intake compared with females, particularly in the

intake of the following: plant protein, carbohydrate, dietary fibre and iron intake, as well

requirements for reference values compared with females.

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Socio-Economic Status and Nutritional Knowledge

Socio-Economic Status (SES) is one of many terms used to characterize social

stratification and it is often used synonymously with socio-economic position and social

class (Viswanath & Kathleen, 2007). In general education, occupation, and income are

considered the three main determinants of socio-economic status (Konstantinos,

Vassillors & Demosthenes, 2009). Given that socio-economic status is a multi

dimensional concept, it has been suggested to incorporate different socio-economic

measures to fully comprehend its influence on health. (Konstantinos et. al., 2009).

Socio-economic status (SES) is postulated to be a major predictor of dietary intake and

nutrition-related knowledge in adults, though; very few studies have addressed this effect

among adolescents. Variation in socio-economic status (SES) has been related to the

variation in rates of dietary practice leading to overweight and obesity (Moreno,Tomas,

Gonzalez-Gross,Buueno,Perez-Gonzalez & Bueno, 2004; Kruger et al., 2002). According

to Ferro-Luzzi and Puska (2004), overweight and obesity tend to be highest among low-

income populations in developed countries, and among more affluent people in

developing countries. It has been observed that as economy improve, so is the risk of

becoming obese as a result of improved access to food, decreased physical activity, and

consumption of a ‘Western’ diet. Most studies noted that the consumption of whole

grains was associated with higher SES, whereas the consumption of refined cereals

(white bread), pasta, and rice was associated with lower SES (Larrieu, Letenneur & Berr

2004). Higher SES groups were more likely to consume vegetables and fruit, particularly

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fresh, not only in higher quantities but also in greater variety (Giskes, Turrell, Patterson

& Newman, 2002). A study was carried out to explore differences in nutrient intake and

nutrition-related knowledge among adolescents of contrasting socio-economic status in

Lebanon using 209 males and females students recruited from a private university with

high tuition and a free public university in Beirut. Results showed that although, nutrition

knowledge was high among all participants, it was higher among those in the high socio-

economic status group. Also, nutrient intake analysis showed that adolescents in the high

SES group consume significantly higher amounts of calories, protein, fat, vitamin A, C,

iron and significantly lower amounts of carbohydrates. This shows that socio-economic

status affects good nutrition related knowledge and more significantly affects dietary

intake among these Lebnese adolescents (Nabhani-Zeidan, et al., 2011).

Studies of dietary habits of lower SES groups have emphasized lack of nutrition

knowledge, lack of cooking skills, lack of motivation (Henry, Reimer, Smith & Reicks,

2006), and a general disinterest in cooking . In a study carried out to evaluate the

nutritional adequacy of student eating habits and to determine the influence of nutrition

knowledge, socio-demographic factors and weight status on students’ diets showed that

socio-demographic variables have influence on nutrient intake, particularly gender, socio-

economic status and ethnicity, although gender proved to be the most significant socio-

demographic variable, socio-economic status also influenced nutrients intake. Another

study carried out to assess the effect of gender, age, and socio-economic status on

nutrition knowledge found a significant difference in children’s nutrition knowledge with

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regard to mother’s occupation level, it was found that children whose mothers’

occupational level was “very high”, “high” and “medium” has more nutrition knowledge

as compared to children whose mothers’ occupational level is “very low”, “low” and

“non-categorizable”. Children nutrition knowledge with regard to father’s occupation

level did not differ at baseline however differed significantly at post intervention and

follow-up. A strong association between the socio-economic status and healthy eating

habits has been documented in literature (Convey, 2004). Many studies reveal that

individuals from the higher/middle socio-economic status demonstrate higher nutrition

knowledge, habits and healthy lifestyles as compared to individuals from lower socio-

economic status (Rasanen, 2003; Wardle, Parmenter, 2000).

Body Mass Index and Nutritional Knowledge/Dietary Practices

The body mass index (BMI), or Quetelet index, is a measure of relative weight based on

an individual's mass and height. Body mass index is a simple index of weight for height

that is frequently used in the assessment of nutritional status and is not gender specific

(Zafar ,Haque, Butt ,Mirza Shafig ,Rhman & Ullah, 2007). A low BMI, or underweight

status, is often associated with an increased risk of mortality or serious illness ( Kitamura,

Nakamura, Nishiwaki, Ueno, & Hasegawa 2010) . Conversely, a high BMI, indicative of

overweight or obesity, is associated with an exacerbation in age-related physical and

cognitive decline and with an increased prevalence or risk of many chronic health

conditions common in older adults such as diabetes, hypertension, and cardiovascular

disease. BMI provides a simple numeric measure of a person's thickness or thinness,

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allowing health professionals to discuss weight problems more objectively with their

patients.  The BMI trait is influenced by both genetic and no genetic factors, thus

provides a paradigm to understand and estimate the risk factors for health problems

(Fareed & Afzal, 2014 ) During adolescence, hormonal changes lead to accelerated

growth, which is faster than at any other time in postnatal development, except for the

first year of life (WHO, 2000). Concern over adolescent obesity has mounted due to its

rapid increase in prevalence, its persistence into adulthood, and its associated morbidity

and mortality. Numerous studies have shown that there is relationship between body

weight and eating behaviour and cultural and socioeconomic factors also play an

important role in the development of eating behaviour (Rampersaud, 2005; Tanofsky-

Kraff, 2006). BMI categorizes individuals as underweight (<18.5 kg/m2), normal weight

(18.5 to 24.9 kg/m2), overweight (25.0 to 29.9 kg/m2) and obese (≥ 30.0 kg/m2)

(Laquatra, 2004). BMI of 20 to 25 kg/m2 is associated with the least risk of early deaths.

The BMI values, however, are most accurate in assessing degrees of obesity and are less

useful for evaluating non obese body fatness (Smolin & Grosvenor, 2008). Studies have

revealed that there is no significant correlation between nutrition knowledge and BMI

(Briens & Dans 2007). In their study it was indicated that obsessed individual and those

of healthy weight had comparable level of nutrition knowledge, suggestive that there may

be other reasons other than poor nutrition knowledge that accounts for higher BMI. Other

researchers such as Santamaris, Vazquez, Caballero & Rodriquez (2009), have shown

that there is association between eating habits of the adolescent and their BMI in their

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study, Eating habits and attitudes and their relationship with Body Mass Index (BMI),

revealed a positive and significant relationship with BMI in the overweight subjects.

 Dietary/Eating Practices of the adolescent

Eating practices refer to dietary intake which includes information about usual daily food

intake, eating pattern and usual nutrient intake (Hammond, 2000). Aspects of eating

practices that will be discussed include; usual food intake, frequency of food

consumption, and guidelines for good eating practices.

Usual Food Intake

Usual food intake refers to normal, customary or typical food consumption or practice.

These practices can either be good or bad. Good eating practices are those that encourage

the consumption of a healthy and nutritious diet that provides the right amount of energy

to keep the weight in the desirable range, the proper types and balance of carbohydrates,

proteins, fats, plenty of water, and sufficient but not excessive amounts of essential

vitamins and minerals (Smolin & Grosvenor 2008). According to Whitney, Debruyene,

Pianna & Rolfes (2007), eating practices that supply all the nutrients required in life can

be achieved through the six basic diet-planning principles which include: adequacy,

balance, energy control, nutrient density, moderation and variety. On the other hand,

wrong eating practices are those that do not encourage consumption of a healthy and

nutritious diet that provides the right amount of energy to keep the weight in the desirable

range, the proper types and balance of carbohydrates, proteins; and fats, plenty of water,

and sufficient but not excessive amounts of essential vitamins and minerals (Smolin et

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al., 2008). Wrong eating practices do not encourage the balance and moderation of food

and nutrients consumed (Whitney et al., 2007).

Frequency of Food Consumption

Frequency of food consumption includes a daily meal pattern such as skipping of meals

and how often a given food is consumed (Piper, 1996). According to Triches & Giugliani

(2005) skipping of meals and how often a food is consumed can influence body weight.

A study conducted on primary school children showed that not eating breakfast in the

morning as well as a low frequency of milk, fruit and vegetable consumption, were the

practices associated with increased body weight and obesity among this group (Triches et

al., 2005). According to Dryden (2005), eating habits that contributed to weight gain in

college students included carbohydrates based not enough of fruit for proper metabolism

of nutrients eating less than five servings of fruit and vegetables per day.

Energy and Nutrients Intake

Energy and nutrient intake come from the food consumed (Whitney et al., 2007). The

nutrients are divided into two groups: the energy yielding nutrients (e.g. carbohydrates,

lipids, proteins) and the non-energy yielding nutrients (e.g. vitamins, minerals) (Ettinger,

2004). Energy producing foods are used in the body to fuel all its activities. If however

more energy is consumed than needed, it is immediately stored as fat (Whitney et al.,

2007). The stored fat provides energy when dietary sources are not available. If more

energy is consumed than is needed, the storage capacity of the body becomes larger, and

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the body weight increases. If less energy is consumed than needed, the body will burn its

stored energy to meet the energy demands, and the body weight will be decreased.

Guidelines for Good Eating Practices

Guidelines for good eating practices for healthy individuals include nutrient based

guideline e.g. dietary reference intakes (DRI’s) and food based dietary guidelines e.g.

food guide pyramids (Escott-Stump & Earl, 2008), food groups and the South African

food based dietary guidelines (SAFBDG) (Gibney & Voster, 2001). These guidelines

point out recommendations for good eating practices to supply energy, nutrients, and

other dietary components that best support good health. Most countries have developed

different tools/guidelines for good eating practices appropriate to circumstances and

needs of their population. These guidelines are often based on the American DRI’s. For

the purpose of this study, the DRI’s, food guide pyramid are discussed.

Dietary Reference Intakes (DRIs)

The DRI’s are a set of values for the dietary nutrient intake of healthy people in the

United States and Canada (Escott-Stump et al., 2008). These values are used for planning

and assessing diets for healthy people. A DRI model has expanded out of the previous

recommended dietary allowance (RDA) which focused only on levels of nutrients for

healthy populations to prevent deficiency diseases, by including four levels and nutrient

recommendations for healthy individuals. Levels of DRI are discussed, as well as the

recommendations.

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i) Levels of the DRI’s

DRI encompasses four types of nutrient levels for healthy individuals: adequate intake

(AI), estimated average requirements (EAR), recommended dietary allowance (RDA),

and tolerable upper intake level (UL).

(a) Adequate Intake (AI)

The AI is a recommended daily nutrient intake level based on observable or

experimentally determined approximations of nutrient intakes by a group or groups of

healthy people. These nutrient intakes are used when sufficient scientific evidence is not

available to calculate a recommended dietary allowance (RDA) or estimated average

requirement (EAR) (Whitney et al., 2007).

(b) Estimated Average Requirements (EAR)

EAR is an average requirement of a nutrient for healthy individuals on which a functional

or clinical assessment has been conducted and on which measures of adequacy have been

made at a specified level of dietary intake (Escott-Stump et al., 2008) An EAR is the

amount of intake of a nutrient at which one half of the experimental subjects would have

their needs met and one half would not. The EAR is used for assessing and making

recommendations for nutrient adequacy of a population and not individuals.

(c) Recommended Dietary Allowance (RDA)

The RDA is the amount of nutrient needed to meet the requirements of 97 to 98 % of a

healthy population of individuals for whom it is developed. According to Escott-Stump

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and Earl (2008), the RDA for a nutrient should serve as a goal for intake for individuals,

not as a benchmark of adequacy of diets of populations.

(d) Tolerable Upper Intake Level (UL)

The UL is the highest level of daily nutrient intake that is unlikely to have any adverse

health effects on almost all individuals in the general population, who consume that

amount (Escott-Stump et al., 2008). The ULs do not reflect the desired levels of intake;

rather, they represent total, daily nutrient intake from food, fortified foods, and

supplements that should not be exceeded (Brown, 2005). ULs have been established for

nutrients for which adequate data are available to reduce the risk of adverse or toxic

effects from increased consumption of nutrients in a concentrated form, either alone or

combined with others (not in food) or from enrichment and fortification.

ii) Recommended energy and Nutrient Intakes According to the DRI’s

Recommendations for energy and nutrient intakes according to DRI are specific for

gender, various ages, stage in life, and pregnant and lactating women (Escott-Stump and

Earl, 2008) (Table 1). The recommendations are made for nutrient intakes and guide to

people on the amount of energy and macro and micro nutrients to consume

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Table 1: Recommended Energy and Nutrient intake for Adolescents
Females Males
9-13 yrs 14-18 yrs 9-13 yrs 14-18 yrs
Energy (kcals/day) 2,071 2,368 2,279 3,152
Carbohydrate (g/day) 130 130 130 130
Total Fiber (g/day) 26 28 31 38
n-6 Polyunsaturated fat
(g/day) 10 11 12 16
n-3 Polyunsaturated Fat
(g/day) 1.0 1.1 1.2 1.6
Protein (g/day) 34 46 34 52
Vitamins
Vitamin A ( μg/d) 600 700 600 900
Vitamin C (mg/d) 45 65 45 75
Vitamin D ( μg/d) 5 5 5 5
Vitamin E (mg/d) 11 15 11 15
Vitamin K ( μg/d) 60 75 60 75
Thiamin (mg/d) 0.9 1.0 0.9 1.2
Riboflavin (mg/d) 0.9 1.0 0.9 1.3
Niacin (mg/d)f 12 14 12 16
Vitamin B6 (mg/d) 1.0 1.2 1 1.3
Folate ( μg/d)9 300 400 300 400
Vitamin B12 ( μg/d) 1.8 2.4 1.8 2.4
Pantothenic acid (mg/d) 4 5 4 5
Biotin ( μg/d) 20 25 20 25
Choline (mg/d) 375 400 375 550
Elements
Calcium (mg/d) 1,300 1,300 1,300 1,300
Chromium ( μg/d) 21 24 25 35
μ
Copper ( g/d) 700 890 700 890
Fluoride (mg/d) 2 3 2 3
μ
Iodine ( g/d) 120 150 120 150
Iron (mg/d) 8 15 8 11
Magnesium (mg/d) 240 360 240 410
Manganese (mg/d) 1.6 1.6 1.9 2.2
Molybdenum ( μg/d) 34 43 34 43
Phosphorus (mg/d) 1,250 1,250 1,250 1,250
Selenium ( μg/d) 40 55 40 55
Zinc (mg/d) 8 9 8 11

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Food Guide Pyramid

Food guide pyramid (Figure 7) translates dietary guidelines of nutrient recommendations

into visual form of the kinds and amounts of food to eat each day (Earl, 2004). The food

guide pyramid was developed based on nutritional problems, food supplies, eating habits

and cultural beliefs of the American population. The aim of the food guide pyramid was

(and still is) to promote good health and reduce the risk of chronic diseases, such as, heart

disease, certain types of cancer, diabetes and stroke (Escott-Stump and Earl, 2008). The

food guide pyramid is built around five main food groups (e.g., grains, vegetables, fruits,

milks, meats and beans), with recommended daily amounts, and with grains at the base.

Food pyramid conveys a message that grains should be abundant and form the foundation

of a healthy diet. Fruit and vegetables share the next level of the pyramid, indicating that

they too should have a prominent place in the diet. Meats and milks appear in a smaller

section near the top meaning that a few servings of each can provide valuable nutrients.

Fats, oils, and sweets occupy the part at the top of the pyramid, indicating that they

should be consumed sparingly and only after basic nutrient needs have been met by

foundation foods. An advantage of the food guide pyramid is that the recommended

number of portions from each food group is indicated which makes this food guide

pyramid a suitable tool for the evaluation of food intake of individuals and groups of

individuals.

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 Figure

6: Food guide pyramid adapted from Cataldo et al (2003)

Food Groups

Food groups is a diet planning tool that sorts foods of similar origin and nutrient content

into groups and then specifies that people should eat a certain numbers of servings from

each group (Cataldo, Debruyne & Whitney, 2003). Food groups assign foods into five

major groups: (1) fruit, (2) vegetables, (3) grains, (4) meat, poultry, fish, legumes, eggs

and nuts, (5) milk, yoghurt and cheese. Food groups also indicate the most noticeable

nutrient of each food group and lists foods within each group sorted by nutrient density.

Food groups also include a Food Guide Pyramid, the eatwell plate which presents the

daily food guide in pictorial form.

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Eat well Plate
The Eatwell Plate is a pictorial summary of the main food groups and their recommended

proportions for a nutritious diet. Eating these types of foods in the proportions shown will

make sure you get the right balance of vitamins (like vitamin C) and minerals (like iron

and calcium). (Wikipedia, 2013) It comes in versions for both men and women, making it

easy for you to control your portion sizes and make better food choices, supporting a

healthy heart and guilt-free meal times. The eatwell plate is based on the five food

groups:

 bread, rice, potatoes, pasta and other starchy foods

 fruit and vegetables

 milk and dairy foods

 meat, fish, eggs, beans and other non-dairy sources of protein

 foods and drinks high in fat and/or sugar

Eat well Plate

Figure 7: Eat well plate as guide102

to a nutritious diet
Guidelines for planning, implementing and evaluation of public health nutrition

Ten guidelines used as a basis for planning, implementing and evaluation of public health

nutrition strategies.

(a) Enjoy variety of foods

Enjoy a variety of foods means including in the diet, grains, vegetables, fruit, meat and

dairy products. Some of the foods listed herein are rich in protein, minerals and

photochemical which are important for good health. A variety of foods means dietary

diversity which involves choosing many different foods from within each food group.

Enjoying a variety of foods will help ensure adequate nutrient intake. Not one food can

provide all the nutrients the body needs for optimum health.

(b) Be active

Be active means physical activities. Physical activity is needed in order to maintain or

improve body weight. Being overweight and gaining weight as an adult are linked to high

blood pressure, heart disease, stroke, diabetes, certain cancer and other illnesses (WHO,

2004). The food eaten should balance the physical activity for good health.

(c) Make starchy foods the basis of most meals

Make starch foods the basis of most meals means, the highest portion of food consumed

per day should come from starchy foods. Starchy foods are usually low in fat, high in

complex carbohydrates and provide the body with an economical source of energy.

(d) Eat plenty of fruit and vegetables every day

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Eat plenty of fruit and vegetables every day means consumption of a variety of fruit and

vegetables daily. Fruits and vegetables contain a wealth of vitamins and minerals as well

as fiber and photochemical that protects the body against diseases.

(e) Eat plenty of beans, peas, lentils and soy regularly

Beans, peas, lentils and soy (legumes) are rich in protein and an economical dietary

source of carbohydrates, fiber, and variety of minerals and vitamins. Legumes are also

low in fat and can help to protect against diseases.

(f) Meat, fish, chicken, milk and eggs can be eaten every day

Meat, fish, chicken, milk and eggs are foods of animal origin. Foods of animal origin

provide nutrients to the diet; but over consumption can increase the risk of various

diseases, due to the high fat content.

(g) Eat fat sparingly

Eat fat sparingly means, fat should be consumed in moderation. A high fat intake is

associated with heart diseases, obesity and certain types of cancer.

(h) Eat salt sparingly

Eat salt sparingly means, salt should be taken in moderation. High intake of salt is

associated with a rise in blood pressure, especially in salt sensitive individuals

(i) Drink lots of clean water

The body is largely made up of water and good hydration is crucial for optimal body

functions (Smolin et al., 2008). Fluids could be replaced by tea, coffee, cool drinks, but

two to three litres or 8 to12 glasses of pure water are recommended per day.

(j) If you drink alcohol, drink sensibly

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Drinking alcohol sensibly means, consuming alcohol in moderation. Alcoholic beverages

supply energy, but no nutrients. Alcohol alters judgment and can lead to dependency and

other health problems, including liver disease and birth defects. A responsible intake of

alcohol is regarded as 0 to 2 portions of alcohol per day, where one portion equals one

beer or one glass of wine (Whitney et al., 2007).

Dietary Assessment

Dietary assessment estimates food consumption or nutrient intake in individuals or

groups of people (Nelson, 2000). Reasons for conducting dietary assessment may vary

widely. For example, one may collect dietary intakes data, to screen, assess, evaluate, and

plan interventions or monitor dietary intakes or nutritional status of individuals, groups or

nations (Dwyer, 1998). However, dietary assessment usually relates to the need to

understand the effects of diet on health (Nelson, 2000). Dietary assessment organizes and

evaluates the information gathered to make a professional judgment about nutritional

status of both individual and group. Once the dietary assessment is complete, the

nutritional care plan can then be developed, implemented and tailored for appropriate

setting. Accurate measurement of an individual’s food intake is the most difficult aspect

of evaluating nutritional status. This task is compounded by weaknesses in data-gathering

techniques: human behaviour, natural tendency of individual’s nutrient intake (which

varies considerably from day to day), and limitations of nutrient composition tables and

data bases (Lee & Nieman, 2003). Despite these weaknesses, food intake data are

valuable in assessing the nutritional status of an individual when used in conjunction with

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anthropometric, biochemical, and clinical data (Lee et al., 2003). Before undertaking a

dietary assessment, it is important to consider the exact purpose for the assessment; what

is to be measured, in whom, over what time period, and how measurements are to be

collected. This will help to determine the most appropriate technique for the given

purpose and avoid using a technique that does not provide an appropriate measure

(Nelson, 2000).

Two main approaches used to assess an individual’s dietary intake include a prospective

approach and a retrospective approach. A prospective approach requires collecting

current dietary data, using food records which are kept for a number of days (Nelson,

2000). The main advantage of the prospective approach is that it provides a direct

measure of a currently consumed diet. The approach may be carried out over a length of

time, depending on the level of accuracy in estimating the food consumption or nutrient

intake needed at individual level.

The retrospective approach of dietary assessment requires that subjects recall their recent

or past diets (Nelson, 2000). A retrospective approach includes dietary assessment

methods, such as the Food Frequency Questionnaire (FFQ) as well as 24–hour recall

(Gibson, 1998; Dwyer, 1998). These two dietary assessment methods may involve

remembering the type and amount of all food items consumed over a specified period of

time, as well as recollecting the frequency of consumption of a specific food or food

groups. Retrospective methods are quick to administer compared to prospective methods.

Retrospective methods are also inexpensive in terms of equipment and the time taken to

106
interview the subjects; there is a low respondent burden required compared to prospective

methods; hence the chances of obtaining a representative sample are increased (Nelson,

2000). Several methods can be used to assess dietary intake. Both the 24-hour recall and

the food frequency questionnaire are quick, easy to administer, and relatively inexpensive

which make them suitable for dietary assessment of groups of individuals.

The 24-hour recall

The 24-hour recall is a method of dietary assessment in which an individual is asked to

remember, in detail, all the foods and drinks consumed during the period of time in the

recent past (Lee et al, 2003). In most cases, the period of recall consists of the previous

24 hours (Hammond, 2004). The 24-hour recall can be obtained in a single or multiple

occasions (Dwyer, 1999). In this method the interviewer assists the respondent to recall

the types of foods and drinks consumed in each meal as well as to estimate portion size.

After the interview, the recall is checked for omission and/or mistakes. The 24-hour

recall is probably the most widely used method for obtaining information on food intake

from individuals. The 24-hour recall is used to determine dietary intake of large

populations (> 50 people). The information gathered from a 24- hour recall is primarily

used to determine the trends of eating patterns.

Advantages

The 24-hour recall method is considered quick and easy (Lee et al 2007; Nelson, 2000;

Hammond, 2000) and a relatively inexpensive method of data collection regarding food

107
consumption (Dwyer, 1998). With a 24-hour recall a subject’s motivation is less of a

barrier, and compliance is good (Nelson, 2000), no long term memory is required. It can

be used to estimate nutrient intakes of food groups. It is an objective method and the

respondent does not alter the usual diet (Lee et al., 1996; Dwyer, 1998). The data

obtained by a 24-hour recall can be repeated with reasonable accuracy, and good

reliability exists between interviewers (Dwyer, 1998).

Disadvantages

The 24-hour recall method of data collection is associated with some problems,

including, (1) inability to recall the kinds and amounts of food eaten; (2) difficulty in

determining whether the day being recalled represents the individual’s typical intake; (3)

the tendency for a person to over-report low intakes and under-report high intakes of

foods. A cross-check of concurrent use of food frequency and 24-hour recall

questionnaires is recommended to improve the accuracy of the data obtained (Hammond,

2004). Lack of knowledge of portion size may create problems. The method does not

reflect differences in intake for weekend versus weekday, season to season, or shift to

shift (Dwyer, 1998). A single 24-hour recall therefore does not represent usual intake,

however according to Gibson (2005) repeated 24 hour recalls, repeated on

nonconsecutive days and/or seasons could be used to establish usual intake of groups of

individuals.

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Review of Related Empirical Studies

Intervention education (nutrition education) has shown to increase nutrition knowledge

and dietary practices among the adolescent using school environment. This has been

proved in empirical studies done by some researchers. Nutrition education intervention

improves nutrition knowledge.

Shariff, Bukhari, Othman, Hashim, Ismail, Jamil, Kasim, Paim, Samah & Hussein

(2008), in their study, evaluated the changes in knowledge, attitude and practices of

primary school children in Malaysia after a nutrition education intervention for 6 weeks,

a sample of 335 students were used for both the experimental group and comparison

group. A generalized linear univaraite procedure was used to compare changes. Findings

shows a significant increments (p<0.01) in the post intervention mean scores of

knowledge (2.17 vs 0. 47), attitude (1.40 vs 0.32) and practice (0.87 vs -0.10) items for

the intervention group compared to comparison group. The changes in knowledge

(F=17.72, P<0.001), attitude (F=6.41, P<0.05) and practice (F=15.49, P<0.001) in the

intervention group were maintained even after adjusting for confounding factors. They

concluded that nutrition knowledge is integral to the achievement of healthful dietary

behaviors and consequently in the improvement of diet quality. Findings from the above

study helped the choice of the research design.

Choi, Shin ,Jung, Park, Lee & Song (2008) in a study, nutrition knowledge and dietary

behavior of school children in Seoul, with a population of 439, ( male 236, female 203) a

109
questionnaire was used to determine students’ nutrition knowledge and dietary

behaviour in both male and female. The average score of nutrition knowledge, nutrition

attitude and dietary bahaviour was 6.8, 7.44 and 7.34 respectively. Dietary behavior of

male subjects was positively correlated with Parents education level, monthly household

income, and nutrition attitude, while Dietary behavior of female subjects was positively

correlated with monthly household income, nutrition knowledge and nutrition attitude,

They conclude that proper nutrition education and intervention are required for the

improvement of school children nutrition knowledge, nutrition attitude and dietary

behavoiurs. Attitudes towards healthy eating pattern have their roots in adolescence or

younger adulthood. The above study helped in the choice of the variables and

instrumentation for the present study.

Abelyen (2003) evaluated the impact of a nutrition course on dietary practices and

nutritional concerns among Medical college students in Armenia. A non equivalent

control group design was used on a population of 228 respondents (114 interventions and

114 comparison group). A post- measure was conducted six months after the pre-test.

Independent samples t test and chi-square analysis were used for between group analysis

and paired samples t-test for within group analyses. Findings show that there was

significant decrease in consumption of chocolate, candy, cake and butter for participants

in intervention group. Both intervention and comparison groups reported an increase in

serving of fruits and vegetable, groups defined by the food guild pyramid. Significantly

higher number of intervention students at post-test reported they have changed their

110
dietary habits due to nutritional knowledge. In conclusion, the study demonstrated that

nutrition education appears to be a predictive of dietary change. Findings from the above

study informed the choice of statistical tool used for the present study.

Eboh & Boye (2006) investigated the effect of a 3-week school based nutrition education

programme on nutrition knowledge and food choices of primary school pupils in the

Niger Delta region of Nigeria. One hundred and ninety seven (197) respondent were

randomly selected and divided into a control (n-102) and an experimental group (n=95).

The control group had no nutrition education intervention, while the experimental group

received 40 minutes of nutrition education 4 days a week for 3 weeks. Nutrition

knowledge scores and 3 day food records were collected at the beginning of the study and

after 3 weeks. Food records were used to evaluate healthy food choices (Dietary

guideline recommended intake for macronutrients and, the food guide pyramid for each

group). Findings shows that there was significant greater increase in nutrition knowledge

score (P=0.001) and significant change in compliance in meeting the dietary guidelines

p=0.0001), study showed the effectiveness of a nutrition education programme on

nutrition knowledge scores and healthy food choice. They recommended integration of

nutrition education into the primary school curriculum through structured and

unstructured instructional methods of educating pupils about healthy eating. The above

study helped in the choice of the treatment package for this study.

Barzegari, Ebrahimi, Azizi & Ranjbar (2011), in their study, examined the nutrition

knowledge, Attitudes and food habits of college students in Iran using a sample size of

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415 students randomly selected. A standard questionnaire adapted from Parmenter k and

Wardle J (1999) was used to measure the students’ nutrition knowledge, attitude and food

habits. The t-test, one-way ANOVA and Pearson correlation co-efficient (P<.0.05) was

used to analyze the data collected. Findings show that nutrition knowledge scores in

physical education student were highest and in business management student were

lowest. There was no significant difference among nutrition knowledge of all majors and

between genders. However there was significant positive correlation between nutrition

knowledge and attitudes, nutrition attitude and food habits of male and female students.

They concluded that more attention be given to college curricula and improvement of the

learning environment, related to nutrition need to be emphasized on college campuses.

The finding from the study guided the utilizations of statistical tools employed in the

study and in the adaption of instrumentation of the study.

Meti & Saraswathe (2007), investigated the impact of Nutrition Intervention programme

on performance of High school kabaddi players, using 24 respondents, and divided into

two groups as control and experimental groups. Pre-test was given to the two groups

before the intervention and the experimental groups received nutrition education for 12

contact hours. Findings from the study revealed that overall nutrition knowledge level

increased significantly by 35% practice by 13%. They recommended that further studies

should be conducted to standardize the technique for evaluation sports performance in

relation to nutrition and other environmental factors.

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Fahlman, Dake, McCaughtry & Martin (2008) in a pilot study examined the effects of a

nutrition intervention on Nutrition knowledge, behavoiur and efficacy expectations in

middle school children. The participants for this study were divided into an intervention

group (n=407) and a control group (n=169). A valid and reliable questionnaire was used

to determine pre-post differences, assessing eating habits, nutrition knowledge and

efficacy expectations towards healthy eating. Analyses of variances were used in the

analysis of data. Findings indicate that the intervention group increased in nutrition

knowledge at post. There was also a significant main effect on groups in the subscales.

Subsequent post hoc analysis revealed that the intervention group was significant more

likely to eat fruits and vegetable and less likely to eat junk food than the control groups.

They concluded that there is significant positive changes in both nutrition knowledge and

behaviours in middle school children and suggested that further research needs to be

conducted to determine the long-term impact. This study helped in the choice of the

design and statistical tool used for the study.

Schinders (2011) in her study, the effect of nutrition education on children’s healthy food

choices was conducted in two different schools with children. Sample size of 58 (n=28)

received intervention about healthy eating, while children at the other school (n=30)

received the healthy information, findings indicates that healthy knowledge increased as a

result of the nutrition education The study however recommended that while providing

children with nutritional information to increase their knowledge about healthy eating,

their willingness to consume healthy foods is enhanced by exposure to fruits and

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vegetables. Nutrition information is important for everyone in order to get healthy life

style and free from any diseases. This findings helped in the design of the study.

Roszanadis & Norazmir (2011) in their study, knowledge, attitude and practices on

healthy eating among special needs, boarding School students, investigated the

effectiveness of the nutrition programme among special needs students aged 13-17 years.

Sample size was eighty (80) students divided as intervention (Visual impaired) and

control group (hearing impaired.) Pre and post test questionnaire was distributed amongst

the two groups and a nutrition programme implemented to the intervention group.

Findings show that a significant improvement in student nutrition scores among

intervention group before (36.30±4.78) and after (36.55 ± 3.34) attending the nutrition

education programme (t= - 4.03, df = 39, P<0.05). Improvement in attitude scores also

seen when intervention group decreased significantly (t=2,4, df = 39, p<0.05) from 18.55

(±4.17) to 17.03 (±2.79). However, for practice scores in intervention and control group

shows no significant changes. They concluded that, nutrition education may help to give

positive impact to the special needs students in healthy eating lifestyle. The study

informed the procedure for the treatment package.

All people have the right to be free from hunger and malnutrition. Walsh, Dannhauser &

Joubert (2002) in their study, evaluated the impact of a nutritional education programme

on the anthropometric nutritional status of low-income children is South Africa. Four

study areas in free state and Northern Cape Provinces were used, two control areas were

included to differentiate between the effect of the education programme and a food aid

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programme that were implemented simultaneous. Sample size was 536 initially and 815

after two year of intervention. Weight-for-age and weight for height were summarizes

using standard deviation. Findings show that weight-for-age improved in all areas, but

not significantly in boys and girls in urban study areas and in boys in one rural area. No

significant improvement in height-for-age occurred in any area. Weight-per-height

improved significantly in the urban study area. In conclusion, the study reveals that

education programme in combination with food aid succeeded in improving the weight

status of children, but was unable to facilities catch-up growth in stunted children after

two years of intervention. This study helped in creating a friendly environment for all

respondents.

Kelishadi, Soghrati, Mohammadzadeh, Najafpour, Arasteh & Ahangar-Nazari (2006) in a

study Can Education through poster, improve the knowledge and practice of pre-schools

about healthy lifestyles. Two hundred and fifty students (250) were selected for the study

via 2-stage random cluster sampling, healthy lifestyle via educational posters was taught

to them. This knowledge on healthy life style was assessed 1 week before intervention

and 3 months after intervention. Collected data were analyzed using SPSS 13 by paired t-

test and Man-Whitning test. Findings show that there was improvement significantly, one

week after intervention compared with baseline, and persisted until the third month after

education intervention. They concluded that the healthy life style education via poster for

pre-school children can significantly improve their knowledge and practice towards

healthy lifestyle and recommended that such intervention must be continued by other

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researchers. The findings of this study informed the use of pictures as a strategy in

improving nutrition knowledge.

Kostanjevec, Jerman & Koch (2011) in their study, the effect of nutrition education on 6th

graders knowledge of nutrition in nine-year primary school, in Slovenia, examined the

effectiveness of nutrition education of 6th graders where Home economics is taught as a

compulsory subject, using 630 pupils from 28 Slovenia primary school. Nutrition

knowledge was tested at the beginning and at the end of the school year, findings show

that nutrition knowledge of the students improved significantly. Data collected was

analysed using the Mean, Standard deviation, Pearson correlation co-efficient,

independent t-test, and one-way Anova. They recommended that nutrition education

should be adopted to the cognitive level of student and later reinforced with

interdisciplinary and constructivist approach.

Anderson, Stanberry, Blackwell & Davidson (2001) studied the effectiveness of nutrition

instruction on student nutrition knowledge and food choices, a quasi experimental study,

where 118 high school students whose age range was between 14 – 18 years. Twenty-five

subjects were in the control group while 93 were in the experimental group. Pre and post

test design was used to determine the effects of fourteen hours of nutrition instruction on

nutrition knowledge and food selection of high school students. Nutrition knowledge was

measured by a 57-items test. Data collected was analyzed using mean and standard

deviation. Findings indicated that student who received instruction in nutrition scored

significantly higher in nutrition knowledge post test than student who did not received the

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instruction, they concluded that nutrition education can improve knowledge of nutrition,

and recommended that, nutrition curriculum must incorporate instruction as well

motivate behavoiur change so that student make an informed and reflective decisions to

act. Findings revealed among other things that treatment significantly affected

participants in this study. This study helped in the choice of research design for the study.

Shirk (2009) in her study; A school based intervention increased nutrition knowledge in

High school students. Eighty two (82) high school student ages 13-18, participated in the

research. The educational intervention focused on physical activity, and nutrition

education. Pre and post test in nutrition knowledge was given before and after three (3)

weeks pilot course. Findings revealed that overall intervention knowledge significantly

increased over the 3-weekd pilot course, conclusion reached by her is that a school-based

nutrition education program is an effective approach to develop an understanding of

healthy life style bahavoiur in adolescent. She recommended, that future researcher

should assess the changes in behavior resulting from such education. This was useful in

the choice of respondent for the study.

Shittu (2011) in her study the role of nutrition education in promoting family health was

investigated. The survey design was used for this study with sample size of 105

respondents. A fifteen items questionnaire was used to collect data and analyzed using

percentage mean and standard deviation; findings show that nutrition education is an

important tool for developing and maintaining a state of health that is optional for family

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members. It thus recommended that funds should be made available by the government to

run the nutrition education programme at all levels.

Harrabi, Maatouq, Gaha, Kebail, Gaha, & Ghannam (2010), in their study school-based

intervention to promote Healthy lifestyle in Sousse Tunisia. Pre-test & post-test quasi

experimental design with a control group was used. Four secondary schools in Sousse,

Tunisia was randomly selected, two for the experiment and two for the control group.

The sample size was 3,702 students. Selection of school was based on age, socio

economic and demographic characteristics. The experimental group was subjected to

classroom –based cardiovascular diseases risk factor prevention curriculum, while the

control group received no intervention. One month before the intervention began and a

month after it ended, the intervention group and the control group were tested so that

effects of the intervention could be ascertained. Findings from the study revealed that

nutrition knowledge, bahaviour and intentions improved in both groups between baseline

and final stage, particularly in the intervention group. They concluded that the study

demonstrated the potential of school as a suitable setting for the promotion of healthy life

styles in children. The study helped in the choice of the design, procedure for treatment

and number of schools used in the study

Sharma (2007), in a study of the impact of nutrition education on school-going

adolescents of Bangalore Urban, evaluated the efficacy of school-based nutritional

education on their nutritional knowledge and behavior of 209 adolescents from two(2)

high schools of Bangalore Urban. Data was collected, using 24 hr recall method for 7

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consecutive days, a pre-test nutrition knowledge was administered before nutrition

education was imparted and afterward, a post-test was given. Findings indicated that

Nutrition Education improved student’s mean scores significantly from 11.89 ± 1.74 to

14.85 ± 2.32. He concluded that Nutrition Education is an effective measure to being

about the favorable and significant change in adolescent nutrient intake. This study

helped in the choice of using the 24 hr recall for dietary practices and a pre-test nutrition

knowledge questionnaire.

Walsh, Dannhauser, & Joubert (2003), in a study, Impact of nutrition education

programme on nutrition knowledge and dietary practices of lower socio-economic

communities in the Free State and Northern Cape. A nutrition education and food aid

programme was implemented for 2 years in one urban and three rural areas. Two rural

areas were used as control where food was given but no nutrition education. All 608

respondents were used. A structured questionnaire was used to measure nutrition

knowledge and dietary practice. Findings revealed that knowledge of what to eat daily to

remain healthy improved significantly. They therefore concluded that a community-based

nutrition education programme can contribute to knowledge of balanced, economical

nutrition and dietary practices in low income communities. The findings of this study

helped in the choice of the variables of the study.

Silverman (2000) in a study, evaluating the effects of multi-component school-based

nutrition intervention program in Elementary school students in Louisiana, a sample of

641 students were used as the sample size for this study. A survey design based on the
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social cognitive theory was used to evaluate nutrition knowledge, fruits and vegetables

consumption before and after the intervention.

A factorial analysis was used to determine the number and nature of underlying factors

affecting the relationship each sector of variables. ANOVA was also used to determine

the relationship between knowledge and other factors. Findings showed that there was an

increase in nutrition knowledge in children who participated in the curriculum (p = 0.07)

and therefore recommended that multi-component school-based nutrition intervention

program may increase fruit and vegetable intakes and improve self-efficacy to consume

fruits and vegetables. The study helped in the choice of the theoretical framework of the

study and in selection of the statistical tools used in the study.

Thus, from the findings of the reviewed related empirical studies, many studies have been

carried out on nutrition education, but no literature was found on pictorial nutrition

education in Edo South Senatorial district, this obvious gap the researcher filled.

Summary of Reviewed Literature

The studies reviewed have shown that Nutrition Education intervention has positive

impact on nutrition knowledge, attitude, and practices of both primary and secondary

schools children. Poor knowledge of nutrition is a key factor involved in the development

of malnutrition and should be addressed as soon as possible. Dietary habits in childhood

have an impact on growth, development and the prevalence of disease throughout the life

cycle. Hence, healthful eating behaviors should be formed early in life and continue

throughout life. Nutrition knowledge is sine qua non in the life of all individuals, the

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knowledge of good nutrition and its application would assist in forming healthful eating

habits.

However, majority of the studies was not based on learning theories and innovative

approach in teaching nutrition knowledge unlike this study that is based on the social

learning theory and at the same time using the Pictorial nutrition education packages as a

new approach. A sufficient implementation period of nutrition intervention is required to

achieve changes in children’s nutrition knowledge, dietary practices and habits. Majority

of the studies reviewed had implementation period of between 5 to 13 weeks, whereas,

studies who had longer periods of implementations of nutrition intervention for 2 years

had consistently reported better behavioral outcomes.

Successful nutrition intervention should include content and teaching strategies that are

developmentally appropriate for the children and address changes in the environment.

Besides the traditional classroom-based teaching mostly adopted by studies reviewed,

other activities such as group discussion or interaction session on nutrition topics, video

presentations, display of nutrition posters, handbook or nutrition can also be developed

and used as it is done in this study.

Schools as indicated by studies reviewed, have also proved to be an effective and

efficient medium to influence the health of school children, in that the school system

have a high penetration rate due to the number of children attending school. It also

provides a formal and informal environment for learning and utilizing classroom teaching

approaches. Some studies investigated nutrition knowledge using schools in urban

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setting, very few studies, who used rural school setting indicated that the level of

nutritional knowledge was significantly higher in students in urban setting than the rural

setting, as socio-economic status of parents played a major role in improving nutritional

knowledge of children.

Many studies have investigated the impact of Nutrition Education on nutrition knowledge

and food habits in Nigeria. None within available literature has developed and

investigated the effect of Pictorial nutrition education packages on nutrition knowledge

and dietary practices which is an innovational approach to learning nutrition education

combined with developing nutrition education tools and implemented as part of a

nutrition education program to provide knowledge and skills that will enable students

make choices that would lead to choosing a nutritious diet and improved health for senior

secondary school students and most of the reviewed studies were not carried out within

Edo South Senatorial district which is the area this study was undertaken. These therefore

created the gap, which this study has filled.

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 CHAPTER THREE

METHODOLOGY

This chapter described the methods that were used in gathering and analyzing the data

collected, in the conduct of the study which developed a Pictorial Nutrition Education

Packages (PNEP) and determined the effect on secondary school student’s nutrition

knowledge and dietary practices in Edo South Senatorial District. It was discussed under

the following sub-headings:-

 Design of the Study

 Population of the Study

 Sample and Sampling Technique

 Instrumentation

 Validity of the Instrument

 Reliability of the Instrument

 Method of Data Collection

 Method of Data Analysis

Design of the Study

Research and Development (R&D) design was adopted in the study. This design is

considered appropriate for this study because is a process used to develop and validate

educational programme (Gall, Gall, & Borg, 2007). R&D involves identification of goals

and the development of instructional programme in phases depending on the extent of the

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programme. Six phases of the R & D cycle was adopted and used in this study. The

phases used include;

1. Identify the instructional goals: this involves identifying the objectives of

intervention programme developed for Pictorial Nutrition Education Packages

(PNEP)

2. Conduct the instructional analysis: this involves determination of learning

contents of PNEP

3. Develop assessment instructional strategy: this involves determining the methods

employed for implementing the developed intervention programme for PNEP

4. Develop and select instructional materials: this involves determining the facilities

employed foe developed intervention programme for PNEP

5. Design and conduct draft: this involves determining the activities that was

employed in evaluating the PNEP

6. Conduct summative evaluation: this involves determining the efficacy of PNEP

on senior secondary school students. This was done in form of tryout test.

The non randomized pretest – post test control group design (quasi experimental research

design) was employed to test the effectiveness of the PNEP. This involves two groups

(experimental and control). The design is represented and illustrated as follows:

Experimental group O1 X1 O2

Control O1   X2           O2

Where O1 and O2 represent the pre test and post test, respectively.

X is the treatment (X1 = (unusual treatment), X2 (usual treatment)

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The two groups were pre-tested and post-tested. The experimental group was exposed to

treatment which is the pictorial nutrition education packages (PNEP) while the control

group was taught with the traditional instructions. The effect of more than one

independent variable was studied, so a factorial design of 2 x 2 x 3 was involved. This is

because the variables were in two and three levels. Two independent variables were

involved in the study, they were; instructional methods (Pictorial nutrition education vs

traditional); gender (Male vs Female), and socio-economic status (high, medium and

low). The study involved two dependent variables (nutrition knowledge and dietary

practices. The variables in the study are shown in Table 2.

Table 2: Variables of the Study

Groups Gender Socio-Economic Status
Male Female High Medium Low

Control 58 52 19 71 20
Experimental 86 49 15 98 22
Total 144 101 34 169 42
Grand Total 245 245

Population of the Study

The population of this study consisted of all senior secondary school year one (SSI)

students offering Foods and Nutrition(an aspect of Home Economics) and their teachers

in Edo South Senatorial district of Edo State, one of the states in South South region, of

Nigeria. There are seven (7) local Government Areas in the district; Egor, Ikpoba-Okha,

Oredo, Orhionwon, Ovia South West, Ovia North East and Uhunmwode.

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The schools spread across the seven local government areas of the study. A total number

of 136 public secondary schools are in Edo South senatorial district of the State with a

population of 13,318 students for the 2012/2013 academic session (Table 3) (Edo State

Ministry of Education, 2013).

Table 3: Distribution of the Population for Public Secondary Schools/Students

   Population by Local Government Area in Edo South Senatorial
District
S/N LGA NO OF SCHOOLS POPULATION
1 Egor 12 1902
2 Ikpoba Okha 19 4279
3 Oredo 13 3677
4 Ovia South West 13 888
5 Ovia North East 28 1095
6 Orhionmwon 29 852
7 Uhunmwode 21 625
Total 136 13,318

Source: Edo State Ministry of Education, 2013.

Sample and Sampling Techniques

Multistage sampling technique was employed in selecting the sample school for the

study. The following stages were used in the study.

Stage I: Two (2) Local Government Areas were randomly selected from the seven (7)

Local Government Areas; they are Oredo and Egor Local Government Areas. There are

thirteen (13) and twelve (12) senior secondary schools from Oredo and Egor Local

Government Areas respectively.

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Stage II: Two (2) schools each that met with the criteria set (Pg 15), were purposively

selected from the two Local Government Areas for the study making a total of four (4),

and were labeled as school A, B, C and D.

Stage III: Schools that served as experimental and as control group from the four schools

selected were randomly assigned. Schools A and C were used for the intervention

(experimental) while schools B and D served as the control group. The schools were

further labeled as AEG1 and CEG2 (experimental) while BCG1 and DCG2 (control).

Stage IV: Simple random sampling technique was used to select intact classes within the

arms for both groups. A total sample size of two hundred and forty five (245) students

was used for the study (135 students for the experimental group and 110 students for the

control group). This was the sum total of four (4) intact classes randomly selected.

The schools selected from Oredo Local Government Area were coded as schools A and

B, Schools in Egor Local Government Area were coded as schools C and D. School A

served as experimental group (AEG1) while School B served as control group (BCG1) in

Oredo Local Government Area. School C served as Experimental group 2 (CEG2) while

school D also served as control group 2 (DCG2) (Table 4).

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 Table 4: Distribution of School Grouping, Coding and Sample Size

S/ Local G. School type For Research Codin Labelin Sample

N Area m purpose g g Size
(Students)
1 Oredo Co- SSI Experiment AEG1 A 75
educational al
Boys / Girls
Oredo Co- SSI Control BCG1 B 55
educational
Boys / Girls
2 Egor Co- SSI Experiment CEG2 C 60
educational al
Boys / Girls
Egor Co- SSI Control DCG2 D 55
educational
Boys / Girls
Key:
AEG1 = Experimental group 1
BCG1 = Control group 1
CEG2 = Experimental group 2
DCG2 = Control group 2

Instrumentation

Five sets of instruments were used for gathering data for the study. They are;

 The demographic data, dietary practices and socio- economic questionnaire

(DDPSESQ)

 Nutrition Knowledge Test (NKT)

 Pictorial Nutrition Achievement (PNAT)

 Pictorial Nutrition Education Packages (PNEP)

 Lesson plan developed for teaching the experimental group

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DDPSESQ was used to collect data on the demographics, socio-economic status and

dietary practices of the students. The instrument had three sections; Sections A, B and C.

Section A, solicited information on Age, gender and body mass index. Section B was

used to index socio- economic status; the various indexes used were based on educational

qualification, income, material possessions and feeding pattern (Appendix C, Pg 189).

Section C, had questions on dietary practices. 24Hr- recall questionnaire by Oldewaga-

Theron et al (2005) was adapted in this study and modified to suit this environment. The

questionnaire contained list of about thirty foods items commonly eaten within this

environment and it was used to gather data of relatively accurate information on students’

dietary practices (Appendix F, Pg 203). This allowed the individual to recall the foods

consumed during the preceding 24 hours, providing details as to the type of eating pattern

practiced. Food models, measuring spoon, cups were used for quantification of foods.

Fadupin (2009) food exchange list was adapted for calculating nutrient composition

(Appendix S, Pg 254).

The Nutrition Knowledge Test (NKT) was designed to determine students’ prior

knowledge of healthy nutritional practices before the treatment packages. The test

comprised of thirty (30) item questions drawn from the senior secondary school year one

syllabus (Appendix D, Pg 193)

Pictorial Nutrition Achievement Test (PNAT) was designed to test the effect of the

treatment packages on students’ academic achievement. PNAT had thirty items from four

(4) instructional units in SS1 syllabus; Introduction to foods and nutrition (8 items), basic

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food nutrient (8 items), food groups (7items) and meal management (7 items) (Appendix

E, Pg 198), which were drawn with the help of table of specification (Table 5)

Table 5: Specification of Items on Pictorial Nutrition Achievement Test

S/N Content level of cognitive thinking
Know Comp High level No of questions
1 Introduction to nutrition 3 3 2 8
2 Basic food Nutrition 3 3 2 8
3 Food groups 2 2 3 7
4 Meal planning 2 2 3 7
Total number of questions 10 10 10 30
Key:
Know = Knowledge
Comp = comprehension
Higher level= application + analysis + synthesis + evaluation
Adapted from Bloom (1979)

Blooms’ specification of test items was used in order to:

 Be sure that the questions on the achievement tests matched the content taught in

the class.

 Make sure the questions cover higher level objectives or more than factual recall.

 Make sure that the most important objectives appropriately emphasized by

assigning a suitable number of items.

 Verify that the test contains a representative sample.

Pictorial Nutrition Education Packages (PNEP) was developed from the instructional

objectives, the content, planned lessons for the treatment group, materials, methods and

activities. The treatment packages comprised of six (6) planned lessons of 40minues

each.

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The fifth Instrument was the lesson plan, developed based on the objectives of the

programme which helped in carrying out the try-out test to determine the effectiveness of

the packages on academic achievement of the students. The notes were guided by the

topics generated from the goals of the developed packages. The treatment packages had

six (6) planned lessons of 40minutes per session. The lesson plan had on it, class, topic,

duration, entry behavior, Instructional objectives, materials needed, Instructional

procedure, activity, feedback from students and assessment/evaluation.

Validity of the Instrument

To determine the content and construct validity of the sets of instruments, the instruments

were given to the researcher’s supervisor (a nutritionist), one Home Economics expert in

the Department of Vocational and Technical Education and one expert in Measurement

and Evaluation from the department of Educational Psychology and Curriculum Studies,

all from the Faculty of Education, University of Benin for scrutiny. The corrections and

suggestions given by the experts were effected in the final instruments. Therefore, there

is confidence in the content and construct validation of the instruments.

Reliability of the Instrument

The reliabilities of the sets of instrument (DDPSESQ and PNAT) were determined. Split

half method was used for the reliability test of the questionnaire, this was done by

administering the DDPSESQ to twenty (20) students in a school that was not part of the

sample but of the population, the data collected was analyzed using Cronbach alpha

method and a reliability coefficient of 0.64 was obtained, while the achievement test

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(PNAT) was tested for reliability using test re-test reliability method by administering the

test twice to twenty students in an interval of two weeks. The two sets of data collected

were analyzed using Pearson Product Moment Correlation coefficient formulae; a

reliability coefficient of 0.84 was obtained (Appendix U, Pg 256).

Method of Data Collection

The study involved four senior secondary schools (co- educational schools). The

procedure for collecting data began with the researcher obtaining permission from the

schools’ authorities for the purpose of carrying out the study through a letter of

introduction from the Head of Department, Vocational and Technical Education

Department, University of Benin, Benin City. (Appendix A, Pg 187).

Two Home Economics teachers in the control schools were briefed on the goals of the

study before assisting in teaching the control groups for both schools,

The research assistants were trained on how to give assistance during treatment. They

were taught how to use the mechanical weight scale and the improvised height meter for

two weeks before the commencement of the field work.

Treatment Package/Intervention Programme

Two treatment techniques (usual and unusual) were involved in the study thus; Pictorial

nutrition education (unusual) and traditional method of teaching (usual). The treatment

package comprised of Six (6) planned lessons of 40 minutes each (single period) on

content areas in Foods and Nutrition taught in sessions to both the experimental and

control groups. The difference in the administration of these treatments was basically in

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the method of application. Pictorial nutrition education Packages were utilized for

teaching the experimental group while the traditional method was employed for the

control group. Administration of the treatment took the following format,

 Pre-treatment
 Treatment
 Post treatment

Pre-Treatment Package

The objective of the session was to introduce the programme to the students (orientation).

Before administering the pre-test to the students, the researcher explained the importance

of the programme, and attendance to the students. The pre-test instrument was

administered to the two groups experimental group and the control group (EG and CG),

this is to get their initial entry level. The Questionnaire (DDPSESQ) containing social

demography data, socio economic status, dietary practices was administered

simultaneously at the point of entry. The instruments were administered to the students to

fill and collected by the researcher, at the end of the session. Their body mass index was

also measured.

Treatment Procedure:

Pictorial Nutrition Education (Experimental Group)

Pictorial nutrition education intervention lessons notes were activity based. Handbook

was designed by the researcher and given to all students involved in the study. The lesson

had a time frame of 40 minutes and was broken down as;

1) The first 5 minutes was used for the revision of the previous lesson.
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 2) The next 5 minutes was used for the explanation of the meaning of each topic via

pictures and post card

3) The next 20 minutes was used to teach the concepts in each topic via pictures and

post cards

4) The next 5 minutes was used by the students for asking questions.

5) The last 5 minutes was used by the researcher to comment on the students’ ideas

on the topic.

The treatment package for each session is described in (Appendix G-L, Pg 205-234). The

package comprised six (6) planned lessons on four content areas in Foods and nutrition.

The lessons were on; Introduction to foods and nutrition, basic food nutrient, food

groupings and meal planning. Table (6) below shows the periods and activities of the

treatment package

Control Group

The control group was taught by the teachers in the two schools. They taught the class in

the traditional way. The lesson had a period of 40minutes and was broken down as thus;

1). The first 5 minutes was used for the revision of the previous lesson.

2) The next 5 minutes was used for the introduction of the topic.

3) The next 20 minutes was used to teach the concepts of the topic.

4) The next 5 minutes was used for evaluation

5) The last 5 minutes was used for the summary of the lesson before the

students copied the chalkboard summary. The treatment package for each session is

described in (Appendix M-R, Pg 235-253). The package comprised six (6) planned

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lessons on four content areas in Home Economics. The lessons were on; Introduction to

foods and nutrition, basic food nutrient, food groupings and meal planning.

Table 6: Periods and Activities of Treatment

Weeks Activities
1 Orientation and Administration of pre – test and the Questionnaire
to both groups,
2-6 Teaching Sessions for both Control and Experimental Group

6 Administration of the post test to both groups

Posttest Treatment:

At the end of the sixth week, the posttest was administered to the two groups.

Method of Data Analysis

The data collected were analyzed using descriptive and inferential statistics. Research

questions 1- 4 were answered using descriptive analysis. Hypotheses 1, 2,4,5.tested

using independent t-test statistics, hypothesis 3 was tested using paired sample t-test,

while hypotheses 6 and 7 were tested using One-Way ANOVA statistics, and hypotheses

8-11 were tested using 2-Way ANOVA. The Independent t-test was used for comparing

the nutrition knowledge and practices between the two groups (experimental and

control),and males and females students, 2-way ANOVA was used to determine the

interactive effect of the intervening variable (SES and Gender) on the dependent

(nutrition knowledge and dietary practices) variables. All hypotheses were tested at 0.05

alpha level of significance. The decision rule was based on the probability value (p). If p-

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value rule is less than or equal to 0.05,the null hypothesis will be rejected, but if p-value

is greater than 0.05, the null hypothesis will be retained.

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 CHAPTER FOUR

DATA PRESENTATION AND DISCUSSION OF FINDINGS

The results of data collected and analyzed in this study are presented in tables for

each research question and the hypotheses formulated. The results were analyzed and

interpreted at 0.05 level of significance.

Research Question One:

What are the instructional objectives of the Pictorial Nutrition Education Packages
(PNEP)?

Table 7: Summary of Instructional Objectives of Pictorial Nutrition Education

Packages    (PNEP)
Explain the meaning of Nutrition.
State the importance of human nutrition.
State the importance of healthy diet.
List the factor affecting choice foods.
Explain what a nutritious diet is.
Identify various foods in the locality.
List the types of food nutrient.
Classify food nutrient into groups.
Classify food nutrients into groups’.
State the function of he various nutrients.
Described diet deficiency as a result of inadequate food consumption.
List the types of food groupings.
State the importance of food grouping in meal planning.
Explain the meaning of meal planning.
List factors guiding meal planning.
State meal patterns using the food pyramid table.
Understand the concept of self-efficiency in learning.
Apply nutrition intervention in solving activity by replacing food terms on the some food
groups on the food puzzle.
Arrange the word puzzle game instructor.

Table 7 shows the instructional objectives of PNEP that was used in improving students
ideas in nutrition that enhanced learning outcome in Nutrition Education.

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Research Question Two:

What are the content of the Pictorial Nutrition Education Packages (PNEP)?

Table 8: Summary of the contents of Pictorial Nutrition Education Packages

(PNEP)
Introduction to Foods and Nutrition
Pictorial Nutrition education
Basic Food Nutrients Food groups
Food groups
Meal planning
Food puzzle activity using self-efficiency and problem solving

Table 8 shows the content of Pictorial Nutrition Education Packages (PNEP) used in the

delivery of the packages.

Research Question Three:

What are the delivery systems (materials and methods) utilized in teaching Pictorial

Nutrition Education Package (PNEP)?

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Table 9: Summary in the delivery system for Pictorial Nutrition Education Package
(PNEP).
Teacher shares to the students manual developed titled “My little book of Nutrition”
Teacher asked the students to bring out their folder containing their material.
Teacher refers students to the food pyramid in their manual showing food groupings
Teacher gives a pictorial view on the principles of meal planning.
Teacher shares to students’ cross-word puzzle game card to fill.
Teacher ask students to design a personal food pyramid

Material
Post cards explaining the meaning of Nutrition with pictures of undernourished, over-
nourished and normal persons.
Post cards- explaining importance of human nutrition
Post cards explaining factors that affect nutrition
Post cards explaining the importance of healthy diet
Post cards explaining what a nutrition diet is
Post cards to identify food found in the country
Using pictures, list the food nutrients and their source.
Using picture explaining the functions all nutrients
Using pictures explaining dietary deficiencies as a result of inadequate food consumption.
Using pictures shows food in the food groups
Using pictures classify food into five major groups of grains, meat, fruits, vegetables and
milk.
Using post cards, explain the meaning of meal planning
Give a pictorial view of the principles of meal planning
Using post card to show factors guiding meal planning
Using food pyramid table explains different serving of food from each group.

Table 9 shows the delivery system (materials and methods) that was utilized in the
teaching of the packages.

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Research Question Four:

What are the evaluation activities used for Pictorial Nutrition Education Packages

(PNEP)?

Table 10: Summary of the Evaluation Activities.

What is Pictorial Nutrition Education?
What is Nutrition?
State five importance of healthy eating
Classify food into the major groups
Give three functions of each nutrients
Classify food into groups.
What is meal planning?
What is recommended daily allowance for an adolescent?
List five importance of self – efficacy in learning
Why is the game important in learning?

Table 10: shows activities used in evaluating PNEP on students’ Nutrition knowledge

and dietary practice

Hypothesis One

There is no significant difference in nutrition knowledge of students exposed to pictorial

nutrition education packages and those not exposed in Edo South Senatorial District

Schools

Table 11: t-test of Independent Samples of Nutrition Knowledge by Exposure

    to Pictorial Nutrition Education
Group N Means Std. Dev t sig.(2tailed)

Posttest Experimental 135 14.63 3 .84

5.811 000
Control 110 12.13 3.65

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 α =0.05
Table 11 shows that for post test, a t-test value of 5.811 and p value of .000.Testing at an

alpha level of 0.05, the p value is less than the alpha level, So the null hypothesis which

states that there is no significant difference in nutrition knowledge of students exposed to

pictorial nutrition education and those not exposed in Edo South Senatorial district

schools is rejected. Therefore there is a significant difference in nutrition knowledge of

students exposed to pictorial nutrition education and those not exposed in Edo South

Senatorial District Schools.

Since the Mean of the experimental group is 14.63 and that of the control group is 12.13,

it shows that the experimental group achieves more nutrition knowledge than the control

group.

Hypothesis Two

There is no significant difference in dietary practices between students exposed to

pictorial nutrition education packages and those who were not exposed to it in Edo South

Senatorial district.

Table 12: t-test of Independent Samples of Dietary Practices of Students by

        Exposure to Pictorial Nutrition Education
`Group N Means Std. Dev t sig.(2tailed)
Posttest Experimental 135 33.78 5.66
3.573 .000
Control 110 31.28 5.13
α = 0.05

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Table 12 reveals that for post-test a t-test value of 3.573 and p value of .000. Testing at an

alpha level of 0.05, the p value is less than the alpha level. So the null hypothesis which

states that there is no significant difference in dietary practices of students exposed to

pictorial nutrition education and those not exposed to it in Edo South Senatorial district,

is rejected. Therefore there is a significant difference in dietary practices of students

exposed to pictorial nutrition education and those not exposed to it in Edo South

Senatorial district.

Since the Mean of the experimental group is 33.78 and that of the control group is 31.28,

it shows that that experimental group achieves more dietary practice than the control

group.

Hypothesis Three

There is no significant difference between pre and post body mass index measures of

students as a result of exposure to pictorial nutrition education packages

Table 13: Paired sample t-test of BMI measures of students exposed to Pictorial
Nutrition Education
N Mean Std. Dev t df Sig (2-tailed)
Pre BMI 135 19.05 4.14
-4.208 129 0.00
Post BMI 135 20.64 2.11

∝=0.05

Table 13 shows a calculated t- value of -4.208 and a P value of .000, testing at an alpha

level of .05 since the P value is less than the alpha level, the null hypothesis which states

that there is no significant different between pre and post body mass index measures of

students as a result of exposure to pictorial nutrition education is rejected. Consequently

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there is a significance difference in pre and post body mass index of students as a result

of exposure to pictorial nutrition education

Hypothesis Four

There is no significant difference in nutrition knowledge of male and female students as a

result of exposure to pictorial education packages in Edo South Senatorial district.

Table 14: t-test of Independent Samples of Nutrition Knowledge of Male and

     Female students due to Pictorial Nutrition Education
Gender N Means Std. Dev t sig.(2tailed)
Male 86 14.34 3.84
Posttest -1.189 .237
Female 49 15.15 3.83
Total 135
α = 0.05

Table 14 shows that for post test, a t- test value of – 1.189 and p value of .237. Testing at

an alpha level of 0.05, the p value is greater than the alpha level. So the null hypothesis

which states that “there is no significant difference in nutrition knowledge of male and

female students as a result of exposure to pictorial nutrition education in Edo South

Senatorial district is retained.

Hypothesis Five

There is no significant difference in dietary practices of male and female students as a

result of exposure to pictorial nutrition education packages in Edo South Senatorial

district.

Table 15: t-test of Independent Samples of Dietary Practices of Male and

      Female students Due to Pictorial Nutrition Education

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 Gender N Means Std. Dev t Sig.(2tailed)
Posttest Male 86 33.17 5.03
-1.661 .099
Female 49 34.84 6.56
Total 135
α = 0.05
Table 15 also reveals that for post test, a t-test value of -1.661 and a p value of .099

testing at an alpha level of 0.05. Since the p value is greater than the alpha level, the null

hypothesis which states that there is no significant difference in dietary practices of male

and female students as a result of exposure to pictorial nutrition education in Edo South

Senatorial district is accepted.

Hypothesis Six

There is no significant difference in nutrition knowledge between students of high,

medium and low socio-economic status as a result of exposure to pictorial nutrition

education packages in Edo South Senatorial district.

Table 16: ANOVA Statistics of Nutritional knowledge of Students as a Result of

     exposure to Pictorial Nutrition Education by Socio-Economic Status
Sums of Square df Mean square F Sig
Pre Nutrition Between Groups 18.545 2 9.227
.583 .560
Knowledge Within Groups 2090.628 132 15.838
Total 2109.081 134
Post Nutrition Between Groups 41.557 2 20.779
1.419 .246
Knowledge Within groups 1933.543 132 14.648
Total 1975.100 134
α = 0.05
Table 16 shows for pre-test, an F-value of .583 and a P value of .560. This indicates no

significant difference in nutrition knowledge among students from high, medium and low

Socio- economic status at pre-test, since the P value is greater than the alpha level. The

table also reveals for post test an F-value of 1.419 and a p value of .246 testing at an

alpha level of .05. Since the p value is greater than the alpha level, the hypothesis which

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 states that there is no significance difference in nutritional knowledge of students of high,

medium and low socio-economic status as a result of exposure to pictorial nutrition

education in Edo South Senatorial district is retained.

Hypothesis Seven

There is no significance difference in dietary practices between students of high, medium

and low socio-economic status as a result of exposure to pictorial nutrition education

packages in Edo South Senatorial district.

Table 17: ANOVA statistics of dietary practices of students as a result of exposure

     to Pictorial Nutrition Education by socio-economic status
Sum of Square df Mean square F Sig
Pre Dietary Between Groups 9.268 2 4.634
.249 .780
Within Groups 2456.924 132 18.613
Total 2466.193 134
Post Dietary Between Groups 179.853 2 89.926
2.881 .060
Within Groups 4120.406 132 31.215
Total 4300.259 134
α = 0.05

Table 17 shows for pre-test an F value of .249 and a value of .780. This indicates no

significant difference in dietary practices among students from high, medium and low

socio-economic status at pre-test since the P value is greater than the alpha level. The

table also reveals for post test an F value of 2.881 and a p value of .060 testing at an alpha

level of 0.05. Since the p value is greater than the alpha level, the hypothesis which states

that there is no significant difference in dietary practices among students’ from high,

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medium and low socio-economic status as a result of exposure to pictorial nutrition

education in Edo South Senatorial is retained.

Hypothesis Eight

There is no significant Group by gender interaction effect in students’ nutrition

knowledge in Edo South Senatorial district.

Table 18: ANOVA of Group by Gender Interaction in Student’s Nutrition

Knowledge
Source Type III sum of df Mean square F Sig.
squares
Corrected model 408.206a 3 136.069 12.093 .000
Intercept 42120.404 1 42120.404 3.743E3 .000
Group 404.291 1 404.291 35.930 .000
Gender 1.487 1 1.487 .132 .717
Group *Gender 25.147 1 25.147 2.235 .136
Error 2711.777 241 11.252
Total 47825.250 245
Corrected Total 3119.984 244
a. R squared = .120
b. NS = significant at p≥ 0.05

Table 18 reveals an F value of 2.235 and a p value of .136 for interaction effect of

students’ nutritional knowledge by gender. Testing at an alpha level of 0.05, the p value

is greater than the alpha level. So, the null hypothesis which states there is no significant

group by gender interaction affect on students’ nutrition knowledge is retained.

Hypothesis Nine

There is no significant group by gender interaction effect in students’ dietary practices in

Edo South Senatorial district.

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Table 19: ANOVA of Group by Gender Interaction Effect in Students’
     Dietary Practices
Source Type III sum of df Mean square F Sig.
squares
Corrected model 493.106a 3 164.369 5.615 .001
Intercept 248678.016 1 248678.016 8.496E3 .000
Group 441.770 1 441.770 15.092 .000
Gender 6.100 1 6.100 .208 .648
Group*gender 106.391 1 106.391 3.635 .058
Error 7054.452 241 29.272
Total 268843.890 245
Corrected Total 75447.559 244
a. R squared = .005
b. NS = significant at p≥ 0.05

Table 19 shows an F value of 3.635 and a p value of .058 for interactive effect of

students’ dietary practices by gender. Testing at an alpha level of 0.05, the p value is

greater than the alpha level. So, the null hypothesis which states that gender will not have

any significant interactive effect on students’ dietary practices when exposed to pictorial

nutrition education in Edo South Senatorial district is retained.

Table 20: Descriptive Statistics of Group by Socio-Economic Status Interaction on

     Nutrition Knowledge
    Dependent Variables: Post
SES Mean Std. N
Deviation
Pre Nutrition Low 13.2273 4.77026 22
knowledge Medium 13.6224 3.81672 98
High 12.4667 3.77712 15
Total 13.4296 3.96729 13
5
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 Post Low 15.3182 3.24237 22
Nutrition Medium 14.6990 3.94599 98
knowledge High 13.2080 3.80225 15
Total 14.6333 3.83921 13
5

Hypothesis Ten

There is no significant Group by Socio-economic status interaction effect in students’

nutrition knowledge in Edo South Senatorial district.

Table 21: ANOVA of Group by Socio- Economic Status Interaction in

        Student’s Nutrition Knowledge
Source Type III sum of df Mean F Sig.
squares square
Corrected model 423.076a 5 84.615 7.499 .000
Intercept 26560.875 1 26560.875 2.354E3 .000
Group 190.762 1 190.762 16.905 .000
SES 16.804 2 8.402 .745 .476
Group *SES 28.450 2 14.225 1.261 .285
Error 2696.908 239 11.284
Total 47825.250 245
Corrected Total 3119.984 244
a. R squared = .136
b. NS = significant at p≥ 0.05

Table 21 reveals an F value of 1.261 and a p value of .285 for interactive effect on

students’ nutrition knowledge by Socio-economic status. Testing at an alpha level of

0.05, the p value is greater than the alpha level. So, the null hypothesis which states that

there is no significant group by socio-economic status interaction is retained.

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 Table 22: Descriptive Statistics of Group by Socio-Economic Interaction on Dietary
     Practices
     Dependent Variables: Post
SES Mean Std. Dev N
Pre Dietary Low 29.3182 4.97983 22
Medium 29.2959 4.12238 98
High 28.4667 4.53347 15
Total 29.2074 4.29004 135
Post Dietary Low 34.1227 5.22603 22
Medium 34.1990 5.64454 98
High 30.5133 5.70349 15
Total 33.770 5.66493 135

Hypothesis Eleven

There is no significant Group by Socio-economic status interaction effect in students’

dietary practices in Edo South Senatorial district.

Table 23: ANOVA of Group by Socio Economic Status Interaction in       Students’

Dietary Practices in Edo South Senatorial District
Source Type III sum of df Mean square F Sig.
squares
Corrected model 583.008a 5 116.602 4.001 .002
Intercept 156492.357 1 156492.357 5.370E3 .000
Group 75.855 1 75.855 2.603 .108
SES 41.224 2 20.612 .707 .494
Group *SES 177.536 2 88.768 3.046 .049
Error 6964.550 239 29.140
Total 268843.890 245
Corrected Total 7547.559 244
a. R squared = .077
b. NS = significant at p≥ 0.05

Table 23 shows an F value of 3.046 and a p value of .049 for interactive effect of

students’ dietary practices by Socio economic status. Testing at an alpha level of 0.05, the

p value is less than the alpha level. So, the null hypothesis which states that there is no

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significant group by socio-economic status interaction is rejected. Consequently, socio-

economic status has significant interactive effect on students’ dietary practices when

exposed to pictorial nutrition education in Edo South Senatorial district. (See Figure 8)

Figure 8: Estimated Marginal Means of POSTDP

Figure 8, shows that while the effect of treatment is stable for the low and medium class,

it is however unstable for the high socio-economic class. As the scores obtained for the

control group in the low and medium class is lower than the scores obtained from the

experimental group, but the scores obtained from the control group are higher than those

obtained from the experimental group for high socio economic status. It therefore means

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that treatment is more effective for the low and medium socio-economic class than the

high socio-economic class is respect of dietary practices.

Discussion of Findings

This study developed and investigated the effect of Pictorial nutrition education packages

on senior secondary school students Nutrition knowledge and dietary practices.

Findings from the first hypothesis revealed that there is a significant difference in

nutrition knowledge of students in experimental group at post test because there was a

significant difference between the mean scores in nutrition knowledge of both groups.

The indication is that the students that were exposed to Pictorial nutrition education

(PNE) (Experimental group) achieved more in nutrition knowledge than those that were

in the control group. The reason for this better performance by the experimental group

could be the integration of visual cues accompanied by oral instruction of nutrition

education which tends to help students recall better than the oral instructions alone, thus

validating the findings of (Huges & Huby, 2003) who found out that pictures can

improve comprehension when they show relationships among ideals. The findings also

corroborate that of Houts et al. (2006), who in their study revealed that when pictorial

education is compared to instructional method, pictures closely linked to written or

spoken text can markedly increase attention to and recall of health education information.

The result of this study does not only show the effectiveness of PNE in the increase of

nutrition knowledge but also corroborates previous research findings of Bandura (1979),

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who noted that more natural method of instruction facilitates learning. The findings of

this study are also in consonance with Eboh & Boye (2006) and Shariff, et. al. (2008)

who in their various studies found out that nutrition education programme improved

nutrition knowledge and healthy food choices. Chou, et. al. (2008) also lend credence to

this result, when they stated that nutrition education is a strong predictive of dietary

change.

The second hypothesis which states that there is no significant difference in dietary

practices of students in the experimental and control group was rejected because there

was a significant difference in dietary practices of the students in the experimental group

after treatment, this corroborates the findings of (Dowse & Ehlers 2005; Mansoor &

Dowse, 2004) who affirmed in their studies on pictorial education, that pictorial

education has a large storage capacity for visual information and good retention over

time that can lead to a change in behavior. Also the findings of this study are in

consonance with Kelishadi et. al. (2008), Eboh & Boye (2006) who found out that

nutrition education programme improved nutrition knowledge and healthy food choices.

However, hypothesis three indicated a significant difference between the pre and post

body mass index as a result of exposure to PNEP. This further buttresses the fact that

students’ dietary practices improved as a result of the intervention, indicating that the

intervention was effective in improving dietary practices of students. This corroborates

the findings of Santamaries et. al.(2009) who revealed in their study that there is an

association between dietary practices and BMI.

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The result of the fourth hypothesis indicated a non significant difference in nutrition

knowledge between male and female students. This shows that the intervention is not sex

biased; as it is effective for both male and female. Thus PNEP can stimulate learning in

both male and female to the needs of preventing malnutrition among students. This

finding is however not in agreement with many other studies of Rodger,1998; Kieter

2005; Lynn 2008; Ruamsup & Charoenchi 2001; Nayga 2002, which constantly

maintained that nutrition knowledge is significantly higher in females than males. Their

findings could be due to the fact that girls tend to be more occupied with their physical

appearance at an earlier stage than boys of the same age; they are also more interested

and careful with diet which often results in higher nutrition knowledge and application.

The finding of this particular study however corroborates the finding of Pirouznia (2001)

who in a study that focused on sixth, seventh and eighth grade adolescent in a middle

school to determine their nutritional knowledge, eating behavior based on gender found

that there was no significant difference in nutrition knowledge and eating behavior

among the sixth grader as revealed by this study.

The fifth hypothesis revealed no significant difference in dietary practices of male and

female as result of exposure to PNEP. This indicates that pictorial nutrition education can

improve dietary practices of both male and female. This finding is in agreement with

Barzegari, Ebrahimi, Azizi & Ranjbar (2011), who in a study examined the nutrition

knowledge attitudes and food habits of college students in Iran, and found that there was

significant positive correlation between nutrition knowledge and food habits of male and

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female students. This finding however contradicts that of Abood, et al. 2004; whose

findings revealed that female student dietary practices are significantly higher than that of

the males.

The sixth hypothesis revealed that there is no significant difference in nutrition

knowledge of students of high, medium and low socio-economic status at post test, thus

the null hypothesis was retained. The result indicates that nutrition knowledge of students

at post test was not different between high, medium and low socio- economic class,

which makes PNEP effective for all levels of socio- economic status. Thus nutrition

knowledge is same irrespective of their Social class. This however contradicts the study

of (Wardle et al, 2000; Rasanen, 2003; Parameter 2000; & Buttress, 1997) who reported

in their various findings that individuals from high and middle socio- economic class

demonstrate higher nutrition knowledge, food habits and healthy life styles as compared

to individual from lower socio-economic class. This is indicative that education and

income largely affect nutrition knowledge.

The finding of hypothesis seven revealed that there is no significant difference in dietary

practices of high, medium and low socio-economic status of students at post test. This

indicates that the dietary practices of high, medium and low socio-economic class are the

same thus PNEP is effective for all levels of SES. This may be attributed to the high

proliferation of eateries (junk food) and easy accessibility of such eateries to adolescent,

resulting in high consumption of junk food as a result poor nutritional knowledge. This

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confirms the study of Ferro-luzzi & Puska (2004) who reported in their findings that

overweight and obesity tend to be highest among the low-income populations and the

affluent people in developing countries. Giskes, Turrell, Patterson & Newman (2002)

reported that higher SES groups were more likely to consume vegetables, fruits not only

in higher quantities but also in greater variety because of higher income. Findings of the

study contradict these findings, claiming that there is no difference in dietary practices of

high, medium and low socio-economic status.

Hypothesis eight which examined the interaction effect of group by gender on students’

nutrition knowledge was retained. It proved that there was no significant interaction of

treatment by gender and group. This implied that the treatment had effect irrespective of

gender (male and female) and group (experimental and control).This would mean that the

treatment produced its effect irrespective of gender and groups. This finding indicated

that though treatment had main effect, the effect was same among both levels of gender

and both groups at post-test. This finding is in agreement with Oloruntegbe (2000) and

Mbah (2003) whose different studies showed that there was no significant difference in

students’ achievement by gender. This finding may be linked to the relevance of nutrition

knowledge in formation of adequate dietary practices and consequent healthy living. This

is an indication that both male and female could achieve highly in nutrition knowledge

for positive dietary practices, though research continues to link gender to nutrition

education, that females tends to achieve more, when compared to male in nutrition

knowledge, as supported by Abood et al. (2004). But there was no previous literature to

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back up the finding of this work as there had been no study designed to investigate the

interactive effect of gender by group on nutrition knowledge of senior secondary school

students.

Hypothesis nine which also examined the interaction effect of group by gender on

students’ dietary practices was retained. It proved that there was no significant interaction

of treatment by gender and group. This means the treatment produced its effect

irrespective of gender by group, meaning that gender is not a significant factor in

achievement of dietary practices. The treatment had effect but was the same at both levels

(male and female) and at both groups (experimental and control).This is an indication that

both male and female can achieve highly in dietary practices for healthy living. This

finding however contradicts the findings of Fahlman et al. (2008),who reported in a post

hoc analysis, that the intervention group nutrition practices was significantly higher than

the control group. There is however no literature found by the researcher to backup this

finding, which therefore provides a solid foundation for future research.

Hypothesis ten which examined the interaction effect of group by socio- economic status

of students on nutrition knowledge was retained. It proved that there was no significant

interaction of treatment by socio- economic status by group. This means the treatment

had effect irrespective of socio- economic status (high, medium and low) and group

(experimental and control), meaning that socio- economic background is not a factor in

achieving nutrition knowledge. Thus this is an indication that the treatment can be

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applied on students irrespective of socio -economic status, as SES is not a determining

factor of nutrition knowledge. Research has continued to show that there is a growing

body of evidence that socio-economic status (SES) and nutrition knowledge are

associated. In a study by Beydoun & Wang (2008), “Do nutrition knowledge and beliefs

modify the association of socio-economic factors and diet quality among US adults” The

study revealed that there was a positive association of SES with diet quality varied by

nutrition knowledge; this only indicates that SES factors may have influence on dietary

choice only for those who have the desirable nutrition knowledge, this however is not in

agreement with the researcher findings.

Hypothesis eleven which states that there is no significant group by socio-economic

status interaction on students’ dietary practices was rejected. The finding reveals that

there is significant interactive effect on students’ dietary practices. This finding indicates

that there is an interactive effect between students from high, medium and low socio-

economic class, in the experimental group the interaction effect was between the High

and the low SES, which was however very marginal. This corroborates the findings of

(Ball et al. 2006; Forshee & Storey, 2006; Friel et. al. 2003; & Hulshof et al. 2003) whose

studies revealed that there is positive association between SES and dietary intake, and

that the lower class adhere less to dietary guidelines.

This finding indicates that the high socio-economic class, often engage in wrong dietary

practices, this may be due to the fact that students in this class do have enough money to

buy whatever they desire to eat, without taking into consideration the health benefit.

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158
 CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATIONS

This chapter presents the summary, conclusion and recommendations of the study based

on the findings of the data analyzed.

Summary

The main purpose of the study was to develop and investigate the effect of Pictorial

nutrition education packages on senior secondary school students’ nutrition knowledge

and dietary practices. Instructional objectives, content of PNEP, and delivery systems for

teaching nutrition concepts were developed. Mediating variables that could influence the

outcome of the study such as gender, body mass index and socio- economic status were

studied along. Fourteen research questions were raised. Research questions 5-14, were

formulated to hypotheses and tested respectively.

The study adopted Research and Development design. The non randomized pretest – post

test control group design (quasi experimental research design) was employed to test the

effectiveness of the PNEP. It consists of experimental and control group. The researcher

had a forty minutes intervention with the experimental group once a week for six weeks.

Pre-test was administered to both groups before treatment commenced and a post-test

followed after treatment sessions.

The population of the study consisted of all the SSI students in South Senatorial District

of Edo State. Multistage sampling technique was used in selecting two (2) co-educational

public schools offering Foods and Nutrition in two local government areas. Four intact

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classes consisting of two hundred and forty-five (245) SSI students were used for the

study and two validated instruments were used.

The study made use of treatment packages developed by the researcher for the

experimental group while the control group was taught traditionally. Treatment package

consisted of six planned lessons of 40 minutes each. The data collected were analyzed

using t-test, paired sample t-test and ANOVA at 0.05 level of significance.

Summary of the Findings

i. There was a significant difference in Nutrition knowledge of students in the

experimental group after exposure to pictorial nutrition Education (PNE) at

post test indicating that students exposed to PNE achieve more nutrition

knowledge than the students not exposed to it.

ii. There was a significant difference in dietary practices of students in the

experimental group after exposure to pictorial nutrition education of post-test.

Indicating that dietary practices of students exposed to PNE improve better

than those not exposed it.

iii. There was no significant difference between male and female nutrition

knowledge on post test treatment in the experimental group indicating that

PNE can be effective for both male and female, it is gender friendly.

iv. There was no significant difference between male and female students’ dietary

practices on post test treatment in the experimental group indicating that PNE

is effective for both male and female in improving dietary practices.

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 v. There was no significant difference in nutrition knowledge of students of high,

medium and low socio-economic status at post-test, this result shows that

student from the high, medium and low SES have the same nutrition

knowledge, none was superior to one another.

vi. Findings also showed that there was no significant difference in students’

dietary practices of high, medium and low social economic status, indicating

that dietary practices of students from high, medium, and low socio economic

status was the same at post test.

vii. There was no significant interaction effect of group by gender on students’

nutrition knowledge after treatment at post-test.

viii. There was no significant interaction effect of group by gender on students’

dietary practices after treatment at post-test.

ix. There was no significant interaction effect of group by socio-economic status

on students’ nutrition knowledge after treatment at post-test.

x. There was a significant interaction effect of group by socio-economic status

on students’ dietary practices after treatment at post-test.

Conclusion

Based on the findings, the researcher concludes that the use Pictorial nutrition education

Packages is an effective approach to increasing health status of the individual as it can be

utilized to eradicate malnutrition among the adolescent.

It was also concluded that pictorial nutrition education was beneficial in that it increased

the nutrition knowledge and dietary practices of the students. Furthermore it has helped to

161
remove the notion that female students were more knowledgeable in nutrition and that

engage in better dietary practices than their male counterpart indicative that PNEP is

effective for all.

Recommendations

Based on the findings of the study, the following recommendations are made.

(1) In order to bolster nutrition knowledge and for a change in dietary behavior of

adolescents to be a lifelong experience, Pictorial Nutrition Education should be

incorporated into the curriculum o secondary schools as a separate subject by

policy makers and curriculum planners.

(2) Nutrition education intervention programme should be organized by government

health sectors, non- governmental agencies, schools on a regular basis for the

adolescent so as to improve and sustain dietary practices for healthy living even

unto healthy adulthood.

(3) Equal opportunities should be given to the boys and girls in Foods and nutrition

classes since nutrition education is beneficial for both boys and girls. Teachers

should be gender sensitive in teaching in order to avoid male alienation especially

in practical classes.

(4) To foster more nutrition knowledge and changes in dietary behavior among boys

and girls in the school, there should be re-training of Home Economics teachers in

nutrition education programme, as empowering the teachers may also empower

the children more.

162
 (5) Same nutrition education intervention should be given to students from high,

medium and low socio-economic status by nutrition educators to enhance their

nutrition knowledge and better choices of healthy food for healthy living and

longevity.

(6) Government and non governmental agencies should provide counseling

centers/services and intervention with the intention of increasing the adolescent

nutritional knowledge and food habits for healthy living.

(7) Effective nutrition interventions for children and adolescents should be activity

based to enhance learning and should also have a behavioral focus that will

minimize the targeted risk factors for chronic diseases such as diabetes and

obesity.

Contributions to Knowledge

The study developed and investigated the effect of pictorial nutrition education

packages on nutrition knowledge and dietary practices of senior secondary school

students. The study was able to:-

 Show that pictorial nutrition education improved nutrition knowledge and dietary

practices of students.

 Contribute useful knowledge to nutrition education studies in providing

information on gender equality in nutrition knowledge and dietary practices. It

removes the notion, according to previous studies, that female students have

better nutrition knowledge and better dietary practices.

163
  show that students’ nutrition knowledge and dietary behaviour can change

through this approach, as it is a programme that can intrinsically motivate

learning and retention, thereby giving way to the reduction of poor dietary

practices.

 highlight the effectiveness of PNE based on self-efficacy and activity such as

puzzle games on students’ nutrition knowledge and dietary practices, to

educational policy makers and the society at large as a way of incorporating PNE

intervention in the curriculum for schools.

 show that pictorial nutrition education can be used for students from both high,

medium and low socio-economic background to achieve same nutrition

knowledge and dietary practices.

Suggestions for Further Studies

Further research investigations should be conducted in the following areas.

- The relationship between nutrition knowledge and dietary practices

- Nutrition intervention for a larger adolescent population within a community,

including parents

- Interactive effect of gender by group on nutrition knowledge

- Replicate the present study in other states of Nigeria, using increased number of

subjects and increased treatment periods.

164
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Woodruff, B., & Bhatia, R. (2000) .Assent of the nutritive status of adolescents in
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Nutrition. Bulletin. 26, 135 – 143.

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Edition: Ithaca, NY: New Strategic Publications.

190
APPENDIX A

191
 APPENDIX B
Mrs. Ihensenkhien I,
Department of Vocational and
Technical Education,
Faculty of Education,
University of Benin,
Benin City,
28th February, 2014.

The Principal,
__________________
__________________
__________________

Dear Sir/Madam,
PERMISSION TO USE YOUR SCHOOL
(TEACHERS, STUDENTS AND SCHOL ENVIRONMENT)

I am a Ph.D. student of the University of Benin. I wish to appeal to you to allow

some of the teachers and students in your school participate in a six-week programme
(3rd March to 7th April 2014) organized by me.
Your approval and cooperation will be highly appreciated.

Yours faithfully,
Mrs. Ihensekhien I.

192
 APPENDIX C

DEMOGRAPHIC DATA/SOCIO-ECONOMICS STATUS QUESTIONNAIRE

(DDPSESQ)

Dear respondent

This questionnaire solicits information from you. The information supplied will be
treated in confidence and this exercise is purely for research purpose. Thank you
Isoken Ihensekhien (Mrs)

Section A : Demographic data

Respondent No____________
Name of school ___________
Local Government Area __________
Class ___________
Gender: male female
BMI ________________________________

Instructions: Please read the questions carefully and ( ) the correct answer of your

choice.

Socio Economic Status Questionnaire (Tick as appropriate)

1. What is the level of educational qualification of the head of your family?
University / polytechnic graduate
NCE / OND
Primary school living certificate
No formal education
2. How many meals do you eat in a day
Thrice
Twice
Once
Sometimes none
3. How often do you go to bed hungry

193
 Everyday
Once a week
Twice a week
Never
4. What kind of house do you live in?
Modern house
Semi modern house
Traditional / modern house
Traditional house
5. What type of Family do you have?
Monogamous
Polygamous
6. Who do you live with?
Parents
Relation
Other
7. Which of this are you likely to drink?
Water
Soft drinks
Others
8. How often do you eat vegetables
Every day
Once a week
Twice a week
Rarely

9. How often do you eat fruits

Everyday
Once a week
Twice a week
Rarely
10. How will you classify yourself
Slim
Chubby
Normal
Other (Specify)_____________
11. Do you have a bedroom to yourself?
Always

194
 Sometimes
Rarely
None
12. Which meal are you likely to skip?
Break fast
Lunch
Dinner
13. How often do you skip meals?
Always
Sometimes
Rarely
None
14. What type of food are you likely to buy in school
Rice
Meat pie
Soucesage roll
Biscuit
15. How many cars do your parents have?
3
2
1
0
16. How often do your parents give you pocket money
Always
Sometimes
Rarely
None
17. What type of fuel do you usually use in food preparation in your house
Gas
Kerosene
Fire wood
Charcoal
18. How often do your parents shop for food
Every day
Once a week
Once a month
None
19. How many children are in your household?
2

195
 3
4
More than
20. Who is likely to be favored during meals?
Self
Sibling
Other

196
 APPENDIX D

Nutrition Knowledge Test (NKT)

Pre-test

Dear respondent

These items are to solicit information from you on your knowledge of nutrition and
dietary practices
1. Which of these food groups should constitute the most in a diet?
a. Meat, fish, poultry
b. Vegetables and fruits
c. Milk, yogurt, cheese
d. I do not know
2. An adequate diet should contain
a. Mostly meat, with smaller amount of starch, fruits, vegetables and dairy
products
b. Mostly vegetables and smaller amount of meat and d airy products
c. Mostly of starches, vegetables and fruits with smaller amount of meat and
dairy product
d. I do not know
3. A Function of vitamin C include building
a. Immune system
b. Good eye sight
c. Strong bones
d. I do not know
4. Proteins are classified into
a. Complete and incomplete Proteins
b. Essential and non essential fatty acids
c. Polysaccharides
d. None of the above

197
5. Which of the following food is rich in fiber?
a. White rolls
b. Whole wheat bread
c. White bread
d. None of the above
6. An adequate diet should contain
a. Mostly meat with smaller amount of starch, fruits, vegetables and dairy
products
b. Mostly vegetables and smaller amount of meat and dairy products
c. Mostly starches, vegetable and fruits with smaller amount of meat and
dairy product
d. I do not know
7. Consume lots of fruits and vegetable because they are high in
a. Fat
b. Sunshine
c. Fibre
d. seeds
8. Which meal gives energy to start the day and think better at school?
a. Breakfast
b. Lunch / dinner
c. Afternoon snack
d. Noon of the above
9. High intake of carbohydrate foods can lead to,
a. Obesity
b. Rickets
c. Grey hair
d. None of the above
10. A well planned meal will be
a. Sweet
b. Nutritious
c. Interesting
d. I do not know

198
11. A nutritious diet is
a. Good for all family member
b. Food and any meal prepared with rice
c. Food that contains all essential nutrient
d. None of the above
12. The nutrient strongly associated with the prevention of rickets is
a. Vitamin A
b. Vitamin K
c. Vitamin D
d. Do not know
13. Carbohydrates are mainly found in which food group
a. Meat, poultry, fish
b. Bread, cereals, rice
c. Vegetables & fruits
d. Do not know
14. Approximately what quantity of the diet should be carbohydrates?
a. Less than 10%
b. 120 %
c. 50%
d. none
15. Which food component has the most calories per gram?
a. Protein
b. Fat
c. Alcohol
d. None
16. Proteins are mainly found in which food group?
a. Meat, poultry, fish
b. Fruits
c. Milk, yogurt, cereal
d. None

199
17. Which of the following is an important function of calcium
a. Muscle contraction
b. Bone growth
c. A and B
d. None of the above
18. Foods are grouped into the following
a. 2 groups
b. Six groups
c. Five groups
d. None of the above
19. How many glasses of water should be consumed daily?
a. 1 – 3 glasses
b. 4 – 6 glasses
c. 6 – 8 glasses
d. None
20. Which vitamins improves eye – sight
a. Vitamin K
b. Vitamin A
c. Vitamin D
d. Do not know
21. The science of food and how the body uses it is known as
a. Nutrient
b. Fats and oils
c. Mono saturated
d. I do not know
22. Polyunsaturated fats are mainly found?
a. Vegetable oil
b. Animal oil
c. Dairy products
d. Do not know
23. What type of fuel do muscles use for energy?
a. Protein
b. Fats
c. Carbohydrates
d. Do not know
24. What advice is most appropriate in weight lose?
a. Increase your activity level and reduce empty calories
b. Lots of highly processed carbohydrates
c. Eat foods high in fiber
d. Do not know

200
25. A poor diet will result in
a. Stunted growth
b. Full growth
c. Bone disorder
d. Incomplete protein\
26. According to the food guide pyramid, the largest number of servings should come
from
a. Meat, poultry, fish, beans and egg group
b. Vegetable group
c. Bread, cereal, rice and pasta group
d. None
27. Energy balance means
a. Balance between calories consumed and calories burned
b. Calories intake is higher than calories burned
c. Calories burned is higher than calories intake
d. None
28. The minimum amount of nutrients needed to meet the health needs of most people
is called the
a. Tolerable upper limit
b. Recommended dietary allowance
c. Nutrient thresh
d. None
29. How many servings of fruits should one have per day
a. 2-4 serving
b. 3-5 serving
c. 6-11 serving
d. Do not know
30. To maintain a balanced healthy diet
a. Eat only vegetables
b. Eat only protein foods
c. Eat only carbohydrates foods
d. Eat varieties of foods

201
 APPENDIX E

Pictorial Nutrition Achievement Test (PNAT)

Posttest

Dear respondent

These items are to solicit information from you on your knowledge of nutrition and
dietary practices
1. Energy balance means
a. Balance between calories consumed and calories burned
b. Calories intake is higher than calories burned
c. Calories burned is higher than calories intake
d. I do not know
2. A Function of vitamin C include building
a. Immune system
b. Good eye sight
c. Strong bones
d. I do not know
3. Which of the following foods are lowest in fats
a. Cornflakes and full cream milk
b. Grilled lean and boiled
c. Vegetable Salad
d. None of the above
4. Proteins are classified into
a. Complete and incomplete proteins
b. Essential fatty acid and non essential fatty acids
c. Saturated fatty acid
d. I do not know

202
5. Consume lots of fruits and vegetable because they are high in
a. Fat
b. Sunshine
c. Fibre
d. seeds
6. Which meal gives energy to start the day and think better at school?
a. Breakfast
b. Lunch / dinner
c. Afternoon snack
d. Noon of the above
7. An adequate diet should contain
a. Mostly meat, with smaller amount of starch, fruits, vegetables and dairy
products
b. Mostly vegetables and smaller amount of meat and d airy products
c. Mostly of starches, vegetables and fruits with smaller amount of meat and
dairy product
d. I do not know
8. High intake of carbohydrate food can lead to,
a. obesity
b. rickets
c. stunted growth
d. None of the above
9. A well planned meal will be
a. sweet
b. nutritious
c. interesting
d. I do not know
10. A nutritious diet is
a. Good for every family member
b. Food and any meal prepared with rice
c. Food that contain all essential nutrient
d. None of the above
11. The nutrient strongly associated with the prevention of rickets is
a. Folic acid
b. Vitamin D
c. Oranges
d. None of the above

203
12. Which vitamins are water soluble
a. A
b. B and C
c. ADEK
d. None
13. Carbohydrates are mainly found in which food group
a. Meat, poultry, fish
b. Bread, cereals, rice
c. Vegetables & fruits
d. Do not know
14. Proteins are mainly found in which food group?
a. Meat, poultry, fish
b. Fruits
c. Milk, yogurt, cereal
d. None
15. Approximately what quantity of the diet should be carbohydrates?
a. Less than 10%
b. 120 %
c. 50%
d. none
16. Which food component has the most calories per gram?
a. Protein
b. Fat
c. Alcohol
d. None
17. Foods are grouped into the following
a. Five group
b. Two group
c. Six groups
d. None of the above

204
18. How many glasses of water should be consumed daily?
a. 1 – 3 glasses
b. 4 – 6 glasses
c. 6 – 8 glasses
d. None
19. The science of food and how the body uses it is known as
a. Nutrients
b. Fats and oils
c. Nutrition
d. I do not know
20. Which vitamins improves eye – sight
a. Vitamin K
b. Vitamin A
c. Vitamin D
d. Do not know
21. Polyunsaturated fats are are mainly found?
a. Vegetable oil
b. Animal oil
c. Dairy products
d. Do not know
22. How many serving of fruits should one have per day?
a. 2-4 serving
b. 3-5 serving
c. 6-11 serving
d. none
23. Which of the following is an important function of calcium
a. Muscle contraction
b. Bone growth
c. A and B
d. None of the above

205
24. A poor diet will result in
a. Stunted growth
b. Full growth
c. Bone disorder
d. Incomplete protein\
25. According to the food guide pyramid, the largest number of servings should come
from
a. Meat, poultry, fish, beans and egg group
b. Vegetable group
c. Bread, cereal, rice and pasta group
d. None
26. What advice is most appropriate in weight lose?
a. Increase your activity level and reduce empty calories
b. Lots of highly processed carbohydrates
c. Eat foods high in fiber
d. Do not know
27. Foods with the eight essential amino acids are classified as
a. Complex carbohydrates
b. Complete proteins
c. Incomplete proteins
d. None
28. What type of fuel do muscles use for energy?
a. Protein
b. Fats
c. Carbohydrates
d. Do not know
29. The minimum amount of nutrients needed to meet the health needs of most
people is called the
a. Tolerable upper limit
b. Recommended dietary allowance
c. Nutrient thresh
d. None
30. To maintain a balanced healthy diet.
a. Eat only vegetables
b. Eat only protein food
c. Eat only carbohydrates food
d. Eat varieties of food

206
 APPENDIX F

Dietary Practices Questionnaire (DPQ)

Respondent No ………………………………………………………….……. Gender: Male Female
Day of 24 – hour recall (for interviewer) ………………………….
(1) Tuesday, (2) Thursday, (3) Weekend
Instructions
 Please tell me everything that you ate and drank yesterday
 Including food you bought, from the time you woke up to the time you went to
bed
Food and fluid intake (expressed in exchanges):

Food Rolls Breakfast Lunch Dinner Estimated Quantity Nutrient

Rice
Bread
Beans
Yam
(Boiled/Fried)
Potatoe
Plantain unripe
Ripe (dodo)
Tea/Bourvita
Fish Stew
Beef Stew
Beef Stew
Chicken Stew
Banga Soup
Okro Soup
Melon Soup
Eba
Fufu
Pounded Yam
Amala
Eggs
Cake/Biscuit
Ice cream
Soft Drinks
Sweets /
chocolates
Chips (crisp)
Peanut butter
Chicken

207
Red meat
Fish
Cereal
cornflakes
Plantain, ripe /
unripe (fried /
boiled
Fruit juice
Fruits
Vegetables
List others not
indicated

Calculated estimated total volumes for carbohydrates (g) ……………………….

Protein (g) ……………………….
Fat (g) ……………………….
Energy (K) ……………………….

208
 APPENDIX G

SAMPLE OF PICTORIAL NUTRITION EDUCATION

LESSON NOTE FOR THE EXPERIMENTAL GROUP

Lesson 1

Subject: Foods and Nutrition

Class: SS 1

Topic: Introduction to Foods and Nutrition

Duration: 40 minutes

Entry Behaviour: Students Eat every day

Instructional Objectives: At the end of the pictorial nutrition education  

students should be able to:

Through pictorial nutrition education

i. Explain the meaning of nutrition

ii. state the importance of human nutrition

iii. state the importance of healthy diet

iv. list the factors affecting the choice of foods

v. explain what a nutritious diet is

Materials needed: Picture of well nourished and malnourished individual

Handbook developed by the researcher.

209
Instructional procedure:

Introduction:

Write the word “PICTORIAL NUTRITION EDUCATION” on the board where

everyone can see it. Ask the class what pictorial nutrition education means. After they

have given their suggestions, the researcher explains to them what pictorial nutrition

education is all about and its importance in improving nutrition knowledge and dieting

practices

Definition of Pictorial Nutrition Education (PNE)

PNE is an innovative learning/ teaching approach that utilized a visual representative

approach accompanied by oral instruction to bring behaviour changes.

A pictorial device is a graphic form of instruction used to create manages and exchange

information and knowledge. The use of interactive PNE increases students understanding

of nutrition instruction.

THE ACTIVITY

Shares to the students a manual developed by the researcher titled “my little book of

Nutrition

Using post cards, explains the meaning of nutrition with pictures of undernourished, over

nourished and normal persons

Using post cards, explains importance of human nutrition

Using post cards, explains the factors that affect nutrition

Using post cards and pictures, explains the importance of healthy diets

Using pictures, explains what a nutrition diet is

210
FEEDBACK FROM STUDENTS

Get feedback from students about the lesson by asking questions such as

- What is pictorial nutrition education?

-what is nutrition?

- State five importance of healthy eating

ASSESSMENT / FOLLOW UP

Write an essay on good nutrition

211
 CLIP FOR LESSON ONE

Nutrition is the science of food and how the body utilizes it for growth, development and

maintenance of the body. We eat food to live, to grow, to keep healthy and well and to

get energy for work and play. When our diet does not meet the required nutrient, the body

suffers from malnutrition. Malnutrition can either be under nourishment or over

nourishment.

Healthy Persons Under-nourished Persons Over-nourished person

Importance of good nutrition

- Maintenance of good health

- Strong bone
- Bright eyes
- Formation of good set of teeth
- Healthy & shinny skin
- Lustrous and shinny hair

Strong bones Bright Eyes Healthy Teeth

Healthy Skin Healthy Hair

212
Factors that affect nutrition

- Availability of food

- Available income

- Food in season

- Storage / preservation facility available

Availability of food

Available Income
Seasonal fruits Preservative Facility

What is a healthy diet?

Healthy diet is eating the right amount of food for your energy needs and eating a variety

of foods such as

-plenty of fruits and vegetables

Plenty of bread, rice, potatoes, paste and one starchy food (whole grains)

213
Some milk and dairy foods, (beans-fat)

Very small amount of foods high in fats & sugar

The eat well plate highlights the different types of food that make rake up our diet

and shows the proportions to be eaten to have a well balanced and healthy diet.

214
 APPENDIX H

PICTORIAL NUTRITION EDUCATION

LESSON NOTE FOR THE EXPERIMENTAL GROUP

Lesson 2/3

Subject: Foods and Nutrition

Class: SS 1

Topic: Basic foods Nutrient

Duration: 40 minutes

Entry Behaviour: Students have knowledge of simple nutrition

Instructional Objectives: At the end of the lesion, students should be able to:

i. Identify various foods in the locality

ii. List the types of food nutrients

iii. Classify food nutrients into groups

iv. State the functions of the various nutrient

v. Describe dietary deficiency as a result of inadequate food consumption

Materials needed: Manual for the lesson, Pictures of food in the locality

Post card of food classification

Pictures of functions of nutrients

Pictures of dietary deficiencies

215
Instructional procedure:

Introduction:

Review the previous lesson. The researcher writes the topic on the chalkboard clearly for

all to see. “BASIC FOOD NUTRIENTS” Ask the students the meaning of food nutrients

after they have given their suggestions; the researcher explains to them the meaning of

food nutrients

Definition of Food Nutrients

Food nutrients are the chemical substances contained in food, which helps food perform

the function of growth, repairs and maintenance of the body

THE ACTIVITY

Ask the students to bring out their folder containing the instructional materials

Using post cards and pictures, identify foods found in the locality

Using pictures, list the food nutrients and their sources

Classify food into five major groups of grains, meat fruits, vegetables and milk

Using pictures explains the functions of various nutrients

Explains the dietary deficiencies as a result of inadequate food consumption and give a

pictorial view of all deficiencies

FEEDBACK FROM STUDENTS

Get feedback from students about the lesson by asking questions such

(a) Classify food into five major groups (b) give 3 functions of each nutrient

216
ASSESSMENT / FOLLOW-UP

Students will be asked questions based on what they have been learnt.

Write an essay on the topic food nutrient

217
 CLIP FOR LESSON TWO AND THREE

What is food?

Food is any substance, liquid or solid which when eaten or drink provide

nutritional support for the body. Food sustains life, generates energy provides growth,

maintenance to the body.

Food is made up of different nutrients; carbohydrates, protein, Fats, minerals and

vitamins. Each nutrient has specific uses in the body. All persons, throughout life have

need for the same nutrient but in varying amounts. The amounts of nutrients needed are

influenced by age, sex, size activity and state of health.

Different types of food

Different types of drink

218
List of food found in locality

- Yam

- Cassava

- Cocoyam

- Plantain

- Leafy vegetables

- Banana, Orange, mango, pinapple

- Rice, beans

- Garden eggs

219
BASIC FOOD NUTRIENTS

Basic nutrients are carbohydrates, protein, fats, minerals, vitamins and water. These are

the basic building blocks of a good diet.

FOOD SOURCE OF NUTRIENTS

CARBOHYDRATES

Carbohydrates are macro nutrients elements carbohydrates supply the body element with

the energy it needs to function.

Classified into;

- Monosaccarides e.g glucose, fructose, galactose

- Disacharrides e.g

- Polysaccharides e.g

Carbohydrates: carbohydrates are macro nutrients, because they are needed in large

amount by the body, carbohydrates supply the body with the energy it needs to function,

and can be classified into simple and complex carbohydrates.

Simple carbohydrates

Simple carbohydrates, sometimes called simple sugars include fructose (fruit

sugar), sucrose (table sugar) and lactose (milk sugar) fruits are one of the richest natural

sources of simple sugars

Cube of Sugar
220 Assorted Fruits
Glucose is the form in which carbohydrates absorbs into the blood system. The glucose

used directly to provide energy for the body

Complex Carbohydrates

Complex carbohydrates include fibre and starches, food rich in complex

carbohydrates include whole grains, beans, vegetables cereals, carbohydrates are the

main source of blood glucose, which is the major fuel of energy for the brain and red

blood cells.

Except fibre which cannot be digested both simple and complex carbohydrate are

converted into glucose.

Bread Rice

Plantain
Millet

221
PROTEINS

Proteins are also macro nutrients. Protein is essentials for growth and development. It is

needed for the manufacture of hormones, antibodies, enzymes and tissues. It also helps to

maintain proper acid alkaline balance in the body. Protein is classified into first class and

second class protein (plant protein and animal protein)

When protein is consumed is broken down into amino acid, the form which the body

absorb protein. Amino acid is classified into essential amino acids and non-essential

amino acids.

FOOD SOURCES OF PROTEIN

222
FATS AND OIL

Fats and oil is another group of macro nutrient, needed to prone energy and support

growth, fat is the most concentrated source of energy available to the body.

During infancy and childhood, fat is necessary for normal brain development, after about

two years of age, the body requires only small amounts of fat.

Excessive fat intake is a major causative factor to obesity, high blood pressure, coronary

heart, disease and colon cancer and has been linked to a number of other disorder as well.

Fatty acid like amino acid is also classified essentials and non-essential fatty acids

Sources of Fat and Oil

223
VITAMINS / MINERALS

Vitamins and minerals are often reflected as micronutrients because they are needed in

relatively small amount compared with other four basic nutrients.

Vitamins are of two types,

Water soluble – vitamin B & C

Fat soluble – vitamins ADEK

Minerals are also classified as macro elements and micro elements. Vitamins protect the

body against diseases and infection, which minerals regulate body processes

SOURCE OF VITAMINS

WATER

Water is an essential nutrient that is involved in easy function of the body. Water

helps to transport nutrients round the body and eliminate waste products in and out of

cells, water should be odourless and tasteless. Water is necessary to digestive, absorption,

224
circulatory and excretory functions. Water is needed for the utilization of the water

soluble vitamins, maintenance of proper body temperature. It is recommended that you

drink at least eight (8) glasses of water each day.

Source of water -

DIETARY DEFICIENCY OF THE NUTRIENTS

Carbohydrates: Excess carbohydrates.

1. Diabetes

2. Obesity / overweight

3. Dental caries

Dental Caries
Obesity / overweight
Thinness

225
DEFICIENCY OF PROTEIN

1. Stunted growth

2. Kwashiorkor

3. Weight loss

Weight loss

Stunted Growth
Kwashiorkor

FATS AND OIL

1. Frequent cold

2. Weakness

3. Scaly skin

Scaly Skin Weakness Frequent Cold

226
 Vitamins / minerals

1. Rickets in children

2. Osteomalacia in adult

3. Poor swelling teeth

4. Abnormal cloth of blood

5. Goitre

Ricket in children Poor swelling teeth Goitre

Osteomalacia in adult

WATER

1. Frequent constipation

2. Thirst

3. Dryness

227
 APPENDIX I

PICTORIAL NUTRITION EDUCATION

LESSON NOTE FOR THE EXPERIMENTAL GROUP

Lesson 4

Subject: Foods and Nutrition

Class: SS 1

Topic: Basic foods Nutrient (Food group)

Duration: 40 minutes

Entry Behaviour: Students have knowledge of different nutrient

Instructional Objectives: At the end of the lesion, students should be able to:

i. List the types of food groups

ii. Classify food nutrients into groups

iii. State the importance of food grouping in meal planning

Materials needed: Manual for the lesson, Pictures of food in the locality

Post card of food classification

Pictures of foods in the different group

Pictures

228
Instructional procedure:

Introduction:

Reviews the previous lesson. The researcher writes the topic on the chalkboard clearly for

all to see. “BASIC FOOD GROUP” Ask the students what they know about food group,

after they have given their suggestions; the researcher explains to them the meaning of

food nutrients

Definition of Food group

Food group is a diet planning tools that sorts food of similar origin nutrient into groups

and specify the number of servings one should consume from each group.

THE ACTIVITY

Ask the students to bring out their folder containing the instructional materials

Refers students to the food pyramid in their manual showing food groupings

Using pictures, shows food in the food groups

Classify food into five major groups of grains, meat fruits, vegetables and milk

FEEDBACK FROM STUDENTS

Get feedback from students about the lesson by asking questions such

(a) Classify food into five major groups (b) give 3 functions of each nutrient

ASSESSMENT / FOLLOW-UP

Students will be asked questions based on what they have been learnt.

1. Classify food into groups.

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 CLIP FOR LESSON FOUR

CLASSIFICATION OF FOOD INTO MAJOR GROUPS.

Foods are generally classified into five (5) major groups. Food grouping enables

one to have a well-balanced diet all the time. Food group is a diet is planning tools that

sorts food of similar origin nutrient content into groups and specify the number of

servings one should consume from each group. They are groups of fruits, vegetables,

grains, meat, poultry, fish, eggs, nuts.

Milk group (Dairy Products)

Food sources

1. Cheese

2. Milk

3. Butter mek

4. Yoghurt

Meat and beans group.

1. Legumes (beans lentils peas).

2. Meat (beef, pork, poultry, gaze meat, fish).

230
 3. Nuts and seeds (almond, nozels nuts, mixed nuts , peer nuts, pear butter, walnut,

sunflower seeds, soy-protein produce).

Chicken
Beans Meat - Beef
Fruit group

Apples, apiroits, avocados, banana, berries, dovces, graps, grape fruit, mangoes, melons,

oranges, peeres, pineapple, raisesss, tangerine. 100& fruit juice

Vegetables group

Broccoli cauliflower, carrot and others green cucumbers, green beans, lettuce, potatoes,

reddish, spinach, squash, sweet potatoes, tomatoes, raisins, tangerine 100% vegetables

juice.

231
Grain group - breads and cereals

whole grain bread, English muffins, cereals ( hot and cold) pasta or rice.

Oil or low fat.

 Low fat margarine

 Vegetable oil

Serving from each group includes

2-4 serving of fruits

2 – 4 serving as vegetable

6 – 11 serving as grains

2 -3 serving as meat, poultry, fish etc.

2 – 3 serving of milk, yoghurt and cheese.

 Fats, oil, sweets and salts should be used sparingly

232
 APPENDIX J

PICTORIAL NUTRITION EDUCATION

LESSON NOTE FOR THE EXPERIMENTAL GROUP

Lesson 5

Subject: Foods and Nutrition

Class: SS 1

Topic: Meal planning

Duration: 40 minutes

Entry Behaviour: Students have knowledge of nutrients groupings

Instructional Objectives: At the end of the pictorial nutrition education students

should be able to:

i. Explain the meaning of meal planning

ii. Understand the principles of meal planning

iii. List factors guiding meal planning

iv. State meal patterns using the pyramid table and recommended dietary

allowance

Materials needed: Handbook on nutrition developed by the researcher

A food guild pyramid table

233
Instructional procedure
Introduction
Review the previous lesson. Writes the topic on the chalkboard clearly for all to see.
“MEAL PLANNING” Ask students what they understand by meal planning after they
have given their suggestions; the researcher explains to them the meaning of meal
planning
Definition of Meal Planning
Meal planning is the process of deciding on what to serve for a given period. It means to
plan healthy family meals taking into consideration the food group shown in the food
pyramid.

THE ACTIVITY
Using post cards, explains the meaning of meal planning
Give a pictorial view of the principles of meal planning
Using post card of factors guiding meal planning
Using food pyramid table, explain different serving of food from each group
Explains what RDA means and how importance is meal planning

FEEDBACK FROM
Get feedback from students about the lesson
Ask questions such as
(1) What is meal planning
(2) What is recommended daily allowance

ASSESSMENT / FOLLOW UP
Write an essay on meal planning

234
 CLIP FOR LESSON FIVE

WHAT IS MEAL PLANNING

Meal planning is organizing and putting together what to serve for a certain amount of

time. It means to plan healthy family meals taking into consideration the food using the

food group pyramid.

Principles meal planning

- Select foods from all groups

- Meal pattern must suit the family members

- Add variety to meals

- Variety in colour

- Variety in texture

- Variety in taste and flavor

Consideration during meal planning

- Nutritional requirement of all individuals in the home.

- Special restriction (obesity, diabetes, ulcer).

- Individual taste and preferences

- Food available

- Money available

Healthy eating tips

-Do not skip breakfast

-Eat at least three meals a day

-Eat foods from each of the food groups at every meal.

235
-Eat diet low in unsaturated fats

-Make starchy foods the basis of most meal.

-Eat plenty of fruits and vegetables every day.

-Eat salt sparingly

-Exercise regularly and reduce activities in which you sit (such as watching TV) -drinks

lots of clean water, at least 8 glasses, a day.

-Read nutrients labels on all processed foods. This will help you know what kind of fats

and how much the food contains.

APPENDIX K

236
 APPENDIX L

PICTORIAL NUTRITION EDUCATION

LESSON NOTE FOR THE EXPERIMENTAL GROUP

Lesson 6

Subject: Foods and Nutrition

Class: SS 1

Topic: Food puzzle activity using self efficacy and problem solving  

activities

Duration: 40 minutes

Entry Behaviour: Students eat every day

Instructional Objectives: At the end of the pictorial nutrition education  

students should be able to:

i. Understanding the concept of self efficacy in learning

ii. Apply nutrition information in solving activity by replacing food items in

the same food groups on the food puzzle

iii. Arrange the cross word puzzle game on nutrition (Appendix V)

Materials needed: cross word puzzle game. Theory of self efficacy explanation   

 on a post card

237
Instructional procedure

Introduction

Review the previous lesson. Write the topic on the chalk board clearly for all to see. Ask

the students what they know about food puzzle game and self efficacy theory after they

have given their suggestions, the researcher explains to them the meaning of self-efficacy

Definition of self efficacy and food puzzle game

Self-efficacy is a subset of social has learning theory of band. Bandura believes that

students learn through observation and modelling in addition to self efficacy.

The concept of self-efficacy is the confidence a person feels about determining a

particular activity, it includes over coming barriers in performing that behaviour

THE ACTIVITY

Give a pictorial view and explanation of the importance of self efficacy theory as it

related to learning

Give students cross word puzzle game card to fill

Ask students to select food items belonging to same group to design a personal food

pyramid

FEED BACK FROM STUDENTS

Get feed back from the students about the lesson, asking questions such as

List five importance of self efficacy in learning

Why is the game important in learning?

ASSESSMENT / FOLLOW UP

Write an essay on the concept of self-efficacy

238
 APPENDIX M

SAMPLE OF NUTRITION EDUCATION LESSON NOTE FOR THE CONTROL

GROUP

Lesson 1

Subject: Foods and Nutrition

Class: SS 1

Topic: Introduction to Nutrition

Duration: 40 minutes

Teaching Aid: Textbook: Food and Nutrition for Senior Secondary  

School

Entry Behaviour: Students have being eating

Instructional Objectives: At the end of the lesson students should be able to:

(1) Define Nutrition

(2) State the importance of nutrition

(3) State factors affecting food and nutrition

Instructional Strategies:

Steps 1: The teacher introduces the new topic

Step II: The teacher defines Nutrition

Step III: Explains the importance of good nutrition to the body

Step IV: State factors affecting nutrition

239
Summary

Definition of Nutrition

Nutrition is the science of food and how the body utilizes the substance in the food for

growth, development and maintenance of life.

Importance of good nutrition

1. Formation of strong healthy bones

2. Bright eyes

3. Formation of good set of teeth

4. Healthy and shinning skin

5. Maintenance of good health

Food

Food can be defined as any substance either liquid or solid eaten to nourish the body

Factors that affect nutrition

1. Availability of food

2. Available income

3. Food in season

4. Storage/preservation facility available

Evaluation: Students should answer the following questions

1. Define nutrition
2. State the importance of human nutrition
3. List three factors that affect good nutrition
Teacher summarizes, the lesson and the students copy the chalkboard summary
Assignment: find out other factors that affect nutrition

240
 APPENDIX N

NUTRITION EDUCATION LESSON NOTE FOR THE CONTROL GROUP

Lesson 2

Subject: Food and Nutrition

Class: SS 1

Topic: Basic Food nutrient

Duration: 40 minutes

Teaching Aid: Food and Nutrition Textbook / chart of different food nutrient

Entry Behaviour: Students have knowledge of simple nutrition

Instructional objectives: At the end of the lesson, students should be able to :

(1) Identify various foods in the locality

(2) List the types of food nutrients

(3) Classify food nutrients into groups

Procedure

Step 1: The teacher introduces the new lesson.

Step II: The teacher defines food nutrient

Step III: The teacher further classify food nutrients into groups

Step IV: The teacher explains in details

241
Summary

Definition of food nutrient

Food nutrient can be defined as chemical substance found in food

Classification of nutrient

Food nutrients are classified into six classes. They are carbohydrates, proteins, fats

and oils, minerals, vitamins and water

Proteins

Proteins are macro nutrient and are made up of element like carbon, hydrogen,

oxygen and nitrogen. Protein is the only nutrient that contain nitrogen

Proteins are complex and contain amino acids which are smaller units. Proteins can

be classified into two main groups’ namely 1st class protein and 2nd class protein

First class protein is also called complete protein or animal protein while second class

protein is known as incomplete protein or plant protein.

Functions of protein

1. It promotes growth and repair worn out tissues

2. Serves as source of energy in the absence of carbohydrates and fats

3. It is responsible for hereditary traits (characteristics) from parents to children

4. They serves as primary source of amino acids which are the building

242
Food sources of protein

Legumes, beans, pears all meats, eggs

Deficiency diseases of protein

1. Stunted growth or growth retardation

2. Kwashiorkor in children

3. Weight lost

Evaluation: The teacher asked the following questions on the topic taught

(a) Define nutrient

(b) State the different types of nutrient

The teacher summarizes the lesson and asks students to copy the chalkboard summary

Assignment:

Find out more food sources of proteins in your locality

243
 APPENDIX O

NUTRITION EDUCATION LESSON NOTE FOR THE CONTROL GROUP

LESSON 3

Subject: Food and nutrition

Class: SS 1

Topic: Basic food nutrients (carbohydrates)

Duration: 40 minutes

Teaching Aid: Textbook,

Entry Behaviour: Students have learnt protein

Instructional objective: At the end of the lesson, students should be able to

(a) Define carbohydrate

(b) State the types of carbohydrates

(c) Identify various food sources of carbohydrate

Procedure:

Step 1: the teacher reviews previous lesson and carbohydrate as one of the food nutrient

Step 2: the teacher defines carbohydrate

Step 3: the teacher further classify carbohydrates and list its four sources

Summary

Carbohydrates

Carbohydrates are macro nutrients and contain element like carbon, hydrogen and

oxygen. Carbohydrates are produced by plants through a process known as

photosynthesis.

244
Carbohydrates can be classified into three main groups

(a) Monosaccharide

(b) Disaccharides

(c) Polysaccharides

Monosaccharides are known as simple sugar and are the simplest units of carbohydrates

that cannot be broken down further. Examples of monosaccharide are glucose, ribose,

lactose, and mannose

Disaccharides are carbohydrates made up of between two and ten units of

monosaccharide units, examples of disaccharides are maltose, sucrose, lactose, rettinose,

and stachyose

Polysaccharides: these are the largest carbohydrates; they are made up of more than ten

monosaccharide units joined together. One of the factors responsible for the difference in

the properties of different polysaccharides is the way they are joined together, for

example both cellulose and starch are polysaccharides formed by the joining together of

many glucose units. The glucose molecules in cellulose are joined together in a different

way from those of starch. Other polysaccharides that occur naturally in plants foods are

protein, gums, and hemicellulose. The polysaccharides glucogen is the polysaccharides

found in chemicals.

FUNCTIONS OF CARBOHYDRATES

1. Carbohydrates are the main source of energy to the body.

2. Spares protein; ie, in the presence of carbohydrates, protein will not be burnt off

to produce energy

245
 3. It adds bulk to the faeces

4. It assists in complete oxidation

5. Starch and sugars give flavor and variety to the diet.

DEFICIENCY OF CARBOHYDRATES

1. Incomplete metabolism of fats and oil

2. Weakness

3. Excessive consumption leads to obesity

4. Protein stored in the muscle will be used to produce energy and this can lead to

thinness

Evaluation: The teacher evaluates the less by asking the students the following

question

1. What is carbohydrate

2. What are the classes of carbohydrates

The teacher summarizes and gives examples of the food sources

246
 APPENDIX P

NUTRITION EDUCATION LESSON NOTE FOR CONTROL GROUP

LESSON 4

Subject: Foods and Nutrition

Class: SSI

Topic: Basic Nutrient (fats and oil)

Duration: 40 minutes

Teaching Aid: Foods and Nutrition Textbook

Entry behaviour: Students have been exposed to basic nutrients

Instructional objective: At the end of the lesson, students should be able to:

1. Define fats and oils

2. Classify fats and oil

3. State the functions of fats and oil

Procedure

Step 1: Teachers reviews the previous lesson of carbohydrates.

Step II: Teacher defines and explains fat and oil

Step III: Teacher explains the classes of fats and oil

Step IV: Teacher list the various functions of fats and oil

Summary

Fats and oil

Fats and oil are another group of macro nutrients needed by the body and they are made

up of elements like carbon, hydrogen and oxygen. Some fats and oils are made up of

247
glycerol and fatty acids and the difference is that, they can be determined by the different

fatty acids they contain. Fats and oil contain generally a minimum of one fatty acid

molecule and three fatty acid molecules, joined to form one molecule of glycerol.

When one molecule of fatty acid joined to the one molecule of glycerol, it is known as

monoglyceride but when two molecules of fatty acids, are joined to one molecules of

glycerol it is known as diglyceride, while if three are joined to one molecule of glycerol

is referred to triglycerides. The major difference between fats and oil is that fats are solid

at room temperature while oil is a liquid at room temperature.

Fatty acids like amino-acid are classified as essential and non essential fatty acids.

Essential fatty acids are those that can be produced by the body all from other food

sources. Non -essential fatty acids are those that the body can get from other sources.

Fatty acids are either saturated or unsaturated.

Saturated fatty acids do not contain any double bond between the carbon atoms while

unsaturated fatty acids contain one or more double bonds between the carbon atoms.

Food sources

Butter, meat, fat, palm oil, all nuts, groundnut oil etc

Deficiencies diseases of fats and oils

Dry skin, frequent cold and weakness

Evaluation: The teacher evaluates the lesson by asking the students the following

question

1. Define fats and oil

248
The teacher summarizes the lesson and asks the students to copy the black board

summary.

Assignment

Explain saturated and unsaturated fatty acids.

249
 APPENDIX Q

NUTRITION EDUCAION LESSON NOTE FOR THE CONTROL GROUP

LESSON 5

Subject: Foods and Nutrition

Class: SS 1

Topic: Basic Nutrient (minerals, vitamin)

Duration: 40 minutes

Teaching Aid: Textbook on foods and nutrition

Entry Behaviour: Students have been taught other types of nutrients

Instructional objections: At the end of the lesson students should be able to:

1. Define Minerals and vitamins

2. State their functions

3. Identify their food sources

Procedure:

Step 1: Teacher reviews the previous lesson of fat and oil

Step II Teacher explains what vitamins mineral are

Step III: Teacher classify vitamins into water and fat soluble vitamin

Step iv: Teacher classify mineral element into macro and micro

Steps v: Teacher explains their functions

250
Summary

Minerals

These are inorganic nutrients. They assist in regulating body processes and if care is not

taken during cooking they are lost but heat and food processing does not normally affect

mineral content of food.

Types of mineral element

Macro and micro mineral element

Macro elements are those they are required in a relatives large amount examples are

calcium, phosphorus, magnesium, sulphur, sodium, potassium iodine, fluoride, zinc,

celenuim and chromium while micro elements are needed in the body in minute quantity

Calcium: It is present in the body more than any other mineral. It works in conjunction

with phosphorus for all issues.

Functions

1. Coagulates blood

2. Helps to rhythmic heart beat

3. Helps in building strong bones and teeth

Deficiencies

1. Rickets in children

2. Osteomalacia in adults

3. Poor quality teeth

4. Irritability and muscular spasm

5. Abnormal clothing and blood

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Food sources:

Milk, cheese, fish

Phosphorus: Phosphorus is also needed for bone formation. It is mostly present in

portentous food and just little or small amounts are found in blood phosphorus is mostly

needed by expectant mothers and children

Functions

1. Strong bones and teeth

2. Help in maintenance of the neutrality of the blood

3. It stores and releases energy

Food sources

Livers, milk, meat, fish, legumes, egg yolk, leafy vegetables and whole grains

Deficiencies

1. Rickets in children

2. Weak teeth

3. Osteomalacia in adults

Sulphur

1. Necessary for formation of connective tissue

2. For formation of skin

3. Necessary for development of hair and nails

Food sources

Present in thiamine and biotin, a diet that is adequate in protein usually supply enough

amount of sulphur.

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Vitamins

Vitamins in like other nutrients, is not required in large quantity by the body

Vitamins are of two types, namely

1. Water soluble vitamins and

2. Fat soluble vitamins

Water soluble vitamins can dissolve in water, examples are B complex and vitamin C.

The B complex vitamins are B1, B2, B6 B12 and folic acid, niacin while the fat soluble

vitamins are vitamins A D, E and K

Sometimes, some food element can be converted into Active vitamins and these are

called pro=vitamins or precursors, similar when some substances interfere with

proper usage or functioning of vitamins in the body, it is called anti vitamin.

Water

Water make up approximately 2/3 of the body composition and it is present in every

cell and tissue. Water has no energy value but it is very important to man. Man can

barely survive without water, just like plants. It is composed of oxygen and hydrogen

in a ratio of 2

Qualities of water

Odourless, Colourless and Tasteless

Functions

1. Regulate body temperature during hot and cold weathers

2. Quenches thirst

3. Helps in digestion of food

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 4. Help in absorption of food nutrients

5. Assist in excretion of waste, products from the body eg faeces and urine

6. Helps in transport substance from one part of the body to another.

Sources

Taps, rivers, well, beverages, soft drink

Deficiencies

1. Constipation (indigestion)

2. Thirst

3. Discomfort

Evaluation

The teacher evaluates by asking the following questions

1. Explain mineral element

2. Give two sources of mineral elements

The teacher summarizes the lesson and asks the students to copy the chalkboard summary

Assignment: Write an essay on fat soluble vitamins

254
 APPENDIX R

NUTRITION EDUCATION LESSON NOTE FOR CONTROL GROUP

LESSON 6

Subject: Foods and Nutrients

Class: SS 1

Topic: Meal planning / Food groups

Duration: 40 minutes

Teaching Aid: Textbook

Entry behavior: Students are familiar with different nutrients and feeding pattern in the

home

Instructional objective: At the end of the lesson students should be able to:

1. Define meal planning

2. Understand the principles of meal planning

3. List factors guiding meal planning

4. Explain food groupings

Procedure:

Step I : Teacher reviews the previous lesson

Step II:Teacher explains the principles of meal planning to the students

Step III: Teacher list factors guiding meal planning

Step iv: Teacher classify food into groups and explains their functions

255
Summary

Meal planning is organizing and putting together, what to serve for a given period. It

means to plan healthy family meals taking into consideration the health status, age and

activities of all family members.

Principles of meal planning

- select food from all groups of food

- meal pattern must suit the family members

- there should be variety in meal

- combine various colour

- variety in texture

- variety in taste and flavour

Consideration during meal planning

- consider meeting the nutritional requirement of all members of the family

- Consider individual taste and preferences

- Consider food that is available and in season

- Consider the health status of all in the home

Food groups

Foods are generally grouped into energy giving, body building and protective foods

Energy giving food

These are carbohydrates and fats they provide energy for movement warmth and work.

There are many food items in this group like yam, cassava, maize, plantain, oil, cake, rice

etc

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Body building food

Body building foods are proteins. They repair worn out tissues in the body and comprise

very small units known as amino acid. They are found in foods such as milk, beans,

cheese, fish, eggs etc

Protective foods

These are vitamins and minerals salt which help to regulate the body processes. Their

functions are

1. Protect the body against disease

2. Help to build strong bones and teeth

3. Keep the skin smooth and healthy

4. Keep the eyes, nerves and brain in good functioning condition

Food sources

All fruits and vegetables spinach oranges, paw-paw, tomatoes, carrots etc

Evaluation: The teacher evaluate the lesson by asking the students the following

question

1. What is meal planning

2. Classify food into group

Teacher summarizes the lesson and the students copy the chalkboard summary

257
 APPENDIX S

Food Exchange List

Nigeria local foods in weight with household measures (dsp = level dessertspoon; tsp
= level tablespoon).
10g carbohydrate 10g carbohydrate
Weight of cooked Household Weight of cooked Household
foods (g) measures foods (g) measures
Cereals
Rice long grain (boiled) 30 2dsp 45 3dsp
Jollof rice 33 2dsp 50 3dsp
Rice-Tuwo 34 2dsp 58 3dsp
Millet amala 70 2dsp 105 3dsp
Maize com amala 65 2dsp 98 3dsp
Maize com-Egbo 35 2dsp 53 3dsp
Milled sieved maize paste 75 2dsp 112 1.5dsp
Maize mould agidi 72 - 108 -
Bread 20 1 thin slice 30 1.5 thin slice
Roots and tubers
Cocoyam boiled 40 1.5large thin silce 60 3large thin silce
Yam (boiled) 5 1thin medium slice 53 1.5 medium than slice
Pounded yam 45 1dsp 68 11.5dsps
Yam flour-amala 54 1.25dsp 81 2dsps
Cassava flou-amala 50 1dsp 75 1.5dsp
Foo foo 40 1dsp 60 1.5dsp
Cassava gari-eba 33 2dsp 50 1.5dsp
Irish potato (boiled) 53 1 large/2 egg size 80 1.5big/3 egg size
Irish potato (fried) 25 1 big/2 small 38 1.5 big/3 small egg seiz
Unriped platain (amala) 63 0.25 medium size\ 95 egg size 5dsp\
Unriped platain (cooked) 40 0.25 medium size\ 60 0.5 medium/3 size\
Unriped platain (fried) 20 0.25 medium size\ 30 0.5 medium size\
Unriped platain roasted 25 0.25 medium size\ 38 0.5 medium size\

Fruits - 1medium size - 1.5medium size

Orange - 2 large size - large size
Tangerine - 1 thin slice - 1.3 thin slices
Pawpaw (fairly ripe) - 0.5 medium size - 1medium slices
Mango (fresh) - 1 large size - large size
Banana - 0.5 medium size - 0.75medium slices
Grape fruit - 1 thin slice - 1.5thin slices
Melon - 2 small size - 3small size
Carrot

Milk - 2dsp - 3dsp

Powdered
Evaporated unsweetened milk 85 6tbld 128.0 3dsp

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Biscuit 15 2pieces 23.0 3 pieces
Plain cracker biscuit
Exchange list for common Nigeria protein foods (each serving contain
approximately 7g protein, 6g fat and 9g calories)
Food Quantity
Beef 28g
Mutton 28g
Chicken 28g
Fish 55g
Evaporated milk ½ medium tin
Powdered milk 2 dessertspoons
Cowpea cooked ½ cup (3 dessertspoons)
Cowpea pudding 112g
Peanut 58g

Fat exchange list (each serving contain 5 g fat and 45 calories.

Food Quantity
Red palm oil 1 tsp (5mls)
Peanut oil 1 tsp (5mls)
Soyabean oil 1 tsp (5mls)
Corn oil 1 tsp (5mls)
Note tsp = teaspoon

259
 APPENDIX T

Researcher in School A Students in Sch

training manua

p photograph Researcher in School B

ool B

Researcher assistance taking anthropometric measures in School B (Height and Weight)

260
APPENDIX U

261
APPENDIX V

262
263