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Presented in this chapter is a synthesis of the variables in this study. The

review of literature entails to discuss the relationship among the school profile,

its nutritional guidelines and school nurses’ contributions in developing and

implementing health and nutritional programs to a school. To support the study,

numerous literatures that are related to the topic were utilized. The chapter

begins with an overview of nutrition, nutritional guidelines internationally and

locally, nursing roles in student nutrition which are supported by findings of

researchers from various studies. The synthesis of the literature deals with

relationship of having occupational injury and diseases attributable to the

company profile and its health and safety practice.


According to the World Health Organization, WHO, (2015) an unhealthy

diet and lack of physical activity are leading global risks to public health. A

healthy diet throughout the lifespan prevents malnutrition and a vast number of

diseases and conditions. In present time people are consuming increasing

amounts of processed foods and the changing lifestyles in correlation with rapid

urbanization are making the people overweight at the same time as


The diversity of the diet will vary owing to significant factors that influence

the diet, e.g. cultural context, locally available foods and dietary customs, but

also individual factors such as age, gender and state of physical activity will
determine a person's health conditions. Worldwide underweight and obesity is

a public health problem that is constantly growing (WHO, 2015).

It was estimated in 2014 that 600 million adults worldwide were obese

and 41 million children under five years old were classified as overweight or

obese. The worldwide prevalence of the issue has doubled from 1980 to 2014.

This is not only a problem in industrialized developed countries as it is on the

rise in low- and middle-income countries as well. In 2014, nearly half of the

children in Asia under five years old were overweight or obese. In Africa the

prevalence of childhood obesity and overweight has doubled from 1990 (WHO,


Sufficient nutrition is the appropriate proportions of food required for

physical development and maintenance as well as supplying energy to the

body. The body mass index (BMI) is a tool for indicating an adult’s proper

weight, and is a criterion used for describing overweight and obesity.

Anthropometric measurements are a common criterion used for nutritional

assessments and a reliable tool for determining changes in nutritional status.

Another nutritional assessment method is the dietary evaluation using a 24-

hour diet recall where the energy intake by the individual and its relationship

with their nutrition and BMI values are taken into account (Rahmani et. al,


Prevalence of malnutrition occurring in various forms (obesity and being

overweight/underweight) in the world, particularly among adolescents and

young people, is a cause for concern. Nearly 70% of children and adolescents

suffering from malnutrition live in Asia (Abedi, 2012) .In Africa, 49.7% of young
people are either overweight or obese; however, at the University of Mutah,

Malaysia, the percentage of overweight and obesity was reported to be 4.9%

and 4.2% for female and male students, respectively (Al-Rewashdeh, 2010).

Recent studies in Saudi Arabia showed that 22.8% of Saudi students

were overweight and 15.7% suffered from obesity (Al-Rethaiaa & Fahmy),

2010). The other main problem in the world is the foodstuff deficiency including

micronutrients. Estimates show that more than 2 billion people around the world

are affected by lack of essential vitamins and minerals, particularly vitamin A,

iodine, and zinc. Nutrients deficiency is a risk factor leading to global burden of

10 diseases (WHO). It is generally believed that once individuals had access to

adequate various foodstuffs, their main nutritional requirements are met.

However, in addition to energy measurements and protein values of foodstuffs,

micronutrients sufficiency must also be considered (WHO) Research shows

that the high price of the foodstuffs containing micronutrients is a main reason

for the deficiency of these nutrients (WHO) and that certain groups in any

society, due to their adverse economic circumstances, are unable to afford such

foodstuffs (WHO). In many studies conducted on socio-economic factors

affecting nutrition, a significant association was observed between such factors

as monthly income, mother’s level of education, and household size and the

following factors: nutritional status (Suliga and Pawlinska, 2010), micronutrients

(Iron, Vitamin B12) deficiency, as well as ferritin and hemoglobin levels.

International guidelines

The Food and Agriculture Organization of the United Nations, FAO, is

responsible to continually review and look for new research and information on

human nutrients, both requirements and recommendations regarding nutrition

intake. These nutrients include protein, fat and lipids, energy, carbohydrates,

vitamins, minerals and trace elements. Many countries around the world rely

on these international guidelines from WHO and FAO when 2 they adopt their

own national dietary allowances and some countries use it as a base for their


National guidelines in Philippines

The Nutritional Guidelines for Filipinos (NGF) is a set of dietary

guidelines based on the eating pattern, lifestyle, and health status of Filipinos.

The NGF contains all the nutrition messages to healthy living for all age groups

from infants to adults, pregnant and lactating women, and the elderly.

Nutritional Guidelines aim to increase knowledge and educate the

population on proper health and nutrition. As a result, it will encourage them to

consume adequate and balanced diet as well as the promotion of desirable

food and nutrition practices in relation to health. The guidelines aim to improve

current dietary practices to prevent or alleviate diet-related public health

problems in line with current scientific knowledge

Because of the rapid growth and development during teenage years,

adolescents have greater needs for certain nutrients. Below are certain

nutrients needed by teenagers in greater amounts. These are based on the

Philippine Dietary Reference Intakes (PDRI) 2015 developed by Food and

Nutrition Research Institute of the Department of Science and Technology

(DOST-FNRI). The PDRI is a new set of multi-level standards wherein the

Recommended Energy/Nutrient Intake (REI/ RNI) is one of the components.

The REI/RNI is the level of intake of energy or nutrient which is considered

adequate for the maintenance of health and well-being of healthy persons in

the population.

 Energy – Adolescent boys need more energy foods because of an

increase in physical activities than adolescent girls. The energy

requirement of adolescents aged 13-15 years is 2700 kcal for 48.5 kg

boys while 2170 kcal for 46 kg girls. For adolescents aged 16-18 years,

it is 3010 kcal for 59 kg boys while 2280 kcal for 51.5 kg girls;

 Protein – The need for body building foods is also high among teenagers

because of accelerated growth and development. The protein need of

adolescents (13 -15 years) is 62 grams per day for boys and 57 grams

per day for girls. For adolescents aged 16-18 years, it is 73 grams per

day for boys while 61 grams for girls is needed;

 Calcium – Teenagers have higher requirements for calcium as the

adolescence period is a vital time for bone development. Teenagers

need extra calcium to store up an optimal amount of bone (peak bone

mass). Building bone mass through a balanced diet, including adequate

calcium may delay the onset or limit chances of developing osteoporosis

later in life. Calcium requirement for an adolescent boy or girl (13-18

years) is 1000 mg per day;

 Iron – Both teenage boys and girls need additional iron due to the growth

spurt. Among teenage girls, the onset of “monthly period” increases the

need for iron. The recommendation for iron is 19 mg/ day for teenage

boys (13-15 years) while it is 28 mg/day for teenage girls (13-15 years).

Iron requirements of teenage girls cannot be met by usual diet alone.

Intake of iron-rich and iron-fortified foods and the use of supplements

are recommended, if necessary.

It is important to plan how to get adequate iron. Iron from meat is better

absorbed by the body than the iron from plant sources. However, the absorption

of iron from plants is improved by eating fruit or drinking juice that contains

vitamin C with the iron-rich food. Meet the changing nutritional needs of a

growing teenager by choosing and enjoying a diet that includes a variety of

foods from the Pinggang Pinoy, coupled with regular physical activity. (PIA

NEWS, 2018)

Poor Eating Habits among Youth

The students are knowledgeable that consuming fast food, soda, and

processed food are unhealthy and they contain additives. They indicated strong

agreement to keep themselves hydrated and choosing food because of taste

preference. Even though majority admitted eating fresh fruits, a significant

number consume processed food such as chips, cookies, and cereal based on
convenience. Smartphone resources, vending machine use, and drinking soda

were their least frequently used habits.

Poor eating habit is a major public health concern among young adults

who experience transition into university/college life during which they are

exposed to stress and lack of inadequate time for food preparation. Rapid

changes in physical growth and psychosocial development have placed these

young adults a nutritionally vulnerable group with poor eating habits that fail to

meet dietary requirements. Some common unhealthy eating patterns among

young adults include meal skipping, eating away from home, snacking and fast

food consumption. Environmental factors contribute greatly to the adoption of

unhealthy eating habits among tertiary institution students. The mushrooming

of shopping malls, convenience stores, vending machines and fast food outlets

has created an alarming situation for young adults to practice unhealthy eating

habits. Students tend to make their own food choices based on cost of food and

availability of fast foods. Studies have shown that university/college students

fail to meet recommended intake of fruits and vegetables due to frequent

snacking habits and higher frequency of fast food consumption. (Adedeji, 2015)

Teens with poor eating habits are at risk academically as well as

physically. An unhealthy diet doesn't meet daily recommendations for fruit and

vegetable intakes and consists of mainly processed foods, refined grains and

foods that are high in fat, sugar, cholesterol, sodium or all four. According to the

Centers for Disease Control and Prevention, students who practice unhealthy

eating are more likely to receive poor grades, get low test scores and pursue

less education. Relatedly, teens who do not get enough food and are often
hungry are more likely to miss school or repeat a grade, according to the

National Education Association.

Research has shown that there is a need for interventions to address the

nutritional contributions of snacking occasions to overall adolescent dietary

intake. The results were in agreement with national data that indicate that

adolescents frequently consume snacks, and it is consequently important to

ensure that the foods and beverages consumed as snacks contribute to

meeting dietary recommendations for the prevention of chronic disease and

support of healthy growth and development. Providers of health services for

adolescents can provide guidance to help young people make healthy food and

beverage choices between meals and advocate in line with growing evidence

that it is imperative for policies to support these choices in schools and other

environments. Efforts are also needed to advocate that food and beverage

marketing targeted to adolescents should promote only healthy foods and

portions. (Larson, 2016)

Quality of Meals

It has been reported that not only the quality of food, operation, and

environment factors, but also additional factors such as the presence of

nutrition teachers in schools, can influence students' level of satisfaction with

school meals. Examining the distribution of nutrition teachers in schools in

2015, that of elementary schools (60.5%) was notably higher than that of middle

(18.7%) and high schools (27.2%), indicating that the presence of nutrition
teachers in schools may be considered one of the factors affecting the level of

school meal satisfaction. (Kwon, 2018)

Impact on Nutritional Intake

According to a study of assessment of weight status, dietary habits,

physical activity, dietary beliefs, and nutrition knowledge among a sample of

students from Central Michigan University (2015) the outcomes of this study

indicated that 78% of female students were within the healthy weight range

compared to 52% of male students. Visceral body fat and waist circumference

scores were higher in males than in females. Most students showed

‘satisfactory’ dietary habits. Almost half of the students reported drinking two

glasses of milk and consuming two cups of fruits and vegetables daily. Physical

activity and lifestyle score indicated that most of the students were not

physically active. Only 7% of students reported having a very active lifestyle,

and 4% had quite good nutritional knowledge.

Overweight or obese children compared to normal weight children,

especially boys, participated in physical activity less and were more sedentary.

Healthy eating habits, such as eating breakfast and an adequate meal size,

were viewed as less desirable in overweight children. Nutrition knowledge was

not significantly different between overweight and normal children, whereas

self-efficacy for physical activity was lower in overweight children than in normal

weight children. Therefore, education program for obesity prevention in children

need to emphasize increased confidence in performing exercise or physical

activity. Education programs should also focus on providing practical tips for
increasing physical activity and modifying eating behaviors. In addition,

education programs need to include topics of body image, body satisfaction,

and adequate methods of weight control. (Ha, 2016)

Intuitive eating, which can be defined as reliance on physiological hunger

and satiety cues to guide eating, has been proposed as a healthy weight

management strategy. Health promotion programs should highlight the

importance of enhancing body appreciation and preventing disordered eating

behaviors among university students in order to promote intuitive eating as one

of the healthy weight management approaches. (Gan, 2017)

Mental disorders, including eating disorders, mostly begin during youth.

Moreover, negative body image is found to cause unhealthy eating habits in the

context of several cross-cultural settings. The negative relationship between

body image and eating habits is not significant. However there was a significant

positive relationship between health perception and eating habits. (Ichsan,


It was concluded that at-risk students should be directed to the related

units for early intervention in accordance with the findings obtained and that

education programs about healthy nutrition should be organized for both

students and their families. Büyük, E. T., & Duman, G. (2014)

Health behavioral patterns, especially eating patterns, established in

childhood often carry over into adulthood, and some of the unhealthy ones are

later associated with adult morbidity and mortality. It is feasible and effective

to improve nutrition and food safety knowledge among primary and junior high
school students through school-based nutrition and food safety education

programs. (Zhou, 2014)

Adolescents over reliance on foods such as nutrient-poor snacks, sugar-

sweetened beverages and take-away foods puts them at significant risk

of obesity and several diet-related chronic diseases. Therefore, the factors that

influence their dietary behaviours need to be better understood in order to

develop effective nutrition promotion strategies. The 52 interviews revealed a

number of factors that may influence adolescents' eating habits including parent

and peer influences, home and school food environments, and the mass media.

Emerging evidence suggests that future health and nutrition promotion

interventions need to target the different influences on Indian teenagers' food

consumption. (Rathi, 2016)

There is a growing need for school-based nutritional educational

programs that promote healthy eating attitudes without increasing an unhealthy

focus on restrictive eating or promoting a poor body image. Research suggests

that intuitive eating (IE) approaches, which encourage individuals to focus on

internal body signals as a guide for eating, have had a positive impact on eating-

related psychological outcomes in adults. (Healy, 2015)

School-based nutrition education programmes have the potential to

reinforce healthy dietary behaviours in adolescents.

The current Indian secondary school curriculum has been criticised for

its failure to deliver relevant skills-based food and nutrition education for

adolescents. The purpose of this paper is to understand the views of

adolescents, their parents, teachers and school principals on the present food
and nutrition curriculum and the role of the schools in developing food skills.

(Rathi, 2017)

Students’ nutrition knowledge improved significantly in intervention

schools after intervention compared with controls. The extent to

which students felt that peer support activities were helpful and that what they

learned in class about nutrition was helpful, was related to their resultant level

of nutrition knowledge. (Wang, 2014)

A teenager’s health and diet are directly related. A nutritious diet has

short- and long-term benefits, while an unhealthy one can cause physical,

mental and emotional problems, as well as chronic illnesses that last into

adulthood. A healthy diet for a teenager is full of nutrient-dense foods and

balanced with physical activity. Teenagers who enjoy healthy foods at a young

age will make better choices in the future. On the other hand, teenagers who

develop a taste for fat, sodium, sugar and processed foods are more likely to

have poor eating habits as adults and increase their risk for nutrition-related

diseases such as heart disease, diabetes and cancer. (Fong, 2018)

Role of Nurses in Nutrition Education

Proper nutrition plays a big role in disease prevention, recovery from

illness and ongoing good health. A healthy diet will help you look and feel good

as well. Since nurses are the main point of contact with patients, they must

understand the importance of nutrition basics and be able to explain the facts

about healthy food choices to their patients. Nutrition classes provide the

information necessary to sort the fact from fiction about healthy eating and pass
that knowledge on to their patients. Not only must nurses be able to explain the

ins and outs of a healthy diet, they must also lead by example. (Arkansas State

University, 2016)

The school nurse, with his or her daily presence in school and access to

large populations of students, is well positioned to prevent and/or intervene on

this health issue through (1) implementing BMI screenings and referrals to the

medical home as needed, (2) collaborating with food service personnel and

administrators to advocate for and to provide nutritional meals and snacks, (3)

working with school staff to promote opportunities for physical activity, (4)

educating parents about healthy lifestyles, and (5) involving the community

providers and organizations in these efforts. (American Academy of Pediatrics,


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