Effectiveness of environmental nutrition program on student dietary intake in boarding schools

Introduction

Female adolescents are also more susceptible to nutritional problems.¹ Overweight girls are more likely to be overweight or obese when they enter adulthood.² Like their counterparts, girls who suffer from undernourishment are at a higher risk of continuing to become undernourished as adults. During pregnancy, undernourished adults tend to give birth to babies with low birth weights, creating a cycle.¹

Globally, overweight girls are more prevalent in American countries, reaching 21% in 10.9% of obese girls. Meanwhile, underweight girls are more prevalent in Southeast Asian countries, reaching 10.4%.³ In Indonesia, the percentage of girls who were overweight reached 15.9%, including 4.5% of obese girls. For underweight girls, it was around 4.3% and was improved by an increase in overweight girls.⁴

Studies have shown that female adolescents are more attentive to health than male adolescents. However, girls are also more likely to be overweight or obese.⁵ Female students seemed to find basic nutrition more comprehensible.⁶ They attempted healthier lifestyles but consumed less nutrients and more fat than male students.^5,7 Girls communicated their preferences for having snacks or light meals with friends after school rather than having dinner with their family. Preferable snacks tend to be sugary and greasy. Therefore, a nutrition initiative targeting female students was suggested to promote and assist them in adopting a proper diet.^8,9

There was a significant improvement in girls’ weight status and waist circumference after implementing a school-based nutrition education program.¹⁰ The findings of this study also explain the improved nutritional behaviors, self-efficacy, and other psychological aspects of the student. In addition, with the provision of iron tablets, adolescent girls seem to adhere to iron tablets.¹¹ However, the implementation of these nutrition programs in Indonesian schools has been hindered by limited resources.¹² According to the teachers’ self-efficacy, experts in health were needed related to competing priorities to teach and communicate balanced nutrition. Food environment is also a concern.

For these reasons, it is recommended that a school-based nutrition program be started in a boarding school. The presence of school doctors or nurses in Indonesian boarding schools was considered an advantage for students to access health during their study. In addition, a closed and facilitated environment enabled them to practice a favorable lifestyle. For example, a program reduced anemia prevalence and changed students’ dietary behavior by providing nutrition education and balanced lunches alongside existing meals from school.¹³ However, there is still a lack of research on nutrition among boarding school students in Indonesia, making this a topic that requires further discussion. The present study offers an alternative environmental approach to the exploration of less burdened nutrition programs applicable to boarding schools with stricter schedules and rules. Consequently, this study aimed to investigate the effectiveness of a program called the Environmental Nutrition Program (ENP) on students’ dietary intake as well as nutritional knowledge.

Methods

A quasi-experimental study was applied in this study and two boarding high schools were purposely selected, one as an intervention school and one as a control school. The study was conducted during the mobility restriction of COVID-19 measures, where schools were conducted online and only several boarding schools were allowed to have onsite learning with conditions set by the government. Therefore, this study proposes criteria for onsite learning with 100% students present at school and staying at school dorms as the main purpose for school selection. Later, the school’s willingness to participate throughout the study period as an intervention or control school was communicated. The entire ENP study was conducted over 12 weeks, from January to April 2022.

Results

Over two weeks, in January 2022, initial meetings were held in both schools for participant recruitment, followed by baseline measurements. Study protocols, activities, and inclusion criteria were explained to all students at the meeting. Students who were interested in joining were asked to obtain their parents’ informed consent by the time the baseline measurement took place. The measurement comprised anthropometric measurement, 24 hours food recall, and a self-registered questionnaire on nutritional knowledge and sociodemographic information. All data collection was conducted onsite or at school. Therefore, with the challenging COVID-19 measure in both boarding schools, only 119 of 177 eligible students completed baseline measurements. Eventually, a total of 113 students completed baseline and post ENP measurements, or approximately 95% retention rate (Figure 1).

Figure 1. Participant flow in ENP.

Table 1 presents the general characteristics of the participants. The median age of the students was 16 (IQR: 1) years, ranging from 14 to 18 years. The students from both schools shared the same characteristics. The only exception was the monthly allowance, where students from the intervention school provided a higher stipend than their counterparts (p-value = 0.008).

At baseline, students’ nutritional knowledge did not differ between schools (p-value = 0.48, Figure 2). The knowledge score were 71.6 and 70.9 in the intervention and control school respectively. Post ENP measurements recorded a significant increase in the nutritional knowledge of the students in the intervention school compared to baseline (diff = +6.45, p-value < 0.001). The knowledge was also higher compared to those in the control group after the ENP (p-value < 0.001).

Figure 2. Nutritional knowledge change of the students after ENP.

Regarding dietary intake, students in the control school consumed more calories, proteins, and carbohydrates than students in the intervention school at baseline (p-value < 0.001, Table 2). There was no difference in students’ fat intake between schools at baseline (p-value = 0.183). After ENP, the carbohydrate intake of students in the intervention school increased compared to baseline measurements (diff = +33.2, p-value = 0.001).

On average, neither student in the intervention nor control school had adequate nutrient intake at baseline and after ENP (Figure 3). Indonesian RDA for high school aged female adolescents was 2050/2100 kcal of total energy intake, 65.0 grams of protein intake, 70.0 grams of fat intake, and 300.0 grams of carbohydrate intake per day.²³ However, the carbohydrate adequacy ratio of the students in the intervention school significantly increased after ENP (diff = +11.02, p-value = 0.001). Further analysis revealed that the protein adequacy ratio of students in the intervention school was positively correlated with their nutritional knowledge change after ENP (r_s = 0.296, p-value = 0.025, data not shown).

Figure 3. Student’s nutrient adequacy ratio changes for (a) total energy, (b) protein, (c) fat, and (d) carbohydrate, respectively.

A combination of the four activities in the ENP yielded a significant increase in students’ nutritional knowledge based on the regression model in Table 3 (β = 4.78, p = 0.023). The activities seemed to lower the total energy, protein, and fat intake and seemed to increase the carbohydrate intake of the students. Both trends of ENP toward students’ nutrient intake and nutrient adequacy ratio were not statistically significant (p > 0.05).

Discussion

Our study assessed an applicable alternative to support a healthy diet among female students in boarding school settings. The environmental approach and communication methods in the study outweighed the time constraints of boarding schools to inform students about health.

This study had several main findings. First, ENP activities increased the students’ nutritional knowledge. Furthermore, students in the intervention group showed an improvement in their daily carbohydrate intake after ENP. Considering the change in the control group and the covariates, ENP was found to be effective at enhancing students’ nutritional knowledge and improving balanced nutrient intake within an 8-week period, despite the insignificant statistics for intake.

The finding of increased nutritional knowledge was consistent with those of previous studies.^13,24 Despite the argument regarding the number or duration of education sessions, an increase in nutritional knowledge in the present study remained effective after eight weeks. The provision of Nutrinfo immediately in front of the food queue lane at the dining hall stood out by its design and size. This allowed the student to notice the infographics at least three times a day during mealtime. Four topics were also delivered in sequence, ensuring the students’ emphasis. In addition, Nutrinfo was available on the dining table where the participating students were seated and on the wall of the tuck shop at school. With persistent but voluntary exposure, Nutrinfo enriched the discussion on communication methods for a limited health education session program.²⁵

A nutrifact display was meant to tell the students about the amount of nutrients in each school food that they consumed. Pairing the use of uniform serving tools with Nutrifact was expected to familiarize students with estimating their daily intake. The findings of this study show that carbohydrate intake as well as the NAR of carbohydrate in students significantly increased post ENP. The intake of total energy, protein, and fat improved, but was not statistically significant. Lack of food might be the reason behind this finding, as students in this intervention school could have staple food as much as they wanted during each mealtime.⁷ Students in the intervention school expressed that the side dish would run out later than most of the students. Some of them would eat staple food with little leftover soup, or they would just skip the meal. Those who tried to substitute the food shortage seemed to choose carbohydrate-rich foods, such as instant noodles, sweet bun, chicken noodle soup, or snacks.²⁶ In fact, they lacked not only carbohydrates but also proteins and some amount of fat. Unlike previous studies of normal and overweight students, the present study considered an increase in dietary intake as an improvement because participants’ intakes were much lower than the national RDA, to begin with.^10,14 An exception was regarding fat intake, which, on average, was about to reach the RDA at baseline; therefore, precaution to control fat intake was conveyed. On the other hand, protein adequacy tended to positively correlate with the change in nutritional knowledge post ENP. This was explained by the increase in correct answers in the nutritional knowledge assessment of the protein portion of a meal and protein sources. A previous study discussed otherwise, in which knowledge of protein sources remained low after the intervention.¹³ With unchanged knowledge, however, the study managed to improve the practice of consuming protein sources and led to better protein intake from the provided lunch.

With regard to intake in the control school, we observed a decrease in student intake, even though there were no specific events or significant menu changes during the study period. The declining trend was not significant. Even so, a plausible cause might be underreporting. This could be triggered by the awareness of what was being interviewed during the 24-hour food recall regarding the amount or type of food, how the food was processed, the situation during the interview, or a biased recall that is common in any dietary assessment.²⁷

After eight weeks of exposure to all ENP activities, trends of improvement in nutritional knowledge, daily carbohydrate intake, and NAR of carbohydrate of the students remained after including changes in control school and the covariates in the model (Table 3). Nevertheless, only a significant increase in nutritional knowledge persisted after adjustment. A study supported our finding that although nutritional knowledge among intervened students was found to increase after nutrition education, it did not significantly improve students’ dietary practices.²⁸ Ariyo et al.²⁹ found that after five weeks of nutrition education with emotion-based messages, participants’ calcium intake did not change, although their source of calcium was multiplied. Conflicting findings have been reported in previous studies. School-based programs have resulted in improved fruit and vegetable intake, iron tablet consumption, and physical activity after 15-month of nutrition education using a multicomponent approach.¹¹ Similar findings were discussed in a study conducted by Rimbawan et al.¹³ The study provided nutrition education along with balanced lunch over 9 months. Subsequently, an increase in students’ knowledge and protein intake was observed. When applying an environmental nutrition that aims to maintain communal retention, some period of time is necessary to sustain good dietary behavior.²²

Despite these valuable findings, the present study had some limitations. The short period of ENP was assumed to be one. Another limitation was related to students’ dietary measurements. Like other dietary measurements, 24-hours food recall demands the respondents’ memory of what and how much food they ate. However, trained personnel in this study performed the multiple pass principle to record the participants’ diets as much as possible.

With a subtle trend in dietary intake, which has been suggested in this study, a longer implementation of ENP may yield better dietary intake for students. Future studies should consider material adaptation when implementing ENP among non-boarders.

Conclusion

ENP activities were effective in increasing students’ nutritional knowledge and daily carbohydrate intake. ENP also improved the students’ intake of total energy, protein, and fat. As an environmental approach, ENP emphasizes voluntary involvement with students but persists in exposure. Considering school readiness to apply for a comprehensive school-based nutrition program in a boarding school, ENP may be appropriate for enhancing basic nutrition literacy among female students.

Authors’ contributions

Conceptualization: all authors; data curation: SA; Formal analysis: all authors; funding acquisition: all authors; Investigation: SA; Methodology: all authors; project administration: SA; Resources: SA; Supervision: NT; Validation: SA; Visualization: SA; Writing–original draft: all authors; writing–review & editing: all authors.